MC Kenzie

The term "Mechanical Diagnosis and Therapy" refers to the discipline of clinical assessment, treatment and prevention for disorders of the musculoskeletal system developed by Robin McKenzie, O.B.E., F.C.S.P., F.N.Z.R.P. (Hon), Dip. MT. The "McKenzie Method" is a unique system of clinical intervention, when provided by a skilled clinician it is: diagnostic, prognostic, therapeutic, and prophylactic.

The McKenzie Method is a disciplined system of clinical interview and physical examination that enables the skilled practitioner to classify the patients disorder and develop a specific, individualized treatment program. The treatment approach places a specific emphasis on patient education and training in the management of spinal disorders. The experience and skills acquired by the patient during this process enables the development of a specific longterm, prophylactic program. McKenzie titled his system, "Mechanical Diagnosis and Therapy" (MDT), which stresses the importance of positions, movements and postures as both the problem and solution in most activity-related spinal disorders. The approach was developed in the late 1950s, and then cultivated over the next 20 years before presented to the world as a unique system. Since its introduction in the 1970s it has become recognized worldwide as one of the most effective methods available for clinical examination, treatment and prevention of spinal disorders. Many of the theoretical propositions and hypotheses put forth by McKenzie in the 1970s have gradually been proven to be correct with scientific investigations in the 1980s and 90s. McKenzie has influenced the modern, conservative approach to the management of activityrelated spinal disorders more than any other single individual. A. History of Mechanical Diagnosis and Therapy (MDT) Robin McKenzie has been a practicing physiotherapist since 1953. He has a strong background in orthopedic and spinal manipulative therapy. His initial musculoskeletal training was in the approach of James Cyriax, MD. Dr. Cyriaxs influence on McKenzie was significant, and can be considered the framework for the development of MDT. However, it was ultimately

McKenzies experience with his patients, combined with a sharp and curious mind that provided the stimulus for the development of his unique approach. The most famous clinical experience occurred serendipitously in 1956. That was when one of McKenzies patients, Mr. Smith, accidentally laid down on a treatment able in position of sustained end range extension (hyperextension). Much to the surprise of McKenzie, and the patient, there was an immediate resolution of a two-week episode of recalcitrant sciatica. This experience prompted McKenzie to begin to regularly explore the use of patient positioning at end range in attempt to resolve back pain. Some patients resolved rapidly, as did Mr. Smith. Some patients did not change in any significant way, and others appeared to worsen with the positioning in end range extension. After 20 years of trial and error, including the exploration of end range flexion, lateral gliding and many combinations of movements and positions, a new system of assessment and treatment had matured. The frequency and consistency by which patients were able to resolve their problems using their own positions and movements led McKenzie to the following conclusion: "If there is the slightest chance that a patient can be educated in any method that enables him to reduce his own pain and disability using his own understanding and resources, he should receive that education. Every patient is entitled to the information, and every therapist should be obliged to provide it." (McKenzie 1989). In 1977, McKenzie provided his first workshop on Mechanical Diagnosis and Therapy for the Lumbar Spine at Ranchos Los Amigos in California. Word of mouth spread, and soon the demand for more information on the McKenzie Method grew beyond expectation. In 1982, the foundational meeting of The McKenzie Institute was held in Anaheim, California. Currently, the International headquarters for The McKenzie Institute is in Waikanae, New Zealand and there are now 26 separate branches throughout the world and growing. The Institutes educational program has formally expanded to a Program of Certification, which includes a sequential four-part series of courses and a credentialing examination. In 2001, the educational program was expanded to include Mechanical Diagnosis and Therapy for the Extremities. The final stage of the educational program is the Diploma in Mechanical Diagnosis and Therapy which has a theoretical component which is provided through Otago University in New Zealand component and a clinical component which is undertaken at one of the Institutes approved clinical sites around the world. Back to top. B. Epidemiology and Natural History: Activity-related disorders of the spine are experienced by approximately 50-80% of the adult population at some point(s) in life. Yearly incidence is approximately 40% with 15-20% experiencing back or neck pain at any given time. The peak prevalence of these disorders appears to occur between the ages of 40-50 years, and progressively tapers off thereafter. Women tend to be affected by disorders of the cervical spine slightly more than men. Men tend to be affected by low back disorders slightly more than women. In general, disorders of the cervical spine are not as debilitating as disorders of the lumbar spine. However, in the clinical management of both areas prevention of chronic pain and disability is always a major concern. Disability due to low back pain has increased dramatically in recent times, in spite of no significant change in the incidence of the disorder over centuries of recorded medical history. Individuals experiencing neck pain disorders are less likely to seek health care for treatment than are patients experiencing low back pain disorders. There does not appear to be a direct correlation between degenerative changes upon imaging and the presence of cervical or lumbar pain disorders or disability. Most neck pain episodes first present as a stiff-neck complaint that rapidly resolves within a 1-3 day time period. The majority of lower back disorders begin with back pain only, which has been thought to resolve rapidly. However, recent studies do not paint as favorable a picture as previously thought. Studies have recently found that only 30-40% of individuals experience complete resolution by 2-3 months. In one

