2 Course GoalsIdentify and discuss common problems encountered in the application of Mechanical Diagnosis and Therapy for the cervical and thoracic spine.Analyse and discuss the MDT assessment and how it assists with patient classification.Discuss the application of clinician forces, and how they fit with McKenzie’s ‘Progression of Forces’ concept.
3 Course Goals4. To perform clinician techniques for the cervical and thoracic spine at an advanced level and to identify problems with their application.5. Analyse case studies of patients presenting with cervical / thoracic symptoms and determine their classification.
4 Course Goals6. Describe and discuss the current evidence base for the use of MDT for upper limb musculoskeletal disorders.7. Describe the characteristics of Derangement, Dysfunction and Postural syndromes as they present in upper limb musculoskeletal disorders.8. Perform MDT assessments for upper limb musculoskeletal disorders and determine the presence of McKenzie syndromes.
5 Course Goals9. Design appropriate management programs for patients who presentwith Derangement, Dysfunction and Postural syndromes in the upper limb.10. Analyse case studies of patients presenting with upper limb symptoms and determine their classification.
18 Review Of Force Progressions Patient Generated ForcePatient Generated OverpressureClinician OverpressureClinician MobilizationClinician Manipulation
19 Review Of Force Progressions Remember:The goal of applying external force is?When do you add force diagnostically?When do you add force therapeutically?
20 Review Of Terminology Define deformity Define lateral shift Define relevant lateral shiftDefine relevant lateral derangementWhat words describe effect during loading?What words describe effect after loading?Describe centralization pattern in the cervical/thoracic spine
22 Extension Principle Procedure One - Retraction Can be performed in sitting, standing, supine, prone1a. Retraction with patient overpressure1b. Retraction with clinician overpressure1c. Retraction mobilisation
23 Procedure Two - Retraction / Extension Can be performed sitting, supine, prone2a. Retraction and extension with rotation2b. Retraction and extension with rotation and clinician traction (supine)Procedure Three - Postural Correction
24 Lateral forcesLateral forces are considered when the sagittal plane has been exhausted.Describe what it means to exhaust the sagittal planeWhat must be found in order to consider relevant lateral?What are the typical loading strategies employed for cervical derangements with a lateral deformity?
25 Lateral PrincipleIn the cervical spine, lateral involves either lateral flexion or rotation.Indicate why you would choose one versus the other.
26 Lateral Principle Procedure Four – Lateral Flexion Can be performed sitting, or supine4a. Lateral flexion with patient over-pressure4b. Lateral flexion with clinician over-pressure4c. Lateral flexion mobilisation4d. Lateral flexion manipulation
27 Lateral Principle Procedure Five – Rotation Can be performed sitting or supine5a. Rotation with patient over-pressure5b. Rotation with clinician over-pressure5c. Rotation mobilisation5d. Rotation manipulation
28 Flexion Principle Procedure Six – Flexion Can be performed sitting or supine6a Flexion with patient over-pressure6b Flexion with clinician over-pressure (supine)6c Flexion mobilisation (supine)
29 Recovery of Function What is evidence of full reduction? When to and how to test for recovery of function?Is it necessary to recover function in the cervical spine?
30 Differential Diagnosis Cervical DerangementCervical Adherent Nerve RootShoulder PathologyPain locationConstant or IntermittentAggravating factorsEasing factorsMovement LossResponse to cervical repeated movementsOther tests
31 Upper cervical spineSelf-treatment procedures for the upper cervical spine are:RetractionFlexionRotationCombination flexion / rotationCombination extension / rotation
33 Thoracic SpineDo not assume that symptoms arise from the thoracic spine simply based on location of symptoms.Cloward 1950 demonstrated that structures in the lower cervical spine could refer to the lower angle of the scapula.The actual incidence of true thoracic problems is quite low.Look for clues in the history.
34 Thoracic SpineRule out cervical/lumbar involvement before examining the thoracic spine.Attempt to target loading to the thoracic spine while minimizing load in the lumbar/cervical. This may be accomplished through attention to detail with the thoracic techniques.The thoracic spine will often require higher levels of force such as over-pressure, mobilization, and sustained loading.
35 What sub-classifications are rarely seen in the thoracic spine?
37 Extension Principle Procedure One ‑ Extension Can be performed sitting (mid thoracic), supine (upper thoracic), prone (mid and lower thoracic).1a. Extension with patient over-pressure1b. Extension with clinician over-pressure1c. Extension mobilisation1d. Extension manipulation in prone
38 Procedure Two ‑ Posture Correction Extension PrincipleProcedure Two ‑ Posture Correction
39 Lateral Principle Procedure Three ‑ Rotation 3a. Rotation with patient over-pressure3b. Rotation with clinician over-pressure3c. Rotation mobilisation in sitting or in prone3d. Rotation manipulation in prone
40 Flexion Principle Procedure Four ‑ Flexion 4a. Flexion with patient over-pressure
49 Evidence Base for MDT in the Upper Limb Surveys of:Prevalence rate of mechanical syndromes in extremity patients27% derangementPrevalence rate of derangement varied quite widely across different surveys and different joint sites.
