This document describes a model of orthopaedic dysfunction that can be used as a clinical decision-making framework in physical therapy. The model outlines how various stimuli can lead to internal tissue responses, impairments, functional disabilities, and handicaps. It presents the internal tissue response section in detail to help therapists analyze patients' impairments in relation to the pathophysiology. The model is intended to help therapists formulate hypotheses about dysfunction, explain examination and treatment choices, and identify appropriate treatment goals. A case study is used to demonstrate how the model can be applied in clinical practice. The document also discusses implications for using the model in education and research.

1. 1989; 69:548-553.PHYS THER.
Bette Ann Harris and Daniel A Dyrek
Decision Making in Physical Therapy Practice
A Model of Orthopaedic Dysfunction for Clinical
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2. A Model of Orthopaedic Dysfunction for Clinical
Decision Making in Physical Therapy Practice
[Harris BA, Dyrek DA: A model of orthopaedic dysfunctionfor clinical decision
making inphysical therapypractice. Phys Ther 69548-553, 1989]
Key Words: Decision making; Decision theory; Education, physical therapist,
general; Orthopedics.
Bette Ann Harris
Daniel A Dyrek
This article describes a model of
orthopaedic dysfunction that we use
as a framework for our advanced mas-
ter's degree orthpaedic and sports
curriculum at the MGH Institute of
Health Professions.1
This model is
offered as an alternative to the tradi-
tional medical model that focuses on
the etiology, diagnosis, and treatment
of disease. The purpose of the model
of orthopaedic dysfunction is to pro-
vide a hypothetical rationale to
explain the cause and effects of soft
tissue dysfunction.1
The purpose of
this article is to present the model of
orthopaedic dysfunction as a clinical
decision-making tool. The model can
be used to analyze the etiology of
dysfunction, which may contribute to
the development of a body of knowl-
edge relevant to the profession of
physical therapy.
This model of orthopaedic dysfunc-
tion was developed because we
believe a key quality of the clinician is
to demonstrate clinical judgment sub-
stantiated by current theory and sci-
ence. Clinicians should be able to
explain why they chose a particular
examination or treatment action or
interpreted signs and symptoms in a
certain manner in terms of the patho-
physiology of the dysfunction.
The model is offered as a guideline
for therapists to formulate and com-
pare hypotheses of dysfunction.
Understanding the etiology of dys-
function is essential in clinical deci-
sion making prior to establishing the
prognosis, duration, and frequency of
treatment. We recognize that there
are other contributing variables, such
as the psychological, social, and func-
tional needs of a patient, which
strongly influence treatment strategies.
The purpose of this model, however,
is to present a unifying framework of
pathophysiological and pathokinesio-
logical processes to theoretically illus-
trate the development of orthopaedic
dysfunction and its effects. The model
of orthopaedic dysfunction is based
on the static and dynamic properties
and function of the neuromuscu-
loskeletal tissues and structures.2-11
The altered properties of those tissues
are related to the etiology of pain,
impairment, and disability.
This article will review the essential
components of the model and, using
the case method, explain how it may
be used to analyze examination and
treatment strategies. We will also dis-
cuss how the content of the model is
applicable to clinical practice, educa-
tion, and research.
Review off the Model off
Orthopaedic Dysfunction
The model expands on the classical
concept of a stimulus causing a
response (Fig. 1). Figure 2 empha-
sizes the stimuli and subsequent inter-
nal tissue responses that hypotheti-
cally result in orthopaedic
dysfunction. Although all sections of
the Figure could be expanded, we
have chosen to diagram the internal
tissue response section in the most
detail to allow clinicians to analyze
the patient's impairments and disabili-
ties in terms of the pathophysiology
of the dysfunction. Although a particu-
lar chain of events will not apply to
all patients, the sequence depicted in
Figure 1 is applicable in most clinical
situations.
B Harris, MS, PT, is Assistant Professor, Program in Physical Therapy, MGH Institute of Health Pro-
fessions, 15 River St, Boston, MA 02108-3402, and Clinical Research Associate, Department of Physi-
cal Therapy, Massachusetts General Hospital, Fruit Street, Boston, MA 02114.
