Cervical Facet Joint / Apophyseal Joint lesion - Guidelines for Treatment

Cervical Facet Joint / Apophyseal Joint lesion - Guidelines for Treatment

K E Y	CONSENT	SUBJECTIVE ASSESSMENT	OBJECTIVE ASSESSMENT	SERIOUS PATHOLOGY	DEFINING AIMS OF TREATMENT	ADVICE AND EXERCISES
A S S E S S M E N T	Valid consent should be gained.	A thorough subjective assessment is needed in order to plan the objective examination and treatment (see separate Metro Physio Ax Procedures)	* Full thorough examination * Signs and symptoms of instability must be referred for further Inx * The Physiotherapist must be able to know when to refer patients on appropriately.	Patients with cervical spine pathology should be screened for Vestibular artery insufficiency and Red flags. N. B. Please see section 3.1 “Serious Pathology”	* Tailored to the individual’s needs * Improve Function * Facilitate patient empowerment * Return to normal task * Relieve symptoms * Provide information leaflet.	* Explain serious physical injury is rare. * Reassurance about prognosis is important. * Over medication is detrimental * Negative beliefs delay recovery * Active exercises should be started within 4 days of injury to reduce pain.

Key	Advice and Education	Treatment Modalities	Exercises
APPT 2	Advise: Self management and encourage the return of normal activities ASAP. Advise: Regarding coping strategies and relaxation techniques along with resting positions if acute, and TMJ unloading if applicable. Educate: Regarding to the origin of pain Postural re-education: Discuss typical postural stresses encountered at work/ home and modify.	Mannual Therapy: Aimed to increase ROM, function and decrease pain. Mobilisations: Maitland or Mulligans, graded appropriately, respecting pain. Manipulations: As appropriate Soft Tissue Techniques: Myofascial Trigger point release +/- Myofascial Stretches. N. B. No sufficient evidence for or against the use of massage. Electrotherapy: TENS can be used to reduce pain. (Patient to follow simple instructions. The following are going to be unlikely at effectively reducing pain….. Infrared light, IFT, US and Laser Rx. N. B. There is no evidence for or against the use of PEMT. Heat / Ice treatment: Ice or heat if acute Acupuncture: No sufficient evidence for or against the use of acupuncture. If desired treatment: use local points around origin of pain with a possible bilateral distal point.	Continue: Active exercises Devise: Individual Exercise programme tailored to individual patient. Can include Mulligans self Snag exercises +/- McKenzie’s Repeated Movements exercise
APPT 3&4	Reinforce the return to normal activities And all of the above	Continue with manual techniques, graded accordingly. Continue with soft tissue techniques: address shoulder, upper back, Thoracic outlet and scapular dysfunctions. Correct TMJ dysfunctions Massage see Appt 2 Electrotherapy see Appt 2 Acupuncture see Appt 2. Can use trigger point acupuncture around the region of the upper fibres of Trapezius if appropriate – No sufficient evidence for or against the use of this.	Continue: Active exercise programme designed for individual patient. Check that the exercises are being performed correctly. Reinforce the importance of the number of repetitions and number of times they are expected to do these throughout the day. Progress: McKenzie repeated movements with force progression as appropriate. Add: Muscle retraining, to include deep neck flexor activity in order to increase function.
APPT5&6	Reinforce postural correction at work and at home – ergonomic modifications. Continue with self car skills.	Continue as “treatment modalities” for Appt 3 & 4	Continue: Force progression of Mckenzie repeated movement exercises if appropriate. Progression: Muscle Retraining exercises. N. B. Propriceptive exs, group exs, extension retraction exs and standard (stretching, isometric, isotonic) exs may be more effective than phasic exs in improving function.
	Discharge	Discharge	Discharge

MMARY OF THE EVIDENCE

2.1 ASSESSMENT

Must include:

ü  Informed Consent

ü  Subjective Assessment

ü  Serious Pathology

ü  Objective Examination

ü  Aims of Treatment

3.2 ADVICE AND EDUCATION

Evidence Summary:

Ø  There is still a lack of directly applicable studies to support the effectiveness of advice and education

Ø  Evidence is sufficiently consistent in guiding patient information and advice.

Ø  Patient empowerment and education is important in providing patient with self-control.

Recommendation:

ü  Explain that serious physical injury is rare.

ü  Reassurance regarding prognosis is very important.

