1. 1. Tara’s story of back pain present for approximately 15 months would be broadly classified as non-specific chronic musculoskeletal pain by many clinicians. Such presentations are frequently linked to nociplastic pain. On the basis of Tara’s story, would you discuss your hypotheses regarding the dominant ‘pain type’ (nociceptive, neuropathic, nociplastic) in her presentation and whether you feel there were any psychosocial factors that may have contributed to the maintenance of her pain and disability?

Although I would agree that Tara’s back pain could be classified as non-specific and chronic, I didn’t believe it was only due to sensitization of her CNS. When her physical, social and emotional behaviours are considered, there were no indications that she was catastrophizing, hypervigilant or demonstrating other maladaptive behaviours/beliefs associated with dominant nociplastic pain type. She continued to work 4 days per week, ski and participate in yoga and Pilates classes. Her symptoms were localized and consistent with a nociceptive pattern of aggravation; thus, it was more likely that her pain was peripherally mediated even though it was chronic. Her beliefs were realistic given the history of events during her pregnancy and worth exploring through physical examination of the abdominal wall. If she did tear the LA and does have herniation of the abdominal contents, her ability to stabilize the joints of her low back and pelvis would be compromised due to loss of the force closure mechanism (Vleeming et al., 1990a, 1990b).

1. 2. Given your hypothesis of a nociceptive-dominant pain type, what structures/tissues do you hypothesize as possible nociceptive sources to her pain?

1. 3. Tara indicated that she believed her lack of abdominal strength was causing her to overuse her back muscles, which then caused her symptoms. Would you please discuss your interpretation of Tara’s beliefs and any associated implications for your physical examination?

Pregnancy and delivery present huge challenges for the abdominal wall and back. Lumbopelvic pain (Albert et al., 2001, 2002; Larsen et al., 1999; Östgaard et al., 1991, 1996), motor control changes of the abdominal wall (Beales et al., 2008; O’Sullivan et al., 2002; Smith et al., 2007; Stuge et al., 2006) and diastasis rectus abdominis (DRA) (Boissonault and Blaschak, 1988; Gilleard and Brown, 1996; Liaw et al., 2011; Mota et al., 2014) are common both during and after pregnancy. With respect to the structure of the abdominal wall, although evidence is limited, it appears that for some, recovery is not spontaneous without intervention (Coldron et al., 2008; Liaw et al., 2011; Mota et al., 2014).

From Tara’s story, two aspects of abdominal wall function would need to be assessed:

1. 1. The structural integrity of the LA and the ability of the abdominal wall to transfer load.
   
2. 2. Her ability to synergistically recruit the deep (transversus abdominis [TrA]) and superficial (internal [IO] and external oblique(s) [EO] and rectus abdominis [RA]) abdominal muscles with the other muscles of her core (back and pelvic floor muscles).

Consideration of pain type (e.g. nociceptive versus nociplastic) is a principal ‘hypothesis category’ discussed in Chapter 1, with significant implications for other clinical decision categories, such as potential sources of symptoms, precautions to examination and treatment, management and prognosis. Although chronicity is often associated with nociplastic pain/maladaptive sensitization, as highlighted in the Answer to Reasoning Question 1, this is not always the case. Maladaptive catastrophizing, hypervigilance and fears, along with social and behavioural factors, are considered here but found not to be evident, and the behaviour of symptoms is instead judged to be more consistent with a nociceptive-dominant presentation. This highlights the reality that pain and disability also can be maintained, in part or full, by continued physical stress and aggravation related to misconceptions (e.g. beliefs about the problem and what is needed, such as insufficient ‘core’ strength), behaviour (e.g. continued stress and aggravation from activities such as running and kayaking), environmental and social factors (not evident here) and physical factors screened later in the physical examination (e.g. alignment, mobility and control).

As discussed in Chapter 1, clinical patterns are not limited to diagnostic classifications of pathologies or syndromes; they also exist with regard to physical, environmental and psychosocial contributing factors, pain type, precautions/contraindications and prognosis. The Answer to Reasoning Question 3 reflects recognition of an evidence-informed clinical pattern of impaired motor control strategies induced by pregnancy with plans to test the hypothesis through specific physical examination assessments.

1. 4. Would you please explain the key features you assess during your analysis of standing posture and how you determine whether asymmetries identified are relevant or not to that patient’s presentation?

• This is a great question and highly appropriate because many clinicians get ‘bogged down’ with findings that, at the end of the examination, have no clinical relevance. Meanwhile, they are overwhelmed by the information and what it all means.

• • Standing for prolonged periods of time
  
• • Sitting
  
• • Squatting
  
• • Lifting
  
• • Running
  
• • Climbing stairs
  
• • Reaching overhead

A quick screen of standing posture allows the clinician to interpret what happens during movement more accurately. Very few of us stand perfectly aligned, and asymmetries in multiple regions of the body are common. So, when are they relevant to the clinical picture? In short, they are relevant when the individual is held in the asymmetric position and is unable to move, or control, the asymmetric region when he or she needs to do so. For example, in standing, it is common to find the pelvis rotated in one direction in the transverse plane and the thorax rotated in the opposite direction. For a squat task, both of these transverse plane rotations should unwind, and the pelvis and thorax should align symmetrically. Loads are increased through the lumbar spine if the thorax and pelvis remain rotated in opposite directions during the squat (Al-Eisa et al., 2006).

