13/09/2012. Flexion. Extension

Transcription

1 The McKenzie Method in 2012 Mechanical Diagnosis & Therapy of the Spine & Extremities Outline Section 1 History and background Principles, evidence overview Section2 The natural history of musculoskeletal conditions The need for classification An outline of MDT classification Outline Section 3 Assessment overview Principles of management Section 4 Case examples Section 5 Summary History of MDT Robin McKenzie Mr. Smith The Key to Effective Therapy - Education - Self-Treatment Flexion Disc Model Extension 1

2 Mechanical Diagnosis and Therapy Not simply Extension exercises A unique, dynamic and comprehensive SYSTEM of assessment, classification, treatment and prevention for musculoskeletal disorders Exploring different loading strategies, postures and movements To classify and treat musculoskeletal conditions Reliable assessment A D T O Valid classifications Patient generated exercises Better outcomes when treatment matched to classification Reliability studies on MDT: Clare 05, 04 Dionne 06 Kilpikoski 02 Laslett 03 May 09 Petersen 03, 04 Seymour 03 Razmjou 00 Werneke pain response studies = good reliability Diagnosis Assessment 2

3 Centralization reliability (5 studies) Agreement 88% to 100% Kappa 0.51 to 0.96 Kappa 4 studies: > 0.70 Good to very good reliability. Level of training influenced the results Clinical subgroup studies: (observational, case series, prognostic, diagnostic validation, surveys) Alexander 92, Brotz 10, Bybee 05, Clare 07, Donelson 90, 91, 97, 90, Erhard 94, Fritz 07, George 05, Hefford 08, Karas 97, Kopp 86, Laslett 05, Long 95, 08, May 06, (Rasmussen 05), Skytte 05, Sufka 98, Young 03, Werneke 99, 04, 01, 03, 05, 08 Reviews: Aina & May 04, Berthelot 07, Hancook 07, May 06, 08, Udermann 04, Wetzel 05, May & Donelson 08, Machado 06, Peterson 99 Treatment Diagnosis 30+ centralization/dp publications Centralization was correlated with RCT s with subgroups MDT, Centralization, or directional preference. Good / excellent overall outcomes Greater reduction in pain intensity Higher return to work rate Greater functional improvement Brennan 06, Browder 07, Brotz 07, Delitto 93, Fritz 03, 07, Long 04, (Spratt 93) Outcomes Treatment Building evidence Section 2: Outcome Treatment Diagnosis Assessment The natural history of musculoskeletal conditions and the implications The need for classification An outline of MDT classification 3

4 Epidemiology & Natural History Common life experience Middle stages of life in spine Epidemiology & Natural History Persistent, episodic and recurrent symptoms common Progressively worse with age in extremities Clinical Implications? Long term management required Who is in the best position to achieve this? The patient Clinical Management Classification and Diagnosis - specific mechanical syndromes - related to mechanism of symptom generation and response Clinical Management Derangement The Three Syndromes Posture Dysfunction Classification and Diagnosis - Fourth classification utilized for specific identifiable pathologies: Other 4

5 13/09/2012 Derangement Derangement Internal derangement causes a disturbance in the normal resting position of the affected joint surfaces Varied clinical presentation Obstruction to movement Centralisation/ Peripheralisation (in spine) Possibility of acute deformities Ability to change rapidly Directional preference Directional Preference (DP) Mechanical loading examination including repeated movements Confirms classification of Derangement Identification of specific directional exercise Centralisation Process by which referred pain is sequentially abolished in response to therapeutic or diagnostic positions or movements Symptoms centralize or decrease or range increases Centralization prevalence (11 studies) Meta-analysis of 1,056 patients MetaCentralization occurred in 681 patients (64.5%) mean prevalence = 58% (31% to 87%) 731 acute or subsub-acute patients 70% 325 chronic patients 52% 5

