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Perspective

Tissue Adaptation to Physical Stress:


A Proposed “Physical Stress Theory”
to Guide Physical Therapist Practice,
Education, and Research
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The purpose of this perspective is to present a general theory—the


Physical Stress Theory (PST). The basic premise of the PST is that
changes in the relative level of physical stress cause a predictable
adaptive response in all biological tissue. Specific thresholds define the
upper and lower stress levels for each characteristic tissue response.
Qualitatively, the 5 tissue responses to physical stress are decreased
stress tolerance (eg, atrophy), maintenance, increased stress tolerance
(eg, hypertrophy), injury, and death. Fundamental principles of tissue
adaptation to physical stress are described that, in the authors’
opinion, can be used to help guide physical therapy practice, educa-
tion, and research. The description of fundamental principles is
followed by a review of selected literature describing adaptation to
physical stress for each of the 4 main organ systems described in the
Guide to Physical Therapist Practice (ie, cardiovascular/pulmonary, integ-
umentary, musculoskeletal, neuromuscular). Limitations and implica-
tions of the PST for practice, research, and education are presented.
[Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed
“physical stress theory” to guide physical therapist practice, education,
and research. Phys Ther. 2002;82:383– 403.]

Key Words: Adaptation, Biomechanics, Force, Stress.

Michael J Mueller, Katrina S Maluf


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Many different theories and
approaches currently used in physical

P
hysical therapists have expertise in the applica-
tion of interventions—such as exercise, pos- therapy share fundamental principles
tural instruction, orthotic devices, and modali-
ties—that allow them to modify the physical that can be organized into a general
stresses applied to tissues of the body.1–5 Physical stress is
defined as the force applied to a given area of biological theory to guide prevention and
tissue.6 Exercise interventions that modify physical stress
have been shown to decrease impairments, functional treatment of a broad range of patient
limitations, disability, and pain in a variety of patient
populations.7–9 These same interventions can help peo- problems.
ple with and without disease increase muscle perfor-
mance,10 bone mineral density,11 and fitness levels.9 An contribute to tissue stress. The PST was developed to
increasing amount of evidence indicates that exercise address how tissues, organs, and organ systems adapt to
can have positive effects on disease processes such as varying levels of physical stress (Tab. 1). In addition, this
diabetes,12 arthritis,7–9 and coronary artery disease.13 theory describes how other factors (Tab. 2) can modify
both the level of physical stress and the response of
We believe that the many different theories and biological tissues to a given stress level.
approaches currently used in physical therapy share
fundamental principles that can be organized into a The PST focuses on the physical stresses that influence
general theory to guide prevention and treatment of a all biological tissues. Tissues are formed from groups of
broad range of patient problems. The general theory we similarly specialized cells that cooperate to perform one
present is based on fundamental principles that appear or more functions within the body.17,18 The 4 fundamen-
to govern the adaptive response of biological tissues to tal types of tissue are: (1) epithelial tissue, which covers
physical stress. Therefore, we refer to this theory as the internal and external surfaces of the body and forms
Physical Stress Theory (PST). The PST integrates exist- glands, (2) connective tissue, which provides structural
ing knowledge into a deliberately broad theory with and functional support to other tissues of the body,
potential application to physical therapist practice, edu- (3) muscular tissue, which has specialized contractile
cation, and research. properties for producing movement, and (4) nervous
tissue, which collects, transmits, and integrates stimuli to
Physical therapists have emphasized the evaluation and control the functions of the body.17,18 These 4 basic
treatment of movement dysfunction.14 –16 Movement can tissues combine to form organs. Groups of anatomically
be defined by the basic physical components (mass ⫻ or functionally related organs are referred to as “organ
acceleration) of a segment or body. The mass ⫻ acceleration systems.”17,18 Our discussion of the PST will be limited to
of a body segment is defined as force (force⫽mass ⫻ tissues that form the organ systems identified as most
acceleration, Newton’s second law of motion). The appli- relevant to physical therapists in the Guide to Physical
cation of force over a given area of tissue during Therapist Practice (ie, cardiovascular/pulmonary, integu-
movement results in stress to the tissue (stress⫽force/area, mentary, musculoskeletal, and neuromuscular sys-
where force may be applied in any direction [tension, tems).14 The PST does not address molecular or cellular
shear, compression]).6 Although movement is a major mechanisms of adaptation. Rather, the PST identifies
source of physical stress on tissues, other forces gener- common principles from the literature that we suggest
ated both inside the body (eg, isometric muscle contrac- may be used to predict adaptive tissue changes that
tions) and outside of the body (eg, gravity) also may occur in response to physical stress.

MJ Mueller, PT, PhD, is Associate Professor and Director of the Movement Science Laboratory, Program in Physical Therapy, Washington
University School of Medicine, 4444 Forest Park Blvd, Campus Box 8502, St Louis, MO 63110-2212 (USA) (muellermi@msnotes.wustl.edu).
Address all correspondence to Dr Mueller.

KS Maluf, PT, MSPT, is a graduate student in the Movement Science Program, Program in Physical Therapy, Washington University School of
Medicine.

Both authors provided concept/project design, writing, and fund procurement. Dr Mueller provided project management. The authors
acknowledge Amy J Bastian, Marybeth Brown, David Brown, Scott D Minor, Barbara J Norton, Shirley A Sahrmann, and Linda VanDillen for
discussions and their review of a previous draft of the manuscript.

This work was supported by grants RO1 HD36802 and RO1 HD36895 to Dr Mueller from the National Center for Medical
Rehabilitation Research, National Institutes of Health, and a Promotion of Doctoral Studies Award from the Foundation for
Physical Therapy to Ms Maluf.

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Table 1. Table 2.
Summary of Fundamental Principles for Physical Stress Theory Factors Affecting the Level of Physical Stress on Tissues or the
Adaptive Response of Tissues to Physical Stress
Basic Premise: Changes in the relative level of physical stress
cause a predictable adaptive response in all biological tissue. Movement and Alignment Factors
Fundamental Principles: Muscle performance (force generation, length)
Motor control
A. Changes in the relative level of physical stress cause a Posture and alignment
predictable response in all biological tissues.
Physical activity
B. Biological tissues exhibit 5 characteristic responses to physical Occupational, leisure, and self-care activities
stress (Fig. 1). Each response is predicted to occur within a
defined range along a continuum of stress levels. Specific Extrinsic Factors
thresholds define the upper and lower stress levels for each Orthotic devices, taping, assistive devices
characteristic tissue response. Qualitatively, the 5 tissue Footwear
responses to physical stress are decreased stress tolerance (eg,
atrophy), maintenance, increased stress tolerance (eg, Ergonomic environment
hypertrophy), injury, and death. Modalities
Gravity
C. Physical stress levels that are lower than the maintenance
range result in decreased tolerance of tissues to subsequent Psychosocial Factors
stresses (eg, atrophy).
Physiological Factors
D. Physical stress levels that are in the maintenance range result Medication
in no apparent tissue change.
Age
E. Physical stress levels that exceed the maintenance range (ie, Systemic pathology
overload) result in increased tolerance of tissues to subsequent Obesity
stresses (eg, hypertrophy).
F. Excessively high levels of physical stress result in tissue injury.
G. Extreme deviations from the maintenance stress range that
exceed the adaptive capacity of tissues result in tissue death. describe the fundamental principles of the PST, fol-
H. The level of exposure to physical stress is a composite value,
lowed by a review of selected literature describing adap-
defined by the magnitude, time, and direction of stress tation to physical stress for each of the 4 main organ
application. systems described in the Guide to Physical Therapist Prac-
I. Individual stresses combine in complex ways to contribute to the tice.14 The fundamental principles are based on an
overall level of stress exposure. Tissues are affected by the
history of recent stresses. analysis of the literature and our clinical experiences.
Because the principles are general and represent what
J. Excessive physical stress that causes injury can occur from 1 or
more of the following 3 mechanisms: (1) a high-magnitude we contend are the “common denominators” of a variety
stress applied for a brief period, (2) a low-magnitude stress of research findings and clinical approaches, references
applied for a long duration, and (3) a moderate-magnitude
stress applied to the tissue many times. are not provided in the description of the theory or in
K. Inflammation occurs immediately following tissue injury and the listing of Fundamental Principles in Table 1. Sup-
renders the injured tissue less tolerant of stress than it was prior porting literature is provided in the subsequent section
to injury. Injured and inflamed tissues must be protected from
subsequent excessive stress until acute inflammation subsides. and is summarized in Table 3. The literature review also
will address how we believe the PST relates to other
L. The stress thresholds required to achieve a given tissue
response may vary among individuals depending on the physical therapy theories and approaches. Limitations
presence or absence of several modulating variables. Factors and implications of the PST for practice, research, and
that can influence thresholds for tissue adaptation and injury
are summarized in Table 2 and include movement and education will then be discussed.
alignment, extrinsic, behavioral, and physiological factors.
Description of Physical Stress Theory
The basic premise of the PST is that changes in the
In its present form, we believe the PST can be applied relative level of physical stress cause a predictable adap-
most easily to the care of patients with primary problems tive response in all biological tissue (Tab. 1). Figure 1
involving the musculoskeletal and integumentary sys- illustrates primary adaptive responses and thresholds for
tems. However, we believe this theory also has potential tissue adaptation in response to physical stress. Factors
applications for patients with primary problems involv- that may influence either the level of physical stress on
ing the cardiovascular/pulmonary and neuromuscular tissues or the adaptive response of tissues to a given stress
systems.14 We contend that the PST relates to a contin- level are outlined in Table 2. The fundamental princi-
uum of care and, therefore, also has direct applications ples of the PST are summarized in Table 1 and are
for issues related to wellness and the prevention of described in further detail below.
physical disabilities.
Fundamental Principle A—Changes in the relative level
The purpose of this perspective is to present a general of physical stress cause a predictable response in all
theory, based on principles of adaptation to physical biological tissues. Physical stress is the force, or load,
stress, that we believe can be used to help guide physical acting on a given area of tissue.6 In the PST, we propose
therapy practice, education, and research. First, we will that tissues accommodate to physical stresses by altering

