䢇

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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Physical Therapy . Volume 82 . Number 4 . April 2002 383

 Many different theories and
approaches currently used in physical

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

384 . Mueller and Maluf Physical Therapy . Volume 82 . Number 4 . April 2002

Table 1.
Summary of Fundamental Principles for Physical Stress Theory
Basic Premise: Changes in the relative level of physical stress
cause a predictable adaptive response in all biological tissue.
Fundamental Principles:
A. Changes in the relative level of physical stress cause a
predictable response in all biological tissues.
B. Biological tissues exhibit 5 characteristic responses to physical
stress (Fig. 1). Each response is predicted to occur within a
defined range along a continuum of stress levels. 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.
C. Physical stress levels that are lower than the maintenance
range result in decreased tolerance of tissues to subsequent
stresses (eg, atrophy).
D. Physical stress levels that are in the maintenance range result
in no apparent tissue change.
E. Physical stress levels that exceed the maintenance range (ie,
overload) result in increased tolerance of tissues to subsequent
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.
H. The level of exposure to physical stress is a composite value,
defined by the magnitude, time, and direction of stress
application.
I. Individual stresses combine in complex ways to contribute to the
overall level of stress exposure. Tissues are affected by the
history of recent stresses.
J. Excessive physical stress that causes injury can occur from 1 or
more of the following 3 mechanisms: (1) a high-magnitude
stress applied for a brief period, (2) a low-magnitude stress
applied for a long duration, and (3) a moderate-magnitude
stress applied to the tissue many times.
K. Inflammation occurs immediately following tissue injury and
renders the injured tissue less tolerant of stress than it was prior
to injury. Injured and inflamed tissues must be protected from
subsequent excessive stress until acute inflammation subsides.
L. The stress thresholds required to achieve a given tissue
response may vary among individuals depending on the
presence or absence of several modulating variables. Factors
that can influence thresholds for tissue adaptation and injury
are summarized in Table 2 and include movement and
alignment, extrinsic, behavioral, and physiological factors.
In its present form, we believe the PST can be applied
most easily to the care of patients with primary problems
involving the musculoskeletal and integumentary sys-
tems. However, we believe this theory also has potential
applications for patients with primary problems involv-
ing the cardiovascular/pulmonary and neuromuscular
systems.14 We contend that the PST relates to a contin-
uum of care and, therefore, also has direct applications
for issues related to wellness and the prevention of
physical disabilities.
The purpose of this perspective is to present a general
theory, based on principles of adaptation to physical
stress, that we believe can be used to help guide physical
therapy practice, education, and research. First, we will
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Table 2.
Factors Affecting the Level of Physical Stress on Tissues or the
Adaptive Response of Tissues to Physical Stress
Movement and Alignment Factors
Muscle performance (force generation, length)
Motor control
Posture and alignment
Physical activity
Occupational, leisure, and self-care activities
Extrinsic Factors
Orthotic devices, taping, assistive devices
Footwear
Ergonomic environment
Modalities
Gravity
Psychosocial Factors
Physiological Factors
Medication
Age
Systemic pathology
Obesity
describe the fundamental principles of the PST, fol-
lowed by a review of selected literature describing adap-
tation to physical stress for each of the 4 main organ
systems described in the Guide to Physical Therapist Prac-
tice.14 The fundamental principles are based on an
analysis of the literature and our clinical experiences.
Because the principles are general and represent what
we contend are the “common denominators” of a variety
of research findings and clinical approaches, references
are not provided in the description of the theory or in
the listing of Fundamental Principles in Table 1. Sup-
porting literature is provided in the subsequent section
and is summarized in Table 3. The literature review also
will address how we believe the PST relates to other
physical therapy theories and approaches. Limitations
and implications of the PST for practice, research, and
education will then be discussed.
Description of Physical Stress Theory
The basic premise of the PST is that changes in the
relative level of physical stress cause a predictable adap-
tive response in all biological tissue (Tab. 1). Figure 1
illustrates primary adaptive responses and thresholds for
tissue adaptation in response to physical stress. Factors
that may influence either the level of physical stress on
tissues or the adaptive response of tissues to a given stress
level are outlined in Table 2. The fundamental princi-
ples of the PST are summarized in Table 1 and are
described in further detail below.
Fundamental Principle A—Changes in the relative level
of physical stress cause a predictable response in all
biological tissues. Physical stress is the force, or load,
acting on a given area of tissue.6 In the PST, we propose
that tissues accommodate to physical stresses by altering
Mueller and Maluf . 385
 Table 3.
Effect of Physical Stress and Activity on Tissues of the 4 Major Organ Systems Listed in the Guide to Physical Therapist Practicea

386 . 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
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.

Physical Therapy . Volume 82 . Number 4 . April 2002


Figure 1.
Effect of physical stress on tissue adaptation. Biological tissues exhibit 5
adaptive responses to physical stress. Each response is predicted to
occur within a defined range along a continuum of stress levels. Specific
thresholds define the upper and lower stress levels for each character-
istic tissue response. The relative relationship between these thresholds is
fairly consistent between people, whereas the absolute values for
thresholds vary greatly.
their structure and composition to best meet the
mechanical demands of routine loading. Deviations
from routine or steady-state loading provide a stimulus
for tissue adaptation that allows tissues to meet the
mechanical demands of a novel environment.
Fundamental Principle B—Biological tissues exhibit 5
characteristic responses to physical stress. Each response
is predicted to occur within a defined range along a
continuum of stress levels. Specific thresholds define the
upper and lower stress levels for each characteristic
tissue response. These thresholds can be viewed as
boundaries for the effective dose-response to physical
stress. The 5 qualitative responses to physical stress are
decreased stress tolerance (eg, atrophy), maintenance,
increased stress tolerance (eg, hypertrophy), injury, and
death.
Fundamental Principle C—Physical stress levels that are
lower than the maintenance range result in decreased
tolerance of tissues to subsequent stresses. Atrophy is
one common mechanism by which tissues become less
tolerant of subsequent physical stresses (Fig. 2). Atrophy
occurs when tissue degeneration exceeds tissue produc-
tion and has been observed in all 4 major organ systems
in response to reduced stress levels (Tab. 3). Other
examples of adaptations that may reduce stress tolerance
include hormonal changes, altered cell membrane excit-
ability, and changes in the material properties of tissues
(Tab. 3).
Fundamental Principle D—Physical stress levels that are
in the maintenance range result in no apparent tissue
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Figure 2.
Effect of prolonged low stress lowers thresholds for subsequent adapta-
tion and injury. Prolonged physical stress levels that are lower than the
maintenance range result in decreased tolerance of tissues to subse-
quent stresses (eg, atrophy). Although relative thresholds remain the
same, the absolute magnitude of physical stress is lower for each
threshold. Injury (and all other adaptations) occurs at a lower level of
physical stress than required previously.
change. Tissue homeostasis occurs when tissue degener-
ation is equal to tissue production, resulting in tissue
turnover without net gain or loss. The range of stress
levels that promote tissue homeostasis is defined as the
maintenance stress range and may be different for different
people. This steady-state or equilibrium response occurs
when tissues are exposed to the same levels of stress to
which they have become accustomed.
Fundamental Principle E—Physical stress levels that
exceed the maintenance range (ie, overload) result in
increased tolerance of tissues to subsequent stresses.
Hypertrophy is one common mechanism by which tis-
sues become more tolerant of subsequent physical
stresses (Fig. 3). Hypertrophy occurs when tissue pro-
duction exceeds tissue degeneration, and can be defined
as a general increase in bulk of a tissue.19 In general,
biological tissues adapt to increased levels of stress by
increasing cross-sectional area, density, or volume
(Tab. 3). Other examples of adaptations that may
increase tissue stress tolerance include hormonal
changes, altered cell membrane excitability, and
changes in the material properties of tissues (Tab. 3).
