1. Mechanical Treatment for the Lumbar Spine

2. Introduction to McKenzie MDT Based on determining a directional preference and mechanical response to repeated movement Based on determining a directional preference and mechanical response to repeated movement Seeks to determine structure(s) responsible for symptoms Seeks to determine structure(s) responsible for symptoms Seeks to classify the problem based on its response to testing Seeks to classify the problem based on its response to testing

3. Indications Nerve root problems Nerve root problems Mechanical back pain (i.e. the pain varies with physical activity and over time) Mechanical back pain (i.e. the pain varies with physical activity and over time) Lumbosacral, buttocks, thigh and leg pain Lumbosacral, buttocks, thigh and leg pain Patient is generally well Patient is generally well

4. Contraindications for MDT Serious spinal pathology Serious spinal pathology Cauda Equina Cauda Equina Cord Signs Cord Signs Cancer Cancer Infections Infections Fractures Fractures Widespread neurological deficit Widespread neurological deficit Non-mechanical back pain Non-mechanical back pain

5. Categories of LBP Postural: Caused by deformation of soft tissues through excessive load Postural: Caused by deformation of soft tissues through excessive load Derangement: Damage to or displacement of annular tissue with or without nuclear displacement Derangement: Damage to or displacement of annular tissue with or without nuclear displacement Dysfunction: Chronic movement loss or adherence of nerve roots Dysfunction: Chronic movement loss or adherence of nerve roots

6. Planes of Movement Sagittal: Movements in the plane of flexion and extension Sagittal: Movements in the plane of flexion and extension Coronal: Movements in the plane of side flexion Coronal: Movements in the plane of side flexion

7. Definitions in MDT Peripheralization: Production or increase of more distal symptoms after repeated movement testing Peripheralization: Production or increase of more distal symptoms after repeated movement testing Centralization: Production of more proximal symptoms or a decrease in peripheral symptoms after repeated testing Centralization: Production of more proximal symptoms or a decrease in peripheral symptoms after repeated testing Directional preference: Centralizing response of symptoms to a specific repeated movement Directional preference: Centralizing response of symptoms to a specific repeated movement Mechanical reponse: Change in range of motion in the tested movement or its opposing movement during or after repeated movement Mechanical reponse: Change in range of motion in the tested movement or its opposing movement during or after repeated movement

8. Definitions (con’t) Increase: Augmentation of pain Increase: Augmentation of pain Decrease: Reduction of pain Decrease: Reduction of pain No Worse (NW): Increase in pain that is not maintained post testing No Worse (NW): Increase in pain that is not maintained post testing No Better (NB): Decrease in pain that is not maintained post testing No Better (NB): Decrease in pain that is not maintained post testing Worse: Maintained increase in symptoms or peripheralization Worse: Maintained increase in symptoms or peripheralization Better: Maintained decrease in symptoms or centralization Better: Maintained decrease in symptoms or centralization Produce: Creation of a pain that was previously not present Produce: Creation of a pain that was previously not present Abolish: Disappearance of a pain that was previously present Abolish: Disappearance of a pain that was previously present

9. Definitions (con’t) Peripheralizing (Ping): Peripheralization of symptoms DURING repeated testing Peripheralizing (Ping): Peripheralization of symptoms DURING repeated testing Peripheralized (Ped): Peripheralization of symptoms maintained POST repeated testing Peripheralized (Ped): Peripheralization of symptoms maintained POST repeated testing Centralizing (Cing): Centralization of symptoms DURING repeated testing Centralizing (Cing): Centralization of symptoms DURING repeated testing Centralized (Ced): Centralization of symptoms maintained POST repeated testing Centralized (Ced): Centralization of symptoms maintained POST repeated testing These definitions apply most reliably to PAIN These definitions apply most reliably to PAIN

10. Disc Forces Most frequently, forces are applied to the anterior annulus Most frequently, forces are applied to the anterior annulus These forces cause a posterior migration of the nucleus on to the annular wall These forces cause a posterior migration of the nucleus on to the annular wall Very few occasions in a given day where posterior forces are applied Very few occasions in a given day where posterior forces are applied Example: sitting Example: sitting

11. Deformities Lateral Shift: Lateral displacement of torso relative to lower body; named for deviation of torso Lateral Shift: Lateral displacement of torso relative to lower body; named for deviation of torso Kyphotic: Reversal of normal lordotic lumbar curve Kyphotic: Reversal of normal lordotic lumbar curve Lordotic: Marked increase of normal lordosis Lordotic: Marked increase of normal lordosis Relevent Shift: Indicates a need to address shift in order to address symptoms Relevent Shift: Indicates a need to address shift in order to address symptoms Relevent Lateral Compartment: Used to name a derangement requiring non-sagittal movements Relevent Lateral Compartment: Used to name a derangement requiring non-sagittal movements

12. Relevant Shift There is a clear shift of the upper body to one side There is a clear shift of the upper body to one side Onset of shift came on with back pain Onset of shift came on with back pain Patient is often unable to self-correct Patient is often unable to self-correct Correction can cause centralization or worsening of peripheral symptoms Correction can cause centralization or worsening of peripheral symptoms

13. Movement loss ROM ROM Is it pain or stiffness that stops the movement? Is it pain or stiffness that stops the movement? Is there any deviation to one side? Is there any deviation to one side? Is the patient confident and willing to move? Is the patient confident and willing to move? Is there a curve reversal? Is there a curve reversal?