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Table 3.
Effect of Physical Stress and Activity on Tissues of the 4 Major Organ Systems Listed in the Guide to Physical Therapist Practicea

. Mueller and Maluf


Stress/Activity Level
Organ System Tissue/Organ Low Normal High Excessive

Musculoskeletal Bone75,88,131–135 2BMD No change 1BMD Fracture


2strength 1strength
Muscle52,136 –140 2contractile protein No change 1contractile protein Strain
2fiber diameter 1fiber diameter
2peak tension 1peak tension
2peak power 1peak power
Tendon126,141 2CSA No change 1CSA Strain
2stiffness 1stiffness
2strength 1strength
Ligament126,141,142 2CSA No change 1CSA Sprain
2stiffness 1stiffness

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2strength 1strength
Cartilage143–148 2proteoglycan content No change 1proteoglycan content Degeneration or tear
2cartilage thickness 1cartilage thickness
2stiffness 1stiffness
Integumentary Skin95 2collagen content No change 1collagen content Abrasion or wound
2collagen fiber diameter 1collagen fiber diameter
2skin thickness 1skin thickness
2strength 1strength
Cardiopulmonary/vascular Heart13,101–105 2cardiac muscle mass No change 1cardiac muscle mass Fibrosis
2capillary density 1capillary density Aneurysm
2stroke volume 1stroke volume Ventricular hypertrophy
1metabolic capacity
Blood vessels101,102,149 –151 2vascular diameter No change 1vascular diameter Fibrosis
2arterial compliance 1arterial compliance Aneurysm
Neuromuscular Neurons106,108,115–118 2maximum discharge rate No change 1maximum discharge rate Axonal demyelination and degeneration
1recruitment threshold 2recruitment threshold
2activation during MVC neuron 1activation during MVC neurogenesis
loss (hippocampus)
1motor unit synchronization
1dendritic arborization
1serotonergic neural activity
1synaptic transmission
a
Strength is defined as maximum stress, strain, and/or energy density prior to failure. 1⫽increase, 2⫽decrease, BMD⫽bone mineral density, CSA⫽cross-sectional area, MVC⫽maximum voluntary contraction.

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Figure 2.
Figure 1. Effect of prolonged low stress lowers thresholds for subsequent adapta-
Effect of physical stress on tissue adaptation. Biological tissues exhibit 5
tion and injury. Prolonged physical stress levels that are lower than the
adaptive responses to physical stress. Each response is predicted to
maintenance range result in decreased tolerance of tissues to subse-
occur within a defined range along a continuum of stress levels. Specific
quent stresses (eg, atrophy). Although relative thresholds remain the
thresholds define the upper and lower stress levels for each character-
same, the absolute magnitude of physical stress is lower for each
istic tissue response. The relative relationship between these thresholds is
threshold. Injury (and all other adaptations) occurs at a lower level of
fairly consistent between people, whereas the absolute values for
physical stress than required previously.
thresholds vary greatly.

their structure and composition to best meet the change. Tissue homeostasis occurs when tissue degener-
mechanical demands of routine loading. Deviations ation is equal to tissue production, resulting in tissue
from routine or steady-state loading provide a stimulus turnover without net gain or loss. The range of stress
for tissue adaptation that allows tissues to meet the levels that promote tissue homeostasis is defined as the
mechanical demands of a novel environment. maintenance stress range and may be different for different
people. This steady-state or equilibrium response occurs
Fundamental Principle B—Biological tissues exhibit 5 when tissues are exposed to the same levels of stress to
characteristic responses to physical stress. Each response which they have become accustomed.
is predicted to occur within a defined range along a
continuum of stress levels. Specific thresholds define the Fundamental Principle E—Physical stress levels that
upper and lower stress levels for each characteristic exceed the maintenance range (ie, overload) result in
tissue response. These thresholds can be viewed as increased tolerance of tissues to subsequent stresses.
boundaries for the effective dose-response to physical Hypertrophy is one common mechanism by which tis-
stress. The 5 qualitative responses to physical stress are sues become more tolerant of subsequent physical
decreased stress tolerance (eg, atrophy), maintenance, stresses (Fig. 3). Hypertrophy occurs when tissue pro-
increased stress tolerance (eg, hypertrophy), injury, and duction exceeds tissue degeneration, and can be defined
death. as a general increase in bulk of a tissue.19 In general,
biological tissues adapt to increased levels of stress by
Fundamental Principle C—Physical stress levels that are increasing cross-sectional area, density, or volume
lower than the maintenance range result in decreased (Tab. 3). Other examples of adaptations that may
tolerance of tissues to subsequent stresses. Atrophy is increase tissue stress tolerance include hormonal
one common mechanism by which tissues become less changes, altered cell membrane excitability, and
tolerant of subsequent physical stresses (Fig. 2). Atrophy changes in the material properties of tissues (Tab. 3).
occurs when tissue degeneration exceeds tissue produc- Although stress overload can promote tissue hypertro-
tion and has been observed in all 4 major organ systems phy and improve stress tolerance, adequate recovery
in response to reduced stress levels (Tab. 3). Other between bouts of increased stress is needed for this
examples of adaptations that may reduce stress tolerance adaptive response to occur (see below).20
include hormonal changes, altered cell membrane excit-
ability, and changes in the material properties of tissues Fundamental Principle F—Excessively high levels of
(Tab. 3). physical stress result in tissue injury. For the purposes of
this theory, injury is defined as tissue damage caused by
Fundamental Principle D—Physical stress levels that are excessive stress resulting in pain or discomfort, impaired
in the maintenance range result in no apparent tissue function of the tissue, or both. Damages that are not felt

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Figure 3.
Effect of “overload” stress raises thresholds for subsequent adaptation
and injury. Prolonged physical stress levels that are higher than the
maintenance range result in increased tolerance of tissues to subsequent Figure 4.
stresses (eg, hypertrophy). Although relative thresholds remain the same, Physical stress level is a composite value. Stress magnitude refers to the
the absolute magnitude of physical stress is higher for each threshold. amount of stress (force per unit area) on a tissue. Time factors include the
Injury (and all other adaptations) occurs at a higher level of physical duration, number of repetitions, and the rate at which stress is applied
stress than required previously. to tissues of the body. Stress will have a different effect depending on
whether it is applied in tension, compression, shear, or torsion.

