徒手療法の実際

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"susrs

ll

ManualTherapyin

Practice*

RichardErhard"

Iam honored to be invited to

Japan

by Dr.Nara and Dr.Takahashi to address the annual Practical

Assembly

of the

Japanese

Physical

Therapy

Associ-ation.

I

would

like

totake thisopportunity to

_give

special thanks to

Professor

Morinaga

and

Mr.

Harada for theirspecial assistance in making this

possible.

My

topictoday,

Manual

Therapy in Prac-tice,along with

Mr.

Searle's

topic,

History

and

Pres-ent Circumstances of Manual Therapy in the

World, has made me realize

how

the practice of

manual therapy has changed in the nearly twenty

years since Iwas elected firstpresidentof IFOMPT.

In

order to

illustrate

rnanual therapy

in

practice,

I

shall attempt to

follow

a

lew

back

pain patient

frorn

presentation

in

theclinic tothe end of the

tre-atment, including the history, behavior of

symp-toms and _physical examination. Ialso hope to be

able toprovide you with

data

supporting manual

therapy. I noted in your

handout

your

desire

for

perhaps

increasing

the scientific

basis

of physical

therapy; we also have thisdesire, We regard itas our mission toelevate the status of manual therapy

to

a science. Ihope

to

be

able

to

allude

to

this

sup-porting

data

as we go through the

presentation-something that

I

wouldn't

have

been

able to

do

until very recently.

Because

of the many technical

changes, manual

intervention

per se will

be

just

one component of the system that we now call

"manual

therapy". Inorder tofacilitateyour

under-standing

I

will use slides and pictures,

.

eelastaoxwa

.. _{AAOMTE.IJ--ft}

Vice President, A.A.O.M. T.,Center forSports cine and Rehabilitation,Universityof Pittsburgh

The Cathedral of Learning at the University of

Pittsburgh is where I_practice with my colleague,

Dr.

Anthony

Delitto,

in

the

Department

of

Physical

Therapy,

School

of

Health

and Rehabilitation Sci-ences.

Low back pain is often regarded as a

practitioner's

dilemna,

thus

it

enables the manual

therapist

to

tread upon ground where there

is

not

good scientific data.The main _problem isthe

patho-physiology

for

low

back

pain

is

not well under-stood. Experts' estimate from 10 to20 _per cent of

back _pain can

be

attributed toan identifiable

patho-logical

entity,

What

we're going todo today isemphasize

classi-fication,

not

diagnosis.

This

was coined by an

or-thopedic surgeon, Dr.Mooney, in 1979 and we have

been trying since that time to utilize the

classifica-tion procedure

in

addressing

low

back

pain.

The

first

order of classification is

"Can

the _patient be

managed

independently

by _physical therapy?", or `tDoes _the

patientrequire referra} toanother

practi-tioner?",or "Dees

the patient require consultation

with another

health

care practitioner?"

The

differ-ence

between

a referral

_.and

consultation

is

that a

referral

is

for

a patient who needs furthermedical

workup, we suspect serious _pathology or _pain ef non musculoskeletal origin. Consultation,however,

can

be

for

a

_patient

who may be helped

by

ad-junctive

medication forexample, non steroidal anti

inflammatories.

Finally,"What

to

do

with a _patient

who exhibits magnified illnessbehavior?" We have

found itisimportant toidentify these _patients as early as

possible.

70

vee#kza{}k

The

first

step then

is

to classify

the

patient-acute versus chronic, _physical versus _psychosocial

or with _{psychological}

factors,

serious _pathology

versus mechanical

low

back _pain.

In

order to

do

this,we must take a thorough historyand do a

care-ful

physical examination.

The

subjective

examina-tion

is

very important inlow

back

pain in

particu-lar

and the spine

in

generaL

We

need

to

have

apa-tient

history. The _patient must be suitable

for

a mechanical diagnosis;therefore,we need a current

history

and historyof _previous episodes as well as

symptom

behavior

with activity and/or

posture-what aggravates

the

_patient,what eases

his

_pain,

what are the risk

factors?

For

example,

is

the pa-tienta smoker, ishe involved in repetitive lifting,

etc.

