In part 1 of this series, we discussed the misconceptions of the McKenzie Method. Part 2 of the this guest post series by Christie Downing will review the three main mechanical syndromes and focus on treatment advice and some words of wisdom based on Christie’s experience. Be sure to go back to Part 1 to learn about the basics of Mechanical Diagnosis and Therapy (MDT) if you haven’t read it already.
Syndrome Classification in MDT
There are three main syndromes in MDT – Derangement, dysfunction, and posture. Each one will be discussed.
Simply put, this is a disruption in the normal articulation of a joint. There are several characteristics that make this syndrome unique including: it can be rapidly reversible, it can be acute or chronic, it can produce distal or local pain, there is loss of movement, it may display a “directional preference” and is the only syndrome to demonstrate “centralization” of symptoms…the hallmark of the disorder.
Possible mechanism: Tissue obstructing movement (i.e., disc protrusion)
Analogy for the patient: A pencil stuck in the door jam…it won’t open or close all the way until you wiggle the door around and get the pencil out of the way.
It exists as both an articular or contractile tissue dysfunction. I will focus on articular because it is the easiest to understand. For those somewhat familiar with MDT, adherent nerve root is also a type of dysfunction, but I will not focus on this today. Basically, dysfunction is shorted and adapted tissues that when stretched or loaded, produce pain. There are several characteristics that can help one identify a dysfunction: it is always chronic, it only produces local pain (except adherent nerve root), it is consistent (the same activity always produces pain), there is loss of movement, it is not rapidly reversible and pain is always intermittent.
Possible Mechanism: restricted tissues that when stretched/loaded produce pain (i.e., a knee flexion contracture)
Analogy for the patient: someone who has been immobilized in a cast. The joint is stiff and each time it is stretched, it produces pain.
In this syndrome, it is faulty postures and positions that place undue mechanical strain on otherwise normal tissue. It’s actually somewhat rare to see this patient in the clinic. Often times, they figure out on their own what needs to be done, namely, posture correction. However, anecdotally, patients with this syndrome are typically teenagers who sit in a slumped position. Often times, a worried parent accompanies the patient to therapy, concerned that a more troublesome diagnosis exists. However, in these situations, the patient is pain free upon activity and only experiences the pain with prolonged sitting or standing with slouched posture. Movement is full and pain free. Education is very important, first, to reduce stress and ease worry; second, to educate about behavioral modification required.
Possible mechanism: deformation of mechanoreceptors with prolonged postures and/or temporary ischemia to joint capsules, ligaments and other soft tissues.
Analogy for the patient: Bend your finger backwards to demonstrate how prolonged stresses can cause pain, but that upon release of the prolonged position, the finger returns to full pain free range of motion.
Treating the derangement syndrome
There are a few pearls I have picked up over the years. Some I’ve learned as part of advanced clinical training and others on personal experience. I’m going to share a few with you that may help you understand how to proceed with the mechanical clinical reasoning. Since the Derangement Syndrome is so common, we’ll use this syndrome as a model.
When it comes down to it, treatment of dysfunction and posture syndromes are really simple: increase tissue extensibility and educate (respectively for each). Truth be told, the literature on these two syndromes in not as well versed, but as far as dysfunction syndrome, therapists can take their knowledge from sources outside MDT regarding connective tissue properties in order to effectively treat dysfunction.
Really Listen to Your Patient
Patients often tell me in their subjective history how to best treat them. They can give you clues not just about what syndrome they have, but how to best treat it.
- Does your patient report that certain movements and positions sometimes hurt and other times do not? This is highly suggestive of derangement syndrome. Patient often need to be reassured that variability is common, as many think they are “crazy” because “one time I bend over and it hurts, and other times I can do it just fine.”
- Do they tend to feel better with certain activities that suggest a directional preference? Is your patient typically better walking and lying prone and worse with sitting and bending? This highly suggests an extension bias. For the acutely injured patient or those with high fear avoidance belief questionnaires, avoiding repetitious motion testing into flexion, in this case, can result in getting to the answer faster while sparing the relationship with your patient.
- Do they need a loaded or unloaded force? While we typically start motion testing in standing, for those who tell me that both standing and walking, but so does sitting while lying is quite comfortable, I may defer a lot of unnecessary testing in standing and go right to the supine or prone position after a general ROM baseline assessment.
Not only will you hopefully arise at a provisional diagnosis before the exam has even begun, but summarizing to the patient that you’ve really listened to them is a great way to establish a rapport: “Based on what you’ve told me, your body want to move in this way in order to help it heal…you were very clear about this in what you told me. The examination only confirmed what you told me…”
Use the “Traffic Light” Guide
Simply stated, this is a way to determine if you need to progress your force or consider an alternative.
- Green light: The more a patient moves in a particular direction results in abolition of pain, lessening of pain, centralizing of peripheral symptoms and/or a rapid mechanical improvement (ie, more range of motion, lessening of neurogenic signs, etc). In this case, continue on with the current regimen. If it’s giving you the desired response, no need to change it.
- Yellow light: Proceed with caution. This happens when one experiences an equivocal response. An example could be someone who is better during a movement, but does not remain so afterwards. It could also mean someone who is worse during a movement, but does not remain so afterwards. Yellow lights mean a force progression. This could mean more time and repetition, giving extra pressure to a movement (ie, mobilization)….or in some cases less pressure. The novice McKenzie practitioner often fails to recognize that force progression is a continuum of treatment in the same direction, but with variable levels of force. An example could be someone who needs to start with mid range extension in lying before proceeding to end range extension in lying.
- Red lights: Stop! This one is obvious: motions that increase or produce symptoms that weren’t there before and/or result in peripheralizing symptoms that remain worse even after the maneuver. Red lights require a force alternative, usually a change in direction and/or loading strategy. This could be someone who is worse with repeated extension in lying who need to have a lateral component entered into the equation.
The traffic light guide is a very simple tool to not only guide clinical reasoning, but is also helpful for patients. I use it even in cases of non-mechanical pain. In treating those with a sensitized pain state, it gives them a guide to know how much to do, how much pain is allowable, what should happen afterwards and when they should “back off.” Giving patients permission to evaluate and respond to their own symptoms is highly empowering! It’s also a good chance to educate them about pain…pain does not always mean harm!
Watch for Mechanical Changes
Watch for mechanical changes when the symptomatic complaint does not seem to change. Novice McKenzie practitioners frequently forget this. For someone with painful and restricted motion, a rapid increase in range of motion in the face of an equivocal symptomatic response is still a green light. In my opinion, this is most easily observable in the cervical spine and extremities. Someone who has painful right rotation who, after doing repetitions of retraction and extension, still has painful right rotation that has improved from 20 degrees to 50 is still a green light. Keep going! Be patient!
I hope this series has helped to shed some light on the usefulness of the McKenzie Method and MDT principles. Are you MDT trained? What other advice would you offer?
Christie Downing, PT, DPT, Dip. MDT, ICLM Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village, IL. She specialize in musculoskeletal care as well as lymphedema management. She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.