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Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 1
Welcome to MyLearning
The Australian Physiotherapy Association’s e‐learning site
This course is powered by EDUCATAThis course is powered by EDUCATA
The McKenzie Method:The Scope and Application of
Mechanical Diagnosis and Therapy (MDT)
Developed by faculty at the McKenzie Institute International:
Richard Rosedale PT, Dip. MDTKathy Hoyt PT, Dip. MDT
and Robert Medcalf PT, Dip. MDT
Mechanical Diagnosis & Therapy®of the Spine & Extremities
Robin A. McKenzieCNZM, O.B.E., FCSP (Hon), FNZSP (Hon), NZCP (HLM), Dip. MT Di MDTMT, Dip. MDT
President of The McKenzie Institute International
Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 2
Outline
• History and background
• Institute and educational program
• The natural history of musculoskeletal conditions
Section 1 Section 2
educational program
• Principles, evidence overview
conditions
• The need for classification
• An outline of MDT classification
Outline
• Assessment overview
• Principles of
• Case examples
Section 3 Section 4
• Principles of management
• Summary
Section 5
History of MDT
• Robin McKenzie
• Mr. Smith
• Key to effective therapy
– Education
– Self‐treatment
Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 3
Disc Model
Flexion Extension
Nuclear Movement
The next slide shows nuclear movement occurring in the lumbar spine in a laboratory setting.
Nuclear Movement
Sheppard J, Rand C. “Internal disc dynamics: a study of 100 specimens.” Hastings, England.
Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 4
McKenzie Institute
• Founded in 1982
• Located in i hRaumati Beach,
New Zealand
• 27 branches worldwide
DenmarkUnited States Netherlands
Argentina Finland New Zealand
Brazil France Nigeria
Canada Germany Poland
Australia Hellas/Cyprus Saudi Arabia
McKenzie Institute International
Czech Republic
Belgium Italy Sweden
Croatia Japan Switzerland
Luxembourg United Kingdom
Hungary SloveniaAustria
McKenzie Institute
• 80 teaching faculty
• Roles of d i heducation, research, promotion
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Mechanical Diagnosis and Therapy®
A unique, dynamicand comprehensive
systemy
of assessment, classification, treatment and prevention
for musculoskeletal disorders.
Mechanical Diagnosis and Therapy®not simply extension exercises…
Mechanical Diagnosis and Therapy®exploring different loading strategies, postures and movements…
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Mechanical Diagnosis and Therapy® to classify and treat musculoskeletal conditions.
What Is the McKenzie System of Mechanical Diagnosis & Therapy (MDT)?
Diagnostic – Reliability
Prognostic – Validity
Therapeutic – Dx/Rx link
Client‐centered – Patient empowerment
Prophylactic – Prevent recurrences
Mechanical Diagnosis & Therapy®(MDT)
Positions
MovementsMovements
Postures
Activities
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Mechanical Diagnosis & Therapy® (MDT)
DD TT OO
Reliable assessment
Patient‐generated exercises
AA DD TT OOValid classifications Better outcomes when
treatment matched to classification
AA
Spratt 2002.
Reliability Studies on MDT15+ pain response studies = good reliability
• Clare 2004, 2005
• Dionne 2006
• Kilpikoski 2002
• Laslett 2003
• May 2009
• Petersen 2003, 2004
• Seymour 2003
• Razmjou 2000
• Werneke 1999
Assessment
Diagnosis
The McKenzie Institute® Education & Certification Program
• Part A: Lumbar spine
• Part B: Cervical & thoracic spine
• Part C: Advanced lumbar spine and extremities: lower limb
• Part D: Advanced cervical spine and extremities: upper limb
• Credentialing examination
• MII Diploma Program
• In the United States: Fellowship in MDT/OMPT
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Centralizationreliability
• Agreement – 88% to 100%
• Kappa – 0.51 to 0.96
Five studies
• Kappa – 4 studies > 0.70
• Good to very good reliability
• Level of training influenced the results
Extremitiesreliability
• Classification
– Kappa: 0.84 (May and Ross 2009)
Clinical Subgroup Studiesobservational, case series, prognostic, diagnostic validation, surveys
Studies:
Alexander 1992; Brotz 2010; Bybee 2005; Clare2007; Donelson 1990, 1991, 1997; Erhard 1994;Fritz 2007; George 2005; Hefford 2008; Karas1997; Kopp 1986; Laslett 2005; Long 1995, May2006, 2008 (Rasmussen 2005); Skytte 2005;Sufka 1998; Young 2003; Werneke 1999, 2001,2003 2004 2005 2008
Treatment2003, 2004, 2005, 2008
Reviews:
Aina & May 2004; Berthelot 2007; Hancook May2006, 2007, 2008; Udermann 2004; Wetzel2005, May & Donelson 2008; Machado 2006;Peterson 1999
Diagnosis
30+ centralization/DP publications
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Resultsprognosis
• 6 studies reported on prognosis.
• Outcomes for centralization subgroup compared to non‐centralization subgroup.