After

considering these,we must make a

pro-visional

diagnosis.

First

we start

by

having

the

patientfi11out a self-assessment

form

called an

Oswestry.

Inour prac-ticewe have

found

that

if

a patient

has

a score of

75% or more of totaldisability,thiswould

indicate

very severe involvement and _{poor prognosis.} We

may need

to

use medical screenlng forthis_patient

or have magnified illness

behavior

investigated.

Each

patient coming

in

every

day

for

treatment

must

fi11

out a

body

diagram.

The

patient

filts

out

the body diagram where he feelspain, paresthesia,

or both. He also fillsout a visual analog scale.

This isnumbered from O

(no

_pain)to 10

(pain

as

severe as could

be>.

In practice,we no longer use

the numbers,

just

the two definitionsbut for pur-poses of explanation today,

I

have

included

the

numbers. Inpractice, we simply take a centimeter

stick, layiton the scale and number

it

after the

pa-tienthas chosen

his

level

of _pain.

We

found

that staging the

patient

with low back

pain

syndrome

is

more related to the severity of

disability

than the

duration of symptoms; thus,sometimes the terms "acute", "subacute"

and "chronic"

are lessuseful, in factmore diMcult, than not using these terms. If

you look at the current literature,thereare several

different

opinions as towhat constitutes the

difini-tionof acute, subacute and chronic.

We

tryto

have

ee

21

gee

2

it

goal oriented. A

Stage

Imeans that the _patient has

diMcttlty

in performing the basic mechanical

functions

of standing, walking, sitting or all of

those.

Stage

II

means the patientcan _perform

base

lineactivities

but

cannot do this

for

any extended

period of time without recurrence or worsening of status of symptoms. In Stage IIIthe _patientcan sit, stand or walk

indefinitely

but

is

unable

to

form

the required

duties

of employment or sport.

Stage IV isprevention of occurrence or recurrence. The examination _procedure then,after the history istaken, starts by the initialobservation of

ing

the

patientremove

his

shoes and socks.

We

also

trytoobserve the patientarising

from

a chair

out him being aware that we are making such an observation. Itisa good idea tocall the _patientin

from the waiting room _yourself,enabling _you to

observe

the

way

the

patient arises

from

the

chair

or,

in

fact,that he may not even take the

nity of sitting while awaiting your calL

Next,

we

look

at thepalpationof the _pelvic

landmarks

in

the

weightbearing pelvic prone knee flexiontestis

tt

itive,we may then intervene and treatthe _pelvis, return the _patientto thestanding _positiontosee if these landmarks

have

changed. Finally,we are

going to perform movement testing-standing,

ting,supine and prone, todetermine which way we

should treatthis_patient. The

lower

_quarter screen isdesigned then to identify problems with the

lower

extremity kinetic chain-is there a pelvic

compenent; istherea leglengthdiscrepancy or are there problems arising

from

the hip area?

These

we need toeliminate as soon as possibletogive us

a clear picture or what

is

occuring

in

the

lumbar

spine

itself.

The

specifics of examination then are to

look

at the signs, the symptoms, and most

portantly to us as

far

as

driving

treatment,

has

the symptorn changed with response to

different

ment?

After

evaluating allthesevariables, we then

rnust commit ourself toa provisional diagnosis. Is

thispatienta mechanical or non mechanical

lem;

is

he

a

Stage

I

or a

Stage

II;

perhaps

he

needs

ftItszaoscwa

exam or

do

we

have

todo _pain modulation before

engaging inmovement testing, Let'stake an

exam-ple of a patient

in

Stage

I,

patients who

demon-strate a change

in

status with

functional

activity of

sitting, standing and walking.

In

thisstage, our goal

is

pain modulation.

These

are the

dfferent

syndromes thatwe

have

identified

that exist inthe

Stage

I,or

Phase

I,

_patient:extension, flexion, later-al shift, mobilization,

traction,

immobilization,

or

the aforementioned

lower

extremity

infiuencing

pelvic involvement,

hip

and/or

leg

Iength.

