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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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Mechanical Diagnosis and Treatment System
Derangement syndrome is reported to be the most common clinical
presentation of spinal problems, and it is defined as internal displacement
within a motion segment. Prevalence rates vary depending on chronicity, but
trained therapists have reported rates of between 60% and 78% in the lumbar
spine
28-33
and between 72% and 87% in the cervical spine.
30,36,37
Because of
its high prevalence, the clinician should rule out this syndrome first when
making a diagnosis. Proper classification of patients in this subgroup is
important because they will respond rapidly to end-range exercise using the
correct directional preference. Therapeutic exercise performed in the wrong
direction may worsen a patient’s condition.
28,29,32,36,37
Dysfunction syndrome is a mechanical deformation of impaired soft
tissue(s) that may be caused by trauma, an inflammatory or degenerative
process that results in contraction, scarring, adherence, adaptive shortening,
and weakness. This pain mechanism is dominated by ischemia, which
indicates the need for therapeutic exercise for remodeling of specific
connective tissues.
24,34
Posture syndrome is a mechanical deformation of soft tissue(s) resulting
from prolonged end-range postures that deprive vascular transmission and
cause ischemia. Joints, muscles, tendons, periosteal insertions, spinal disks,
and peripheral nerves may be affected.
24,34
Treatment-based Classification System
The most recent revision of the TBC system occurred in 2007,
8,10,11
but that
revision did not acknowledge the biopsychosocial aspects of LBP.35 This
deficit in the TBC system illustrates the benefit of collaborative classification
systems. The TBC has the following four main classification categories:
manipulation, stabilization, specific exercise, and traction.
35
Manipulation
Patients in the manipulation category meet the following criteria: recent onset
of symptoms, symptoms localized to the back, hypomobility in the lumbar
spine, and low scores on the Fear Avoidance Behavior Questionnaire.35 A
patient who meets the clinical prediction rule for lumbar manipulation also
should be included in this category. Treatment includes mobilization and/or
thrust manipulation followed by range-of-motion exercises.
35
Stabilization
Patients in the stabilization category typically meet the following criteria:
positive result on the prone instability test, the presence of aberrant motions,
a straight leg raise test of greater than 90°, and recurrent episodes of spine
pain.35 Treatment includes exercises that focus on core strengthening and/or
motor control.
35
Specific Exercise
Patients in the specific exercise category meet the following criteria:
symptoms that radiate into the lower extremity, a strong preference for either
sitting or walking, and centralization and peripheralization of symptoms with
repeated lumbar spine movements.35 Treatment includes exercises or manual
interventions that focus on centralizing and abolishing symptoms.35 The most
common treatment includes repeated and/or sustained lumbar extension;
however, specific movements of flexion or lateral gliding are less commonly
used directional preference exercises.
35
Traction
Patients in the traction category meet the following criteria: pain radiating
into the lower extremity, no directional preference, and a positive (crossed)
straight leg raise test.35 Treatment includes manual and/or mechanical lumbar
traction.35 The main goals of treatment are improvement in symptoms,
function, and education to allow self-management of pain.
35
Using Multiple Systems and Determining Risk Groups
The use of several classification systems (ie, PMCS, MDT, and TBC) is
recommended to manage the risks associated with LBP across the entire pain
continuum. The provider should determine which form of therapeutic
exercise is appropriate for the patient and which classification system should
be used to guide treatment. In general, patients with LBP should be triaged
into one of four risk groups to guide referral to specialists and therapeutic
exercise providers.
Risk Group 1
Risk group 1 includes patients with serious pathology, comorbidities, or red
flags. Fewer than 5% of patients with spine pain are classified into this
group.38 The subjective information in the patient’s history requires
immediate medical management and referral to a specialist for diagnosis.
Close monitoring should continue until an appropriate referral source is
identified and care is transitioned. The objective evaluation shows symptoms
that do not respond to repeated movements, positions, or provocation tests.
The patient may demonstrate the following signs and symptoms: constant
pain unrelated to position or movement and not relieved by rest, severe night
pain unrelated to position or movement, recent unexplained weight loss, a
history of direct blunt trauma, an appearance of acute illness, generalized
weakness or malaise, abdominal pain that radiates to the groin and is
associated with hematuria, sexual dysfunction, recent menstrual irregularities,
bowel or bladder dysfunction, and anesthesia perineum.