• Treatments were based primarily on MDT principles.
Resultscentralization
• Good/excellent overall outcomes
• Greater reduction in pain intensity
Centralization was correlated with:
Greater reduction in pain intensity
• Higher return‐to‐work rate
• Greater functional improvement
Randomized Clinical Trials with SubgroupsMDT, centralization, directional preference
• Brennan 2006
• Browder 2007
• Brotz 2007
• Delitto 1993
Treatment
Out‐comes
• Delitto 1993
• Fritz 2003, 2007
• Long 2004
• (Spratt 1993)
Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 10
Treatment
DD TT OOAA DD TT OOAA
Building Evidence
Treatment
Outcomes
Diagnosis
Assessment
Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 11
Section 2
The natural history of musculoskeletal conditionsand the implicationsand the implications
The need for classification
An outline of MDT classification
Epidemiology & Natural History
• Common life experience
• Middle stages of life in ispine
• Progressively worse with age in extremitieshttp://farm3.static.flickr.com/2443/4056452089
_2b169b685d.jpg
Epidemiology & Natural History
Persistent, episodic and recurrent symptoms common
http://www.pro‐motionphysicaltherapy.com/images/top/low_back_pain_program.jpg
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EpidemiologyLBP, etc.
Natural History of LBP
• “Not a self‐limiting condition … almost half still have pain at one year.” (Schiotz‐Christensen)
• “At 12‐month review, only 25% of patients with acute LBP hadpatients with acute LBP had completely recovered.” (Croft)
• “During the 12‐month observation period, 76% of patients had a recurrence of their LBP.” (Van den Hoogen)
http://www.globalwellnesscentre.com/images/lower‐back‐pain.jpg
Clinical Implications?
• Long‐term management required
• Who is in the best position to achieve this?position to achieve this?
the patient
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Clinical Management
• Specific “mechanical” syndromes
Classification and diagnosis
• Related to mechanism of symptom generation and response
Derangement
Mechanical Syndromes
The Three Syndromes
g
Dysfunction
Posture
Why the Need for Non‐Pathoanatomical Diagnoses?
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Clinical Management
• Fourth classification utilized for specific identifiable pathologies:
Classification and diagnosis
– “Other”
Derangement
Internal derangement causes a disturbance in the normal resting
position of the affected joint surfaces.
http://www.reviewmylife.co.uk/data/2009/0902/knee‐mri‐scan‐front1.jpg
Derangement
• Varied clinical presentation
• Obstruction to movement
• Centralization/peripheralization (in spine)p p p
• Possibility of acute deformities
• Ability to change rapidly
• Directional preference
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Directional Preference (DP)
Mechanical loading
examination,including
Identification of specific directional
Symptoms centralize
or decrease
Confirms classification
ofincluding repeated
movements
directional exercise or range
increases
of derangement
Prevalence Rates of DP
40
50
60
70
80
90
• A. 130 patients in 3 reliability studies
• SR centralization – B = 731 ALBP; C = 325 CLBP
• D. Long – 312 A‐CLBP
0
10
20
30
A B C D E F G H J
MDT Training No MDT training
• E. May – N = 607
• F. Hefford – N = 341
• G. Fritz – N = 120
• H. Browder – N = 300
• J. George
Derangement
• Central/symmetrical
In the spine, location of pain indicates sub‐classification:
• Unilateral/asymmetrical to the knee/elbow
• Unilateral/asymmetrical below the knee/elbow
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Centralization
Process by which referred pain is sequentially
abolished in response to therapeutic or diagnostic positions or movements.
Centralizationtransitions
Centralizationprevalence
• Meta‐analysis of 1,056 patients
• Centralization occurred in 681 patients
Eleven studies
(64.5%)
• Mean prevalence = 58% (31% to 87%)
• 731 acute or sub‐acute patients – 70%
• 325 chronic patients – 52%
Not to be copied without the express permission of EDUCATA and the MII.Copyright ©2010 The McKenzie Institute International. All rights reserved. 17
Peripheralization
• The opposite of centralization
h i• When exercises or positions cause the spread of pain distally
Dysfunction
• Mechanical deformation of structurally impaired soft tissues.
• Contraction, scarring, adherence, adaptive shortening, or imperfect repair. g p p
http://www.evpedia.org/IMG/jpg/F35.jpg
Dysfunction• Local pain (except nerve root adherence)
• Intermittent, chronic
• Movement loss with pain reproduced at
• end range
• Consistent end rangeresponse
• No rapid changespain reproduced at
http://www.evpedia.org/IMG/jpg/F35.jpg
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Extremity Dysfunction
• Articular: same criteriaas spinal dysfunction.
• Contractile: Whenstructural changesaffect contractile tissueaffect contractile tissue.
– Pain will be felt duringresisted movements,
– Or loading at any point through the range, i.e., when thetissue contracts.
– Pain may also be provoked when the tissue is stretched.
http://farm3.static.flickr.com/2099/2450480466_97aa0ffcb6_o.jpg
Postural
Caused by mechanical deformation of soft tissues or vascular
insufficiency arising from prolonged postural stresses affecting the articular or contractile
structures.