We wouid then subcategorize these_patientsintoone or

more of thesevarious syndromes so that we can

in-itiate

treatment.

The

first

syndrome that

I

would

like

to

discuss

with you

is

one that

improves

with avoidance of

movement, the one we call immobilization. The

first

example would

be

a _patientthat exhibits

un-stable spondylolisthesis;

this

would

be

described

as a

bony

instability,

however

_you can also see that there

is

discal

instability

associated with this

par-ticular_patient

_(making

reference tothe x-ray

being

observed).

The

next x-rays viewed are of a

differ-ent patient,

first

standing erect and second when asked to bend forward while inthe standing

posi-tion.

From

the

x-ray, _you can see hislordosis

has

actually

increased

slightly compared

to

his erect

standing position.

The

next view shows

the

same

patient

in

forward

bending

after repeating

4

for-ward bending movements. Now you can see that

with

the

_protectivemuscle spasm inhibited,the

pa-tient

has

now losthis lordosisand, in fact,has

ex-hibited

what we call "Discal

instability",

that

is

to

say there

is

no real translation

_present

but

the

disc

has lostitsintegrity when asked to assume load

bearing with the

flexion

of the lumbar spine, The

functions of lumbar immobilizaiton are to serve as a rerninder

for

l)

restriction of movement; 2)to

apply abdominal _pressure to

decrease

loads

on the

lumbar

spine; and

3)

tomaintain a normal

lumbar

lordosis.

We

are of theidea thatwe can't truly

im-mobilize a spine,

but

we are _going

to

_prevent

it

from _getting to the ends of the range of motion.

71

One

of

the

several

devices

we can use

for

thisisthe

MacNab

brace.

The

patient

is

placed

in

this

brace

which

has

a lumbar componerrt as well as a

thorac-ic

component. This enables this_patient

to

remain

imrnobilizedinthe standing _positionas well as the

sitting. One of the

big

_problems with using

exter-nal immobiLization iscompliance. One of the

ad-vantages of thisparticular

device

is

that

it's

easy to

get

into

and out of

by

oneseLf.

There

are also syndromes thatimprove with

pas-sive movement. Remember we talked about the

immebilizaiton _patient who actually improved

his

status with avoidance of movement.

Now

we are going totalk about those who

im-prove with passive movement, First,the

mobiliza-tionand tractionpatients.

Mobilization

and Manip-ulation

Symptoms

IIrefers to thelumbar spine

pa-tient.

We'11

talkabout

the

_pelvisa littlelater.

The

history

is

frequently

acute, sudden onset, without

deformity-that

is,

when _you see the

_patient,

he

has

no shift or

kyphosis.

Frequently

the _pain has

occurred during extension from the forward

bend-ing

_positionand sometimes with rotation.

There

is

unilateral pain and

if

referred pain

is

present,

it

confined toabove the

knee.

Signs

present

in

this type of patientare negative or absent neurological signs, unilateral pain with flexion

in

side

bending

tothe opposite side;

in

order tomake this

diagno-sis, we

have

torule out muscle spasm, The other

option isunilateral _pain with extension and side

bending

on

the

same side; we rnust rule out manip-ulation and mobilization

L

The next x-ray isa

pa-tient standing, neutral position

(not

side

bend-ing).

Now

thepatient

is

attempting

to

side

bend

to

the left;there issome motion in the iower lumbar segrnents as

he

attempts thismotion. When

the

pa-tientside bends to the right, the lefthip is_pulled

up off the

floor,

16oking at L3, we can see a

consid-erable amount of motion istaking _placebetween L

3

ancl

L4,

The

problem

is

thatno motion is'taking

place at

L4,

L5

or

L5,

SL

This

is

the opposite of

the

immobilization

patient that we showed eariier

72

wa\mstw\

enough movement, This treatment isvery sirnilar

to

what Ian demonstrated earlier on his _patient;in

this _particularcase, we are doing soft tissueto

insure

that

this

patient'sproblem isnot

just

restric-tion of soft tissue. Note that we have him in the

leftside

bent

_position.Moving on tea mobilization or manipulative procedure, we want toopen up the side opposite towhich he

is

restricted. Inthe same

type of _pattern shown on the x-ray, the _patient would not close down on theside towhich he was

bending

and, in thiscase, after undergoing thesoft

tissueand the traction or opening maneuver, we

would

be

obliged to close down on the side to

which

he

is

restricted.

