Muskuloskeletalt Forum 2 - 2003...Referat fra møder i IFOMT 18 ... to assess progress by focusing on the pain response to the technique (what’s happening to your pain, where is

Muskuloskeletalt

Forum

3. årgang

Maj 2003

2Dansk Selsk

ab for

Muskuloskeletal Medicin &

Danske Fysioterapeuters

Fagforum

for Muskuloskeletal Ter

api

Leder: Synlighed44

Leder: Fagforum og

specialisto

rdning55

Perspectiv

es on the

biopsychosocial model

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Leder 4 Allan Gravesen

Patientpjecer 4

DSMM’s hjemmeside 4

Leder 5Niels Honoré

Send dit indlæg elektronisk 5

Perspectives on the biopsychosocial model – part 2: the shopping basket approach 6Louis Gifford

Referat fra møder i IFOMT 18Per Kjær

Bedre lindring af nakkesmerter 19Christian Couppé

Referat fra Manuel Terapi-kongres i Estoril 20Per Kjær

DSMM’s Columnapris 21

Boganmeldelse: Physical therapies in sprot and exercise 22Christian Couppé

Kursuskatalog 23

DSMM, kursuskalender 24

DSMM, kongreskalender 25

McKenzie, kursuskalender 25

DFFMT, kursuskalender 25

MT-kurser 26

Forskning 28

DSMM’s læregruppe 29

Læsetips 29

DSMM og DFFMT – Bestyrelser og udvalg 30

Indhold

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��Synlighed er et mantra for alle virksomheder, derhar et produkt de gerne vil sælge, vise eller på an-den måde bringe frem.

I DSMM vil vi gerne være synlige over for vo-res målgruppe. Det er alle læger med interesse formuskuloskeletal medicin eller med mulig interessefor muskuloskeletal medicin.

Yngre læger under uddannelse har selvfølgeligen fornemmelse af hvad deres uddannelse skal in-deholde, men det er ikke altid at man lige ved manstår og mangler et kursus i rygundersøgelse og –behandling. Mange praktiserende læger vil i dereskliniske hverdag have glæde af at komme på kursusi muskuloskeletal medicin, ikke mindst hvis der ioverenskomsten bliver indført specialtakst for ma-nuel behandling af patienterne.

Mange speciallæger inden for reumatologi ogortopædkirurgi vil også i deres kliniske virke kunnebruge vore kurser.

En anden målgruppe er de fysioterapeuter, derer under uddannelse i manuel terapi, og som søgerden måde vi tilrettelægger vores kurser.

Derfor vil vi i DSMM gerne prøve at blive meresynlige. Vores kurser er vores produkt og vores kur-sustilbud skal vi sørge for kommer bredt ud.

Uddannelsesudvalget og lærergruppen skalprimo maj diskutere nye kurser og ny tilrettelæg-gelse af de eksisterende kursustilbud.

Vi vil i løbet af i år forsøge at lancere en an-noncekampagne i forskellige medier. En annonce-kampagne, hvor du som medlem af DSMM megetgerne må bakke op om vores produkt og fortælledine kolleger om dine erfaringer med at være påmuskuloskeletal kursus.

Måske mangler du selv en opdatering eller harlyst til at lære om nye behandlingsmuligheder?

Vi glæder os til at beskrive og fortælle omvores nye kursusstruktur i det næste nummer afMuskuloskeletalt Forum.

Leder

Allan Gravesen

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Patientpjecerne kan du bruge i din klinik tiludlevering. I pjecen beskrives muskuloskeletalmedicin og behandling på et letlæst og for-ståeligt sprog.

Kontakt Birthe Skov

�!!"��#

DSMM har oprettet et lukket område på vores hjemmeside.

Det skal bruges til f.eks. regnskaber o.lign.Du finder det ved at skrivewww.dsmm.org/lukket

Brugernavn: dsmmPasswrd: myogen

HUSK at password er til medlemmernes brugog det skal ikke videregives til andre.

Allan Gravesen

$��Hovedbestyrelsen har godkendt vores ansøgning ognu hedder vi altså Danske Fysioterapeuters fagfo-rum for Muskuloskeletal Terapi! Endvidere harhovedbestyrelsen nu endeligt vedtaget specialist-ordningen. De to første områder der kan søge omgodkendelse er speciale i neurofysioterapi og speci-ale i muskuloskeletal fysioterapi. Kravene til fremti-dens specialister er følgende:

%��&��• Grunduddannelse til fysioterapeut 180/210 ECTS• Dansk autorisation som fysioterapeut• Medlem af Danske Fysioterapeuter• Generel arbejdserfaring svarende til 2 års fuld-

tidsarbejde

��'(• 3 års klinisk arbejde indenfor specialistområdet

med dokumenteret klinisk vejledning Arbejdsti-den må mindst være gennemsnitlig 18 timer pr.uge

• De 3 år kan løbe parallelt med specialistuddan-nelsesforløbet

• Kompetenceudvikling indenfor supervision, mi-nimum 150 timer

• Undervisning og formidling opgivet i ECTS• Dokumenteret efteruddannelse med relevans til

området opgivet i ECTS

)��'(• Master eller kandidateksamen med projekt i re-

lation til specialistområdet• Foredrag med emne i specialistområdet, konfe-

rencedeltagelse med indsendt abstract, eller ac-cepteret artikel i forskningstidsskrift

• Dokumenteret deltagelse i kurser, workshops,konferencer på specialistområdet opgivet i ECTS

• Dokumenteret efter- og videreuddannelse opgi-vet i ECTS

*��(�+�+��'��#�• Specialistens faglige kompetence er kroppens

biomekaniske forhold: led, knogler, sener,muskler, nervesystem, og bindevævs funktionerog indbyrdes påvirkninger.

• Specialisten kan identificere komplekse og kom-plicerede dysfunktioner i bevægeapparatet og

kan behandle disse udfra et velargumenteretløsningsforslag på baggrund af klinisk ræssone-ring.

Det bliver spændende at se hvor mange specialistervi får, og mon ikke en af de første specialister iDanmark bliver en fra Danske Fysioterapeuters fag-forum for Muskuloskeletal Terapi.

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Leder

Niels Honoré

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Indlæg modtages gerne elektronisk.Send pr. e-mail til redaktøren (ansvarshavende).Eller indsend på diskette.

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Published in: In Touch, The Journal of the Organi-sation of Chartered Physiotherapists in PrivatePractice. Spring Issue 2002 No 99. Pages: 11-22

.��/�0��1��0��1��When I first trained, in the early 1980’s, and later,when I did my manual therapy training, a majoremphasis of assessment was to find the structural ortissue source of the patient’s problem and to thenperform one technique at a time to the presumedsource. While giving the technique it was importantto assess progress by focusing on the pain responseto the technique (what’s happening to your pain,where is your pain, how does this feel, what’s hap-pening now, etc etc …) and then re-examining thepain response and quality of a physical movement(where’s the pain now, what’s happening to thepain; better, same or worse? etc.). Taking a termfrom basic electricity wiring diagrams, this processcan be seen as an “in series” one, whereby one pro-cedure at a time had to be proved and performingseveral techniques at once i.e. “in-parallel”, wouldmuddy the proving process. In much of my trainingand early work as a manual therapist even givingan exercise before a technique had been proven wasfrowned upon – if you do many things at once, onething might be helping, while another may be detri-mental – was the logic that was applied. It fitted theapproach and seemed a logical way to work.

In the light of currently available research thispurist “in series” style of approach appears incom-plete, inefficient and needs to be criticised:

• It is very passive. It takes control away from thepatient and leaves them with little responsibility.It promotes passivity by the patient and the ex-pectation that the clinician will fix the problem.

• It is over-reliant and over-focused on pain re-sponse and pain relief. It assumes that instant-aneous improvements in pain and pain responseto movement are a reliable indicator of recovery(see discussion on pain and pain treatments, partI (Gifford 2001). Restoration of good quality andless painful movements is not being criticised, solong as the new movements gained can in someway be generalised into the patients active life.

• It focuses on pain, sometimes almost continu-ously. Therapists trained in this way almostconstantly and automatically use “pain talk”when assessing and managing the patient (avery difficult habit to break – I think its takenme 10 years at least). As argued elsewhere (Gif-ford 1998), if you focus too often and too muchon pain, you may in effect help to memorise itthereby increasing its potential long-term im-pact on the circuitry of the central nervous sys-tem – hence chronic pain.

• It is over-focused on a single physical source(see part I (Gifford 2001)).

• It assumes that we are capable of finding asingle “source” of a problem and it focuses toomuch attention on individual structures andtissues as being “pathological”, damaged; dys-functional, imbalanced, weak, vulnerable … It over-focuses on single or multiple physicalimpairments found by the clinician. In realityany “in series” approach like this one is verymuch linked to the biomedical model of healthand disease. Unfortunately, the available evid-ence suggests that a purely biomedical approach– such as one where physical impairments are amain source of attention, is only very weaklylinked to levels of pain and the development ofpain disability.

A freer “In parallel” analysis and management ap-proach allows clinical reasoning to consider multiplefactors that may play a role in the following twoimportant issues for patients reporting musculo-skeletal pain:

1. The generation and maintenance of the patientspain.

2. The generation and maintenance of the patientsphysical incapacity or disability.

Perspectives on the biopsychosocial model – part 2: the shopping basket approach

Louis Gifford MAppSc. BSc. FCSP SRP

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When I learnt them, the approaches outlined abovedid not separate the two issues. There was littlefocus on function or disability and an assumptionthat they would right themselves once the painwent. If the pain did not go or diminish with treat-ment – the patient either drifted off or was referredback to the Dr. I had nothing left to offer.

If it helps the following are three significant“steps forward” that happened to me.

• The first major step occurred when I realisedthat a patient’s disability or incapacity relatedto their performance – in other words their wil-lingness or confidence to do a movement. Forexample, I used to examine forward flexion byasking about resting pain then asking the pa-tient to bend forward and report what hap-pened to the pain. Now I might approach for-ward bending by asking the patient if they arewilling to bend forward and if so to show mewhat they can do or feel confident to do. I aminterested in their willingness to move and intheir fear of the movement. I also look at thesame movement performed from different start-ing positions in order to find out if the patientis capable of the movement in a more confidentway. Performance, and hence range and qualityof movement relates to psychological factors, inparticular to fear and anxiety.

• The second occurred when I started to see painand disability as separate issues, but to investi-gate and manage them together and in a muchmore balanced way. The joy of this approach isthat with the majority of sub-acute, pre-chronicand longer term chronic-pain patients there isan ever increasing shift away from an ineffici-ent and frustrating focus on pain reasoning, as-sessment and relief, towards improved function,improved physical confidence and pain man-agement. This was a style of approach that wasat once far more rewarding, a lot more predict-able and far less pressurised. Life is nothingwithout physical confidence and physical func-tion – you simply cannot live if you cannot do.Also, the common spin-off to improved per-formance/ physical confidence is a reduction insymptoms, a better acceptance of symptoms anda much improved ability to cope.

• The third, was when I came to feel comfortablewith the notion that “pain treatments” are notvery effective and frustratingly unpredictable –and that the longer a problem has been aroundthe less effective any form of pain treatmenttended to become. When treatments are success-ful I now reason that their mode of action ismost likely to be via altered “information pro-cessing” rather than any significant change inthe tissues where the treatments are applied.This allows me to feel comfortable as well asconfident with the placebo phenomenon andthus with any form of pain relief approach. Ifit’s helpful – use it!

