An Overview Mechanical Diagnosis & Therapy of the Spine: A Dynamic System of Examination, Diagnosis, Intervention and Prevention
History MDT
Robin McKenzie
Clinical experience
Mr. Smith 1956 2 weeks of radicular sx then serendipitous surprise Exploration of End Of Range - some improved, while others worsened
History - cont
Over next 20 years developed approach Began teaching approach 1977 Rancho Los Amigos McKenzie Institute formed in 1982 26 branches around the world
Epidemiology
5050-80% population experience back pain Peak prevalence 40-50 years of age and tapers after that 40Csp -Women tend to be affected more men Lsp Men tend to more affected than women First episodes of sx start in the 20s w/ recurrency rates between 393971% Majority (80-90%) of low back disorders occur at the L4/5 and/or (80L5/S1 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 (C5level), 34.6% C7 (C6-7 level) and 25.2% C8 (C7-T1 level) (C6(C7-
Spitzer WO. Scientific approach to the assessment and management of activity-related spinal disorders: A mono-graph activitymonofor clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59. Suppl):1Class 1 2 3 4 5 6 7 8 9 10 11 Symptoms Pain w/o radiation Pain + radiation-proximal extremity radiationPain + radiation- distal extremity radiationPain + radiation + neuro signs Nerve root compression -fx, instab Nerve root compression -image, EMG Spinal stenosis S/P surgery-6 months surgeryS/P surgery->6 months surgeryChronic pain syndrome Other dx
BIOMECHANICS
Nucleus pulposa
Conceptual Framework:
DISC MODEL
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. 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.
Literature
Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine; 22(10):1115-22, 22(10):11151997.
63 subjects sent for PRE SURGICAL Discogram w/ Gadolinium for confirmation of disc pre surgical diagnosis.
Comparisons were made between the findings of the Discography and those predicted by the therapist.
Discogenic?
%Agreement 83.3%
Level?
%Agreement 93%
Fissure Pattern?
%Agreement rated good/excellent
Conclusion
Dynamic disc injection outcomes are reliably predictable w/ MDT exam and the dynamic internal disc model This strongly supports a mechanical cause effect relationship between IVD dynamics and the symptom response patterns of centralization MDT exam appears to be a dynamic, nonnoninvasive functional evaluation of symptomatic disc pathology
Nociception stimulation of receptors which provide feedback for pain Mechanical application of forces that contain the receptors is sufficient to irritate the free nerve endings (pressure, distraction, distension, abrasion, contusion, laceration) Chemical/Thermal - chemical irritation when concentration of chemical substances is sufficient to irritate free nerve endings. It is essential to identify the type of pain (chemical or mechanical) because this will establish the tissue state and the subsequent treatment selection
Clinical Management
Goal:
Classification
Pain of spinal origin can be classified into 3 syndromes.
Posture Syndrome
Posture Syndrome
End range stress on normal structures Mechanical deformation due to prolonged stress eventually produces pain
Dysfunction Syndrome
Dysfunction Syndrome
End range stress of adaptively shortened structures Mechanical deformation immediately produces pain at end of range May be discogenic, zygapophyseal, ligamentous, muscular, apeneurosis, etc
Derangement Syndrome
Derangement Syndrome
Anatomical disruption and/or displacement of structures The structures increased mechanical deformation immediately or eventually produce pain
Definition of Terms
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.
Centralization/Periperalization - cont
Defn - cont
Lateral shift (right) A lateral shift exists when the vertebra above has laterally flexed to one side in relation to the vertebra below, carrying the trunk with it. (The upper trunk and shoulders are displaced to the right.) 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, left back pain, with / without thigh / leg pain, and upper trunk and shoulders displaced to the right.
Lateral Shift
Defn - cont
Criteria for Relevant lateral shift (structural vs habitual)
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
Defn - cont
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. The measurable changes that occur in movement loss, dural tension, neurological function, tolerance to functional activities and positions, or change in tested physical abilities.
Examination terms
Terms used to determine the response to repeated movements, sustained positions, treatment procedures and/or functional activities and positions on pain patterns in musculoskeletal disorders. These are used BEFORE, DURING and AFTER the procedure to accurately evaluate the response.
