mechanical diagnosis and therapy of the cervical spine the mckenzie … · 2006-10-09 · therapy®...
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Mechanical Diagnosis And Mechanical Diagnosis And TherapyTherapy®® of the Cervical Spineof the Cervical Spine
The McKenzie MethodThe McKenzie Method®®
Allan Besselink, PT, Allan Besselink, PT, Dip.MDTDip.MDTSmart Sport InternationalSmart Sport International™™
Austin, TexasAustin, Texas
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BackgroundBackground
Physical TherapistPhysical TherapistQueenQueen’’s University 1988s University 1988
McKenzie TrainingMcKenzie TrainingDiploma Program 1998Diploma Program 1998Editor, Journal of MDTEditor, Journal of MDT®®
Certified CoachCertified CoachUSA TriathlonUSA TriathlonUSA Track and FieldUSA Track and Field
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Austin, Texas Austin, Texas
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Smart Sport InternationalSmart Sport International™™
Sports Science Sports Science Solutions for Solutions for
Rehabilitation and Rehabilitation and TrainingTraining™™
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ItIt’’s All About s All About The Journey, The Journey, Not The Not The Destination Destination ……
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““McKenzieMcKenzie””
The word conjures up many things to The word conjures up many things to many people many people …… depending on your depending on your perspective and context perspective and context ……
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The McKenzie MethodThe McKenzie Method®®
Robin McKenzie Robin McKenzie ––New ZealandNew ZealandThree texts:Three texts:
Lumbar spine 1981; Lumbar spine 1981; 20032003Cervical/Thoracic spine Cervical/Thoracic spine 19901990Extremities 2000Extremities 2000
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The McKenzie MethodThe McKenzie Method®®
Myths:Myths:ItIt’’s not s not ……..
…… Only the lumbar spine Only the lumbar spine ………… ““McKenzie extension exercisesMcKenzie extension exercises”” ………… A treatment protocol (i.e. A treatment protocol (i.e. ““what do I what do I
do if the McKenzie protocol do if the McKenzie protocol doesndoesn’’t work?t work?””))
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The McKenzie MethodThe McKenzie Method®®
Mechanical Diagnosis Mechanical Diagnosis and Therapyand Therapy®®
A Dynamic System of Assessment, Diagnosis, Treatment and Prevention
a process of thinking a process of thinking and clinical reasoningand clinical reasoning
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Mechanical Diagnosis And Mechanical Diagnosis And TherapyTherapy®®
Mechanical Assessment And DiagnosisMechanical Assessment And Diagnosis
Logical, wellLogical, well--defined algorithmdefined algorithm
Consistent, standardized terminologyConsistent, standardized terminology
Reproducible and reliableReproducible and reliable
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Mechanical Diagnosis And Mechanical Diagnosis And TherapyTherapy®®
Mechanical Assessment And DiagnosisMechanical Assessment And Diagnosis
CostCost--effectiveeffective
Identifies responders AND nonIdentifies responders AND non--responders, responders, mechanical and nonmechanical and non--mechanical presentationsmechanical presentations
Applicable to contact and nonApplicable to contact and non--contact injuriescontact injuries
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Mechanical Diagnosis And Mechanical Diagnosis And TherapyTherapy®®
Treatment And PreventionTreatment And Prevention
Active patient treatment philosophyActive patient treatment philosophy
Encourages patients to be involved in the Encourages patients to be involved in the management of their own treatmentmanagement of their own treatment
Most patients can successfully treat themselves Most patients can successfully treat themselves when provided the necessary knowledge and toolswhen provided the necessary knowledge and tools
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But first But first ……
…… some basic concepts would be some basic concepts would be appropriate appropriate ……..
