The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice

[ viewpoint ]
GREGORY J. LEHMAN, MSc, DC, MScPT1

Downloaded from www.jospt.org at Sociedade Nacional de Fisioterapia Esportiva (SONAFE) on June 2, 2018. For personal use only. No other uses without permission.
The Role and Value

of Symptom-Modification
Approaches in
Musculoskeletal Practice
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
J Orthop Sports Phys Ther 2018;48(6):430-435. doi:10.2519/jospt.2018.0608
C
linicians and researchers working in the same clinical area confidence. In addition, there is generally
(eg, low back pain) often make recommendations on how a poor correlation between the findings
best to manage patients, and these recommendations are of imaging investigations and symptoms
in the absence of trauma and sinister
often characterized by different clinical and philosophical
pathology. These 2 findings suggest that
approaches that range from biomechanical to psychological. The in many instances, musculoskeletal pain
Journal of Orthopaedic & Sports Physical Therapy®
diversity of models of care in contemporary musculoskeletal physical may be structurally and anatomically
therapy can be confusing for patients ingly disparate approaches may help to indeterminable. To address this uncer-
and practicing clinicians. There is, how- reconcile these differences and poten- tainty, clinicians and researchers have
ever, a common theme to many of these tially delineate commonality in contem- suggested that clinical practice could be
seemingly disparate models of care: porary practice. Symptom modification guided by the identification and modifi-
symptom modification. may serve as the overarching rationale for cation of potential kinematic, kinetic, or
Symptom modification aims at reduc- a variety of techniques and approaches motor control impairments in musculo-
ing symptoms and improving function used in contemporary practice. skeletal function, that is, a kinesiopatho-
with a variety of clinical approaches. This logical approach.10,33 The presumption is
Viewpoint explores the role of symptom Symptom Modification Within the that the correction of movement to an
modification in rehabilitation and specifi- Kinesiopathological Model of Pain assumed ideal movement and the cor-
cally addresses (1) symptom modification One goal of musculoskeletal practice has rection of proposed impairments are
within the kinesiopathological model of been to identify the structure associated necessary to alleviate pain and promote
pain, (2) symptom modification in clinical with the patient’s pain and symptoms. ideal function.
practice, and (3) potential commonality To achieve this, orthopaedic tests were The identification of an impairment
in seemingly divergent models of clinical developed to implicate a source of symp- assumes that there is an ideal position
practice. toms. The ability to achieve this goal has or movement pattern and that devia-
Clinicians are often confronted with been challenged by multiple investigations from this ideal predispose an indi-
conflicting advice in the literature and tions that suggest that, in isolation or in vidual to pain and may negatively impact
from advocates of a particular approach combination, clinical tests are often in- recovery. A limitation of the kinesio-
to the treatment of patients in pain. Find- capable of identifying the structure asso- pathological approach is the common
ing common themes within these seem- ciated with the symptoms with sufficient research finding of an inconsistent rela-
Private practice, Toronto, Canada. The author certifies that he has no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject
1
matter or materials discussed in the article. Address correspondence to Dr Gregory J. Lehman, 26 Woodfield Road, Toronto, ON M4L 2W3 Canada. E-mail: greglehmanphysio@gmail.com
t Copyright ©2018 Journal of Orthopaedic & Sports Physical Therapy®
430 | june 2018 | volume 48 | number 6 | journal of orthopaedic & sports physical therapy