D Dyrek, MS, PT, is Assistant Professor, Program in Physical Therapy, MGH Institute of Health Pro-
fessions, and Director, MGH Physical Therapy Associates, 60 Staniford St, Boston, MA 02114.
Address correspondence to Ms Harris at Program in Physical Therapy, MGH Institute of Health Pro-
fessions, 15 River St, Boston, MA 02108-3402 (USA).
This article was presented in poster format at the Sixty-Third Annual Conference of the American
Physical Therapy Association, San Antonio, TX, June 28-July 2, 1987.
38/548 Physical Therapy/Volume 69, Number 7/July 1989
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3. Stimulus
Internal Tissue Response
Impairments
Functional Disability
Handicap
Fig. 1. Overview of model ofortho-
paedic dysfunction.
The terminology chosen for the last
three category headings of the model
and their definitions are derived from
the World Health Organization's
International Classification ofImpair-
ments, Disabilities, and Handicaps.12
Impairments refer to the abnormali-
ties of anatomic, physiologic, or psy-
chologic origins within specific
organs or systems of the body. Physi-
cal therapists tend to evaluate or mea-
sure impairments (eg, decreased
range of motion, limited muscle per-
formance). Functional disability refers
to a restriction or inability to perform
a normal range of activities of daily
living. The World Health Organization
has classified functional disability into
four categories: 1) physical, 2) mental,
3) social, and 4) emotional. Examples
of physical disabilities we deal with as
physical therapists are limitations in
performing ADL skills such as trans-
fers and gait and higher level skills
such as athletic activities. Handicap
describes limitations in the fulfillment
of an individual's normal role,
depending on age, sex, and other
social and cultural factors. An example
of a handicap is inability to perform
one's occupation.
In keeping with this terminology,
therefore, it can be said that specific
impairments contribute to an individ-
ual's functional disability. After careful
examination and the formulation of
an assessment, an important aspect of
clinical decision making is to select
the correct therapeutic action for the
patient. This treatment must be based
on the individual's needs but must
also be related to the etiology of the
patient's dysfunction. Physical thera-
pists traditionally evaluate and mea-
sure those limitations identified in the
impairment section of the model.
Subsequently, treatment interventions
may be limited to only addressing the
impairment. Perhaps this intermediate
level of assessment and treatment is
fostered by the patient's tendency to
describe their own problems in terms
of pain and functional disability. By
reviewing the chain of events
diagrammed in the internal tissue
response section of the model accord-
ing to the patient's mechanism of
injury, however, the therapist can for-
mulate a hypothesis of dysfunction. By
identifying what phase of reaction the
involved tissues are in, the therapist
can propose more sensitive treatment
techniques based on the altered tissue
properties. For example, if a patient
has limited knee flexion and exten-
sion secondary to an acute inflamma-
tory process, the treatment strategy
should be targeted at reducing the
inflammation, improving tissue nutri-
tion, and preventing the sequela of
the inflammatory response such as
fibrous reaction of the contractile tis-
sue. By using finer examination tech-
niques and integrating the informa-
tion with the pathological condition,
the clinician will have a clearer sup-
porting rationale for the treatment.
From this model, generic treatment
goals were developed according to
the sequence outlined in the internal
tissue response section progressing
through the impairments and func-
tional disability levels (Appendix 1).
These goals are based on the events
documented in the internal tissue
response section, and interventions
are determined by whether certain
responses have taken place or need
to be prevented.
Applications off the Model
This section will use a case study to
illustrate how to apply the model in a
clinical situation. After reading the
history and subsequent examination
findings of this case study, formulate a
provisional patient assessment.
Case Study
"GW" is a right-handed, 53-year-old
man who was referred to physical
therapy for examination and treat-
ment of a painful, stiff right shoulder.
History of present problem. Three
months ago, GW was lifting his 25-hp
outboard engine out of the water
when he felt a sudden sharp "pop"
over the anterior portion of his shoul-
der followed by burning pain over
the lateral aspect of his proximal arm.
He reports that his symptoms gradu-
ally subsided over the next week,
although he continued to have pain
on any attempt to do overhead activi-
ties. He stopped playing tennis and
exercising at the health club. During
the past two months, he noticed that
he seemed to be "getting stiffer" and
was having difficulty working. GW
also complained of difficulty sleeping
because he was unable to lie on his
painful right shoulder.