EVALUATION PROCESS
PATIENT HISTORY 1* role is to HISTORY establish a hypothetical diagnosis
Location of pain Duration of current episode of pain Intermittent or Constant pain MOI Symptomatic and Mechanical responses to: 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
How many previous episodes and similarities? RED FLAGS and possible contraindications to MDT? Occupation:
PHYSICAL EXAMINATION
Primary role is to confirm hypothetical diagnosis from patient history along w/ determining appropriate loading strategy Posture:
Habits Acute spinal deformity lateral shift, torticollis, etc Other abnormalities: leg length difference, scoliosis, atrophy, etc
Willingness to move/quality/quantity Baseline for determination of the mechanical response of the test movements/positions Observations are made as to symptom and mechanical response after several repetitions can be performed if the repeated test movements dont provide adequate information to come to a conclusion
Repeated Movement
Sustained test
Protrusion
Retraction
Retraction Extension
Flexion
Sidebend
Rotation
Derangement Syndromes
Derangement Syndromes
Derangement 1 Clinical Presentation Central or symmetrical pain across C5-7 C5Rarely Scap or shoulder pain NO DEFORMITY Extension limited Rapidly Reversible Central or symmetrical pain across C5-7 C5W/ or W/O Scap/Sh or Upper arm pain KYPHOTIC DEFOMITY Rarely Rapidly reversible
Derangement Syndromes
Derangement 3 Clinical Presentation Unilat or Asymmetrical pain across C5-7 C5w/ or w/o Scap/Sh or Upper arm pain NO DEFORMITY Ext, Rot and later flex or combo limited Rapidly reversible Unilat or Asymmetrical pain across C5-7 C5w/ or w/o Scap/Sh or Upper arm pain Relavent LATERAL SHIFT or Torticollis Ext, Rot and later flex limited
Derangement Syndromes
Derangement 5 Clinical Presentation Unilat or Asymmetrical pain across C5-7 C5w/ or w/o Scap/Sh or Upper arm pain AND w/ arm sx distal to elbow W/ Leg pain extending below knee NO DEFORMITY Ext, ipsilateral lat flex limited Rapidly Reversible Unilat or Asymmetrical pain across L4/5 w/ or w/o Scap/Sh or Upper arm pain AND w/ arm sx distal to elbow Relavent LATERAL SHIFT- Csp Kyphosis SHIFTor Torticollis Not rapidly reversible
Derangement Syndromes
Derangement 7 Clinical Presentation Unilat or Asymmetrical pain across C5-7 C5w/ or w/o Ant/Ant-lat neck pain Ant/AntNo deformity Flex limited Rapidly reversible
Posture Age Pathology Pain Location Pain Referred Deformity ROM Loss Rep Test Mvt: PDM Rep Test Mvt: ERP Rep Test Mvt: Effects Definition Younger None Local None None None None None NE Normal tissue/ Abnormal stress Posture Correction Posture Ed Prophalaxis
Dysfunction Adaptively shortened tissue Local (except ANR) None (except ANR) None (exceptions) Yes None (except ANR) Yes P, ERP, NW Adaptively shortened tissue/ normal stress Remodel: Rep mvt TOWARD direction of restriction Prophalaxis
Derangement 20-40 20Yes Local or remote Possible Possible Yes Possible Yes P/A, B/W, Incr/Decr, NB/NW, Cent/Peri
Rapid change w/ mvt Mechanical displacmnt of motion segment
Treatment
References
Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine; 22(10):1115-22, 1997. 22(10):1115Long A; The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain, a pilot study. Spine; 20(23):251320(23):25132521, 1995. Long A, Donelson R, Fung T; Does it matter which exercise? A randomized control trial of exercises for low back pain. Spine; Dec 1;29(23):2593-2602, 2004. 1;29(23):2593McKenzie Course notes A, B, C, D, E McKenzie RA 1990. The lumbar spine: mechanical diagnosis and therapy. Spinal Publications, New Zealand. McKenzie RA 1990. The cervical and thoracic spine: mechanical diagnosis and therapy. Spinal Publications, New Zealand McKenzieMDT.org Petty NJ 2006. Neuromusculoskeletal examination and assessment: a handbook for therapist, 3rd ed. Elsevier Limited. Spitzer WO. Scientific approach to the assessment and management of activityactivityrelated spinal disorders: A mono-graph for clinicians. Report of the Quebec Task monoForce on Spinal Disorders. Spine 1987;12(7 Suppl):1-59. Suppl):1-