Although stress overload can promote tissue hypertro-
phy and improve stress tolerance, adequate recovery
between bouts of increased stress is needed for this
adaptive response to occur (see below).20
Fundamental Principle F—Excessively high levels of
physical stress result in tissue injury. For the purposes of
this theory, injury is defined as tissue damage caused by
excessive stress resulting in pain or discomfort, impaired
function of the tissue, or both. Damages that are not felt
Mueller and Maluf . 387
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
stresses (eg, hypertrophy). Although relative thresholds remain the same,
the absolute magnitude of physical stress is higher for each threshold.
Injury (and all other adaptations) occurs at a higher level of physical
stress than required previously.
or are not causing noticeable dysfunction are not con-
sidered clinically significant injuries. The maximum stress
threshold is defined as the amount of stress the tissue can
bear just before it fails, if the tissue is fully rested and
recovered from previous stresses. Stress levels that
exceed the maximum stress threshold are considered
excessive and result in tissue injury.
Fundamental Principle G—Extreme deviations from the
maintenance stress range that exceed the adaptive
capacity of tissue result in tissue death. The PST repre-
sents the potential range of responses of viable tissues to
a given level of physical stress. To the extent that the
stress level can be altered, viable tissues exhibit a variable
stress response. For example, healthy tissues that are
injured as a result of exposure to high stress levels may
return to the maintenance range if stress levels are
appropriately reduced. In cases where stress levels devi-
ate substantially from maintenance conditions, tissues
may no longer be viable and tissue death can result.
Thus, tissue death can occur when tissues are exposed to
either extremely high or extremely low stress levels and
are unable to adapt or recover.
Fundamental Principle H—The level of exposure to
physical stress is a composite value, defined by the
magnitude, time, and direction of stress application (Fig. 4).
Stress magnitude refers to the amount of stress (force
per unit area) on a tissue at any given moment in time.
Time factors include the duration, the number of repe-
titions, and the rate at which stress is applied to tissues of
the body. Each of these factors has a direct relationship
with the level of stress exposure. For example, a longer
388 . Mueller and Maluf
Figure 4.
Physical stress level is a composite value. Stress magnitude refers to the
amount of stress (force per unit area) on a tissue. Time factors include the
duration, number of repetitions, and the rate at which stress is applied
to tissues of the body. Stress will have a different effect depending on
whether it is applied in tension, compression, shear, or torsion.
duration of stress application results in a greater level of
stress on the tissue. The direction of stress application
also influences tissue adaptation. Stress will have a
different effect depending on whether it is applied in
tension, compression, shear, or torsion. Use of a com-
posite measure to quantify the level of stress exposure
implies that stress levels may be altered by changing one
or more of the stress-related variables that comprise this
measure.
Fundamental Principle I—Individual stresses combine
in complex ways to contribute to the overall level of
stress exposure. Tissues are affected by the history of
recent stresses. In the PST, the effect of any given stress
will depend on the previous stress experience of the
tissue. For example, 1 repetition of a biceps muscle curl
against a resistance of 13.6 kg (30 lb) may have little
effect on subsequent muscle performance. However, 3
sets of 10 repetitions, 3 times a week, for 2 weeks can lead
to muscle hypertrophy and increase the muscle’s ability
to generate force. One consequence of the cumulative
effect of repeated stresses is that tissues require periods
of rest in which the level of stress exposure is substan-
tially reduced so that they can adapt and recover from
previous stresses.
Fundamental Principle J—Excessive physical stress that
causes injury can occur through 1 or more of the
following 3 mechanisms: (1) a high-magnitude stress
applied for a brief duration, (2) a low-magnitude stress
applied for a long duration, and (3) a moderate-
magnitude stress applied to the tissue many times. This
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principle is closely related to Fundamental Principle H
(Tab. 1), which identifies stress magnitude and time
factors (eg, duration and number of repetitions of stress
application) as important variables used to determine
the composite level of stress to which tissues are exposed.
Fundamental Principle K—Regardless of the mechanism
of injury, inflammation occurs immediately following
tissue injury and renders the injured tissue less tolerant
of stress than it was prior to injury. In the context of the
PST, the threshold for subsequent tissue injury is low-
ered as a result of previous injury and the presence of
inflammation. Stress levels that did not cause pain
before the tissue was injured would then have the
potential to cause pain and further tissue damage.
Injured and inflamed tissues must be protected from
subsequent excessive stress until acute inflammation
subsides. Continued stress, even at a level considered
normal for uninjured tissue, can prevent tissue regener-
ation following injury.
Fundamental Principle L—The stress thresholds
required to achieve a given tissue response may vary
among individuals depending on the presence or
absence of several modulating variables. In developing
the PST, we identified 4 categories of variables (Tab. 2)
that can modulate either: (1) the level of stress on
tissues, or (2) the response of tissues to a given level of
physical stress (ie, threshold values for tissue adaptation
and injury). Because of the complex interaction among
variables, it is not yet possible to determine the absolute
value of the thresholds for tissue adaptation proposed
within this theory. However, we propose that the PST
can be used to construct models that predict the relative
influence of both stress-related and nonmechanical vari-
ables on tissue adaptation and injury. With additional
research, it should be possible to estimate the relative
threshold value, based on a percentage of maximum
stress tolerance, that is required to promote a desired
tissue response given the individual circumstances of
each patient. Rehabilitation programs then could be
tailored to enhance factors contributing to tissue repair
and to minimize factors contributing to tissue failure.
Factors that can change the level of stress on tissues or
the threshold values for tissue adaptation and injury are
summarized in Table 2 and include movement and
alignment, extrinsic, psychosocial, and physiological fac-
tors. Each of these factors is described below, and those
factors that can be modified with physical therapy inter-
ventions are emphasized.
Movement and Alignment Factors
According to the PST, movement is the most important
factor that physical therapists can use to influence tissue
adaptation. As noted, movement occurs because of
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forces. Forces are applied to tissues over a given area that
result in stresses, which contribute to tissue adaptation as
outlined in this theory. Physical therapists often focus on
the treatment of movement dysfunction,15,16,21,22 and
one theory has designated movement as its core princi-
ple.15 By comparison, the core principle of the PST is
tissue adaptation in response to physical stress. As sum-
marized in Table 3, movement can have beneficial
effects (eg, exercise-related tissue hypertrophy) as well as
detrimental effects (eg, overuse injury) on tissues of the
body. According to the PST, movement and alignment
factors are considered primarily for their ability to place
stress on biological tissue. The components of move-
ment and alignment considered by this theory are
muscle performance, motor control, posture and align-
ment, and physical activity.
Muscle Performance
Muscle performance (force generation, muscle length)
is a critical aspect of movement that can influence tissue
stress. Muscles are highly adaptable. They generate
movement and, hence, forces that place stress on tissues.
Muscle also is an important “shock absorber,” and
muscle contraction is well recognized for its ability to
protect bones, cartilage, and ligaments from excessive
stress.23 As a general theory, the PST can be used in
combination with other theories and approaches that
provide a more detailed analysis of the mechanisms by
which muscle performance contributes to stress on
tissues of the body.24 –30
Motor Control
Motor control has been defined as the study of the nature
and cause of movement,31 and it, therefore, represents a
major component of physical therapists’ expertise.21
Evaluation of the ways in which people control their
movements to accomplish tasks provides physical thera-
pists with insight into how stresses are applied to tissues
of the body during movement. For example, Maluf
et al32 have proposed that the daily repetition of similar
movements and postures may result in excessive stress on
tissues of the low back. These authors suggest that
physical therapists can identify and modify motor
recruitment patterns which potentially contribute to
patients’ low back pain during the performance of daily
activities. Maluf et al32 contend that an important role of
physical therapists is to identify patterns of movement
that contribute to excessive tissue stress and to teach
patient-appropriate movement strategies to prevent tis-
sue injury and pain.
