Osteopathic Journals and Research by Darren Chandler


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  1. Contents

    • Introduction
    • Definition.
    • Burnout in physicians.
    • Causes of burnout.
    • Stages of burnout.
    • Treatment of burnout.
    • Therapeutic models used in Transactional Analysis for the treatment of burnout.
    • Developing Emotional Intelligence.


    “It’s all a balancing act; you just have to get used to the ride” Jack Nicholson

    Having an awareness of the process of burnout, as well as working patterns, environmental and personality traits that predispose to burnout, will, it is hoped, if taken in context, inform the individual how to benefit from making positive changes.

    The context in which to interpret the research on burnout is of course paramount. The danger of rigidly labelling any deviations from a 'tepid norm' as negative dictates unyielding laws for simply ticking boxes. While convenient, this approach lacks the uniqueness that characterises and separates each individual and their circumstances. Whilst this article, for the purposes of clarity, aims to present the research within a clear framework, it requires the reader to establish a personal context to make it applicable to them.

    What makes one person prone to burnout and another not? Management strategies and distribution of workload are undoubtedly key factors but can personality traits play a role?

    Scott (2018) found two personality traits that can predispose to burnout:

    • The ‘pathological driven’ that neurotically works trying to constantly achieve the literally unachievable.
    • The 'apathetic’ that distances themselves from any true meaning of their work seeing all obstacles as oppressive. 

    As well as individuals with these personality traits new medical graduates prone to experiencing frustration and insecurity are also vulnerable to burnout (Farber 1983, as cited by Scott 2018).

    Swan (2017) addressed the effects of these issues to his third year medical students:

    mistakes come from bad judgment; good judgment comes from mistakes … You will make mistakes ….. It may be painful, but never let it be the end of the road ….. remember the ancient phrase, Illegitimi non carborundum”.

    This positive, adaptive and humorous mind set engenders qualities associated with resilience (Matheson et al 2016). Resilience places the individual in a better place to develop Emotional Intelligence (EI). 

    EI removes the biases that taints the perspective an individual has of their relationship with themselves, their colleagues, their patients and their job (Drigas & Papousi et al 2018). This engenders a progressive view point on success and failure that increases job satisfaction, compassion and communication skills (Efstathia et al 2016) to reduce the chance of burnout.

    Through shared similarities Mindfulness practice has been shown to help develop EI (Rodriguez-Ledo et al 2018). Transactional Analysis is also used in the treatment of burnout (Karpman 1984, Sakai & Hassan 2017, Benedetti et al 2020) through developing shared qualities associated with EI.


    Burnout is a physical, emotional and mental exhaustion that arises from a mismatch between expectations and reality (Sakaki & Hassan 2017). It is characterized by emotional exhaustion, depersonalization and a sense of reduced accomplishment in day-to-day work.

    Burnout is a syndrome resulting from chronic stress both in and out of the work place generated by external pressure and/or a negative relationship with the individual and themselves or others. It is defined by:

    • Feelings of energy depletion or exhaustion (Bendetti et al 2020).
    • Increased mental distancing or feelings of negativism or cynicism. This is characterised by negative or inappropriate attitudes towards patients and oneself, irritability, a loss of idealism and withdrawal (Maslatch & Leiter 2016). This can lead to hostile attitudes and detached feelings towards patients treating them as objects rather than human beings (Patel et al 2018).
    • Reduced professional efficacy. This is defined by reduced productivity or capability, low morale and an inability to cope (Maslatch & Leiter 2016).
    • Reduced personal accomplishment in the form of negative self-appraisal, feelings of incompetence and inefficiency in daily work (Patel et al 2018).

    Burnout in physicians

    Patel et al (2018) reported that 25%–60% of physicians experience exhaustion across various specialties.

    Scott (2018) found physician burnout negatively affects both clinical performance and the patient’s perceptions of the therapist resulting in:

    • Incorrect diagnoses and care.
    • Reduced empathy leading to detachment or dehumanization of the patient.
    • Frustration with the patient’s lack of progress.
    • The practitioner losing confidence in their own skills and feeling disillusioned.

    Causes of burnout

    Personal and interpersonal relationships

    Scott (2018) found two personality traits prone to burnout the 'pathological driven' and 'apathetic'. These traits or tendencies may exist to varying degrees or in different forms depending upon the individual:

    • Type one: 'pathologically driven'. This individual becomes increasingly frantic and refuses to accept that their initial aims are unachievable. This results in them working extra hard failing to keep within professional boundaries trying to achieve the unachievable until they reach breaking point. They neglect their personal lives for the hope of professional success.

    Benedetti et al (2020) described these people as being influenced by the experience “I must”. These authors highlighted a potential cause of this personality type as being a neurotic need for acceptance whereby the individual starts experiencing conflicts and problems in the system as faults of their own. This ultimately leads to frustration and a lack of self appreciation.

    • Type two: 'apathetic'. This individual fails to internalize their success or lack thereof as being representative of themselves. This lack of internal self generating reward and motivation from wanting to be better means they view obstacles as oppressive, seem worn out and lack motivation.

    Radostina et al (2010) found minor differences in numbers between men and women experiencing burnout. Women experienced emotional exhaustion more prevalently than men, whereas men experienced greater depersonalization than women.

    These authors found this to be consistent with gender role theory which predicts that women should be more likely to express feelings of emotional and physical fatigue because they learn to display their emotions. On the other hand, men, as they learn to conceal their emotions, are more likely to shut off and withdraw under stress (i.e. experience depersonalization). This study was completed in 2010. It would be interesting to correlate burnout in the sexes along side any cultural advancements in the gender role since then.

    An additional factor for therapists experiencing burnout is their inexperience (Farber 1983, as cited by Scott 2018). Inexperienced therapists are less equipped to deal with patient difficulties and are unfamiliar with the limitations of their therapy rendering them more vulnerable to burnout.