series, 48% of patients were still reporting disabling symptoms three months after the onset. These episodes of neck and back pain begin in the early twenties (often earlier for the neck) and are frequently recurrent. Relapse rates within a given year have been found to be between 39% and 71% (average 58%). Of those who experience recurrent episodes, a significant percentage will progress to the development of brachialgia or sciatica in the middle years of life. The natural resolution of these disorders is generally favorable, but over a much longer time frame than simple back and neck pain disorders. It is frequently the case that a bout of sciatica or brachialgia will take 4-6 months to resolve, interfering significantly with function during the course of the episode. Motor vehicle injuries have become a major medico-legal concern in westernized societies. However, when looking at the big picture, trauma is an infrequent cause of most back or neck pain disorders. Most spinal disorders develop insidiously or upon performing a physical task that does not place enough stress onto the spine to be traumatic. In other words, most disorders of the spine are a problem of lifestyle. This includes most industrial injuries, as most are labeled repeated strain or cumulative trauma disorders. These modern labels are another way of saying, lifestyle (work-style, play-style and rest/relax-style). The majority of lower back disorders (80 - 90%) occur at the L4-5 and/or L5-S1 levels. Most cervical disorders are found in the lower region with 41% occurring at the C5/6 level and 33% at the C6/7 level. When the nerve root is affected, 36.1% involve the C6 root (C5-6 level), 34.6% C7 (C6-7 level) and 25.2% C8 (C7-T1 level). These junctional areas of the spine (cervico-thoracic, lumbo-sacral) are the location of the greatest concentration of mechanical stress and strain. This brief overview of epidemiological finding acts to provide a rationale for the proposal that lifestyle plays a major role in the development, recurrence and progression of these disorders. MDT attacks the lifestyle factors that contribute to the onset, recurrence and progression of these disorders. This will include correction of poor postural habits (static & dynamic) and the interruption (balancing) of frequently performed end range movements and positions. An argument will be put forth that it is inactivity, causing an imbalance of sustained end range strain of supporting ligamentous system, which is the major culprit leading to the development of many spinal disorders. Reduced ability to perform and tolerate activity is the consequence of the disorder created. Back to top. C. Qubec Task Force Reports (QTF): The original Qubec Task Force Report was published as a special supplement in the Spine Journal in 1987. The report was a comprehensive, scientific, multi-disciplinary look at the problems associated with activity-related disorders of the spine (cervical/thoracic/lumbar). One of the conclusions of the report was that most disorders defied specific structural diagnosis and a new system of classification was required (Table 1), and that most diagnostic procedures and treatment procedures lacked scientific validation.
TABLE 1 Qubec Task Force Classification of Activity-related Spine Disorders Class 1 Symptoms Pain w/o rad'n TABLE 2 The Qubec Classification of Whiplash-Associated Disorders Grade 0 Cinical Presentations No complaint about the neck No physical sign(s) Neck complaint of pain, stiffness or tenderness only No physical sign(s) Neck complaint AND Musculoskeletal sign(s)a

Pain + rad'n-prox'l extrem

Pain + rad'n-distal extrem

II

Pain + rad'n + neuro signs

III

Neck complaint AND Neurological sign(s)b Neck complaint AND Fracture or dislocation

N. rt compr'n-fx, instab

IV

N. rt compr'n-image, EMG

a Musculoskeletal signs include decreased range of motion and point tenderness. b Neurologic signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits. Symptoms and disorders tha can be manifested in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia and temporomandibular joint pain. - - - - dotted lines indicate terms of reference of the Task Force

7 8 9 10 11

Spinal stenosis S/P surgery-6 months S/P surgery->6 months Chronic pain syndrome Other dx

Spitzer WO. Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians. Report of the Qubec Task Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59.

In 1995, a second Qubec Task Force Report was published on whiplash-associated disorders. There were similar conclusions regarding the scientific support for diagnostic and treatment interventions, and a new classification of these disorders was proposed (Table 2). In addition, a challenge to the Physical Therapy profession to develop clinically effective and cost efficient treatment was raised by Dr. Bogduk. The primary importance of the QTF for the purpose of this presentation will be the classification system as a means of defining distinct populations of patients for outcome study, clinical trials and general discussion. The QTF also provides an ideal starting point to evaluate the status of scientific support for the many diagnostic procedures and treatment interventions provided in the health care system.

