Meckenzie approach

A manual therapy school. Extension and Flexion based exercises.

1. MCKENZIE APPROACH Radhika Chintamani

2. CONTENTS Introduction History Phenomenon of centralization Progression of forces Mechanical diagnosis Spine Extremities Predisposing and precipitating factors Precautions Physical examination Procedures and techniques Management of syndromes Summary Evidence

3. INTRODUCTION A progression of mechanical forces applied by or to the patient in such a way that a minimal amount is utilized to effect a therapeutic change in the presenting mechanical syndrome. ( Robin Mckenzie , 1981)

4. HISTORY Accidental discovery by Robin Mckenzie

5. PHENOMENON OF CENTRALIZATION As a result of certain repeated movements/ adoption of certain postures, radiating symptoms originating from the spine and referred distally are caused to move proximally towards the midline. Occurs in derangement syndrome Increase in localized central pain Reliable predictor

6. Evidence A study was conducted on 289 patients to determine the centralization phenomenon with acute neck and back pain. During repeated movement testing 31% subjects had their pain centralized or abolition of symptoms in 4 sessions. 46% subjects showed centralization on 8 sessions 23% showed no change in symptoms site or intensity in 8 sessions.

7. PROGRESSION OF FORCES Static patient-generated force positioning in mid-range positioning at end-range Dynamic patient-generated force patient motion in mid range patient motion to end range patient motion to end range with overpressure Therapist generated forces patient motion to end range with therapist overpressure therapist overpressure- mobilization therapist overpressure- manipulation traction- manual, intermittent or sustained

8. THE THREE LIGHTS Red light Pain in derangement & dysfunction is produced/ increased & remains worsened (not centralized) Green Pain in derangement is reduced/ abolished and remains better. Pain in dysfunction produced at the end range disappears when stretch is released. Amber - pain is not worsened nor better.

9. MECHANICAL DIAGNOSIS Postural syndrome Dysfunctional syndrome Derangement syndrome Syndrome ? A characteristic group of symptoms & pattern of happenings typical of a particular problem. ( Chamber’s dictionary)

10. POSTURAL SYNDROME Definition : mechanically deformed soft tissues due to sustaining end range postures and positions. Mechanism of pain : Prolonged static loading of soft tissues within/adjacent to spine Causes overstretching & mechanical deformation Ligamentous followed by muscle fatigue Bent finger syndrome Clinical picture age< 30 yrs Sedentary occupation Insidious onset, gradually worsens Local, intermittent & symmetrical pain Associated with headaches for Cx spine Active pain free movements Worsens at the end of day No radiating pain

11. DYSFUNCTION SYNDROME Definition : shortened tissues are mechanically deformed by overstretching at end range Mechanism of pain : Adaptive shortening, scarring, contracture, adherence/ fibrosis Reduced extensibility of soft tissues Static/ dynamic loading in end range ->mechanical stress on abnormal soft tissues-> mechanical deformation-> pain Causes: trauma, degeneration, posture/ derangement Clinical picture: age: >30 yrs Past h/o trauma or derangement Poor posture Intermittent pain at end range No radiating pain Reduced spinal mobility Early morning stiffness & pain Structural deformities Asymmetrical movement loss

12. DERANGEMENT SYNDROME Definition : disruption or displacement of structures within the intervertebral segment Mechanism of pain Unequal loading of IV disc-> nucleus purposes in eccentric position ->asymmetric compression->disruption in normal resting position of vertebrae-> discomfort-> pain Types -> anterior - > posterior Clinical picture age: 20-55 yrs 12-55 yrs Sudden onset Asymmetrical Radiating symptoms Pain alters & differs Constant in nature Painful ROM Structural deformities

13. For extremities: POSTURAL SYNDROME Pain caused by mechanical deformation/ vascular deprivation of soft tissues due to prolonged postures Affects articular structures / contractile tissues, tendons / periosteul insertions Joint capsule/ ligament pain-> prolonged end range position Contractile tissue pain-> prolonged static mid range loading Leads to CTDs

14. DYSFUNCTION SYNDROME Definition Cause of pain: d/t mechanical deformation of structurally impaired tissues seen in previous h/o trauma/ inflammation/ degenerative processes. These events cause scarring, contraction, adherence/ adaptive shortening. capsule/ligaments affected-> painful restriction at end-range Contractile tissues affected-> pain during resisted movements/ loading at any point of range Articular structures-> restricted end range & intermittent pain Pain in contraction & stretching