The biopsychosocial model of health and disease(see Waddell 1998, Roberts 2000) is multidimen-sional (in parallel) in that it seeks to explore all thefactors that may be involved in the pain and thedisability related to the patient and their presenta-tion.

The factors are:

1. The social and work environment.2. The type of behaviour adopted by the patient

(illness behaviour).3. The levels of distress.4. The patients attitudes and beliefs.5. The pain.

The approach advocated is for physiotherapists toembrace the biopsychosocial model of health anddisease and as a result embrace a far broader andmultidimensional perspective on all conditions thatwe see. This ultimately involves dealing with morethan one thing at a time, often holding back on“hands on” or passive/active correction of minorimpairments and thinking and managing in a verymuch more “in parallel” style.

For me, the result of the last 10 or so years ofintegration of pain science into clinical reasoningand the integration of the biopsychosocial modelinto management and thinking is simply that amajor goal for the patient is restoration of thought-less fearless movement. Goal orientated movementis processed differently to pain focused/physicallyfocused movement assessment.

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)��(��Changing thinking, reasoning and management ap-proaches in never easy (see Muncey 2000). Just asestablished habits of movement and pain behaviourare difficult to change for many long term patients,so too are changes in our own “habitual” clinicalreasoning and treatment approaches.

As already argued, the biopsychosocial modelis a model for broader based thinking, it is multi-dimensional in its approach and seeks answers topain and disability associated with pain, that arebeyond the tissue and pain focused styles that manyof us have been schooled in.

The “shopping basket approach” has evolvedfrom my own analysis of how I think I think andreason with a patient. It may not suit everyone, buthopefully clinicians will find that it is simple and auseful way to see a bigger picture and possibly howa process of change is possible.

Whenever I see a patient, take their history andperform a physical examination, I start gatheringinformation – I put it in the “shopping basket” andthe shopping basket contains seven compartments:

• Compartment 1: Biomedical factors• Compartment 2: Psychosocial barriers to

recovery• Compartment 3: Disability/functional

limitations• Compartment 4: Physical impairments• Compartment 5: Physical fitness – general• Compartment 6: Physical fitness – local• Compartment 7: Pain

Each compartment will be discussed below and inpart 3 of this series a patient example will be pre-sented.

4��5#�(��(See figures …) See also the “Diagnosis section inpart 1 of this series.

This compartment requires therapists to “thinklike a Dr should” based on the best and most recentinformation – and be able to answer the following:

• Is the condition serious and require further in-vestigation or appropriate medical managementand intervention? Therapists need to assess the

“red flags” as written up in Waddell (1998) andRoberts (2000). The importance of therapistsknowing how to assess red flags was emphasisedin part one of this series.

• Is the problem a common syndrome? The reasonfor wanting to know this is that many presenta-tions seen are clear cut and have well knownnatural histories. Some standard managementprotocols and treatments are available for manyconditions. For example, frozen shoulder, wryneck, acute low back pain, hip OA, carpal tunnelsyndrome etc. Clinicians need to be aware thatmany of the long established treatment proto-cols used for the management of these condi-tions have not necessarily got good support fromclinical trials.

• Is the nervous system competent? This requiresskilled and appropriate neurological testing.

• Do you feel confident that the tissues that hurt orthat may be responsible for the hurt are stable orstrong enough to be progressively loaded? Whattissue mechanisms are going on? In part, the redflag assessment may help here. But time sincethe onset of the problem also tells us how long ahealing process will have been going on. If weare to feel confident about getting people withpain moving and fitter we really want to feelconfident that the tissues we are concerned abouthave a reasonable physical strength. Because theamount of pain a patient reports has so influen-ced therapists for so long the tendency is to holdback on function rather than keep it going orsteadily increase from early stages. A great manyof the “pre” chronic patients that I see are heldback functionally because of an over-focus onbeing guided by the pain or on fears of re-damaging the tissues. Overcoming this difficultproblem in a way that guides patients to increa-sed function without fear or causing a set-back isa major part of the graded exposure approach tofunctional recovery (patient example, see part 3).

• What pain mechanisms are operating and canthey be considered adaptive/helpful or malad-aptive/unhelpful? The recent integration of painscience into clinical reasoning (Gifford 1997,Gifford & Butler 1997, Butler 1998, Jones et al2002) allows us to reason the type of pain me-chanisms that may be operating. For example, in

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an acutely twisted ankle, although considerableneurochemical activity will be taking place incentral, motor and sympathetic systems, the pre-dominant cause of the pain is most likely due tointense activity in nociceptors serving the dama-ged tissues. By contrast, a patient with ongoingpain of 4 or 5 years following a road traffic acci-dent is likely to have heightened sensitivity andreactivity of central nervous system connectionsand pathways and far less dominant nociceptivemechanisms. Clearly, pain and nociceptive acti-vity in the twisted ankle can be viewed as an“adaptive” response of the tissues injured – ifyou like, the tissues, via the nociceptors, arescreaming for help from the nervous system –their message reads “help me, do something willyou, make him limp or take the weight off me,look after me, send me the paramedics …” and assuch this is a necessary and normal part of theinjury and its healing. Note that even here, howthe person reacts to the nociception and subse-quent pain could well be maladaptive, for ex-ample they may not move the ankle, they mayover-focus on the pain, constantly tending to itand rubbing it, they may rest it for days, limptoo much and for far too long etc. It is here, veryoften, that inappropriate (maladaptive!) advice isoften given by clinicians and others. How oftenhave you seen patients with ankle sprains thathave been told to rest, take pills and be guidedby the pain? Isn’t it harder the longer this typeof behaviour has been going on? Very often thelong immobilised tissues have become hypersen-sitive and stiff and the patient is very tense andfearful of movement.

In the second case, central activity and highlevels of pain are likely to be considerably outof proportion to any remaining tissue abnor-mality, here the pain mechanism and the paincan be seen as much more maladaptive in na-ture. For the patient and the clinician it is help-ful to understand that hurt does not equate withtissue harm or damage, and this new concept ofpain needs to be taken on – by us, by medicine,and by our patients. Patients need to hear aconsistent message from health carers, not dif-ferent messages or conflicting ones. Great caremust be taken not to dismiss pain that may be

designated “maladaptive”, high levels of painare disturbing, unpleasant and often make lifeunbearable. To dismiss chronic, ongoing, highlevels of pain as not being “harmful” or asbeing of no consequence is totally unreason-able. Recognising and feeling comfortable withmaladaptive pain is a key issue and not at alleasy – for patients and clinicians.

Please also note, even here, people can havechronic maladaptive pain but cope well with itand lead relatively productive and normal lives– even with maladaptive/useless/unhelpful levelsof pain, people can lead functionally “adaptive”lives.

4��7#�8��(��As already discussed in part 1 (Gifford 2001), psy-chosocial factors have been shown to be vital con-siderations in predicting outcome from a musculo-skeletal pain problem. Psychosocial factors arestronger predictors of outcome than any individualbiomedical measures. For example a patient with asignificant disc protrusion will not necessarily havea poor outcome. However, a patient with back painwho believes that any activity that provokes theslightest discomfort should be avoided and as aresult rests and avoids activity a great deal, can bepredicted to not get going, get back to normal act-ivities or back to work as well as those who con-front their problem and try to keep going. How apatient “ends up” is hugely determined by howthey interpret and react to the situation they are in.Everyone tends to cope with their “pain” situationin different ways and some have more adaptive ormaladaptive styles than others. Clinicians can havea huge impact on how well patients cope and howthey recover, most especially early on. Be awarethough, the impact can just as easily be negative –for example, erring towards fear of movement andover focus on pain, as positive, whereby functionalconfidence gradually gains momentum and the pa-tient quickly gets back to normal activity.

Clinicians need to be wary of their own label-ling, attitudes and assessment of a patient in termsof things like “psychogenesis” “malingering” or“over-reaction” for example. The plea, whatever youmay want to think, is that the patient in front of youis what you have to deal with – their way of coping,

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their way of behaving, their way of attributing, orblaming or understanding the problem they have.Further, if you understand these things and under-stand where the patient is coming from, you aremore likely to be able to shift them towards a moreproductive way of thinking and dealing with theirsituation and hence positively influence their reco-very and reactivation processes. Very often these ty-pes of “frustrating” patients have rarely had a fairhearing, have not been taken seriously or listened toand further dismissal or trivialising of their problemis likely to lead to more disability, more misery anddemands for more investigations and treatments.

We also need to be aware that as time goes onpatients who have not recovered are likely to havereceived a great many treatments that have beenunsuccessful in fixing or relieving their pain andthat failure of treatment causes disappointment andincreased feelings of helplessness and hopelessness.Physiotherapists are urged to be more aware thatlargely passive approaches or approaches that aredominated with correction of one or two physicalimpairments given high significance, are the sortsof approaches that have come under criticism forbeing iatrogenic (disease or disability producing).

Further reading:The assessment of psychosocial barriers is fully pre-sented and discussed in the chapters by Paul Watsonand Nick Kendall in:

Gifford L S (ed) 2000 Topical Issues in Pain 2. Biopsycho-social assessment. Relationships and pain. CNS Press,Falmouth.

Other highly recommended books:

Main C J, Spanswick C C 2000 Pain Management. Aninterdisciplinary approach. Churchill Livingstone,Edinburgh.

Waddell G 1998 The Back Pain Revolution. Churchill Liv-ingstone, Edinburgh.

I believe that the psychosocial aspects of assess-ment and management are the most challengingarea to take on for Physiotherapy. A personal com-ment, if it is helpful by being persuasive, – is that it has been two things for me – on one hand it hasbeen the most exciting and most rewarding thing

to understand and take on in my whole career as aphysiotherapist – and on the other it has been themost difficult. Intuitive feel for a patients predica-ment is one thing, but understanding the practicalways in which a patients can be assessed and movedon is what is so highly skilled.

Readers are urged to study the referencesabove and go on courses targeting skills in psycho-social assessment and management of pain usingcognitive-behavioural methods. Bear in mind here,just as anywhere, that new fads are often pushed to “overkill” by enthusiastic believers! Look for acomfortable and well balanced presentation if at all possible.

The term “yellow flags” is perhaps the buzzword associated with the psychosocial factors thatmay be significant barriers to recovery. Briefly, theareas that can be assessed are divided into 7 groups,easily remembered using the headings A B C D E F& W.

It is important to bear in mind while conduc-ting this part of our clinical assessment that a keyquestion for the clinician is: “What can be done tohelp this person experience less distress and disabil-ity, get back to normal activities quickly and im-prove their physical confidence?”.

0:1 :��(��(��Pain associated with joints and muscles naturallycauses guarding and care with movement. Rest andavoidance of movement is reinforced if activityhurts and resting is comfortable. Patients are oftenfearful of causing more pain or re-damaging orputting their problem back to “square-one”. This isparticularly so when patients have very high levelsof pain or have had high levels of pain associatedwith the problem. Reducing the pain, if it can ef-fectively be reduced, clearly helps (see pain com-partment below), but often significant strides canbe made if patients attitudes and beliefs about thenature of their pain or problem can be changed toa more positive one and which is less threatening.