Posture and Alignment
Kendall et al25 have emphasized the relationship
between posture, impairments, and pain. The Kendalls’
basic premise, based on their clinical observations, is
that there is a standard or “ideal” posture and that
Mueller and Maluf . 389
deviations from this ideal posture lead to characteristic
patterns of musculoskeletal impairments and pain.25(p5)
For example, the Kendalls predict that a person with
excessive lumbar lordosis would have weak abdominal
and hamstring muscles, with short, strong low-back and
hip flexor muscles.25(p126)
Some studies33–37 have questioned, and even refuted, a
large relationship between these variables in people with
and without back pain. Rather than emphasizing an
ideal standard of posture and hypothesizing that there is
a large relationship among specific postures, impair-
ments, and pain patterns, the PST proposes that pain is
caused by excessive tissue stress and that postural devia-
tions are one of many potential variables that contribute
to the excessive stress levels that result in pain. We
commonly observe people with “poor” posture who are
pain-free and other people with “good” posture who
have pain. The types of activities performed by people
varies widely, resulting in different stress demands on
tissues of the body.
The PST predicts that no one ideal posture exists for all
people because tissues will adapt to meet the unique
stress demands of each person. Injury occurs when
tissues are unable to adapt to meet the demands of a
given posture or task. Therefore, rather than comparing
a person’s posture to an ideal standard, the therapist’s
examination should focus on the postures or movements
that cause pain.26,32,38,39 Within this context, postural
deviations become one of many potential factors that
may place stress on injured tissues. In some people, the
postural deviation may be the primary factor contribut-
ing to excessive tissue stress (see “Implications for Phys-
ical Therapist Practice” and “Implications for Research”
sections). In our view, the PST expands upon the
Kendalls’ theory by proposing that postural deviations
are one important component of musculoskeletal pain;
however, pain patterns should be evaluated in a broader
context that considers other potential sources of tissue
stress.
Physical Activity
Physical activity is another component of movement that
results in tissue stress. The US Department of Health
and Human Services and the American College of Sports
Medicine have adopted the definition of physical activity
as “bodily movement that is produced by the contraction
of skeletal muscle and that substantially increases energy
expenditure.”40(p4) Physical activity may be divided into
the specific subcategories of occupational, leisure, and
self-care activities. The PST predicts that physical activity
improves health because it increases stress on a broad
range of tissues, making the tissues more tolerant of
subsequent physical activity. Because the tissues are
more tolerant of physical stress, they are less likely to be
390 . Mueller and Maluf
injured. This reduction in the likelihood of injury occurs
regardless of whether the tissue is part of the cardio-
vascular/pulmonary, integumentary, musculoskeletal, or
neuromuscular system. Increased physical activity has
been linked to many positive health benefits, including
lower risk for non–insulin-dependent diabetes melli-
tus,41 stroke,42 and obesity.43 The federal government, in
Healthy People 2010, has set a number of goals to
increase physical activity (Objective 22; Physical Activity
and Fitness) in people who are otherwise healthy. We
believe that physical therapists should use their expertise
to provide instruction on how people can increase
overall physical activity without injuring specific struc-
tures (ie, back or knee).
Extrinsic Factors
Extrinsic factors are factors outside of the body that can
influence either the level of stress on tissues or the
thresholds for tissue adaptation and injury. For the
purpose of this perspective, those extrinsic factors that
can be modified or utilized by physical therapists are
emphasized.
Orthotic devices can be used to modify physical stress on
biological tissues and can be used as an adjunct to other
interventions in several phases of tissue adaptation. An
orthotic device can be used to relieve stress from injured
tissue (eg, a resting hand splint for patients with carpal
tunnel syndrome, a lumbosacral corset for a person with
low back pain). An orthotic device also can be used to
apply stress to tissue to cause a change in the tissue
(eg, orthotic devices that apply low loads for prolonged
periods to increase muscle length and joint range of
motion at the elbow).44 According to the PST, orthotic
devices are an appropriate adjunct to treatment when
other means of movement can not adequately control
stress on the tissue to meet desired guidelines. We
contend that components of the orthotic device should
be chosen for their ability to achieve a desired stress level
on the tissue. Likewise, taping45,46 and assistive devices
(eg, crutches, walkers, canes) may be effective adjuncts
to help modify stress on injured tissues.
Footwear is another extrinsic factor that can influence
stresses applied to the foot. Narrow toe boxes are
thought to apply damaging stresses to the forefoot that
lead to the formation of bunions and hammer-toe
deformities.47 However, footwear also can be used for
therapeutic purposes such as helping to decrease stress
on the foot and ankle at heel strike (ie, shock absorp-
tion) or helping to control excessive movement of the
rear foot.48
The ergonomic environment is another extrinsic factor
that can be modified to influence tissue stress. Changes
in the ergonomic environment can be achieved by
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redesigning the job site or work tools to reduce the
demands of jobs that require high force, high repetition,
and awkward postures.49 Primary principles of ergo-
nomic design include reduction of extreme joint
motion, excessive force magnitudes, and highly repeti-
tive movements. Appropriate size and placement of a
workstation can reduce extreme joint motion. Tools or
machines can be designed to reduce excessive forces or
repetitive motions (eg, using an electric drill rather than
a manual one).49
Modalities (eg, heat, cold, electrical stimulation) are
extrinsic factors that can be used to modify the level of
tissue stress or the response of biological tissues to stress
application. As described in the PST, modalities have a
secondary role in treatment but may be indicated to
augment the body’s own adaptive capabilities. For
instance, electrical stimulation can be used to augment
short- and long-term muscle force production, especially
in the presence of pathology that limits the normal force
generating capacity of muscle (eg, after ligament injury50
or spinal cord injury51). Heat is an example of a modality
that can be used to modify the response of tissues to
physical stress. For example, elevation of muscle temper-
ature is thought to help prevent strain injuries (ie, raise
the threshold for muscle injury) by allowing muscles to
stretch more and tolerate higher loads before failure.52
Gravity is an extrinsic factor that physical therapists can
use to modify the external load on the body. By modi-
fying the orientation of the body or limbs with respect to
the ground, physical therapists can increase or decrease
forces exerted on the body during movement and,
consequently, alter the forces that must be generated
internally to produce movement.53 Modalities or devices,
such as aquatic therapy54 or weight-supported walking
devices,55 also may be used to modify tissue stress by
altering the effects of gravity.
Psychosocial Factors
Psychosocial factors represent those factors that are
unique to the lifestyle of each person and that poten-
tially can be modified. Psychosocial factors can have a
profound influence on tissue adaptation, especially as
related to tissue injury.56 We believe psychosocial factors
primarily influence individual threshold values for tissue
adaptation and injury. For example, researchers investi-
gated the role of mechanical and psychosocial factors in
the onset of forearm pain in a 2-year-long prospective
study (N⫽1,953).56 Besides linking injury to repetitive
movements of the arm or wrist (relative risk of 4.1 and
3.4, respectively), the investigators reported that people
who were “only occasionally” or “never” satisfied with
support from supervisors and colleagues had a relative
risk of 4.7 (95% confidence interval⫽2.2, 10) for fore-
arm injury. These data indicate that, in some circum-
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stances, psychosocial factors can be as important as
mechanical factors for tissue injury. Although we recog-
nize that psychosocial factors can play an important role
in a person’s response to physical stress, this role is not
developed extensively in this perspective. We encourage
others to develop the psychosocial component of the
PST.