tionship between assumed impairments may be warranted, considering that the provoke symptoms and then to intro-
in posture, kinematics, kinetics, and correction of the assumed impairment duce a change to that movement. The ra-
motor control and pain and disability. may not occur and may be unnecessary. tionale for the movement modifier, how
For example, altered scapular kinemat- The hypothesis and contention of this the movement is explained to the patient,
ics are inconsistently linked to shoulder Viewpoint is that kinematic behaviors and how that change is delivered may
pain,23 and altered scapular kinematics may not be addressed with the goal of differ across the approaches. All seem to
have been shown to not be predictive of creating ideal or optimal movement rela- agree, however, that the correct change
future shoulder pain.27 Conversely, other tive to a standard of movement, but with is the one that eventuates in a reduction
research has suggested that deviations in a primary objective of altering symptoms. in pain and symptoms. Although these
scapular kinematics do predispose ath- The corrected movement may then (1) be models appear to suggest that biome-
letes to future shoulder pain.19 A poor pain free, (2) permit the resumption of chanics may be partially relevant with
relationship between spinal posture and activities, or (3) function as a desensitizer respect to symptoms, the guiding ra-
neck pain25 and shoulder pain1 has been for other movements. tionale for the intervention is symptom
documented. Similarly, conflicting re- modification and symptom control, not
sults have also been reported in the lower Symptom Modification the assumed biomechanical correction. A
limb, with research findings suggesting in Clinical Practice biomechanical explanation, applied post
increased hip adduction being associated Many approaches that use symptom hoc, may be hypothesized when attempt-
with iliotibial band syndrome in run- modification have been based, in part, ing to explain the possible mechanism of
ners.7 Others have reported no relation- in a biomechanical/kinesiopathological the symptom modification.
ship,9 while some suggest that decreased paradigm, where it is assumed that pain This is well illustrated in the case se-
hip adduction is linked with iliotibial may be a result of restricted joint move- ries by Ikeda and McGill13 and contrasted
band syndrome.8 Within the same re- ment, suboptimal alignment/control of with the cognitive functional therapy ap-
search study, inconsistencies in proposed anatomical structures, excessive struc- proach.30 Ikeda and McGill13 identified
kinematic flaws and their relationship to tural loads, lack of stability, or inabil- pain-provocative movements and then
injury have also been documented. For ity to relax muscles during movement. made changes (movement modifiers) to
example, in recreational runners, in- Treatment based on changes in move- the movements, with the intention of re-
creased hip adduction has been prospec- ment behaviors, and thus biomechanics, ducing pain during measures of muscle
tively linked to patellofemoral pain, but justifies the movement corrections based activity, kinematics, lumbar joint loads,
not to calcaneal eversion or hip internal on symptom response alone. Across dif- and joint stability. The authors report-
rotation.21 The inconsistent relationship ferent treatment models, the hypotheses ed that each participant had different
between biomechanics and pain24 chal- underpinning the models and the appli- pain-provoking activities and different
lenges the existence of ideal movements cation of the procedures may appear po- responses to suggested interventions (ie,
and the use of an ideal movement stan- larized and contradictory. For example, to movement modifications). In that case
dard to guide clinical decisions. reduce lumbar symptoms, some modifi- series, a number of movement modifica-
Further, while the process of attempt- cation models recommend bracing and tions were attempted, and the “correct”
ing to change presumed kinematic or others recommend relaxing the lumbar modification was the one that changed
kinetic impairments or movement be- spine during functional activities, such as symptoms. When identified, the authors
haviors may be helpful in decreasing pain bending or squatting. Many approaches then quantified spinal biomechanics dur-
and disability, this is not always associat- to symptom modification are described ing the activity now performed with less
ed with changes in the assumed kinesio- in the literature, and the approaches de- pain.13
logical dysfunction. For example, studies tailed in the TABLE highlight how seem- For example, one participant experi-
investigating shoulder kinematics follow- ingly different approaches have similar enced dramatic reductions in pain during
ing exercise interventions designed to treatment components. The quotations a squat when taught to minimize lumbar
change joint kinematics have often shown describing each approach illustrate that spine flexion, increase hip flexion, and
improvements in symptoms with little to the primary and common objective (the consciously increase the activation of the
no change in joint kinematics.2,18,28 This practical application) of part of the inter- latissimus dorsi to create a “bracing” ac-
Viewpoint recognizes that the clinical ap- vention is based on, and guided by, symp- tion. The authors reported that this new,
proach of changing movement parame- tom modification. The proposed rationale less painful movement occurred with
ters and assumed impairments may enjoy for the movement modifier is often based decreased lumbar flexion and increased
clinical success; therefore, an alternative on, or evolved from, biomechanics. mediolateral shear forces.13 A second
rationale for changing movement behav- The common objective of these ap- participant experienced pain with a sit-
iors and guiding changes in movement proaches is to identify movements that to-stand task. This pain was abolished
journal of orthopaedic & sports physical therapy | volume 48 | number 6 | june 2018 | 431

