PT 714 MDT & Mobilization with Movement Lecture 2025 [Autosaved]

What is Mechanical Diagnosis & Therapy (MDT)

• Examination and intervention classification-based approach

• Utilizes repeated movements in addition to single movements

• Rapidly identifies fast/slow/non-responders

• Focuses on the patient and their potential to self-manage and recover their previous level of function

effectiveness of Mckezie method on acute low back pain

effectiveness of Mckezie method on chronic low back pain

Examination: repeated movement testing

• In addition to standard orthopedic exam

• Response to repeated end-range movements

• NOT a ROM test

• Proceed from loaded to unloaded position

• Drives classification

  • Directional preference

  • Centralization

Directional Preference vs Centralization

• Directional preference

  • One direction makes symptoms “better”

  • One direction makes symptoms “worse”

    • Usually the opposite direction

• Centralization

  • A subset of directional preference

  • Unique definition

• Might have a directional preference without centralization/peripheralization

Definition of centralization

with repeated motion or sustained positions, pain moves from distal to proximal and remains there

Centralization: Operational Definition

• In response to loading strategies pain is progressively abolished in a distal-to-proximal direction with each progressive abolition being retained over time until all symptoms are abolished

• If back pain only is present, this moves from a widespread to a more central location and then is abolished

This is a clinical phenomenon:

• Must be observed in the clinic

• Cannot be taken from history

_______

You have to see it – not just take their word

It also must stay in that area – if it reverts back immediately its not centralizing – should only go back with different motion like flexion

Evaluation/Classification (postural vs dysfunction vs derangement) 

____

Postural- named for aggravating static or sustain posture  Dysfunction- direction of restriction and pain provacation is the same, if you can’t flex and flexion causes you pain…then you are a flexion dysfunction

Derangement- based on conceptual model of disc; named for the direction in which the NP is shifted in the disk.

Pproblems with a disc typically come from repeated ans sustained flexion – so you do repeated extension to get the fluid back into the disc since it’s a jelly doughnut

Evaluation/Classification 

Ignore the postural one

Derangement: pain all the way through the movement – lateral shift as example

Derangement changes quickly, dysfunction does not

Intervention: McKenzie Treatment Philosophy

Intervention: treatment principle

Intervention: exercise progression

____

Postural- named for aggravating static or sustain posture

Dysfunction- direction of restriction and pain provocation is the same, if you can’t flex and flexion causes you pain…then you are a flexion dysfunction

Derangement- named for the direction in which the NP is shifted in the disk…use posterior derangement…someone walks into the room bent over, how did that happen and how do we fix it?

Exercise progression: traffic light guide

Intervention
Extension Dysfunction

• Slow responder (6-12 weeks)

• Soft tissue remodeling

• Therex every 2-3 hours, 10-15 reps

• Must reproduce their pain!

  • “No Pain, No Gain”

• Monitor for changes in pain and ROM

• Add overpressure, mobilization, manipulation if not progressing

Intervention
Extension Derangement (4 steps to manage derangements)

• Quick responder if compliant

• Guided by centralization or directional preference

• 4 steps to manage derangements

  • Reduce derangement (day 1-3)

  • Maintain reduction (at least > 72  hrs)

  • Recover function

    • Progressive forces

    • Critical phase!!!

  • Prevent recurrence

Maitland vs McKenzie interventions

Case:

• MDT classification

  • Is centralization or a directional preference present?

  • Derangement or dysfunction

• MDT intervention

  • Exercise: prone press ups

  • Frequency per day: every hour

  • Sets/repetitions: 2x10

  • Education: avoid flexion and sitting for long periods of time – you can use a lumbar roll to get lordosis when sitting:

Centralization because of the “abolished” calf pain

Derangement because of the rapid change

If it was a dysfunction the sx would come back as soon as you stop

Can do bridges because it is an extension based

Mulligan Concept

• Developed in the 1980’s by Brian Mulligan, a physical therapist from New Zealand

• Based on the work of Kaltenborn, Maitland, and Paris

• Uses NAGS, SNAGS, and MWMS … articular techniques with neuromuscular effects

• Pain-free techniques

• Immediate improvement in pain/function

Avoid injections at the muscle tendon – tendonopathy is not inflammation

It is time for clinicians to finally update themselves on the nature of tendinopathy and to embrace, along with medical educators, that corticosteroid injections for tennis elbow worsen the long-term outcomes of patients.  Corticosteroid injections should not be used to treat most patients with tennis elbow with symptom duration of less than 12 months.