ü  Over Medication is detrimental.

ü  Recovery is improved by early return to normal pre-accident activities, self-exercise & manual therapy

ü  Positive attitudes and beliefs are helpful in regaining activity levels.

2.3 MANUAL THERAPY

Evidence Summary:

Ø  Manual therapy can consist of soft tissue deep and superficial effleurage / massage, soft tissue mobilisations of ligamentous, fascial and muscular structures, as well as mobilisations to the vertebrae.

Ø  Manual Therapy has been proven to be most effective when combined with other treatment techniques such as active exercise and advice.

Ø  There is some reliable evidence for the use of spinal manipulation, however there is urgent need for further research into the differences in effectiveness between mobilisation and manipulation.

Recommendation:

ü  Manual mobilisations should be considered in the early stages to improve range of movement and function.

ü  Soft tissue techniques should be considered to reduce pain in the acute Facet Joint syndrome patient.

ü  Combined manipulation and mobilisation can be considered in the sub acute and chronic stages in order to improve function and reduce pain.

2.4 EXERCISE

Evidence Summary:

Ø  There is good evidence to support the effectiveness of active exercise post Cervical facet joint lesion in all stages of recovery (acute, sub acute and chronic).

Ø  Active exercises within pain free range should be practised, progressing to isometric and then isotonic strengthening exercises.

Ø  Exercise combined with advice and other treatments can be more effective in assisting an early return to work and restoration of normal activities.

Recommendation:

ü  Active exercise should be used to reduce pain and started within 4 days of injury.

ü  An exercise programme should be devised for each individual based on the outcome of the objective assessment. This is likely to have more of an effect that general exercises in improving function.

ü  Muscle retraining including deep neck flexor exercises, retraction exercises and proprioceptive exercises can all be beneficial in improving function.

ü  In the chronic stage, isometric, isotonic and stretching exercises are more likely to be effective than phasic exercise.

ü  Combined exercise with advice regarding coping strategies is better than exercise alone. This will probably assist in the patient’s return to normal activity.

2.5 ELECTROTHERAPY

Ø  There is insufficient evidence to support or refute the use of electrotherapy for patients with cervical facet joint lesion

Recommendation:

ü  The use of ultrasound treatment, interferential therapy, infrared light, pulsed electromagnetic therapy and laser treatment cannot be supported or refuted in the treatment of mechanical neck disorders such as Cervical facet joint lesion.

3.6 ACUPUNCTURE

There is lack of directly applicable clinical studies of good quality to neither support nor refute the use of acupuncture for patients with cervical facet joint lesion.

Recommendation:

ü  The use of acupuncture in the acute, sub acute or chronic stages of cervical facet joint lesion cannot be supported or refuted.

3.7 RECOMMENDATION SUMMARY

Mechanism of injury

Physiotherapists should be aware of recent theories in order to explain the mechanism of the cervical facet joint lesion and be able to relate the site of injury to the patient’s symptoms. This will form the basis of their treatment management.

Recovery

Physiotherapists should reassure patients that they are likely to recover

Risk factors should be identified at assessment as they can affect prognosis…..

Barriers to recovery

Psychosocial (yellow Flags)…..

Physiotherapists need to be aware of the wide range of psychosocial barriers to recovery and should assess for such barriers at all stages after injury…

* High fear of pain and movement * Low self-efficacy

* Severe anxiety or depression * Low pain locus of control

* High use of passive coping strategies * Chronic widespread pain

* High tendency to catastrophise * Problems in relationships with others

* A series of previously failed treatments * Non-compliance with treatment and advice

* Unrealistic expectations of treatment * Inability to work because of the pain

* Negative expectations of treatment * Poor understanding of the healing mechanism

* Poor clinical reasoning by Physiotherapist. * Failure of the Physiotherapist to meet the needs of

the individual patient

Occupational barriers to recovery…

Physiotherapists need to be aware that working conditions, perception of job and job context may be barriers to recovery.

Moor et al (2005).

3. THE EVIDENCE

These recommendations are clinical guidelines for physiotherapists to help in the management of mechanical facet syndrome of the cervical spine.

Neck pain is common, affecting a third of the general population and even more common in a chronic pain management practise. (Wyatt 2004). Facet syndrome was a term devised by Ghormley in 1933 to describe symptoms associated with degenerative changes of the lumbar spine. More recently cervical facet syndrome has appeared in literature and implies axial pain secondary to involvement of the posterior element. (Windsor, 2002).

