Layers Of Diagnosis In Physical Therapy
There are many schools of thought in diagnosing musculoskeletal lesions. Some schools look at the specific tissue whilst others look more globally. Clinically they each have their merit but perhaps the real value is in appreciating all approaches. To discuss the integration of approaches the following example will be used.
- Excessive lordosis, pain on walking and standing,
- Relief of pain with repeated flexion,
- Unable to crawl with a neutral spine, unable to pass a lower abdominal function test,
- Trigger points in her lumbar longissimus and quadratus lumborums
- Facet joint inflammation at the L4/5 levels on magnetic resonance imaging (MRI)
The analysis of this patients crawling suggests she is not showing the development of a 7-month-old child. Further, she is unable to pass a lower abdominal function test, which is done by maintaining a neutral spine during lifting the femurs up to 90 degrees with the knees bent to 90 degrees. This suggests she is not showing the development of a 3-month-old child. Thus the developmental approach may start conditioning at the level of the 3 month old child.
This patient has pain on walking and standing as well as an increased lumbar lordosis. These symptoms fit with an extension dysfunction in Sahrmann’s classification. This would lead to a treatment using exercises to maintain a neutral spine in all planes in key functional positions.
Mechanical Diagnosis and Therapy
As the patient has relief of symptoms in flexion they would be labelled with a flexion dysfunction. The treatment would therefore be repeated flexions progressing in intensity until resolution.
In this patient trigger points were identified in the lumbar longissimus and quadratus lumborum bilaterally. Treatment would be focussed on relieving the trigger points through manual techniques and possibly needling.
On posterior to anterior palpation of the spinous process of L4 and L5 the patient’s symptoms were reproduced. Thus these would be deemed the symptomatic levels and the patient may be treated with grade 2 posterior to anterior mobilisation of these levels.
In orthopaedic medicine the diagnosis of the specific sight of the lesion is seen as essential. In this patient there was inflammation on MRI in the facet joints at the L4/5 level. In orthopaedic medicine the treatment approach may be a CT guided corticosteroid injection to the exact site of the inflammation.
|Level||Mode of thinking||Example|
|Developmental level||Prague School, Dynamic Neuromuscular Re-education||<3 months in supine|
|Movement diagnosis||Shirley Sahrmann||Extension dysfunction|
|Mechanical diagnosis and therapy||Robin McKenzie||Flexion dysfunction|
|Myofascial diagnosis||Trigger point therapy||Trigger points in the longissimus and quadratus lumborum|
|Vertebral level||Maitland||L4/5 positive|
|Specific tissue||Orthopaedic medicine||Inflammation at the L4/5 facets|
Arguably the developmental, movement and mechanical diagnosis are all attempting to counteract a poor movement pattern and optimise movement. Whilst myofascial treatment may focus on the trigger points in this instance this itself may have similar effect as may the vertebral mobilisations. Clinically I have seen cases where patients given cortisone injections to inflamed facets have come back with improved movement. Having said that my personal preference is to target treatment to the movement pattern or development level where possible and use more tissue specific treatments when necessary. This is often the case with more severe symptoms.