A. The Spinal Motion Segment: The basic functional unit of the spine is the motion segment (Figure 1). It consists of the vertebra, the intervertebral discs and the connecting ligamentous and soft tissue structures. By an analysis of the response of the motion segment to load, position and movement the clinician can gain insight into the mechanical response of the spine to various examination and treatment procedures, as well as the many functional demands placed upon the region.

( Figure 1 ) Back to top. B. Spinal Biomechanics: The biomechanical changes that occur in the sagittal plane will be discussed only as they have primary significance for the conceptual model, which MDT is based on.

Flexion of the Spine ( Figure 2 ) Zygapophyseal joint surfaces distract as the inferior articular processes of the superior vertebra glide up and forward upon the superior articular surfaces of the vertebra below. Anterior loading of the intervertebral disc occurs with compression of the anterior portion, with relaxation and bulging of the outer anterior annular wall. (Figure 2) The posterior annular wall is stretched and pulled taut. The nucleus distorts posteriorly. The vertebral canal lengthens, stretching the cord, dura and root filaments and opening the intervertebral foramina.

Extension of the Spine ( Figure 3 ) Inferior articular processes of the vertebra above glides down and backward on the superior articular surfaces of the vertebra below. Posterior loading of the intervertebral disc occurs with distraction of the anterior portion of the

annulus, which is stretched and pulled taut. The posterior annular wall is relaxed and there is posterior bulging of the outer, posterior annular wall. The nucleus distorts anteriorly. The vertebral canal shortens, which relaxes the cord, dura and root filaments, and reduces the size of the intervertebral foramina. Cervical Spine The cervical spine has the unique ability to perform an accentuated forward and backward translatory movement. These cervical movements are termed protrusion (anterior translation) and retraction (posterior translation). Protrusion and retraction plays a major role in the mechanical function and failure of the cervical spine. As a result, they are extremely important procedures of assessment and treatment in the cervical region. In its most simplistic terms, protrusion causes the upper most segments to extend and lower most segments to flex. Retraction causes the upper most segments to flex and the lower most segments to extend. The middle segments vary in their response significantly amongst normal individuals. The influence of protrusion and retraction on lower cervical function is profound, and requires thorough clinical exploration in the management of cervical disorders. Back to top. C. Pain Mechanisms: Nociception is the activation of the pain warning system in response to stimulation of the nociceptive receptors. This activation occurs in response to sufficient amounts of mechanical deformation of the connective tissues (distortion, distention, and disruption), adequate amounts of chemical irritation (inflammation, infection) or significant changes in temperature (excessive cold or heat). The identification of the nature of the pain (chemical and or mechanical) is essential as it serves to establish the state of the tissues, the pain mechanism involved and thus the treatment required. Mechanical diagnosis procedures involve a disciplined assessment of the activity of the nociceptive receptor system. The identification of certain patterns of change in nociceptive activity allows the clinician to distinguish three main groups of mechanical disorders: derangement syndrome, dysfunction syndrome and postural syndrome. By providing a thorough assessment and being alert to atypical responses to the history or physical examination, the clinician using MDT is able to recognize serious spinal pathology. MDT also enables the clinician to recognize the patterns of chronic pain states where neurophysiological, psychological and social factors dominate the maintenance of pain. The goals for clinical intervention with activity-related spinal disorders are; 1. to reli ev e sy mp to ms to res tor e fun ctio n, an d to pre ve nt rec

2.

3.

urr en ce. In order for any system of intervention to achieve this it must have a process through which patients can be selected for treatment and inappropriate patients are channeled into other avenues.