Physiological Factors
Physiological factors influence the ability of tissue to
respond to physical stress, but these factors often are
difficult, if not impossible, to modify. Physiological fac-
tors assume a less important role in physical therapy
treatment compared with the factors described previ-
ously because physical therapists usually can not modify
or treat physiological factors directly. Physical therapists
should be aware of the influence of physiological factors,
however, because these factors will affect the prognosis
of tissue adaptation and recovery from injury.
Medications can influence tissue physiology and, conse-
quently, the ability of tissues to adapt to physical stress.
For example, corticosteroid use has a complex effect on
tissue. Corticosteroids can simultaneously cause a
decrease in inflammation in one tissue (positive effect
on stress tolerance) and cause atrophy in other tissues
such as skin, bone, and muscle (negative effect on stress
tolerance).57 Physical therapists do not prescribe medi-
cations. However, the impact of medications on the
adaptive capacity of tissue is important, and physical
therapists should be aware of these effects on their
patients. In addition, exercise may help to offset muscle
atrophy from medications such as glucocorticoids.58
Age is another important physiological factor. Although
it is beyond the scope of this perspective to discuss the
effects of age on tissue adaptation, it is important to
discuss several general points. Aging has a negative effect
on tissue adaptation. The magnitude of this negative
effect in humans, however, is not clear. Kohrt59 believes
that a considerable portion of the negative effects that
have been attributed to aging may be due to age-
associated decreases in activity. Two predictions regard-
ing the effects of age can be derived from the PST. The
first prediction is that aging lowers the ability of tissues to
tolerate stress and has a general tendency to lower the
threshold for injury, similar to the effect illustrated in
Figure 2. The level of stress required to promote tissue
hypertrophy and increase stress tolerance generally is
greater for young subjects who are healthy compared
with older subjects. Young people, therefore, can exer-
cise and stress their tissues more aggressively with less
fear of injury than older people. The second prediction
is that the negative effects of aging can be modified
through increased stress on the tissue. Increased stress,
applied through progressive increases in activity or exer-
Mueller and Maluf . 391
cise, theoretically can help prevent or reverse some of
the negative effects of aging (Fig. 3). Increasing evi-
dence suggests that tissues remain responsive to physical
stress well into old age and that positive adaptations to
increased activity and exercise can result in decreases in
functional limitations and disability.7,8,10
Systemic pathology includes the many diseases that can
affect the ability of tissues to adapt to physical stress.
Examples of systemic pathology that physical therapists
often encounter are diabetes mellitus and rheumatoid
arthritis. Similar to the effects of aging, many forms of
systemic pathology lower the ability of tissue to tolerate
stress, and they have a general tendency to lower the
threshold for injury. One example of this principle is the
effect of peripheral neuropathy on cortical bone mass in
the feet and hands of patients with diabetes. Patients
with diabetes and peripheral neuropathy have been
shown to have lower cortical bone mass, with a higher
incidence of metatarsal fractures, compared with a
matched group of patients with diabetes alone.60 As
interpreted by the PST, pathology associated with
peripheral neuropathy reduces the injury threshold for
bone to a level experienced during normal walking.
Although the PST recognizes the negative impact of
systemic pathology on tissue adaptation, it also proposes
that carefully applied physical stresses can have positive
effects for people with chronic disease. Growing evi-
dence supports this prediction.9,13,61– 63 Traditionally,
people with rheumatoid arthritis have been excluded
from vigorous activities that might exacerbate joint
inflammation.9 However, studies have shown that pro-
gressive resistive exercises and aerobic exercise pro-
grams can increase muscle performance, fitness levels,
and bone mineral density with no exacerbation of dis-
ease activity in patients with rheumatoid arthritis.9,61,62
The positive effects of aerobic exercise for patients with
cardiovascular disease have been well documented.13
Likewise, evidence indicates that increased activity, even
in small increments, can have positive effects on reduc-
ing the burden of hyperinsulinemia and diabetes.63
William H Herman, an associate editor for Clinical
Diabetes, summarized the effect of exercise on diabetes:
An ideal treatment for type 2 diabetes would lower
blood glucose concentrations acutely, improve long-
term glycemic control, and enhance insulin sensitiv-
ity. It would improve mild to moderate hypertension,
reduce low-density lipoprotein cholesterol and triglyc-
erides, increase high-density lipoprotein cholesterol,
and serve as an adjunct to caloric restriction for
weight reduction. Finally, it would increase patients’
sense of well-being and improve their quality of life.
As a drug, such an agent would be a blockbuster, with
greater than $1 billion per year sales potential. Yet
392 . Mueller and Maluf
such a treatment exists and has been recognized for
centuries. It is regular physical activity—that is
exercise.12
Although systemic pathology may lower the threshold
for tissue injury, many people with systemic pathology
respond positively to exercise, both in terms of increased
stress tolerance and reduction of disease complications.
We also consider obesity a physiological factor within the
context of the PST that can be modified, but not easily.
Obesity is defined as an increase in body weight beyond
the limitation of skeletal and physical requirements, as
the result of an excessive accumulation of fat.64 Body
weight provides an indication of the stresses that must be
borne by tissues of the body during physical activity. The
PST predicts that obesity is a risk factor for certain types
of injury and a negative factor for recovery from injury.
In addition, obesity has been linked with low activity
levels.43 People who are obese, therefore, may be at
greater risk of injury than people who are not obese
because high-stress, low-repetition activities are thought
to be more damaging than low-stress, high-repetition
activities.49,65– 68 Evidence exists to support this predic-
tion. For example, a population-based (n⫽350, 95 men
and 255 women, 55 years of age or older) longitudinal
study (mean follow-up duration⫽5.1 years) reported
that the risk of incident radiographic knee osteoarthritis
was significantly increased among subjects with higher
baseline body mass index (odds ratio⫽18.3, 95% confi-
dence interval⫽5.1– 65.1).69
Literature Review
The PST focuses on how biological tissues respond to
physical stress. Existing evidence and approaches that
share common principles with the PST will be described
next for each of the 4 major systems described in the
Guide to Physical Therapist Practice.14 Because physical
therapists often work with patients with injuries, each
section will begin by discussing how physical stress can
contribute to injury. Discussion of the effects of physical
stress on injury will then be followed by a discussion of
the effects of physical stress on tissue atrophy, mainte-
nance, and hypertrophy. These effects are summarized
in Table 3.
Musculoskeletal System
Some authors29,70 have described mechanical principles
involved in the management of patients with low back
pain. McGill70 proposed that injury, or “failure of a
tissue,” occurs when the applied load exceeds the failure
tolerance of the tissue. In addition, McGill70 contended
that the structures of the back are influenced by the
history of recent physical stresses, so that the accumula-
tion of individual stresses can cause injury. He argued
that the characteristics of the load (load rate, mode of
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load compression, bending, torsion, shear) and the
properties of the tissue determine the type and extent of
tissue damage.
McGill70 described the same 3 mechanisms of injury to
low back tissues that are proposed within the PST
(Principles H, I, and J, Tab. 1). One mechanism of injury
to low back tissues is a single application of a relatively
high load or stress. McGill provided the example of a
person riding a snowmobile who is thrown from the
machine and lands on a flexed spine and experiences a
sudden posterior disk herniation. A second mechanism
of injury to low back tissues is multiple moderate loads or
stresses applied to the structures of the low back. In this
case, injury is the result of accumulated trauma. McGill
provided the example of a worker lifting boxes in which
tissues of the low back are loaded repeatedly, causing a
slow degradation of the tissue tolerance. A third mech-
anism of injury is low loads sustained by the low back
over a long period of time. An example of this mecha-
nism of injury is construction workers who install rods in
the floors of a new building and remain in a flexed
posture for prolonged periods of time.
Injury to other types of tissue can result from the same
mechanisms as those described above for the low back.
