Mechanical Diagnosis & Therapy of the Spine: The McKenzie Method An Overview Mechanical Diagnosis & Therapy of the Spine: A Dynamic System of Examination, Diagnosis, Intervention and Prevention PART II

Objectives Evaluation of Clinical Exam Prognosis Interventions Treatment Principles Force progression ReEval/Intervention Progression

Characteristics of Three Syndromes See handout

Derangement Syndromes Clinical Presentation 1 Central or symmetrical pain across L4/5 Rarely buttock or thigh NO DEFORMITY 2 W/ or W/O buttock or thigh pain LUMBAR KYPHOSIS

Derangement Syndromes Clinical Presentation 3 Unilat or Asymmetrical pain across L4/5 w/ or w/o pain to buttock &/or thigh NO DEFORMITY 4 RELAVENT LATERAL SHIFT

Derangement Syndromes Clinical Presentation 5 Unilat or Asymmetrical pain across L4/5 w/ or w/o pain to buttock &/or thigh W/ Leg pain extending below knee NO DEFORMITY 6 RELAVENT LATERAL SHIFT

Derangement Syndromes Clinical Presentation 7 Unilat or Asymmetrical pain across L4/5 w/ or w/o pain to buttock &/or thigh INCREASED LUMBAR LORDOSIS

Prognosis Posture – posture correction Dysfunction - time factor Derangement - Centralizer?

Long 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):2513-2521, 1995. A pilot study indicating that centralization is useful as an outcome predictor in chronic patients. There was a superior outcome comparing centralizers to non-centralizers in an interdisciplinary work-hardening programme.

Force Progression Patient generated Patient generated w/ self OP Patient generated w/ therapist OP Mobilization Manipulation

Intervention Principles Lumbar Extension principle Lateral principle Flexion principle

Extension Principle - Static Prone Prone on elbows Sustained extension Other: Posture Correction

Extension Principle - Dynamic EIL EIL w/ self OP EIL w/ therapist OP Mobilization Manipulation EIS Other: Slouch/Overcorrect

Lateral Principle SGIS Manual Correction of Lateral Shift

Flexion Principle FlL FISitting FIS

Intervention Principles Cervical Extension principle Lateral principle Flexion principle

Dynamic Ret Ret w/ self OP Ret w/ therapist OP Ret Mobilization Ret-Ext Ret-Ext w/ rotation Ext mobilization prone

Lateral Principle Lat Flex Lat Flex w/ pt OP Lat Flex Mobilization sitting/lying Lat Flex Manipulation Rot Rot w/ pt OP Rot Mobilization Rot Manipulation

Flexion Principle Flex w/ pt OP Flex mobilization Flex w/ rotation mobilization

Exercise Prescription Once a provisional mechanical diagnosis has been established and directional preference, the patient will continue on an independent basis until follow up. Typically bouts of 10 reps 4-5x /day is a minimum to produce change Dependent upon patients mechanical diagnosis, severity of problem, capabilities of the patient.

Long A, Donelson R, Fung T. Does it matter which exercise 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. Following a mechanical evaluation all patients who demonstrated directional preference (DP) (230/312, 74%) were randomized to receive exercise matched to DP (1), exercise opposite to DP (2) or evidence-based management (3). Over 30% of groups 2 and 3 withdrew because of failure to improve or worsening, compared to none in group 1. Over 90% of group 1 rated themselves better or resolved at 2 weeks, compared to just over 20% (group 2) and just over 40% (group 3). There were further significant differences between the groups in back and leg pain, functional disability, depression and QTF category.

Reevaluation/Treatment Progression Confirm, reject or modify the provisional mechanical diagnosis Determine the need for progressions/regression 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 long-term, prophylactic benefit.

Discharge Planning and Prophylactic Concepts 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.

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. Long 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):2513-2521, 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. McKenzie 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 activity-related spinal disorders: A mono-graph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59.