A thoracic ring is defined as two adjacent thoracic vertebrae, the left and right ribs of the same number as the inferior vertebra, the sternum or manubrium to which the ribs attach and all the joints that connect these bones (D. Lee, 1994) (Fig. 11.1A). Each thoracic ring has the potential to rotate in the same or opposite direction to the one above/below. Thus, whereas a quick screen of the thorax is regional (lower, middle, upper), a more detailed segmental thoracic ring analysis considers the positional relationship between each thoracic ring and provides information as to which thoracic ring is ‘driving’ the regional rotation. Linda-Joy Lee has developed novel assessment techniques (L-J. Lee, 2003a, b, 2005, 2007, 2008, 2012) for the analysis of both position and mobility of an entire thoracic ring. These particular tests, combined with biomechanical and arthrokinematic mobility tests (D. Lee, 1993, 1994, 2003), were used to understand the clinical relevance of Tara’s specific thoracic rings shifts as noted previously.

A thoracic ring shift is another way of saying that the thoracic ring is positioned in rotation. The word ‘shift’ refers to the direction of translation of a thoracic ring, which is a congruent motion that occurs when the thoracic ring rotates (D. Lee, 1993) (Fig. 11.1B). This translation is easy to detect when the thoracic ring position is assessed in the mid-axillary line (L-J. Lee, 2003a, 2005, 2008, 2012).

The clinical relevance of each asymmetry is determined by correcting the rotation/shift and assessing the following:

• • Whether a correction is possible or not (stiff, fibrotic or fixated joints will not allow the alignment of the thoracic or pelvic ring to correct)
  
• • The impact of the correction on the position/alignment of the other noted asymmetries
  
• • The impact of the correction on performance of the task being evaluated (standing posture, squat, arm elevation, one leg stand etc.)
  
• • The impact of the correction on the patient’s symptom experience (pain, tingling, burning, ability to breathe etc.)

In the Integrated Systems Model for Disability and Pain (Lee L.-J. and Lee D., 2011), this is called ‘Finding the Primary Driver’. Of note, the position of the trunk (thorax and pelvis) can also be influenced by the posture/position of the lower extremity, shoulder girdle, head and neck, so the ‘driver’ may not be within the trunk!

1. 5. Please discuss how you relate your analysis of regional and segmental postural corrections to contemporary motor control theory, and highlight what you attend to visually, kinaesthetically and via patient response in determining their relevance. Would you also comment on the current levels of evidence underpinning this assessment?

Multiple studies suggest that the response to back pain is individual and task specific (see the review article on pain and motor control by Hodges [2011]), although there are common features to most clinical presentations. Hodges (2011, p. 222) notes that back pain patients present with a ‘redistribution of activity within and between muscles (rather than inhibition or excitation of muscles in a stereotypical manner)’. All of the multisegmental muscles of the trunk contribute to movement and control, and when their activity is ‘redistributed’, they can produce specific vectors of force that contribute to thoracic ring shifts and pelvic rotations. Thus, Hodges states, ‘If the goal of rehabilitation (e.g. using motor learning strategies) is to modify the adaptation (remove, modify or enhance) then this needs to be considered on an individual basis with respect to the unique solution adopted by the patient’ (Hodges, 2011, p. 222–223).

The clinician’s challenge is to determine which muscles are ‘actors’ (creating the primary vector of force) and which are ‘reactors’ (reacting to the primary vector). Increased muscle activation noted on palpation or during a certain posture (standing, sitting) or task (seated trunk rotation, single leg standing) does not mean that this muscle should be released or stretched. Releasing ‘reactors’ allows the primary muscle (the actor) to increase the rotation/twist (and often the symptoms). Therefore, when looking for the driver, the clinician should also pay attention to the vectors of resistance to movement encountered during specific corrections and the location, direction, length and velocity of pull of the vector upon release of the correction. This vector analysis provides further information about the underlying source of the pull (articular, myofascial, neural, visceral) (Lee D. and Lee, 2011a).

The patient is engaged (focused attention and awareness) in this entire ‘correct and release’ process and is asked to provide feedback on the experience. Symptoms should not increase when the driver is corrected; rather, a sense of well-being, or ease, in the body is desirable, as is an improvement in the ability to breathe or any lessening of intra-abdominal, intra-thoracic or intra-cranial pressure. Less effort should be required to perform the task when the driver is held in a corrected position and the alignment, biomechanics and control are facilitated.

I am unaware of any research that has considered changes in the ‘gestalt’ of the patient’s experience specifically with thoracic ring corrections or any research that has investigated the impact of thoracic ring corrections on pelvic position, hip position, foot position and so forth. Currently, there are no measuring systems that are able to accurately measure segmental thoracic ring position or mobility, nor intra-pelvic mobility. These are clinical observations.

Application of research evidence to practice is challenging and requires judgment regarding the applicability of findings from the population studied to your patient and their context, and whether the intervention can be replicated in the clinic. Insufficient information is often reported on precisely what was implemented in the study, including details of treatment (e.g. positions, dosage, sequence, progression), patient–therapist therapeutic alliance (e.g. rapport, collaboration) or therapeutic education (e.g. explanations, advice, instructions) to enable clinicians to replicate the assessments and management (educatively, behaviourally and humanistically) with confidence. In the absence of empirical research evidence, as acknowledged here, existing biologically plausible theory (e.g. Hodges, 2011) can be applied to clinical practice, combined with careful monitoring of individual treatment effects to guide reasoning and overall management. Although monitoring of outcomes to judge overall success will include any changes in the patient’s activity (function) and participation restrictions and capabilities, monitoring (re-assessment) to determine relevance of physical findings, specific treatment interventions and progression of treatment requires attention to broader and more detailed (often qualitative) variables, as discussed here. These can include patient awareness and individual muscle activation patterns and their effects on patient symptoms, thoughts, movement control and other body sensations experienced during the functional task.