We

haye

a very

big

problem

in

that

determining

what works

has,

to date,been very

individual

and, as

Mr.Searle

has

pointed out,

has been emperical. There are a number of

differ-ent approaches,

but

we think itistime for us to

become

more scientific, so we

have

to

determine

what works. Currently, we're using a consensus

panel opinion and what we want to

head

toward

is

a _peerreview _publication,

As we go

from

case study to _{quasi-experimental}

study to true experimental studies, we have in-creasing diMculty in doing _these types of studies.

On

the

other

hand,

the

relationship of

treatment

to

the outcome is

better.

We

think we have to

do

all

of the above,

but

ideally

we would

like

to

be

able

to do experimental studies. This

_proves

much

more dithcultin the clinic than most kinds of

'perlments.

First,we're _going to use a case _{presentation.}

This

is

something that

I

urge allof _you to

do.

It

was once considered thatcase _presentation was not

scientific;

however,

if

you read medical

journals,

in

particularorthopedic

journals,

they use case

pre-sentations very well. We need to do more of these

-this

_is

_the

_{simplest method of}

_justifying

_{what we}

do.

This _{particularpatient}isa manual laborerand

presented with

left

back

and

left

leg

_pain.

He

was

shifted away from his _pain; he had flexion,side

bending

and rotation tothe right; he had

neurolog-icalsigns eminating from L4, L5; his straight leg

E21gee2g

raising on the leftwas 20"; his extensor hallisus

longus was weak and he had a

decrease

in

his

Achil-les refiex. This is the way he _presented to the

clinic-he is

deviated

to

the

right, he is

fixed

in

kyphosis, he isinright rotation, and heis

attempt-ing totake weight off

his

Ieft

lower

extremity.

Fol-lowing the treatment categories that we discussed

earlier, we are going toplace him intothecategory

of lateralshift correction-very much inPhase

I.

A

lateralshift syndrome isa movement-related

symp-tom

behavior.

He

is

unable tosit

for

prolonged

periods;

he

worsens with activity

involving

fiexion;

he

also worsens with walking. Sittingand walking are worse than standing. Usually a listis

noticea-blewhile standing. Very asymmetrtcal side

bend-ing,

this iskey to driving the treatment;

he

has

to be able to side bend further in one directionthan the other.

He

improves

with _pelvic translocation

and extension and

he

worsens with straight _plane

extension or flexionmovement. This isthe clinical

picture of the Iateralshift _patient.

AsI mentioned earlier, some of the technical

ad-vantages have made manual _techniques

just

a part,

or component, of our approach now.

This

particu-lardevice,auto _trac,isextremely useful

in

treating

this

type

of patient.

It

is

a system of mechanically

facilitated

passive movernents, which utilizes

com-binations

of active muscle contractions, traction, and controlled spinal stabilization

in

order

to

expe-dite

return tonormal functionalactivity with what

we callunloading and reloading.

The

system

con-sists of an electrohydraulic table and its ac-cessories, a very simplified examination system and

specific treatment protocol. Originally

this

table

was manually controlled with largewheels and the greatest advantage to the more modern version is

the ability toreload the_patient.Inother words, it's a tilt

table.

Looking at our _patient again,

he

is

in

antalgia, and this

largely

determines

how

we wili

begin

with

him on,the bable. The firststep istoaccomedate

his

defermity.

Since

he

was

in

antalgia

in

theposi: tion described earlier, we do the same thing with

ftltazadiXwa

the tabletop toaccomodate te

his

deformity,

allow-ing the table to take responsibility forhis spasm.