One month ago he consulted with an
orthopaedic surgeon who began a
work-up. Radiographs showed some
glenohumeral joint-space narrowing
and a mild joint effusion. There was
no evidence of calcification. The phy-
sician suggested that he begin taking a
nonsteroidal anti-inflammatory drug
(Feldine®*
) and start physical therapy.
GW's past medical history is noncon-
tributory. He is a dentist who lives
with his wife and three teenage chil-*Pfizer Laboratories Division, Pfizer Inc, 235 E 42nd St, New York, NY 10017.
Physical Therapy/Volume 69, Number 7/July 1989 549/39
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4. MODEL OF ORTHOPAEDIC DYSFUNCTION:
IMPLICATIONS FOR EXAMINATION AND TREATMENT
STIMULUS
ALTERED MECHANICAL
PROPERTIES OF TISSUES
AND STRUCTURES
INTERNAL TISSUE RESPONSE
NON-CONTRACTILE TISSUE CONTRACTILE TISSUE
ARTICULAR STRUCTURES
IMPAIRMENT
of
MOVEMENT
DYSFUNCTION
FUNCTIONAL
DISABILITY
HANDICAP
Fig. 2. Model of orthopaedic dysfunction: Implicationsfor examination and treatment.
dren. GW's initial physical therapy
evaluation is presented in Appendix 2
and the Table.
Application of model to results of
patient examination. By referring
to Figure 2, we can identify that the
initial stimulus was physical trauma;
for discussion purposes, we can
hypothesize it caused immediate tis-
sue insufficiency of the rotator cuff,
which created altered internal tissue
stress. Stress refers to the magnitude
of internal load in a structure or a
tissue. A closer look at the internal
tissue response section allows the
chain reaction, which can occur from
the tissue insufficiency, pain, and sub-
sequent inflammatory responses, to
be identified. We then follow down
through the left side of the internal
tissue response section and identify a
result of the inflammatory process on
the noncontractile tissues involved (ie,
the fibrous reaction resulting in soft
tissue contracture). A subsequent pro-
gression of the contracture is dysfunc-
tion of the articular structures. The
contracture and articular dysfunction
each contribute to altered internal
tissue stress. This stress can be mani-
fested as premature or latent loading
of tissue, excessive or reduced magni-
tude of load, or altered site of tissue
load. For example, the resultant
Table. PassiveJoint Mobility (in Degrees) of Patient "GW" in Supine Position
Combined flexion
Glenohumeral joint flexion
Combined abduction
Glenohumeral joint abduction
Extension
Internal (medial) rotation
External (lateral) rotation
Elbow, hand, fingers, cervi-
cal spine
Right
100a
65a
90a
45a
30
30
0a
within normal limits
Left
170
90
180
90
60
85
85
within normal limits
a
Complains of pain.
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5. abnormal loading of tissue can result
in pain from excessive stimulation of
articular neuroreceptors and chronic
inflammatory reactions, altered pro-
prioception, and myoarthrokinetic
reflexes.
The above discussion is one exam-
ple of how the data gathered during
an examination can be related to
the internal tissue response section
of the model to hypothesize why
the patient exhibits specific impair-
ments. In this patient, for example,
joint mobility at three months
postinjury is limited in a capsular
pattern. We know that there is
marked supraspinatus muscle
tenderness and joint tenderness at
the rotator cuff insertion. There is
also general muscle wasting. By
relating these findings to the inter-
nal tissue response section of the
model, the student can then logi-
cally map out the sequence of
pathophysiological events and iden-
tify appropriate treatment strategies
aimed at the tissue dysfunction of
the impairment.
In summary, from the case example,
some objectives of this model for
clinical practice are 1) to provide a
framework for clinical decision
making based on the physiological
and mechanical sequelae of soft tis-
sue dysfunction and 2) to identify a
rationale for the etiology and man-
agement of pain and dysfunction.