Bones can fracture from one bout of high-magnitude
force (eg, sudden impact fracture of the femur bone
from a motor vehicle accident) or from bouts of
moderate-magnitude force that occur many thousands
of times (eg, stress fracture of the tibia or metatarsal
bones from running,71 prolonged marching72). Similar
to bones, ligaments can tear with one bout of a high-
magnitude force (eg, injury of the medial collateral
ligament from a tackle to the lateral knee). Increasing
evidence, however, suggests that ligaments also can fail
from repeated bouts of moderate-magnitude stress.73
For example, women have a much higher incidence of
anterior cruciate ligament injury from noncontact sport-
ing events compared with men.73 Huston et al73 specu-
lated that this finding may be related to anatomical
differences, such as a wider pelvis and greater Q angle in
women, that result in greater cumulative stress on the
anterior cruciate ligament during typical activities such
as walking or running. Radin and colleagues65– 68 have
described similar mechanisms of injury (Principle J,
Tab. 1) involved in degeneration of articular cartilage
and joints.
McPoil and Hunt27 also have recognized the importance
of mechanical stress in the management of foot and
ankle injuries. These authors have described a treatment
approach based on a “Tissue Stress Model.” This
approach proposes that clinicians focus on reducing
excessive mechanical stress from injured tissues in the
foot and ankle rather than attempting to place the foot
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in an ideal posture, or subtalar joint neutral position, as
advocated by the Root Theory.74 The authors use a case
study to illustrate application of their model.27
Stress levels that are higher than the maintenance stress
range, yet are lower than the threshold value for injury,
can have positive effects on tissue adaptation. Based on
Principle E of the PST, musculoskeletal tissues subjected
to levels of stress that are higher than normal become
more tolerant to subsequent physical stresses and are
more resistant to injury (ie, tissues become stronger).
Principle I suggests that this type of adaptation occurs
only when tissues are able to recover and adapt to
previous bouts of physical stress. Controlled increases in
physical stress through progressive resistive exercise
cause muscle fibers to hypertrophy and become capable
of generating greater force. Likewise, higher-than-
normal levels of physical stress can promote remodeling
in bone.75 Wolff’s Law provides an excellent example of
how one specific biological tissue, bone, responds to
physical stress by remodeling. Wolff’s Law states that the
thickness, number, and orientation of trabeculae will
correspond to the distribution of mechanical stresses on
bone.75 A consequence of stress-induced bone remodel-
ing is that the strength of bone is greatest in the
direction in which loads are most commonly imposed.76
For example, the maximum stress tolerated by bone just
prior to failure has been found to be higher for com-
pressive loads than for tensile or shear loads, reflecting
the predominantly compressive loads experienced by
bone during weight bearing.77 Runners with a docu-
mented increase in bone mineral density (BMD) in the
leg, but not arm, compared with nonathletes provide
one example of mechanically induced adaptations in
bone.51 Similarly, contralateral differences in arm BMD
have been observed in volleyball, basketball, and tennis
players, but not in swimmers.78,79
Similar to bone, models of tendon and ligament adap-
tation predict that deviations from a typical range of
strain (change in length relative to original length)
stimulus values promote adaptive responses in these
tissues. According to these models, strain values of 1.5%
to 3.0% are required to maintain tissue homeostasis.80
Strain values above this range will lead to increases in the
cross-sectional area and stiffness of tendon and ligament,
whereas strain values below this range predict decreases
in these parameters. The models further predict that the
more the strain stimulus deviates from steady-state val-
ues, the faster adaptive responses occur in tissue. Model-
based simulations of tissue adaptation are consistent
with histology data for tendon and ligament in animals
and humans.80 Other research has demonstrated that
both tendon and ligament respond to exercise-induced
stress with increases in cross-sectional area, stiffness, and
tensile strength.81– 84
Mueller and Maluf . 393
Evidence also supports the idea that tissues within the
musculoskeletal system atrophy and become less tolerant
of physical stress if stress on the tissue diminishes below
a baseline level.59,85– 88 Unfortunately, tissues typically
atrophy at a faster rate than they hypertrophy.59,85 Mus-
cle can lose 6% to 40% of its ability to generate force
over a 4- to 6-week period of bed rest or immobiliza-
tion.86 Bone mineral density also is lost in response to
diminished physical stress. Leblanc et al87 found that
BMD is reduced 3% to 4% at the femoral neck and
lumbar spine after 17 weeks of bed rest in young men
who are healthy. Holick88 summarized the current liter-
ature by indicating that unloading of the skeleton, either
due to strict bed rest or in zero gravity, leads, on average,
to a 1% to 2% reduction in BMD at selected skeletal sites
each month.
Likewise, ligaments respond to reduced mechanical
stress. Woo and colleagues85,89 have documented a
decline in the mechanical properties of the rabbit
medial collateral ligament in response to 9 weeks of
immobilization. These researchers reported that the
stiffness, the ultimate load before failure, and the
energy-absorbing capacity of the immobilized medial
collateral ligament-bone complex were approximately
one third of those variables in the contralateral, nonim-
mobilized control limb.89
Integumentary System
Tissues in the integumentary system also demonstrate
patterns of response to physical stress similar to those
described for the musculoskeletal system. Mechanisms of
excessive stress resulting in injury to the skin have been
described by Brand24 regarding his work with patients
with Hansen disease and foot ulcers. Brand24 proposed
the same 3 basic mechanisms of injury to skin that we
describe for musculoskeletal tissues and that are out-
lined in this theory (Principle J, Tab. 1). According to
Brand,24 direct mechanical damage to the skin can occur
with high levels of pressure (100 kg/cm2 or 1,300 psi)
applied for a brief duration, such as when a person steps
on a tack. Ischemic skin lesions can occur when a
relatively low magnitude of pressure (1–5 psi) is applied
to the skin for a long duration, such as when people wear
tight shoes or are confined to bed for prolonged periods
of time. “Inflammatory autolysis,” similar in concept to
cumulative trauma injury, can occur when pressures of a
moderate magnitude (20 psi) are applied to the skin
hundreds or thousands of times each day, such as
stresses applied to plantar tissues during normal walk-
ing.24 Integument failure due to repetitive stress was
shown when repetitive stress (10,000 repetitions per day)
was applied to denervated rat footpads in an attempt to
simulate stress on the foot during walking. Footpad
ulcers occurred within 7 to 10 days of commencing the
simulated walking procedures.90 Brand24 and others91,92
394 . Mueller and Maluf
subsequently documented similar relationships among
time, pressure, and skin breakdown in patients with
diabetes and peripheral neuropathy.
Skin also exhibits positive adaptations to controlled
increases in physical stress. Clinicians have observed that
skin adapts to progressive loading with improved stress
tolerance. A common practice for treating patients with
a new orthotic or prosthetic device is to slowly progress
the magnitude and duration of weight-bearing to allow
skin and underlying tissues to adapt to new weight-
bearing forces.93 In addition, the incidence of blisters in
the feet of runners has been found to be highest in the
early stages of training, and it is much lower in people
who consistently run relatively long distances (eg, 48 km
[30 miles] per week) as compared with people who are
just beginning to run.94
Sanders et al95 have provided a review of the growing
body of literature that suggests that skin exhibits an
adaptive response to stress similar to the response of
other biological tissues. Skin under tension shows
changes similar to ligaments and tendons under tension.
Increases in collagen fibril diameter, collagen cross-
linking, and sulfated proteoglycan content render skin
more resistant to tensile forces. Skin adapts to increases
in shear stress with an increase in the size and density of
cells at the basement membrane and an increase in the
thickness of the stratum corneum (the outermost cell
layer on the surface of the skin). Increased thickness of
the stratum corneum results in a greater volume of skin
through which shear loads can be distributed. Distribu-
tion of shear loads causes a reduction in the shear
gradient and, consequently, decreases the potential for
skin breakdown.