or are not causing noticeable dysfunction are not con-


sidered clinically significant injuries. The maximum stress duration of stress application results in a greater level of
threshold is defined as the amount of stress the tissue can stress on the tissue. The direction of stress application
bear just before it fails, if the tissue is fully rested and also influences tissue adaptation. Stress will have a
recovered from previous stresses. Stress levels that different effect depending on whether it is applied in
exceed the maximum stress threshold are considered tension, compression, shear, or torsion. Use of a com-
excessive and result in tissue injury. posite measure to quantify the level of stress exposure
implies that stress levels may be altered by changing one
Fundamental Principle G—Extreme deviations from the or more of the stress-related variables that comprise this
maintenance stress range that exceed the adaptive measure.
capacity of tissue result in tissue death. The PST repre-
sents the potential range of responses of viable tissues to Fundamental Principle I—Individual stresses combine
a given level of physical stress. To the extent that the in complex ways to contribute to the overall level of
stress level can be altered, viable tissues exhibit a variable stress exposure. Tissues are affected by the history of
stress response. For example, healthy tissues that are recent stresses. In the PST, the effect of any given stress
injured as a result of exposure to high stress levels may will depend on the previous stress experience of the
return to the maintenance range if stress levels are tissue. For example, 1 repetition of a biceps muscle curl
appropriately reduced. In cases where stress levels devi- against a resistance of 13.6 kg (30 lb) may have little
ate substantially from maintenance conditions, tissues effect on subsequent muscle performance. However, 3
may no longer be viable and tissue death can result. sets of 10 repetitions, 3 times a week, for 2 weeks can lead
Thus, tissue death can occur when tissues are exposed to to muscle hypertrophy and increase the muscle’s ability
either extremely high or extremely low stress levels and to generate force. One consequence of the cumulative
are unable to adapt or recover. effect of repeated stresses is that tissues require periods
of rest in which the level of stress exposure is substan-
Fundamental Principle H—The level of exposure to tially reduced so that they can adapt and recover from
physical stress is a composite value, defined by the previous stresses.
magnitude, time, and direction of stress application (Fig. 4).
Stress magnitude refers to the amount of stress (force Fundamental Principle J—Excessive physical stress that
per unit area) on a tissue at any given moment in time. causes injury can occur through 1 or more of the
Time factors include the duration, the number of repe- following 3 mechanisms: (1) a high-magnitude stress
titions, and the rate at which stress is applied to tissues of applied for a brief duration, (2) a low-magnitude stress
the body. Each of these factors has a direct relationship applied for a long duration, and (3) a moderate-
with the level of stress exposure. For example, a longer magnitude stress applied to the tissue many times. This

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principle is closely related to Fundamental Principle H forces. Forces are applied to tissues over a given area that
(Tab. 1), which identifies stress magnitude and time result in stresses, which contribute to tissue adaptation as
factors (eg, duration and number of repetitions of stress outlined in this theory. Physical therapists often focus on
application) as important variables used to determine the treatment of movement dysfunction,15,16,21,22 and
the composite level of stress to which tissues are exposed. one theory has designated movement as its core princi-
ple.15 By comparison, the core principle of the PST is
Fundamental Principle K—Regardless of the mechanism tissue adaptation in response to physical stress. As sum-
of injury, inflammation occurs immediately following marized in Table 3, movement can have beneficial
tissue injury and renders the injured tissue less tolerant effects (eg, exercise-related tissue hypertrophy) as well as
of stress than it was prior to injury. In the context of the detrimental effects (eg, overuse injury) on tissues of the
PST, the threshold for subsequent tissue injury is low- body. According to the PST, movement and alignment
ered as a result of previous injury and the presence of factors are considered primarily for their ability to place
inflammation. Stress levels that did not cause pain stress on biological tissue. The components of move-
before the tissue was injured would then have the ment and alignment considered by this theory are
potential to cause pain and further tissue damage. muscle performance, motor control, posture and align-
Injured and inflamed tissues must be protected from ment, and physical activity.
subsequent excessive stress until acute inflammation
subsides. Continued stress, even at a level considered Muscle Performance
normal for uninjured tissue, can prevent tissue regener- Muscle performance (force generation, muscle length)
ation following injury. is a critical aspect of movement that can influence tissue
stress. Muscles are highly adaptable. They generate
Fundamental Principle L—The stress thresholds movement and, hence, forces that place stress on tissues.
required to achieve a given tissue response may vary Muscle also is an important “shock absorber,” and
among individuals depending on the presence or muscle contraction is well recognized for its ability to
absence of several modulating variables. In developing protect bones, cartilage, and ligaments from excessive
the PST, we identified 4 categories of variables (Tab. 2) stress.23 As a general theory, the PST can be used in
that can modulate either: (1) the level of stress on combination with other theories and approaches that
tissues, or (2) the response of tissues to a given level of provide a more detailed analysis of the mechanisms by
physical stress (ie, threshold values for tissue adaptation which muscle performance contributes to stress on
and injury). Because of the complex interaction among tissues of the body.24 –30
variables, it is not yet possible to determine the absolute
value of the thresholds for tissue adaptation proposed Motor Control
within this theory. However, we propose that the PST Motor control has been defined as the study of the nature
can be used to construct models that predict the relative and cause of movement,31 and it, therefore, represents a
influence of both stress-related and nonmechanical vari- major component of physical therapists’ expertise.21
ables on tissue adaptation and injury. With additional Evaluation of the ways in which people control their
research, it should be possible to estimate the relative movements to accomplish tasks provides physical thera-
threshold value, based on a percentage of maximum pists with insight into how stresses are applied to tissues
stress tolerance, that is required to promote a desired of the body during movement. For example, Maluf
tissue response given the individual circumstances of et al32 have proposed that the daily repetition of similar
each patient. Rehabilitation programs then could be movements and postures may result in excessive stress on
tailored to enhance factors contributing to tissue repair tissues of the low back. These authors suggest that
and to minimize factors contributing to tissue failure. physical therapists can identify and modify motor
recruitment patterns which potentially contribute to
Factors that can change the level of stress on tissues or patients’ low back pain during the performance of daily
the threshold values for tissue adaptation and injury are activities. Maluf et al32 contend that an important role of
summarized in Table 2 and include movement and physical therapists is to identify patterns of movement
alignment, extrinsic, psychosocial, and physiological fac- that contribute to excessive tissue stress and to teach
tors. Each of these factors is described below, and those patient-appropriate movement strategies to prevent tis-
factors that can be modified with physical therapy inter- sue injury and pain.
ventions are emphasized.
Posture and Alignment
Movement and Alignment Factors Kendall et al25 have emphasized the relationship
According to the PST, movement is the most important between posture, impairments, and pain. The Kendalls’
factor that physical therapists can use to influence tissue basic premise, based on their clinical observations, is
adaptation. As noted, movement occurs because of that there is a standard or “ideal” posture and that