Implications for Education
and Research
The model is also applicable in the
educational setting. The main objec-
tive is to establish a framework for
the critical analysis of clinical practice
concepts in orthopaedic physical ther-
apy and other disciplines. The assess-
ment by the physical therapist may be
analyzed to determine whether the
specific etiology or the patient's
impairment has been identified or
whether the assessment is merely a
restatement of the impairment itself.
In a similar manner, the goals and
treatment plan can be evaluated for
their relevance and thoroughness
based on the diagnosis. Additionally,
various theories and strategies of ther-
apeutic intervention, from within and
from outside the physical therapy pro-
fession, can be compared for their
relative strengths and weaknesses.
The model is used at the MGH Insti-
tute of Health Professions (Boston,
Mass) as a framework for teaching
students how to make clinical judg-
ments that can be substantiated by
clinical theory, practice customs, and
science. We have developed a core
course teaching these basic concepts
using analysis of case studies for prac
tice. The content areas are divided
into topics identified in the internal
tissue response section of the model
and include lectures and discussion
examining clinical implications of
inflammation, pathokinesiology of
joint and soft tissue contracture and
instability, mechanical behavior of
connective tissue, muscle structure
and function, and analysis of generic
treatment strategies. Dysfunction of
contractile and noncontractile soft
tissues and articulations are related to
clinical examination and treatment
techniques.
Examples of the study objectives gen-
erated by this model are given in
Appendix 3. These types of analyses
allow therapists to relate why they
have chosen to apply a particular
treatment strategy to the pathophysiol-
ogy of the dysfunction. Furthermore,
they can clearly define in the litera-
ture which strategies have been sub-
stantiated or warrant investigation.
Therefore, the model can also be
used to aid the therapist in identifying
research goals such as 1) to deter-
mine the role of various etiologies in
the production of pain, 2) to formu-
late research questions investigating
the manner in which manual and
modality therapeutic interventions
work, and 3) to compare the effective-
ness of tissue-based and nontissue-
based treatment strategies. The model
itself is subject to analysis for confir-
mation. Currently, it is based on
knowledge obtained from the applied
science literature.
Summary
This model serves as a framework for
the critical analysis of current practice
concepts. The analysis obtained from
Appendix 1. Generic Treatment Goals
1. Promote healing by improving the nutritional status of soft tissue.
2. Prevent abnormal soft tissue flexibility and length for contractile and noncontractile tissues or restore normal flexibility and length.
3. Prevent the loss of normal joint alignment or restore normal joint alignment.
4. Prevent the loss of normal joint mobility or restore normal joint mobility.
5. Promote normal myoarthrokinetic reflexes.
6. Promote normal motor control.
7. Promote normal cardiopulmonary and cardiovascular status.
8. Decrease pain and associated symptoms.
9. Prevent recurrence of the lesion.
10. Improve the functional status of the patient.
Physical Therapy/Volume 69, Number 7/July 1989 551/41
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6. Appendix 2. Initial Physical Therapy Evaluation of Patient "GW"
Initial evaluation
—denies history of shoulder lesion
—complains of dull ache in lateral arm and anterior shoulder with minimal motion
—complains of sharp, pinching pain in shoulder with overhead motions
—difficulty sleeping
—difficulty performing activities of daily living and dentistry because of pain and decreased movement
—becoming discouraged that pain is "interfering with his life"
—patient's goal to "get rid of the pain and get back full use of his right upper extremity"
—denies gross weakness or neural symptoms
—negative cervicothoracic spine findings
Inspection
—no visible edema or effusion in right upper extremity
—skin unremarkable
—right shoulder girdle is depressed and protracted
—increased depression noted in right supraspinatus fossa compared with left supraspinatus fossa
Palpation
—complains of sharp tenderness over anterior glenohumeral joint, anterosuperior subluxation of glenohumeral joint is present
—increased myofascial and capsular tissue density in anterior portion of glenohumeral joint
—complains of point tenderness over humeral rotator cuff insertion
—supraspinatus muscle tenderness present throughout supraspinatus fossa
—mild atrophy noted in deltoid and supraspinatus muscles
—cervical spine, acromioclavicular joint, sternoclavicular joint, and rest of right upper extremity unremarkable
Accessory joint motion
Glenohumeral joint of right upper extremity
—distraction: positive for pain and minimal excursion (Grade 1)
—caudal glide, anteroposterior glide: positive for pain and moderate excursion (Grade 2)
Other right upper quarter joints
—unremarkable for pain or mobility deficits
Muscle strength
—not tested secondary to pain
Neurological status
—unremarkable for sensory deep tendon reflexes, peripheral nerve provocation tests, and myotomal deficits
Functional status
—must dress affected arm first
—unable to comb hair with right arm
—holds right arm stiffly, decreased arm swing in gait
using this model should be integrated
with other physiological systems of
the body during examination and
treatment processes. Currently used
as a basis for graduate study in ortho-
paedic physical therapy, the model
helps students identify fundamental
research questions, compare various
examination and treatment philoso-
phies, and comprehend generic treat-
ment goals and strategies.
