1989; 69:548-553.PHYS THER. Bette Ann Harris and Daniel A DyrekDecision Making in Physical Therapy PracticeA Model of Orthopaedic Dysfunction for Clinical

http://ptjournal.apta.org/content/69/7/548be found online at: The online version of this article, along with updated information and services, can

Collections

Physical Therapist Education     Musculoskeletal System/Orthopedic: Other    

Clinical Decision Making     in the following collection(s): This article, along with others on similar topics, appears

e-Letters

"Responses" in the online version of this article. "Submit a response" in the right-hand menu under

or click onhere To submit an e-Letter on this article, click

E-mail alerts to receive free e-mail alerts hereSign up

by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

A Model of Orthopaedic Dysfunction for Clinical Decision Making in Physical Therapy Practice

[Harris BA, Dyrek DA: A model of orthopaedic dysfunction for clinical decision making in physical therapy practice. Phys Ther 69548-553, 1989]

Key Words: Decision making; Decision theory; Education, physical therapist, general; Orthopedics.

Bette Ann Harris Daniel A Dyrek

This article describes a model of orthopaedic dysfunction that we use as a framework for our advanced mas­ter's degree orthpaedic and sports curriculum at the MGH Institute of Health Professions.1 This model is offered as an alternative to the tradi­tional medical model that focuses on the etiology, diagnosis, and treatment of disease. The purpose of the model of orthopaedic dysfunction is to pro­vide a hypothetical rationale to explain the cause and effects of soft tissue dysfunction.1 The purpose of this article is to present the model of orthopaedic dysfunction as a clinical decision-making tool. The model can be used to analyze the etiology of dysfunction, which may contribute to the development of a body of knowl­edge relevant to the profession of physical therapy.

This model of orthopaedic dysfunc­tion was developed because we believe a key quality of the clinician is to demonstrate clinical judgment sub­

stantiated by current theory and sci­ence. Clinicians should be able to explain why they chose a particular examination or treatment action or interpreted signs and symptoms in a certain manner in terms of the patho­physiology of the dysfunction.

The model is offered as a guideline for therapists to formulate and com­pare hypotheses of dysfunction. Understanding the etiology of dys­function is essential in clinical deci­sion making prior to establishing the prognosis, duration, and frequency of treatment. We recognize that there are other contributing variables, such as the psychological, social, and func­tional needs of a patient, which strongly influence treatment strategies. The purpose of this model, however, is to present a unifying framework of pathophysiological and pathokinesio-logical processes to theoretically illus­trate the development of orthopaedic dysfunction and its effects. The model of orthopaedic dysfunction is based

on the static and dynamic properties and function of the neuromuscu-loskeletal tissues and structures.2-11

The altered properties of those tissues are related to the etiology of pain, impairment, and disability.

This article will review the essential components of the model and, using the case method, explain how it may be used to analyze examination and treatment strategies. We will also dis­cuss how the content of the model is applicable to clinical practice, educa­tion, and research.

Review off the Model off Orthopaedic Dysfunction

The model expands on the classical concept of a stimulus causing a response (Fig. 1). Figure 2 empha­sizes the stimuli and subsequent inter­nal tissue responses that hypotheti-cally result in orthopaedic dysfunction. Although all sections of the Figure could be expanded, we have chosen to diagram the internal tissue response section in the most detail to allow clinicians to analyze the patient's impairments and disabili­ties in terms of the pathophysiology of the dysfunction. Although a particu­lar chain of events will not apply to all patients, the sequence depicted in Figure 1 is applicable in most clinical situations.

B Harris, MS, PT, is Assistant Professor, Program in Physical Therapy, MGH Institute of Health Pro­fessions, 15 River St, Boston, MA 02108-3402, and Clinical Research Associate, Department of Physi­cal Therapy, Massachusetts General Hospital, Fruit Street, Boston, MA 02114.

D Dyrek, MS, PT, is Assistant Professor, Program in Physical Therapy, MGH Institute of Health Pro­fessions, and Director, MGH Physical Therapy Associates, 60 Staniford St, Boston, MA 02114.