The facet joints are the articulations between the vertebrae of the spine and like other joints, are able to bend and twist. Thus putting them at risk of inflammation due to injury or arthritis, resulting in pain and stiffness.

The evidence listed below demonstrates which physiotherapy treatments are most effective for assisting people with cervical facet syndrome resume normal day to day activities. Unfortunately there is little information available from Clinical trials to support many of the treatments.

3.1 ASSESSMENT

Informed Consent

Ø  Valid consent must be gained and documented in accordance with national standards and guidance, and local organisational policy.

Subjective Assessment

Ø  Subjective assessment needs to be detailed in an effort to plan the subsequent objective examination according to severity, irritability and nature of injury.

Ø  Possible symptoms of cervical facet syndrome can include neck pain, headache, along with referred pain into the shoulder and upper extremity or mid back. This pain is sclerotomal pain referral patterns rather than dermatomal patterns associated with radiculopathy.

Serious Pathology

Ø  All patients with cervical facet syndrome must be screened for red flags:

Ø  Contraindications to treatment are as follows and should be referred immediately to the nearest

A&E Department….

bilateral paraesthesia, progressively worsening neurological signs

spastic paresis positive Lhermittes sign

hyper reflexia nerve root signs at more than two adjacent levels

symptoms of cervical instability gait disturbance

non-mechanical pain which is unremitting.

Ø  Precautions to treatments are as follows….

positive stress test of Cranio-vertebral joints A past history of cancer

rheumatoid arthritis Long-term steroid use

osteoporosis Systemically unwell

vertebral column malignancy or infection structural deformity

Other conditions and syndromes associated with instability or hypermobility

Objective Examination

Ø  Tenderness on palpation over the facet joints or paraspinal muscles.

Ø  Pain with cervical extension and / or rotation.

Ø  No neurological deficit / abnormalities.

Ø  Cervical manipulation and pre-manipulation testing should be performed if this is the treatment of choice.

Ø  The physiotherapist should know when special tests and investigations are indicated and how to carry out such tests or know how to refer appropriately.

Ø  Imaging studies are not generally helpful. They usually only exclude other sources of pain – tumour, fracture. Spondylosis, narrowing of the intervertebra foramina, osteophystes and degenerative changes are often seen in people with and without neck pain.

Ø  Joint instability testing conducted by a specially trained Physiotherapist.

Ø  Patients presenting with instability signs and symptoms must be referred immediately for further investigation.

Ø  Inexperienced staff must know when to ask for advice from senior members of staff.

Aims of Treatment

Ø  Define the aims of physiotherapy with the patient – these should be to improve function, facilitate empowerment of the patient, and return the patient to normal activity / work and relieve symptoms.

Pain Relief

Ø  Advise on pain relief by referring to local guidelines for the prescription of analgesia, if these do not exist, patients should seek medical advice.

Moore et al (2005).

3.2 ADVICE AND EDUCATION

There is a lack of randomised control trials of overall quality and consistency addressing the effectiveness of advice and education for patients with cervical facet joint lesion or mechanical neck disorders. Haines et al (2008) conducted a systemic review of quasi or randomised trials investigating the effectiveness of patient education strategies for neck disorders. From the ten studies collected, only two were rated high quality. Advice was measured by being focused on activation compared to no treatment or compared to active treatment such as exercises and manual treatments. It was found that there was no difference in pain, spanning a full range of follow up periods and cervical disorders. Overall the review did not show effectiveness for educational interventions in various cervical disorders and follow up times, including advice to activate, advice on stress coping skills, and 'neck school'. In future research, further attention to methodological quality is necessary.

At Congress in 2004, Mark Rosenfield from Sweden’s Gsteborg University spoke from experience of his own extensive research that patient education and empowerment increases the patient’s control over their symptoms. This leads to greater self-efficacy and better coping strategies, thus has been shown to have strong prognosis values in such patients with mechanical neck disorders and whiplash associated disorders (WAD).

Evidence Summary:

Ø  There is still a lack of directly applicable studies to support the effectiveness of advice and education

Ø  Evidence is sufficiently consistent in guiding patient information and advice.

Ø  Patient empowerment and education is important in providing patient with self-control.

Recommendation:

ü  Explain that serious physical injury is rare.