Acknowledgments
We would like to acknowledge Terry
Michel, Mary Watkins, and Valerie
Grande for their help in preparing
this manuscript.
References
1 Dyrek DA, Harris BA, Riegger CA: A model
of orthopaedic dysfunction: Implications for
examination and treatment. Abstract. Phys Ther
67:740, 1987
2 Akeson WH, Dip DA, Abel MP: Effects of
immobilization on joints. Clin Orthop 219:28-
36, 1986
3 Brooks VB: Motor control: How posture and
movements are governed. Phys Ther 63:664r-
673, 1983
4 Cailliet R: Soft Tissue Pain and Disability.
Philadelphia, PA, F A Davis Co, 1977
5 Gabbiani G, Hirshel BJ, Ryan GB, et al:
Granulation tissue as a contractile organ: A
study of structure and function. J Exp Med 135:
719-734, 1972
6 Hubbard RP: Mechanical behavior of con-
nective tissue. In Greenman PE (ed): Concepts
and Mechanisms of Neuromuscular Functions.
42/552 Physical Therapy/Volume 69, Number 7/July 1989
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7. Appendix 3. Sample Study Objectives
1. State a provisional assessment of the patient's problem and support your assessment by relating tissue physiology and biomechanics to the
patient's medical history, subjective report, and manifestation of findings during the examination.
2. Identify five of the patient's specific physical therapy problems. (Consider tissue, structural, and body systems and functional problems.)
3. Identify specific short-term goals of treatment for your patient. (Consider specific tissue and structural goals for each problem identified in item 2.)
4. Choose one of the problems and corresponding goals identified in items 2 and 3 to perform the following objectives:
-Describe and analyze the rationale of your goal based on tissue physiology and the mechanical behavior of contractile and noncontractile
soft tissues. (Support your discussion with a minimum of two references.)
-Identify one treatment technique or modality to enable you to achieve your goal.
-Describe and analyze the relationship of your technique to your goal based on tissue physiology and the mechanical behavior of contrac-
tile and noncontractile soft tissues. (Support your discussion with a minimum of two references.)
5. Identify and discuss three criteria you would use to decide the magnitude, frequency, and duration of your treatment techniques for each
treatment session.
New York, NY, Springer-Verlag New York Inc,
1984, pp 47-54
7 Little RW: Biomechanics modeling and con-
cepts. In Greenman PE (ed): Concepts and
Mechanisms of Neuromuscular Functions. New
York, NY, Springer-Verlag New York Inc, 1984,
pp 34-36
8 Newham DJ, Mills KR, Quigley BM, et al:
Pain and fatigue after eccentric and concentric
muscle contractions. Clin Sci 64:55-62, 1983
9 Ross R: Wound healing. Sci Am 220(6):40-
50,1969
10 Thorstensson A, Grimby G, Karlsson J:
Force-velocity relations and fiber composition
in human knee extensor muscles. J Appl Phys-
iol 40:12-16, 1976
11 Wyke BD: The neurology of joints. Ann R
Coll Surg Engl 41:25-50, 1967
12 International Classification of Impairments,
Disabilities, and Handicaps. World Health
Organization, Geneva, Switzerland, 1980
Physical Therapy/Volume 69, Number 7/July 1989 553/43
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8. 1989; 69:548-553.PHYS THER.
Bette Ann Harris and Daniel A Dyrek
Decision Making in Physical Therapy Practice
A Model of Orthopaedic Dysfunction for Clinical
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