Mikenzie's approach.pptx................

mikenzie's approach

1. Mckenzie’s approach 1

2. origin MECHANICAL DIAGNOSIS AND THERAPY (MDT) for SPINE- Application and progression of patient or therapist generated forces for the treatment of spinal disorders of mechanical origin. 2

3. Cardinal features Classification of syndromes based on symptoms or mechanical response Use of Repeated Movement testing for diagnosis and management Focus on Centralization and Direction Preference Progression of forces 3 PATIENT THERAPIST

4. MECHANICAL PAIN Joint between two bone has been placed in a position that overstretches the surrounding soft tissues. Pain produced intermittently only in direction of specific movement or position which loads the tissues Movement in opposite direction or rest relieves pain Repeated loading of tissues in painful direction- damage 4

5. CLASSIFICATION OF SYNDROMES 5

6. DERRANGEMENT SYNDROME Symptoms produced due to Mechanical obstruction of affected joint Commonest presentation in middle age group (25-55) Sudden onset of symptoms with disability History of Recurrence Location of pain- local, referred or radicular Symptoms -Constant or Intermittent, variable during the day Diminished range or altered Quality of movement Associated with temporary deformity 6

7. McKenzie uses ‘disc mechanics’ as the basis for pain production. As the spine moves, the nucleus pulposus migrates towards the area of least load. Prolonged asymmetric or unequal loading of spine cause disc protrusion resulting in pain. Main predisposing factor is sustained flexion: -nucleus migrates posteriorly -tangential stress on posterior annulus is increased -disc pressure is raised The annulus fibrosis is weakened by loss of elasticity. Fissures and rupture develop which allow the degenerated nucleus to migrate.

8. Sustained loading- Worsen or Improve symptoms Repeated Movements Change in symptoms lasts over a period of time Exhibits Directional preference 8 CENTRALIZE OR PERIPHERALIZE SYMPTOMS INCREASE OR DECREASE SYMPTOMS INCREASE OR DECREASE RANGE

9. Repetitive movements Reduce pressure over the inner annulus Decrease distension of outermost annulus Relocation of displacement Diminish nerve root compression or irritation Abolition of peripheral symptoms Central location of symptoms

10. CENTRALIZATION- In response to repeated movement or sustained posture- Distal to proximal migration of symptom location Reduction in distal symptoms (often increase central symptoms) Movement of localized symptoms from widespread to central area PERIPHERALIZATION- In response to repeated movement or sustained posture- Symptoms migrate from proximal to distal location Worsening of neurological symptoms 10

11. DIRECTIONAL PREFERENCE- Clinical phenomenon where a specific direction of repeated movement and/ or sustained posture results in clinically relevant improvement in either symptoms and/or mechanics though not always centralization of symptoms 12

12. Types of derrangement Based on Disc pathology with associated Directional Preference- POSTERIOR DERRANGEMENT- Due to posterocentral or posterolateral displacement of the nuclear/annular complex. DP for extension movements or positions. ANTERIOR DERRANGEMENT - Due to antero or antero -lateral migration of the nuclear/annular complex. DP for flexion movements or positions. 13

13. Dysfunction syndrome Symptoms arising out of mechanical loading of structurally impaired articular or contractile structures History of trauma or degeneration or inflammation Age > 30 years, Chronic course >8-12 weeks Localized and intermittent pain Pain produced in loading -felt at end range of movement, Ceases immediately on off loading Repeated movements- Produce symptoms in specific direction (no increase or decrease, centralize or peripheralize ) 14

14. Shortened soft tissues around the spinal segments Reduced elasticity or extensibility Minor microtears due to flexion forces Repair of damaged structure and formation of fibrous soft tissue Formation of inextensible scar with less strength and range Overstretch loading on such structure Dysfunctional pain

15. Postural syndrome Mechanical deformation of soft tissues due to prolonged postural stresses on articular or contractile structures give rise to symptoms. Young population with sedentary l ifestyle Habitual poor posture Local, intermittent symptoms Sustained postures- produces symptoms (TIME factor) Correction of posture abolishes symptoms No change with movements Repeated Movements- No effect 16

16. Muscles supporting low back become tired and relax Static postural support is provided by ligaments Overstretching Mechanical deformation Postural pain End-range of flexion in prolonged sitting or bending forward. When low lumbar spine is in sustained extension (relaxed standing).

17. EXAMINATION Movement loss Range Pain stopping the movement Movement transitions Repeated Movements Flexion in standing Flexion in Lying Extension in standing Extension in Lying Sustained Positions Sitting erect Sitting Slouched Standing erect Standing slouched Prone lying in extension Symptom Response- Baseline symptoms Pain during movement or End range pain Symptoms after testing- Increased, decreased, no effect

18. In dysfunction syndrome , test movements that enhance the symptoms must be used. In derangement syndrome , the test movements that reduce, centralize or abolish the symptoms must be used.

19. PROGRESSION OF FORCES 20

20. Principles of management 21 Extension principle Lying prone Sustained extension in lying Extension in standing Slouch overcorrect Extension in lying with patient overpressure Extension in lying with therapist overpressure Extension mobilization Flexion principle Flexion in lying Flexion in sitting Flexion in standing Flexion in lying with therapist overpressure

21. Traffic light guide PAIN RESPONSE MOVEMENT RANGE INFERENCE Increases+ Stays worse Produces + Stays w orse Peripheralization Decreases + stays worse Incorrect direction of movement Reduce force Progression Produce/ No worse Decrease/ No better No change Force Progression needed, Applied force is insufficient Decreases+ Stays better Abolishes+ stays better Produce+ better with repetition Centralization Increases+ stays better Correct direction of movement and force applied; continue with the same 22 STOP PROGRESS CONTINUE