Cardiovasuclar/Pulmonary System
Similar to what can occur to tissues in the musculo-
skeletal and integumentary systems, excessive physical
stress can injure tissues in the cardiovascular/pulmonary
system. Mechanical stretch induced by high blood pres-
sure is thought to be an initial event that leads to cardiac
hypertrophy and eventual cardiac failure.96 High blood
pressure is an established risk factor for conditions such
as stroke,97 myocardial infarction,98 and atherosclerotic
disease.99 In addition, vigorous and unaccustomed phys-
ical activity has been associated with a higher incidence
of cardiovascular events.100
The positive effects of physical stress in the form of
exercise also are well documented for tissues in the
cardiovascular/pulmonary system. McArdle et al13 out-
lined fundamental principles of exercise training for the
cardiopulmonary system. The “overload principle” states
that exercise overload specific to an activity must be
applied to enhance physiologic improvement and bring
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about a training effect. As described for other systems,
achieving overload without tissue injury requires an
appropriate balance among training intensity (or mag-
nitude), frequency, and duration (time factors). When
developing training programs, physical therapists also
must consider whether stress levels designed to improve
cardiovascular performance have the potential to cause
injury to tissues in the musculoskeletal system.
Training can enhance cardiovascular function in ath-
letes, people who are sedentary, people with disabilities,
and people with previous cardiac impairments.13 Train-
ing causes adaptations in tissues within the cardio-
vascular and pulmonary systems, including an increase
in the weight and volume of the heart, an increase in the
size of the left ventricular cavity and the thickening of its
walls, an increase in plasma volume, an increase in
maximum cardiac output, and an increase in lung
volumes. Intensive training can increase aerobic capacity
15% to 30% during the first 3 months, with as much as
a 50% increase over a 2-year period (Tab. 3).101–105
Similar to other systems described, the positive effects of
physical stress (ie, aerobic exercise training) are quickly
reversible for tissues in the cardiopulmonary system.13
Reductions in metabolic and exercise capacity can occur
after only 1 to 2 weeks of detraining, and many other
improvements are lost within several months of detrain-
ing.13 McArdle et al,13 for instance, reported a 25%
reduction in maximum oxygen consumption in 5 sub-
jects who remained bedridden for 20 consecutive days.
Maximal stroke volume and cardiac output also
decreased, resulting in a loss of aerobic capacity by an
average of 1% per day.13(p396)
Neuromuscular System
In our opinion, adaptation of the nervous system in
response to physical stress has not been studied as
extensively as the adaptive response of tissues in the
musculoskeletal, integumentary, and cardiovascular/
pulmonary systems. Increasing evidence, however, sug-
gests that physical stress and activity affect the peripheral
and central nervous systems in a manner similar to that
of other tissues in the body.106 –108 Excessive stress can
cause injury to tissues within the nervous system via the
3 mechanisms discussed for other systems. Examples of
nerve injuries caused by high-magnitude stress applied
over a brief duration include spinal cord injuries result-
ing from gunshot wounds or motor vehicle accidents.
Nerve injury also may be caused by lower-magnitude
stresses applied repetitively or over a long duration.
Examples of these mechanisms of nerve injury include
carpal tunnel syndrome, tarsal tunnel syndrome, tho-
racic outlet syndrome, ulnar nerve palsy, spinal stenosis,
and lumbar root lesions.
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Novak and Mackinnon28,109,110 described excessive phys-
ical stress from various postural alignments and repeti-
tive motions that can contribute to nerve injury and
pain. The incidence of cumulative trauma disorders has
risen dramatically over the last 15 years and has been
linked to jobs that require high-force and high-
repetition activities, especially when performed in awk-
ward postures.49(pp3–7) The odds ratio for developing
carpal tunnel syndrome has been reported to be greater
than 15 for high-force, high-repetition jobs compared
with jobs requiring low-force, low-repetition activities.111
Pressures within the carpal tunnel have been shown to
be higher when the wrist is in extreme flexion or
extension compared with a neutral position.112 Further-
more, jobs requiring excessive wrist deviations are con-
sidered a risk factor for injury to the median nerve.109
Lumbar spinal stenosis is another condition that can
place excessive physical stress on neural tissues.113 Move-
ments and postures of lumbar extension can further
reduce the diameter of the spinal canal and vertebral
foramen in people with spinal stenosis, causing compres-
sion of lumbar nerves and resulting in lower-extremity
pain and parathesias.113 People with lumbar stenosis
generally have reduced lower-extremity symptoms when
their spine is flexed because this posture allows the
vertebral foramen to widen, thereby reducing compres-
sive and shear forces on neural tissues.114
Mechanical injury of nerve tissue can occur with low-
magnitude stresses applied for a long duration (com-
pression injury) or from repetitive bouts of moderate-
magnitude stresses (cumulative trauma disorders).
Although some nerve injuries may require surgical cor-
rection, we believe one role of the physical therapist is to
determine how excessive stress on the nerve can be
relieved in a conservative fashion to facilitate healing of
the nervous tissue.
We have limited our discussion of the neuromuscular
system to nerve injuries caused by mechanical stress on
the nerve and surrounding structures. Although beyond
the scope of this perspective, a growing body of litera-
ture suggests that neurons adapt to high and low levels
of physical activity by altering their electrical activi-
ty106,108,115–118 (Tab. 3; eg, rate of discharge, threshold of
recruitment). The observation that physical activity can
stimulate neural adaptation has important implications
for the rehabilitation of patients with primary neurolog-
ical disorders (eg, stroke, traumatic brain injury). We
predict that the fundamental principles outlined in the
PST can be used to describe neural adaptations follow-
ing central or peripheral nervous system injury, and we
encourage others to investigate this prediction.
Mueller and Maluf . 395
Limitations of the Physical Stress Theory
The PST represents an effort to integrate common
principles from the approaches and evidence described
above. We also expand existing theories to place the role
of tissue injury within a continuum of tissue viability so
that the theory encompasses pathological conditions
and principles of wellness and prevention. Like any
theory, the PST has limitations. These limitations will be
discussed next, followed by a discussion of the implica-
tions of the theory for physical therapist practice, edu-
cation, and research.
In the PST, we assume that tissue exposure to physical
stress can be quantified, and we assume that knowledge
of the level of stress exposure and factors that influence
the adaptive capacity of tissues (eg, age, disease) can be
used to predict tissue adaptation and injury. In its
current form, however, the PST does not define absolute
threshold values for tissue adaptation and injury. For
example, we do not know whether a tissue is about to be
injured until it begins to show signs of inflammation
(ie, pain, heat, swelling, or redness). Although attempts
are being made to identify biological markers that may
identify thresholds of adaptation or injury (ie, integrins
in the muscle119 and serum keratan sulfate in interver-
tebral disks120), much more research is needed to define
these thresholds in multiple tissue types.
We believe the PST provides an appropriate framework
for investigating the influence of multiple factors on the
level of physical stress required for tissue adaptation and
injury avoidance. Despite the absence of specific values
for thresholds of change, the PST currently provides an
overall framework that outlines relative relationships
along a continuum of tissue responses to physical stress.
Elaboration and refinement of this preliminary frame-
work should eventually allow for a quantitative under-
standing of the thresholds that indicate when atrophy,
maintenance, hypertrophy, injury, and death of various
tissues begin.
Another limitation of this theory is that it describes
changes at the tissue level and does not indicate how
tissue change is related to functional limitations or
disability. Therefore, we believe the PST must be used in
combination with other theories or models of disable-
ment121 to address the entire spectrum of physical
disability. We believe that physical disablement models
are critical for understanding the overall relationship
between disease or pathophysiology and resulting
impairments, functional limitations, and disability.121 We
further believe that the PST can be used to complement
the physical disablement models by helping us to under-
stand the mechanisms of injuries and repair at a tissue
level.