    This can result in therapists becoming frustrated with the variability of success in their work trying to work even harder to achieve their desired response, including thinking about patients outside of work, which can be emotionally draining.

    In contrast to the personality traits leading an individual prone to burnout Matheson et al (2016) investigated the attributes of individuals with greater resilience.

    These authors found greater resilience enabled the individual to positively adapt to adverse situations instilling the confidence to be able to instigate a positive change to a negative situation.

    The characteristic traits of individuals with resilience are optimism, flexibility and adaptability, initiative, tolerance, organisational skills, being a team worker, keeping within professional boundaries, assertiveness, humour and a sense of self-worth.

    Rodriguez-Ledo et al (2018) found resilience can be fostered through learning Mindfulness to self-regulate emotions. Using Mindfulness to become self-aware provides an unbiased perception of maladaptive behaviour which enhances flexibility and resilience. This increases tolerance to adversity, while reducing tension, fears and worries.

    Pressures in and out of the workplace

    Maslach & Leiter (2007) identified six critical areas of work life that can contribute to burnout:

    • A mismatch in workload. An excessive workload means there is little opportunity to rest, recover, and restore balance. A sustainable workload, in contrast, provides opportunities to use and refine existing skills as well as becoming effective in new areas of activity (Benedetti et al 2020).
    • Loss of control. There is a clear link between a lack of control and high levels of stress and burnout. However, when employees have the perceived capacity to influence decisions, exercise professional autonomy and gain access to both job and personal resources necessary to work effectively, they are more likely to experience job engagement (Maslach & Leiter 2007).
    • Lack of appropriate reward (financial, institutional, or social): a lack of reward devalues both the work and the worker, and is closely associated with feelings of inefficacy. In contrast encouraging rewards between the person and the job means there are both material rewards and opportunities for intrinsic satisfaction (Maslach & Leiter 2016).
    • Loss of positive connection with others in the workplace and between the person and the job. When relationships are characterized by a lack of support and trust and unresolved conflict the individual experiences a lack of social support and is less likely to experience job engagement (Benedetti et al 2020).
    • Lack of perceived fairness in the workplace. People use the quality of the procedures and their own treatment during the decision-making process as an index of their place in the community. Cynicism, anger, and hostility are likely to arise when people feel they are not being treated with the respect that comes from being treated fairly (Benedetti et al 2020).
    • When there is a conflict between values. Once an individual detaches themselves from the unique value and meaning of the work and orientates themselves towards an external aim or goal or reward they become emotionally disengaged (Benedetti et al 2020). This results in reduced contact with a person’s true values. This gap between the individual and organizational values results in the employees making a trade-off between work they want to do and work they have to do which can lead to greater burnout. 

    Maslach & Leiter (2016) also highlighted the influence of personal relationships outside of work as a contributor to burnout.

    Stages of burnout

    “What if it doesn't get any better than this? What else is possible?"

    Sakai & Hassan (2017) found in high levels of stress information processing is distorted. This results in a decrease in positive emotions and an increase in negative emotions.

    This intern can set the individual on to the path of a twelve step model of burnout development (Benedetti et al 2020):

    • Compulsion to prove oneself e.g. excessive ambition and trying to demonstrate one's own worth obsessively.

    • Working harder e.g. incapacity to switch off from work.

    • Neglecting own needs e.g. sleeping, eating and interacting.
    • Displacement of conflicts and needs e.g. problems are dismissed with psychosomatic disturbs and more mistakes are made.
    • No longer any time for non-work related needs e.g. personal values are shifted giving no space for family, friends and hobbies.
    • Increasing denial of the problem and decreasing flexibility of thought/behaviour resulting in intolerance of others.
    • Withdrawal, lack of direction and cynicism, very little or no social life, person can start abusing alcohol or drugs.
    • Behavioural changes/psychological reactions. 
    • Depersonalization is a distancing and loss of contact. It can be with yourself, your own needs, or that of the patient by neglecting the qualities that make the interaction unique. In such cases burnout ensues when there is a lack of accomplishment born from the individual showing an indifference to themselves and others (Gong et al 2019).
    • Inner emptiness, anxiety and addictive behaviour characterised by activities being exaggerated to overcome negative feelings.
    • Depression in the form of increasing feeling of meaninglessness, exhaustion and a lack of interest.
    • Burnout syndrome i.e. psychophysical exhaustion that can be life threatening with suicidal thoughts.

    Scott (2018) found three main responses to burnout amongst therapists:

    • Feelings of emotional exhaustion.
    • Negative perceptions and feelings of the therapist towards their patients.
    • Emotional turmoil which results in a professional crisis and feeling that perhaps the individual is not good at their job.

    Treatment of burnout

    Personal and interpersonal relationships

    Burnout caused by a negative relationship with oneself and others occurs due to an individual’s ability to set non-idealistic expectations and inability to cope with changes in circumstance (Sakaki & Hassan 2017).

    Scott (2018) found two personality traits prone to burnout referred to in 'Causes of burnout; Personal and interpersonal relationships'. These personality traits, that may exist to various degrees and in different forms, are the 'pathologically driven' and 'apathetic'.

    Sakaki & Hassan (2017) found that disturbances of relationships is not always related to the behaviours of the other side or life circumstances. These authors found it can also be due to the beliefs and opinions that is held by the individuals regarding such behaviours and failures.

    Much like Scott (2018) who reviewed relationship causes of burnout Sakaki & Hassan (2017) found it can be a negative mind set which leads to either anger and a turbulent relationship or a positive mind set which leads to patience and resilience.

    Emotional Intelligence and Transactional Analysis in burnout

    EI is the ability to positively identify, understand and regulate emotions in oneself and others. It then informs the individual how to adapt to a situation by using this information to guide one’s thinking and actions.

    At a fundamental level EI provides the individual with a better inner world to cope with the outside world (Drigas & Papoutsi 2018). Transactional Analysis and Mindfulness can provide a valuable perspective to developing EI as it aims to develop shared characteristics.