15. DERANGEMENT SYNDROME Internal derangement is a common of pain in extremities. (Cyriax,1981) Commonly seen in knee with meniscoid cartilage tear/ displacement of deranged menisci. Causes locking/ restricted ROM. Internal derangement disturbs normal resting position of joint Deforms capsule & periarticular ligaments pain

16. PREDISPOSING AND PRECIPIATING FACTORS Predisposing: Precipitating: Prolonged sitting - Movements Frequency of flexion - trauma - lifting - lateral flexion or rotation

17. PRECAUTIONS Increase in central pain, decrease in distal pain. The increased spinal pain may be disconcerting to clients. Hence, prior to treatment they must be explained & fully assured. Stop the exercises if distal pain/ centralization worsens which should occur during and not after several hours. If symptoms occur after several hours, cause is posture. Unused to exs clients may have new pains in thoracic, extremities d/t new positions movements. In dysfunction, be cautious with clients recovered from a recent derangement. Exs should not provoke pain. Manipulation may cause minor trauma & perpetuate the cycle of repair & failure to remodel.

18. RED FLAGS Cauda equina syndrome Possible cancer Inflammatory disorders Stenosis Serious spinal pathology Hip pathology Symptomatic SIJ Symptomatic spondylolisthesis Mechanically inconclusive Chronic pain state

19. PHYSICAL EXAMINATION History Physical examination Aims of physical examination:- Usual posture Symptomatic response to posture correction Deformities/ asymmetries related to episode Neurological examination Baseline measures of mechanical presentation Symptomatic & mechanical response to repeated movements Conclusion:- Syndrome classification Appropriate therapeutic loading strategy Appropriate testing loading strategy

20. 1. POSTURE: Sitting Standing Leg length discrepancy 2. NEUROLOGICAL TESTS Sensations Muscle power Reflexes Nerve tension tests 3. Movement loss Flexion Extension Rotation Side flexion Side gliding

21. 4. MOVEMENTS IN RELATION TO PAIN Standing Lying 5. REPEATED MOVEMENTS Diagnostic in derangement and dysfunction syndromes In derangement: movement towards painful side - derangement & peripheralising pain movement away from painful side- derangement/ centralization In dysfunction: pain is produced at end range of movement & does not worsen In postural: pain not produced with movement aggravates on sustained positioning

22. PHYSICAL EXAMINATION FOR EXTREMITIES: Active movements Passive movements Passive movement with overpressure Resisted tests Repeated movements Postural syndrome Dysfunction syndrome Derangement syndrome Neurological examination

23. PROCEDURES CERVICAL SPINE Retraction Retraction with extension (sitting/ standing) Retraction with extension (lying/prone) Retraction with extension with traction or rotation Extension mobilization (lying prone/ supine) Retraction and lateral flexion Lateral flexion mobilization and manipulation Retraction and rotation Retraction mobilization and manipulation Flexion Flexion mobilization Traction

24. THORACIC Erect sitting flexion Extension in lying Extension mobilization/ manipulation Erect sitting rotation Rotation mobilization/ manipulation

25. LUMBAR Lying prone Lying prone in extension Extension in lying Extension in lying with belt fixation Sustained extension Extension in standing Extension mobilization Extension manipulation Rotation mobilization in extension Rotation manipulation in extension Sustained rotation/ mobilization in flexion Rotation manipulation in flexion Flexion in lying Flexion in step standing Correction of lateral shift Self-correction of lateral shift

26. MANAGEMENT OF SYNDROMES DERANGEMENT SYNDROME: Stages – Reduction Maintenance of reduction Recovery of function Prophylaxis Treatment principles – Extension Flexion Lateral Combination Irreducible

27. DYSFUNCTION SYNDROME Process is lengthy & measured in week/months Frustration d/t lack of apparent change Exercises performed repeatedly every 2-3 hours Each session of 10-15 stretches Do not strain and cause micro trauma If pain persist after treatment: Overstretching Micro trauma wrong diagnosis Pain is mandatory but subsides after 10 mins Stop exs if pain spreads distally/ deteriorates

28. POSTURAL SYNDROME Explain the correlation between posture & symptoms Educate on posture correction Attain posture Maintain posture Educate on avoidance of aggravating postures Correct posture

29. EXTREMITIES: POSTURAL SYNDROME Education in self management Exs can be performed 10 times 3-4 times daily repeated end range active movements progress with self applied overpressure Resistance towards/ away from direction of limitation at end range Resistance throughout the movement