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deviations from this ideal posture lead to characteristic injured. This reduction in the likelihood of injury occurs
patterns of musculoskeletal impairments and pain.25(p5) regardless of whether the tissue is part of the cardio-
For example, the Kendalls predict that a person with vascular/pulmonary, integumentary, musculoskeletal, or
excessive lumbar lordosis would have weak abdominal neuromuscular system. Increased physical activity has
and hamstring muscles, with short, strong low-back and been linked to many positive health benefits, including
hip flexor muscles.25(p126) lower risk for non–insulin-dependent diabetes melli-
tus,41 stroke,42 and obesity.43 The federal government, in
Some studies33–37 have questioned, and even refuted, a Healthy People 2010, has set a number of goals to
large relationship between these variables in people with increase physical activity (Objective 22; Physical Activity
and without back pain. Rather than emphasizing an and Fitness) in people who are otherwise healthy. We
ideal standard of posture and hypothesizing that there is believe that physical therapists should use their expertise
a large relationship among specific postures, impair- to provide instruction on how people can increase
ments, and pain patterns, the PST proposes that pain is overall physical activity without injuring specific struc-
caused by excessive tissue stress and that postural devia- tures (ie, back or knee).
tions are one of many potential variables that contribute
to the excessive stress levels that result in pain. We Extrinsic Factors
commonly observe people with “poor” posture who are Extrinsic factors are factors outside of the body that can
pain-free and other people with “good” posture who influence either the level of stress on tissues or the
have pain. The types of activities performed by people thresholds for tissue adaptation and injury. For the
varies widely, resulting in different stress demands on purpose of this perspective, those extrinsic factors that
tissues of the body. can be modified or utilized by physical therapists are
emphasized.
The PST predicts that no one ideal posture exists for all
people because tissues will adapt to meet the unique Orthotic devices can be used to modify physical stress on
stress demands of each person. Injury occurs when biological tissues and can be used as an adjunct to other
tissues are unable to adapt to meet the demands of a interventions in several phases of tissue adaptation. An
given posture or task. Therefore, rather than comparing orthotic device can be used to relieve stress from injured
a person’s posture to an ideal standard, the therapist’s tissue (eg, a resting hand splint for patients with carpal
examination should focus on the postures or movements tunnel syndrome, a lumbosacral corset for a person with
that cause pain.26,32,38,39 Within this context, postural low back pain). An orthotic device also can be used to
deviations become one of many potential factors that apply stress to tissue to cause a change in the tissue
may place stress on injured tissues. In some people, the (eg, orthotic devices that apply low loads for prolonged
postural deviation may be the primary factor contribut- periods to increase muscle length and joint range of
ing to excessive tissue stress (see “Implications for Phys- motion at the elbow).44 According to the PST, orthotic
ical Therapist Practice” and “Implications for Research” devices are an appropriate adjunct to treatment when
sections). In our view, the PST expands upon the other means of movement can not adequately control
Kendalls’ theory by proposing that postural deviations stress on the tissue to meet desired guidelines. We
are one important component of musculoskeletal pain; contend that components of the orthotic device should
however, pain patterns should be evaluated in a broader be chosen for their ability to achieve a desired stress level
context that considers other potential sources of tissue on the tissue. Likewise, taping45,46 and assistive devices
stress. (eg, crutches, walkers, canes) may be effective adjuncts
to help modify stress on injured tissues.
Physical Activity
Physical activity is another component of movement that Footwear is another extrinsic factor that can influence
results in tissue stress. The US Department of Health stresses applied to the foot. Narrow toe boxes are
and Human Services and the American College of Sports thought to apply damaging stresses to the forefoot that
Medicine have adopted the definition of physical activity lead to the formation of bunions and hammer-toe
as “bodily movement that is produced by the contraction deformities.47 However, footwear also can be used for
of skeletal muscle and that substantially increases energy therapeutic purposes such as helping to decrease stress
expenditure.”40(p4) Physical activity may be divided into on the foot and ankle at heel strike (ie, shock absorp-
the specific subcategories of occupational, leisure, and tion) or helping to control excessive movement of the
self-care activities. The PST predicts that physical activity rear foot.48
improves health because it increases stress on a broad
range of tissues, making the tissues more tolerant of The ergonomic environment is another extrinsic factor
subsequent physical activity. Because the tissues are that can be modified to influence tissue stress. Changes
more tolerant of physical stress, they are less likely to be in the ergonomic environment can be achieved by

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redesigning the job site or work tools to reduce the stances, psychosocial factors can be as important as
demands of jobs that require high force, high repetition, mechanical factors for tissue injury. Although we recog-
and awkward postures.49 Primary principles of ergo- nize that psychosocial factors can play an important role
nomic design include reduction of extreme joint in a person’s response to physical stress, this role is not
motion, excessive force magnitudes, and highly repeti- developed extensively in this perspective. We encourage
tive movements. Appropriate size and placement of a others to develop the psychosocial component of the
workstation can reduce extreme joint motion. Tools or PST.
machines can be designed to reduce excessive forces or
repetitive motions (eg, using an electric drill rather than Physiological Factors
a manual one).49 Physiological factors influence the ability of tissue to
respond to physical stress, but these factors often are
Modalities (eg, heat, cold, electrical stimulation) are difficult, if not impossible, to modify. Physiological fac-
extrinsic factors that can be used to modify the level of tors assume a less important role in physical therapy
tissue stress or the response of biological tissues to stress treatment compared with the factors described previ-
application. As described in the PST, modalities have a ously because physical therapists usually can not modify
secondary role in treatment but may be indicated to or treat physiological factors directly. Physical therapists
augment the body’s own adaptive capabilities. For should be aware of the influence of physiological factors,
instance, electrical stimulation can be used to augment however, because these factors will affect the prognosis
short- and long-term muscle force production, especially of tissue adaptation and recovery from injury.
in the presence of pathology that limits the normal force
generating capacity of muscle (eg, after ligament injury50 Medications can influence tissue physiology and, conse-
or spinal cord injury51). Heat is an example of a modality quently, the ability of tissues to adapt to physical stress.
that can be used to modify the response of tissues to For example, corticosteroid use has a complex effect on
physical stress. For example, elevation of muscle temper- tissue. Corticosteroids can simultaneously cause a
ature is thought to help prevent strain injuries (ie, raise decrease in inflammation in one tissue (positive effect
the threshold for muscle injury) by allowing muscles to on stress tolerance) and cause atrophy in other tissues
stretch more and tolerate higher loads before failure.52 such as skin, bone, and muscle (negative effect on stress
tolerance).57 Physical therapists do not prescribe medi-
Gravity is an extrinsic factor that physical therapists can cations. However, the impact of medications on the
use to modify the external load on the body. By modi- adaptive capacity of tissue is important, and physical
fying the orientation of the body or limbs with respect to therapists should be aware of these effects on their
the ground, physical therapists can increase or decrease patients. In addition, exercise may help to offset muscle
forces exerted on the body during movement and, atrophy from medications such as glucocorticoids.58
consequently, alter the forces that must be generated
internally to produce movement.53 Modalities or devices, Age is another important physiological factor. Although
such as aquatic therapy54 or weight-supported walking it is beyond the scope of this perspective to discuss the
devices,55 also may be used to modify tissue stress by effects of age on tissue adaptation, it is important to
altering the effects of gravity. discuss several general points. Aging has a negative effect
on tissue adaptation. The magnitude of this negative
Psychosocial Factors effect in humans, however, is not clear. Kohrt59 believes
Psychosocial factors represent those factors that are that a considerable portion of the negative effects that
unique to the lifestyle of each person and that poten- have been attributed to aging may be due to age-
tially can be modified. Psychosocial factors can have a associated decreases in activity. Two predictions regard-
profound influence on tissue adaptation, especially as ing the effects of age can be derived from the PST. The
related to tissue injury.56 We believe psychosocial factors first prediction is that aging lowers the ability of tissues to
primarily influence individual threshold values for tissue tolerate stress and has a general tendency to lower the
adaptation and injury. For example, researchers investi- threshold for injury, similar to the effect illustrated in
gated the role of mechanical and psychosocial factors in Figure 2. The level of stress required to promote tissue
the onset of forearm pain in a 2-year-long prospective hypertrophy and increase stress tolerance generally is
study (N⫽1,953).56 Besides linking injury to repetitive greater for young subjects who are healthy compared
movements of the arm or wrist (relative risk of 4.1 and with older subjects. Young people, therefore, can exer-
3.4, respectively), the investigators reported that people cise and stress their tissues more aggressively with less
who were “only occasionally” or “never” satisfied with fear of injury than older people. The second prediction
support from supervisors and colleagues had a relative is that the negative effects of aging can be modified
risk of 4.7 (95% confidence interval⫽2.2, 10) for fore- through increased stress on the tissue. Increased stress,
arm injury. These data indicate that, in some circum- applied through progressive increases in activity or exer-