Address correspondence to Ms Harris at Program in Physical Therapy, MGH Institute of Health Pro­fessions, 15 River St, Boston, MA 02108-3402 (USA).

This article was presented in poster format at the Sixty-Third Annual Conference of the American Physical Therapy Association, San Antonio, TX, June 28-July 2, 1987.

38/548 Physical Therapy/Volume 69, Number 7/July 1989

by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

Stimulus

Internal Tissue Response

Impairments

Functional Disability

Handicap

Fig. 1. Overview of model of ortho­paedic dysfunction.

The terminology chosen for the last three category headings of the model and their definitions are derived from the World Health Organization's International Classification of Impair­ments, Disabilities, and Handicaps.12

Impairments refer to the abnormali­ties of anatomic, physiologic, or psy­chologic origins within specific organs or systems of the body. Physi­cal therapists tend to evaluate or mea­sure impairments (eg, decreased range of motion, limited muscle per­formance). Functional disability refers to a restriction or inability to perform a normal range of activities of daily living. The World Health Organization has classified functional disability into four categories: 1) physical, 2) mental, 3) social, and 4) emotional. Examples of physical disabilities we deal with as physical therapists are limitations in performing ADL skills such as trans­fers and gait and higher level skills such as athletic activities. Handicap describes limitations in the fulfillment of an individual's normal role,

depending on age, sex, and other social and cultural factors. An example of a handicap is inability to perform one's occupation.

In keeping with this terminology, therefore, it can be said that specific impairments contribute to an individ­ual's functional disability. After careful examination and the formulation of an assessment, an important aspect of clinical decision making is to select the correct therapeutic action for the patient. This treatment must be based on the individual's needs but must also be related to the etiology of the patient's dysfunction. Physical thera­pists traditionally evaluate and mea­sure those limitations identified in the impairment section of the model. Subsequently, treatment interventions may be limited to only addressing the impairment. Perhaps this intermediate level of assessment and treatment is fostered by the patient's tendency to describe their own problems in terms of pain and functional disability. By reviewing the chain of events diagrammed in the internal tissue response section of the model accord­ing to the patient's mechanism of injury, however, the therapist can for­mulate a hypothesis of dysfunction. By identifying what phase of reaction the involved tissues are in, the therapist can propose more sensitive treatment techniques based on the altered tissue properties. For example, if a patient has limited knee flexion and exten­sion secondary to an acute inflamma­tory process, the treatment strategy should be targeted at reducing the inflammation, improving tissue nutri­tion, and preventing the sequela of the inflammatory response such as fibrous reaction of the contractile tis­sue. By using finer examination tech­niques and integrating the informa­tion with the pathological condition, the clinician will have a clearer sup­porting rationale for the treatment.

From this model, generic treatment goals were developed according to the sequence outlined in the internal

tissue response section progressing through the impairments and func­tional disability levels (Appendix 1). These goals are based on the events documented in the internal tissue response section, and interventions are determined by whether certain responses have taken place or need to be prevented.

Applications off the Model

This section will use a case study to illustrate how to apply the model in a clinical situation. After reading the history and subsequent examination findings of this case study, formulate a provisional patient assessment.

Case Study

"GW" is a right-handed, 53-year-old man who was referred to physical therapy for examination and treat­ment of a painful, stiff right shoulder.

History of present problem. Three months ago, GW was lifting his 25-hp outboard engine out of the water when he felt a sudden sharp "pop" over the anterior portion of his shoul­der followed by burning pain over the lateral aspect of his proximal arm. He reports that his symptoms gradu­ally subsided over the next week, although he continued to have pain on any attempt to do overhead activi­ties. He stopped playing tennis and exercising at the health club. During the past two months, he noticed that he seemed to be "getting stiffer" and was having difficulty working. GW also complained of difficulty sleeping because he was unable to lie on his painful right shoulder.