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PainPain
ChemicalChemical
MechanicalMechanical
Consistent behaviorsConsistent behaviors
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Chemical PainChemical Pain
Sufficient chemical concentration to Sufficient chemical concentration to activate activate nociceptorsnociceptorsCauses can include:Causes can include:
TraumaTraumaAcute Inflammatory ResponseAcute Inflammatory Response
Constant symptoms Constant symptoms –– ““car stereocar stereo””
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Mechanical PainMechanical Pain
Mechanical deformation of tissueMechanical deformation of tissueSustained loadingSustained loadingRepetitive loadingRepetitive loading
Constant or intermittent symptomsConstant or intermittent symptomsNo pathology need exist (No pathology need exist (““bent fingerbent finger””))Most spinal pain is mechanical in natureMost spinal pain is mechanical in nature
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CentralizationCentralizationFirst described by McKenzie in his lumbar First described by McKenzie in his lumbar spine text in 1981 spine text in 1981 …… first experience first experience clinically in 1956clinically in 1956Diagnostic and prognostic indicatorDiagnostic and prognostic indicator
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The Cervical SpineThe Cervical Spine
ItIt’’s not just a s not just a ““little lumbar spinelittle lumbar spine””Form Follows FunctionForm Follows Function
Vertebral body shapeVertebral body shapeFacet joint orientationFacet joint orientationIntervertebralIntervertebral disc constructiondisc construction
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The goal is to understand how this The goal is to understand how this problem behaves mechanically problem behaves mechanically ……
…… using a wellusing a well--defined algorithm, classify defined algorithm, classify the problem the problem ……
…… and use that classification to guide and use that classification to guide treatment.treatment.
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Athlete InterviewAthlete Interview
HistoryHistory
Current symptomsCurrent symptomsOnset and nature of symptomsOnset and nature of symptomsBetter/WorseBetter/WorseRed Flags Red Flags –– contraindications to mechanical contraindications to mechanical therapiestherapies
Establish a hypothetical mechanical diagnosisEstablish a hypothetical mechanical diagnosis
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Physical ExaminationPhysical Examination
PosturePostureNeurological examinationNeurological examinationMovement lossMovement lossMechanical loading strategiesMechanical loading strategies
Repeated movementsRepeated movementsStatic testsStatic tests
Other testsOther tests
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Mechanical Loading StrategiesMechanical Loading Strategies
Mechanical Loading Strategies = applied Mechanical Loading Strategies = applied mechanical forcesmechanical forces
Repeated movementsRepeated movements
Sustained posturesSustained postures
SagittalSagittal plane before frontal planeplane before frontal plane
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Repeated MovementsRepeated Movements
Repeated end range movementsRepeated end range movements
ProtrusionProtrusionRetractionRetractionRetraction ExtensionRetraction Extension
FlexionFlexionSide bendingSide bendingRotationRotation
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Repeated MovementsRepeated Movements
ProtrusionProtrusionUpper cervical Upper cervical end range end range extensionextensionLower cervical Lower cervical midrange midrange flexionflexion
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Repeated MovementsRepeated Movements
RetractionRetractionUpper cervical Upper cervical end range end range flexionflexionLower cervical Lower cervical midrange midrange extensionextension
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Repeated MovementsRepeated Movements
Retraction Retraction Extension Extension
Upper cervical Upper cervical end range end range extensionextensionLower cervical Lower cervical end range end range extensionextension
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Sustained PosturesSustained Postures
Static end range loadingStatic end range loading
ProtrusionProtrusionRetractionRetractionFlexionFlexionExtensionExtension
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Sustained PosturesSustained Postures
Protrusion Retraction
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AssessmentAssessment
Before the application of mechanical loads Before the application of mechanical loads -- establish baselinesestablish baselines
Symptoms/Mechanics/FunctionSymptoms/Mechanics/Function
During the application of mechanical loadsDuring the application of mechanical loads
After the application of mechanical loads After the application of mechanical loads ––assess response and review baselinesassess response and review baselines
Symptoms/Mechanics/FunctionSymptoms/Mechanics/Function
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The goal is to understand how this The goal is to understand how this problem behaves mechanically problem behaves mechanically ……
…… using a wellusing a well--defined algorithm, classify defined algorithm, classify the problem the problem ……
…… and use that classification to guide and use that classification to guide treatment.treatment.