Pain’s primary purpose is to drive a change inbehaviour – sometimes it demands rest and carewith movement or exertion, but very often it de-mands that we move – the exact opposite. Stayingstill can hurt, moving makes you feel better. Beingforced to stay completely still, to many, is a form

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of torture. Pain by its very nature does not presenta consistent message, and if you think about it, inthe acute stages this is what the tissues actuallyneed – a bit of take it easy go carefully, a bit of restand looking after it if there’s time and a bit ofmovement too. We have evolved to heal while stillon the move, in nature pain sneaks in when it can and is quickly pushed out when life gets exciting.A major point is that survival dictates that rest hasto be minimal, in nature not moving for long is notliving for long. In contrast, modern living may giveus too much free time – an amount never cateredfor during evolution! Pain has never had such agood opportunity as now!

There are many dimensions to this “doing noth-ing while it heals” mistake. Being unoccupied al-lows the brain to listen to the ongoing nociceptioncoming in from the tissues and may reinforce it,especially if it is given high significance by the pa-tient. How you interpret your pain dictates how itis processed by your brain. Remember, “gates” closeto sensory information when our attention is fo-cused elsewhere, when we are occupied mentallyand physically. An individual that has little to domay well turn their attention towards their body sothat even modest nociceptive activity can soon takea well established hold on consciousness in theform of pain. The longer and more continuously weare aware of pain, the more significance we give topain, the more established and secure become thepain representational pathways within the brainand its consciousness “circuits” – and the harderthey are to shift away. It seems that patients whodo not understand their pain, who are fearful of it,who give it high significance, who are fearful ofmoving and who do not remain mentally and phy-sically occupied from the early stages on, are biolo-gically and psychologically giving pain a betterchance of becoming permanently established.

The messages for us are simple – find out wherethe patient is coming from in terms of their pain –ask questions that relate to their perception of thepain, what it means to them about what they shouldor should not be doing, what they believe is wrong,how they see their future, whether they feel theyhave any control over their pain and whether theyare keen to be actively involved in their own re-covery.

Our patients words can be useful:

• “Understand your pain, see it as less threaten-ing, start to see that you can move and getstronger even with the pain and your confidencegrows, you see out of yourself, you don’t noticethe pain quite so much … and then you realisethat your pain has lessened! The most difficultpart, but most helpful was learning how to paceactivity and be gradual with exercises …” (35year old patient writing about her experiencewith 6 month old sciatica who had been offwork and resting for the whole time and whosepain was gradually getting worse and worse).

• “The therapist frightened me, I was told that Ihad a disc derangement and that if the pain in-creased in my buttock and thigh I should stopwhat I was doing. I had difficulty doing any-thing! I also felt more upset after seeing her be-cause she always looked so concerned about thepain and gave me the impression that my spinewas going to breakdown if I bent or moved tooquickly or coughed without holding onto my-self. It seemed that the only thing that wouldprotect me was if I could tense my stomach whenI moved or coughed – it seemed so difficult andI just got tenser and tenser all over the more Itried …” (45 year old policewoman with oneyear ongoing back and upper thigh pain).

I hope that clinicians can see that an important partof their “in-parallel” management is to understandand to then rework patients attitudes and beliefsabout their pain if they are found to be unhelpfulto recovery of function and restoration of physicalconfidence.

0�1 ��This is all about what patients do or don’t do, howthey are responding to their pain, what they areavoiding and having difficulty with and how theyreact and report their situation.

It is hugely influenced by what they are told to do or not do by Drs., health care practitioners,friends, and magazine articles for example. Clearguidance is essential, but for far too long patientshave been told not to do something or to avoidsomething – when at a future time it may well

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be possible. Guidance needs changing as time pro-ceeds.

Time and time again I find patients with kneeproblems relating to modest degenerate changes ormedial ligament strains being told not to do breaststroke! Once someone has been told “never to do”or “not to do” something by someone with author-ity – it is very difficult to persuade them that it maybe possible again – even if they take it on verygradually. One issue is that there is no evidencethat breast stroke causes further knee damage ormakes knee pain worse – another is that the onlyway to find out if it is possible is to gradually try itand find out. Most patients find it is possible. A rarefew find that however gradually they try, it still doesexacerbate their problem and that there is no wayfound round it so avoiding it has to be accepted.This example is only of modest consequences, butwhat if a back pain patient was told never to bend– like many so often are in the early stages of man-agement. Fine to suggest care with some forms ofbending to start out in the early stages perhaps, but surely bending confidence should be restored in a graded way at some stage? It is my belief thataround 20 years of propaganda based on the discderangement model and the concept of centralisa-tion of pain relating to dubious biomechanicalmodels for back pain has led to an unprecedentedtherapist fear of flexion that is passed on to pa-tients (nice research project for someone!). Oldertherapists and those who have looked into earlierapproaches to back pain will be aware that therewas a time when the “Williams” lumbar flexion ex-ercises were the “in” thing. A re-balancing focusedon restoration of confident movement and multiplehypotheses that embrace broader dimensions ofreasoning needs a far bigger voice. For example,increased emphasis on thoughts relating to centralnervous system processing such as gating related to focus of attention, expectations, fear of pain ordamage and changes in tension related to this.

This section brings our attention to how pa-tients behaviour can effect the outcome and to howthe management emphasis needs to be on reactiva-tion, patient responsibility and the feeling of havingcontrol via active means, good pacing of activity,rest and exercise, and reduced reliance on passivetherapy.

041 4��There are a great many clinicians who are quick tolabel the patient as “difficult to help” as soon asthey find out that they are seeking compensation orthat lawyers and disputes are involved. Compensa-tion, disputes, financial hassles or medico-legalhassles certainly do not help, but to label patientsquickly as “difficult” is to slip back into an “inseries” single issue style of thinking. Far better toweigh-up all the other yellow flag factors and putin a bigger context before siding too strongly on asingle issue. Far better to enquire as to the effectthat the compensation/dispute/financial hassles maybe having.

Quite often I have short sessions with patientswith ongoing pains called “hassles that may not behelping”. The word “hassles” is written in the middleof a piece of paper and the patient is asked to voiceall the hassles that relate to their problem – as youjot them down. It’s fun, the patients seem to enjoyit and constructive action plans usually evolve outof it. Calling the last consultant or therapist a “com-plete bastard” can sometimes be very therapeutic,more especially if the patient can come round toseeing why the clinician might have responded inthe way they did. A major goal is to discuss whathappened, with the aim of putting the experienceinto a less tension creating context. In this way thepatient can start to learn the skills of re-evaluationof the very things that get to them.

Hassles often create tension, anger, frustration,and patients can spend many hours dwelling onthem – a common one is the half a dozen or sowords that they remember from the last consultant– “get on with your life there’s nothing wrong withyou …” Or the report they’ve just had for their liti-gation that virtually denies they have a problem.Having your veracity challenged is very disturbing.Many patients have run out of ways to know howto explain or show the reality of their problem.How can they get well unless they are believed bythose who they feel should know better?

Once all the “hassles that are not helping”have been written on the paper I might ask thequestion – “Is there anything you think that couldbe done to lessen these hassles?”

I get another piece of paper and we list the onesthat can be worked on.

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We might get a long list of things.At the top might be “responding to the incon-

sistencies in the last consultants legal report” – he’sbeen putting it off for ages, the solicitor is hasslinghim and he keeps churning it over in his mind be-cause it made him so angry and he doesn’t knowhow to find good enough words to express his si-tuation or his feelings. I get him to have a go – Imake some suggestions and the process continuesuntil it’s done and ticked off the list.

We do one thing at a time and when it getsdone it gets ticked off the list, we start with themost annoying and we may just do a little of thatuntil it is eventually done. The patient learns to puta small part of the day aside for “dealing withhassles”. We both problem solve the hassles and thepatient learns how it can be done. Often the patientfeels better because they’re getting a sense of con-trol, they’re seeing the light at the end of the tunnel,they’re able to respond to things in a balanced wayand get them done before they become a burden.

Some hassles are difficult to deal with. Forexample, “the bloke who hit me, who smashed mycar up and left me like this, he never said sorry, hedidn’t even offer to help me … he’s now denying itwas his fault!”

We can’t deal with patients lives, we all havehassles, but we can take one or two, show how theycan be better managed and teach the skills to ourpatients. But we must be careful not to take over.

0 1 ��.��There is now a good body of evidence to show thatwhat clinicians/medicine says to patients may helpto create the conditions that lead to long term in-capacity. For example, complicated language anddiagnoses, conflicting diagnoses, explanations thatcreate notions of physical weakness and frailty orlong term incapacity (you’ve a spine of a 70 yearold …), dramatic explanations of pathology, andsalesman approaches to therapy that raise expecta-tions of a quick and easy cure.

Ask the patient, find out what they have beentold, what it means to them, what they think oftheir previous treatments and management andwhat their role has been in it all. Ask them whatthey want from you – what are their expectations?A great many patients merely want some kind of

better understanding of their problem and adviceabout how to deal with it themselves, yet gethooked on regular long term treatments and followups quite unnecessarily.

The message here is clear – listen to what thepatient has been told, think about its detrimentaleffects, avoid rubbishing others efforts, try andsteer the patient towards more positive confidencebuilding information that makes sense and that fitswith a reactivation approach and check what thepatient understands from what you have said.Above all, try and shift the patient from being fear-ful of structure, having the notion that there is apassive fix for their problem, to one that engendersmore responsibility and a gradual return of phys-ical confidence. Positive information is one thingthat helps a bit, but starting to get a few move-ments going and gradually building from a soundconfident baseline is ultimately the thing that sup-ports the veracity of the information and gets thepatient back into life again.

0*1 *��Most people with pain feel fed up. Fed up with thepain and fed up with the negative spin-offs asso-ciated with it. The longer a pain goes on the morefed up we tend to become. For some patientsmerely being fed up and frustrated can developinto increasing levels of distress and sometimesclinical depression. When people feel down theytend to change routines and habits, they may stopsocialising sometimes to the point that they feel abit anxious about mixing with people, they feel lessinclined towards physical activities, they lose selfesteem, feel hopeless and helpless and sometimestake great deal less care of themselves. It can bevery difficult to motivate people to get going andget fitter or become actively involved in their ownmanagement when they feel miserable, distressedor depressed. Sometimes people can snap out of thesituation they are in, make a big effort and turn acorner, but often they wallow on occasionally drag-ging themselves up, but soon drifting back into un-healthy routines and behaviours that require littleeffort. Change requires a great deal of effort andwhen you are low effort is very difficult to sustain.

Patients who are significantly distressed or aresuffering emotionally are difficult to manage on a

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one to one basis in Physiotherapy departments. It is no wonder that patients who have a significantdegree of distress, have a poorer outcome and areharder to help. If I really think about many of thepatients that I have treated in the past who havebeen really difficult I have to acknowledge that myawareness of their emotional state, there concernsabout their situation, their levels of stress, theirinterest in themselves or their level of socialising –were things that I had never given hardly a thoughtto, but if I had I am sure I would have a better in-sight into why they were so problematic.

Many patients have all sorts of hassles andproblems going on in their lives, physiotherapistsare not trained councillors or psychologists and itis not our place to deal with these areas. However,many patients with pain are low in spirits becauseof the pain and the problems that they have en-countered as time has gone on. Getting patientsinvolved in taking responsibility, reassuring themabout their pain and getting them to tackle andreach a few simple physical goals are the sorts ofthings that can help them turn a corner, pick them-selves up, start to improve their self esteem andconfidence and move forward.

0$1 $��This is a very interesting area and one which hasbeen discussed in detail in chapters 6 & 7 in Topi-cal Issues in Pain 2 (Gifford 2000). The reaction offamily and friends can often have a big impact onhow the individual reacts and feels. Families maybecome very protective and fearful for the patient – reinforcing a “be careful don’t move” style ofcoping while at the same time taking away respons-ibilities and making the patient feel hopless anduseless. It is easy to ask the patient how their fam-ily may be reacting to their problem as well as toinclude them in the rehabilitation process.

