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Prof. Eyal Lederman DO PhDProf. Eyal Lederman DO PhD
Process approach in
physical therapies
CPDO Ltd CPDO Ltd
www.cpdo.netwww.cpdo.net
[email protected]@cpdo.net
Process Approach
Co-create with the patient environments in which their
recovery can be optimised.
Look at the patient’s underline processes and match the
intervention according to these needs
Why do we need a new model?
Physical therapies: alignment to a structuralPhysical therapies: alignment to a structural--orthopaedic orthopaedic
modelmodel
Conceptual model for musculoskeletal health
A model for how the body fails
Structural observational and diagnostic procedures
Recovery is associated with structural modifications
Structural-physical treatment
Utopian view of the body
Optimum structure = optimum functionAlso
Optimum control = optimum function
Technotopia
Mechanical Mechanical ““hardwarehardware”” idealsideals
Control Control ““softwaresoftware”” idealsideals
“Asymmetry within the pelvic structures can lead to a cascade of postural compensations throughout the axial spine, predisposing persons to recurrent somatic dysfunction and decreased functionality”
Juhl J et al Prevalence of Frontal Plane Pelvic Postural Asymmetry Part 1. J. American Osteopathic Association 104(10):411-421 2004
Utopian view of the body
Postural appearance: socialPostural appearance: social--cultural constructs of healthcultural constructs of health
Pretty = healthy, good, resilient Pretty = healthy, good, resilient
Unsightly = unhealthy, bad, weak, injury proneUnsightly = unhealthy, bad, weak, injury prone
No association between structure, biomechanics
and LBP
Trunk asymmetry, thoracic kyphosis and lumbar
lordosis in teenagers and developing LBP in adulthood
(Poussa MS 2005)
Elevation of one shoulder, elevation of one hip, and
deviation of the spine from the midline of the body to
LBP & neck pain (Dieck GS, 1985)
Low muscle strength, low muscle endurance,
or reduced spinal mobility and erector spinea
pairs imbalances during extension
(Hamberg-van Reenen HH 2007 & Reeves PN
2006)
Lumbar lordosis (Norton BJ 2004).
Spinal scoliosis (Christensen ST 2008 syst. rev.)
Increased lumbar lordosis and sagittal pelvic tilt on back
pain during pregnancy (Franklin ME 1998)
Differences in regional lumbar spine angles or range of
motion (Mitchell T, 2008)
Pelvic obliquity and the lateral sacral
base angle pelvic asymmetry
(Fann AV 2002 & Levangie PK 1999)
Inflexibility of the lower extremities or leg length
discrepancy (Nadler SF 1998)
Hamstrings and psoas tightness (Hellsing, 1988)
Correcting foot mechanics have no
effect on preventing back pain (Sahar
T, et al, 2007)
Lederman E 2010 Fall
of the postural-
structural-
biomechanical model
in manual and
physical therapies:
exemplified by LBP.
CPDO online journal.
www.cpdo.net
Disparity between pathomechanics and LBP
No corrolation:
Facet degeneration (n=160)
Spina bifida,
Transitional lumbar vertebra,
Spondylolysis / spondylolisthesis
Modic changes
Kalichman L, et al Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976).
2008 Nov 1;33(23):2560-5.
van Tulder et al 1997, syst. review, Luoma, 2004; Brooks et al 2009
Kalichman L, et al. 2010 Changes in paraspinal muscles and their association with low back pain and spinal degeneration:
CT study. Eur Spine J. Jul;19(7):1136-44
Keller A, et al 2011 Are Modic changes prognostic for recovery in a cohort of patients with non-specific low back pain? Eur
Spine J. Aug 12
Postural-behavioural factors
Lack of association:
Prolonged: standing, bending, twisting Awkward postures (kneeling or
squatting) Sitting posture at work
Prolonged sitting at work / homeRecreational sports activities
(Hartvigsen et al 2000 syst. review; Chen et al 2009 syst. review; Bakker et al 2009 syst. review; Roffey et al 2010 syst. review; Wai
et al 2010, syst. review).