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cise, theoretically can help prevent or reverse some of such a treatment exists and has been recognized for
the negative effects of aging (Fig. 3). Increasing evi- centuries. It is regular physical activity—that is
dence suggests that tissues remain responsive to physical exercise.12
stress well into old age and that positive adaptations to
increased activity and exercise can result in decreases in Although systemic pathology may lower the threshold
functional limitations and disability.7,8,10 for tissue injury, many people with systemic pathology
respond positively to exercise, both in terms of increased
Systemic pathology includes the many diseases that can stress tolerance and reduction of disease complications.
affect the ability of tissues to adapt to physical stress.
Examples of systemic pathology that physical therapists We also consider obesity a physiological factor within the
often encounter are diabetes mellitus and rheumatoid context of the PST that can be modified, but not easily.
arthritis. Similar to the effects of aging, many forms of Obesity is defined as an increase in body weight beyond
systemic pathology lower the ability of tissue to tolerate the limitation of skeletal and physical requirements, as
stress, and they have a general tendency to lower the the result of an excessive accumulation of fat.64 Body
threshold for injury. One example of this principle is the weight provides an indication of the stresses that must be
effect of peripheral neuropathy on cortical bone mass in borne by tissues of the body during physical activity. The
the feet and hands of patients with diabetes. Patients PST predicts that obesity is a risk factor for certain types
with diabetes and peripheral neuropathy have been of injury and a negative factor for recovery from injury.
shown to have lower cortical bone mass, with a higher In addition, obesity has been linked with low activity
incidence of metatarsal fractures, compared with a levels.43 People who are obese, therefore, may be at
matched group of patients with diabetes alone.60 As greater risk of injury than people who are not obese
interpreted by the PST, pathology associated with because high-stress, low-repetition activities are thought
peripheral neuropathy reduces the injury threshold for to be more damaging than low-stress, high-repetition
bone to a level experienced during normal walking. activities.49,65– 68 Evidence exists to support this predic-
tion. For example, a population-based (n⫽350, 95 men
Although the PST recognizes the negative impact of and 255 women, 55 years of age or older) longitudinal
systemic pathology on tissue adaptation, it also proposes study (mean follow-up duration⫽5.1 years) reported
that carefully applied physical stresses can have positive that the risk of incident radiographic knee osteoarthritis
effects for people with chronic disease. Growing evi- was significantly increased among subjects with higher
dence supports this prediction.9,13,61– 63 Traditionally, baseline body mass index (odds ratio⫽18.3, 95% confi-
people with rheumatoid arthritis have been excluded dence interval⫽5.1– 65.1).69
from vigorous activities that might exacerbate joint
inflammation.9 However, studies have shown that pro- Literature Review
gressive resistive exercises and aerobic exercise pro- The PST focuses on how biological tissues respond to
grams can increase muscle performance, fitness levels, physical stress. Existing evidence and approaches that
and bone mineral density with no exacerbation of dis- share common principles with the PST will be described
ease activity in patients with rheumatoid arthritis.9,61,62 next for each of the 4 major systems described in the
The positive effects of aerobic exercise for patients with Guide to Physical Therapist Practice.14 Because physical
cardiovascular disease have been well documented.13 therapists often work with patients with injuries, each
Likewise, evidence indicates that increased activity, even section will begin by discussing how physical stress can
in small increments, can have positive effects on reduc- contribute to injury. Discussion of the effects of physical
ing the burden of hyperinsulinemia and diabetes.63 stress on injury will then be followed by a discussion of
William H Herman, an associate editor for Clinical the effects of physical stress on tissue atrophy, mainte-
Diabetes, summarized the effect of exercise on diabetes: nance, and hypertrophy. These effects are summarized
in Table 3.
An ideal treatment for type 2 diabetes would lower
blood glucose concentrations acutely, improve long- Musculoskeletal System
term glycemic control, and enhance insulin sensitiv- Some authors29,70 have described mechanical principles
ity. It would improve mild to moderate hypertension, involved in the management of patients with low back
reduce low-density lipoprotein cholesterol and triglyc- pain. McGill70 proposed that injury, or “failure of a
erides, increase high-density lipoprotein cholesterol, tissue,” occurs when the applied load exceeds the failure
and serve as an adjunct to caloric restriction for tolerance of the tissue. In addition, McGill70 contended
weight reduction. Finally, it would increase patients’ that the structures of the back are influenced by the
sense of well-being and improve their quality of life. history of recent physical stresses, so that the accumula-
As a drug, such an agent would be a blockbuster, with tion of individual stresses can cause injury. He argued
greater than $1 billion per year sales potential. Yet that the characteristics of the load (load rate, mode of

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load compression, bending, torsion, shear) and the in an ideal posture, or subtalar joint neutral position, as
properties of the tissue determine the type and extent of advocated by the Root Theory.74 The authors use a case
tissue damage. study to illustrate application of their model.27

McGill70 described the same 3 mechanisms of injury to Stress levels that are higher than the maintenance stress
low back tissues that are proposed within the PST range, yet are lower than the threshold value for injury,
(Principles H, I, and J, Tab. 1). One mechanism of injury can have positive effects on tissue adaptation. Based on
to low back tissues is a single application of a relatively Principle E of the PST, musculoskeletal tissues subjected
high load or stress. McGill provided the example of a to levels of stress that are higher than normal become
person riding a snowmobile who is thrown from the more tolerant to subsequent physical stresses and are
machine and lands on a flexed spine and experiences a more resistant to injury (ie, tissues become stronger).
sudden posterior disk herniation. A second mechanism Principle I suggests that this type of adaptation occurs
of injury to low back tissues is multiple moderate loads or only when tissues are able to recover and adapt to
stresses applied to the structures of the low back. In this previous bouts of physical stress. Controlled increases in
case, injury is the result of accumulated trauma. McGill physical stress through progressive resistive exercise
provided the example of a worker lifting boxes in which cause muscle fibers to hypertrophy and become capable
tissues of the low back are loaded repeatedly, causing a of generating greater force. Likewise, higher-than-
slow degradation of the tissue tolerance. A third mech- normal levels of physical stress can promote remodeling
anism of injury is low loads sustained by the low back in bone.75 Wolff’s Law provides an excellent example of
over a long period of time. An example of this mecha- how one specific biological tissue, bone, responds to
nism of injury is construction workers who install rods in physical stress by remodeling. Wolff’s Law states that the
the floors of a new building and remain in a flexed thickness, number, and orientation of trabeculae will
posture for prolonged periods of time. correspond to the distribution of mechanical stresses on
bone.75 A consequence of stress-induced bone remodel-
Injury to other types of tissue can result from the same ing is that the strength of bone is greatest in the
mechanisms as those described above for the low back. direction in which loads are most commonly imposed.76
Bones can fracture from one bout of high-magnitude For example, the maximum stress tolerated by bone just
force (eg, sudden impact fracture of the femur bone prior to failure has been found to be higher for com-
from a motor vehicle accident) or from bouts of pressive loads than for tensile or shear loads, reflecting
moderate-magnitude force that occur many thousands the predominantly compressive loads experienced by
of times (eg, stress fracture of the tibia or metatarsal bone during weight bearing.77 Runners with a docu-
bones from running,71 prolonged marching72). Similar mented increase in bone mineral density (BMD) in the
to bones, ligaments can tear with one bout of a high- leg, but not arm, compared with nonathletes provide
magnitude force (eg, injury of the medial collateral one example of mechanically induced adaptations in
ligament from a tackle to the lateral knee). Increasing bone.51 Similarly, contralateral differences in arm BMD
evidence, however, suggests that ligaments also can fail have been observed in volleyball, basketball, and tennis
from repeated bouts of moderate-magnitude stress.73 players, but not in swimmers.78,79
For example, women have a much higher incidence of
anterior cruciate ligament injury from noncontact sport- Similar to bone, models of tendon and ligament adap-
ing events compared with men.73 Huston et al73 specu- tation predict that deviations from a typical range of
lated that this finding may be related to anatomical strain (change in length relative to original length)
differences, such as a wider pelvis and greater Q angle in stimulus values promote adaptive responses in these
women, that result in greater cumulative stress on the tissues. According to these models, strain values of 1.5%
anterior cruciate ligament during typical activities such to 3.0% are required to maintain tissue homeostasis.80
as walking or running. Radin and colleagues65– 68 have Strain values above this range will lead to increases in the
described similar mechanisms of injury (Principle J, cross-sectional area and stiffness of tendon and ligament,
Tab. 1) involved in degeneration of articular cartilage whereas strain values below this range predict decreases
and joints. in these parameters. The models further predict that the
more the strain stimulus deviates from steady-state val-
McPoil and Hunt27 also have recognized the importance ues, the faster adaptive responses occur in tissue. Model-
of mechanical stress in the management of foot and based simulations of tissue adaptation are consistent
ankle injuries. These authors have described a treatment with histology data for tendon and ligament in animals
approach based on a “Tissue Stress Model.” This and humans.80 Other research has demonstrated that
approach proposes that clinicians focus on reducing both tendon and ligament respond to exercise-induced
excessive mechanical stress from injured tissues in the stress with increases in cross-sectional area, stiffness, and
foot and ankle rather than attempting to place the foot tensile strength.81– 84