0;1 ;��As discussed above, doing nothing or being unoc-cupied is detrimental to recovery and ultimatelydetrimental to an individuals health. It is also detri-mental to business, to the economy and the nationshealth. It is where pain and disability from painmeet politics. Since the early 1980’s the number ofpeople not working due to back pain has risen at

an alarming rate. The graphs are everywhere andrepresent increasing disability in Western societyfrom a disorder (back pain) that is just as prevalentas it always has been (Waddell 1998). Back painhas not increased in prevalence, but disability fromit has. Increasingly sophisticated physical therapy,surgery and drug therapy has had no impact on thetragic and unnecessary disability curve.

Getting people back to work or keeping themin work if at all possible should be a major goal ofphysiotherapy. The barriers that prevent people fromreturning to work come under this “W” category.The patient’s work situation needs our understand-ing, it has several dimensions which are dealt withexcellently by Main and Burton ((Main & Burton2000)). Two will be discussed briefly here to whetthe appetite for their chapter!

• Physical factors?: – clearly if a patient’s workinvolves heavy physical activity with little op-portunity for changing conditions, return towork may be more of a problem than if thework was less strenuous or more flexible. How-ever, with regard the “physical” dimension ofinjury and disability, therapists need to be awarethat traditional thinking – that there is a directrelationship between the physical demands ofwork and the occurrence of injury – is not wellsupported by the scientific literature and is quitecomplicated. While a great many “perceive” thattheir problem was related to work the evidenceseems to suggest that although the back cancertainly be injured in various ways, the “injurymodel” is not able to explain the wide variationin resultant disability. The important issue tograsp is that the initial occurrence of back painmay well relate to physical stressors but recur-rence and disability are mediated more by psy-chosocial phenomena.

• Work stress – blue flags!: How an individualperceives their work is of such significance ithas now been given its own coloured flag –blue (Main & Burton 2000). Patients may bewary of returning to work if they perceive thattheir work is physically demanding and likely tore-injure them. There are many other “blue”factors too, for example, return to work is lesslikely if patients don’t like their work, if they

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see it as repetitive and boring, if there is littlesatisfying about it, or it is too pressured withpoor rewards and meagre support from mana-gers or colleagues, or if they have little controlat work, there may be conflicts with colleagues.Clearly, issues like these, and ones that many ofus will think are obvious, are significant barri-ers to getting people back to work. Human na-ture very often follows a simple law of all na-ture – that is, to get as much as you can for theleast amount of effort!

If we are to help in getting people back to work, orhelp them to stay at work, we need to understandtheir work situation, how they perceive their workand their relationship with their work colleagues aswell as the attitudes and beliefs about the causesand nature of their problem.

Care with the Yellow flags …All patients, whether acute or chronic have someyellow flags. The more that are present or the higherthe scoring on the “Yellow flag” questionnaire, themore strength with which a poor outcome can bepredicted.

Three issues are important here. Firstly, it isunfair to label a patient as being difficult based onone or two positive findings. For example, as al-ready discussed, patients who are involved in litiga-tion or compensation are often blindly labelled asno-hopers and given little credibility. Careful assess-ment of other areas may well indicate good poten-tial for recovery or a specific management need.

Secondly, the identification of significant yel-low flags helps direct management to give attentionto the identified barriers/problems. For example, apatient may believe that their pain indicates majorstructural damage or disease that has not beenfound. Time taken with history taking and a tho-rough physical examination accompanied by a re-assuring discussion regarding the nature of theinjury and pain may make a positive impact here.“Structural reassurance” however, can only beachieved if therapists know their “red flags” andhave fully assessed them (giving confidence thatnothing serious is wrong structurally or patho-logically). The development of a high competencein assessment needs to be paralleled by a high

competence in explaining clearly in terms that thepatient understands and which has a useful andpositive message. In my opinion this is a hugelyunder-practised area of pre and post graduatetraining, and it is so easy to get wrong and verydifficult to get just right.

Thirdly, high “yellow flag” scores should notmean that physiotherapy is inappropriate. However,it may mean that far better outcomes will occur ifthe patient is managed using a multidisciplinaryteam approach. The current growth in the number ofhigh quality pain management units utilising cogni-tive behavioural principles is a very positive step.

Good clinical reasoning is all about pickingout all the issues and then being able to prioritisethem – dealing with the most important findingsand issues first. Quite often significant yellow flagsneed addressing before any “physical progress” canbe made.

4��#� ��(��<��From my own clinical reasoning perspective, I seedisability/functional limitations as “what the patientreports they have difficulty doing, or cannot do, asa result of their pain problem.

Disability may relate to “activities” – like walk-ing, housework, lifting, sport etc.

Or it may relate to “inactivities” like sitting,standing or lying.

During the clinical interview I put emphasis onfinding out what the patient is doing now comparedto what they normally do, what they feel they coulddo and what they want to get back to (see “B” Be-haviour section above too – there is overlap). Thebarriers to them getting back to doing those thingsneed assessing and understanding too.

Because I was so schooled in a biomedical/in-series/single tissue style of approach, getting the pa-tient to start working on avoided activities was of-ten left a long way down the management prioritylist or given little real focus of attention. I wasn’tthat interested, perhaps it wasn’t really intellectu-ally stimulating enough and if I am honest, thethought of function mucking up the pain after allthose treatments was very off-putting! I thus didn’treally have a clue about how to constructively getthe patient back into activity in a way that didn’tstir everything up again.

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Having now seen a great many patients whoare well down the chronic disability pathway itseems quite obvious that in the early stages theirdisability could have been prevented if earlier ac-tivation had occurred. In part 3 of this series thepatient example is typical of these patients andclearly demonstrates that a “graded exposure” styleof approach to functional confidence is probablythe most important and useful tool that good re-habilitative physiotherapists have to offer.

4��#�.��Impairments are the things that physiotherapistsfind during the physical examination. Thus, loss ofrange of joints, muscles, nerves, motion segments,hypermobility, sensitivity to movement or palpa-tion, weaknesses, altered movement patterns, al-tered reflexes, physical asymmetry, altered anatomyetc.

This is the area that many physiotherapistshave become experts in. We love our complicatedinstability tests, our neurodynamic tests, our muscletests our joint accessory movement tests and soforth. The problem is that the evidence at this stageis not that supportive for the importance of impair-ments in relation to pain, function and disability.Far more evidence supports compartments two andthree above and these therefore, in most cases,should head the management priority list beforegetting down to the impairment nitty-gritty.

I am not against these skills, but I am con-cerned that a great many put a great deal of em-phasis on them at the expense of other compart-ments.

On the more positive side however, a goodphysical examination is a very reassuring thing forthe patient, focus on improving impairments is oftena useful tool in reactivating the patient and canhelp alter pain. So long as we are aware of thedangers of physically over-focusing, of the patientspotentially negative interpretation of what we un-cover and explain and that the explanations asso-ciated with tissue abnormalities have weaknessesthen we should be comfortable here. Most import-antly, if at all possible patients should be given thetools and the responsibility to work on the impair-ments themselves, rather than being reliant on thetherapist.

4��,#�8��/��All of us will be aware that being physically fitterfeels good. Physically fitter people tend to copebetter and manage their lives better than unfitpeople. Clinicians will know of many patients withongoing pain who have significantly moved on orimproved once they started to get fitter and as aresult feel more in control.

Patients with significant pain often get frus-trated with the lack of exercise, many become de-conditioned and become more moody as a result.Pain and low mood leads to “bad behaviours” –over-indulgence, lack of activity leading to evenlower mood, poor sleep, and the emergence ofother physical symptoms.

Graded physical fitness programmes are a veryimportant part of management at an appropriatestage, or may even be a key component of recoveryearly on.

It is quite simple to ask patients how fit theyfeel now compared to before their problem orwhether or not they feel as fit as they would like tobe. Assessment of function can often be linked withassessment of fitness.

This section will be explored further in part 3of the series.

4��-#�8��/��The long standing biomedical reasoning modelsused in physiotherapy have consistently directed usto managing a presumed “source” of the pain orproblem. For example, a pain down the leg deemedto be coming from the back resulted in therapy andexercises to the back, even though there may wellbe quite significant impairments/deconditioning inmany of the tissues in the leg as a result of the pain.

This compartment is a plea for clinicians tothink beyond the hypothetical sources and causesof the pain and address the tissues affected by theproblem too. Patients with referred pain into theleg often have stiff and painful peripheral joints ordemonstrate loss of power and endurance in relatedmuscles. Progressively working and moving thesetissues, especially in a functional way, may welltrigger a biological message of recovery that says“we need you, improve your function” and then thelater retort from the nociceptive and nervous systemthat goes “we feel safer, we will decrease our sens-

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itivity now”. A key paradigm might be that a weakorganism “senses” its own vulnerability and henceup-regulates levels of sensitivity, whereas a strongerorganism “senses” less vulnerability and as a resultlowers the sensitivity setting. Local fitness manage-ment of tissues that either contain the pain, are af-fected in some way by it, or that may in part influ-ence it, are all worthy of some input.

A significant step forward in improving con-fidence is to activate the areas the patient feelsvulnerable in – and this is often the area that theythink the problem is coming from as well as theareas where the pain is felt when there is referredpain.

4��2#�8��Pain is at the end because it has been at the begin-ning for so long. It is still important and is ofcourse the primary reason for the patients problemsand their suffering. If pain relief was more effectivethe whole process would be so much easier. Whilethe most recent findings of research urge us to bevery cautious in over focusing on pain that doesnot mean it has to be forgotten. If we can relieve itfine, but if we are making patients dependent ontherapy then there is something wrong unless weare merely in this for economic gain.

A major aim is to help to get the patient in-volved in managing their pain better. This oftenmeans adequate pacing of rest and activity; explor-ing movements and resting postures that may help.As argued earlier, there are a great many pain “treat-ments” available – from magnetic and copperbangles to sophisticated medicines and surgeries.What is clear is that there is always something outthere that can help a bit and occasionally a lot –which presses us to be open to any possibility thatmay help. Everyone has their personal style, theirfavourite techniques and their favourite beliefs. Iwould simply urge that physiotherapists involvedin the management of patients pain see the import-ance of self management and patient responsibilityif at all possible.

The final part of this series takes a patient ex-ample using “graded exposure” principles of man-agement. Hopefully the case will demonstrate manyof the issues discussed in this and the previousarticles.

Further reading:Gifford L S (ed) 1998 Topical Issues in Pain 1. Whiplash –

science and management. Fear-avoidance beliefs andbehaviour. CNS Press, Falmouth.


Gifford L (ed) 2002 Topical Issues in Pain 3. Placebo.Sympathetic Nervous System and Pain. Muscles andpain. CNS Press, Falmouth. In Press.

Main C J, Spanswick C C 2000 Pain Management. Aninterdisciplinary approach. Churchill Livingstone,Edinburgh.


References:Butler D S 1998 Integrating pain awareness into physio-

therapy – wise action for the future. In: Gifford L S(ed) Topical Issues in Pain I. Whiplash science andmanagement. Fear-avoidance behaviour and beliefsCNS Press., Falmouth 1-23.

Gifford L S 1997 Pain. In: Pitt-Brooke (ed) Rehabilitationof Movement: Theoretical bases of clinical practiceSaunders, London 196-232.