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Mechanical Diagnosis and Mechanical Diagnosis and ClassificationClassification
Posture SyndromePosture SyndromeEnd range stresses on normal structuresEnd range stresses on normal structures
Derangement SyndromeDerangement SyndromeAnatomical disruption or displacement within the Anatomical disruption or displacement within the motion segmentmotion segmentCentralization/Centralization/peripheralizationperipheralization
Dysfunction SyndromeDysfunction SyndromeEnd range stresses on shortened structuresEnd range stresses on shortened structures
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Relevant Features Relevant Features -- PosturePostureSymptomsSymptoms
Movement LossMovement Loss
Effect of Loading Effect of Loading StrategiesStrategies
DescriptionDescription
LocalLocal
NoneNone
Symptoms reproduced Symptoms reproduced with static loading onlywith static loading only
Physical exam normalPhysical exam normal
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Relevant Features Relevant Features -- DerangementDerangementSymptomsSymptoms
Movement LossMovement Loss
Effect of Loading Effect of Loading StrategiesStrategies
DescriptionDescription
Local +/Local +/-- PeripheralPeripheral
YesYes
Lasting changeLasting changeDecreaseDecreaseAbolishAbolishCentralizeCentralize
““The barking dogThe barking dog””
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Relevant Features Relevant Features -- DysfunctionDysfunctionSymptomsSymptoms
Movement LossMovement Loss
Effect of Loading Effect of Loading StrategiesStrategies
DescriptionDescription
Local +/Local +/-- PeripheralPeripheral
YesYes
No lasting change No lasting change ––pain only at limited pain only at limited end rangeend range
““The grandfather The grandfather clockclock””
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AlgorithmAlgorithm
HistoryHistoryEstablish a hypothetical mechanical diagnosisEstablish a hypothetical mechanical diagnosis
Physical ExaminationPhysical ExaminationEstablish a mechanical diagnosisEstablish a mechanical diagnosis
RED FLAGSRED FLAGSContraindications to mechanical therapiesContraindications to mechanical therapies
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AlgorithmAlgorithm
Day 1 classification:Day 1 classification:Loading strategies decrease, abolish or Loading strategies decrease, abolish or centralisecentralisesymptoms symptoms –– DERANGEMENT (reducible)DERANGEMENT (reducible)No loading strategies decrease, abolish or No loading strategies decrease, abolish or centralisecentralise symptoms symptoms –– DERANGEMENT DERANGEMENT (irreducible)(irreducible)Pain ONLY at limited end range Pain ONLY at limited end range –– DYSFUNCTIONDYSFUNCTIONPain ONLY on static loading with physical exam Pain ONLY on static loading with physical exam normal normal –– POSTUREPOSTUREOTHEROTHER
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AlgorithmAlgorithm
Classification confirmed within 3 to 5 visitsClassification confirmed within 3 to 5 visitsIf failure to enter a spinal mechanical If failure to enter a spinal mechanical classification classification –– consider other optionsconsider other options
Lateral canal Lateral canal stenosisstenosisCentral canal Central canal stenosisstenosisMechanically inconclusiveMechanically inconclusiveShoulderShoulderChronic pain statesChronic pain statesInflammatoryInflammatory
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Classification SummaryClassification Summary
SymptomsSymptoms
Movement LossMovement Loss
Effect of Effect of Loading Loading StrategiesStrategies
ModelModel
PosturePostureLocalLocal
NoNo
Pain on staticPain on staticloading onlyloading only
End rangeEnd rangestresses onstresses onnormalnormalstructuresstructures
DerangementDerangementLocal +/Local +/--PeripheralPeripheral
YesYes
DecreaseDecreaseAbolishAbolishCentralizeCentralize
AnatomicalAnatomicaldisruption ordisruption ordisplacementdisplacementwithin motionwithin motionsegmentsegment
DysfunctionDysfunctionLocal +/Local +/--PeripheralPeripheral
YesYes
Produced only atProduced only atlimited end rangelimited end range
End rangeEnd rangestresses onstresses onshortenedshortenedstructuresstructures
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The Numbers GameThe Numbers Game
The largest percentage of The largest percentage of clinical cases will beclinical cases will be