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Evidence also supports the idea that tissues within the subsequently documented similar relationships among
musculoskeletal system atrophy and become less tolerant time, pressure, and skin breakdown in patients with
of physical stress if stress on the tissue diminishes below diabetes and peripheral neuropathy.
a baseline level.59,85– 88 Unfortunately, tissues typically
atrophy at a faster rate than they hypertrophy.59,85 Mus- Skin also exhibits positive adaptations to controlled
cle can lose 6% to 40% of its ability to generate force increases in physical stress. Clinicians have observed that
over a 4- to 6-week period of bed rest or immobiliza- skin adapts to progressive loading with improved stress
tion.86 Bone mineral density also is lost in response to tolerance. A common practice for treating patients with
diminished physical stress. Leblanc et al87 found that a new orthotic or prosthetic device is to slowly progress
BMD is reduced 3% to 4% at the femoral neck and the magnitude and duration of weight-bearing to allow
lumbar spine after 17 weeks of bed rest in young men skin and underlying tissues to adapt to new weight-
who are healthy. Holick88 summarized the current liter- bearing forces.93 In addition, the incidence of blisters in
ature by indicating that unloading of the skeleton, either the feet of runners has been found to be highest in the
due to strict bed rest or in zero gravity, leads, on average, early stages of training, and it is much lower in people
to a 1% to 2% reduction in BMD at selected skeletal sites who consistently run relatively long distances (eg, 48 km
each month. [30 miles] per week) as compared with people who are
just beginning to run.94
Likewise, ligaments respond to reduced mechanical
stress. Woo and colleagues85,89 have documented a Sanders et al95 have provided a review of the growing
decline in the mechanical properties of the rabbit body of literature that suggests that skin exhibits an
medial collateral ligament in response to 9 weeks of adaptive response to stress similar to the response of
immobilization. These researchers reported that the other biological tissues. Skin under tension shows
stiffness, the ultimate load before failure, and the changes similar to ligaments and tendons under tension.
energy-absorbing capacity of the immobilized medial Increases in collagen fibril diameter, collagen cross-
collateral ligament-bone complex were approximately linking, and sulfated proteoglycan content render skin
one third of those variables in the contralateral, nonim- more resistant to tensile forces. Skin adapts to increases
mobilized control limb.89 in shear stress with an increase in the size and density of
cells at the basement membrane and an increase in the
Integumentary System thickness of the stratum corneum (the outermost cell
Tissues in the integumentary system also demonstrate layer on the surface of the skin). Increased thickness of
patterns of response to physical stress similar to those the stratum corneum results in a greater volume of skin
described for the musculoskeletal system. Mechanisms of through which shear loads can be distributed. Distribu-
excessive stress resulting in injury to the skin have been tion of shear loads causes a reduction in the shear
described by Brand24 regarding his work with patients gradient and, consequently, decreases the potential for
with Hansen disease and foot ulcers. Brand24 proposed skin breakdown.
the same 3 basic mechanisms of injury to skin that we
describe for musculoskeletal tissues and that are out- Cardiovasuclar/Pulmonary System
lined in this theory (Principle J, Tab. 1). According to Similar to what can occur to tissues in the musculo-
Brand,24 direct mechanical damage to the skin can occur skeletal and integumentary systems, excessive physical
with high levels of pressure (100 kg/cm2 or 1,300 psi) stress can injure tissues in the cardiovascular/pulmonary
applied for a brief duration, such as when a person steps system. Mechanical stretch induced by high blood pres-
on a tack. Ischemic skin lesions can occur when a sure is thought to be an initial event that leads to cardiac
relatively low magnitude of pressure (1–5 psi) is applied hypertrophy and eventual cardiac failure.96 High blood
to the skin for a long duration, such as when people wear pressure is an established risk factor for conditions such
tight shoes or are confined to bed for prolonged periods as stroke,97 myocardial infarction,98 and atherosclerotic
of time. “Inflammatory autolysis,” similar in concept to disease.99 In addition, vigorous and unaccustomed phys-
cumulative trauma injury, can occur when pressures of a ical activity has been associated with a higher incidence
moderate magnitude (20 psi) are applied to the skin of cardiovascular events.100
hundreds or thousands of times each day, such as
stresses applied to plantar tissues during normal walk- The positive effects of physical stress in the form of
ing.24 Integument failure due to repetitive stress was exercise also are well documented for tissues in the
shown when repetitive stress (10,000 repetitions per day) cardiovascular/pulmonary system. McArdle et al13 out-
was applied to denervated rat footpads in an attempt to lined fundamental principles of exercise training for the
simulate stress on the foot during walking. Footpad cardiopulmonary system. The “overload principle” states
ulcers occurred within 7 to 10 days of commencing the that exercise overload specific to an activity must be
simulated walking procedures.90 Brand24 and others91,92 applied to enhance physiologic improvement and bring

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about a training effect. As described for other systems, Novak and Mackinnon28,109,110 described excessive phys-
achieving overload without tissue injury requires an ical stress from various postural alignments and repeti-
appropriate balance among training intensity (or mag- tive motions that can contribute to nerve injury and
nitude), frequency, and duration (time factors). When pain. The incidence of cumulative trauma disorders has
developing training programs, physical therapists also risen dramatically over the last 15 years and has been
must consider whether stress levels designed to improve linked to jobs that require high-force and high-
cardiovascular performance have the potential to cause repetition activities, especially when performed in awk-
injury to tissues in the musculoskeletal system. ward postures.49(pp3–7) The odds ratio for developing
carpal tunnel syndrome has been reported to be greater
Training can enhance cardiovascular function in ath- than 15 for high-force, high-repetition jobs compared
letes, people who are sedentary, people with disabilities, with jobs requiring low-force, low-repetition activities.111
and people with previous cardiac impairments.13 Train- Pressures within the carpal tunnel have been shown to
ing causes adaptations in tissues within the cardio- be higher when the wrist is in extreme flexion or
vascular and pulmonary systems, including an increase extension compared with a neutral position.112 Further-
in the weight and volume of the heart, an increase in the more, jobs requiring excessive wrist deviations are con-
size of the left ventricular cavity and the thickening of its sidered a risk factor for injury to the median nerve.109
walls, an increase in plasma volume, an increase in
maximum cardiac output, and an increase in lung Lumbar spinal stenosis is another condition that can
volumes. Intensive training can increase aerobic capacity place excessive physical stress on neural tissues.113 Move-
15% to 30% during the first 3 months, with as much as ments and postures of lumbar extension can further
a 50% increase over a 2-year period (Tab. 3).101–105 reduce the diameter of the spinal canal and vertebral
foramen in people with spinal stenosis, causing compres-
Similar to other systems described, the positive effects of sion of lumbar nerves and resulting in lower-extremity
physical stress (ie, aerobic exercise training) are quickly pain and parathesias.113 People with lumbar stenosis
reversible for tissues in the cardiopulmonary system.13 generally have reduced lower-extremity symptoms when
Reductions in metabolic and exercise capacity can occur their spine is flexed because this posture allows the
after only 1 to 2 weeks of detraining, and many other vertebral foramen to widen, thereby reducing compres-
improvements are lost within several months of detrain- sive and shear forces on neural tissues.114
ing.13 McArdle et al,13 for instance, reported a 25%
reduction in maximum oxygen consumption in 5 sub- Mechanical injury of nerve tissue can occur with low-
jects who remained bedridden for 20 consecutive days. magnitude stresses applied for a long duration (com-
Maximal stroke volume and cardiac output also pression injury) or from repetitive bouts of moderate-
decreased, resulting in a loss of aerobic capacity by an magnitude stresses (cumulative trauma disorders).
average of 1% per day.13(p396) Although some nerve injuries may require surgical cor-
rection, we believe one role of the physical therapist is to
Neuromuscular System determine how excessive stress on the nerve can be
In our opinion, adaptation of the nervous system in relieved in a conservative fashion to facilitate healing of
response to physical stress has not been studied as the nervous tissue.
extensively as the adaptive response of tissues in the
musculoskeletal, integumentary, and cardiovascular/ We have limited our discussion of the neuromuscular
pulmonary systems. Increasing evidence, however, sug- system to nerve injuries caused by mechanical stress on
gests that physical stress and activity affect the peripheral the nerve and surrounding structures. Although beyond
and central nervous systems in a manner similar to that the scope of this perspective, a growing body of litera-
of other tissues in the body.106 –108 Excessive stress can ture suggests that neurons adapt to high and low levels
cause injury to tissues within the nervous system via the of physical activity by altering their electrical activi-
3 mechanisms discussed for other systems. Examples of ty106,108,115–118 (Tab. 3; eg, rate of discharge, threshold of
nerve injuries caused by high-magnitude stress applied recruitment). The observation that physical activity can
over a brief duration include spinal cord injuries result- stimulate neural adaptation has important implications
ing from gunshot wounds or motor vehicle accidents. for the rehabilitation of patients with primary neurolog-
Nerve injury also may be caused by lower-magnitude ical disorders (eg, stroke, traumatic brain injury). We
stresses applied repetitively or over a long duration. predict that the fundamental principles outlined in the
Examples of these mechanisms of nerve injury include PST can be used to describe neural adaptations follow-
carpal tunnel syndrome, tarsal tunnel syndrome, tho- ing central or peripheral nervous system injury, and we
racic outlet syndrome, ulnar nerve palsy, spinal stenosis, encourage others to investigate this prediction.
and lumbar root lesions.