Gifford L S 1998 Central mechanisms. In: Gifford L S (ed)Topical Issues in Pain 1. Whiplash – science and mana-gement. Fear-avoidance beliefs and behaviour. CNSPress, Falmouth 67-80.


Gifford L S 2001 Perspectives on the biopsychosocialmodel part 1: Some issues that need to be accepted? In Touch, The Journal of the Organisation of CharteredPhysiotherapists in Private Practice Autumn issue No97: 3-9.

Gifford L S, Butler D S 1997 The integration of pain scien-ces into clinical practice. Hand Therapy 10(2): 86-95.

Jones M A, Edwards I, Gifford L S 2002 Conceptual mo-dels for implementing biopsychosocial theory in Clini-cal Practice. Manual Therapy In Press.

Main C J, Burton A K 2000 Economic and occupationalinfluences on pain and disability. In: Main C J, Spans-wick C C (eds) Pain Management, an interdisciplinaryapproach Chuchill Livingstone, Edinburgh 63-87.

Muncey H 2000 The challenge of change in practice. In:Gifford L (ed) Topical Issues in Pain 2. Biopsychosocialassessment and management. Relationships and painCNS Press, Falmouth 37-54.

Roberts L 2000 Flagging the danger signs of low backpain. In: Gifford L (ed) Topical Issues in Pain 2. Bio-psychosocial assessment and management. Relation-ships and pain CNS Press, Falmouth 69-54.


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I forbindelse med kongressen »Touch our Minds«blev der holdt to møder. Derudover var der rig lej-lighed til at diskutere manuel terapi på internatio-nalt plan med de øvrige delegerede i IFOMT. På detlukkede IFOMT-ECE-møde for delegerede var der fåpunkter på dagsordenen, og det var i forvejen fast-lagt, at der ikke ville blive taget referat af mødetfor at få en mere fri debat.

IFOMT arbejder i øjeblikket ud fra en 5-punktsstrategiplan. I det følgende skitseres kort de enkelteområder, formål inden for disse og status i oktober2002:

Inden for ressource management er formålet atforbedre hjemmesiden og at forbedre de økonomiskemuligheder gennem medlemskontingent, annonce-ring og flere medlemmer. Ligeledes er det formåletat øge aktiviteten i de enkelte medlemslande. Hjem-mesiden blev diskuteret med henblik på forslag tilindhold. Den canadiske gruppe arbejder med sagen.

Inden for PR og kommunikation er formålet atfremme IFOMT's image samt at etablere et effektivtinternt informationssystem og udvikle en marke-tingsstrategi. Også her arbejdes der via websiden iøjeblikket.

Inden for området akademiske standarder erformålet at fremskynde implementering af uddan-nelsesmæssige standarder, at udvikle et ressource-center med et »buddy system« for nye og kommendemedlemmer. Der skal udvikles procedurer for revi-dering og evaluering af standarder i de enkeltemedlemslande, og der skal sikres en kontinuerligudvikling af IFOMT-standarder. Der er annonceretefter eksperter, som skal indgå i ressourcecentret.

Inden for strategiområdet uddannelse er for-målet at etablere et uddannelsesressourcecenter, atdefinere specialisering og at fremme det bevægeligearbejdsmarked for manuelle terapeuter. Der er gen-nemført en rundspørge blandt medlemslandene forat få klarlagt, hvordan MT-uddannelse er rangeret ide enkelte medlemslande. Resultatet af denne un-dersøgelse blev fremlagt på det åbne møde i Estorilog fremgår herunder.

Inden for forskning og evidensbaseret praksiser formålet at etablere en IFOMT-forskningskomitéog at etablere og promovere forskningsbevidsthedog forskningssamarbejde internationalt mellemmedlemmer. Dette skal ske gennem et web-baseretressourcecenter. Status november 2002: Der er an-nonceret efter nationale ressourcecentre i medlems-landende. Det meningen at disse skal indgå i detweb-baserede center og på den måde fungere sominternationalt netværk.

På det åbne møde præsenterede to ansøger-lande, Irland og Spanien, deres manuel terapi-pro-grammer. Den belgiske gruppe introducerede etkvalitetssikringssystem og et reklamefremstød, somvakte nogen forargelse, måske lige bortset fra i denbelgiske gruppe.

Marina Wallin, fra Sverige, havde gennemførten undersøgelse af de uddannelsesmæssige stan-darder inden for manuel terapi i de enkelte med-lemslande. Resultaterne blev fremlagt, og det visersig, at der er meget stor variation i den uddannel-sesmæssige standard fra land til land.

Antonio Lopez, fra WCPT-Europe, gennemgiken rapport som er udarbejdet i dette regi. I dennerapport er hvert enkelt EU-lands (og i øvrigt ogsåandre europæiske landes) uddannelsesmæssige bag-grund beskrevet, således at det er muligt at sam-menligne standarder. I denne rapport er der en langrække definitioner af f.eks. en specialist, som ermeget vigtige i forhold til internationalisering afuddannelser og sikring af arbejdsmarkedets frie bevægelighed. WCPT har en strategi omkring ettransfer-system mellem landene, som skal være im-plementeret i 2010.

Mødet blev afsluttet med en noget tam panel-diskussion.

Det overordnede indtryk fra IFOMT-mødernevar, at der nu arbejdes seriøst og målrettet efter enfornuftig strategi. Formanden, Agneta Lando, bæreren stor del af æren for det, sammen med IFOMT'sbestyrelse. Det skal blive spændende at være medtil at føre de forskellige strategier ud i livet. Dan-marks delegerede, som er forfatteren til denne arti-kel, sidder i den gruppe som arbejder med uddan-nelse. Gruppen består af den svenske repræsentantMarina Wallin, finske Maarit Keskinen og under-tegnede.

Referat fra møder i IFOMTC��*�� ""

Per Kjærfysioterapuet, DipMT, MSc, ph.d.-studerende

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��Hoving J, Koes B, de Vet H, van der Windt D, AssendelftW, van Mameren H, Deville W, Pool J, Scholten R og Bou-ter L (2002). Artikel: Manuel terapi, fysioterapi eller be-handling af praktiserende læge for patienter med nakke-smerter. Et randomiseret kontrolleret studie. Annals ofInternal Medicine 136: 713-722 (Sammendraget er efterChris Maher, redaktionsmedlem ved Australian Journal ofPhysiotherapy i samarbejde med Fysioterapeuten iNorge).

ProblemstillingHvilken behandling er mest effektiv for nakkesmerter;manuel terapi, fysioterapi eller behandling hos praktise-rende læge?

DesignRandomiseret studie med skjult randomiseringsprocedure.

StedHolland.

Patienter183 patienter i aldersgruppen 18–70 år, med nakkesmer-ter. Inklutionskriterier var nakkesmerter eller stivhed imindst to uger, nakkesmerterne kunne reproduceres vedfysisk undersøgelse og at patienten ikke havde modtagetmanuel terapi eller fysioterapi de sidste seks måneder. Enpatient mødte ikke op til re-test efter syv uger.

Intervention60 patienter blev fordelt til manuel terapi, 59 til fy-sioterapi (undtaget manuel terapi) og 64 til almindeliglægelig behandling. Manuelterapien bestod af op til seks60-minutters behandlinger som kunne inkludere blød-delsbehandling, specifikke ledmobiliseringsteknikker, ko-ordinations- eller stabiliseringsøvelser, men ikke manipu-lation. Fysioterapien bestod af op til 30-minutters be-handlinger med aktive øvelser. Manuel stræk/traktion,massage eller andet kunne gå forud for øvelserne. Prakti-serende læge- gruppen modtog standard behandling somkunne inkludere råd, vejledning og medicinering.

EffektmålHovedeffekten var: 1) »godt behandlingsresultat« define-ret ved at patienten beskriver sin tilstand som rigtig godeller meget bedre, 2) forskers måling af fysisk dysfunk-tion (skala 0 = ingen fysisk dysfunktion, 10 = maksimaldysfunktion), 3) besværlige smerter, gennemsnitligesmerter og største smerter målt på en 0–10-skala, og 4)funktionshæmning målt med »neck disability index«(skala fra 0 = ingen funktionshæmning, 50 = maksimal

funktionshæmning). Opfølgningstiden var syv uger, re-sultaterne blev målt blindet og analyseret i forhold til»intention to treat«-princippet.

ResultatVed syv uger var der en statistisk signifikant større andelaf deltagerne i Manuel terapi-gruppen (68%) som havdepositiv effekt end i fysioterapigruppen (51%) eller prakti-serende læge-gruppen (36%). Manuel terapi-gruppenhavde større bedring end praktiserende læge-gruppen forfysisk funktion (between-group difference og 95 procentCI 1,7 [0,9-2,5]) og for alle tre smertemål (for eksempelbesværlige smerter 1,5 [0,4-3,5]) men ikke for funktions-niveau 1,9 point (–0,3-4,1). Sammenligning af manuelterapi versus fysioterapi og fysioterapi versus prak-tiserende læge gav forskelle mellem grupperne som varsmå og/eller ikke statistisk signifikante.

KonklusionPatienter med nakkesmerter som får manuel terapi harstørre sandsynlighed for at rapportere at deres tilstand erblevet god eller bedret end dem som har fået fysioterapi(uden manuel terapi) eller behandling hos praktiserendelæge.

��Studiet er interessant, men Nick Bogduk har efterføl-gende fremkommet med disse væsentlige kommentarer tilstudiet:

To besøg hos praktiserende læge kan knap nok sigesat være tid nok til at vurdere patienten og skrive en re-cept. Man bør derfor være opmærksom på hvor gode ogoverbevisende råd om prognose, råd om psykosociale til-tag, råd om ergonomi og opmuntring til videre bedringhar været i dette studie. En kynisk forståelse af resulta-terne i dette studie kan være at manuel terapi er bedreend suboptimal behandling hos praktiserende læge. Deter ikke det samme som at bevise at manuel terapi »vir-ker«. Det virker bare bedre end halvt så god medicinskbehandling. Et mere udfordrende studie ville være at ladepraktiserende læge give en bedre intervention ved athave 3 til 6 konsultationer. Det studiet peger på er, atmanuel terapi er bedre end det praktiserende læger giveraf tilbud i dag.

Bedre lindring af nakkesmerter��1��%��%��(��

Christian Couppé

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Som den første internationale kongres afholdt afden portugisiske manuel terapi-gruppe må mansige, at det var et meget vellykket arrangement. Tiltrods for en række spændende foredragsholdere, vardet kun lykkedes at tiltrække godt 100 deltagere.Derfor blev kongressen holdt på et hospital i udkan-ten af Estoril, og for at fylde lidt op på de tommepladser var de fysioterapeutstuderende på dette hos-pital inviteret med. Temaet for kongressen var somtitlen antyder: »Touch our Minds« og der var pro-gramsat 30 indlæg. Der var meget fokus på patient-perspektivet og klinisk ræsonnering fyldte meget. Idet følgende har jeg valgt at referere de indlæg,som efter min mening har størst klinisk relevans.

Det første indlæg blev afholdt af Ann Moore,professor ved Universitetet i Brighton. Titlen var»patientens perspektiv på lænderygbesvær«. I for-hold til patienten var der fokus på en lang rækkefaktorer som spiller ind ved lænderygbesvær såsomevidensbaseret praksis, patientens oplevelse og for-ventninger til behandling, og endelig relationenmellem behandler og patient.