[ viewpoint ]
when the participant performed a move- ing symptoms as a guide may be illus- approach. For example, a patient who
ment modification consisting of abdomi- trated further when the “spine stability” experiences pain while performing lum-
nal bracing and attempting to minimize approach is contrasted with the osten- bar spine flexion might be instructed to
lumbar spine flexion while increasing hip sibly different approach of the cognitive perform the painful task in a slightly dif-
flexion. However, instead of an increase functional therapy research group.30 ferent context or position.20,30 This might
in mediolateral shear (reported in the Cognitive functional therapy is an involve spinal flexion while on all fours,
previous patient), a decrease in mediolat- approach that aims to address the mul- sitting, or lying on the back. This slight
eral shear was quantified.13 Here we have tidimensional nature of low back pain. change in technique might also be ac-
a short-term clinical “success” based on Within this approach is a respect for companied by changes in how the trunk
symptoms with different response to me- biomechanical contributors to a patient’s muscles create or control that movement.
diolateral shear stability. Clinicians can’t pain. Much like the previous “spine sta- In contrast to the movement modifier
measure these biomechanical variables, bility” approach, a cognitive functional involving spinal bracing, these clinicians
and the complexity of these cases and therapy–trained clinician will perform a might encourage a patient to bend with
what correlates with symptom changes physical assessment to find painful pos- the trunk muscles more relaxed and/or
suggest that the biomechanical variable tures (eg, sleeping, standing) and painful with a focus on relaxed breathing. The
cannot be used to guide the treatment. movements (eg, sit-to-stand, squatting, correct way to move the spine or perform
Rather, it is symptom modification bending forward). the task is not driven by an assumed ideal
that is important, which is in turn influ- Cognitive functional therapy aims to of spine function, but rather the chosen
enced by changing biomechanics. But the address the multiple dimensions of pain, movement modification is justified via
correct biomechanical change may only and one component of the intervention symptom modification. While cogni-
be validated via symptom modification, involves changing the movement behav- tive functional therapy may have justi-
not via an a priori goal (eg, changing ior associated with pain. Many of the fied movement modification based on a
mediolateral shear). Additionally, both common movement modifications seen biomechanical rationale, it appears that
successful movement modifications mini- within the cognitive functional therapy the model has expanded to also acknowl-
mized the painful type of movement (spi- approach for patients with pain asso- edge the role of pain-inhibitory processes
nal flexion). Thus, the correct movement ciated with lumbar spine flexion con- linked to reducing fear of pain using an in-
strategy was avoiding the movement that trast some of the strategies seen in the terplay of disclosure of pain beliefs as well
hurt, that is, symptom modification. Us- previously described “spine stability” as emotional and physical impact of pain

TABLE Symptom Modification in Contemporary Clinical Practice
Name Practical Application Proposed Rationale

