1. Mechanical Treatment for the Cervical Spine

2. Introduction to McKenzie MDT
How McKenzie developed his initial concept
McKenzie courses and benefits to practice
Addresses weaknesses of our schooling
Great tool for new therapists to develop confidence and evaluation skills
Mainly patient generated forces
Promotes client independence
Success where many other approaches fail

3. Introduction to McKenzie MDT
Based on determining a directional preference and mechanical response to repeated movement
Seeks to determine structure(s) responsible for symptoms
Seeks to classify the problem based on its response to testing
Classification based on symptom location and positional / postural findings

4. Indications Nerve root problems
Mechanical neck pain (i.e. the pain varies with physical activity and / or over time)
Cervico-dorsal, scapular, shoulder and arm pain
+ / - neurological symptoms
Patient is generally well
Cervical headache

5. Contraindications for MDT
Serious spinal pathology
Cord Signs
Cancer
Infections
Fractures
Widespread neurological deficit
Non-mechanical neck pain
Caution : Vertebral artery / VBI – testing (5D’s)
Caution : RA, AS, Acute Whiplash, chronic steroid use (ligament laxity), pregnancy, Down’s Syndrome

6. Syndromes
Postural: Caused by deformation of soft tissues through excessive load (time)
Derangement: Damage to or displacement of annular tissue with or without nuclear displacement, or mechanical pain from soft tissues
Dysfunction: Chronic movement loss or adherence of nerve roots

7. Classification of Derangement
D1 – Central, symmetrical - 35%
D2 – Central, symmetrical (kyphotic deformity) - 3%
D3- Asymmetrical, above elbow – 39%
D4 – As per D3 with wry neck – 2%
D5 – Asymmetrical below elbow – 15%
D6 – As per D5 with deformity – 6%
D7 – Anterior derangement, symmetrical, possible “choking” feeling – 4%

8. Recent Changes
In recent years, classification has been shifted to clinical impression > movement response > symptom location
Example : Posterior lateral derangement, lateral responder, asymmetrical

9. Planes of Movement
Sagittal: Movements in the plane of flexion and extension, protrusion and retraction
Coronal: Movements in the plane of side flexion
Axial: Movements in the plane of rotation

10. Definitions in MDT
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
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

11. Definitions (con’t) Increase: Augmentation of pain
Decrease: Reduction of pain
No Worse (NW): Increase 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
Better: Maintained decrease in symptoms or centralization
Produce: Creation of a pain that was previously not present
Abolish: Disappearance of a pain that was previously present

12. Definitions (con’t)
Peripheralizing (Ping): Peripheralization of symptoms DURING repeated testing
Peripheralized (Ped): Peripheralization of symptoms maintained POST repeated testing
Centralizing (Cing): Centralization of symptoms DURING repeated testing
Centralized (Ced): Centralization of symptoms maintained POST repeated testing
These definitions apply most reliably to PAIN
Current nomenclature refers mainly to symptoms post repeated testing
Changes are named in comparison to prior symptoms, not initial symptoms

13. Disc Forces
Most frequently, compressive forces are applied to the anterior annulus
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
Example: sitting

14. Anatomy

15. Deformities Wry Neck Forward head Posture
C0-1-2 Malposition can contribute to “Cervical Headache”
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

16. Wry Neck

17. Forward Head Posture

18. Postural Issues

19. Wry Neck There is a clear tilt of the head to one side
Often below the age of 15, due mainly to underdeveloped unco-vertebral joints
Onset of wry neck came on with neck pain
Patient is often unable to self-correct
Correction can cause centralization or worsening of peripheral symptoms

20. Red Flags Hx of cancer Unexplained weight loss
Constant, progressive, non-mechanical pain, worse at rest or at night
Systemically unwell
Persisting severe restriction of cervical movement (Acute MVA)
Widespread neuro deficits
History of significant trauma (i.e. fractures, dislocations)
No movement or position centralises, decreases or abolishes pain.
5 D’s – Who knows them all?