A major strength of the MDT system is its ability to rapidly expose those suitable for this form of treatment and those who are not. In general, MDT will apply to approximately 80% of the patient population. It is this along with the ability to quickly recognize unsuitable patients, which argues for the use of MDT as a gatekeeper in the management of musculoskeletal disorders. However, the ability to use MDT successfully is dependent upon the training, skill and experience of the clinician(s) involved. A. Classification and Diagnosis Despite the technological advances that have been made in recent years, the ability to identify the precise structure that generates symptoms and the exact nature of the pathology affecting it remains extremely limited. In the absence of clear diagnoses, classification systems are an alternative means by which sub-groups of patients within the non-specific spinal pain population can be identified. The McKenzie Method utilizes a classification system related to the mechanism of symptom generation with three non-specific mechanical syndromes being utilized derangement, dysfunction and postural. A fourth classification Other' is utilized to include those patients with specific identifiable pathologies. The Quebec Task Force advocates the classification of non-specific spinal disorders by the use of pain patterns. They determined that Non-specific ailments of back pain with or without radiation of pain, compromise the vast majority of problems (Spitzer et al 1987) hence accurate diagnosis was a problem and a classification system giving an indicator of pain severity was appropriate. McKenzie first proposed the use of a pain pattern classification in 1981 and his original classification had many similarities to that of the QTF classification. Within the McKenzie Method, pain pattern identification is used in conjunction with the three classifications as a means of monitoring symptom severity and response to therapeutic loading strategies. Back to top. Derangement Syndrome: Internal derangement causes a disturbance in the normal resting position of the affected joint surfaces. Internal displacement of articular tissue of whatever origin will cause pain to remain constant until such time as the displacement is reduced. Internal displacement of articular tissue obstructs movement. Derangement syndrome is characterized by a varied clinical presentation, but typical responses to loading strategies. This includes worsening or peripheralization of symptoms in response to certain postures and movements. It also includes the reduction, abolition, or centralization of symptoms, and the restoration of normal movement in response to therapeutic loading strategies. It is only in this syndrome that the presence of the centralization phenomenon is

found. This group is characterized by the ability to change rapidly for the better and/or for the worse. These conditions can be acute, subacute or chronic. Symptoms can be constant or intermittent. Pain frequently changes site and location, is often felt constantly, and exhibits itself during the movement. The deformities of acute kyphosis, lateral shift, wry neck and acute accentuated lordosis are forms of significant derangement. Both symptomatic and mechanical responses can be caused to change, and paradoxical pain responses are common. The following are the sub-classifications of the Derangement Syndrome: Central/Symmetrical (Previously Derangements #1, 2, 7) Unilateral/Asymmetrical Symptoms to Knee (Previously Derangements #3, 4, 7) Unilateral/Asymmetrical to Below the Knee (Previously Derangements #5, 6) Back to top. Dysfunction Syndrome: Pain from the dysfunction syndrome is caused by mechanical deformation of structurally impaired soft tissues. This abnormal tissue may be the product of previous derangement, trauma, or inflammatory or degenerative processes. These events cause contraction, scarring, adherence, adaptive shortening, or imperfect repair. Pain is felt when the abnormal tissue is loaded. Contractile or articular structures can be affected the latter are most common in the spine. Local pain only is experienced (exception is the nerve root adherence), always intermittent, has to be a chronic condition, has to have some degree of movement loss in the direction of the dysfunction. Test procedures reveal a very fixed and consistent symptomatic and mechanical response. The patient's pain is always produced once end range is achieved, but fails to improve, worsen or change with repetition of the mechanical stress. There is no effect or change on the test movements and positions in the opposite direction, and rapid changes are NOT possible. The overpressure test must yield a very consistent end range response. The dysfunction is named by the direction of movement that produces the symptomatic and mechanical response. A nerve root adherence is a special case of dysfunction in which spinal movements can be found to reproduce the radiating symptoms into the limb at end range when they produce root tension (special tests are required and must be meticulously performed in order to differentiate from other pathologies that can also produce root tension). Flexion Dysfunction symptoms are produced at end range flexion only. Extension Dysfunction - symptoms are produced at end range extension only. Lateral Flexion Dysfunction symptoms are produced at end range lateral flexion only. Rotation Dysfunction - symptoms are produced at end range rotation only. Nerve Root Adherence - symptoms are produced in the limb at the end of flexion or lateral flexion away when root tension is already present only. Multi-directional Dysfunction - more than one of the above found to occur simultaneously. Back to top. Postural Syndrome: Pain from the postural syndrome is caused by mechanical deformation of soft tissues or vascular insufficiency arising from prolonged positional or postural stresses affecting the articular structures or the contractile muscles, their tendons or the periosteal insertions. Local pain only is experienced, it always intermittent, no movement loss, no effect with repeated end range test procedures. Symptoms are only produced after an end range position is sustained for an adequate period of time (usually 20 - 30 minutes). As a result of the production of these symptoms there is no change in the location of pain, nor any mechanical or

symptomatic effect when moving out of the test position or into the end range in the opposite direction. The postural syndrome can be identified by sustaining the offending end range position in lying, sitting, standing or while performing an activity which involves sustained end range spinal positioning. Back to top. Other: This includes the identification of other conditions that do not fit the McKenzie spinal mechanical classification. These include symptoms arising from the relevant peripheral joints (e.g. hip and sacro-iliac joints for the lumbar spine and shoulder for the cervical spine), specific spinal disorders (e.g. spinal stenosis, spondylolisthesis), mechanically inconclusive symptoms and chronic pain states. The three syndromes are separate entities: they present in quite distinct ways, respond differently to mechanical testing and require quite different management. In the derangement syndrome, reductive forces must be applied to relocate displace tissue, and loading strategies are applied that reduce, abolish or centralize symptoms. In the dysfunction syndrome structurally impaired tissue must be remodeled by repeatedly stressing the abnormal tissue. Whilst in the postural syndrome, postural correction must be performed to relieve the development of prolonged mechanical loading in normal tissue It should be emphasized that the most common reason for patients to seek medical assistance is for derangement so this is the entity that is most commonly seen in the clinic. Back to top. B. Classification Algorithm THE MCKENZIE METHOD CLASSIFICATION ALGORITHM