Bishop MD, et al 2011 Magnitude of spinal muscle damage is not statistically associated with exercise-induced low back pain intensity. Spine
J. Dec;11(12):1135-42.
Increased signal intensity
Disparity between symptoms and pathology
Disparity between symptoms and pathology
Time Time -- weeks.. months.. yearsweeks.. months.. years
PathologyPathology
SymptomsSymptoms
Carragee, E et al 2006 Does Minor Trauma Cause Serious Low Back Illness? Spine. 31(25):2942-2949
Videman T 2006 Determinants of the progression in lumbar degeneration: a 5-year follow-up study of adult male
monozygotic twins. Spine. Mar 15;31(6):671-8
Battié MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime
exposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec 15;20(24):2601-12
Number of MRI
abnormalities
PRR (95% CI) [adjusted for treatment and other confounders]
Any pain Disabling pain
0 1 1
1 0.8 (0.6-1.1) 0.9 (0.4-2.0)
2 0.9 (0.7-1.1) 0.9 (0.4-2.0)
3 0.9 (0.7-1.1) 0.9 (0.4-1.9)
4 0.8 (0.8-1.2) 1.8 (0.9-3.6)
McNee P, et al 2011 Predictors of long-term pain and disability in patients with low back pain investigated by magnetic
resonance imaging: a longitudinal study. BMC Musculoskelet Disord. Oct 14;12:234.
Anomalies examined: Disc herniation (protrusion, extrusion or sequestration)Nerve root deviation or compression Disc degeneration High intensity zonesN=240
Disparity between spinal pathologies & LBP
Disparity between spinal pathologies &
LBP
Karppinen J, et al 2001 Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine. Apr 1;26(7):E149-5
Masui T, et al 2005 Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. Apr;18(2):121-6.
Degree of disc displacement, nerve root enhancement or nerve compression not correlated with pain level or disabilityN=160
SherSher JSJS et al Abnormal findings on magnetic resonance images of asymptoet al Abnormal findings on magnetic resonance images of asymptomatic shoulders. matic shoulders. J Bone Joint J Bone Joint SurgSurg Am.Am. 1995 Jan;77(1):101995 Jan;77(1):10--5. 5.
In all age groups, 34% had partial or full rotator cuff tears
The frequency of full-thickness and partial-thickness tears
increased significantly with age:
60 yrs +, had 54% (28% full tear, 26% partial)
40-60 yrs, (4% full tear, 24% partial)
19-39 yrs, only 4% had a partial tear
Disparity between structure and symptoms: can be applied elsewheDisparity between structure and symptoms: can be applied elsewherere
Control is highly variable - not like a computer
Jacobs JV, Henry SM, Nagle KJ 2009. People with chronic low back pain exhibit decreased variability in the timing of their anticipatory postural adjustments. Behav Neurosci. Apr;123(2):455-8.Moseley GL, Hodges PW. 2006 Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. Apr;120(2):474-6
2 individuals, 75 overlaid trials
Why not mechanical?
Biological dimension
1. Genetic factors2. Capable of repair and adaptation3. Contains reserves4. Non-linear behaviour (systems)5. We don’t know
Why spinal degeneration?Why spinal degeneration?
Progression of degenerative signs:
Genetic and shared environmental influences47% to 66%
Resistance training and occupational physical loading together2% to 10%
N=116 twins. Study over 5yrs.
Videman TDeterminants of the progression in lumbar degeneration: a 5-year follow-up study of adult male monozygotic twins. Spine. 2006 Mar 15;31(6):671-8Battié MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec 15;20(24):2601-12
1) MacGregor AJ, et al 2004 Structural, psychological, and genetic influences on low back and neck pain: a study of adult female twins. Arthritis Rheum. Apr 15;51(2):160-72) Battie MC et al 2007 Heritability of low back pain and the role of disc degeneration. Pain 131:272–280Valdes AM, et al 2005 Radiographic progression of lumbar spine disc degeneration is influenced by variation at inflammatory genes: a candidate SNP association study in the Chingford cohort. Spine;30:2445–51Holliday KL, McBeth J. 2011 Recent advances in the understanding of genetic susceptibility to chronic pain and somatic symptoms. Curr RheumatolRep. Dec;13(6):521-7.
Heritability for LBP 52-68%1 / 30% to
46%2
Neck pain 35-58%.
Why pain?
Mechanical systems in overloadingMechanical systems in overloading
Ran
geR
ange
ToleranceTolerance
DamageDamage
Progressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failureProgressive or catastrophic failure
ToleranceTolerance
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by LBP. CPDO online journal
Lederman E. 2011 The fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.
Physiological Physiological rangerange
End rangeEnd range
End rangeEnd range
Potential Potential adaptive rangeadaptive range
Potential Potential adaptive rangeadaptive range
Biological systems in overloading: acute option Biological systems in overloading: acute option -- repairrepair
InjuryInjuryInjuryInjuryInjuryInjuryInjuryInjury
RepairRepairRepairRepairRepairRepairRepairRepair
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by LBP. CPDO online journal
Lederman E. 2011 The fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.