Through

a gradual process of pulling and pushing,

we correct the patienttaking

him

out of

his

antal-gic posture and _put

him

into

the restriction of

his

deformity. This iscalled the corrected step,

Following the successful completion of those two

steps, we _put

him

in

a _gradual reloading _position,

inother words what made

it

_possibletomake these

corrections was the

fact

that we

had

taken _gravity

away. Now, having made thiscorrection, we had to

be

very cautious and careful about resuming the effect of gravity. After

the

patient has achieved

fullweightbearing, we make sure that,as

he

comes off

the

table,

he stays in the erect _position,

main-taining

his

correction as much as _possible,as well as the lordosis.Then we'11

have

the _patient

ambu-late.

That was an example of a case study using one

particularcategory

(that

of the

lateral

shift

correc-tion) in Stage I where our _{primary goal} is_pain

modulation.

We

are able toiRustrateseveral

exam-ples: the patient who

is

inacute pain therefore

qua-lifyingas Stage I,utilizing a case study and

being

able todemonstrate theeffectiveness of

(in

this

par-ticularca$e) the auto tractabletreatment of Iateral

shift correction.

Next,

we're going to move toward a more

73

cult

but

more

_powerful

form

of

justification,

and

thatistheexperimental _process. For _the most _part

today there are more studies done on manipulation

than any Qther modality ef treatment

in

the spine,

and

in

particular, the

lumbar

spine.

However,

the

process has been to take the patients,divide them intotreatment _groups and comparison _{groups; give}

one _group treatment with manipulation and anoth-er _group treatment with some _placebo or other

type of treatment.･

The

big

diMculty

with this

pro-cess isthat

_you

don't

have

a classification, that

is

tosay this

is

not the way we _practice.

We

want to

determine what _patientis_going torespond towhat

treatment.

We

wouldn't think of putting allthe pa-tients

into

one group and

doing

manipulation-there would have to be indication in this area,

Therefore, we have considered that intervention is

more than

just

treatment. Firstwe have todo clas-sification, then we _put one _group

in

an unmatched

treatment and another group

in

a matched treat-ment.

In

the case of extension-type _patientand

manipu-lation_patient,ifwe matched these _patients with

the appropriate treatment, we should get a

better

outcome than

if

they

had

unmatched

treatment---thaVs the hypothesis. When we're matching

treat-ments by category, the matched treatment should

be more efficacious than the unmatched treatment.

Fig. 1. The manipulative technique

for

the sacroiliac

joint.

<Reprinted

with perrnissionof American

Physical

Therapy

Association frern

Cibulka

MT.

The treatment of the

sacroili-ac

joint

component to

low

back

pain. a case report.

Phys

74

ve\tsza\

Will

this result

in

earlier work return and,

there-fore.

result

in

cheaper

health

care costs.

We

have a

lotof attention inthe United Statesnow regarding

the

cost of healthcare. We have to

be

able to

'

onstrate that our treatments are not

just

effective,

but

cost effective.

This

is

a study that was _published inApril 1993

in the

Journal

of the

American

Physical

Therapy

Association.

Our

group was

Dr.Anthony

Delitto,

Michael Cibulka and

Janet

Tenhula of St.Louis,

Richard

Bowling

of the

University

of Pittsburgh,

and

I.

The

study was titled"Evidence for

Use

of an

Extension-Mobilization Category in

Acute

Low Back Syndrome:

A

Prescriptive Validation Pilot Study." Inother words, we identifiedextension and

mobilization _patients and mobilization _patient in

acute

low

back

pain and

divided

thosg

by

the toss

of a cein into treatment involving both

mobiliza-tionand extension

in

the experimental group.

The

control _group received treatment involving flexion

exercises as you shall see, The acute _patientscame

into the clinic referred with low back _pain

syn-drome.

We

then classified the patient and placed

sorne of those _patients

(determined

by

the

flip

of a coin) jnto the designated treatrnentcategory. The

eg

21

geg

2

rest of those patients went intoa non specifie, but

acceptable, treatment-in this case, Williarns'

flexion

exercises.

We

measured the outcomes of

the two groups and compared one tothe other.

All

patients in the study were referred _primarily for low

back

pain,that isthey could have had

thing else in addition, but the _primary reason for referral was

low

back

_pain.

They

were all referred

by

physicians.

Thirtynine

patients were

initiallS

admitted; 24 were classified as the

lization

category. The remaining

15

were

missed

from

thisparticularstudy.

