Mechanical Diagnosis And Therapy of the Cervical Spine...

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

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

Austin, Texas Austin, Texas

Smart Sport InternationalSmart Sport International™™

Sports Science Sports Science Solutions for Solutions for

Rehabilitation and Rehabilitation and TrainingTraining™™

ItIt’’s All About s All About The Journey, The Journey, Not The Not The Destination Destination ……

““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 ……


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


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?””))


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

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


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


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

But first But first ……

…… some basic concepts would be some basic concepts would be appropriate appropriate ……..

PainPain

ChemicalChemical

MechanicalMechanical

Consistent behaviorsConsistent behaviors

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””

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

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

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

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.

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

Physical ExaminationPhysical Examination

PosturePostureNeurological examinationNeurological examinationMovement lossMovement lossMechanical loading strategiesMechanical loading strategies

Repeated movementsRepeated movementsStatic testsStatic tests

Other testsOther tests

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

Repeated MovementsRepeated Movements

Repeated end range movementsRepeated end range movements

ProtrusionProtrusionRetractionRetractionRetraction ExtensionRetraction Extension

FlexionFlexionSide bendingSide bendingRotationRotation


ProtrusionProtrusionUpper cervical Upper cervical end range end range extensionextensionLower cervical Lower cervical midrange midrange flexionflexion


RetractionRetractionUpper cervical Upper cervical end range end range flexionflexionLower cervical Lower cervical midrange midrange extensionextension


Retraction Retraction Extension Extension

Upper cervical Upper cervical end range end range extensionextensionLower cervical Lower cervical end range end range extensionextension

Sustained PosturesSustained Postures

Static end range loadingStatic end range loading

ProtrusionProtrusionRetractionRetractionFlexionFlexionExtensionExtension

Sustained PosturesSustained Postures

Protrusion Retraction

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


…… using a wellusing a well--defined algorithm, classify defined algorithm, classify the problem the problem ……


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

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

Relevant Features Relevant Features -- DerangementDerangementSymptomsSymptoms




Local +/Local +/-- PeripheralPeripheral

YesYes

Lasting changeLasting changeDecreaseDecreaseAbolishAbolishCentralizeCentralize

““The barking dogThe barking dog””

Relevant Features Relevant Features -- DysfunctionDysfunctionSymptomsSymptoms




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””

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

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

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

Classification SummaryClassification Summary

SymptomsSymptoms


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

The Numbers GameThe Numbers Game

The largest percentage of The largest percentage of clinical cases will beclinical cases will be

DerangementsDerangements

Clinical ExamplesClinical Examples

CyclingCyclingTriathlonTriathlon

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


35 year old 35 year old triathletetriathlete with with intermittent right cervical and intermittent right cervical and suprascapularsuprascapular painpain


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

Clinical ExamplesClinical Examples

Football Football

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



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


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


…… 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 ……


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 ……

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

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

SelfSelf--Treatment ConceptTreatment Concept

““Treat Your Own Treat Your Own BackBack””““Treat Your Own Treat Your Own NeckNeck””

TreatmentTreatment

ReeducationReeducation

ReductionReduction

RemodelingRemodeling

Posture

Yes

No

No

Derangement

Yes

Yes

No

Dysfunction

Yes

No

Yes

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

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)

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

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


35 year old 35 year old triathletetriathlete with with constant right cervical and constant right cervical and suprascapularsuprascapular painpain


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


35 year old 35 year old triathletetriathlete with with intermittent right cervical and intermittent right cervical and suprascapularsuprascapular painpain


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



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


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



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


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

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

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””


““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


Applicable to Applicable to all sports all sports injuries injuries ––contact and contact and nonnon--contact contact sportssports

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””

MDT In The Big PictureMDT In The Big Picture

““ItIt’’s not just for spines anymores not just for spines anymore””!!

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

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

Today is brought to youToday is brought to youby the letter G by the letter G ……

…… and the number and the number ……. 7 . 7 …… ☺☺

Mechanical Diagnosis And Therapy of the Cervical Spine...

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