6 Peripheralisation The opposite of centralisation When exercises or positions cause the spread of pain distally Dysfunction Mechanical deformation of structurally impaired soft tissues Contraction, scarring, adherence, adaptive shortening, or imperfect repair. Dysfunction Local pain (except nerve root adherence) Intermittent, chronic Movement loss with pain reproduced at end range Consistent end range response No rapid changes Extremity Dysfunction Articular: same criteria as spinal dysfunction Contractile: When structural changes affect contractile tissue Pain will be felt during resisted movements Or loading at any point through the range i.e. when the tissue contracts Pain may also be provoked when the tissue is stretched Postural Caused by mechanical deformation of soft tissues or vascular insufficiency arising from prolonged postural stresses affecting the articular or contractile structures Postural Local pain Intermittent Symptoms with sustained end range positioning No movement loss No effect with dynamic movement testing 6

7 Other Spinal other conditions Red flags Trauma Hip / Shoulder SIJ Stenosis Spondylolisthesis Chronic pain state Mechanically inconclusive MDT Assessment of the effect of loading and movement on symptoms Dysfunction Posture Other Directional Preference Derangement Centralization Specific Directional Exercise Alternate loading Strategy Section 3 Assessment overview Assessment process 1. History taking Principles of management 2. Physical Examination - Posture - Neurological - Movement Loss (Active, passive and resisted in extremities) 7

8 2. Physical Examination - Repeated Movements Examples of Test Movements in Lumbar Spine Flexion in standing Extension in standing Flexion in lying Extension in lying Side gliding in standing 8

9 Example of cervical test movements Example of knee test movements Retraction Extension Knee extension Knee flexion Definition of terms Symptomatic response Symptomatic Responses Mechanical Responses VAS 4/10 VAS 1/10 VAS 2/10 Mechanical Response 2. Physical Examination - Static tests - Other tests Establish Mechanical baseline Repeated movement Re-check Mechanical baseline 9

10 Assessment Process Principles of Management 3. Provisional Classification 4. Reassessment 5. Confirm Classification Spine Posture Correction Flexion Extension Lateral Principles of Management Extremities Management of Derangement Achieve reduction = Centralisation and / or abolishing of symptoms = Obstruction removed = Condition remains Better Maintain reduction Recover function Educate in Prophylaxis Management of Dysfunction Remodelling of tissue To regain the lost function (range) Produce symptoms at end range No pain, no gain Education and postural correction Prophylactic training Management of Postural Syndrome Education re: mechanism of pain production Train correction of postural habits Prophylactic instructions 10

11 Force progression Patient overpressure Patient generated Therapist overpressure Mobilization Manipulation Section 4 Spinal Case Study Extremity Case Study Independent Dependent McKenzie A 6 Spinal Case Study: 40 year old female with acute lumbar pain Date Feb 06 Name Daphne Sex M / F Address THE MCKENZIE INSTITUTE LUMBAR SPINE ASSESSMENT Telephone Date of Birth Age 40 Referral: GP / Orth / Self / Other Work: Mechanical Stresses Administration Sitting++ Leisure: Mechanical Stresses Stand/walk > sitting Functional Disability from present episode Cannot sit >2-3 mins Functional Disability score RM: 19/24, Fear Avoid:14/24 (act) VAS Score (0-10) 9/10 Clinical reasoning Possible Hypotheses? HISTORY Present Symptoms Present since Yesterday Improving / Unchanging / Worsening Commenced as a result of Doing the bow in yoga Or no apparent reason Symptoms at onset: back / thigh / leg Intermittent symptoms: back / thigh / leg Constant symptoms: back / thigh / leg walking Worse bending Sitting / rising standing lying Derangement Posture Dysfunction SIJ Chronic Pain Trauma Hip Spinal Stenosis Red Flag Spondylolisthesis Mechanically Inconclusive am / as the day progresses / pm when still / on the move other lying Better bending sitting standing walking am / as the day progresses / pm when still / on the move other Disturbed Sleep Yes / No Sleeping postures: prone / sup / side R / L Surface: firm / soft / sag Previous Episodes Year of first episode Previous History 1 episode 7 years ago, resolved in 1 month nothing since Previous Treatments none 11