Risk Group 2
Risk group 2 includes patients with disability resulting from pain and the
presence of yellow flags. According to the scientific literature, approximately
35% of patients are classified into this group (most have spine-related pain).
All patients should be screened for potential yellow flags, which are
characteristic of CNS pain mechanisms.
7,39,40
Instruments such as the Yellow
Flag Risk Form (YFRF)
39,40
or the STarT Back Tool
41,42
can aid in screening
for these central characteristics. Low scores on these types of assessment
tools indicate a low occurrence of CNS characteristics and psychological
distress; no uncontrolled comorbidities; and, typically, normal neurologic
status.
The PMCS recommends that patients in this category be treated with
education about CNS pain mechanisms (central sensitivity, affective,
motor/autonomic), reassurance about movement-safe pain, and advice on
certain active care procedures. The YFRF can be used to screen for pain
disability risk and identify CNS pain characteristics to promote proper
referral. The tool has 13 simple questions that highlight the four domains
known to be key markers for transitioning to chronic pain and disability.
43
The four domains include (1) confidence and self-efficacy in mortality, pain
control, and activity return; (2) emotional stability and balance, specifically
affecting depression, anxiety, and sleep; (3) fear avoidance and
catastrophizing related to activity and movement; and (4) the presence of
nerve-related symptoms during the day or night.
The YFRF was created in the mid-1990s after previous peer-reviewed
questionnaires were consolidated to simplify screening for yellow-flag
domains.
39,40
This tool is appropriate for patients with pain in any part of the
body. The higher the score, the greater the likelihood that central
characteristics are present and CNS pain mechanisms are dominant. The
recommended cutoff scores will guide referral to certain providers who can
direct appropriate patient education and therapeutic exercise (Table 3). If a
patient’s score is less than 55, classification into risk groups 3 or 4 should be
considered.
Risk Group 3
Risk group 3 includes patients whose condition may worsen with active care
or exercise. Three situations exist in which active care can worsen the
condition of a patient with a spine disorder. (1) If structural spine instability
is present, the patient will exhibit progressive neurologic/structural instability
signs. Surgical stabilization is required before active care can begin. A
surgeon should be consulted. (2) If chemical inflammation is present, the
patient is neurologically stable and has no structural abnormality; however,
there will be objective findings of constant pain, with morning stiffness;
noncentralization with movements or positions; worsening of pain in all
positions and with repeated movements; and symptoms not affected by
traction. The patient should be referred to a physiatrist for an epidural steroid
injection. After chemical inflammation is managed, directional preference
exercise should be considered. (3) In patients with directional preference, one
or two directions or positions will centralize and alleviate symptoms, and one
or two directions or positions will cause peripheralization and worsen
symptoms. The patient should be referred to a PMCS, MDT, or TBC provider
for treatment.
Table 3
Risk Group 4 For patients in risk group 4, active care has no effect. Because
therapeutic exercise results in no improvement, a patient may attempt
“provider jumping,” which is defined as a history of attempted treatment with
many different types of exercise providers and no substantial improvement.
In patients with ischemia or peripheral neurogenic pain mechanisms, there is
a risk that therapeutic exercise will have no effect.16 Treatment failure occurs
because the education and exercise prescription are not specific or intense
enough to alleviate the pain mechanism or alter the patient’s condition,
function, or tissue status. In these patients, the exercise prescription must be
specifically directed at the dominant pain mechanism and specific tissue
and/or function. These patients experience moderate to low levels of pain that
increase with certain movements and daily activities, but return to baseline
levels when activity is stopped. Patients may report sudden and unexpected
bouts of pain along with other pain-free periods. Active spinal movements
are not obstructed and do not cause pain. Findings of decreased flexibility
and poor motor control may exist, but there is no effect when treated with
exercises and measured using functional outcome measures. The
rehabilitation goal for these patients is proper classification of the pain
mechanism to allow guided patient education and active care. The patient
should be referred to a PMCS, MDT, TBC, or progressive exercise provider.