C. Definition of Terms: Any systematic approach is required to have uniformity and standardization in order to be measurable, reliable and valid. Definitions are the foundation of this process. The following are some definitions commonly used in MDT, and throughout the presentation: Centralization Describes the phenomenon in which limb pain emanating from the spine is progressively abolished in a distal to proximal direction in response to therapeutic loading strategies , with each progressive symptom change being retained over time. If back pain only is present this is reduced and then abolished.

Peripheralization Describes the phenomenon by which pain emanating from the spine spreads distally into or further into the limb as a result loading strategies. If pain is produced in the limb, spreads distally or increases distally and remains worse the loading strategy should be avoided. Right and left lateral shift

A right lateral shift exists when the vertebra above has laterally flexed to the right in relation to the vertebra below, carrying the trunk with it. The upper trunk and shoulders are displaced to the right. A left lateral shift exists when the vertebra above has laterally flexed to the left in relation to the vertebra below, carrying the trunk with it. The upper trunk and shoulders are displaced to the left.

Contralateral and ipsilateral shift

A contralateral shift exists when the patient's symptoms are on one side and the shift is in the opposite direction. For instance, right back pain, with / without thigh / leg pain, and upper trunk and shoulders displaced to the left. An ipsilateral shift exists when the patient's symptoms are on one side and the shift is to the same side. For instance, right back pain, with / without thigh / leg pain, with upper trunk and shoulders displaced to the right.

Criteria for a relevant lateral shift

Upper body is visibly and unmistakably shifted to one side Onset of shift occurred with back pain Patient is unable to correct shift voluntarily If patient is able to correct shift they cannot maintain correction Correction affects intensity of symptoms Correction causes centralization or worsening of peripheral symptoms

Back to top. Symptomatic responses

The changes in the patient symptoms that are elicited and recorded with the application of assessment procedures, treatment procedures or in response to functional activities and positions.

Mechanical responses

The measurable changes that occur in movement loss, dural tension, neurologic al function, tolerance to functional activities and positions, or change in tested physical abilities.

Assessment Terms: The following will define the use of terms to determine the effect of repeated movements, sustained positions, treatment procedures and/or functional activities and positions on pain patterns in musculoskeletal disorders. It must be recognized that there are 3 distinct stages in the assessment of the symptomatic and mechanical responses in MDT in order to use these terms correctly:

1. 2. 3.

Before the Application of Mechanical Force (loading): During the Application of Mechanical Force (loading): After the Application of Mechanical Force (loading):

Terms used 'during loading' Either by repeated movements or sustained posture Increase Symptoms already present are increased in intensity.

Decrease Produce Abolish Centralizing Peripheralizing No Effect

Symptoms already present are decreased in intensity. Movement or loading creates symptoms that were not present prior to the test. Movement or loading abolishes symptoms that were present prior the test. Movement or loading moves the most distal pain in a proximal direction. Movement or loading moves the pain more distally. Movement or loading has no effect on the symptoms.

Terms used 'after loading' Either by repeated movements or sustained postures Worse Symptoms produced or increased with movement or loading remain aggravated following the test.

Not Worse Better

Symptoms produced or increased with movement or loading return to baseline after testing. Symptoms decreased or abolished with movement or loading remain improved after testing. Or Symptoms produced, decrease on repetition, remain better after testing

Not Better Centralized Peripheralized No Effect

Symptoms decreased or abolished with movement or loading return to baseline after testing. Distal symptoms abolished by movement or loading remain abolished after testing. Distal pain produced during movement or loading remain after testing. Movement or loading has no effect on symptoms after testing.