One month ago he consulted with an orthopaedic surgeon who began a work-up. Radiographs showed some glenohumeral joint-space narrowing and a mild joint effusion. There was no evidence of calcification. The phy­sician suggested that he begin taking a nonsteroidal anti-inflammatory drug (Feldine®*) and start physical therapy.

GW's past medical history is noncon-tributory. He is a dentist who lives with his wife and three teenage chil-*Pfizer Laboratories Division, Pfizer Inc, 235 E 42nd St, New York, NY 10017.

Physical Therapy/Volume 69, Number 7/July 1989 549/39 by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

MODEL OF ORTHOPAEDIC DYSFUNCTION: IMPLICATIONS FOR EXAMINATION AND TREATMENT

STIMULUS

ALTERED MECHANICAL PROPERTIES OF TISSUES AND STRUCTURES

INTERNAL TISSUE RESPONSE

NON-CONTRACTILE TISSUE CONTRACTILE TISSUE

ARTICULAR STRUCTURES

IMPAIRMENT of

MOVEMENT DYSFUNCTION

FUNCTIONAL DISABILITY

HANDICAP

Fig. 2 . Model of orthopaedic dysfunction: Implications for examination and treatment.

dren. GW's initial physical therapy evaluation is presented in Appendix 2 and the Table.

Application of model to results of patient examination. By referring to Figure 2, we can identify that the initial stimulus was physical trauma; for discussion purposes, we can hypothesize it caused immediate tis­sue insufficiency of the rotator cuff, which created altered internal tissue stress. Stress refers to the magnitude of internal load in a structure or a tissue. A closer look at the internal tissue response section allows the chain reaction, which can occur from the tissue insufficiency, pain, and sub­sequent inflammatory responses, to be identified. We then follow down through the left side of the internal tissue response section and identify a result of the inflammatory process on the noncontractile tissues involved (ie, the fibrous reaction resulting in soft

tissue contracture). A subsequent pro­gression of the contracture is dysfunc­tion of the articular structures. The contracture and articular dysfunction each contribute to altered internal

tissue stress. This stress can be mani­fested as premature or latent loading of tissue, excessive or reduced magni­tude of load, or altered site of tissue load. For example, the resultant

Table . Passive Joint Mobility (in Degrees) of Patient "GW" in Supine Position

Combined flexion Glenohumeral joint flexion Combined abduction Glenohumeral joint abduction Extension Internal (medial) rotation External (lateral) rotation Elbow, hand, fingers, cervi­cal spine

Right

100a

65a

90a

45a

30 30 0a

within normal limits

Left

170 90

180 90 60 85 85 within normal limits

aComplains of pain.

40/550 Physical Therapy/Volume 69, Number 7/July 1989

by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

abnormal loading of tissue can result in pain from excessive stimulation of articular neuroreceptors and chronic inflammatory reactions, altered pro­prioception, and myoarthrokinetic reflexes.

The above discussion is one exam­ple of how the data gathered during an examination can be related to the internal tissue response section of the model to hypothesize why the patient exhibits specific impair­ments. In this patient, for example, joint mobility at three months postinjury is limited in a capsular pattern. We know that there is marked supraspinatus muscle tenderness and joint tenderness at the rotator cuff insertion. There is also general muscle wasting. By relating these findings to the inter­nal tissue response section of the model, the student can then logi­cally map out the sequence of pathophysiological events and iden­tify appropriate treatment strategies aimed at the tissue dysfunction of the impairment.

In summary, from the case example, some objectives of this model for clinical practice are 1) to provide a framework for clinical decision making based on the physiological and mechanical sequelae of soft tis­sue dysfunction and 2) to identify a rationale for the etiology and man­agement of pain and dysfunction.

Implications for Education and Research

The model is also applicable in the educational setting. The main objec­tive is to establish a framework for the critical analysis of clinical practice concepts in orthopaedic physical ther­apy and other disciplines. The assess­ment by the physical therapist may be analyzed to determine whether the specific etiology or the patient's impairment has been identified or whether the assessment is merely a restatement of the impairment itself. In a similar manner, the goals and treatment plan can be evaluated for their relevance and thoroughness based on the diagnosis. Additionally, various theories and strategies of ther­apeutic intervention, from within and from outside the physical therapy pro­fession, can be compared for their relative strengths and weaknesses.