DerangementsDerangements
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Clinical ExamplesClinical Examples
CyclingCyclingTriathlonTriathlon
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Case Study #1 Case Study #1 -- CyclingCyclingHistoryHistory
35 year old 35 year old triathletetriathlete with with constant right cervical and constant right cervical and suprascapularsuprascapular painpain
Onset during a long training Onset during a long training rideride
Worse with cycling, sitting, Worse with cycling, sitting, turning to the right; Better turning to the right; Better when supine lyingwhen supine lying
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– extension extension and right and right sidebendingsidebending
Repeated movements Repeated movements ––symptoms decrease/centralize symptoms decrease/centralize and remain better after and remain better after retraction and retraction retraction and retraction extension; movement improves extension; movement improves
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Case Study #2 Case Study #2 -- CyclingCyclingHistoryHistory
35 year old 35 year old triathletetriathlete with with intermittent right cervical and intermittent right cervical and suprascapularsuprascapular painpain
Onset during a long training Onset during a long training rideride
Worse with cycling only (> 1 Worse with cycling only (> 1 hour)hour)
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– nilnil
Repeated movements Repeated movements –– no no effecteffect
Symptoms reproduced with Symptoms reproduced with static positioning in aero static positioning in aero position on bike only, no worse position on bike only, no worse after changing positionafter changing position
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Clinical ExamplesClinical Examples
Football Football
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Case Study #3 Case Study #3 -- FootballFootballHistoryHistory
20 year old offensive lineman 20 year old offensive lineman with intermittent right cervical, with intermittent right cervical, shoulder and arm painshoulder and arm pain
Onset during a scrimmage Onset during a scrimmage ––no specific mechanism that no specific mechanism that player remembersplayer remembers
Worse with sitting, reading, Worse with sitting, reading, turning to the right; Better turning to the right; Better when supine lyingwhen supine lying
No dizziness, tinnitus, No dizziness, tinnitus, headacheheadache
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– flexion, flexion, extension, right rotation and extension, right rotation and right right sidebendingsidebending
Repeated movements Repeated movements ––symptoms decrease/centralize symptoms decrease/centralize and remain better after and remain better after retraction and retraction retraction and retraction extension; movement improves extension; movement improves in all planesin all planes
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Case Study #4 Case Study #4 -- FootballFootballHistoryHistory
20 year old offensive lineman 20 year old offensive lineman with intermittent right cervical, with intermittent right cervical, shoulder and arm painshoulder and arm pain
Onset during a scrimmage 2 Onset during a scrimmage 2 years ago years ago –– no specific no specific mechanism that player mechanism that player remembersremembers
Does not report being better or Does not report being better or worse with any specific worse with any specific activitiesactivities
No dizziness, tinnitus, No dizziness, tinnitus, headacheheadache
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– flexion and flexion and left left sidebendingsidebending
Repeated movements Repeated movements ––symptoms reproduced with symptoms reproduced with flexion and left flexion and left sidebendingsidebendingand do not remain worse and do not remain worse afterwards; no change in afterwards; no change in movementmovement
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The goal is to understand how this The goal is to understand how this problem behaves mechanically problem behaves mechanically ……
…… using a wellusing a well--defined algorithm, classify defined algorithm, classify the problem based on mutually exclusive the problem based on mutually exclusive criteria criteria ……
…… and use that classification to guide and use that classification to guide treatment.treatment.
