Mechanical Diagnosis & Therapy Advanced Cervical and Thoracic Spine & Extremities – Upper Limb 1

Course Goals Identify 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.

Course Goals 4. 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.

Course Goals 6. 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.

Course Goals 9. Design appropriate management programs for patients who present with Derangement, Dysfunction and Postural syndromes in the upper limb. 10. Analyse case studies of patients presenting with upper limb symptoms and determine their classification.

About the course C P R Content Participation Review

Mechanical Diagnosis and Therapy Advanced Cervical and Thoracic Spine

Module One Cautions and Contra-indications

Review of the pre-manipulative stages in Mechanical Diagnosis and Therapy STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5

ABSOLUTE CONTRA-INDICATIONS Looking at the assessment forms, indicate where you would be alerted to the presence of these contra-indications

RELATIVE OR QUALIFIED CONTRA-INDICATIONS Looking at the assessment forms, indicate where you would be alerted to the presence of relative or qualified contra-indications

CLINICAL RECOGNITION OF CONTRA-INDICATIONS Cervical Arterial Disease (VBI) Cord Compression — Cervical Cauda Equina Compression Signs and Symptoms Clinical Tests Clinical Findings (with positive test)

Non-Mechanical Sources / Causes of Pain Inflammatory Disorders Structural Anomalies Referred from Pathologies Elsewhere Other Cervical Spine Thoracic Spine Lumbar Spine

Problem Areas and Problem Solving Guide Module Two Problem Areas and Problem Solving Guide

Problem Areas Assessment Classification Management History Physical Examination Classification Management Educational Component Mechanical Component

Problem Areas Reassessment Force Progressions Procedures Patient procedures Clinician procedures Other problem Areas

Cervical Spine Workshop Module Three Cervical Spine Workshop

Review Of Force Progressions Patient Generated Force Patient Generated Overpressure Clinician Overpressure Clinician Mobilization Clinician Manipulation

Review Of Force Progressions Remember: The goal of applying external force is? When do you add force diagnostically? When do you add force therapeutically?

Review Of Terminology Define deformity Define lateral shift Define relevant lateral shift Define relevant lateral derangement What words describe effect during loading? What words describe effect after loading? Describe centralization pattern in the cervical/thoracic spine

TABLE OF CERVICAL PROCEDURES

Extension Principle Procedure One - Retraction Can be performed in sitting, standing, supine, prone 1a. Retraction with patient overpressure 1b. Retraction with clinician overpressure 1c. Retraction mobilisation

Procedure Two - Retraction / Extension Can be performed sitting, supine, prone 2a. Retraction and extension with rotation 2b. Retraction and extension with rotation and clinician traction (supine) Procedure Three - Postural Correction

Lateral forces Lateral forces are considered when the sagittal plane has been exhausted. Describe what it means to exhaust the sagittal plane What must be found in order to consider relevant lateral? What are the typical loading strategies employed for cervical derangements with a lateral deformity?

Lateral Principle In the cervical spine, lateral involves either lateral flexion or rotation. Indicate why you would choose one versus the other.

Lateral Principle Procedure Four – Lateral Flexion Can be performed sitting, or supine 4a. Lateral flexion with patient over-pressure 4b. Lateral flexion with clinician over-pressure 4c. Lateral flexion mobilisation 4d. Lateral flexion manipulation

Lateral Principle Procedure Five – Rotation Can be performed sitting or supine 5a. Rotation with patient over-pressure 5b. Rotation with clinician over-pressure 5c. Rotation mobilisation 5d. Rotation manipulation

Flexion Principle Procedure Six – Flexion Can be performed sitting or supine 6a Flexion with patient over-pressure 6b Flexion with clinician over-pressure (supine) 6c Flexion mobilisation (supine)

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?

Differential Diagnosis Cervical Derangement Cervical Adherent Nerve Root Shoulder Pathology Pain location Constant or Intermittent Aggravating factors Easing factors Movement Loss Response to cervical repeated movements Other tests

Upper cervical spine Self-treatment procedures for the upper cervical spine are: Retraction Flexion Rotation Combination flexion / rotation Combination extension / rotation

Thoracic Spine Workshop Module Four Thoracic Spine Workshop

Thoracic Spine Do 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.

Thoracic Spine Rule 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.

What sub-classifications are rarely seen in the thoracic spine?