The model is used at the MGH Insti­tute of Health Professions (Boston, Mass) as a framework for teaching students how to make clinical judg­ments that can be substantiated by clinical theory, practice customs, and science. We have developed a core course teaching these basic concepts using analysis of case studies for prac tice. The content areas are divided into topics identified in the internal tissue response section of the model and include lectures and discussion examining clinical implications of inflammation, pathokinesiology of joint and soft tissue contracture and

instability, mechanical behavior of connective tissue, muscle structure and function, and analysis of generic treatment strategies. Dysfunction of contractile and noncontractile soft tissues and articulations are related to clinical examination and treatment techniques.

Examples of the study objectives gen­erated by this model are given in Appendix 3. These types of analyses allow therapists to relate why they have chosen to apply a particular treatment strategy to the pathophysiol­ogy of the dysfunction. Furthermore, they can clearly define in the litera­ture which strategies have been sub­stantiated or warrant investigation.

Therefore, the model can also be used to aid the therapist in identifying research goals such as 1) to deter­mine the role of various etiologies in the production of pain, 2) to formu­late research questions investigating the manner in which manual and modality therapeutic interventions work, and 3) to compare the effective­ness of tissue-based and nontissue-based treatment strategies. The model itself is subject to analysis for confir­mation. Currently, it is based on knowledge obtained from the applied science literature.

Summary

This model serves as a framework for the critical analysis of current practice concepts. The analysis obtained from

Appendix 1. Generic Treatment Goals

1. Promote healing by improving the nutritional status of soft tissue. 2. Prevent abnormal soft tissue flexibility and length for contractile and noncontractile tissues or restore normal flexibility and length. 3. Prevent the loss of normal joint alignment or restore normal joint alignment. 4. Prevent the loss of normal joint mobility or restore normal joint mobility. 5. Promote normal myoarthrokinetic reflexes. 6. Promote normal motor control. 7. Promote normal cardiopulmonary and cardiovascular status. 8. Decrease pain and associated symptoms. 9. Prevent recurrence of the lesion.

10. Improve the functional status of the patient.

Physical Therapy/Volume 69, Number 7/July 1989 551/41 by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

Appendix 2. Initial Physical Therapy Evaluation of Patient "GW"

Initial evaluation —denies history of shoulder lesion —complains of dull ache in lateral arm and anterior shoulder with minimal motion —complains of sharp, pinching pain in shoulder with overhead motions —difficulty sleeping —difficulty performing activities of daily living and dentistry because of pain and decreased movement —becoming discouraged that pain is "interfering with his life" —patient's goal to "get rid of the pain and get back full use of his right upper extremity" —denies gross weakness or neural symptoms —negative cervicothoracic spine findings

Inspection —no visible edema or effusion in right upper extremity —skin unremarkable —right shoulder girdle is depressed and protracted —increased depression noted in right supraspinatus fossa compared with left supraspinatus fossa

Palpation —complains of sharp tenderness over anterior glenohumeral joint, anterosuperior subluxation of glenohumeral joint is present —increased myofascial and capsular tissue density in anterior portion of glenohumeral joint —complains of point tenderness over humeral rotator cuff insertion —supraspinatus muscle tenderness present throughout supraspinatus fossa —mild atrophy noted in deltoid and supraspinatus muscles —cervical spine, acromioclavicular joint, sternoclavicular joint, and rest of right upper extremity unremarkable

Accessory joint motion Glenohumeral joint of right upper extremity

—distraction: positive for pain and minimal excursion (Grade 1) —caudal glide, anteroposterior glide: positive for pain and moderate excursion (Grade 2)

Other right upper quarter joints —unremarkable for pain or mobility deficits

Muscle strength —not tested secondary to pain

Neurological status —unremarkable for sensory deep tendon reflexes, peripheral nerve provocation tests, and myotomal deficits

Functional status —must dress affected arm first —unable to comb hair with right arm —holds right arm stiffly, decreased arm swing in gait

using this model should be integrated with other physiological systems of the body during examination and treatment processes. Currently used as a basis for graduate study in ortho­paedic physical therapy, the model helps students identify fundamental research questions, compare various examination and treatment philoso­phies, and comprehend generic treat­ment goals and strategies.