D. Assessment Process The assessment process begins with history taking, proceeds to observation, mechanical testing procedures and ends with other tests if required. The results of the assessment lead to provisional classification, which, then leads to a particular principle of treatment to be implemented. The patient is then instructed in a specific regime of procedures to follow until the next visit and the patient's response to treatment is then reassessed. Provided the patient responds appropriately, the treatment is continued until the condition is stable and the next phase of treatment is initiated. If the patient does not respond as expected, a problem solving / reassessment process is initiated. This leads to confirmation, rejection or modification of the provisional classification drawn at the end of the first session. Appropriate

changes in the treatment program are implemented. 1. History Taking The primary aim of the history taking is to establish a hypothetical diagnosis by syndrome. The key information required to establish this mechanical diagnosis relates to: Location of the present symptoms? How long has this episode been present? Are the current symptoms constant or intermittent? How did this episode commence and what are the effects of the following questions of the patient's symptomatic and mechanical responses; bending, sitting, rising from sitting, turning, lying, rising form lying; upon waking, as the day progresses, in the evening, when still and when on the move? Is your sleep disturbed by your symptoms? What position do you sleep in, upon what surface and how many pillows? Have you had previous episodes? Were they different from this one? How were they managed? Specific questions are also asked in the history to identify Red Flag clues and potential contraindications to MDT. 2. Physical Examination The primary aim of the Physical examination is to confirm the hypothetical diagnosis that was established with the History taking. The appropriate therapeutic loading strategy is also determined. a) Posture This section of the assessment involves a determination of the patient's postural habits in sitting, standing and positional change. The clinician will also be looking for the presence or absence of acute spinal deformity. In the lumbar spine, the clinician is looking for kyphosis, lateral shift or an accentuation of lordosis. In the cervical spine, the clinician is looking for flexion (protruded) or a lateral (wry neck) deformity. The clinical relevance of any of these findings is determined by assessing the symptom response when these deformities are subjected to repeated movements. Any other observation that may be relevant is noted. This could include assessment of structural scoliosis, leg-length inequality, atrophy etc. b) Neurological examination A neurological examination should be performed if there are symptoms of paraesthesia. Or weakness in the limb or when the limb symptoms present in a radicular pattern. The components to the neurological examination are sensation, reflexes, strength, and nerve tension tests. c) Movement Loss The range of movement is grade subjectively as major, moderate, minimal or no (nil) loss of movement. The movements that are assessed are the appropriate sagittal and lateral movements for the particular region of the spine being examined. This involves 1) Cervical : protrusion, flexion, retraction, extension, right and left rotation, and lateral flexion. 2) Thoracic : flexion, extension and left and right rotation. 3) Lumbar : flexion, extension and left and right side gliding. Determination of the amount of movement loss includes consideration of the willingness to move the quality and quantity of the motion. Ultimately, the movement loss portion of the assessment provides a baseline of information from which a determination of the mechanical response of the test movements/positions can be made; i.e. does the amount of movement loss change or remain the same. Other components assessed include the presence of deviation, the ease of curve reversal and whether the movement is stopped by either pain or stiffness. d) Repeated movements The repeated movement part of the physical examination provides the most useful information on symptom response and is the ultimate guide to the management strategy that will be required. They allow differentiation between the three mechanical syndromes and also clarify

the directional preference of derangement Sagittal movements are tested first as clinically flexion and extension, have the greatest effect of the patients pain. The movements can be performed loaded (standing or sitting) or they can be performed unloaded. If all the sagittal tests prove to be uninformative, or indicate a worsening of the patients condition then the appropriate lateral movements are explored. When a lumbar patient presents with an obvious and relevant lateral shift, exploration of side gliding in standing (usually manual shift correction) is first. The amount of testing, what tests to perform and the positions of testing are, determined by the clinician according to the patient's presentation. Once a directional preference (centralization) has been demonstrated further testing is unnecessary e) Static tests Static tests or sustained postures can be performed should the repeated test movements not provide adequate information to come to a conclusion. The history will often indicate when prolonged loading at end range is the aggravating mechanical force and this will guide the clinician to perform static tests. f) Other Tests The most commonly required, other tests involve determining the involvement of peripheral joints e.g. shoulder joint, sacroiliac joint and hip joint. Other important tests involve testing for signs of vertebro-basilar artery insufficiency, vestibular malfunction. Other tests may include those that measure the patient's ability to function e.g. ADL activities or recreational activities. Back to top. E. Evaluation of Clinical Presentations a. Repeated movements in derangement syndrome Repeated movements in the direction that produces greater deformation of structures will:

o o

Produce symptoms, worsen the symptoms and peripheralize the pain And cause an obstruction to movement

Movements in the opposite direction will reduce deformation of those structures

o o

Cause abolition, reduction of symptoms and cause centralization of pain And cause an increase in range of movement

Thus repeated movements are diagnostic of the derangement syndrome as well as confirming the directional preference of the management strategy, to which clues will have been provided in the interview. Once a repeated movement has been found that reduces, abolishes, or centralizes symptoms, and/or improves the mechanical presentation, no further testing is necessary and that movement is used in the management strategy. Often this response is apparent on day one, sometimes further testing over up to three visits is necessary to confirm. b. Repeated movements in dysfunction syndrome Repeated movements in the direction that puts tension on adaptively shortened structures will:

Produce end-range pain on every occasion

o o o o o

Alternatively, repeated compression of structurally impaired tissue could consistently reproduce the patient's symptoms at end-range They will not make the patient progressively worse When they return to the neutral position the pain will abate Pain will not be peripheralized; but distal symptoms will be produced with an Adherent Nerve root There will be no rapid change in range of movement

Thus repeated movements are diagnostic of dysfunction syndrome, and also reveal the movement that requires repetition to remodel adaptively shortened tissues. c. Repeated movements in postural syndrome o No pain on any test movements or their repetition o No loss of normal range of movement o Pain only on sustained posture Thus repeated movements will have no effect in postural syndrome d. Repeated movements in other categories o None of the above symptomatic or mechanical responses o No lasting favorable response o Inconsistent responses

Other categories and irreducible will give different symptomatic and mechanical responses. Back to top. F. Principles of Management The principle of management guides the mechanical treatment to be provided. There are four basic principles of treatment: posture correction, flexion, extension and lateral. The principle of treatment is determined by the mechanical conclusion, as is the response to the procedures to be utilized. When the conclusion is derangement, the intention of management is to: 1. 2. 3. 4. Achieve reduction Maintain reduction Recover function Train the patient in prophylaxis

Reduction is achieved when the pain is centralized (or abolished), the obstruction to motion is removed, and the condition remains better. Reduction is maintained through appropriate postural correction procedures (static & dynamic), avoidance of the end range position or movement that causes the derangement, regular performance of the reductive maneuvers and early reaction to warning signs. Function is ready to be recovered when the reduction is demonstrated to be stable. This is identified when the movement or position that once caused derangement is found to no longer be able to worsen the condition. Prophylactic instructions generally involve using the procedures and instructions that achieved reduction (and stability of reduction) to prevent the recurrence of the same problem. Patients are advised to remain as fully active as is possible and appropriate. When the mechanical conclusion is dysfunction, the intention of the treatment procedures is to produce the symptoms at end range in order to initiate a remodeling effect upon the adaptively shortened, scarred and/or fibrosed tissues. This is the, no pain, no gain group. It is assumed that appropriate education and postural correction procedures are included. The emphasis of

treatment is to regain the lost function due to the loss of tissue extensibility. Ultimately prophylactic training is emphasized. When the mechanical conclusion is postural syndrome, there is no movement loss and no pain produced with movement. Therefore, the only intent of treatment is to educate the patient in the mechanism of pain production, and train the patient to correct the postural habits at fault. This includes the rationale and procedures for the maintenance of correct postures when still (sitting, standing and lying) and when active, and the use of assistive devices for postural support. Ultimately, the postural syndrome patient is provided the opportunity to prevent the development of dysfunction and/or derangement. This becomes a main goal in the prophylactic instructions. PRINCIPLES OF MANAGEMENT IN MECHANICAL THERAPY

Back to top. G. Procedures of Mechanical Therapy Patient techniques are used first, and will frequently be effective in resolving the problem without the need for more interventions. Provided there is adequate instruction and careful explanation regarding management of the problem, the self-treatment concept can be successfully applied to most back pain patients. In the derangement syndrome the majority of patients can successfully manage their own condition, whilst about 30% of patients will not recover with exercises alone and will need therapist techniques in addition. In the dysfunction syndrome only the patient is able to provide the appropriate loading strategies with sufficient regularity to enable a remodeling of the structural impairment. Therapist techniques may aid this process, but by themselves are generally inadequate to resolve the tissue abnormality. Patients with postural syndrome can only resolve their problem with self-management strategies. Therapist interventions will be ineffective without the patient being educated regarding the role of posture as a cause of their pain. Patient techniques are only supplemented by therapist techniques when this becomes necessary because of a failure to improve. Whilst the patient is improving with selfmanagement strategies there is absolutely no need to supplement treatment with additional interventions that encourage patient dependency. In certain instances, most notably the acute lateral shift deformity, therapist techniques may be needed to bring about a situation that the patient can begin to manage him or herself. Progression of Forces 1. 2. Establish and confirm the mechanical diagnosis on consecutive treatment days. Patient-generated forces have been explored in the appropriate direction based upon the treatment principle. These forces have progressed from mid-range to end-range and then end-range with overpressure. Progression of forces occurs only when the patient benefits from self-generated forces but the benefit is not complete or not lasting. Therapist overpressure has been used to insure end-range with overpressure at the appropriate segments according to the treatment principle. Progression of forces occurs only when the patient benefits from therapist overpressure forces but the benefit is not complete or not lasting. Therapist mobilization has been thoroughly explored to end-range at the appropriate segments in the appropriate direction according to the treatment principle. Progression of forces occurs only when the patient benefits from mobilization forces but the benefit is not complete or not lasting. Prior to applying a manipulation, pre-manipulative pressures are applied in the appropriate direction and at the appropriate segments according to the treatment principle and ultimately according to the patient's pain response.