30. DYSFUNCTION SYNDROME Articular dysfunction End range self mobilizations Client moves the joint actively towards restriction until pain is felt Repetitions:10-12 Frequency: 3-4 times/day Review in 2 days & at the end of 1 week Progress with resisted exercises Musculotendinous/ contractile dysfunction static/ dynamic loading Target zone identified Active movements, static resisted movements, concentric & eccentric loading given in inner, outer or in the target zone Frequency: 3-4 times/day

31. DERANGEMENT SYNDROME Repeated end range movement loading in pain free direction Active exercises at end range overpressure ( progression) Resistance towards/ away from direction of limitation at end range

32. SUMMARY Definition: Mckenzie approach - a progression of mechanical forces from patient to therapist generated. Centralization- radiating symptoms originating from the spine and referred distally are caused to move proximally towards the midline due to adaption to certain postures. History: Accidental discovery of Robin Mckenzie Forces: Static Dynamic Therapist generated

33. Postural Dysfunction Derangement Definition Deformation d/t sustained postures Deformation d/t shortened structures Disruption/displacement of structures Mechanism of pain Overstretching & mechanical deformation Scarring, adherence, contracture, fibrosis Unequal loading Clinical features Age: < 30 Age: > 30 Age: 20-55( Cx ) 12-55 (Lx) Insidious onset insidious/ aware about onset Sudden onset No referred pain No referred pain Referred to arm/ leg Local & symmetrical Symmetrical/ asymmetrical Asymmetrical Intermittent Intermittent Constant Worsens at the end of the day Worsens in morning Worsens in morning Sedentary occupation Poor posture occupation Repetitive / strainousmovements No loss of movement Loss of movement Loss of movement

34. Examination: History Physical examination SPINE EXTREMITIES Posture - Active movements Neurological examination - neurological examination Movements - resisted movements Repeated movements - repeated movements Painful movements - passive movements Procedures: Cervical Thoracic Lumbar

35. Management: Derangement Dysfunction Postural posture correction Extension flexion principle lateral principle principle Postural syndrome: Educate Correct Avoid

36. Dysfunction syndrome Stretch Maintain Derangement syndrome Reduction Maintain Recovery Prophylaxis

37. EVIDENCES A RCT study was conducted by Rosedale et al on the efficacy of exercise intervention in patients with knee OA based on Mckenzie’s mechanical diagnosis. 180 patients were assigned to MDT and a control group. Pain & function were assessed after 3 months of intervention The study concluded that MDT group showed superior outcomes than the control groups

38. Stanish et al conducted a study on the effect of eccentric exercises on 200 chronic tendononitis subjects. Eccentric strength training program was given daily over a six week period. Among 200 patients, 44% had complete relief of symptoms & return to normal function. 43% had a marked decrease in pain & function 9% had their problems unchanged 2% had worse outcomes at the end of treatment. Study concluded that eccentric loading in particular was extremely useful in rehabilitation of chronic tendonitis.

39. Kjellman & Oberg in 2002 conducted a RCT on 77 patients to find out the effect of general exercises, Mckenzie group and control group. Pain intensity & NDI were calculated. Pain intensity and disability scale showed improvements in all groups with no significant difference. But, there was significant difference in Mckenzie group than the control group & general mobility exercise group.

40. REFERENCES Jeffrey Boyling , Nigel Palastanga ; GRIEVE’S modern manual therapy, chap 28, 42, 55; 2 nd edition, the vertebral column.; Churchil Livingstone. Robin Mckenzie , Stephan May; The lumbar spine: mechanical diagnosis & therapy. Volume I, II. 2 nd edition, Spinal publications. Robin Mckenzie , Stephan May; The cervical & thoracic spine: mechanical diagnosis & therapy. Volume I, II. 2 nd edition, Spinal publications. Robin Mckenzie , Stephan May; Human extremities: mechanical diagnosis & therapy. Volume I, II. 2 nd edition, Spinal publications. Stanish WD, Rubinovich RM. Eccentric exercises in chronic tendonitis. Clinical Ortho & Rel Res 208. 65-68. Rosedale R et al. efficacy of exercise intervention as determined by Mckenzie system of mechanical Diagnosis & therapy for knee osteoarthritis: aRCT . Journal of orthopaedic and sports physiotherapy; 44(3).

41. Werenke M, Hart DL, Cook D. Descriptive study of the phenomenon. A prospective analysis. Spine 1999; 24(7): 676-83. Kjellman , Oberg B. a critical analysis of randomized clinical trials on neck pain and treatment efficiency. A review of literature. Scand J rehab Med 31. 139-152. Stanish WD, Rubinovich RM, Curvin S. eccentric exercise in chronic tendonitis. Clinical ortho & rel res 208.65-68.