The Shoulder Symptom Modification “The person with shoulder symptoms An aim of the Shoulder Symptom Modification Procedure is to assess the response to (1) chang-
Procedure17 informs the clinician if an individual pro- ing the thoracic kyphosis, (2) changing scapular position, and (3) muscle contraction aiming
cedure: partially or completely alleviates to influence the glenohumeral joint. The rationale is not to produce a permanent change in
symptoms; has no change on symptoms; posture but to use any positive change as a potential treatment technique, challenging the
or makes symptoms worse”17 individual’s previous experience of symptoms
Mobilization with movement31 “The technique is indicated if, during its An aim is to identify positional faults that occur secondary to injury and that lead to maltracking
application the technique enables the of the joint, resulting in symptoms such as pain, stiffness, or weakness11
impaired joint to move freely without pain
or impediment”31
Correction of “instability catches” “A clinical kinesiologist then used verbal and Increasing the stiffness of the torso has been suggested to arrest micromovements of the spine to
and the “McGill” approach13 manual cues to alter motion and muscle- reduce pain in those with instability.16 Minimizing spinal flexion and increasing torso stiffness
activation patterns in attempt [sic] to during lifting or bending have been suggested to be optimal for spine mechanics13
immediately reduce or remove pain”13
Cognitive functional therapy30 “In this manner they were instructed to Historically, interpretation of reductions in pain via cognitive functional therapy interventions was
change old pain provocative move- explained by a reframing of patients’ beliefs about their spine, along with the unloading of
ment behaviours and to reinforce their pain-sensitive structures3 via reducing abnormal tissue loading induced via unnecessary trunk
new functionally enhancing movement muscle cocontraction or rigid spinal postures.5 More recently, movement modifications along
behaviours”30 with other interventions may involve a process that commonly reduces pain responses during
the exposure, creating opportunities to violate expectations that movement is painful and
threatening, thereby facilitating inhibitory learning processes32

during the interview, combined with expo- and neuroimmune systems.31 In practice, symptomatic movement and incorporat-
sure to feared, avoided, or painful activi- a painful movement is identified, and ing the change into functional move-
ties while reducing sympathetic responses, then a hand or treatment belt provides ments, aiming to disrupt pain memories).
abolishing protective and safety behaviors, a force to either the region of the painful Many clinicians will have observed that
and normalizing body schema.22 joint or a joint remote to the symptoms after repeating this assistance and then
The biomechanical justifications for that has been determined to influence the slowly removing the assistance, the pa-
both models appear to be vastly contra- pain. However, as the aberrant joint ar- tient will still continue to have less pain,
dictory, but if viewed from the perspective throkinematics or positional faults (much or the same patient may report reduced
of the apparent aim of both approaches, like measures of spine stability or shear symptoms with multiple testing proce-
symptom modification, then the appro- loads) cannot be measured or assessed dures. This may be due to a biomechani-
priate technique is the one that allows clinically and can only be hypothesized, cal overlap in the different techniques
the movement to be performed with as such, the changes in symptoms guide or to a nonbiomechanical effect of the
a reduction in the experience of pain. the intervention. modification procedure. Again, it is the
Thus, the approaches are quite similar in The SSMP is embedded within a symptom modification that drives the
their practical applications, even though comprehensive management package decision making, rather than an “ideal”
their views of ideal joint movement or including advice, education, exercises for biomechanical movement.
the proposed mechanism of effect dif- the rotator cuff, and, frequently, whole- Symptom-modification applications
fer substantially. Both approaches may body rehabilitation. When applying the are described in many other approaches.
also contribute to improved outcomes SSMP,17 a symptomatic movement is Those treating tendinopathy will often
by demonstrating to patients that they identified, and then the clinician makes advocate 30 to 45 seconds of isometric
are able to control their pain, which in various changes in 3 areas (thoracic spine, loading.26 This is essentially a symptom
turn may influence self-efficacy, locus of scapula, glenohumeral region) to deter- modifier to allow a person to function
control, emotional responses, and the re- mine whether shoulder-related symp- with less pain. Mechanical Diagnosis
sumption of meaningful and functional toms change. While the initial rationale and Therapy29 uses preferred-direction
activities. Thus, components of the treat- for those changes may have previously techniques that are essentially chosen
ment that might appear driven and ex- been driven by a potential kinesiological for their ability to modify symptoms.
plained by biomechanics may lead to effect, it is the symptom modification that Neurodynamic techniques that involve
changes in pain via other contributors to is of primary importance to guide treat- the movement of neural tissue are often
sensitization. ment. Practically, the SSMP techniques chosen on the basis of finding and chang-
Other symptom-modification ap- are individual clinical experiments that ing pain,4 and running re-education
proaches include mobilization with aim to reduce symptoms. For example, may utilize changes in gait that modify
movement (MWM) and the Shoul- pain may be experienced with shoulder symptoms.6
der Symptom Modification Procedure flexion that is abolished with scapular re- Symptom modification is the common
(SSMP). Similar to cognitive functional positioning. It could be hypothesized that thread among many seemingly disparate
therapy and Ikeda and McGill’s case this decrease in pain is due to alterations approaches used in contemporary mus-
series,13 a symptomatic movement or in the subacromial space, altered joint culoskeletal practice. Perhaps there is an
activity is identified, and then a modifi- positioning, changes in muscle length- unnecessary focus on the presumed dif-
cation is made to determine whether the tension relationships, changes in neural ferences between approaches, similar to
symptoms are reduced during the move- tension, or reduced vascular compromise the unexplored assumptions that have
ment. With MWM, the initial rationale resulting in potentially less mechani- led to clinical differences in how spinal
for the treatment was historically based cal pressure on a sensitized structure. It disorders are treated versus extremity
on aberrant joint arthrokinematics “re- is acknowledged and clearly stated that disorders.14 It is possible that common
lated to minor positional faults that oc- the mechanisms underpinning any re- themes link the SSMP, cognitive func-
cur secondary to injury and that lead duction in symptoms using the SSMP tional therapy, the McGill approach,
to mal-tracking of the joint, resulting are not known.16 The intention is not to MWM, and other symptom-modifying
in symptoms such as pain, stiffness, or change posture but to use the change in approaches. A common aim is symptom
weakness.”11 It should be noted that while symptoms as a way of challenging the reduction, which, if achieved, allows the
this mechanical explanation has been individual’s beliefs relating to the symp- individual to move with less pain. How
proposed, proponents of MWM also sug- toms (eg, being told a rotator cuff tear this is achieved is unknown and may
gest that other explanations for the pos- will only respond to surgery), and then to involve myriad multidimensional pro-
sible mechanisms of action include the use the technique that reduces symptoms cesses. People move differently when
role of the endocrine, neurophysiological, in treatment (eg, repeating the previously they experience pain,12 and a reduction