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TreatmentTreatment
““Just as the Three RJust as the Three R’’s s –– ReadinReadin’’, , RitinRitin’’ and and ‘‘RithmeticRithmetic –– were the basics of primary were the basics of primary education education ……
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TreatmentTreatment…… so are the three Rso are the three R’’s in the treatment s in the treatment
of musculoskeletal conditions, of musculoskeletal conditions, ““Reeducation Reeducation of posture, of posture, RemodelingRemodelingof dysfunction, and of dysfunction, and ReductionReduction of of derangementderangement””, the basics of therapy , the basics of therapy for mechanical spinal disorders.for mechanical spinal disorders.””
Robin McKenzie, 1990Robin McKenzie, 1990
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SelfSelf--Treatment ConceptTreatment Concept
““Give a man a fishGive a man a fishand you feed him for a day. and you feed him for a day. Teach a man to fishTeach a man to fishand you feed him for a lifetime.and you feed him for a lifetime.””
Chinese ProverbChinese Proverb
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SelfSelf--Treatment ConceptTreatment Concept
““Treat Your Own Treat Your Own BackBack””““Treat Your Own Treat Your Own NeckNeck””
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TreatmentTreatment
ReeducationReeducation
ReductionReduction
RemodelingRemodeling
Posture
Yes
No
No
Derangement
Yes
Yes
No
Dysfunction
Yes
No
Yes
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TreatmentTreatment
Reeducation of postureReeducation of posture
Maintenance of Maintenance of lordosislordosis (static; dynamic)(static; dynamic)
Daily function (i.e. sitting)Daily function (i.e. sitting)
SportSport--specificity specificity -- knowledge of biomechanics of knowledge of biomechanics of sport techniquesport technique
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TreatmentTreatment
Remodeling of DysfunctionRemodeling of Dysfunction
Shortened tissue Shortened tissue –– must be taken to end range to must be taken to end range to remodelremodel
Direction that reproduces symptomsDirection that reproduces symptoms
Cyclical loading Cyclical loading vsvs sustained loading (creep)sustained loading (creep)
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TreatmentTreatment
Reduction of DerangementReduction of Derangement
““directional preferencedirectional preference””
Mechanical loading strategies that cause Mechanical loading strategies that cause symptoms and mechanics to remain bettersymptoms and mechanics to remain better
Temporary avoidance of mechanical loading Temporary avoidance of mechanical loading strategies that cause symptoms and mechanics to strategies that cause symptoms and mechanics to remain worseremain worse
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TreatmentTreatment
Reduction of DerangementReduction of Derangement
PatientPatient--generated forces before therapist generated forces before therapist generated forces are appliedgenerated forces are applied
70% of patients will be able to successfully self70% of patients will be able to successfully self--treat without adding therapisttreat without adding therapist--generated forcesgenerated forces
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Case Study #1 Case Study #1 -- CyclingCyclingHistoryHistory
35 year old 35 year old triathletetriathlete with with constant right cervical and constant right cervical and suprascapularsuprascapular painpain
Onset during a long training Onset during a long training rideride
Worse with cycling, sitting, Worse with cycling, sitting, turning to the right; Better turning to the right; Better when supine lyingwhen supine lying
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– extension extension and right and right sidebendingsidebending
Repeated movements Repeated movements ––symptoms decrease/centralize symptoms decrease/centralize and remain better after and remain better after retraction and retraction retraction and retraction extension; movement improves extension; movement improves
Derangement Syndrome
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Case Study #2 Case Study #2 -- CyclingCyclingHistoryHistory
35 year old 35 year old triathletetriathlete with with intermittent right cervical and intermittent right cervical and suprascapularsuprascapular painpain
Onset during a long training Onset during a long training rideride
Worse with cycling only (> 1 Worse with cycling only (> 1 hour)hour)
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– nilnil
Repeated movements Repeated movements –– no no effecteffect
Symptoms reproduced with Symptoms reproduced with static positioning in aero static positioning in aero position on bike only, no worse position on bike only, no worse after changing positionafter changing position
Posture Syndrome
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Case Study #3 Case Study #3 -- FootballFootballHistoryHistory