Biological systems in overloading: chronic option - adaptation
Physiological Physiological rangerange
End rangeEnd range
End rangeEnd range
Potential Potential adaptive rangeadaptive range
Potential Potential adaptive rangeadaptive range
OverloadingOverloadingOverloadingOverloadingOverloadingOverloadingOverloadingOverloadingRemodelled end Remodelled end rangerange
AdaptationAdaptationAdaptationAdaptationAdaptationAdaptationAdaptationAdaptation
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by LBP. CPDO online journal
Lederman E. 2011 The fall of the postural-structural-biomechanical model in manual and
physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. Apr;15(2):131-8.
No progressive failureK
Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. 2009 Pain in the lumbar, thoracic or cervical
regions: do age and gender matter? A population-based study of 34,902 Danish twins 20-71 years of
age. BMC Musculoskelet Disord. Apr 20;10:39.
Frequency of back and neck pain same at all ages (20-71yrs)Duration slightly longer in older age
Supraspinatous calcification: cure or calm?
Left
Right
A scan of my “uncured” but “calmed” supraspinatous calcification
Recovery depends on cure or/and calmRecovery depends on cure or/and calm
CureCalm
or/and
Repair Adaptation Homeostasis(e.g. Short term pain alleviation)
No evidence to suggest that we
should treat humans like a structure
out of alignment
What is the use of a profound knowledge of
anatomy? Does it help the treatment?
What is the purpose of a standing examination?
Is palpation useful to explain a condition?
What are the aims of manual techniques or
exercise?
ClinicallyClinically
Process Approach
An alternative
modelK
Process Approach
Co-create with the patient environments in which their
recovery can be optimised.
Identify the processes that underlie the patient’s
condition and match the intervention according to these
needs
Complex adaptive systemsThe number of elements is sufficiently large that conventional descriptions cease to assist in understanding the system
The elements interact dynamically. Interactions can be physical or involve the exchange of information.
Interactions are multi-directional. Any element in the system is affected by and affects several other systems.
The interactions are non-linear - small causes can have large results.
Any interaction can feed back onto itself directly or after a number of intervening stages, such feedback can vary in quality.
Systems are open - may be difficult or impossible to define system boundaries
Operate far from equilibrium conditions
All complex systems have a history, they evolve and their past is co-responsible for their present behaviour
Some elements in the system are autonomous responding only to what is available to it locally
CLBP as a processCLBP as a process
Too much to considerComplexity
Worse, better, chronic, recurrent etcSeveral possible outcomes
Is the pain new injury or sensitisation / inability to identify tissue
causing symptomsUncertainty
Condition is still there even during pain-free periodOutcome is only a particular point
within a continuum
Motor and behavioural responses associated with pain experience Inter-related processes
Sensitization + protective motor reorganizationMultiple systems, sub-events,
processes
Repair in local dimension, muscular reorganisation in neurological
dimension as well as psychological distressOccur in different dimensions
Pain associated with repair in acute changes to sensitization in chronicUnderlying mechanisms change
over time
Turning in bed is painful, but playing squash is OKNon-linear relationship between
input-output
Pain is not an indication of damageComplex relationships between
processes
Undefined time scale, can be recurrent, various duration. Switch on-off
without obvious causeContains a time dimension
Management and recovery: multidimensional Management and recovery: multidimensional
processesprocesses
Repair
Fluid flow
Length adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
Repairor / and
Adaptation
Long term change in any process depends on..
� Intrinsic processes
� Time dependent
� Environment dependent
LBP: a multidimensional condition in many dimensionsLBP: a multidimensional condition in many dimensions
PROCESSES
Psychological
Neural
Physical /
Local
tissue
DIMENSION CLBP
??? Not associated with tissue damage
(except in acute)
Repair??
More likely in acute LBPFluid flow
Tissue shortening or ROM sensitization?Adaptation
Persistent sensitizationNociceptive
Motor reorganisation
Loss of movement variability
Neuromuscular
Higher centre mediated sensitization
Reduced pain tolerance
Psycho-physiological
Pain / suffering
Fear avoidance
Catastrophizing
Psychological distress: depression,
anger, anxiety, hopelessness
Psychological/cognitive/
behavioural
To be as they were before: full functionality
What the patient wants
Pain and ROM
Pain alleviation is multiPain alleviation is multi--dimensionaldimensionalKK
Assist tissue repair
Normalisation of motor
control
PROCESSES
Nociceptive inhibition
Reduce fear avoidance
and catastrophizingPsychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Active movement (task specific / functional)
Dynamic movement (passive or active)
Dynamic movement (passive or active)
Support / reassurance / empathyRaise pain tolerance
Reduce sensitization
condition time-line
Support repair
Acute Subchronic Chronic
Tissue dimension
Neurological dimensionManaging pain: Treatment strategies / processes Managing pain: Treatment strategies / processes
change over timechange over timeKK
RepairAdaptation
Pain alleviation and desensitization
Obscure protective roleApparent protective role
ROM Recovery is also multiROM Recovery is also multi--dimensionaldimensionalKK
Length adaptation
Recover control of
active ROM
PROCESSES
Promote ROM
desensitization
Reduce fear avoidance
Reduce catastrophizing
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Task specific, working with task parameters
Passive or active stretching approaches? (may not be effective!)
