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The McKenzie Method was developed in the 1960s by Robin McKenzie, a physical therapist in New Zealand. In his practice, he noted that extending the spine could provide significant pain relief to certain patients and allow them to return to their normal daily activities
With the McKenzie approach, physical therapy and exercise used to extend the spine can help "centralize" the patients pain by moving it away from the extremities (leg or arm) to the back. Back pain is usually better tolerated than leg pain or arm pain, and the theory of the approach is that centralizing the pain allows the source of the pain to be treated rather than the symptoms
Syndromes
McKenzie originally noticed specific patterns of response to the loading assessment, which he used to categorize patients conditions into different syndromes: posture, dysfunction, or derangement.
SYNDROMES
1) POSTURAL SYNDROME 2) DYSFUNCTION SYNDROME 3) DERANGEMENT SYNDROME
Posture syndrome
results from prolonged loading of normal tissue leading to pain. This pain is eradicated with change of position.
Dysfunction syndrome
occurs when abnormally shortened tissue restricts normal, pain-free movement. This is characterized by intermittent pain and partial loss of movement in a particular direction. Lastly,
Evaluation components
Thorough history taking Repeated flexion in standing Repeated extension in standing Repeated flexion in lying Repeated extension in lying Lateral movements if necessary Neurological testing
Classification based on
Assessment Derangement syndrome Dysfunction syndrome Posture syndrome
POSTURAL SYNDROME
DEFINITION:
In the postural syndrome patients complain of pain because they are
mechanically deforming their spinal soft tissue due to sustaining end-range postures and positions.
CLINICAL PICTURE
- Typically under 30 years. - Local pain.
- Gradual onset.
- No known reason / sedentary.
CLINICAL PICTURES
- Intermittent symptoms. - Better with movement.
- Poor posture.
- Treatment by Postural correction.
Posture Syndrome
There will be no loss of movement Repetitive movements will not be painful
Posture Syndrome
Pain produced from holding spinal tissue at End range for a long period of time Pain will be local to the spine Pain will occur only when sustaining the End range, such as in prolonged slumped Sitting Once the position is changed the pain will Go away
DYSFUNCTION SYNDROME
DEFENITION:
The patients feel pain when they
mechanically deform previously shortened structures surrounding and within their spine on attempting normal end-range movement.
Dysfunction Syndrome
Characterized by intermittent spinal pain Pain is reproduced only at the end-range of a restricted movement Cause is painful adaptively shortened tissues from contracture, scarring or fibrosis
joint movement.
It implies incorrect functioning without trying
CLINICAL PICTURE
- Age usually > 30 years
CLINICAL PICTURE
- Loss of End range of motion (due to shortened structures). - End range pain which is the same with repetitions. - Treatment by Correct Posture, Stretching shortened structures.
Derangement Syndrome
Most common of the three syndromes Characterized by intermittent or constant spinal +/- leg pain During mechanical examination, there will be pain during movement and obstruction to movement
DERANGEMENT SYNDROME
DEFENITION:
Pain in the derangement syndrome arises as a result of disruption and or displacement within the intervertebral segment.
CLINICAL PICTURE
- Age : 20 - 55 years - Local, referred or radicular pain. - Sudden onset. - Constant or intermittent pain.
- May or may not have deformity.
- Poor posture.
Characteristics of Derangement
Often have directional preference One direction of movement, when performed repeatedly, progressively lessens the pain Centralization of pain commonly occurs with movement in the direction of preference Movement in the opposite direction often worsens the pain
Characteristics of Derangement
Syndrome May be acute or chronic McKenzie theorized that the derangement presentation resulted from internal displacement of the disc
DEFINITIONS
CENTRALISATION
The most distal symptoms decrease and abolish as symptom at or near midline are increased or produced
PERIPHERALISATION Most distal symptoms are progressively increased or produced. Change in distal symptoms remain worse
LUMBAR SPINE
Derangement 1 :
- No deformity.
Derangement 2 :
- Central or symmetrical pain across Low back. - With or without pain over gluteal or thigh region. - Loss of extension range. - Deformity - lumbar kyphosis - Easily converted into a derangement four.
Derangement 3 :
- Unilateral or asymmetrical pain across Low back. - With or without pain over gluteal or thigh region. - No deformity.
Derangement 4 :
- Unilateral or asymmetrical pain across Low back . - With or without pain over gluteal or thigh region. - Loss of full extension range, flexion range or both. - With deformity - lumbar scoliosis.