20 year old offensive lineman 20 year old offensive lineman with intermittent right cervical, with intermittent right cervical, shoulder and arm painshoulder and arm pain
Onset during a scrimmage Onset during a scrimmage ––no specific mechanism that no specific mechanism that player remembersplayer remembers
Worse with sitting, reading, Worse with sitting, reading, turning to the right; Better turning to the right; Better when supine lyingwhen supine lying
No dizziness, tinnitus, No dizziness, tinnitus, headacheheadache
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– flexion, flexion, extension, right rotation and extension, right rotation and right right sidebendingsidebending
Repeated movements Repeated movements ––symptoms decrease/centralize symptoms decrease/centralize and remain better after and remain better after retraction and retraction retraction and retraction extension; movement improves extension; movement improves in all planesin all planes
Derangement Syndrome
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Case Study #4 Case Study #4 -- FootballFootballHistoryHistory
20 year old offensive lineman 20 year old offensive lineman with intermittent right cervical, with intermittent right cervical, shoulder and arm painshoulder and arm pain
Onset during a scrimmage 2 Onset during a scrimmage 2 years ago years ago –– no specific no specific mechanism that player mechanism that player remembersremembers
Does not report being better or Does not report being better or worse with any specific worse with any specific activitiesactivities
No dizziness, tinnitus, No dizziness, tinnitus, headacheheadache
Physical ExaminationPhysical ExaminationMovement loss Movement loss –– flexion and flexion and left left sidebendingsidebending
Repeated movements Repeated movements ––symptoms reproduced with symptoms reproduced with flexion and left flexion and left sidebendingsidebendingand do not remain worse and do not remain worse afterwards; no change in afterwards; no change in movementmovement
Dysfunction Syndrome
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PreventionPrevention
Minimize recurrence Minimize recurrence -- TYONTYON
Activities of Daily LivingActivities of Daily Living
Sport technique/biomechanicsSport technique/biomechanics
Rapid management if symptoms do recurRapid management if symptoms do recur
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MDT MDT –– A Functional Approach To A Functional Approach To Sports InjuriesSports Injuries
Quickly and effectively differentiate Quickly and effectively differentiate responders and non respondersresponders and non responders
Athlete mindset Athlete mindset –– ““confrontersconfronters””
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MDT MDT –– A Functional Approach To A Functional Approach To Sports InjuriesSports Injuries
““Training sessionsTraining sessions”” consist of sustained consist of sustained postural loading and repetitive mechanical postural loading and repetitive mechanical loadingloading
MDT has a functional emphasis on MDT has a functional emphasis on mechanical loading strategies as part of mechanical loading strategies as part of itit’’s assessment algorithms assessment algorithm
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MDT MDT –– A Functional Approach To A Functional Approach To Sports InjuriesSports Injuries
Applicable to Applicable to all sports all sports injuries injuries ––contact and contact and nonnon--contact contact sportssports
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Challenges Of AnChallenges Of AnActive PopulationActive Population
““More must be betterMore must be better””
Athletes Athletes -- the opposite of the opposite of ““nonnon--organicorganic””!!
““Day affects playDay affects play””
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MDT In The Big PictureMDT In The Big Picture
““ItIt’’s not just for spines anymores not just for spines anymore””!!
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Continuing EducationContinuing Education
““a 40 minute a 40 minute adventureadventure”” –– strongly strongly suggest taking the suggest taking the courses!courses!Continuing Education Continuing Education programprogram–– Parts A, B, C, D, EParts A, B, C, D, E–– Credentialing Exam Credentialing Exam ––
competencycompetency–– DiplomaDiploma
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Where To Find Out MoreWhere To Find Out Morewww.mckenziemdt.orgwww.mckenziemdt.org
Great reference list Great reference list
[email protected]@mckenziemdt.org
315315--471471--76127612
McKenzie products and McKenzie products and assessment forms are assessment forms are available at available at www.optp.comwww.optp.com
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Today is brought to youToday is brought to youby the letter G by the letter G ……
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…… and the number and the number ……. 7 . 7 …… ☺☺