External focus of attention, dynamic, active movement
Cognitive and behavioural reassurance
condition time-line
Support repair
Acute Subchronic Chronic
Tissue dimension
Neurological dimensionManaging ROM: Treatment strategies / processes Managing ROM: Treatment strategies / processes
change over timechange over timeKK
RepairAdaptation
ROM loss obscure protective roleROM loss apparent protective role
Psychological dimension
ROM desensitization
Alleviate fear of movement
Higher disability levels
Psychological distress
More social dysfunction
More social isolation
Receiving higher compensation
Work relations
Low job satisfaction
Low social support
Fear avoidance
Depression
Anxiety
Sexual & physical abuse
Psychological
Frequent heavy lifting (small
effect)Occupational
Initial high intensity pain
Specific LBP
Referred pain to LEX
Delay in treatment
Female > males
Previous history of LBP
Genetic factorsPhysiological-
biological
Long term sick leaveRisk factors
Risk factors for CLBPRisk factors for CLBP
Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53
Occupational and Environmental Medicine 2005;62:851-860
Balagué F, et al 2012 Non-specific low back pain. Lancet. Feb 4;379(9814):482-91.
LBP lottery: Uncertainty of cause
Focusing on a single factor may be ineffective
The uncertainty of diagnosis
FacetFacet
DiscDisc
MuscleMuscle
1. Many spinal tissues share the same symptomatology
2. Sensitization spreads(Undamaged tissues will become sensitive to mechanical loading)
3. Physical examination is not tissue specific(Individual loading of tissue is highly unlikely)
LBP + LEXLBPChronicOver 8 wks
LBP + LEXLBPAcuteUp to 8 wks
Embracing uncertainty: presentation lead management (rather thanEmbracing uncertainty: presentation lead management (rather than tissue tissue
diagnosis)diagnosis)
Intervention as a processes
Intervention: environment reconstruction for changeIntervention: environment reconstruction for change
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
Recovery in the tissue dimensionRecovery in the tissue dimension
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
Fibroblast
Myocyte
Change in physical environment
MechanotransductionMechanotransduction
A
B
C
D
A. Normal ligament
B. Ligament after 6 weeks
of immobilisation
C. Effects of immobilisation
D. Effects of 6 weeks of
passive movement
Mechanotransduction and adaptationMechanotransduction and adaptation
Effects on tensile strengthEffects on tensile strength
Trans-synovial pump
Alteration in intra-
articular pressure
Increased blood flow
around the joint
Increase lymphatic flow &
drainage around the joint
Fluid flow
Movement
High(in functional rehabilitation)
HighHighHighLow stress
active
movement
LowLowLowLowCranial
LowLowLow to mediumLowTraction
Low
Low
Low
Low
Medium to high
Medium to high
Perfect
Resemblance to
real movement
HighHighHighHuman
movement
HighHighHighArticulation
low
Low
Low to medium
High (if in compression)
High
Adequate stress RepetitiveDynamicTechnique
HighHighHarmonic
HighHighMassage ST
LowLowHVT
LowLowFunctional
LowLowStretch
Matching techniques to physiology of repair
Recovery in the neurological dimensionRecovery in the neurological dimension
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
A functional approach to functionality
Functional movement - the unique movement repertoire of an individual.
Functional rehabilitation - the process of helping a person recover their
movement capacity by using their own movement repertoire (whenever
possible).