21. The 5 D’s Dysphagia Disarthria Drop Attack Diplopia Dizziness
Other concerns – nystagmus, nausea, tinnitus

22. CORD SIGNS Upper Motor Neuron Bilateral / quadrilateral P&N
Bilateral / quadrilateral Weakness
Csp: 4 limbs; Tsp: 2 limbs; Lsp: 2 limbs
Hyper-reflexia
Increased sensation
Spastic “key muscles” (i.e. Myotomes)
Positive Babinski / clonus
Ataxic / wide base gait
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 lower limbs)
Extremely rare, but we need to be vigilant – NO EVAL

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

24. Repeated movements
Always take their baseline, i.e. What are you feeling right now?
Protrusion, Retraction, Flexion, Retraction/Extension (all repeated as required)
Repeated Side Flexion or Rotation as needed
What is happening during the movement?
Is it Cing, Ping, ↑, ↓, PROD, ABOL, NE
Change in ROM
What happens after?
Is it Ced, Ped, B, W, NB, NW, NE
Maintained change in ROM
May need to send client home with a repeated movement in order to evaluate its effect on symptoms
Watch for loss of ROM in opposing direction or temporary pain relief with loss of ROM

25. History taking
A good history allows the therapist to guide the evaluation towards helpful movements quickly
As an example: “I have severe arm pain when I read in bed with a pillow behind my head” – client has already told you flexion/protrusion peripheralizes the pain
AM stiffness may require additional questioning on sleeping habits/position – Night Roll
Carefully evaluate client’s activities and daily postures
Use posture as a test (sit unsupported)

26. Sustained posture When NE with repeated movements
Derangement that is very difficult to expose (stable)
When patient is too acute to perform repeated movements
With certain deformities (i.e. wry neck)
May require time +++
To educate the patient, i.e. when you stay in this position, you worsen…

27. Neuro Testing Key Muscles “Myotomes” Dermatomes Reflexes
Neural tension (i.e. NDT)

28. Dermatomes

29. Education Most important treatment that can be done on day one
Essential to ensure patient motivation and compliance
Anatomy review and explanation of forces on structures can be helpful
Need to implicate patient as much as possible
Postural correction +++
Sleeping position / pillow / work station
Need to see client soon after eval for follow-up (acute 1-3 days)

30. Key Factors ROM testing prior to repeated testing (baselines)
“Scared Stiff”
Correct for protrusion pre-testing
Exhaust Sagittal before going lateral, but get back to Sagittal
Get to end of ROM before progression (what is max ROM today, may not be true end of ROM)
Goal is to progress into WB exercise
Maintenance (pain was their motivator)
Recovery of Function (no reproduction of pain, maintain ROM)
Postural exercises / strengthening as prophylaxis and maintenance
Benefits of our other services for prevention / maintenance

31. Patient Techniques (Repeated)
Sagittal Techniques
Retraction in Sitting (WB)
Retraction / Extension (WB)
Retraction in Supine
Retraction / Extension in Supine
Flexion
Retraction / Flexion
(Belts/towel or hand support can be used – “heavy head”)
Lateral Techniques
Retraction with Side Bending (WB)
Retraction with Rotation (WB)
Retraction with SB / Rot (WB)

32. Therapist Techniques Traction / Retraction
Traction / Retraction / Extension
Retraction mob (supine or sitting)
Extension mob (prone)
Rotation mob (supine or sitting)
Side bending mob (supine or sitting)
Upper Cervical Flexion Mob (supine)
Lower Cervical Flexion Mob (supine)

33. Additional Techniques
Cervical Traction
Soft Tissue Mobilization
Suboccipital Release
Elevated / Depressed First Rib
Thoracic Traction
Thoracic Extension
Frontal Lift for Headache
Muscle Energy (future IPD)

34. Additional Concerns Posture +++ and work station Lumbar support
Scapular Control
Stress and fatigue
Lung or breathing issues
Poor technique at home or at work
Thoracic pain above T7 is often neck related

35. Myth Busters
Most often, cervical spine will respond to heat despite mild inflammatory responses
Lumbar rolls will not damage the spine if used for a prolonged period
Neck braces are not a viable long-term solution to any condition – they actually promote protrusion!
Traction is not a maintained relief and no research exists to suggest reduction
Transient / faint numbness or P&N is not normally considered peripheralization (release phenomenon

36. Questions?
THANK YOU!!