Ann Moore refererede en kvalitativ undersø-gelse på 8 akutte og 8 kroniske patienter med lænde-rygbesvær. Ved hjælp af interview fandt man ud af,at patienternes forventning er, at der stilles en dia-gnose, at der gives gode råd, at en behandling stil-les i udsigt, at der opnås en forståelse for den sund-hedsprofessionelles rolle, at der opnås en vishedfor, hvad det drejer sig om, og endelig at der op-sættes mål. Hendes konklusion på undersøgelsenvar, at det er yderst vigtigt for terapeuten at kendepatientens forventninger, at der er tid nok, at kom-munikationen er entydig, så patienten er helt klarover, hvad der kan forventes. Den sidste del af fore-draget refererede forskellige arbejder, som under-støtter at behandling lykkes bedre, når patienten eraktivt involveret, og der findes en velfunderet rela-tion mellem terapeut og behandler.

Det følgende foredrag blev også holdt af AnnMoore på grund af afbud. Hun refererede en rando-miseret, klinisk kontrolleret undersøgelse som er

publiceret i Lucy Goldbys ph.d.-afhandling fra2002. I studiet blev 346 patienter med kronisk læn-derygbesvær inkluderet og 303 deltog. De blev ran-domiseret til hhv. manuel terapi, stabiliserendeøvelser og pjece. I gruppen som fik manuel terapiblev denne givet på baggrund af terapeutens kli-niske ræsonnering, og der måtte ikke gives øvelsertil m. transversus abdominis eller mm. multifidii.Stabiliseringsgruppen fik forevist en video mangegange. Der var tale om 6 øvelser med fokus på træ-ning af det aktive sub-system af muskler. Der blevtrænet i grupper, hvor man hjalp hinanden. Densidste gruppe fik en pjece at læse i. Resultaternevar, efter 75 droppede ud af undersøgelsen, at efter6 måneder havde stabilitetsgruppen signifikantstørre smertelindring og efter 12 måneder ogsåbedre funktion. På alle målte effektparametre varder en trend mod bedre resultater i stabilitetsgrup-pen men ikke signifikant. Studiet svækkes afmange dropouts specielt i pjecegruppen. Studiet erikke publiceret i peer reviewed-tidsskrift.

Nicola Petty holdt et indlæg om Maitlandsgraduering af bevægelse og modstand. Hun gen-nemgik bevægelsesdiagrammet og de problemer,der er med reproducerbarhed af disse. Det har hidtilværet antagelsen at der i begyndelsen af en bevæ-gelse, hvad enten den er accessorisk eller fysiolo-gisk, ikke er nogen modstand og at denne, R1, førstsætter ind senere for at stige eksponentielt. For atvalidere bevægelsesdiagrammets udseende med detflade tåparti, målte man kraftudviklingen via entrykplade, når der blev appliceret en maskinel ud-viklet kraft på L3, et ankelled og et skulderled. Detviste sig, at så snart kraften appliceres begyndermodstanden at udvikle sig, og det gjorde den line-ært uanset hvilket led, der var tale om. Den kliniskekonsekvens af dette er, at når vi taler om at mobili-sere i grad 1 eller grad 2 uden modstand, så er detikke sandt. Der er modstand. Det vi klinisk harkaldt R1, den første modstand, må derfor være etudtryk for det punkt, hvor vi kan begynde at regi-strere spænding. Det kan jo være med til at for-klare, hvorfor det er så svært at blive enige om hvorR1 ligger henne.

Kareen Beaton holdt et indlæg om cervikal in-stabilitet og gennemgik anatomi, patologi og demere eller mindre kendte test. En litteraturgennem-gang viste, at kun sharp purser-test var valideret,

Referat fra Manuel Terapi-kongres i Estoril

Per Kjærfysioterapuet, DipMT, MSc, ph.d.-studerende

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men det var gjort på patienter med RA. Konklusio-nen var, at der er meget lidt evidens for at mindregrader af instabilitet i cervikal columna eksisterer.

Susan Mercer refererede sit kadaverstudie påthoracal columna og især discus intervertebrale.Det interessante var, at nucleus her har en andenkonsistens, end lumbalt. Opadtil er den fibrocartila-ginøs for at blive mere og mere blød nedadtil. Der,hvor costa mødes med discus, er der ingen annulus.

Catherine Doody holdt et indlæg omkring kli-nisk ræsonnering hos 10 eksperter i manuel terapi isammenligning med 10 novicer. Det var et observa-tionsstudie, hvor der blev brugt direkte observatio-ner på undersøgelse og behandling af patienter, vi-deo, feltnoter samt interview. Man havde specieltfokus på om terapeuterne benyttede ICIDH- og ICD-klassifikation og -diagnoser. Ifølge undersøgelsenopsatte alle fysioterapeuterne flere hypoteser. Eks-perterne opsatte deres hypoteser hurtigere og havdeoftere allerede inden den kliniske undersøgelse endiagnose. Derimod nåede novicerne først sent iundersøgelsen frem til en diagnose. Konklusionenvar at diagnostisk ræsonnering bør introduceresallerede i fysioterapeutuddannelsen. Et megetlignende indlæg blev holdt af Eduardo Cruz.

Jane Greening holdt et blændende indlæg om-kring de neurogene, patogene og smertefysiologiske

elementer ved mindre nervelæsioner opstået somfølge af vedvarende tryk eller repetetive belastnin-ger. Ved hjælp af ultralydsoptagelser så vi, hvordann. medianus hele tiden bevæges ved museklik bådei aksiale og longitudinelle snit. Ikke underligt, atdet nogen gange giver problemer. Hun påviste,hvordan n. medianus bevæger sig ved respirationhos ikke symptomatiske individer, og hvordan be-vægelsen er hæmmet hos patienter med diffuse arm-smerter. Ud fra dette opstillede hun en hypotese omsammenhæng mellem smerte og nedsat mobilitet inervevævet. (Lynn et al, 2002; Greening et al, 2001).

Det sidste indlæg som jeg desværre kun hørtehalvdelen af var af Mark Comerford. Det meste varen lang opremsning af evidensen for ideerne omsegmental stabilitet og mangel på samme. Detsamme kan læses i Comerford og Mottrams artikel iManual Therapy fra 2001.

Der var som nævnt i indledningen 30 indlægog jeg har valgt at referere bare nogle få, men be-tydningsfulde af dem. Alt i alt synes jeg at denportugisiske manuel terapi-gruppe fortjener applausfor deres vellykkede arrangement. Synd at der ikkevar flere deltagere, men en anden gang kan jeg kunopfordre til at drage til Portugal til kongres. Der erjo også andet end lige kongressen, f.eks. portvin,strand og 20 grader i slutningen af oktober.

4��

Dansk Selskab for Muskuloskeletal Medicin har ind-stiftet en pris, der uddeles en gang årligt til en danskforsker, der har præsteret et vigtigt videnskabeligt ar-bejde inden for hvirvelsøjleforskning og dermed be-slægtede emner.

Prisen er på kr. 15.000 og kan eventuelt deles.Uddelingen finder sted ved den årlige ordinære gene-ralforsamling, og det forventes, at modtageren af pri-sen præsenterer sit videnskabelige arbejde for selska-bets medlemmer.

Indstillingen til prisen foretages blandt videnska-belige arbejder inden for hvirvelsøjleforskning og der-med beslægtede emner, der er egnede til publikation,respektive er publiceret i »Peer-reviewed« nationale el-ler internationale videnskabelige tidsskrifter.

Ansøgningsfrist med henblik på bedømmelse af arbej-derne er den 31. december i det år, der er forudgået afprisuddelingen.

Arbejder der ønskes bedømt mhp. tildeling af Columnaprisen, bedes sendt i 4 eksemplarer til for-manden for Videnskabeligt Udvalg under Dansk Sel-skab for Muskuloskeletal Medicin:

Overlæge, dr.med. Lars Remvig, Klinik for Medicinsk Ortopædi og Rehabilitering, H:S Rigshospitalet 7611, T9, Blegdamsvej 9, 2100 København Ø,

senest den 31. december 2003.

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0��3��*7��A��*$%��%��A7�1�� ""�*+22��*)��*2,"��*+" D'�-�="22�"95,2�

The contributing authors are world leaders in their re-spective fields and include mostly clinicians, but also re-searchers.

The purpose of this book is provide physical ther-apist and other rehabilitation specialist with how to man-agement injuries in sport and exercise.

The text is divided into five parts and here I willdescribe what I think is the best in this book:

1. Section 1, Management Principles for MuskuloskeletalTissue in Physical Therapies. This section deals withfive groups of body tissue: muscle, tendon, ligamentbone and nerves. These chapters provide coverage ofthe basic structure and biomechanics of the tissues,the principles relating to the adaption of the tissue tomechanical load, and response of the tissue to injuryand healing.

2. Section 2, Concepts in Managing Sport and Exercise.The Chapter in this section provide general informa-tion that is important in the mangement of injuriesfrom various regions in the body. Motor Control,covers the theory an d appliction of motor controland relearning in the management of sport and ex-ercise related injury. Pain, outlines the mechanismsand theories of pain perception, and presents strate-gies to assess and manage pain from both physicaland cognetive/behavioral perspective. Exercise-basedConditioning and Rehbilitation, outlines the evidencefor the use of varoius forms of exercise in injury pre-vention and and management. Psychology of injuryand rehabilitation, works through Psychological fac-tors that affect the onset and rehabilitation of injury.Also, issues related to rehabilitation adherence andthe role of physical therapist in applying basic cog-nitive/behavioral techniques are covered. ScreeningSport and Exercise participation focuses on the prin-ciples and practical application of screening proced-ures that are used for sport and exercise participa-tion. Issues related to general health and sport speci-fic helath fitness are adressed. Out come Measures inSport and Exercise Physical Therapies, covers a rangeof outcome measures that can be used in sport and

exercise physical therapies. This adresses the bothclinical measures and condition specific measures.Electro Agents in Sport and Exercise injury manage-ment, evaluates, from a scientific perspective variouselectrophysical agents commonly used by sport phys-ical therapist. The emphasis is on outlining the evid-ence to support or refute the role of such modalitiesin sports medicine. This chapter was in someway dis-appointing by one of the absolute world leaders inthe electrotherapy field and suffered from lack ofdepth.

3. Regional Sport And Exercise injury management. The 10 chapters in this section deal with the Spine,Shoulder, Elbow, Wrist and Hand, Pelvis and Groin,Thigh, Knee, Patellofemoral Joint, Leg, ankle andfoot. In each of these chapters the content focuses onsport/specific applied anatomy, examination, and themanagement of common and less common sport andexercise related injuries to the region.I really enjoyed reading the chapter by Reinold andWilk covering the chapter of the elbow with in-depthand systematic information in how to manage the elbow.

4. The last to sections covers the role of sport and ex-ercise and physical therapies in active groups suchchildren older participants, active females and Med-ical Considerations for rehabilitation practitioners in sport and exercise settings like pharmacologicalagents, drug on the athlete's health and well/being.

In Summary, the text is very well written, with adequateillustrations and tables.

The organization of the text follows a logical orderof progression and encompasses a variety of topics thatare very relevant to the field of physical therapy.

I highly recommend this book to all physical ther-apist and physicians. Other health professionals, such asathletic trainers, and exercise physiologist would find thisbook appropriate for their libraries.

However, this book does not replace tomes like Ni-cholas and Hershmans volumes on the upper and lowerextremities, rather, the intent is to serve as a practicalinduction into properly caring for the special athlete whocompetes at any level.

