Management of LBP: McKenzie Approach (vinny)

What does the acronym MDT stand for in the context of the McKenzie Method?

Mechanical Diagnosis and Treatment

In MDT, when should the loading strategy be avoided?

If pain is produced in the limb and spreads distally or increases distally and remains worse

What is the primary assessment technique utilized in the McKenzie Method?

Repeated motions

In MDT, what term describes the phenomenon where pain spreads further into the limb as a result of loading strategies?

Peripheralization

In MDT, what term describes the phenomenon where limb pain is abolished in a distal to proximal direction?

Centralization

A situation where movement in one direction improves pain and range of motion while the opposite direction worsens it is defined as a _____.

Directional Preference

A patient who exhibits centralization would be considered to have what?

Directional preference

True or False: centralization is a prerequisite for directional preference

False

How does Directional Preference differ from Centralization regarding symptom location?

Directional Preference is based on pain intensity rather than specific location.

Under what conditions is a patient considered to have a right lateral shift?

The vertebra above has laterally flexed to the right in relation to the vertebra below, displacing the upper trunk and shoulders to the right.

Under what conditions is a patient considered to have a left lateral shift?

The vertebra above has laterally flexed to the left in relation to the vertebra below, displacing the upper trunk and shoulders to the left.

Name the four general classifications in the McKenzie system.

Derangement, Dysfunction, Postural, and Other

What is the mechanical cause of Derangement syndrome?

Internal disturbance in the normal resting position of the affected joint surfaces

What does derangement typically respond to

Loading strategies

Which McKenzie classification is the only one characterized by the presence of centralization?

Derangement

True or False: derangement can include worsening or peripheralization of symptoms in certain postures and movements

True

How does the site and location of pain typically behave in Derangement syndrome?

It changes rapidly for the better or for the worse
Often felt constantly
Exhibits itself during the movement

How may a patient with derangement present

Lateral shift deformity

Characteristics of dysfunction syndrome

Local pain (exception = nerve root adherence)
Always intermittent
Consistent and mechanical response at end range reproducing pain
No centralization or peripheralization with repeated motion

What is the primary cause of pain in Dysfunction syndrome?

Mechanical deformation of structurally impaired soft tissues (e.g., scarring or adaptive shortening)

When is pain felt by a patient with Dysfunction syndrome?

When the abnormal tissue is loaded at end range.

What structures are most often effected by dysfunction syndrome

Articular structures

How are Dysfunction syndromes named?

By the direction of movement that produces the symptomatic and mechanical response.

In the case of nerve root adherence, when does spinal motion reproduce radiating symptoms?

At end range when root tension is produced

When considering postural syndrome, what causes mechanical deformation of soft tissue

Prolonged positional or postural stresses affecting the articular structures or the contractile muscles, tendons, or periosteal insertion

In Postural syndrome, what is the effect of repeated movement on symptoms

There is no effect

How long must an offending end range position usually be sustained to produce symptoms in Postural syndrome?

20-30 minutes

How do repeated end range test procedures affect a patient with Postural syndrome?

There is no effect on pain or movement loss.

What is the primary treatment goal for Postural syndrome?

Postural correction to relieve prolonged mechanical loading

What are other conditions that do not fit the McKenzie spinal mechanical classifications

Symptoms arising from relevant peripheral joints
Specific spinal disorders (spinal stenosis, spondylolisthesis)
Mechanically inconclusive symptoms
Chronic pain states

How to manage Derangement syndrome?

Reductive forces to relocate displaced tissue
Loading strategies are applied to reduce, abolish, or centralize symptoms

What is the management strategy for Dysfunction syndrome?

Remodeling the structurally impaired tissue by repeatedly stressing it

What is the general agreement in the major factor in the failure of the IV disc

Loss of the normal hydrostatic mechanism

What are the two most common types of disc failure

Disc prolapse
Internal disc disruption

What is the typical mechanical result of disc prolapse of the annulus?

Outward annular protrusion

What is the typical mechanical result of internal disc disruption on the annulus?

Inward annular buckling

What percentage of the load do the IV disc nuclei bear in a healthy state?

75%

What does internal disc disruption begin with

Damage to the cartilage of the endplate which bulges into the vertebral body

How does damage to the cartilage endplate affect the nucleus pulposus pressure?

It drops the pressure as the nucleus bulges into the vertebral body.

Where do radial fissures typically develop during a disc prolapse?

Posterolateral region

Why do posterolateral radial fissures develop

In response to sudden or repetitive loading

What is the most accurate methods of identifying a symptomatic disc

Discograms

Characteristics of discogenic LBP

Dull ache
Worse with sitting and forward flexion)
Most common protrusions are posterolateral
Pain below the knee (or elbow) usually from nerve root involvement
90% protrusions are at L4/5 and L5/S1

Why can a significant disc bulge occur asymptomatically initially?

Only the outer annulus is innervated.

What is linked to discogenic pain

The centralization phenomenon

The presence of __________ alters the centralization response of discogenic LBP on assessment

Psychosocial factors

List the eight standardized test movements used in the MDT protocol.

Flexion/extension in standing
Side gliding (L/R) in standing
Flexion/extension in lying
Asymmetric extension in lying
Rotation in flexion

What is the difference in treatment sessions required for full centralizers versus partial centralizers?

Full centralizers required four sessions while partial centralizers required eight.

How does intradiscal pressure in sitting compare to standing?

Sitting increases intradiscal pressure.

When should you suspect discogenic pain

Pain is worse sitting than walking
Pain exacerbation with valsalva maneuvers
Pain worsened by forward flexion and when rising from flexion

When should you suspect discogenic pain

Significant change in pain or movement loss with repeated movements
Centralization/peripheralization occurs
Pain is more frequently referred and may be localized to a distal site
There is often pain at rest and at mid range
Pain not relieved by recumbent position
No history of trauma in patients < 55 yo

What is the most sensitive clinical finding reported for proven discogenic pain?

Centralization or peripheralization of symptoms

What are the 4 main contributions of the “McKenzie Approach”

Assessment is symptom-based
The centralization phenomenon is used to guide Assessment & Treatment
The use of repeated movements
Movements are assessed in lying

Why is reduction of a derangement more likely during assessment in lying?

Decreased intradiscal pressure due to unloading

How does muscle activity differ between assessment in standing versus lying?

Lying typically results in less muscle spasm or guarding.

Contrast the spinal movement sequence of standing flexion with flexion in lying.

Standing flexion moves L1 to L5; flexion in lying moves L5 first then upward.

How does flexion in lying help differentiate nerve root adherence from disc impingement?

Flexion in lying avoids stretching the sciatic nerve(s) due to knee flexion

Which movement acts as a 'double SLR' and stretches the sciatic nerves?

Flexion in standing

What will knowing directional preference help direct

Education
Lifestyle modifications
Manual therapy techniques
Exercise prescription