Derangement 5 :
- Unilateral or asymmetrical pain across Low back. - With or without pain over gluteal or thigh region. - With leg pain extending below the knee. - No deformity.
Derangement 6 :
- Unilateral or asymmetrical pain across Low back. - With or without pain over gluteal or thigh region. - With leg pain extending below the knee. - With deformity of sciatic scoliosis and reduced lordosis.
Derangement 7 :
- Symmetrical or asymmetrical pain across Low back. - With or without pain over gluteal or thigh region. - With deformity - accentuated lumbar lordosis. - Loss of flexion range of motion.
CERVICAL SPINE
Derangement 1 : - Central or symmetrical pain about C5-C7.
Derangement 2 :
- Central or symmetrical pain about C5-C7. - With or without scapula, shoulder pain or upper arm pain. - Kyphotic deformity.
Derangement 3 :
- Unilateral or asymmetrical pain about C5-C7 - With or without scapula, shoulder pain or upper
arm pain.
- No deformity.
Derangement 4 :
- Unilateral or asymmetrical pain about C5-C7. - With or without scapula, shoulder pain or upper arm pain. - With deformity of acute wry neck or torticollis.
Derangement 5 :
- Unilateral or asymmetrical pain about C5-C7. - With or without scapula, shoulder pain or upper arm pain. - With arm symptoms distal to the elbow. - No deformity.
Derangement 6 :
- Unilateral or asymmetrical pain about C5-C7. - With or without scapula, shoulder pain or upper arm pain. - With arm symptoms distal to the elbow. - With deformity of Cervical kyphosis, acute wry neck or torticollis.
Derangement 7 :
- Symmetrical or asymmetrical pain about C5C7. - With or without scapula, shoulder pain or upper arm pain. - With arm symptoms distal to the elbow. - No deformity.
CONTRAINDICATIONS
Bone weakening or destructive disease Circulatory disturbances Inflammatory Arthropathies
Neoplasms
Directional Preference
Refers to what occurs with Derangement Syndrome Refers to the direction of movement that progressively lessens the pain Centralization commonly occurs when the patient is moved in the direction of preference
Directional Preference
When centralization occurs there is also commonly a significant improvement in range of motion in the obstructed direction If patients are exercised in their directional preference rapid recovery often follows If patients are exercised in the opposite direction, worsening or no improvement often occurs
Centralization
The progressive retreat of referred pain towards the midline of the back in response to repeated movement testing
Peripheralization is the progressive movement of the pain further from the midline of the back towards the periphery
Centralization
Has been shown to occur commonly 30-70% depending on population studied
Centralization
McKenzie postulated that reduction of internal displacement within the disc was the underlying cause of centralization A few studies now support the internal disc model as the underlying cause
Centralization
Centralization
In relation to positive discography, centralization observed during a McKenzie evaluation Specificity of 89% Among patients without severe disability or distress specificity is 100%
Centralization
Non-occurrence accurately predicts poor treatment outcome with mechanical therapy Quickly identifies who might be appropriate for further medical intervention
Clinical Application
All spinal patients should undergo a mechanical assessment as described by McKenzie
All patients tested will rapidly demonstrate that they have A reversible condition An irreversible condition
Clinical Application
Patients with a reversible condition often have a directional preference +/or centralization occurs with repeated movement testing
These patients should receive exercise in their direction of preference and taught to avoid movements into the opposite direction
Clinical Application
Most of the patients with a directional preference will have rapid improvement when exercise is initiated in this direction
Average 3-7 physical therapy visits
Clinical Application
A smaller number of patients will have a reversible condition and will be classified into the dysfunction category They can remodel shortened tissue by performing exercise into the shortened painful end range every 2 hours Self-manage very effectively Posture syndrome patients = pain goes away with correcting posture
Clinical Application
Irreversible condition Patients without a directional preference and cannot be classified after 3 days of testing Unlikely to respond to this type of intervention and can quickly be moved on to other interventions
Clinical Application
Lack of centralization with a McKenzie assessment plus positive findings on specific pain provocation tests has been found to be useful in predicting symptomatic sacroiliac joints
These particular lesion presentations can often be reversed quite rapidly. On the basis of more than 45,000 patients evaluated, McKenzie states that at least 70% of low back pain patients fall into one of the three categories described.
USES
Acute, sub-acute or chronic low back pain Slowly or suddenly occuring sharp pain With or without radiation over the gluteal region or slightly down the leg Recurrent symptoms Intermittent sciatica without neurological deficit