�=%:>!*? *?�*

Physical therapies in sport and exercise

Christian Couppé

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%��Sted: Comwell Kolding, Skovbrynet 1,6000 Kolding. Tlf. 76 34 11 00.

Kursusafgift: Er anført under de enkelte kurser. For kur-sister, som ikke er medlem af DSMM, Danske Fysiote-rapeuters Fagforum for Muskuloskeletal Terapi ellerMcKenzie Institut Danmark, vil der være et administra-tionsgebyr på 500 kr. For Basiskursus, Columna, er prisendog den samme for alle faggrupper, idet dette kursus eret introduktionskursus.

Der indbetales depositum på 1.000 kr. hvilket sikrer pladspå kurserne. Ved skriftlig framelding senest 2 måneder før kursusstart tilbagebetales halvdelen af depositumbeløbet.

Kursussekretær: Birthe Skov, Comwell-Kolding,Skovbrynet 1, 6000 Kolding. Tlf. 76 34 11 00.

Tilmelding: Skriftlig til kursussekretæren. Optagelsefinder sted i den rækkefølge, tilmeldingerne modtages.

Anvend venligst tilmeldingsblanketterne i bladet,(fotokopi eller e-mail).Kursusarrangør: DSMM’s uddannelsesudvalg.

��Professor, dr.med. Henning Bliddal, 2000 FrederiksbergOverlæge Johannes Fossgreen, 8270 HøjbjergSpeciallæge Allan Gravesen, 4220 KorsørSpeciallæge Torben Halberg, 2760 MåløvSpeciallæge Steen Hecksher-Sørensen, 8700 HorsensOverlæge Palle Holck, 8000 Århus C

Speciallæge Niels Jensen, 2760 MåløvSpeciallæge Jørgen Korsgaard, 3200 HelsingeSpeciallæge Lene Krøyer, 2800 LyngbySpeciallæge Palle Lauridsen, 5800 NyborgSpeciallæge Gerd Lyng, 3770 AllingeSpeciallæge Jes Lætgaard, 8700 HorsensSpeciallæge Jette Parm, 4400 KalundborgOverlæge Glen Gorm Rasmussen, 9000 AalborgOverlæge, dr.med. Lars Remvig, KøbenhavnSpeciallæge Berit Schiøttz-Christensen, 8000 ÅrhusSpeciallæge Pierre Schydlowsky, 3500 VærløseSpeciallæge André Soos, 6100 HaderslevSpeciallæge Lisbeth Wemmelund, 8270 HøjbjergSpeciallæge Peter Silbye, 4600 KøgeSpeciallæge Lars Faldborg, 8300 OdderSpeciallæge Finn Johannsen, 2820 Gentofte

��Professor, dr.med. Kristian Stengaard-PetersenOverlæge, dr.med. Bente Danneskiold-Samsøe

��Niels Jensen, formandPalle Lauridsen, sekretærHenning Bliddal, Steen Hecksher-Sørensen, Lisbeth Wemmelund

�� kan rekvireres hos kursussekretærBirthe Skov, Comwell KoldingSkovbrynet 1, 6000 KoldingTlf. 76 34 11 00

Eller via internetadressen www.dsmm.org

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BasiskursusColumna

BasiskursusEkstremiteter

Columna AMobilisering

Columna BMobilisering

MFR BMyofasciel teknik

MFR AMyofasciel teknik

MET AMuskelenergiteknik

MET BMuskelenergiteknik

Muskulærdiagnostik og

øvelsesbehandling

IN J + IMSInjektionsteknik og

intramuskulær stimulation

MFR CMyofasciel teknik

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Jeg tilmelder mig herved bindende de ovennævnte kurser, som jeg har afkrydset.

Navn:

Adresse:

Postnr. og by:

Telefon:

Jeg er medlem af: DSMM McK MT-gr.

Jeg tilhører følgende fraktion: P.L.O FAS FAYL

Depositum indsender jeg inden for 1 uge efter modtagelsen af optagelsesbekræftigelse på kurset/kurserne, og restbeløbet skal være foreningen i hænde senest 6 uger før påbegyndelse af kursus.

Dato: Underskrift:

Tilmeldingsblanketten sendes til : Birthe Skov, Comwell Kolding. Skovbrynet 1, 6000 Kolding. Sammen med check på beløbet.

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Kursusarrangør: Danske Fysioterapeuters Fagforum forMuskuloskeletal Terapi.

Tid: 28.-29. august 2003.

Sted: Odense.

Kursusform: Eksternat.

Deltagere: Fysioterapeuter.

Undervisere: Medlemmer af MT-gruppens under-visningsgruppe.

Kursuspris: 2.400 kr. For medlemmer er prisen 2.300 kr.Heri indgår kursusmateriale og kaffe/te i pauserne.

Tilmelding: Senest den 20. juni 2003 på tilmeldings-blanket fra Fysioterapeuten, samt crosset, udateret checkpå beløbet til: Inger Skjærbæk, Rønnebær Allé 2, 3000Helsingør. Beløbet kan sættes ind på MT-gruppens kur-suskonto i Nordea, Stengade 45, 3000 Helsingør. Konto2255-1905637077.

Husk at få dit navn noteret på kontoudtoget veddenne form for indbetaling.

Tilmelding kan foretages over e-mail.Oplys fulde navn, adresse (inkl. postnr.) og telefon-

numre, samt medlemsnr i DF.Med hensyn til betaling skal beløbet være indsat se-

nest den 27. juni 2003 for at tilmeldingen tages i betragt-ning.

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Kurset vil i detaljer gennemgå den sammensatte un-dersøgelses og behandlings approach af bevægedysfunk-tion i skulderen. Undervisning vil fokusere på genoptræ-ning af stabilitetsdysfunktionen og impingement set udfra det lokale og globale muskelsystem.

Tid: 8.–9. september 2003.

Sted: Kerteminde Vandrehjem.

Underviser: Fysioterapeut Dip. MT Flemming Enoch.

Kursuspris: 2.800 kr. inkl. let morgenmad og frokost.

Overnatning og evt. aftensmad betales separat. Værelses-pris: 345 kr. pr. nat. Angiv om du ønsker enkelt/dobbelt-værelse eller ingen overnatning. Der kan ved min. 15 be-stillinger arrangeres aftensmad, angiv venligst om detteønskes.

Tilmelding: Spørgsmål og tilmelding til Niels Honoré på:[email protected] Medlemmer af Muskuloskeletal fag-forum har fortrinsret.

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For at kunne deltage i del II-eksamen skal den tilmeldtefysioterapeut have bestået Danske fysioterapeuters fag-forum for Muskuloskeletal Terapi’s del I-eksamen, havegennemført 150 timers klinisk supervision af godkendtesupervisorer i Muskuloskeletal Terapi. Fysioterapi ellerbeslægtede fagområder.

Endvidere skal tilmeldte fysioterapeut have deltaget ifagforum for Muskuloskeletal Terapi’s kurser på trin III,Mobilisering I og II samt klinisk supervision (trin 3C).

Det godkendes endvidere, hvis tilsvarende viden ogfærdigheder er tilegnet af anden vej.

@��Mål og niveau for kurser taget uden for Danmark måmindst være på højde med mål og niveau for den danskekursusrække og dermed IFOMT’s krav. Der skal foreliggedokumentation for deltagelse i udenlandske kurser oguddannelser inklusiv mål, indhold og timetal.

Klinisk supervision opnået i udlandet skal dokumente-res og godkendes af fagforum for Muskuloskeletal Terapi.

Kursusrrangør: Danske fysioterapeuters fagforum forMuskuloskeletal Terapi (MT).

Tid: Torsdag den 18. september 2003.

Sted: Fysiocenter Roskilde.

Kursuspris: 500 kr. for medlemmer og 1.000 kr. for ikkemedlemmer

Tilmelding: Senest 15. juli 2003 på MT fagforums tilmel-dingsblanket, sammen med en crosset check på beløbettil Aase Krog, Lobeliavej 5, 8541 Skødstrup.

NB! Eksamensgebyret går tabt ved afmelding senereend 15. august 2003.

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Kurset præsentere en sammensat model inden for move-ment dysfunction. Behovet for at undersøge for bevæge-funktion og korrigere bevægedysfunktion i forhold tilmuskuloskeletal smerte vil bliver gennemgået.

Konceptet identificerer artikulær og myofaciel give ogrestriktioner i bevægeapparatet og giver anvisninger tilgenoptræning af dysfunktionen.

Integrationen af specifikke øvelser og muskuloskeletalterapi vil blive gennemgået.

Tid: 6.–7. oktober 2003.

Sted: København, Fysioterapeutskolen.




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Kurset vil i detaljer gennemgå den sammensatte un-dersøgelses og behandlings »approach« af bevægedys-funktion i lumbal columna og truncus.

Undervisning vil fokusere på genoptræning af stabili-tetsdysfunktionen af det lokale og globale muskelsystem.

Tid: 20.–22. oktober 2003.

Sted: København, Fysioterapeutskolen.




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Tid: 1. del: 31. august-2. september 2003.2. del: 14.-15. september 2003.

Sted: Cromwell, Skovbrynet 1, 6000 Kolding.Kursusform: Eksternat.

Deltagere: Fysioterapeuter, der har gennemført Trin 1,kursus A og B.

Undervisere: Medlemmer af MT-gruppens un-dervisningsgruppe.

Kursuspris: 5.300 kr. + 3.000 kr. til lokaleleje inkl. mål-tider. Der er mulighed for overnatning på ScanticonComwell. Hvis dette ønskes angives det på tilmeldings-blanketten. Beløbet for internat er 5.050 kr.

Tilmelding: Senest 4. juli på tilmeldingsblanket fraFysioterapeuten, samt crosset, udateret check på 8.300til: Inger Skjærbæk, Rønnebær Allé 2, 3000 Helsingør.

Beløbet kan sættes ind på MT-gruppens kursuskonto iNordea, Stengade 45, 3000 Helsingør. Konto 2255-1905637077.


Tilmelding kan foretages over e-mail: [email protected] – angiv navn, adresse, telefon-numre, samt dit medlemsnr. i DF. Med hensyn til beta-lingen skal beløbet være indsat senest den 4. juli 2003for at tilmeldingen tages i betragtning.

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Dates: 21-26 March 2004.

Venue: International Convention Centre, Cape Town,South Africa.

Details: This promises to be one of the most excitingevents in the history of physiotherapy in South Africaand you are encouraged to start your planning now.

Academic: The theme for the conference is “Balancingthe Outcome of Manual Therapy”. The programme willrange from research based to clinical outcomes papers.Several speakers of international standing have indicated

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their willingness to participate. The programme will in-clude sessions on Pain, Outcome Based Research, Com-munity and Industrial Considerations, Musculo-SkeletalSpinal and Peripheral Dysfunctions.

Social: This promises to be an exciting programme andwill include a banquet, wine tasting, and a theme eveningat a typical South African venue.

Accomodation: to suit all budgets will be available.

Cape Town: We are very proud of our superb ConventionCentre and our beautiful surroundings and know thatyou will enjoy every aspect of your visit. Richard Busch,Travel Editor, National Geographic Traveler agrees withus and writes as follows: “By any standard, the CapeTown region of South Africa is one of the most beautifuland compelling places to visit on the planet. Here, in ad-dition to a city with fascinating historical sites, excellentmuseums, vibrant markets and a handsomely restoredwaterfront, I encountered mountain wilderness, ruggedcoastlines, sandy beaches, lush gardens, beautiful wineestates, superior hotels and some of the warmest, mostwelcoming people I've ever met”.