Acknowledgments

We would like to acknowledge Terry Michel, Mary Watkins, and Valerie Grande for their help in preparing this manuscript.

References

1 Dyrek DA, Harris BA, Riegger CA: A model of orthopaedic dysfunction: Implications for examination and treatment. Abstract. Phys Ther 67:740, 1987

2 Akeson WH, Dip DA, Abel MP: Effects of immobilization on joints. Clin Orthop 219:28-36, 1986 3 Brooks VB: Motor control: How posture and movements are governed. Phys Ther 63:664r-673, 1983 4 Cailliet R: Soft Tissue Pain and Disability. Philadelphia, PA, F A Davis Co, 1977 5 Gabbiani G, Hirshel BJ, Ryan GB, et al: Granulation tissue as a contractile organ: A study of structure and function. J Exp Med 135: 719-734, 1972 6 Hubbard RP: Mechanical behavior of con­nective tissue. In Greenman PE (ed): Concepts and Mechanisms of Neuromuscular Functions.

42/552 Physical Therapy/Volume 69, Number 7/July 1989 by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

Appendix 3 . Sample Study Objectives

1. State a provisional assessment of the patient's problem and support your assessment by relating tissue physiology and biomechanics to the patient's medical history, subjective report, and manifestation of findings during the examination.

2. Identify five of the patient's specific physical therapy problems. (Consider tissue, structural, and body systems and functional problems.) 3. Identify specific short-term goals of treatment for your patient. (Consider specific tissue and structural goals for each problem identified in item 2.) 4. Choose one of the problems and corresponding goals identified in items 2 and 3 to perform the following objectives:

-Describe and analyze the rationale of your goal based on tissue physiology and the mechanical behavior of contractile and noncontractile soft tissues. (Support your discussion with a minimum of two references.)

-Identify one treatment technique or modality to enable you to achieve your goal. -Describe and analyze the relationship of your technique to your goal based on tissue physiology and the mechanical behavior of contrac­

tile and noncontractile soft tissues. (Support your discussion with a minimum of two references.) 5. Identify and discuss three criteria you would use to decide the magnitude, frequency, and duration of your treatment techniques for each

treatment session.

New York, NY, Springer-Verlag New York Inc, 1984, pp 47-54 7 Little RW: Biomechanics modeling and con­cepts. In Greenman PE (ed): Concepts and Mechanisms of Neuromuscular Functions. New York, NY, Springer-Verlag New York Inc, 1984, pp 34-36

8 Newham DJ, Mills KR, Quigley BM, et al: Pain and fatigue after eccentric and concentric muscle contractions. Clin Sci 64:55-62, 1983 9 Ross R: Wound healing. Sci Am 220(6):40-50,1969 10 Thorstensson A, Grimby G, Karlsson J: Force-velocity relations and fiber composition

in human knee extensor muscles. J Appl Phys­iol 40:12-16, 1976 11 Wyke BD: The neurology of joints. Ann R Coll Surg Engl 41:25-50, 1967 12 International Classification of Impairments, Disabilities, and Handicaps. World Health Organization, Geneva, Switzerland, 1980

Physical Therapy/Volume 69, Number 7/July 1989 553/43 by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from

1989; 69:548-553.PHYS THER. Bette Ann Harris and Daniel A DyrekDecision Making in Physical Therapy PracticeA Model of Orthopaedic Dysfunction for Clinical

Information Subscription http://ptjournal.apta.org/subscriptions/

Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml

Information for Authors http://ptjournal.apta.org/site/misc/ifora.xhtml

by guest on November 3, 2014http://ptjournal.apta.org/Downloaded from