    Gong et al (2019) found employees with higher levels of EI can adjust their perception of their work environment as well as the emotional stimuli from the environment. Individuals with a high level of EI can:

    • Formulate and apply suitable solutions more easily.
    • Apply emotional resources.
    • Access social support via communication and interaction with people. This reduces the possibility of failure and depersonalization.

    Employees with high level of EI perform well and have a higher level of satisfaction with their jobs. They are also more likely to build a good social support system reducing the chance of depersonalization.

    Efstathia et al (2016) found trainees in the Intensive Care Unit with lower levels of EI had higher rates of burnout. Conversely, these authors found a positive correlation with higher levels of EI and higher rates of job satisfaction, compassion and communication skills.

    Through developing shared qualities associated with EI, Sakai & Hassan (2017) found Transactional Analysis to reduce burnout through:

    • Increasing levels of enthusiasm.
    • Increasing relationship satisfaction by increasing interest and decreasing unrealistic expectations.
    • Reducing stress, emotional exhaustion and apathy.
    • Kindling interest in relationships.
    • Increasing adaptation to realities and life’s fluctuations.
    • Positively changing an individual's style of communication.

    This results in the individual reducing anxiety and frustration and increasing forbearance.

    Forbearance is the level of tolerance before an individual shows a negative reaction.

    Individuals with low forbearance exhibit high pessimism and low-level depression which lowers their resilience. This diminishes their hope of making a positive change to a negative situation making them susceptible to burnout (Sakai & Hassan 2017).

    Alternatively, individuals with high levels of resilience are able to positively adapt to adverse situations. These individuals are characterised by optimism, flexibility and adaptability, initiative, tolerance, organisational skills, being a team worker, keeping within professional boundaries, assertiveness, humour and a sense of self-worth (Matheson et al 2016).

    These positive qualities defining resilience are similar to those described by Gong et al (2019) for psychological capital.

    Psychological capital is the fundamental psychological element of the individual that has a positive impact on performance. It strongly correlates to EI. These traits are:

    • Self-efficacy. This is the individual's belief in their capacity to execute behaviours necessary to perform.
    • Hope.
    • Optimism.
    • Tenacity.

    EI can be developed directly or by developing some of the same qualities fostered in Transactional Analysis and Mindfulness (Rodríguez-Ledo et al 2018). Developing EI can teach personality traits associated with resilience and psychological capital and has been linked to self esteem (Rodríguez-Ledo et al 2018 & Weilgosz et al 2019).

    Self esteem is developed by empowering the individual to set their own goals and embrace new challenges (Torkoman et al 2020). Enhancing EI to develop the attributes associated with resilience and psychological capital produces a positive mind set to these goals and challenges validating the individuals fundamental sense of worth to reduce the chance of burnout.

    Pressures in and out of the workplace

    Fawkes (2019) gave practical advice for osteopaths exhibiting workplace stressors:

    • Change work patterns e.g. take more breaks, give greater space between patients to avoid feeling constantly rushed, pay attention to natural energy peaks and troughs and reduce working hours if possible.
    • Develop coping skills e.g. use better time management, step back from issues as they arise and try to analyse problems from a neutral standpoint and compartmentalise different types of work to avoid the pressures of multi-tasking.
    • Build social support e.g. maintain contact with family and friends, join a regional society or create a virtual community.
    • Promote good health e.g. pay attention to diet and exercise and use relaxation techniques.
    • Reflect on your practice and be aware if you feel less engaged with your work.

    Therapeutic models used in Transactional Analysis for the treatment of burnout: Drivers and Scripts & The Drama Triangle

    “I need to be myself
    I can't be no one else

    I’m feeling supersonic” Oasis, Supersonic (1994)

    Transactional Analysis empowers the individual to acknowledge and internalise the essential value they see in themselves and others. These values are the true positive and negative contributions an individual(s) makes to a situation. This helps prevents burnout by increasing efficiency and allows the individual to consciously orientate themselves towards a personal ethos.


    'Okay-ness' in Transactional Analysis is defined by how someone perceives both their own and another's essential worth, value and dignity. Someone may perceive themselves as an individual that is 'not okay'; in other words, they see themselves as fundamentally lacking self worth, value and dignity. In such a case a 'driver' is how this 'I'm not okay' mind set manifests itself and plays out in a real life scenario.

    There are five different 'I'm not okay' drivers. Karpman (1984) identified how each one of these drivers influence the individual's perceptions of themselves directly contributing to burnout:

    • 'Be Perfect' driver: "I'm only okay if I do everything right" (Stewart & Joines 2007 pg 160). A person no longer does a good job out of personal pride. They define their okay-ness by the job being completed to an unachievable perfect standard ... which of course by definition is unachievable.
    • 'Be Strong' driver: "I'm only okay if I hide my feelings and wants from other people. I must not let them see I'm weak" (Stewart & Joines 2007 pg 161). A person 'toughs out' bad work conditions and denies the effect on their body and feelings. Such individuals consider it a weakness to ask for the help and changes necessary to create a healthier workplace. These people may stay too long in a bad job.
    • 'Try Hard' driver: "I'm only okay if I try hard to do things" (Stewart & Joines 2007 pg 161). These people make work unnecessarily hard placing emphasis on the effort but not the completion of the task. These people aim to tire themselves without refuelling by reflecting on and internalizing their achievements.
    • 'Please Me' driver: "I'm only okay if I please other people" (Stewart & Joines 2007 pg 161). This individual is a people pleaser who stakes their okay-ness on approval from others. This crave for external approval is never as satisfying as it is for the person who achieves personal goals to experience a deeper sense of pride and satisfaction. Criticism can be devastating for the 'Please Me' person who, in their Child ego state, will feel the criticism as Parental disapproval.
    • 'Hurry Up' driver: the person gets their okay-ness from looking busy and overworked. They won't give themselves enough time nor ask for enough time to get work done. They are too busy to intelligently reflect on the overall picture. Stewart & Joines (2007) (pg 162) found this driver to only appear as an accompaniment to other drivers.