12 SPECIFIC QUESTIONS Cough / Sneeze / Strain / +ve / -ve Bladder: normal / abnormal Gait: normal / abnormal Medications: Nil / NSAIDS / Analg / Steroids / Anticoag / Other Robaxacet, Ibuprofen General Health: Good / Fair / Poor Imaging: Yes / No Recent or major surgery: Yes / No Night Pain: Yes / No Accidents: Yes / No Unexplained weight loss: Yes / No Other: McKenzie Institute International 2005 What have we ruled out? X Chronic Pain Trauma Red Flags Posture Dysfunction Hip Spinal Stenosis What s left? POSTURE EXAMINATION Sitting: Good / Fair / Poor Standing: Good / Fair / Poor Lordosis: Red / Acc / Normal Lateral Shift: Right / Left / Nil Derangement SIJ Spondylolythesis Extension Flexion Lateral Mechanically Inconclusive Correction of Posture: Better / Worse / No effect Other Observations: NEUROLOGICAL Motor Deficit Sensory Deficit MOVEMENT LOSS Reflexes Dural Signs Maj Mod Min Nil Pain Flexion * LBP (No loss of lordosis) Extension * LBP Side Gliding R * LBP Side Gliding L * LBP Relevant: Yes / No TEST MOVEMENTS Describe effect on present pain During: produces, abolishes, increases, decreases, no effect, centralising, peripheralising. After: better, worse, no better, no worse, no effect, centralised, peripheralised. Mechanical Response Symptoms During Testing Symptoms After Testing No Rom Rom Effect Pretest symptoms standing: LBP FIS Rep FIS EIS Increase LBP Rep EIS Increase LBP W * Pretest symptoms lying: NIL FIL Produce LBP Rep FIL Produce LBP B in F EIL Produce LBP Rep EIL Produce LBP W In F If required pretest symptoms: SGIS R Rep SGIS - R SGIS - L Rep SGIS- L Provisional Classification Derangement Flexion Principle STATIC TESTS Sitting slouched Standing slouched Lying prone in extension Sitting erect Standing erect Long sitting OTHER TESTS 12

13 Principle of Management Flexion: RFIL x 10 / 1-2 hours Posture: Neutral (sit and stand) Avoid Extension Follow Up (4 days later) Hx: 85% Better, much less pain and moving well Exam: Movement Loss: Flexion: No loss (full reversal of lordosis) Extension: No loss Extremity Case Study: 34 yr. old female with long history of left knee pain History 4 year Hx of intermittent left knee pain Progressively worsened over years Night pain Unable to squat at all, run and pain / unsteadiness with walking Pain with ascending/descending stairs Examination Knee flexion 135 degrees: painful lack of 5-8 degrees Full and pain-free extension Squat painful and less WB on left Resisted strength strong, painless Repeated Movement Exam Repeated flexion produced knee pain, but no worse symptomatically Mechanically: increased range squatting 50% less pain on 13

14 Classification? Derangement Treatment The classification of derangement determines the treatment of a specific directional exercise In this case it is end range repeated knee flexion repetitions 5-6x per day Prognosis The classification also determines the prognosis In this case the classification of a derangement would predict a rapid and successful outcome Outcome 24 hours: walking is much better best its been in the past few months jogging on treadmill with no pain pain-free squat 1 week follow up: 80% better since initial visit full range knee movement pain-free squat (still WB less on left) 3 week follow up: full squat, not experiencing pain Summary Section 5: Summary Comprehensive system Spine and extremities Principles are based on sound scientific rationale Identifies those that are appropriate for therapy 14

15 Summary Meticulous assessment / reassessment of patient Emphasis on patient education & training in self-management Use and timing of treatment progressions Summary Research is extensive and growing: Reliability Validity Prognostic value Summary Effective and efficient use of MDT is dependent upon the level of clinical training of the practitioner Thank you for participating 15