ü  Reassurance regarding prognosis is very important.

ü  Over Medication is detrimental.

ü  Recovery is improved by early return to normal pre-accident activities, self-exercise & manual therapy

ü  Positive attitudes and beliefs are helpful in regaining activity levels.

3.3 MANUAL THERAPY

Manual therapy includes effleurage – deep and superficial, myofascial trigger point therapy, soft tissue mobilisation to the muscle and ligaments plus mobilisations and manipulations of the bony spinal structures. The effects of manual therapy can be classified under two headings, Mechanical and neural effects. Mechanical effects include skin, muscle and fascial stretching, articulation of joints with a stretch on the ligaments, as well as creating movement to intra-articular structures. The neural effects include the stimulation of receptors within the affected tissues, this activation then causes the reflex effects.

David et al (1998), Hoving et al (2002) and Hemilla ((2005) conducted trials demonstrating a positive change from mobilisation treatment for mechanical cervical spine pain up to 5-7 weeks post treatment. From these trials, it showed that 70% of patients achieved a significant level of improvement at the 6-7 week point. Hemilla (2005) and Korthals-de Bos et al (2003) provided long-term data showing a full recovery in approximately 70% of subjects at 13 and 52 weeks.

A trial by Dziedzic et al (2005) included a group that received exercise and manual therapy, compared to exercises alone, and a group receiving exercise with heat modality. There was no significant improvement or differences in neck pain reported at 6 months between either of the groups.

Allison et al (2002) compared three groups but only had a small sample size of 10 subjects in each set, Group one received manual therapy – neural treatment, group two received articular treatment (shoulder and thoracic spine) and group three served as the control. Both treatment groups one and two showed statistically significant and clinically important reduction in the pain VAS Scores at 8 weeks, compared to the control group whose pain VAS score increased.

Mulligan’s concept consisted of therapist-applied passive physiological movements and therapist-applied accessory techniques in the form of sustained natural apophyseal glides (SNAGS) in the cervical spine. Hall in 2007 demonstrated in a randomised control trial how SNAGS cam help in the management of cervicogenic headaches, which often involve dysfunction at the apophyseal joint of C0-C1, C1-2 and / or C2-3.

Hurwitz et al (1996) and Bronfort et al (2001) both conducted studies showing mobilisations and manipulations to be more effective in relieving neck pain than GP care.

Similarly, Gross et al (2004) conducted a study showing that mobilisation and manipulation treatment are more effective in relieving neck pain than no treatment (control).

In a later randomised trial by Hurwitz et al in 2002, 336 subjects suffering with chronic neck pain were randomized to four groups either receiving manipulation with or without heat, manipulation with or without electrical muscle stimulation (EMS), Mobilisation with or without heat and mobilisation with or without EMS. All groups received one or more treatments of either manipulation or mobilisation. If they were receiving heat or EMS, this was applied 10 minutes prior to the mobilisation or manipulation. Results from both the manipulation and mobilisation groups were similar, and at the 6 month follow up there was a reduction in both their pain severity and disability scores. There were no adverse events relating to this study experienced.

The use of cervical manipulation presents concern due to a risk of developing devastating side effects of trauma to the vestibular artery. 1 in 1,000,000 result in serious complications such as death, locked in syndrome, wallenberg syndrome and vertebrobasilar stroke in young adults.

Haneline (2005) conducted a literature review including randomised and non-randomised clinical trials. From 267 citations, less than 10 marginally dealt with neck pain treated by manipulation, with only one trial dealing with manipulative therapy as the choice of treatment in acute cervical pain.

Cassidy et al (1992) and Pikula (1999), both showed that a single manipulation provides immediate increase in range of movement than passive mobilisation, however there was no long term follow up in this study.

Vernon and Humphrey’s (2007) carried out an overview on randomised clinical trials and systemic reviews looking at manual therapy as the treatment for mechanical neck pain. In the manipulation trials there were three trials identified where by manipulation treatment was used in acute neck pain. One of the trials by Pikula (1999) was the only trial that employed a control group. However this trial only looked at on treatment session of manipulation with the immediate outcome. Similarly, Howe et al (1983) only looked at one manipulation treatment and then monitored the outcome over a three-week period. Leaving the third trial by Nordemar and Thorner in 1981, to be the only trial within the review that can be appropriately generalised to the typical clinical situation. They looked at six sessions of manipulation treatment over a 6 week 2-week period in comparison to electrotherapy and collars. Thus highlighting the effectiveness of spinal manipulation. However, it must be noted that unfortunately there were no studies or trials identified for the use of massage, traction, acupuncture or ultrasound as the treatment choice for acute neck pain.