    Scripts & The Drama Triangle

    In Transactional Analysis an initial mind set is formed when young as an early interpretation of positive or negative early life events and experiences. This mind set forms a perception an individual has of not only themselves but others. This constructed identity of oneself and others is not real, it is inauthentic, formed through the eyes of a child interpreting what is happening to them and around them. This constructed childhood identity one forms of themselves and others is called a 'script'.

    Part of being an adult progressing though life is to process emotionally detached logical thought. Through this process the initial script, formed through the eyes of a child, should be challenged and continually re-written. This permits a reinterpretation of yourself and others allowing the individual to continually grow and evolve. This process allows for the popular phrase "I'm flipping the script" to signify the individual undergoing fundamental change.

    "Flipping the script" empowers the individual to become self-aware of maladaptive behaviour enhancing flexibility and resilience. Both the Adult ego state used in Transactional Analysis and Mindfulness practice aims to provide a true untainted perspective that brings an authentic awareness to the current-moment state of self (Weilgosz et al 2019).

    In some cases, a script may have a negative impact on an individual's interaction with themselves and others. When this interaction is marked by a destructive dramatic relationship predetermined to create power and conflict a person (or people) are said to be acting in a drama triangle. In a drama triangle the individuals involved can adopt one of three roles:

    • Persecutor: someone who belittles others by putting them down.
    • Rescuer: someone who belittles others by offering help from an one-up position.
    • Victim: someone who belittles themselves disproportionately beyond the normal scope of their abilities. "I can't cope by myself" without analysing, as an adult, their true potential in a given situation.

    In the context of the drama triangle, these roles are born from an individual’s faulty perception making them inauthentic (Stewart & Joines 2007 pg 237). It is inauthentic because an individual fails to use their non-biased, logical thinking, adult perspective to truly understand themselves and others in a given situation.

    In contrast, if an individual perceives themselves as being, for example, victimised against, using an adult perspective then this is true, authentic, victimisation and they are not deemed to be in the drama triangle.

    Karpman (1984) found the drama triangle produces burnout through frustration i.e. "I've had a frustrating week". Being trapped in the Drama Triangle involves being frustrated playing out the same patterns over and over again failing to achieve any positive results. He suggested using scripts and the Drama Triangle to find out how an individual generates this frustration by understanding how they see themselves, others and extraneous events (e.g. time).

    Benedetti et al (2020) found burnout is in the script that induces the individual to repeat the game “I am Only Trying to Help You” whereby they repeatedly do unsolicited work for ungrateful people. In this game individual's burnout when the Rescuer, deliberately exhausting themselves to try and "save the day", repeatedly begins to feel like a Victim - frustrated, unappreciated and burnt out.

    Emotional Intelligence in the treatment of burnout

    Emotion can be understood as an internal event that energizes human behaviour. Intelligence has been explained as the ability to adapt to this context (Rodriguez-Ledo et al 2018)  

    Gong et al (2019) listed the four skill dimensions required for EI that informs how to process and express thoughts and emotions:

    • Perception, assessment and expression of emotions.
    • Facilitation of thought using emotions i.e. the ability to harness emotional information into one’s thinking.
    • Understanding emotions and emotional knowledge and information.
    • Regulating and managing emotions for personal and interpersonal development. 

    These qualities rely on attributes developed through Mindfulness and Transactional Analysis. One of the characteristic traits of Mindfulness is being able to maintain moment-to-moment attention in a non-evaluative manner to make conscious the perceptions of ones own emotional states. Through Mindfulness practise one can enhance EI by achieving a level of attention and clarity as well as voluntarily modifying ones own emotional states (Rodriguez-Ledo et al 2018). 

    This engenders a progressive view point on success and failure to increase job satisfaction, compassion and communication skills (Efstathia et al 2016) reducing the chance of burnout.

    Gilar-Corbi et al (2019) found training interventions improved selected dimensions of EI:

    • Ability to positively perceive, understand and accept an individual's own and others emotions.
    • Self-reliance.
    • Achievement of personal goals.
    • Stress management.
    • Development of a positive attitude.
    • Control and management of emotions.

    Drigas & Papousi et al (2018) developed the pyramid of Emotional Intelligence. Progressing through each one of the seven levels of the pyramid is an attempt to develop EI through personal growth.

    This personal growth is achieved by developing skills in perception, evaluation and management of emotions in both yourself and others. 

    From the bottom of the pyramid up these seven stages to continually reflect and improve on rather than 'master' are:

    1. Self awareness.

    2. Self management.

    3. Social awareness; empathy; discrimination of emotions.

    4. Social skills.

    5. Self actualization.

    6. Transcendence.

    7. Emotional Unity.

    These seven stages can be broadly split into two sections:

    Section one: levels 1-4

    These levels help the individual recognise and manage one's own emotions and that of others.

    It does this by helping identify personal values and ego identities to help the individual assess their own strengths and weaknesses, thoughts, beliefs, motives and feelings.

    Recognising and managing other people's emotions involves learning empathy and how to appropriately respond to others.

    Recognising, understanding and responding to emotions in others can help build rapport and make people feel their voice is being heard. In the context of EI empathy can be developed in a healthy way. This avoids the pitfalls of highly empathetic individuals in neglecting their own needs.

    By continually reflecting and improving upon the process of learning EI one can appropriately react to other people's emotions developing greater flexibility in communication.

    Section two: levels 5-7

    These levels inform how to effectively use these skills as to contribute to society in a broader context to help the individual achieve a sense of meaning and relevance.


    Being aware of the process of burnout, as well as any personal and environmental predispositions to developing burnout, can empower the individual to make positive changes.

    Developing EI and resilience, possibly with the help of Transactional Analysis and Mindfulness, can be a valid tool in preventing burnout. It is hoped that by bringing to the consciousness a clear research based framework that some level of guidance, if it's deemed necessary, can be ascertained.