14. Repeated movements Always take their baseline, i.e. What are you feeling right now? Always take their baseline, i.e. What are you feeling right now? RFIS, REIS, RFIL, REIL, R.SGIS (as required) RFIS, REIS, RFIL, REIL, R.SGIS (as required) What is happening during the movement? What is happening during the movement? Is it Cing, Ping, ↑, ↓, PROD, ABOL, NE Is it Cing, Ping, ↑, ↓, PROD, ABOL, NE Change in ROM Change in ROM What happens after? What happens after? Is it Ced, Ped, B, W, NB, NW, NE Is it Ced, Ped, B, W, NB, NW, NE Maintained change in ROM Maintained change in ROM

15. Sustained posture When NE with repeated movements When NE with repeated movements Derangement that is very difficult to expose (stable) Derangement that is very difficult to expose (stable) When patient is too acute to perform repeated movements When patient is too acute to perform repeated movements With certain deformities (i.e. kyphotic Lsp) With certain deformities (i.e. kyphotic Lsp) To educate the patient, i.e. when you stay in this position, you worsen… To educate the patient, i.e. when you stay in this position, you worsen…

16. Red Flags Hx of cancer Hx of cancer Unexplained weight loss Unexplained weight loss Constant, progressive, non-mechanical pain, worse at rest Constant, progressive, non-mechanical pain, worse at rest Systemically unwell Systemically unwell Persisting severe restriction of lumbar flexion Persisting severe restriction of lumbar flexion Widespread neuro deficits Widespread neuro deficits History of significant trauma (i.e. fractures, dislocations) History of significant trauma (i.e. fractures, dislocations) No movement or position centralises, decreases or abolishes pain. No movement or position centralises, decreases or abolishes pain.

17. CORD SIGNS Upper Motor Neuron (above L2) Upper Motor Neuron (above L2) Bilateral / quadrilateral P&N Bilateral / quadrilateral P&N Bilateral / quadrilateral Weakness Bilateral / quadrilateral Weakness Csp: 4 limbs; Tsp: 2 limbs; Lsp: 2 limbs Csp: 4 limbs; Tsp: 2 limbs; Lsp: 2 limbs Hyper-reflexia Hyper-reflexia Increased sensation Increased sensation Spastic “key muscles” (i.e. Myotomes) Spastic “key muscles” (i.e. Myotomes) Positive Babinski / clonus Positive Babinski / clonus Ataxic / wide base gait Ataxic / wide base gait Fine coordination may be affected (i.e. writing, buttons, zippers) Fine coordination may be affected (i.e. writing, buttons, zippers) L’Hermitte’s sign (Csp flex: Positive for Csp if P&N 4 limbs; Positive for Tsp if 2 limbs) L’Hermitte’s sign (Csp flex: Positive for Csp if P&N 4 limbs; Positive for Tsp if 2 limbs)

18. CAUDA EQUINA Lower motor neuron (below L2) Lower motor neuron (below L2) Lsp: 2 limbs Lsp: 2 limbs Bladder & Bowel: Inability to control Bladder & Bowel: Inability to control Urinary incontinence Urinary incontinence Bladder Retention Bladder Retention Sphincter weakness/paralysis Sphincter weakness/paralysis Hypo-reflexia Hypo-reflexia Bilateral SLR +ve Bilateral SLR +ve Paresthesia/anesthesia perianal area, genitals, medial upper thighs (usually bilateral) Paresthesia/anesthesia perianal area, genitals, medial upper thighs (usually bilateral) Flaccid “key muscles” (i.e. myotomes) Flaccid “key muscles” (i.e. myotomes)

19. Laminectomy Laminectomy: Removal of bone &/or discal material causing neural impingement. Laminectomy: Removal of bone &/or discal material causing neural impingement. 4 Signs leading to laminectomy: 4 Signs leading to laminectomy: Bilateral leg symptoms Bilateral leg symptoms Perianal anesthesia Perianal anesthesia Urinary retention Urinary retention Loss of anal tone Loss of anal tone

20. Neuro Testing Key Muscles “Myotomes” Key Muscles “Myotomes” Dermatomes Dermatomes Reflexes Reflexes Neural tension (i.e. SLR, PKB) Neural tension (i.e. SLR, PKB)

21. Evaluation Forms Lumbar Evaluation Form at McKenzie Institute International Lumbar Evaluation Form at McKenzie Institute International Lumbar Evaluation Form at McKenzie Institute International Lumbar Evaluation Form at McKenzie Institute International

22. Education Most important treatment that can be done on day one Most important treatment that can be done on day one Essential to ensure patient motivation and compliance Essential to ensure patient motivation and compliance Anatomy review and explanation of forces on structures can be helpful Anatomy review and explanation of forces on structures can be helpful Need to implicate patient as much as possible Need to implicate patient as much as possible

23. Patient Techniques Prone on elbows or pillows Prone on elbows or pillows REIL REIL Shifted REIL / Roadkill Shifted REIL / Roadkill REIS / shifted REIS REIS / shifted REIS RFIL RFIL RFISit RFISit RFIS RFIS Unilateral RFIS / Sit / Lying Unilateral RFIS / Sit / Lying Shift @ wall Shift @ wall Flexion / Rotation Flexion / Rotation

24. Therapist Techniques REIL with PT O/P or belt REIL with PT O/P or belt Shift correction by PT Shift correction by PT Flexion / Rotation Flexion / Rotation Ext mobs Ext mobs Rotation mobs Rotation mobs

25. Myth Busters Most often, lumbar spine will respond to heat despite mild inflammatory responses Most often, lumbar spine will respond to heat despite mild inflammatory responses Lumbar rolls will not damage the spine if used for a prolonged period Lumbar rolls will not damage the spine if used for a prolonged period Lumbar braces are not a viable long-term solution to LBP Lumbar braces are not a viable long-term solution to LBP Traction is not a maintained relief and no research exists to suggest reduction Traction is not a maintained relief and no research exists to suggest reduction Transient / faint numbness or P&N is not normally considered peripheralization Transient / faint numbness or P&N is not normally considered peripheralization