396 . Mueller and Maluf
Certain areas within physical therapy are not well devel-
oped in the PST in its current form. For example, the
PST does not address issues of adaptation in the central
nervous system. In addition, the PST does not identify
the specific psychosocial factors that most influence
tissue adaptation and injury. We believe the current
theory, however, does provide a useful framework a wide
range of physical therapy issues and has implications for
practice, research, and education.
Implications for Physical Therapist Practice
We believe the PST provides a useful framework to
approach patient care. It emphasizes the role of physical
stress by addressing factors known to influence the level
of physical stress and the response of tissues to stress
application. According to this theory, the primary role of
the physical therapist is to modify physical stresses to
achieve a desired goal. Two broad goals will be discussed.
The first goal is to reduce pain and subsequent impair-
ments, functional limitations, and disabilities that result
from injury. The second goal is to increase activity
tolerance. Each of these goals will be discussed further in
subsequent sections.
Implications for Treating Patients With Tissue Injury
The PST provides a general model for evaluating and
treating people with injury. Chronic tissue injury, defined
as injury that results in pain lasting greater than 8 weeks,
often is caused by stresses of moderate magnitude that
are repeated hundreds or even thousands of times a
day.24,49,63 Examples of injuries resulting from this mech-
anism include many forms of back and cervical pain,70
patellofemoral pain,122 tendinitis injuries (eg, Achilles
tendon, posterior tibial tendon), impingement syn-
drome of the shoulder, stress fractures,71,72 neuropathic
plantar ulcers,24 and carpal tunnel syndrome.49 The
primary questions asked in the evaluation and treatment
of these and other forms of tissue injury are: (1) What
factors appear to be contributing to excessive stress on
the injured tissue? and (2) How can these contributing
factors be modified to reduce stress on the tissue and
allow the tissue to heal?
We believe proper identification of the injured tissue
usually can help determine the factors contributing to
excessive stress on the tissue. For example, suspected
tendinitis might lead the clinician to investigate sources
of stress caused by movements that are controlled by the
muscle and tendon. In many cases, however, physical
therapists are not able to confirm injury of a specific tissue
using the tools currently available to them. The PST
describes general principles of tissue adaptation and
injury, applicable to all types of biological tissue, that can
be used to guide treatment regardless of whether the
injury can be localized to a specific structure. In our
view, appropriate treatment, therefore, does not always
Physical Therapy . Volume 82 . Number 4 . April 2002

require accurate identification of the injured structure.
For instance, if low back pain can be eliminated by
teaching the patient to move at the hips rather than
moving at the lumbar spine when movements of the
lumbar spine cause pain, identifying the specific injured
tissue is of little benefit.
We believe general principles that govern the response
of all biological tissues to stress can be used to guide
physical therapy intervention, even when pathology of a
specific structure cannot be determined. In this context,
we contend that the most important question to guide
treatment becomes: What factors appear to be contrib-
uting to excessive stress on the injured tissue? This
question relates to Fundamental Principles F, I, J, and K
in Table 1. In our opinion, the factors in Table 2 should
be systematically evaluated for their potential to contrib-
ute to excessive tissue stress or for their potential to
modify the response of tissues to stress application. In
our experience, various types of injury tend to be
associated with a similar set of contributing factors. For
example, we have observed that factors contributing to
overuse injuries of the foot and ankle often include
movement and alignment factors (ie, excessive prona-
tion or supination,123 changes in activity) and extrinsic
factors (ie, footwear). Factors that contribute to exces-
sive tissue stress or modify the tissue response can be
added to or subtracted from the model depending on
individual characteristics of the patient and the thera-
pist’s current working set of hypotheses.
We suggest that a physical therapist develop a hypothesis
regarding the factors that are contributing to excessive
tissue stress and causing injury. The next logical ques-
tion is: How can I modify these contributing factors to
reduce stress on the tissues and allow the tissues to heal?
Successful outcomes, in our opinion, help to confirm
the initial hypothesis, whereas poor outcomes direct the
clinician to investigate other potential sources of stress
not identified by the initial hypothesis. This approach is
consistent with the hypothesis-oriented algorithm for
clinicians.124
The basic principles discussed can be illustrated with
several examples. Maluf et al32 described evaluation and
treatment of a patient with chronic low back pain. The
authors speculated that repetition of rotation and exten-
sion movements of the lumbar spine contributed to
excessive stress and injury to structures within the low
back region. Low back symptoms improved following
instructions designed to restrict lumbar rotation and
extension movements during the performance of daily
activities.32 McPoil and Hunt27 described a similar
approach in the treatment of a patient with heel pain.
The authors speculated that a recent change in activity
level, poor footwear, and excessive pronation at the
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subtalar joint contributed to excessive stress on the
plantar fascia and resultant heel pain. The treatment
plan, therefore, was designed to modify these factors to
decrease stress on the plantar fascia (eg, modifying the
patient’s work schedule to limit weight-bearing time,
purchasing shoes with cushioned midsoles, obtaining
temporary orthotic devices to control excessive
pronation).27
Similar principles can be applied to the evaluation and
treatment of many types of wounds. Mueller and Dia-
mond125 described an approach emphasizing reduction
of stress on plantar tissues in a patient with diabetes,
peripheral neuropathy, and a chronic plantar ulcer (21
months). They speculated that a fixed equinus and
rear-foot varus deformity contributed to excessive pres-
sure on tissues in the forefoot during walking and
prevented the chronic ulcer from healing. The wound
healed after a total contact cast, followed by protective
footwear, was applied to reduce excessive stress at the
site of the wound.125 An approach based on principles of
stress reduction also has been described for the treat-
ment of peripheral nerve injuries such as carpal tunnel
syndrome and brachial plexus injuries.109 Novak and
Mackinnon109 have described how postures, movements,
impairments, and physical activities can contribute to
stress on peripheral nerve tissue. Furthermore, these
authors have described how factors contributing to
excessive stress on peripheral nerves can be modified to
allow the nerve tissue to heal and, consequently, reduce
the symptoms associated with nerve injury.109
Even after sources of excessive stress have been identi-
fied and removed, we contend that injured tissues will be
less tolerant of stress than they were prior to injury due
to pain, inflammation, and disuse associated with the
injury (Principles C and K, Tab. 1). Therefore, after pain
and inflammation have subsided, previously injured
tissues, in our opinion, should be exposed to progres-
sively higher levels of physical stress to gradually restore
the tissues’ ability to tolerate greater levels of stress
(Principle E, Tab. 1). Stress, we contend, should be
applied progressively, with attention paid to the body’s
need for rest and recovery.
Implications for Improving Activity Tolerance
Our examples were designed to illustrate how to pro-
mote healing and progressive strengthening of injured
tissues. The goal of helping patients to improve activity
tolerance will now be considered. Examples of this goal
include increasing muscle peak force production,
achieving independence in transfers, and improving
walking tolerance. Activity can be considered a form of
physical stress.40 Therefore, a systematic approach for
evaluating and treating individuals with the goal of
improving activity tolerance can be derived from the
Mueller and Maluf . 397
PST. We propose that the following questions are rele-
vant to the goal of increasing activity tolerance: (1) What
is the activity goal? (2) What are the current modifiable
factors limiting the activity goal? and (3) How should
these factors be modified to meet the activity goal? For
example, the activity goal of an elderly person may be to
stand independently from a sitting position. A physical
therapist may hypothesize that the primary modifiable
factors limiting this goal are: (1) lower-extremity muscle
atrophy resulting in poor force production, (2) de-
creased dorsiflexion range of motion, (3) poor motor
control (movement and alignment factors), and (4) a
low seat surface (extrinsic factor). The person’s age is an
important physiological factor that may limit the poten-
tial for tissue adaptation and lower the threshold for
tissue injury. A treatment plan designed to modify these
factors based on the PST might include: (1) a progres-
sive resistive exercise program for lower-extremity exten-
sor muscles with at least 70% of maximum effort, 2 to 3
times a week, for several weeks to increase muscle force
production, (2) stretching exercises to increase dorsi-
flexion range of motion, (3) practice standing from a
seated position using appropriate movement strategies,
and (4) advising the patient to obtain a higher chair so
that lower muscle force production is needed to achieve
the activity.