    Torkaman M, Farokhzadian J, Miri S & Pouraboli B (2020).The effect of transactional analysis on the self-esteem of imprisoned women: a clinical trial.

    Benedetti G, Benelli E and Zanchetta M (2020). Development of a Transactional Analysis Diagnostic Tool for Burnout with a Case Study Application in Switzerland.

    Scott C (2018). An Exploration of Burnout in Improving Access to Psychological Therapy (IAPT) Services: An Interpretative Phenomenological Analysis. 

    Maslach C & Leiter M (2007). Burnout 


    Sakaki S & Hassan T (2017). Effectiveness of Group Therapy Based on Transactional Analysis (TA) in Marital Burnout and Forbearance of Female Students

    Patel R, Bachu R, Adikey A, Malik M and Shah M (2018). Factors Related to Physician Burnout and Its Consequences: A Review

    Maslach C & Leiter M (2016). Understanding the burnout experience: recent research and its implications for psychiatry

    Matheson C, Robertson D, Elliott A, Iversen L, Murchie P (2016). Resilience of primary healthcare professionals working in challenging environments: a focus group study

    Fawkes C (2019). Resilience and burnout in clinical practice

    Radostina K. Purvanova, Muros J (2010). Gender differences in burnout: A meta-analysis

    Gong Z, Chen Y, and Wang Y (2019). The Influence of Emotional Intelligence on Job Burnout and Job Performance: Mediating Effect of Psychological Capital

    Stewart I & Joines V (2007). TA today. A new introduction to transactional analysis

    Gilar-Corbi R, Pozo-Rico T,  Sánchez B, Castejón J (2019). Can emotional intelligence be improved? A randomized experimental study of a business-oriented EI training program for senior managers 

    Drigas A, and Papoutsi C. (2018). New Layered Model on Emotional Intelligence

    Efstathia M. Vlachou E, Damigos D, Lyrakos G, Chanopoulos K, Kosmidis G and Karavis M (2016). The Relationship between Burnout Syndrome and Emotional Intelligence in Healthcare Professionals 

    Stewart I & Joines V (2008). TA Today. A New Introduction To Transactional Analysis

    Efstathia M. Vlachou E, Damigos D, Lyrakos G, Chanopoulos K, Kosmidis G and Karavis M (2016). The Relationship between Burnout Syndrome and Emotional Intelligence in Healthcare Professionals 

    Swan K (2017). On becoming a physician

    Rodríguez-Ledo C, Orejudo S, Jesús Cardoso M, Balaguer A and Zarza-Alzugaray J (2018). Emotional Intelligence and Mindfulness: Relation and Enhancement in the Classroom With Adolescents

    Wielgosz J, Goldberg S, Kral T, Dunne J, Davidson R (2019). Mindfulness Meditation and Psychopathology

  2. Typical and atypical rib articulations

    Ribs 2-9: are typical ribs. They articulate via inferior and superior costal facets connecting to the bodies of two adjacent vertebrae; the vertebra of the same number and the vertebra above.

    Ribs 1, 10, 11 and 12: are atypical ribs. Each rib articulates with only one vertebra. Ribs 11 and 12 (floating ribs) don’t have a costotransverse joint due to their absence of an articulation with the sternum.

    Costovertebral joint capsule and ligaments

    Fibrous capsule

    The fibrous capsule connects the rib head with the articular cavities formed from the intervertebral discs and adjacent vertebrae. Some of the upper fibers of the capsule pass through the intervertebral foramen to the back of the disc. The posterior fibers are continuous with the costotransverse ligament.

    Radiate ligament

    Connects the anterior rib head with the bodies of the two adjacent vertebrae and disc. Although rib 1, 10, 11 and 12 attach to a single vertebrae the radiate ligament still attaches to the corresponding vertebrae and the one above, but not the vertebrae below.

    Intraarticular ligament

    Attaches to the crest of the rib extending to the intervertebral disc. These ligaments are absent in rib 1, 10, 11 and 12.

    The atypical ribs fail to provide as much intersegmental stability as the typical ribs. This is because the costovertebral joints are not located at the level of the intervertebral disc and have a diminished ligamentous structure (Liebsch et al 2016).

    Costotransverse joint capsule and ligaments

    The articular part of the tubercle of the rib artriculates with a reciprocal facet on the transverse process to which it corresponds numerically.

    Ribs 1-5 (or 6): the joint surfaces are reciprocally curved. This allows a pump handle movement of the ribs during respiration.

    Ribs 7 (or 6) to 10: the joint surfaces are more flattened. This allows a bucket handle movement at the ribs during respiration.

    Ribs 11 and 12: the costotransverse joints are absent.

    Fibrous capsule

    The fibrous capsule is a thin membrane that is attached to the circumference of the articular surfaces and lined with a synovial membrane.

    Lateral costotransverse ligament

    The lateral costotransverse ligament connects the posterior surface of the transverse process to the nonarticular part of the tubercle of the rib. These fibers run horizontally.

    Costotransverse ligament

    The costotransverse ligament connects the anterior surface of the transverse process to the posterior neck of the neighbouring rib. These fibers run more horizontally.

    Superior costotransverse ligaments

    The superior costotransverse ligament connects the anterior surface of the transverse process of the vertebra above to the posterior neck of the rib below. These fibers run vertically.

    This ligament is frequently absent on rib 1.

    The superior costotransverse ligament is composed of anterior and posterior fibers.

    • Anterior fibers of the superior costotransverse ligament extends from the anterior surface of the superior transverse process to the rib neck below.
    • Posterior fibers of the superior costotransverse ligament extends from the inferior border of the superior transverse process to the rib crest below.

    Jiang et al (1994) found the superior costotransverse ligament to be involved in active lateral balancing of the spine. Saker at al (2016) found the costotransverse ligaments allow sidebending and rotation.