[ viewpoint ]
in symptoms may permit changes to the sensitizing. The inability to modify tasks, and, in so doing, “disrupt” the
way people move by decreasing the threat symptoms may also cause consterna- previous memory and association of
and fear associated with that movement. tion in the clinician that, in turn, may that task with symptoms.32,34
Modifying symptoms may demonstrate be imparted to the patient. This is also
to patients that their pain is reducible or a potential issue with other forms of Summary
controllable, and may increase movement clinical management, such as long- Symptom modification is a commonly
variability and may also influence the term exercise programs that similarly used approach in contemporary muscu-
manner in which afferent information is fail to reduce symptoms. Appropriate loskeletal practice and was born out of
processed. Alternative explanations sug- education, advice, and explanations, the realization that identifying the struc-
gest that moving with less pain results together with appropriate clinician- tural source of symptoms is generally
in an expectancy violation that might patient interaction, should moderate not possible and that making movement
involve inhibitory learning processes this concern. modifications based on kinesiological
that influence pain and fear.32,34 Perhaps 5. Modifying biomechanics may be ben- ideals may be unnecessary and unsup-
most importantly, all of the mentioned eficial for other reasons beyond symp- ported. The proponents of symptom-
approaches appear to reduce symptoms tom modification. Biomechanics may modification procedures have proposed
via repeated movements that are then in- be relevant for performance benefits15 seemingly divergent mechanisms to ex-
tegrated into meaningful and functional and, perhaps, injuries to specific tis- plain the technique. The definitive mech-
activities for the patient. sues where the load exceeds the abil- anisms underpinning any reduction in
ity of the structural properties of that symptoms using these procedures are not
Uncertainties With tissue (eg, anterior cruciate ligament clearly understood. Research on the un-
Symptom Modification tears). certainties associated with this approach
Although symptom reduction may be is needed to fully understand these com-
part of a comprehensive approach that The Value of Symptom Modification monly used procedures in contemporary
addresses the multidimensional nature The commonality of the symptom-modi- clinical practice. t
of pain, there are ongoing challenges fication approach in contemporary mus-
and uncertainties associated with this culoskeletal practice may in part be due
approach. to myriad variables: REFERENCES
1. Symptom modifiers are often used as 1. Pain relief may be considered as an
1. Barrett E, O’Keeffe M, O’Sullivan K, Lewis J, Mc-

