the mckenzie method an overview mechanical diagnosis & therapy of the spine: a dynamic system of...

The McKenzie MethodThe McKenzie Method

An OverviewAn OverviewMechanical Diagnosis & Therapy of the Mechanical Diagnosis & Therapy of the

Spine:Spine:A Dynamic System of Examination, A Dynamic System of Examination,

Diagnosis, Intervention and PreventionDiagnosis, Intervention and Prevention

PART IIPART II

ObjectivesObjectives

Evaluation of Clinical ExamEvaluation of Clinical Exam

PrognosisPrognosis

InterventionsInterventions Treatment PrinciplesTreatment Principles Force progressionForce progression

ReEval/Intervention ProgressionReEval/Intervention Progression

Characteristics of Three Characteristics of Three SyndromesSyndromes

See handoutSee handout

Derangement SyndromesDerangement Syndromes

DerangementDerangement Clinical PresentationClinical Presentation

11 Central or symmetrical pain across L4/5Central or symmetrical pain across L4/5

Rarely buttock or thighRarely buttock or thigh

NO DEFORMITYNO DEFORMITY

22 Central or symmetrical pain across L4/5Central or symmetrical pain across L4/5

W/ or W/O buttock or thigh painW/ or W/O buttock or thigh pain

LUMBAR KYPHOSISLUMBAR KYPHOSIS



33 Unilat or Asymmetrical pain across L4/5Unilat or Asymmetrical pain across L4/5

w/ or w/o pain to buttock &/or thighw/ or w/o pain to buttock &/or thigh




RELAVENT LATERAL SHIFTRELAVENT LATERAL SHIFT





W/ Leg pain extending below kneeW/ Leg pain extending below knee




W/ Leg pain extending below kneeW/ Leg pain extending below knee

RELAVENT LATERAL SHIFTRELAVENT LATERAL SHIFT





INCREASED LUMBAR LORDOSISINCREASED LUMBAR LORDOSIS

PrognosisPrognosis

Posture Posture – posture correction– posture correction

Dysfunction - Dysfunction - time factortime factor

Derangement - Derangement - Centralizer?Centralizer?

Long A; The centralization phenomenon: its usefulness as a predictor Long A; The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain, a pilot of outcome in conservative treatment of chronic low back pain, a pilot study. Spine; 20(23):2513-2521, 1995.study. Spine; 20(23):2513-2521, 1995.

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

Force ProgressionForce Progression

Patient generatedPatient generated

Patient generated w/ self OPPatient generated w/ self OP

Patient generated w/ therapist OPPatient generated w/ therapist OP

MobilizationMobilization

ManipulationManipulation

Intervention PrinciplesIntervention PrinciplesLumbarLumbar

Extension principleExtension principle

Lateral principleLateral principle

Flexion principleFlexion principle

Extension Principle - StaticExtension Principle - Static

ProneProne

Prone on elbowsProne on elbows

Sustained extensionSustained extension

Other: Other: Posture CorrectionPosture Correction

Extension Principle - DynamicExtension Principle - Dynamic

EILEIL

EIL w/ self OPEIL w/ self OP

EIL w/ therapist OPEIL w/ therapist OP

MobilizationMobilization

ManipulationManipulation

EISEIS

Other:Other: Slouch/OvercorrectSlouch/Overcorrect

Lateral PrincipleLateral Principle

SGISSGIS

Manual Correction of Lateral ShiftManual Correction of Lateral Shift

Flexion PrincipleFlexion Principle

FlLFlL

FISittingFISitting

FISFIS

Intervention PrinciplesIntervention PrinciplesCervicalCervical

Extension principleExtension principle

Lateral principleLateral principle

Flexion principleFlexion principle

DynamicDynamic

RetRet

Ret w/ self OPRet w/ self OP

Ret w/ therapist OPRet w/ therapist OP

Ret MobilizationRet Mobilization

Ret-ExtRet-Ext

Ret-Ext w/ rotationRet-Ext w/ rotation

Ext mobilization proneExt mobilization prone

Lateral PrincipleLateral Principle

Lat FlexLat FlexLat Flex w/ pt OPLat Flex w/ pt OPLat Flex Mobilization sitting/lyingLat Flex Mobilization sitting/lyingLat Flex ManipulationLat Flex Manipulation