    Lumbocostal ligament

    The lumbocostal ligament attaches rib 12 to the L1-2 transverse processes.

    Transforaminal ligaments

    The transforamonal ligaments traverse the intervertebral foramen diminishing the space available for, and protecting, the nerves and blood vessels.

    Gkasaris et al (2016) listed these ligaments as

    • Superior corporopedicular ligament: extends from the superior pedicle to the posterolateral vertebral body and related annulus fibrosus.
    • Inferior corporopedicular ligament: extends from the inferior pedicle to the posterolateral vertebral body and related annulus fibrosus.
    • Superior transforaminal ligament: extends from the arches of the superior and inferior vertebral notches to the articular capsule of the superior pedicle.
    • Mid transforaminal ligament: extends from the annulus fibrosus and superior and inferior corpopedicular ligaments to the articular capsule.
    • Inferior transforaminal ligament: extends from the junction of the annulus fibrosus and the posterior vertebral body to the superior articular facet. 

    Extraforaminal ligaments

    Kraan et al (2009) named the extraforaminal ligaments as the superior costotransverse ligament and the inferior transforaminal ligament. These ligaments anchor the nerve as it exits the intervertebral foramina.

    From T2–T10 these authors describe these ligaments as being important for craniocaudal positioning of the thoracic spinal nerve.

    Superior costotransverse ligaments

    Kraan et al (2009) gave a different description of this ligament to Saker et al (2016) and described it as extending from the superior costovertebral joint capsule and transverse process to the inferior transverse process. This ligament attaches to the spinal nerves anteriorly. 

    Therefore this ligament attaches the spinal nerves to the neighbouring, superior and inferior, transverse processes and to the costovertebral joint capsule.

    Inferior extraforminal ligament

    Gkasdaris et al (2016) described this ligament as extending from the superior transverse process to the inferior transverse process. This ligament attaches to the spinal nerve posteriorly.

    Therefore this ligament attaches the spinal nerve to the superior and inferior transverse processes.

    Variations in the extraforaminal ligaments

    Kraan et al (2009) described the variations of the extraforminal ligaments at different levels.

    T10 & T11

    At T10 and T11 the nerve is posteriorly attached to the internal intercostal membrane. At T11 the spinal nerve is attached caudally to the capsule of the costovertebral joint and the intervertebral foramen.

    Zhang et al (2016) found the internal intercostal muscles rotated the lower ribs more than the upper ribs during expiration. Therefore could 'expiratory lesions' of the ribs at this level predispose to greater nerve pain?

    T12 & L1

    At T12 and L1 the superior costotransveres ligament and inferior transforaminal ligament cross the spinal nerves anteriorly connecting them to the intervertebral foramen and disc.

    Biomechanics of the thoracic spine

    The thoracic cage plays an important role in load-bearing, providing between 30-40% of thoracic spine stiffness. Rib joint stiffness is greatest at T2 and weakest at T10 (Saker et al 2016).

    Rotation occurs inversely to flexion-extension.


    Liebsch et al (2017) found the costovertebral joints provide stability to the thoracic spine primarily in rotation.

    T1 rotates 9 degs incrementally decreasing to 2 degs at T12.

    Ribs 2-10: in rotation there is a slight contralateral transverse plane translation that occurs between the ribs and their relative transverse processes (Lee 2015). Liebsch et al (2016) found sidebending in one direction induced a considerable amount of rotation in the opposite direction.

    Ribs 1, 11, 12: do not appear to translate in the transverse plane during axial rotation (Lee 2015).

    As these joints possess a diminished ligamentous structure (refer 'costovertebral joint capsule and ligaments') and rib 11 and 12 also lack a costotransverse and sternocostal joint they fail to provide as much intersegmental stability (Liebsch et al 2016). Could this lack of stability be the reason why these joints can freely rotate within their range of motion without producing a coupled sidebending?


    T1 flexes-extends to 4 degs and increases incrementally to 12 degs at T12.


    During side-bending, the ribs approximate on the concave side and separate on the convex side. This is accompanied by an ipsilateral>contralateral rotation (Lee 2015). Saker at al (2016) found the costotransverse ligaments allow sidebending and rotation.

    Respiratory mechanics

    The bucket and pump handle movements of the ribs are primarily produced by the intercostal muscles (Zhang et al 2016)

    Pump handle movement: rib 1 to 5 (or 6)

    Ribs 1-5 (or 6): the costotransverse joint surfaces are reciprocally curved. This allows a pump handle movement of the ribs.

    The pump handle motion increases the anterior-posterior dimensions of the thorax. Because the ribs are sloped downward, any elevation during deep inspiration will result in a cephalic and anterior movement of the sternum. This increases the anterior-posterior diameter of the thorax.

    The external intercostal muscles are the most important muscles for elevating the rib cage. However the cervical accessory muscles, i.e. sternocleidomastoid and scalene muscles, facilitate the pump handle movement not only in the upper ribs but play a role in elevating the entire rib cage (Zhang et al 2016).

    Bucket handle movement: rib 7 (or 6) to 12

    Ribs 7 (or 6) to 10: the costotransverse joint surfaces are more flat. This allows a bucket handle movement at the ribs. Ribs 11 and 12 don’t possess a costotransverse joint.

    The bucket handle movement results in a lateral motion of the ribs when they are elevated. This increases the transverse diameter of the thorax.

    At ribs 11 ands 12 there is a lack of articular stability. This is from the rib articulating with a sole vertebrae, an absent intraarticular ligament, partial radiate ligament attachment and no sternocostal attachment.

    This articular instability could serve a functional role to help absorb force from the diaphragm.

    Wallden (2017) found most of the contractile force of the diaphragm is transmitted peripherally to the lower ribs around a fulcrum formed from the phrenopericardial ligament (Bordoni & Zanier 2013); not downward to the viscera. This acts to dampens down the vertical pressure directed down to the pelvic floor.