a temporary desensitizer, yet it is un- outcome desired by many patients and Creesh K. Is thoracic spine posture associated
known how long modifications need to therapists. with shoulder pain, range of motion and function?
persist to contribute to a meaningful 2. Reducing the experience of pain with A systematic review. Man Ther. 2016;26:38-46.
https://doi.org/10.1016/j.math.2016.07.008
change. There is evidence that move- concomitant improvement in func-
2. Camargo PR, Alburquerque-Sendín F, Avila MA,
ment modifications need to persist for tion may contribute to reducing the Haik MN, Vieira A, Salvini TF. Effects of stretching
pain or disability to be reduced.20 impact of negative influences, such as and strengthening exercises, with and without
2. Are symptom-modification tech- reduced self-efficacy, catastrophizing, manual therapy, on scapular kinematics, func-
tion, and pain in individuals with shoulder
niques necessary, and do they confer locus of control, fear avoidance, and
impingement: a randomized controlled trial. J Or-
any additional benefit, or are other kinesiophobia. thop Sports Phys Ther. 2015;45:984-997. https://
components of clinical management 3. Symptom modification may be uti- doi.org/10.2519/jospt.2015.5939
sufficient? lized to promote or reinforce other 3. Cañeiro JP, Ng L, Burnett A, Campbell A,
O’Sullivan PB. Cognitive functional therapy
3. Symptom reduction should not always educational messages related to pain.
for the management of low back pain in an
be seen as an end in itself, especially If the clinician is communicating adolescent male rower: a case report. J Orthop
if there are additional requirements, educational information that pain is Sports Phys Ther. 2013;43:542-554. https://doi.
such as strength training. However, a an alarm, is poorly related to damage, org/10.2519/jospt.2013.4699
4. Coombes BK, Bisset L, Vicenzino B. Management
reduction in symptoms may then fa- and can change, then symptom modi-
of lateral elbow tendinopathy: one size does not
cilitate attainment of other treatment fication may be helpful in challenging fit all. J Orthop Sports Phys Ther. 2015;45:938-
goals and aims. potentially conflicting beliefs pertain- 949. https://doi.org/10.2519/jospt.2015.5841
4. Symptom reduction might not be ing to pain, and may reduce the threat 5. Dankaerts W, O’Sullivan P, Burnett A, Straker L,
Davey P, Gupta R. Discriminating healthy controls
possible, and attempting symptom imposed by the symptoms.
and two clinical subgroups of nonspecific chronic
change that does not achieve its goal 4. If symptoms are reduced, then the low back pain patients using trunk muscle activa-
may create hypervigilance or unrea- patient may be able to repeat the task tion and lumbosacral kinematics of postures and
sonable patient expectations that ul- multiple times and introduce that movements: a statistical classification model.
Spine (Phila Pa 1976). 2009;34:1610-1618.
timately become demotivating and movement into meaningful functional