A multicentre Randomised clinical trial by Jull (2002) was conducted to measure the effectiveness of the physiotherapy management of cervicogenic headaches, involving manipulative therapy as treatment. 200 subjects were randomised to three groups. Group one received manipulative therapy combined with exercises, group two received manipulative therapy only and group three acted as a control group. The manipulative therapy included passive mobilisations and / or manipulation as developed by Maitland. All patients received between eight and twelve treatment sessions over a six-week period. Results showed that from all the treatment sessions delivered, 77.6% involved passive mobilisation only, 15.9% involved both passive mobilisation and manipulation, 4.3% involved only manipulative therapy and 2.1% of group one involved only exercise in at least one treatment session. Overall nearly 50% of all subjects (42 out of 100) received manipulative therapy at some stage in their course of treatment. It was concluded that both low velocity passive mobilisations and high velocity manipulations were delivered to the upper cervical joints selectively. Maitland believes that manipulation is a progression of passive mobilisation, which was seen in this study as the majority of manipulations were performed in the latter 7 sessions. Results showed that both groups one and two (manipulative therapy combined with exercise, and manipulative therapy alone) saw a reduction in frequency and intensity of headaches more than what group three (control) did, immediately after the intervention (7 weeks) and at 12 months. Thus concluding that patients with cervicogenic headache, manipulative therapy and a low load exercise programme. A combination of manipulative therapy and exercise was not better than individual therapy.

Only three trials have been published to date, which look at massage treatment for chronic neck pain. Levoska et al (1993) conducted a trial where one group received a combination of massage, heat and passive stretches, whilst the other group received active therapy only. Results show that there was a significant favouring the active group at 8 weeks. Gam et al ( 1998) showed a positive outcome for a group receiving massage and exercises at week 6 of treatment.

Evidence Summary:

Ø  Manual therapy can consist of soft tissue deep and superficial effleurage / massage, soft tissue mobilisations of ligamentous, fascial and muscular structures, as well as mobilisations to the vertebrae.

Ø  Manual Therapy has been proven to be most effective when combined with other treatment techniques such as active exercise and advice.

Ø  There is some reliable evidence for the use of spinal manipulation, however there is urgent need for further research into the differences in effectiveness between mobilisation and manipulation.

Recommendation:

ü  Manual mobilisations should be considered in the early stages to improve range of movement and function.

ü  Soft tissue techniques should be considered to reduce pain in the acute Facet joint syndrome patient.

ü  Combined manipulation and mobilisation can be considered in the sub acute and chronic stages in order to improve function and reduce pain.

3.4 EXERCISE

Jordan et al (1998) conducted a randomised prospective clinical trial in patients with chronic neck pain. 119 patients were randomly selected into three groups. The intensive training group were under the guidance of a physiotherapist which involved Sessions involved a 5-6 minute warm up on a static bike, followed by stretching of the cervical, shoulder and scapular muscles. Intensive training of the neck muscles was then carried out on neck training apparatus in flexion, extension, and bilateral side flexion. All strength was measured and exercises progressed accordingly along with a home exercise programme issued to each patient. The Physiotherapy treatment group were treated according to an individual treatment plan laid out by the physiotherapist involving hot packs, traction, massage, passive joint mobilisation, proprioceptive neuromuscular facilitation or / and ultrasound, along with a home exercise programme, instruction in ergonomics as related to work and spare time. The Manipulative treatment group were treated according to an individual treatment plan laid out by a Chiropractor, involving manipulations and in addition traction, manual treatment of tender muscles, individual advice and a home training programme. All treatment groups received 2 sessions a week for 6 weeks. All patients participated in neck school which was one and a half hours of theory and practical instruction.

Results showed that patients from all three groups showed significant improvement at 4 months and 12 months follow up regarding self reported pain, medication use reduction and disability. There was no significant difference between any of the three groups at each assessment period.