    Muscles of respiration 

    The muscles of deep inspiration involved in raising the rib cage are the:

    • External intercostals.
    • Serratus anterior.
    • Scalenes.
    • Sternocleidomastoid.
    • Levatores costarum.
    • Serratus posterior superior.
    • Additionally: pectoral muscles and serratus anterior.

    Zhang et al (2016) found the cervical accessory muscles, i.e. sternocleidomastoid and scalene muscles, facilitate the pump handle movement not only in the upper ribs but play a role in elevating the entire rib cage.

    In a forced inspiration the scapula is raised and fixed using the:

    • Levator scapulae.
    • Trapezius.
    • Rhomboids. to raise and fix the scapula.

    The muscles of forced expiration that pull the rib cage downward are the:

    • Internal intercostals
    • Abdominal muscles.
    • Minor contributions from the quadratus lumborum, subcostals, transverse thoracic and serratus posterior inferior.


    Innervation of the costovertebral ligaments is from the lateral branch of the thoracic dorsal rami of C8 to T11

    The costovertebral joints receive this innervation in a segmental fashion with each joint receiving fibers from the level above and directly below it.

    Due to the segmental innervation of the joints their pain pattern is well-localized and level specific but can radiate to the scapula or chest wall. However in cases of central sensitisation pain patterns are less predictable.

    Relations of the costovertebral and costotransverse joints and brachial plexus

    Whilst the costovertebral ligaments are innervated by C8 and T1 they are innervated by the dorsal rami and not the ventral rami that make up the brachial plexus.

    In approximately 60% of individuals, there is a linkage of the brachial plexus to the first and/or second intercostal nerve and stellate ganglion, known as Kuntz’s nerve. This nerve carries sympathetic fibers to the brachial plexus without passing through the sympathetic trunk (Zaidi & Ashraf 2010).

    Therefore, disorders affecting the first or second costovertebral joints can result in arm pain referred via this pathway.



    The diaphragm is divided into three functional groups:

    • Sternal part: attaches to the xiphoid.
    • Costal part: these vertical fibers attach to the internal surfaces of rib 7-12 and blends with the transversus abdominis. Most of the contractile force of the diaphragm is transmtted to its costal attachments.
    • Lumbar group: attaches to the L1-3 bodies (right) and L1-2 bodies (left) via the crus; L1 TP via the arcuate ligaments. The lateral arucate ligament (rib 12 to L1 TP) is a thckening of the quadratus lumborum fascia. The medial arcuate ligament (L1 body to L1 TP) is a thickening of the psoas fascia.  The crural fibers have a minor role in respiration being more orientated to gastrointestinal function (Wallden 2017).

    Innervation of the diaphragm

    The innervation of the diaphragm is from:

    • Phrenic nerve (C3,4,5 and sometimes C6): motor and sensory innervation to the diaphragm. The phrenic nerve does not innervate the crural fibers.
    • Intercostal nerves 6-12: sensory innervation

    Wallden (2017) attributed the clinical relevance of the diaphragms innervation as being:

    • Phrenic nerve courses within the fascia associated with the anterior scalene. Could trauma to this muscle possibly affect sensory and motor drives in the phrenic nerve accounting for trophic changes to the diaphragm?
    • The phrenic nerve spans both the cervical plexus and brachial plexus. Could aberrant afferent impulses from the diaphragm alter motor control at neck or into the shoulder and arm?

    Verlinden et al (2018) investigated the phrenic nerve's autonomic fibers and connections describing it not only as a motor nerve for the diaphragm but also a conduit for the peripheral autonomic nervous system. These autonomic functions include regulating blood flow to the diaphragm and providing pressure recpetors for central venous pressure.

    These authors noted an asymmetry in distribution of the autonomic fibres in the two phrenic nerves. The right side exhibited a predominance of catecholaminergic fibres in the intradiaphragmatic part; there was a complete absence of these fibers in the left phrenic nerve.  

    This right side predominance of autonomic fibers is possibly due to the presence of paraganglia in the wall of the (right-sided) inferior cava vein.

    These authors identified paraganglia in the wall of the inferior cava where it passed through the diaphragm. These ganglia may have a role in regulating plasma volume. Just as the vagus nerve monitors central venous pressure as stretch of the atrial wall, the phrenic or autonomic nerve endings in the wall of the inferior cava could act as low-pressure receptors for the central venous pressure.

    Interestingly these authors also found longitudinal cardiac muscle strands in the wall of the inferior cava. A caval sphincter supplied by the right phrenic nerve is a well-known feature of diving mammals. Myocardial ‘sleeves’ with such properties have also been described in pulmonary veins and at the base of the pulmonary trunk, where their presence can establish extranodal pacemaker activity.

    Autonomic connections to the phrenic nerve are:

    • Celiac plexus: the phrenicoabdominal branch is a separate catecholaminergic nerve branch from the right phrenic nerve. As it arises from the celiac ganglia it is therefore more appropriately termed the ‘phrenic branch of the celiac plexus’.
    • Ansa cervicalis.
    • Subclavian ansa (contributes to the inferior cervical sympathetic cardiac nerve), the cervical sympathetic trunk (including the middle and stellate ganglion) and the splanchnic nerves. These nerves are potential vasoregulators of the diaphragmatic vessels.
    • CN: X, XI, XII

    Biomechanics of respiration


    Hudson et al (2010) found the external intercostals < posterior portion of the cephalic interspaces contract during inspiration and the internal intercostals < caudal interspaces contract during expiration. However the parasternal (intercartilagenous) intercostals function as an inspiratory muscle (Hudson et al 2011).

    Intercostal intimi contract during expiration.

    However when contraction of the neck muscles fixes the first two ribs, the lateral parts of the intercostals increase rib cage volume. If, however, the abdominal muscles fix the most caudal rib, contraction of the same muscles would have the opposite effect (Wallden 2017).