https://doi.org/10.1097/BRS.0b013e3181aa6175 SSC.0000000000000130 ptj.20150660
6. Esculier JF, Bouyer LJ, Roy JS. The effects of a 16. L ee BC, McGill SM. Effect of long-term isometric 26. Rio E, van Ark M, Docking S, et al. Isometric
multimodal rehabilitation program on symp- training on core/torso stiffness. J Strength Cond contractions are more analgesic than isotonic
toms and ground-reaction forces in runners Res. 2015;29:1515-1526. https://doi.org/10.1519/ contractions for patellar tendon pain: an in-
with patellofemoral pain syndrome. J Sport JSC.0000000000000740 season randomized clinical trial. Clin J Sport
Rehabil. 2016;25:23-30. https://doi.org/10.1123/ 17. L ewis JS, McCreesh K, Barratt E, Hegedus EJ, Med. 2017;27:253-259. https://doi.org/10.1097/
jsr.2014-0245 Sim J. Inter-rater reliability of the Shoulder JSM.0000000000000364
7. Ferber R, Noehren B, Hamill J, Davis IS. Symptom Modification Procedure in people 27. Struyf F, Nijs J, Meeus M, et al. Does scapular
Competitive female runners with a history of with shoulder pain. BMJ Open Sport Exerc positioning predict shoulder pain in recreational
iliotibial band syndrome demonstrate atypical Med. 2016;2:e000181. https://doi.org/10.1136/ overhead athletes? Int J Sports Med. 2014;35:75-
hip and knee kinematics. J Orthop Sports Phys bmjsem-2016-000181 82. https://doi.org/10.1055/s-0033-1343409
Ther. 2010;40:52-58. https://doi.org/10.2519/ 18. M cClure PW, Bialker J, Neff N, Williams G, Kar- 28. Struyf F, Nijs J, Mollekens S, et al. Scapular-
jospt.2010.3028 duna A. Shoulder function and 3-dimensional focused treatment in patients with shoulder
8. Foch E, Reinbolt JA, Zhang S, Fitzhugh EC, Milner kinematics in people with shoulder impingement impingement syndrome: a randomized clinical
CE. Associations between iliotibial band injury syndrome before and after a 6-week exercise trial. Clin Rheumatol. 2013;32:73-85. https://doi.
status and running biomechanics in women. program. Phys Ther. 2004;84:832-848. https:// org/10.1007/s10067-012-2093-2
Gait Posture. 2015;41:706-710. https://doi. doi.org/10.1093/ptj/84.9.832 29. Surkitt LD, Ford JJ, Chan AY, et al. Effects of indi-
org/10.1016/j.gaitpost.2015.01.031 19. M øller M, Nielsen RO, Attermann J, et al. Hand- vidualised directional preference management
9. Grau S, Krauss I, Maiwald C, Axmann D, Horst- ball load and shoulder injury rate: a 31-week versus advice for reducible discogenic pain: a
mann T, Best R. Kinematic classification of cohort study of 679 elite youth handball players.
pre-planned secondary analysis of a randomised
iliotibial band syndrome in runners. Scand J Br J Sports Med. 2017;51:231-237. https://doi.
controlled trial. Man Ther. 2016;25:69-80.
Med Sci Sports. 2011;21:184-189. https://doi. org/10.1136/bjsports-2016-096927
https://doi.org/10.1016/j.math.2016.06.002
org/10.1111/j.1600-0838.2009.01045.x 20. N g L, Cañeiro JP, Campbell A, Smith A, Burnett
30. Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A,
10. Harris-Hayes M, Czuppon S, Van Dillen LR, et al. A, O’Sullivan P. Cognitive functional approach to
Kvåle A. Efficacy of classification-based cognitive