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Limitations of the Physical Stress Theory Certain areas within physical therapy are not well devel-
The PST represents an effort to integrate common oped in the PST in its current form. For example, the
principles from the approaches and evidence described PST does not address issues of adaptation in the central
above. We also expand existing theories to place the role nervous system. In addition, the PST does not identify
of tissue injury within a continuum of tissue viability so the specific psychosocial factors that most influence
that the theory encompasses pathological conditions tissue adaptation and injury. We believe the current
and principles of wellness and prevention. Like any theory, however, does provide a useful framework a wide
theory, the PST has limitations. These limitations will be range of physical therapy issues and has implications for
discussed next, followed by a discussion of the implica- practice, research, and education.
tions of the theory for physical therapist practice, edu-
cation, and research. Implications for Physical Therapist Practice
We believe the PST provides a useful framework to
In the PST, we assume that tissue exposure to physical approach patient care. It emphasizes the role of physical
stress can be quantified, and we assume that knowledge stress by addressing factors known to influence the level
of the level of stress exposure and factors that influence of physical stress and the response of tissues to stress
the adaptive capacity of tissues (eg, age, disease) can be application. According to this theory, the primary role of
used to predict tissue adaptation and injury. In its the physical therapist is to modify physical stresses to
current form, however, the PST does not define absolute achieve a desired goal. Two broad goals will be discussed.
threshold values for tissue adaptation and injury. For The first goal is to reduce pain and subsequent impair-
example, we do not know whether a tissue is about to be ments, functional limitations, and disabilities that result
injured until it begins to show signs of inflammation from injury. The second goal is to increase activity
(ie, pain, heat, swelling, or redness). Although attempts tolerance. Each of these goals will be discussed further in
are being made to identify biological markers that may subsequent sections.
identify thresholds of adaptation or injury (ie, integrins
in the muscle119 and serum keratan sulfate in interver- Implications for Treating Patients With Tissue Injury
tebral disks120), much more research is needed to define The PST provides a general model for evaluating and
these thresholds in multiple tissue types. treating people with injury. Chronic tissue injury, defined
as injury that results in pain lasting greater than 8 weeks,
We believe the PST provides an appropriate framework often is caused by stresses of moderate magnitude that
for investigating the influence of multiple factors on the are repeated hundreds or even thousands of times a
level of physical stress required for tissue adaptation and day.24,49,63 Examples of injuries resulting from this mech-
injury avoidance. Despite the absence of specific values anism include many forms of back and cervical pain,70
for thresholds of change, the PST currently provides an patellofemoral pain,122 tendinitis injuries (eg, Achilles
overall framework that outlines relative relationships tendon, posterior tibial tendon), impingement syn-
along a continuum of tissue responses to physical stress. drome of the shoulder, stress fractures,71,72 neuropathic
Elaboration and refinement of this preliminary frame- plantar ulcers,24 and carpal tunnel syndrome.49 The
work should eventually allow for a quantitative under- primary questions asked in the evaluation and treatment
standing of the thresholds that indicate when atrophy, of these and other forms of tissue injury are: (1) What
maintenance, hypertrophy, injury, and death of various factors appear to be contributing to excessive stress on
tissues begin. the injured tissue? and (2) How can these contributing
factors be modified to reduce stress on the tissue and
Another limitation of this theory is that it describes allow the tissue to heal?
changes at the tissue level and does not indicate how
tissue change is related to functional limitations or We believe proper identification of the injured tissue
disability. Therefore, we believe the PST must be used in usually can help determine the factors contributing to
combination with other theories or models of disable- excessive stress on the tissue. For example, suspected
ment121 to address the entire spectrum of physical tendinitis might lead the clinician to investigate sources
disability. We believe that physical disablement models of stress caused by movements that are controlled by the
are critical for understanding the overall relationship muscle and tendon. In many cases, however, physical
between disease or pathophysiology and resulting therapists are not able to confirm injury of a specific tissue
impairments, functional limitations, and disability.121 We using the tools currently available to them. The PST
further believe that the PST can be used to complement describes general principles of tissue adaptation and
the physical disablement models by helping us to under- injury, applicable to all types of biological tissue, that can
stand the mechanisms of injuries and repair at a tissue be used to guide treatment regardless of whether the
level. injury can be localized to a specific structure. In our
view, appropriate treatment, therefore, does not always

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require accurate identification of the injured structure. subtalar joint contributed to excessive stress on the
For instance, if low back pain can be eliminated by plantar fascia and resultant heel pain. The treatment
teaching the patient to move at the hips rather than plan, therefore, was designed to modify these factors to
moving at the lumbar spine when movements of the decrease stress on the plantar fascia (eg, modifying the
lumbar spine cause pain, identifying the specific injured patient’s work schedule to limit weight-bearing time,
tissue is of little benefit. purchasing shoes with cushioned midsoles, obtaining
temporary orthotic devices to control excessive
We believe general principles that govern the response pronation).27
of all biological tissues to stress can be used to guide
physical therapy intervention, even when pathology of a Similar principles can be applied to the evaluation and
specific structure cannot be determined. In this context, treatment of many types of wounds. Mueller and Dia-
we contend that the most important question to guide mond125 described an approach emphasizing reduction
treatment becomes: What factors appear to be contrib- of stress on plantar tissues in a patient with diabetes,
uting to excessive stress on the injured tissue? This peripheral neuropathy, and a chronic plantar ulcer (21
question relates to Fundamental Principles F, I, J, and K months). They speculated that a fixed equinus and
in Table 1. In our opinion, the factors in Table 2 should rear-foot varus deformity contributed to excessive pres-
be systematically evaluated for their potential to contrib- sure on tissues in the forefoot during walking and
ute to excessive tissue stress or for their potential to prevented the chronic ulcer from healing. The wound
modify the response of tissues to stress application. In healed after a total contact cast, followed by protective
our experience, various types of injury tend to be footwear, was applied to reduce excessive stress at the
associated with a similar set of contributing factors. For site of the wound.125 An approach based on principles of
example, we have observed that factors contributing to stress reduction also has been described for the treat-
overuse injuries of the foot and ankle often include ment of peripheral nerve injuries such as carpal tunnel
movement and alignment factors (ie, excessive prona- syndrome and brachial plexus injuries.109 Novak and
tion or supination,123 changes in activity) and extrinsic Mackinnon109 have described how postures, movements,
factors (ie, footwear). Factors that contribute to exces- impairments, and physical activities can contribute to
sive tissue stress or modify the tissue response can be stress on peripheral nerve tissue. Furthermore, these
added to or subtracted from the model depending on authors have described how factors contributing to
individual characteristics of the patient and the thera- excessive stress on peripheral nerves can be modified to
pist’s current working set of hypotheses. allow the nerve tissue to heal and, consequently, reduce
the symptoms associated with nerve injury.109
We suggest that a physical therapist develop a hypothesis
regarding the factors that are contributing to excessive Even after sources of excessive stress have been identi-
tissue stress and causing injury. The next logical ques- fied and removed, we contend that injured tissues will be
tion is: How can I modify these contributing factors to less tolerant of stress than they were prior to injury due
reduce stress on the tissues and allow the tissues to heal? to pain, inflammation, and disuse associated with the
Successful outcomes, in our opinion, help to confirm injury (Principles C and K, Tab. 1). Therefore, after pain
the initial hypothesis, whereas poor outcomes direct the and inflammation have subsided, previously injured
clinician to investigate other potential sources of stress tissues, in our opinion, should be exposed to progres-
not identified by the initial hypothesis. This approach is sively higher levels of physical stress to gradually restore
consistent with the hypothesis-oriented algorithm for the tissues’ ability to tolerate greater levels of stress
clinicians.124 (Principle E, Tab. 1). Stress, we contend, should be
applied progressively, with attention paid to the body’s
The basic principles discussed can be illustrated with need for rest and recovery.
several examples. Maluf et al32 described evaluation and
treatment of a patient with chronic low back pain. The Implications for Improving Activity Tolerance
authors speculated that repetition of rotation and exten- Our examples were designed to illustrate how to pro-
sion movements of the lumbar spine contributed to mote healing and progressive strengthening of injured
excessive stress and injury to structures within the low tissues. The goal of helping patients to improve activity
back region. Low back symptoms improved following tolerance will now be considered. Examples of this goal
instructions designed to restrict lumbar rotation and include increasing muscle peak force production,
extension movements during the performance of daily achieving independence in transfers, and improving
activities.32 McPoil and Hunt27 described a similar walking tolerance. Activity can be considered a form of
approach in the treatment of a patient with heel pain. physical stress.40 Therefore, a systematic approach for
The authors speculated that a recent change in activity evaluating and treating individuals with the goal of
level, poor footwear, and excessive pronation at the improving activity tolerance can be derived from the