    Therefore could hypertonic abdominal muscles or reduced abdominal breathing play a role in compromising the ability of the lateral intercostals to increase rib cage volume?

    The intercostals may be more involved in postural control and locomotion than in respiratory movements (Wallden 2017) although Zhang et al (2016) described the intercostal muscles as being the primary movers in producing bucket-handle and pump-handle motions of the ribs not the diaphragm.

    Liebsch et al (2017) found the intercostal stretched in sidebending and rotation. Whitelaw et al (1992) found the lateral portion of the external intercostals induces contralateral rotation whereas the lateral portion of the internal intercostals induces ipsilateral rotaion. Hudson et al (2010) found the parasternal intercostals (the intercartilagenous portion of the internal intercostals) induce an ipsilateral rotation and sidebending.

    The fibers of the transversus thoracis contract during expiration and contralateral rotation. Therefore through reciprocal inhibition contraction of the transversus thoracis diminishes or prevents activation of the parasternal intercostals during contralateral rotation and expiration (Hudson et al 2010).


    Diaphragm and the thorax

    When it contracts the diaphragm shifts in a caudad-anterior direction. This is because the muscle fibres are shorter anteriorly (between the sternum and central tendon) and longer posteriorly on both sides of the diaphragm. This results in the posterior portion of the diaphragm descending caudally more than the anterior portion (Zhang et al 2016).

    The anterior fibers, on isolated contraction of the diaphragm, although don't descend as much as the posterior fibers show a more complex pattern of movement.

    Using a FEM Zhang et al (2016) found an isolated contraction of the diaphragm paradoxically folded the anterior ribs/sternum posteriorly-caudally into an "expiratory position". This occurred as the anterior fibers of the diaphragm contracted in an antero-posterior and lateral-medial direction back towards the central tendon of the diaphragm whilst the whole diaphragm was descending. 

    This “expiratory” position of the rib cage stretches the parasternal intercostals which function as inspiratory muscles.

    This resultant stretch of the parasternal intercostal muscles acts as a stimulus for their contraction (Zhang et al 2016). The contraction of the parasternal intercostals, conversely to that of the diaphragm, moves the ribs cephalic and anteriorly to an "inspiratory" position and therefore stretches the diaphragm muscle fibres. Hudson et al (2011) found the inspiratory activity in the parasternal intercostals increases when individuals attempt to breath with the diaphragm alone.

    This could be why the inspiratory position of the ribs manually recreated in techniques such as “doming the diaphragm” have been shown to improve diaphragmatic function by stretching its muscle fibers (Nair et al 2019).

    This recpirocal action does not just exist between the diaphragm and the parasternal intercostals but also the parasternal intercostals and the triangularis sterni (Hudson et al 2010). Just as the parasternal intercostals are used for inspiration the triangularis sterni is used for expiration; and just as the parasternal intercostals are used for ipsilateral rotation of the rib above relative to the rib below the triangularis sterni is used for contralateral rotation.

    The diaphragm does not stay stretched in inspiration. By extending and stretching the diaphragm muscle fibres they approach their optimal length to provide more muscle contraction force to resist the abdominal and pleural pressures during breathing (Zhang et al 2016). 

    Diaphragm and the abdomen and pelvis 

    Most of the contractile force of the diaphragm is transmitted peripherally to the lower ribs around a fulcrum formed from the phrenopericardial ligament (Bordoni & Zanier 2013); not downward to the viscera. This dampens down the vertical pressure directed down to the pelvic floor (Wallden 2017).

    This lateral pressure on the lower ribs may account for the relative instability of rib 11 and 12 to accomodate this pressure. This instability is from these ribs articulating with a sole vertebrae, an absent intraarticular ligament, partial radiate ligament attachment and no sternocostal attachment.

    Therefore it is the mechanics of the lower ribs that mitigates risk to pelvic floor integrity; and so, any restriction in these ribs as a result of injury, postural dysfunction or emotional bracing, may be a causative pathway to drive pelvic floor issues, such as stress incontinence or hernia (Wallden 2017).

    The diaphragm functions as part of the abdominal cylinder along with the transversus abdominis, pelvic floor and deep intrinsic muscles of the spine. The abdominal cylinder helps to create stability of the spine.

    The abdominal wall and pelvic floor may play a larger role than merely “pushing back” against the visceral pressure created by the diaphragm contracting.

    The diaphragm has a very low level of spindle cells and therefore may not itself be able to regulate pressure effectively. Instead, it is likely to rely on information from the spindle cells in the abdominal wall and pelvic floor to regulate its level of activation in a neural feedback loop (Wallden 2017).

    Diaphragm and gastrointestinal disturbances

    Due to the crural diaphragm's mechanical influences Wallden (2017) attributed diaphragmatic dysfunction to:

    • GORD.
    • Swallowing.
    • Vomiting.

    In order for a food bolus to pass easily into the stomach, the crural diaphragm must briefly relax, while the rest of the diaphragm may be contracting during inspiration. This allows the bolus to transit across the diaphragm.

    During vomiting the costal and crural diaphragm dissociate their activities. The costal diaphragm contracts to increase intra-abdominal pressure forcing up the gastric contents while the crural diaphragm relaxes to allow it to pass up the oesophagus. 

    Walldren (2017) proposed the dual respiratory-gastrointestinal function as having an evolutionary origin.

    He hypothesised aquatic ancestors developed the diaphragm as a mechanism to prevent aerophagia (swallowing air) that would have left them vulnerable on the water's surface and unable to dive.

    A different hypothesis is that the crural diaphragm may have played a role in preventing live prey, swallowed whole, from exiting the stomach.

    Verlinden et al (2018) found a catecholaminergic nerve branch from the right phrenic nerve to the celiac plexus. As it arises from the celiac ganglia it is therefore more appropriately termed the ‘phrenic branch of the celiac plexus’.

    Could this association of the phrenic nerve to the celiac plexus have a reflex effect in regulating digestion?


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