50 Evidence Base for MDT in the Upper Limb Two surveys have assessed reliabilityPilot study using 11 patient vignettes and 3 Credentialed therapists there was 82% agreement with a kappa value of 0.70 (Kelly et al 2008).25 patient vignettes and 97 therapists with MDT diploma status worldwide there was 92% agreement, with a kappa value of (May and Ross 2009).
51 Evidence Base for MDT in the Upper Limb Case StudiesShoulder derangement, (Aina and May 2005).Shoulder contractile dysfunction, (Littlewood and May 2007).Thumb derangement. (Kaneko et al. 2009).
52 Characteristics of the Three Syndromes Module EightCharacteristics of the Three Syndromes
53 MDT at the shoulder – 3 surveys with 134 shoulder patients total (%)
55 Three Syndromes Operational Definition Derangement - lasting abolition or decrease of symptoms, and/or an increase in restricted range of movement in response to repeated movements.
56 Three Syndromes Operational Definition Articular dysfunction - intermittent pain consistently produced at a restricted end-range with no rapid change of symptoms or range.Contractile dysfunction - intermittent pain, consistently produced by loading the musculotendinous unit, for instance with an isometric contraction against resistance.
57 Three Syndromes Operational Definition: Postural syndrome - only produced by sustained loading, which once avoided, the rest of the physical examination would be normal.
58 eg recent trauma, post-surgery or chronic pain state. OtherOperational Definition‘Other’ refers to failure to classify as one of the above mechanical syndromes.eg recent trauma, post-surgery or chronic pain state.
64 Problem Areas History Physical Examination Active movements Passive movements (+/- over-pressure)Resisted movementsRepeated movementsSustained postures.
65 Implication The Response to Repeated Movements No pain during repeated movements.Pain produced only at limited end‑range, no worse afterwards.Pain produced only by resisted tests, no worse afterwards.Increasing symptoms in one direction, decreasing symptoms in the other.All directions cause lasting increase in pain in sub-acute condition.Persistent pain in which initial active therapy causes some temporary aggravation of symptoms.
66 Assessment Keep an open mind. Do not assume that the diagnosis provided, the imaging findings, or the patient’s beliefs are correct.Ensure to clear the spine – assume spine first then chase extremity disorder.Check baselines in both areas.Remember to achieve end range and alter the load.If inconclusive test over 2/3 days.
70 Education Component Information about the problem itself; What patients can do to help themselves;Information about tests, diagnosis and interventions;An idea about the prognosis of the problem.70
71 Education ComponentPatient education should not be seen as a ‘nice extra’,but as an effective treatment in itself.
72 Active Mechanical Therapy Component Following an explanation of the role of the exercise:Specific exercises should be demonstrated to the patients,They should practice these,Expected pain response should be explained,72
73 Active Mechanical Therapy Component Exercises should be repeated 10 times 3 or 4 times a day, initiallyCan be done every 2 hours once response clearProgressions and force alternatives should be used.
74 EmpowermentActive self-management rather than compliance is the preferred outcome (Brady 1998).Can be achieved if the patient is sufficiently informed and empowered.It is the therapist’s responsibility to try to create this state of mind.74
75 Derangement Syndrome Repeated Reductive Movement Avoidance of aggravating factor75
82 Common Upper Extremity Articular Dysfunctions ShoulderElbowWrist
83 Contractile Dysfunction Key features of Contractile Dysfunction from the assessment
84 Contractile Dysfunction Education in Self ManagementSelf TreatmentRepeat mid-range loadingUse of Target ZoneUse of Eccentric loading84
85 Why is loading therapeutic? ‘Mechanotransduction’- Turning Movement into repairCells convert mechanical signals into biochemical responses,Physiological - adjusts structure to demandNon-neural communication (gap junctions)
86 So how does one prescribe that ‘optimal load’ Excessive load – injures tendonOptimum load – stimulates healingUnder-load – no stimulus for repair
87 Where to start the loading ? Start with what is tolerable and functionally relevant.Symptom response should be P, NWRemember to progress forces and use force alternatives
88 Force Options Active Movements Static / isometric Resisted Concentric / EccentricOuter range/inner range/mid rangeAmplitudeSpeed88
89 A few RCTs Brox et al (1999) 125 patients with chronic RC disease 1-2 years duration failed to improve with ‘physio’ NSAIDs etc1 = arthroscopy2 = resisted exercises3 = placebo laserNeer scores (1&2 SD 3)
90 Haahr et al (2005) 90 patients with RC disease – majority > 1year 1 = arthroscopy2 = strengthening exercisesConstant score (NS)
91 Jonsson et al 20069 patients with chronic impingement (mean 41 months) on surgical waiting list.Lots of previous treatment.Treated with progressive eccentric training for supraspinatus and deltoid.15-20 point improvement in mean VAS Constant score5/12 withdrew from surgical waiting list.
92 Jonsson et al 2006Ulla –sling used to elevate arm, 30 degrees of horizontal abduction.Eccentric work achieved by lowering the arm.
93 Jonsson et al 2006 End position Progression by adding weight for eccentricexerciseProgression by adding weight