3.

4.

5.

Treatment principles

Extension principle forces (procedures 1-10) Extension principle with lateral component (procedures 11-15) Lateral principle forces (procedures 16-17) Flexion principle forces (procedures 18-21) Flexion principle with lateral component (procedures 22-25)

Lumbar Procedures (not all in order of force progression)

Extension principle static 1. 2. 3. 4. Lying prone Lying prone in extension Sustained extension Posture correction

Extension principle dynamic 5. 6. Extension in lying (with patient overpressure) EIL

a. Extension in lying with clinician overpressure b. Extension in lying with belt fixation 7. Extension mobilization (in neutral or in extension) 8. Extension manipulation 9. Extension in standing EIS 10. Slouch-overcorrect Extension principle with lateral component dynamic 11. Extension in lying with hips off center 12. Extension in lying with hips off center with clinician overpressure (a: sagittal; b: lateral) 13. Extension mobilization with hips off center 14. Rotation mobilization in extension 15. Rotation manipulation in extension Lateral principle 16. Self-correction of lateral shift or side gliding 17. Manual correction of lateral shift Flexion principle 18. 19. 20. 21. Flexion in lying FIL Flexion in sitting Flexion in standing FIS Flexion in lying with clinician overpressure

Flexion principle with lateral component 22. 23. 24. 25. Flexion in step standing FISS Rotation in flexion Rotation mobilization in flexion Rotation manipulation in flexion

Most techniques, though not all, are done as repeated movements. The optimum number of movements is about ten to fifteen repetitions in one set'. In certain instances several sets' of exercises may be done in succession. The number of times in a day that the series of exercises should be done will vary according to the mechanical syndrome, the severity of the problem, and the capabilities of the patient. In most instances a minimum of four or five sets a day is necessary to produce a change. Exercises or mobilizations will generally be performed in a rhythmical pattern the procedure should be followed by a brief moment of relaxation. With each subsequent movement the range or pressure exerted should be increased, as long as the symptomatic response is favorable. In assessing the patient's response to any technique, the symptomatic and mechanical presentation must be considered. In terms of the symptomatic response, the site, the severity,

and the frequency of the pain may alter. In terms of the mechanical presentation, the range of movement and the functional level may alter. Back to top. H. Reassessment / Treatment Progressions The reassessment process is the most important part in clinical management. The reassessment process will: 1. 2. 3. 4. 5. 6. Confirm, reject or modify the clinician's conclusions of the initial assessment, Determine the need for progressions of force, Determine when it is appropriate and how to initiate recovery of function/reactivation, Determine any worsening or progression of the disorder which prompts the need to contact the referring medical physician, Determine the need and timing for discharge planning, Develop the patient's self management and problem-solving skills essential for longterm, prophylactic benefit.

The focus of the reassessment process changes as the number of treatment sessions and the amount of time on program progresses. Initially, the main concern is to determine if the mechanical conclusions were correct and to insure that the patient is responding as expected. This includes a continued emphasis on training and education of the patient in selfmanagement of their problem. The clinician's ability to help the patient effectively problem-solve their areas of difficulty is a key issue in both the short and long term management of the patient's condition. Early in the treatment program, there is a careful assessment of the need to use of greater mechanical forces in the management of patient's with confirmed derangement and/or dysfunction syndromes. As soon as possible and appropriate, the patient is tested for stability of reduction and recovery of function procedures initiated. Patients are always encouraged to maintain the highest level of activity appropriate while recovering. Specific obstacles to the return to work, home or play activities are targeted as a part of the treatment program. Ultimately, discharge planning and the finalizing of prophylactic instructions are the treatment focus. The prophylactic concept consists of:

Provision of education Encouragement of patients to problem solve' their own difficulties should be part of treatment. Supervision of patients must, in the light of the epidemiology of back pain, involve the nurturing of self-management strategies. This should be done from day one and those strategies will need to be individualized according to the patient.

In summary, many patients are involved in back care management or practice preventative strategies, or wish to be informed about such. Patients place considerable emphasis on information from clinicians about self-management strategies and prognosis. The most commonly adopted strategies, and therefore presumably the most useful, relate to exercises and posture.