Extra-functional – a movement pattern outside the individual’s movement
repertoire
Lederman E. 2010 Neuromuscular Rehabilitation in manual and
physical therapies. Elsevier
Competition in adaptation: intervention vs. condition
processes
Pain Pain Pain Pain sensitizationsensitizationsensitizationsensitization
ororororROMROMROMROM
Treatment
Transforming habitual cognitive and behavioural patterns is essential for success
Repetition
Cognition
Specificity
FeedbackActive
Conditions for learning, adaptation and recovery
Functional approach
Shared skillsShared skills Unique skillsUnique skills
Functional repertoireFunctional repertoire
Increase stair Increase stair
climbingclimbing
+ 2 stairs at a + 2 stairs at a
timetimeIncrease Increase
walking + walking +
walking on walking on
heels or toesheels or toesSkipping Skipping
over an over an
obstacleobstacle
Tapping Tapping
with heel with heel
or toesor toes Gentle Gentle
running on running on
treadmilltreadmill
Lederman E. 2010 Neuromuscular Rehabilitation in manual and physLederman E. 2010 Neuromuscular Rehabilitation in manual and physical therapies. Elsevierical therapies. Elsevier
YesHighHighHighHighFunctional
rehabilitation
noLowLowLow -HighLowMET
noLowLownoLowHVT
LowLowHighHighHighCore stability
noLowLownoLowTraction
no
low
no
no
no
Perfect
Similarity
To real
movement
Low
Low
Low
Low
Low
High
Repetition
LownoLowStretch
no
no
no
no
High
Active FeedbackCognitionTechnique
HighHighHuman
movement
LowLowMassage ST
LowLowArticulation
LowLowFunctional
LowLowCranial
Matching approach to motor control recovery
Recovery in the psychological dimensionRecovery in the psychological dimension
Repair
Fluid flow
Adaptation
Neuromuscular
PROCESSES
Nociceptive
Psychological/cognitive/
behavioural
Psycho-physiological
Psychological
Neural
Physical /
Local
tissue
DIMENSIONINTERVENTION
Pain / suffering
Aims in the psychological dimension
To explore and understand the To explore and understand the psychological processes that can assist or psychological processes that can assist or impede recoveryimpede recovery
Therapeutic encounter
TreatmentBackground Background
HistoryHistory
BeliefsBeliefs
AttitudesAttitudes
Etc.Etc.
Background
History
Beliefs
Attitudes
Etc.Practitioner Patient
Relationship
Physical/contractual
boundaries
Fox S 2008 Relating to clients. Jessica Kingsley Publishing. London
Working with cognition and behaviour
CognitionsFear
Anxiety
catastrophising
BehaviourWithdrawal from activities
Activity cycling
Illness behaviour
Behavioural spheres
Therapeutic focus
Therapeutic focus
Contextual affects / factors
Treatment outcomes are highly dependent on contextual affects
The closer you look the
less you’ll see..
Behavioural spheres and LBP management
TaskTask--behaviourbehaviour
PsychosocialPsychosocial--behaviourbehaviour
OrganisationalOrganisational--behaviourbehaviour
Lederman E. 2010 Neuromuscular Rehabilitation in manual and
physical therapies. Elsevier
Treatment as
optimisation
TreatmentTreatment
Daily activityDaily activity
General / specific exerciseGeneral / specific exercise
Injury / illnessInjury / illness
BehaviourBehaviour
Patient dependant
Therapist dependant
Success of treatment rely on:
• Patient’s repair and adaptation status
• The ability of therapist to identify the underlying
process
• The ability to match the ideal management / care
/treatment to facilitate a change in these processes
The down sideThe down sideKK..
A process approach ultimately relays on research to inform
us about the condition and underlying processes:
1. May be wrong.. (e.g. the core model – loss of core
stability = back pain
2. May be insufficient research or knowledge (e.g. why
some individuals can have profound musculoskeletal
damage but no pain, and why others become
symptomatic
3. Research is about the average, individuals are individual
Differences between structural and process approaches
Accepts variability and individualityAccurate / precise
Processes ruleAnatomy rules
Towards co-created managementTherapist dominates the treatment
Uncertainty is OKCertainty
Condition is understood through its underlying processes Condition is understood by structural factors
Based on bio-psycho-social sciencesBased on biomechanical models (many now obsolete)
Diagnosis embraces uncertainty and is informed by processesDiagnosis is dominated by structural examinations and
considerations
Broad multidimensional assessment (difficult to define)Examination is mostly structural
Patient needs / processes dictate management Technique led – often a series of manual events
Condition occurs in many dimensionsOften in single biomechanical dimension
Treatment aims to facilitate processes associated with
recovery, such as repair / adaptation
Create an environment for change
Treatment aim to correct, improve or enhance physical
structure
(many techniques have no effect on what they try to achieve)
Techniques don’t exist. Manual / physical events are seen as
a vehicle to deliver signals / stimulation for change
Part of the co-created environment
Techniques are seen as mechanical forces that can alter and
correct structure
Open, creative and continuously changing according to needsProtocol based
Process modelStructural-orthopaedic model
Find out more:
Books:The science and practice of manual therapy.
Neuromuscular rehabilitation in manual and physical therapies
Workshops:See: www.cpdo.net
Contact: [email protected]