Identified pain mechanisms in this risk group are described and treatment
prescribed based on the classification system used because of overlap within
the systems. Ischemia as defined in the PMCS requires aggressive
intervention with remodeling exercises for the affected tissue or function.
Subgroup classification of this pain mechanism allows a more specific
therapeutic exercise prescription.
16
Tissue dysfunction as defined in the MDT system is managed with
progressive therapeutic exercise (achieving effort levels of 6 of 10 on effort
scales, and pain levels of 4 to 7 on 10-point pain scales during exercise to
achieve remodeling effects).
8,16,24
Exercise frequency is two to four times
daily for 6 to 8 weeks to achieve 10% to 20% statistical improvement.
Therapeutic exercises should be continued until pain is totally alleviated,
which can take up to 24 months in some patients with chronic conditions.
7,16
Functional loss from pain caused by pathologic ischemia is treated with
therapeutic exercise(s) along with a holistic approach that includes weight
management, improvement in cardiovascular health, general strength
training, and balance exercises. The timeline to maximal improvement can be
up to 24 months, depending on the patient’s compliance and readiness for
change in performance of the therapeutic exercise.16 Setting goals to improve
confidence and competence in a self-care program can affect overall success.
In patients with postoperative ischemia, therapeutic exercise is aimed at
promoting healing of injured or repaired tissues. The timeline to maximal
improvement may be as little as 12 weeks or as long as 24 months, depending
on the severity of tissue injury, healing complications, and the surgical
procedures performed.16 Patient compliance, readiness to change the
performance of therapeutic exercise, and setting goals to improve confidence
and competence in their self-care program are important areas that influence
overall success.
Figure 3
Illustration depicting the unique nociceptive pain
mechanism related to the peripheral nerve and representing
the trapped versus tight mechanical elements. (Reproduced with
permission from O’Connor A, Kolski MC: Peripheral neurogenic pain
mechanism, in O’Connor A, Kolski MC: A World of Hurt: A Guide to
Classifying Pain. St. Louis, MO, Thomas Land, 2015, pp 105-106.)
Therapeutic exercise can be tailored to optimize management of ischemia
related to poor physical performance of the kinetic chain (posture in the MDT
system or stabilization in the TBC system) to achieve the ability to meet
higher-level demands in sport- or job-related activities. The quality of
movement is a primary concern. Biomechanical pitfalls can be identified by
repeated functional testing and are associated with a preponderance of
loading of passive inert structures rather than establishing quality activation
patterns of muscles. The predictors of success are consistent daily practice,
recognition and correction of movement patterns, and recognition and
prioritization of quality rather than quantity as the patient progresses to
higher contextual applications of movement patterns.
16
Figure 4
Photograph of a patient performing a neurodynamic slider
exercise in which tension is directed at the distal
component of the nervous system by kicking the leg straight out, but
released in the proximal aspect of the nervous system by looking
upward.
The risk of therapeutic exercise producing no effect is common in
patients with peripheral neurogenic pain as defined by the PMCS.16 The
peripheral nerve often requires direct remodeling via neurodynamic exercise
to alter the common peripheral neurogenic pain mechanism associated with
spine-related conditions20 (Figure 3). It is important to note that the primary
goal of exercise in this group is to produce and increase nerve symptoms and
pain to restore normal movement and health to the peripheral nerve
associated with the entrapment or tightness related to the LBP. Aggressive
therapeutic exercises are directed at the tissues of the peripheral nervous
system (more specifically, the actual nerve). Subgrouping the peripheral
neurogenic mechanism as “trapped” or “tight” will further refine the
education and neurodynamic therapeutic exercise prescription.
For improvement in a patient with a trapped nerve, attention is needed to
provide healthy movement for the tissues surrounding the nerve as well as the
nerve itself. This requires a slider-type neurodynamic exercise with a focus
on sliding the nerve through the interfacing tissue that is trapping the nerve.
To restore health to the nerve, the nerve should slide through the interfacing
tissue to promote movement in the neural container
14,16
(Figure 4). For a
tight nerve, therapeutic exercise is aimed at improving the actual neural tissue
and its movement characteristics of elasticity, tensile, and compressive
loading. Remodeling requires a tensioner-type neurodynamic exercise in
which movement is focused on the tensile properties of the nerve’s
tissues
14,16
(Figure 5).
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