The

mean age

was 32±11,including 14men, 10women, and 4 tientswith symptoms below the knee;

the

der had symptoms stopping at the knee er above.

Thus,

only _patientsassigned totheclassification of

extension and rnobilization were admitted. This

was a number thattotaled 24. Subjects were then randomly assigned totheirmatched _group, zation/extension, or the unmatched _group, flexion

exercise. The mobilization _treatment was a

Grade

5

(manipulation)

purportedly

directed

tothe

iliac

joint.

The extension regimen was _given

ly as described by Mackenzie, including _pressups and use of a lumbar roll. The flexionregimen

(the

Fig.

2.

Between-group

comparison of.Oswestry

question-naire scores

initially

and at 3-and 5-day

follow-uPs.

(Error

eeE]!twVidi=wa

other

_group)

was

_given

a regimen exactly as

de-scribed by Williams and the subjects were seen

three times _per week fora

total

of one week,

The

outcome measure was the Oswestry low

back

pain

questionnaire,which

is

a

functional

self assessment

that addresses the

diMculty

a

_patient

has with

rou-tineactivities of daily living,such as sleeping,

wal-king,

standing, sitting,

lifting

etc.

One

of

these

was

fi11edout

before

each visit and the treating thera-pistwas unaware of what the

individual

Oswestry

scores were on each _patient. The way we assigned

these _patientstoextension syndrome was

by

asses-sing

their

movements, so

flexion

in

standing,

supine and extension

in

standing and extension prone. were performed.

Pelvic

translocation,

both

directions,with _pressup. Additionally, _postural advice was _given and the _patientwas supplied with a

lumbar

roll

to

maintain extension,

The

data

anal-ysis

is

dene

by

2×3

(treatment

group by treatment

period)

ANOVA,

Comparisons

with age, onset

period and initialOswestry scores were

done.

There was a significant differencebetween the two

groups

in

age,

the

manipulation extension _group was significantly older than the other

_group.

There

were no other

differences.

A

bar

graph showing

the three treatments refiects the flexion _group's Oswestry score at onset to be in the low 40s

(I

should say

that

the

Oswestry

is

like

golf-the

lower

thescore, the

better,

because

what you are

looking

for

is

the percentage of

disability>.

The

second

bar

shows the second visit

in

the

flexion

exercise

_group

and the thirdbar shows the thirdand final

Oswes-try score

in

this control _group. The

first

day's

score of the extension/manipulation _group was

done

before

any intervention,as was

the

score

for

the fiexionexercise _group. When the _patient

pre-sented

for

the second time,an

Oswestry

form

was

fi11edout beforethe treatment. Please note thatthe

second score

in

thisgroup was

lower

than the

ulti-mate score

in

the

flexion

exercise group.

Finally,

the third

bar

represents the

fifth

day

(final)

visit, in

which case

the

Oswestry

score

in

the experimental

group was about 11%

(See

Fig. 2).

We

recognize

75

that we

have

some severe limitation$,

We

had

a

very small N, so we called ita _pilotstudy.

Only

one clinician classified the _{patients,therefore} we

had

limited

_{generalizabi]ity.} We did not

have

a

controt _group, in other words,

it's

possible that

what we saw with the treatment _group was the normal

_process

of

low

back

_pain inthe acute stage and

by

_giving

fiexion

exercises, we

just

retarded

the _progress inthe other _greup,

With

no control

group, we really could not _prove that was not the

case.

Finally,

there was no way of dissecting out

the effect of manipulation versus theeffect of exer-cise

because

in

the experimental _group, we

did

both.

We then move

into

_the next stage, which is

Phase

II.

Please

note that we use these _phases

rather than acute, sub acute and chronic because

the chronology

does

not always help us in

determi-ning which stage the _patient isin.

What

We

have

to address here isto manage other things such as

checking

the

_patient's

flexibility,

strength, levelof

fitness,_posture and occasionally we'11 try for

cor-rection of

identifying

_positive factorssuch as

leg

length discrepancy, _{poor posture,} too much/too

littleflexibility,too littlestrength or poor

fitness.