Physical
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PST. We propose that the following questions are rele- In the PST, we propose that several key content areas
vant to the goal of increasing activity tolerance: (1) What should be emphasized. Kinesiology, we argue, should be
is the activity goal? (2) What are the current modifiable taught with an emphasis on tissue mechanics and how
factors limiting the activity goal? and (3) How should different types of movement contribute to stress on
these factors be modified to meet the activity goal? For specific tissues. Classes related to exercise physiology, in
example, the activity goal of an elderly person may be to our view, should present guidelines for exercise and
stand independently from a sitting position. A physical activity prescription that are designed to fall within the
therapist may hypothesize that the primary modifiable range of stress that promotes tissue hypertrophy while
factors limiting this goal are: (1) lower-extremity muscle avoiding injury. We contend that instruction about
atrophy resulting in poor force production, (2) de- orthotic devices or modalities should focus on their use
creased dorsiflexion range of motion, (3) poor motor in modifying either the level of stress applied to the body
control (movement and alignment factors), and (4) a or the body’s response to stress. The content of classes
low seat surface (extrinsic factor). The person’s age is an related to medicine and pathology should focus on
important physiological factor that may limit the poten- providing an understanding of how particular diseases
tial for tissue adaptation and lower the threshold for or pathologies modify the body’s response to various
tissue injury. A treatment plan designed to modify these forms of physical stress including exercise and activity.
factors based on the PST might include: (1) a progres- Classes related to clinical diagnosis and management
sive resistive exercise program for lower-extremity exten- could be organized using the approach described in the
sor muscles with at least 70% of maximum effort, 2 to 3 section titled “Implications for Physical Therapist Prac-
times a week, for several weeks to increase muscle force tice.” We contend that the list of factors in Table 2 could
production, (2) stretching exercises to increase dorsi- form the focus of factors to consider for evaluation and
flexion range of motion, (3) practice standing from a intervention. Although there are other content areas
seated position using appropriate movement strategies, that must be addressed in a curriculum (eg, administra-
and (4) advising the patient to obtain a higher chair so tion), we contend that the factors listed above are the
that lower muscle force production is needed to achieve most important and could serve as the focus of content
the activity. unique to a physical therapy curriculum. Students
should be trained to develop a clinical hypothesis that
The overload principle (Principle E, Tab. 1),13,40 in identifies the most important factors contributing to a
which maintenance stress levels are raised to the range patient’s problem, to address each modifiable factor,
of stress that promotes tissue hypertrophy, has tremen- and to revise the initial hypothesis based on evaluation
dous implications for physical therapy and forms the of treatment outcomes.
basis for progressive resistance exercises to increase
muscle performance and activity tolerance. Physical Implications for Research
stress must be of sufficient magnitude and repetition to The PST provides a framework for generating research
cause the desired change in performance. The role of hypotheses that focus attention on what we believe to be
the physical therapist, in our view, is to instruct people in the most important and basic treatment technique used
the appropriate magnitude and repetition of exercise or by physical therapists: modifying physical stresses to
activity to provide an adequate stimulus for hypertrophy facilitate tissue adaptation and prevent injury. Although
of intended tissues without injuring other tissues. emphasizing the role of physical stress (Tab. 1), the PST
Although clinicians are accustomed to using the over- also recognizes the multifactorial nature of tissue adap-
load principle to achieve hypertrophy of muscle, these tation and injury (Tab. 2).
same principles can be applied to other tissues such as
ligament, tendon,126 and skin95 (Tab. 3). We believe this theory helps to clarify and expand on
documented theoretical approaches currently used in
Implications for Physical Therapist Education physical therapy. Disablement models have provided an
In a time when scientific and medical knowledge is excellent theoretical framework for studying the rela-
expanding at an exponential rate, we believe the PST tionship among impairments, functional limitations, and
can help educators focus on appropriate content for a disability. We agree that a limitation of these models,
substantial portion of the physical therapy curriculum. however, is that they often do not address the underlying
According to the PST, key elements of the curriculum cause of the patient’s symptoms.127 For example, disable-
should include a clear understanding of how the body ment models postulate that back pain leads to certain
adapts to physical stress and how physical therapists can functional limitations, such as difficulty performing
apply or modify stress on the body to achieve desired household chores. However, we believe these models do
outcomes (Tabs. 1 and 3). not encourage identification of the specific mechanisms
that cause the pathology leading to low back pain. The
PST helps to fill this theoretical void by proposing that

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ўўўўўўўўўўўўўўўўўўўўўўўў
excessive physical stress causes the pathology, resulting ing a patient’s risk for skin breakdown (Fundamental
in pain and subsequent disability. Principles H and J, Tab. 1).24 Furthermore, the thresh-
old for injury is influenced by individual movement and
We believe the PST also can be used to complement the alignment factors (eg, activity level, foot deformities),
American Physical Therapy Association’s current Clini- extrinsic factors (eg, type of shoes), psychosocial factors
cal Research Agenda for Physical Therapy.128 The (eg, adherence), and physiological factors (eg, severity
agenda was designed to “support, explain, and enhance of peripheral vascular disease and peripheral neuropa-
physical therapy clinical practice by facilitating research thy) (Tab. 1). Researchers who are attempting to inves-
that is useful primarily to clinicians.”128(p499) The Clinical tigate the complex issue of skin breakdown would need
Research Agenda consists of 72 questions, organized to account for these many factors. The PST provides a
according to the elements of the physical therapist framework for connecting the factors that can be used to
patient/client management model. In addition to gen- guide research questions for a broad range of problems
erating new research questions, we believe the PST encountered by physical therapists.
provides a theoretical framework to help direct research
for questions in the research agenda. For example, Conclusion
question 1.4.9. of the agenda asks, “Do measures of The PST emphasizes the application and modification of
postural alignment in people with spinal disorders influ- physical stress on tissues of the human body to elicit
ence clinical decision making, and, if so, how?”128(p505) positive adaptations and avoid injury. Many of the
The PST directs the investigator to consider posture and thoughts presented in this article are not new. The
alignment factors in the context of how these factors summary and integration of these thoughts into a
might contribute to excessive physical stress on the defined theory, however, does offer a comprehensive
spine. Based on the PST, an investigator might hypoth- approach that we believe can help to direct physical
esize that, in the general population, posture and align- therapist practice and research for a wide range of
ment contribute a small but meaningful effect size to people with and without impairments. We assert that
spinal dysfunction. The PST suggests that other factors there is considerable evidence to support current phys-
such as movement patterns, age, ergonomic environ- ical therapist interventions directed at modifying physi-
ment, and psychosocial factors also must be considered cal stress. We challenge readers to test, modify, and
in clinical decision making when examining and man- develop this theory through practice and published
aging patients with spinal dysfunction. Furthermore, we research. Our hope is that readers will see common
believe the PST provides an organized framework for elements described in this perspective in their own areas
identifying and studying the relative contribution of of practice and that physical therapy can continue to
each of these factors to the development, persistence, move forward in a more systematic and evidence-based
and recurrence of spinal disorders. This is one example manner.
of the many multifactorial problems encountered by
physical therapists. In the PST, we suggest that contrib- References
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