RotRotRot w/ pt OPRot w/ pt OPRot MobilizationRot MobilizationRot ManipulationRot Manipulation

Flexion PrincipleFlexion Principle

Flex w/ pt OPFlex w/ pt OP

Flex mobilizationFlex mobilization

Flex w/ rotation mobilizationFlex w/ rotation mobilization

Exercise PrescriptionExercise Prescription

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

Long A, Donelson R, Fung T. Does it matter which exercise? A Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercises for low back pain. Spine; Dec randomized control trial of exercises for low back pain. Spine; Dec 1;29(23):2593-2602, 2004.1;29(23):2593-2602, 2004.

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

Reevaluation/Treatment Reevaluation/Treatment ProgressionProgression

Confirm, reject or modify the provisional mechanical Confirm, reject or modify the provisional mechanical diagnosisdiagnosis

Determine the need for progressions/regression of forceDetermine the need for progressions/regression of force

Determine when it is appropriate and how to initiate Determine when it is appropriate and how to initiate recovery of function/reactivationrecovery of function/reactivation

Determine any worsening or progression of the disorder Determine any worsening or progression of the disorder which prompts the need to contact the referring medical which prompts the need to contact the referring medical physicianphysician

Determine the need and timing for discharge planningDetermine the need and timing for discharge planning

Develop the patient's self management and problem-Develop the patient's self management and problem-solving skills essential for long-term, prophylactic benefit.solving skills essential for long-term, prophylactic benefit.

Discharge Planning and Discharge Planning and Prophylactic ConceptsProphylactic Concepts

Provision of education Provision of education

Encouragement of patients to ‘problem solve' their own Encouragement of patients to ‘problem solve' their own difficulties should be part of treatment. difficulties should be part of treatment.

Supervision of patients must, in the light of the Supervision of patients must, in the light of the epidemiology of back pain, involve the nurturing of self-epidemiology of back pain, involve the nurturing of self-management strategies. management strategies.

This should be done from day one and those strategies This should be done from day one and those strategies will need to be individualized according to the patient. will need to be individualized according to the patient.

ReferencesReferencesDonelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of 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. lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine; 22(10):1115-22, 1997.Spine; 22(10):1115-22, 1997.Long A; The centralization phenomenon: its usefulness as a predictor of outcome in 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-conservative treatment of chronic low back pain, a pilot study. Spine; 20(23):2513-2521, 1995.2521, 1995.Long A, Donelson R, Fung T; Does it matter which exercise? A randomized control 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.trial of exercises for low back pain. Spine; Dec 1;29(23):2593-2602, 2004.McKenzie Course notes A, B, C, D, EMcKenzie Course notes A, B, C, D, EMcKenzie RA 1990. The lumbar spine: mechanical diagnosis and therapy. Spinal McKenzie RA 1990. The lumbar spine: mechanical diagnosis and therapy. Spinal Publications, New Zealand.Publications, New Zealand.McKenzie RA 1990. The cervical and thoracic spine: mechanical diagnosis and McKenzie RA 1990. The cervical and thoracic spine: mechanical diagnosis and therapy. Spinal Publications, New Zealandtherapy. Spinal Publications, New ZealandMcKenzieMDT.org McKenzieMDT.org Petty NJ 2006. Neuromusculoskeletal examination and assessment: a handbook for Petty NJ 2006. Neuromusculoskeletal examination and assessment: a handbook for therapist, 3therapist, 3rdrd ed. Elsevier Limited. ed. Elsevier Limited.Spitzer WO. Scientific approach to the assessment and management of activity-Spitzer WO. Scientific approach to the assessment and management of activity-related spinal disorders: A mono-graph for clinicians. Report of the Quebec Task related spinal disorders: A mono-graph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59.Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59.

the mckenzie method an overview mechanical diagnosis & therapy of the spine: a dynamic system of...

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