Kay et al in 2005 conducted a systemic review looking at the effectiveness of exercise therapy used as the treatment for neck pain. The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic mechanical neck disorders, with or without headache. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic mechanical neck disorders with or without headache, reduced pain, improved function, and global perceived effect in the short and long term. The relative benefit of other treatments (such as physical modalities) compared with exercise or between different exercise programs needs to be explored. The quality of future trials should improve through more effective 'blinding' procedures and better control of compliance and co-intervention.

Evidence Summary:

Ø  There is good evidence to support the effectiveness of active exercise post Cervical facet joint lesion in all stages of recovery (acute, sub acute and chronic).

Ø  Active exercises within pain free range should be practised, progressing to isometric and then isotonic strengthening exercises.

Ø  Exercise combined with advice and other treatments can be more effective in assisting an early return to work and restoration of normal activities.

Recommendation:

ü  Active exercise should be used to reduce pain and started within 4 days of injury.

ü  An exercise programme should be devised for each individual based on the outcome of the objective assessment. This is likely to have more of an effect that general exercises in improving function.

ü  Muscle retraining including deep neck flexor exercises, retraction exercises and proprioceptive exercises can all be beneficial in improving function.

ü  In the chronic stage, isometric, isotonic and stretching exercises are more likely to be effective than phasic exercise.

ü  Combined exercise with advice regarding coping strategies is better than exercise alone. This will probably assist in the patient’s return to normal activity.

3.5 ELECTROTHERAPY

There is lack of directly applicable randomised controlled clinical trials to support or refute the use of individual electrotherapy modalities in the treatment for cervical facet joint lesion.

A systemic review by Kroeling et al (2005), fourteen comparisons were included. For the pain outcome, we found limited evidence of benefit, ie, pulsed electromagnetic field (PEMF) therapy resulted in only immediate post-treatment pain relief for chronic mechanical neck disorders and acute whiplash (WAD). Other findings included unclear or conflicting evidence (Galvanic current for acute or chronic occipital headache; iontophoresis for acute, subacute WAD; TENS for acute WAD, chronic mechanical neck disorders; PEMF for medium - or long-term effects in acute WAD, chronic MND); and limited evidence of no benefit (diadynamic current for reduction of trigger point tenderness in chronic, mechanical neck disorders cervicogenic headache; permanent magnets for chronic mechanical neck disorders, electrical muscle stimulation (EMS) for chronic mechanical neck disorders). It was concluded that there was insufficient or conflicting randomised controlled clinical trials, to support the use of several electrotherapy modalities for different mechanical neck disorders.

Evidence Summary:

Ø  There is insufficient evidence to support or refute the use of electrotherapy for patients with cervical facet joint lesion

Recommendation:

ü  The use of ultrasound treatment, interferential therapy, infrared light, pulsed electromagnetic therapy and laser treatment cannot be supported or refuted in the treatment of mechanical neck disorders such as Cervical facet joint lesion.

3.6 ACUPUNCTURE

There is lack of directly applicable clinical studies of good quality to neither support nor refute the use of acupuncture for patients with cervical facet joint lesion.

Recommendation:

ü  The use of acupuncture in the acute, sub acute or chronic stages of cervical facet joint lesion cannot be supported or refuted.

3.7 RECOMMENDATION SUMMARY

Mechanism of injury

Physiotherapists should be aware of recent theories in order to explain the mechanism of the cervical facet joint lesion and be able to relate the site of injury to the patient’s symptoms. This will form the basis of their treatment management.

Recovery

Physiotherapists should reassure patients that they are likely to recover

Risk factors should be identified at assessment as they can affect prognosis…..

Barriers to recovery

Psychosocial (yellow Flags)…..

Physiotherapists need to be aware of the wide range of psychosocial barriers to recovery and should assess for such barriers at all stages after injury…

* High fear of pain and movement * Low self-efficacy

* Severe anxiety or depression * Low pain locus of control

* High use of passive coping strategies * Chronic widespread pain

* High tendency to catastrophise * Problems in relationships with others

* A series of previously failed treatments * Non-compliance with treatment and advice

* Unrealistic expectations of treatment * Inability to work because of the pain

* Negative expectations of treatment * Poor understanding of the healing mechanism

* Poor clinical reasoning by Physiotherapist. * Failure of the Physiotherapist to meet the needs of

the individual patient

Occupational barriers to recovery…

Physiotherapists need to be aware that working conditions, perception of job and job context may be barriers to recovery.

Moor et al (2005).

4.0 REFERENCES – to follow