Table of Thoracic Procedures

Extension Principle Procedure One ‑ Extension Can be performed sitting (mid thoracic), supine (upper thoracic), prone (mid and lower thoracic). 1a. Extension with patient over-pressure 1b. Extension with clinician over-pressure 1c. Extension mobilisation 1d. Extension manipulation in prone

Procedure Two ‑ Posture Correction Extension Principle Procedure Two ‑ Posture Correction

Lateral Principle Procedure Three ‑ Rotation 3a. Rotation with patient over-pressure 3b. Rotation with clinician over-pressure 3c. Rotation mobilisation in sitting or in prone 3d. Rotation manipulation in prone

Flexion Principle Procedure Four ‑ Flexion 4a. Flexion with patient over-pressure

Module Five Reflective learning

Module Six Case Studies

EXTREMITIES – UPPER LIMB MECHANICAL DIAGNOSIS AND THERAPY EXTREMITIES – UPPER LIMB

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Epidemiology / Evidence Base for MDT in the Upper Limb Module Seven: Epidemiology / Evidence Base for MDT in the Upper Limb

Site of the problems – % general population (Badley 1992) 47

Site (N = 522) 48

Evidence Base for MDT in the Upper Limb Surveys of: Prevalence rate of mechanical syndromes in extremity patients 27% derangement Prevalence rate of derangement varied quite widely across different surveys and different joint sites.

Evidence Base for MDT in the Upper Limb Two surveys have assessed reliability Pilot 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 0.83. (May and Ross 2009).

Evidence Base for MDT in the Upper Limb Case Studies Shoulder derangement, (Aina and May 2005). Shoulder contractile dysfunction, (Littlewood and May 2007). Thumb derangement. (Kaneko et al. 2009).

Characteristics of the Three Syndromes Module Eight Characteristics of the Three Syndromes

MDT at the shoulder – 3 surveys with 134 shoulder patients total (%)

Shoulder mechanical syndromes (N = 116) 54

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.

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.

Three Syndromes Operational Definition: Postural syndrome - only produced by sustained loading, which once avoided, the rest of the physical examination would be normal.

eg recent trauma, post-surgery or chronic pain state. Other Operational Definition ‘Other’ refers to failure to classify as one of the above mechanical syndromes. eg recent trauma, post-surgery or chronic pain state.

Shoulder (N = 157) 59

MDT at the shoulder – 3 surveys with 134 shoulder patients total (%)

Shoulder mechanical syndromes (N = 116) 61

Derangement Articular Dysfunction Contractile Posture State Status Const/Intermittent Chemical Component Movement Loss Response during loading Response after loading Prognosis

Module Nine Assessment

Problem Areas History Physical Examination Active movements Passive movements (+/- over-pressure) Resisted movements Repeated movements Sustained postures.

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.

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.

Module Ten Derangement Syndrome

Derangement Key features of Derangement from the assessment

Therapeutic management Consists of: Educational component Active mechanical therapy component. 69

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

Education Component Patient education should not be seen as a ‘nice extra’, but as an effective treatment in itself.

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

Active Mechanical Therapy Component Exercises should be repeated 10 times 3 or 4 times a day, initially Can be done every 2 hours once response clear Progressions and force alternatives should be used.

Empowerment Active 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

Derangement Syndrome Repeated Reductive Movement Avoidance of aggravating factor 75

Direction specific exercises (May 2006)

Progression of forces that may be used in the management of derangements:

Common Upper Extremity Derangements Shoulder Elbow Wrist

Module Eleven Dysfunction Syndrome

Key features of Articular Dysfunction from the assessment

Articular Dysfunction: end-range repeated loading Education in Self Management Self-treatment procedures 81

Common Upper Extremity Articular Dysfunctions Shoulder Elbow Wrist

Contractile Dysfunction Key features of Contractile Dysfunction from the assessment

Contractile Dysfunction Education in Self Management Self Treatment Repeat mid-range loading Use of Target Zone Use of Eccentric loading 84

Why is loading therapeutic? ‘Mechanotransduction’ - Turning Movement into repair Cells convert mechanical signals into biochemical responses, Physiological - adjusts structure to demand Non-neural communication (gap junctions)

So how does one prescribe that ‘optimal load’ Excessive load – injures tendon Optimum load – stimulates healing Under-load – no stimulus for repair

Where to start the loading ? Start with what is tolerable and functionally relevant. Symptom response should be P, NW Remember to progress forces and use force alternatives

Force Options Active Movements Static / isometric Resisted Concentric / Eccentric Outer range/inner range/mid range Amplitude Speed 88

A few RCTs Brox et al (1999) 125 patients with chronic RC disease 1-2 years duration failed to improve with ‘physio’ NSAIDs etc 1 = arthroscopy 2 = resisted exercises 3 = placebo laser Neer scores (1&2 SD 3)

Haahr et al (2005) 90 patients with RC disease – majority > 1year 1 = arthroscopy 2 = strengthening exercises Constant score (NS)

Jonsson et al 2006 9 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 score 5/12 withdrew from surgical waiting list.

Jonsson et al 2006 Ulla –sling used to elevate arm, 30 degrees of horizontal abduction. Eccentric work achieved by lowering the arm.

Jonsson et al 2006 End position Progression by adding weight for eccentric exercise Progression by adding weight

Module Twelve Postural Syndrome

Postural Syndrome Key features of Postural Syndrome from the assessment

Postural Syndrome Education towards self-management Interruption of aggravating posture Ergonomic interventions Prevention easier than treatment 96

Postural syndromes seen in the upper extremities ?

Module Thirteen Case Studies