Clinical Masterclass

Clinical Decisions in the Diagnosis and Management of Complex Musculoskeletal Pain and Dysfunction

In the real world, by the time a patient has a chronic or recurrent pain disorder there are multi-factorial competing issues to manage.

This course makes 3 diagnoses:

1. Dysfunction - (identify the sites and directions of uncontrolled movement)

2. Symptoms - (identify the various pain sensitive tissues)

3. Pain mechanisms. Treatment options and priorities are presented.

Course Outline

This Masterclass looks at the reality of clinical practice. Patients present with problems where there is more than one source of pain. The conventional medical model is based on diagnosis or pathology of the most damaged or pain-producing tissues. The problem with this model is that it labels only one tissue: the squeaky wheel gets the oil!

In the real world, by the time a patient has a chronic or recurrent pain disorder there are:

• multiple tissues that are the source of symptoms
• multiple mechanisms of movement dysfunction – more than one site and direction of uncontrolled movement
• significant slow motor unit recruitment difficulties, linked to proprioceptive changes
• usually disuse atrophy problems due to disability and altered functioning
• multiple pain mechanisms present contributing to the overall adverse experience of pain
• frequently, behavioral and psycho-social factors that contribute to pain or appear as a result of pain.

During the course we shall employ two ‘real patient’ clinical case-studies for illustration.

The course will explore and explain:

• where to start and where not to start;
• what you can fast-track and what to hold back on;
• how to develop appropriate strategies to use movement to influence neurogenic pain

Key Features

This course addresses:

• why people with chronic and recurrent pain present with:

- multiple sites and directions of uncontrolled movement
- multiple pain sensitive tissues
- more than one pain mechanism

• how to prioritize - where to start
• how to best manage these competing interests

This course reviews the concepts of the uncontrolled movement theory. It uses patient demonstration to highlight how stability assessment and rehabilitation compliments other therapeutic approaches. This details a logical clinical reasoning approach to integrate assessment and correction of dysfunction in the articular, myofascial and neural systems. It develops rehabilitation strategies to facilitate clinical problem solving and common areas of clinical difficulty are reviewed.

Learning Outcomes

At the end of this course the participant should be able to:

• Make 3 clinical diagnoses for patients with complex musculo-skeletal pain

- Tissues / Structures; Movement Dysfunction; Pain mechanisms

• Discuss the differences in clinical presentations of dysfunction in different tissues

- Articular structures; Myofascial tissues; Connective tissues; Neural tissues

• Understand the development of Un-Controlled Movement (UCM) and analyse the relationship between restrictions and compensation
• Assess for and develop strategies to manage different pain mechanisms
• Identify clinical indicators for possible presence of sensitisation & neurogenic pain and discuss management options for issues of neuro-dynamic sensitivity
• Understand and discuss how clinical presentations determine priorities in management strategies
• Recognise the clinical indications and discuss management options for:

- low threshold training of the local system as a clinical priority

- low threshold training the global system as a clinical priority

- Indications for high threshold training the global system as a clinical priority

• Develop an understanding of using outcome measures and re-assessment tools to evaluate the effectiveness of interventions to manage symptoms, dysfunction, disability and demonstrate how these tools can help to guide the rate of progression of an individual patient through their rehab programme

The participant should demonstrate the ability to apply principles of assessment and motor control retraining to:

• Use clinical reasoning to prioritise initial management and plan a progression of rehab
• Demonstrate an understanding of the clinical reasoning behind the choice of therapeutic exercise options

Programme Outline

Movement system assessment: Inter-related systems

• Articular structures assessment
• Myofascial tissues assessment
• Connective tissues assessment
• Neural tissues assessment
• Behavioural / psychosocial issues

Tissue systems as a source of pain Pain mechanisms and clinical indicators

Diagnostic frameworks:

• 3 diagnoses

- Tissues / Structures - more than one
- Movement Dysfunction (site and direction) - more than one
- Pain mechanisms - more than one

• Mechanical subgroups of neuro-musculo-skeletal pain

Clinical judgement

Clinical reasoning

Physiology: Motor Control Update

Core stability

Outcome measures: is treatment making a difference?

Update: Principles of ‘motor control’ rehab

Therapeutic Exercise: Decision-making Framework

Clinical scenarios

Case reviews