Terminology

• Natural Apophyseal Glides (NAGS): passive accessory mobilizations which can be applied to facet joints between C2 and T3; glide one facet on its neighbor

• Mobilizations With Movements (MWM):  sustained repositioning of one articular surface on its neighbor while a movement or function is performed

• Sustained Natural Apophyseal Glides (SNAGS): combination of sustained facet glide with movement; a SNAG is a MWM

• Spinal Mobilizations With Arm Movements (SMWAMS): sustained transverse glide to spinous process of a vertebra is applied while the restricted peripheral joint is mobilized actively or passively

KEY Principles: PILL

If a PILL response is not achieved, do not use the technique!

KEY Principles: CROCKS

• C … contraindications

• R … repetitions (2-3x10, except L-S)

• O … overpressure (key to lasting success)

• C … communication (with the patient, explain PILL response)

• K … knowledge (of treatment planes and pathologies)

• S … sustain the mobilization throughout treatment

Key principles

Mobilization w/ Movement: Mulligan Concept

Mobilization w/ Movement: combined movement to add dosage

key principles advantages vs disadvantages 

• Advantages: 

  • Pragmatic approach with often immediate results

  • Focus on performance in weight-bearing (functional)

  • Emphasis on eventual self-performance

  • Combination of physiologic (osteokinematic) and accessory (arthrokinematic) motion

  • Techniques are pain-free and safe

• Disadvantages

  • Techniques may not adhere to the biomechanics of the joint

  • Does not attempt to identify anatomic cause of impairment

Key Principles: indications

• Painful restrictions of spinal and peripheral joint mobility

• Commonly seen orthopedic conditions include:

  • Mechanical neck pain

  • Headache

  • Subacromial shoulder pain

  • Lateral epicondylitis

  • Hip pain (FAI/OA)

  • Patellofemoral pain

  • Ankle sprain/pain

Mobilization with Movement
Procedure

• Identify pain producing movement

• Apply passive accessory glide to the joint at approximately 50-75% of maximal force

  • Spine (SNAG): start at most symptomatic level

  • Extremity: usually a plane perpendicular to the joint axis

• Patient actively performs previously restricted or painful motion (or active muscle contraction) while the PT maintains the accessory glide

Mobilization with Movement
Procedure if symptoms remain or worsen…

• If symptoms remain or worsen …

  • Change direction of force

  • Change location of force (spinal level, patellofemoral vs tibiofemoral vs proximal tib-fib)

  • Ensure consistent glide is provided throughout the entire range

  • MWM not indicated

Mobilization with Movement
Procedure - if pain improved but not eradicated

• If pain improved but not eradicated, fine-tune the glide (pressure, angle, et cetera)

_____

• If pain improved but not eradicated, fine-tune the glide (pressure, angle, et cetera)

• If asymptomatic, perform ten repetitions of the previously symptomatic movement

• Re-test movement without the glide being applied

• If not symptomatic …

  • Perform more repetitions of glide with movement

  • Pain-free over-pressure at end of range

  • Teach patient how to replicate the technique at home

  • Tape the joint in the desired position

Mobilization with Movement
Procedure - if asymptomatic

• If asymptomatic, perform ten repetitions of the previously symptomatic movement

_____

• If pain improved but not eradicated, fine-tune the glide (pressure, angle, et cetera)

• If asymptomatic, perform ten repetitions of the previously symptomatic movement

• Re-test movement without the glide being applied

• If not symptomatic …

  • Perform more repetitions of glide with movement

  • Pain-free over-pressure at end of range

  • Teach patient how to replicate the technique at home

  • Tape the joint in the desired position

Mobilization with Movement
Procedure - if not symptomatic 

• Perform more repetitions of glide with movement

• Pain-free over-pressure at end of range

• Teach patient how to replicate the technique at home

• Tape the joint in the desired position

____

• If pain improved but not eradicated, fine-tune the glide (pressure, angle, et cetera)

• If asymptomatic, perform ten repetitions of the previously symptomatic movement

• Re-test movement without the glide being applied

• If not symptomatic …

  • Perform more repetitions of glide with movement

  • Pain-free over-pressure at end of range

  • Teach patient how to replicate the technique at home

  • Tape the joint in the desired position

pain free

long-lasting

overpressure (key to lasting success)