The overload principle (Principle E, Tab. 1),13,40 in
which maintenance stress levels are raised to the range
of stress that promotes tissue hypertrophy, has tremen-
dous implications for physical therapy and forms the
basis for progressive resistance exercises to increase
muscle performance and activity tolerance. Physical
stress must be of sufficient magnitude and repetition to
cause the desired change in performance. The role of
the physical therapist, in our view, is to instruct people in
the appropriate magnitude and repetition of exercise or
activity to provide an adequate stimulus for hypertrophy
of intended tissues without injuring other tissues.
Although clinicians are accustomed to using the over-
load principle to achieve hypertrophy of muscle, these
same principles can be applied to other tissues such as
ligament, tendon,126 and skin95 (Tab. 3).
Implications for Physical Therapist Education
In a time when scientific and medical knowledge is
expanding at an exponential rate, we believe the PST
can help educators focus on appropriate content for a
substantial portion of the physical therapy curriculum.
According to the PST, key elements of the curriculum
should include a clear understanding of how the body
adapts to physical stress and how physical therapists can
apply or modify stress on the body to achieve desired
outcomes (Tabs. 1 and 3).
398 . Mueller and Maluf
In the PST, we propose that several key content areas
should be emphasized. Kinesiology, we argue, should be
taught with an emphasis on tissue mechanics and how
different types of movement contribute to stress on
specific tissues. Classes related to exercise physiology, in
our view, should present guidelines for exercise and
activity prescription that are designed to fall within the
range of stress that promotes tissue hypertrophy while
avoiding injury. We contend that instruction about
orthotic devices or modalities should focus on their use
in modifying either the level of stress applied to the body
or the body’s response to stress. The content of classes
related to medicine and pathology should focus on
providing an understanding of how particular diseases
or pathologies modify the body’s response to various
forms of physical stress including exercise and activity.
Classes related to clinical diagnosis and management
could be organized using the approach described in the
section titled “Implications for Physical Therapist Prac-
tice.” We contend that the list of factors in Table 2 could
form the focus of factors to consider for evaluation and
intervention. Although there are other content areas
that must be addressed in a curriculum (eg, administra-
tion), we contend that the factors listed above are the
most important and could serve as the focus of content
unique to a physical therapy curriculum. Students
should be trained to develop a clinical hypothesis that
identifies the most important factors contributing to a
patient’s problem, to address each modifiable factor,
and to revise the initial hypothesis based on evaluation
of treatment outcomes.
Implications for Research
The PST provides a framework for generating research
hypotheses that focus attention on what we believe to be
the most important and basic treatment technique used
by physical therapists: modifying physical stresses to
facilitate tissue adaptation and prevent injury. Although
emphasizing the role of physical stress (Tab. 1), the PST
also recognizes the multifactorial nature of tissue adap-
tation and injury (Tab. 2).
We believe this theory helps to clarify and expand on
documented theoretical approaches currently used in
physical therapy. Disablement models have provided an
excellent theoretical framework for studying the rela-
tionship among impairments, functional limitations, and
disability. We agree that a limitation of these models,
however, is that they often do not address the underlying
cause of the patient’s symptoms.127 For example, disable-
ment models postulate that back pain leads to certain
functional limitations, such as difficulty performing
household chores. However, we believe these models do
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
Physical Therapy . Volume 82 . Number 4 . April 2002

excessive physical stress causes the pathology, resulting
in pain and subsequent disability.
We believe the PST also can be used to complement the
American Physical Therapy Association’s current Clini-
cal Research Agenda for Physical Therapy.128 The
agenda was designed to “support, explain, and enhance
physical therapy clinical practice by facilitating research
that is useful primarily to clinicians.”128(p499) The Clinical
Research Agenda consists of 72 questions, organized
according to the elements of the physical therapist
patient/client management model. In addition to gen-
erating new research questions, we believe the PST
provides a theoretical framework to help direct research
for questions in the research agenda. For example,
question 1.4.9. of the agenda asks, “Do measures of
postural alignment in people with spinal disorders influ-
ence clinical decision making, and, if so, how?”128(p505)
The PST directs the investigator to consider posture and
alignment factors in the context of how these factors
might contribute to excessive physical stress on the
spine. Based on the PST, an investigator might hypoth-
esize that, in the general population, posture and align-
ment contribute a small but meaningful effect size to
spinal dysfunction. The PST suggests that other factors
such as movement patterns, age, ergonomic environ-
ment, and psychosocial factors also must be considered
in clinical decision making when examining and man-
aging patients with spinal dysfunction. Furthermore, we
believe the PST provides an organized framework for
identifying and studying the relative contribution of
each of these factors to the development, persistence,
and recurrence of spinal disorders. This is one example
of the many multifactorial problems encountered by
physical therapists. In the PST, we suggest that contrib-
uting factors should not be investigated in isolation
when studying the etiology of any given disorder.
Another example of how the theory could be used to
generate and test hypotheses put forth in the agenda is
in the management of skin breakdown on the plantar
surface of the foot in patients with diabetes and periph-
eral neuropathy. Question 2.2.1. asks, “What are the
modifiable risk factors for cumulative trauma
syndrome?”128(p505) Neuropathic plantar ulcers are one
of many conditions that can be considered cumulative
trauma syndrome.24 Investigators91,129 have determined
that the location of plantar ulcers corresponds with areas
of high physical stress, identified by peak plantar pres-
sure. Identifying the magnitude of pressure that predicts
injury of plantar tissues, however, has been elusive.130
The PST predicts that there is no single threshold of
peak pressure that predicts injury for all patients. Rather,
the theory suggests that a combination of stress-related
variables (eg, magnitude, duration, repetition, and
direction of pressures) must be considered when assess-
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ing a patient’s risk for skin breakdown (Fundamental
Principles H and J, Tab. 1).24 Furthermore, the thresh-
old for injury is influenced by individual movement and
alignment factors (eg, activity level, foot deformities),
extrinsic factors (eg, type of shoes), psychosocial factors
(eg, adherence), and physiological factors (eg, severity
of peripheral vascular disease and peripheral neuropa-
thy) (Tab. 1). Researchers who are attempting to inves-
tigate the complex issue of skin breakdown would need
to account for these many factors. The PST provides a
framework for connecting the factors that can be used to
guide research questions for a broad range of problems
encountered by physical therapists.
Conclusion
The PST emphasizes the application and modification of
physical stress on tissues of the human body to elicit
positive adaptations and avoid injury. Many of the
thoughts presented in this article are not new. The
summary and integration of these thoughts into a
defined theory, however, does offer a comprehensive
approach that we believe can help to direct physical
therapist practice and research for a wide range of
people with and without impairments. We assert that
there is considerable evidence to support current phys-
ical therapist interventions directed at modifying physi-
cal stress. We challenge readers to test, modify, and
develop this theory through practice and published
research. Our hope is that readers will see common
elements described in this perspective in their own areas
of practice and that physical therapy can continue to
move forward in a more systematic and evidence-based
manner.
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