Website: Our website will be continually updated as fur-ther information becomes available – please keep wat-ching: www.uct.ac.za/depgc/pgc/

Enquiries: If you would like further information, pleasesend an expression of interest to:Sally Elliott, Conference Management Centre, UCT Medical SchoolAnzio Road, Observatory 7925, Cape Town, South AfricaTel: +27 21 406-6381. Fax: +27 21 448-6263.E-mail: [email protected]

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Sted: Odense.

Deltagere: Fysioterapeuter, der har gennemført Trin 1 ogTrin 2 A + B eller kurser efter den gamle struktur.

Tid: 28.–29. november 2003.

Undervisere: Medlemmer af Dansk Selskab ForForskning.

Kursuspris: 6.000 kr., lokaleleje 500 kr.Beløbet dækker 2 dages kursus, 1 vejledningsdag, vejled-

ningstimer og rettelse af den færdige case-rapport.

Kursusform: Eksternat.

Tilmelding: Senest den 22. august 2003 på tilmeldings-blanket fra Fysioterapeuten, samt crosset, udateret checkpå 6.500 kr til: Inger Skjærbæk, Rønnebær Allé 2, 3000Helsingør.

Beløbet kan sættes ind på MT-gruppens kursuskonto iNordea, Stengade 45, 3000 Helsingør. Kontonr. 2255-1905637077.


Tilmelding kan foretages over e-mail: [email protected] – angiv navn, adresse og tele-fonnumre, samt medlemsnr. i DF.

Med hensyn til betaling skal beløbet være indsat se-nest den 22. august 2003 for at tilmeldingen tages i be-tragtning.

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DSMM har nedsat et videnskabeligt udvalg.Hvis du har forskningstanker og ønsker råd ogvejledning, kan du henvende dig til:Forskningsudvalgets formand, overlægedr.med. Lars Remvig, Klinik for MedicinskOrtopædi og Rehabilitering, H:S Rigshospitalet,2100 København Ø.

Der gøres opmærksom på, at Scientific Com-mittee i FIMM har udarbejdet to forsknings-protokoller, der kan hentes på DSMM’s hjem-meside: www.dsmm.org under videnskab.

Det drejer sig om reproducibility and validitystudies of diagnostic procedures in Manual/Musculoskeletal Medicine og efficacy-Trials ofTherapeutic Procedures in Manual/Musculo-skeletal Medicine.

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DSMM’s lærergruppe har fredag den 2. maj 2003 afholdt møde om den nye kursusstruktur. Det er i forbindelse medtidligere møde blevet besluttet at sammenlægge basiskurset der handler om ekstremiteterne med basiskurset der handlerom columna. På forårets møde blev der nedsat arbejdsgrupper der i løbet af de nærmeste måneder vil beskæftige sig medat få hele kursusstrukturen til at fremstå mere overskuelig og enkel. Det nye er, at vi opdeler basiskurset i to kurser. Detførste kursus omhandler nedre kvadrant som et hele, dvs. lumbalcolumna, bækken, hofte, knæ, ankel og fodens led. Detandet kursus omhandler øvre kvadrant, dvs. thoracal-og cervicalcolumna med costae, skulder, albue, hånd- og fingerled.Som noget nyt planlægger vi, på opfordring fra kursister gennem årene, faste repetitionskurser der er datolagt i forbin-delse med de aktuelle kurser. Den nye kursusstruktur forventes klar i løbet af 2004 (Gerd Lyng).

�� Leinonen V et al. Eur J Applied Physiol 2002;88:42-9.

Dette studie viste, at de paraspinale muskler aktivereres hurti-gere ved en »ventet« belastning sammenlignet med »uventet«belastning af OE målt med overflade-EMG hos raske perso-ner. Studiet viste også, at en visuel forventning reducerergraden af de paraspinale musklers respons ved en pludseligbelastning af OE. /cc

Activation of paraspinal and abdominal muscles duringmaually assisted and nonassisted therapeutic exerciseArokoski JP et al. Am J Phys Med Rehabilitation2002;81(5):326–35.

Dette studiet af samme finske forsker gruppe viste, at EMG-aktiviteten er mindre i de paraspinale og abdominale musklerved manuel terapeutiske (MT)-øvelser sammenlignet medikke-manuel terapeutiske (IMT)-øvelser også målt med over-flade-EMG. Dermed synes ikke-MT at være mere effektiv i ataktivere de paraspinale muskler i lumbalcol., men forfatternepåpeger, at IMT kan skabe højere kompressionskræfter i lum-bal col., hvilket kan forværre lændesmerter i den initielle faseaf et progressivt øvelsesprogram designet til lændesmerter. /cc

MT og Kiropraktik giver kortere sygefravær i NorgeEn ny af rapport viser at manuel terapeuter og kiropraktorerreducerer både sygedagpenge udbetalingerne og sygefraværknyttet til muskelskeletsygdomme. Gå ind på:

http://www.fysioterapeuten.no/artikler/dokumenter/arkiv.html Gå derefter ind på 02/2003 som er en PDF-fil af bladet. Arti-kel står på side 6 med svar på kritik fra Den norske lægefor-ening.

Comparing the satisfaction of low back pain patientsrandomized to receive medical or chiropractic care resultsfrom the UCLA low back pain studyHertz-Miller RP et al. Am J Public Health 2002;92(1):1628-33.

Men en separat analyse ved 4-ugers-målingen viste en for-skel til fordel for kiropratisk behandling for hvad angår til-fredshed. Det ser ud til at kiropraktorer var bedre til at giveråd og information omkring lænderygsmerter end læger,hvilket medførte større tilfredshed. /cc

A randomized trial of medical care with or without physicaltherapy and chiropractic with or without physical modalitiesfor patients with low back pain: six month follow-upoutcomes from the UCLA low back pain studyHurwitz E et al. Spine 2002;27(20):2193-204.

I et nyligt studie fra UCLA, hvor 672 patienter med lænde-rygsmerter (med/uden ischias-påvirkning) blev randomiserettil enten kiropraktisk behandling (med/ uden fysisk aktivitet)eller standard medicinsk behandling (med/uden fysioterapi)viste ingen forskel imellem de 2 grupper for hvad angårsmerte og disability 6 måneders followup. /cc

Læsetips

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DANSK SELSKAB FOR MUSKULOSKELETAL MEDICIN

� �� Formand:Speciallæge i almen medicinAllan GravesenNorvangen 34220 KorsørTlf. 58 37 10 48E-mail: [email protected]

Næstformand:Speciallæge, ph.d.Pierre Schydlowsky Bymidten 12 B3500 VærløseTlf. 44 48 15 07E-mail: [email protected]

Sekretær:Speciallæge i almen medicinJette ParmStrandstræde 24400 KalundborgTlf. 59 51 00 66E-mail: [email protected]

Kasserer:Speciallæge i almen medicinPeter Frost SilbyeRøglebakken 44320 LejreTlf. 56 65 90 40DSMM giro 809 6414E-mail: [email protected]

Medlemmer:Speciallæge i reumatologiFinn JohannsenEllebækvej 102810 GentofteTlf. 39 65 62 11E-mail: [email protected]

Formand for UddannelsesudvalgetSpeciallæge i almen medicinNiels JensenMåløv Hovedgade 692760 MåløvTlf. 44 65 54 43Fax 44 65 54 05E-mail: [email protected]

Speciallæge i reumatologiFinn Elkjær JohansenStaunsholtvej 333520 FarumTlf. 44 95 49 40E-mail: [email protected]/bestyrelse.htm

Overlæge, speciallæge i reumatologiPalle HolckMedicinsk afdelingFalkevej 1-38600 SilkeborgTlf. 87 22 21 00E-mail: [email protected]

Økonomiudvalg:Speciallæge i almen medicinPeter Frost Silbye

Speciallæge i almen medicinNiels Jensen

Nordisk kontaktudvalg:Speciallæge i almen medicinPeter Frost Silbye

Speciallæge i almen medicinAllan Gravesen

Uddannelsesudvalget:Speciallæge i almen medicinNiels Jensen

Speciallæge i almen medicinLisbeth WemmelundOddervej 978270 HøjbjergTlf. 86 27 00 11 E-mail: ???

Speciallæge i almen medicinPalle LauridsenKystvej 185800 NyborgTlf. 65 31 31 91E-mail: [email protected]

Speciallæge i almen medicinSteen Hecksher-SørensenÅboulevarden 788700 HorsensTlf. 75 61 13 55E-mail: [email protected]

Professor, overlæge, dr.med.Henning BliddalReumatologisk KlinikFrederiksberg HospitalNdr. Fasanvej 57-592000 FrederiksbergTlf. 38 16 38 16E-mail: [email protected]

Videnskabeligt udvalg:Overlæge, dr.med.Lars RemvigKlinik for Medicinsk Ortopædi og RehabiliteringH:S Rigshospitalet 7611, T9,Blegdamsvej 92100 København ØE-mail: [email protected]

Afdelingslæge, Overlæge Berit Schiøttz-ChristensenReumatologisk afdeling Århus KommunehospitalTlf. 89 49 33 33E-mail: [email protected]

Speciallæge i reumatologiFinn Johannsen

Professor, overlæge, dr.med. Henning Bliddal

Overlæge, speciallæge i reumatologiPalle Holck

Redaktionsudvalget:Speciallæge i almen medicinFritz O. ChristensenPostvænget 19440 AabybroTlf. 98 24 13 11E-mail: [email protected]

Speciallæge i almen medicinGerd LyngKæmpestranden 213770 AllingeTlf. 57 48 13 21E-mail: [email protected]

Overlæge, dr.med.Lars Remvig


PR-udvalg:Speciallæge i almen medicinGerd Lyng

Overlæge, speciallæge i reumatologiPalle Holck


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Specialepolitisk udvalg:Overlæge, dr.med.Lars RemvigSpeciallæge i reumatologi, ph.d.Pierre SchydlowskyOverlæge Berit Schiøttz-ChristensenSpeciallæge i almen medicinAllan Gravesen

Kursussekretær:Birthe SkovTlf. 76 34 11 00Fax 76 34 13 00

DANSKE FYSIOTERAPEUTERS FAGFORUM FOR MUSKULOSKELETAL TERAPIFormand:Niels HonoréRebekkavej 92900 HellerupTlf. 32 52 35 60

Næstformand:Flemming EnochLøjtegårdsvej 1572770 KastrupTlf. 32 52 35 60

Sekretær:Dorthea PetersenGyvelvej 386621 GestenTlf. 75 55 73 95

Kasserer og medlemskartotek:Aase TroestLobeliavej 58541 SkødstrupTlf. 86 22 88 60E-mail: [email protected]

Bestyrelsesmedlemmer:Inger Birthe BjørnlundF.F. Ulriksgade 242100 København ØTlf. 39 18 64 96

Vibeke LaumannBakkedraget 493460 BirkerødTlf. arb. 44 44 11 15Tlf. priv. 45 81 28 74E-mail: [email protected]

M.Sc.PT.Christian CouppéTEAM DANMARKIdrættens Hus2605 Brøndby E-mail: [email protected]. 26 58 68 18

Documents

Muskuloskeletalt Forum 2 - 2003...Referat fra møder i IFOMT 18 ... to assess progress by focusing on the pain response to the technique (what’s happening to your pain, where is