Movement-pattern training to improve function manage low back pain in male adolescent row-
functional therapy in patients with non-specific
in people with chronic hip joint pain: a feasibility ers: a randomised controlled trial. Br J Sports
chronic low back pain: a randomized controlled
randomized clinical trial. J Orthop Sports Phys Med. 2015;49:1125-1131. https://doi.org/10.1136/
trial. Eur J Pain. 2013;17:916-928. https://doi.
Ther. 2016;46:452-461. https://doi.org/10.2519/ bjsports-2014-093984
org/10.1002/j.1532-2149.2012.00252.x
jospt.2016.6279 21. N oehren B, Hamill J, Davis I. Prospective
31. Vicenzino B, Paungmali A, Teys P. Mulligan’s
11. Hing W, Bigelow R, Bremner T. Mulligan’s mobi- evidence for a hip etiology in patellofemoral
lization with movement: a systematic review. J pain. Med Sci Sports Exerc. 2013;45:1120-1124. mobilization-with-movement, positional faults
Man Manip Ther. 2009;17:39E-66E. https://doi. https://doi.org/10.1249/MSS.0b013e31828249d2 and pain relief: current concepts from a critical
org/10.1179/jmt.2009.17.2.39E 22. O ’Sullivan P, Caneiro JP, O’Keeffe M, O’Sullivan K. review of literature. Man Ther. 2007;12:98-108.
12. Hodges PW, Smeets RJ. Interaction between pain, Unraveling the complexity of low back pain. J Or- https://doi.org/10.1016/j.math.2006.07.012
movement, and physical activity: short-term thop Sports Phys Ther. 2016;46:932-937. https:// 32. Vlaeyen JW. Learning to predict and control
benefits, long-term consequences, and targets doi.org/10.2519/jospt.2016.0609 harmful events: chronic pain and conditioning.
for treatment. Clin J Pain. 2015;31:97-107. https:// 23. P lummer HA, Sum JC, Pozzi F, Varghese R, Pain. 2015;156 suppl 1:S86-S93. https://doi.
doi.org/10.1097/AJP.0000000000000098 Michener LA. Observational scapular dyskine- org/10.1097/j.pain.0000000000000107
13. Ikeda DM, McGill SM. Can altering motions, sis: known-groups validity in patients with and 33. Wainner RS, Whitman JM, Cleland JA, Flynn TW.
postures, and loads provide immediate low back without shoulder pain. J Orthop Sports Phys Regional interdependence: a musculoskeletal ex-
pain relief: a study of 4 cases investigating spine Ther. 2017;47:530-537. https://doi.org/10.2519/ amination model whose time has come. J Orthop
load, posture, and stability. Spine (Phila Pa 1976). jospt.2017.7268 Sports Phys Ther. 2007;37:658-660. https://doi.
2012;37:E1469-E1475. https://doi.org/10.1097/ 24. R atcliffe E, Pickering S, McLean S, Lewis J. org/10.2519/jospt.2007.0110
BRS.0b013e31826c97e5 Is there a relationship between subacromial 34. Zusman M. Associative memory for movement-
14. Jull G. Discord between approaches to spinal impingement syndrome and scapular orienta- evoked chronic back pain and its extinction
and extremity disorders: is it logical? J Orthop tion? A systematic review. Br J Sports Med. with musculoskeletal physiotherapy. Phys
Sports Phys Ther. 2016;46:938-941. https://doi. 2014;48:1251-1256. https://doi.org/10.1136/ Ther Rev. 2008;13:57-68. https://doi.
org/10.2519/jospt.2016.0610 bjsports-2013-092389 org/10.1179/174328808X251948
15. Kushner AM, Brent JL, Schoenfeld BJ, et al. The 25. R ichards KV, Beales DJ, Smith AJ, O’Sullivan
back squat part 2: targeted training techniques PB, Straker LM. Neck posture clusters and their
@ MORE INFORMATION
to correct functional deficits and technical fac- association with biopsychosocial factors and
tors that limit performance. Strength Cond neck pain in Australian adolescents. Phys Ther.
J. 2015;37:13-60. https://doi.org/10.1519/ 2016;96:1576-1587. https://doi.org/10.2522/ WWW.JOSPT.ORG
VIEW Videos on JOSPT’s Website

Videos posted with select articles on the Journal’s website (www.jospt.org)
show how conditions are diagnosed and interventions performed. To view
the associated videos for an article, click on Supplementary Material and
scroll down to stream the videos online or download them to your
computer or device.

The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice

Uploaded by

Copyright:

Available Formats

[ viewpoint ]

GREGORY J. LEHMAN, MSc, DC, MScPT1