This is

the

goal of

the

second stage,

We

have

pro-gressed technicallyso that we

have

some

sophisti-cated products of exercise equipment

that

we can use when the _patients still have some _pain.

Re-member the _patient isno longer

in

Stage

L

but

these_phases are not _permanently separated,

i.e.,

the

patient can fall

back

from

one stage tothe next.

For example,

the

_patient may

be

in

Stage

IIbut

after

doing

something at

home,

he has a regression

which _puts

him

back

in

Stage

I.

There isno clear cut

deliniation

between

these

stages.

IVs

primarily forour purposes that we use these, In this

particu-lar

type of equiptnent, we have

the

ability toutilize

strength training and also accommodate

for

pain

anywhere in the range of motion.

This

is

accom-plished through a series of weight6 allowing us to

maxirnize or minimize resistance at virtually any

76

Eeiktaza\

perform early strength

training

without

aggravat-ing

thepatient's symptoms.

Six to ten

per

cent of the totalnumber of

low

back _{pain patients} that we see

have

to

be

_placed

into

the

phase

III

group. This includes

job

simula-tion;

for

example, inour areaa good percentage of our patients are underground coal miners so we

have a situation where thepatientsatthisstage go intothe work

hardening

facility

and practice sho-veling. We have simulated mining conditions that

the patientcan use and _{gradually get} back toa full

shift.

Coal

mining isa _good example of a use

for

this

because

once the underground miner goes

down

on the mantrip,

he

has

to

stay underground

forthe remainder of

his

shift except incases of ab-solute emergency. Itisimpossible to

have

the

pa-tient

work

Less

than

a fullshift. When the _patient

returns

to

work, he must be able te_perform a full

shift of employment otherwi$e the company will

not take

him

back.

This isthe kind of thing we do as faras

job

simulation.

We

also have other things

we can do in thisapproach; the type of exercise equipment Ishowed you earlier isfor stabilization

-stabilizing

_the

muscles and increasingendurance.

When we _get to this stage we have anether type of

equipment where

it

enables us to provide forces

that are unexpected,

in

other words, more of the

real lifefunctionalexperience.

The

best example

I

can _{give you} wouLd bea wheelbarrow.

If

you were standing at a loaded wheelbarrow on a slight

grade

where the _grade was running away from _you, and

you picked the wheelbarrow up from the _ground,

not onLy would you have toliftthe weight, but _you

would

have

to control

it

from

rolling away

from

you.

On

the other

hand,

if

you were

facing

up the

fi

21

igee

2

e

inc}ine,as _{you picked} up the wheelbarrow, you would not only have tolift

the

weight but also

lean

intoitso that itdid not push _you over backwards.

We

have

another _group of exercise machines that

we can use at thisstage toprepare the patientfor

more reaL functionalwork-type experiences.

Unlike

Stage

II

where we are looking at stabilization, we call thismobilization. You have

to

have a certain

amount of stability already

before

you enter

this

stage or you will

fall

back

tothe second stage very quickly. Incidentally,

both

of these types of

equip-ment are

in

Japan.

To

continue then,we

do

work

evaluation, sequence training

(which

iswhat we

just

talked about) and we also do

job

simulaiton.

Sometimes inthis stage, itisimportant forus to

do

wellness.

Some

of the studies we

have

found,

in

the

States

indicate

that many of the reasons

pa-tientsdon't want to return to work aren't

just

having to do with their_physical weil being

but

with their

_relationship

_with their _supervisor, fellow

workers, etc.

Finally,

Phase IV isfor an

individual

without

back

pain or with

low

grade back pain. That could

be

a _person who

is

tryingto _prevent occurrence or one thatistryingto_prevent recurrence. Infact,ail of the _{patients go} through Phases I,IIand IV

but

just

a very few _go through Phase III.

Some

of the thingswe might

have

todo are a work site

evalua-tion,ergonomic assessment, work modification and

education. Very seldom do we

get

involved in

these components,

but

we invariably

do

education

for_prevention of recurrence.

Ihope that Ihave covered some topicsand have

stimulated some questions

for

you

in

this

presenta-tion.