Postural
• Local pain
• Intermittent
• Symptoms with sustained end range gpositioning
• No movement loss
• No effect with dynamic movement testing
http://www.structuralwisdom.com/images/forward_head.jpg
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Spinal “Other” Conditions
• Red flags
• Trauma
• Hip/shoulder
• SIJ• SIJ
• Stenosis
• Spondylolisthesis
• Chronic pain state
• Mechanically inconclusivehttp://www.faqs.org/photo‐dict/photofiles/list/695/1106spine.jpg
“Other” Conditionsin the Extremities
• Red flags
• Trauma
• Inflammatory
• Chronic pain state
• Articular structurally compromised
http://www.choa.org/images/photography/little_league_elbow.jpg
Centralization
MDT
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Section 3
Assessment overview
Principles of management
A Day With McKenziepart one
Before we move on, here’s Robin McKenzie, in his own words, during a live presentation at the
2007 McKenzie Institute Conference2007 McKenzie Institute Conference in Queenstown, New Zealand.
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A Day With McKenziepart one
Assessment Process1. history taking
Assessment Process: History Taking
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Assessment Process2. physical examination
• Posture
• Neurological
• Movement loss (active, passive, & resisted in extremities)
Assessment Process2. physical examination: repeated movements
Examples of Test Movements in Lumbar Spine
flexion in standing
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Examples of Test Movements in Lumbar Spine
extension in standing
Examples of Test Movements in Lumbar Spine
flexion in lying
Examples of Test Movements in Lumbar Spine
extension in lying
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Examples of Test Movements in Lumbar Spine
side gliding in standing
Examples of Cervical Test Movements
Retraction Extension
Examples of Knee Test Movements
Knee extension Knee flexion
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Definition of Terms
• Symptomatic responses
• Mechanical responses
Symptomatic Response
VAS 4/10 VAS 1/10 VAS 2/10
Mechanical Response
Establishmechanical baseline
Repeated movementRe‐check
mechanical baseline
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Assessment Process2. physical examination: static tests, other tests
Assessment Process
3. Provisional classification
4. Reassessment
5. Confirm classification
A Day With McKenziepart two
Here are a few more words from Robin during the McKenzie Institute
Conference proceedings.
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A Day With McKenziepart two
Principles of Management
• Posture correction
Spine
• Flexion
• Extension
• Lateral
Principles of Management
Extremities
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Management of Derangement
• Achieve reduction
= Centralization and/or abolishing of symptoms
= Obstruction removed
= Condition remains better
• Maintain reduction
• Recover function
• Educate in prophylaxis
Management of Dysfunction • Remodelling of tissue
• To regain the lost function (range)
• Produce symptoms at end range
• “No pain, no gain”
• Education and postural correction
• Prophylactic training
Management of Postural Syndrome
• Education re: mechanism of pain production
• Train correction ofTrain correction of postural habits
• Prophylactic instructions
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Principles of Management examples
Derangement
Flexion Principle
Principle treatment for:
gw/ directional preference for flexion
Flexion dysfunction
Nerve root adherence in spine
Principles of Management examples
Derangement w/ directional
Extension Principle
Principle treatment for:
erangement w/ directionalpreference for extension
Extension dysfunction
Principles of Management examples
Derangement w/ directional
Knee Extension
Principle treatment for:
erangement w/ directionalpreference for extension forces
Extension dysfunction
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Principles of Management examples
Derangement w/ directional
Shoulder Internal Rotation
Principle treatment for:
Derangement w/ directional preference for internal rotation
Internal rotation dysfunction
Procedures of Mechanical Therapy
Static patient‐generated forces: Positioning mid‐end range
Dynamic patient‐generated forces:Patient motion mid‐end range,then with over‐pressure (O/P)
Procedures of Mechanical Therapy
• Patient motion with clinician O/P
• Clinician mobilization ‐manipulation
Clinician‐generated forces:
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Patientoverpressure
Therapistoverpressure
Mobilization
ManipulationForce Progression
McKenzie A
Patient‐generated
overpressure
Independent Dependent
Reassessment/Treatment Progressions
1. Confirm,
Reject,
Modify provisional classification
Reassessment/Treatment
Progressions
2. Determine need for progressions of forceprogressions of force.
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Reassessment/TreatmentProgressions
3. Determine when to initiate recovery of function.
Reassessment/Treatment Progressions
4. Determine when further treatment with MDT is not appropriate.
Reassessment/TreatmentProgressions
5. Develop patient’s self‐management skills and
h l iprophylactic program.
6. Determine the need and timing for discharge.
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Section 4
Spinal case study
Extremity case study
Spinal Case Study
40‐year‐old female with acute
lumbar painlumbar pain
http://www.stylishandtrendy.com/wp‐content/uploads/2009/06/women‐back_pain‐300x299.jpg
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Date Feb 06
Name Daphne Sex M / F
Address
Telephone
Date of Birth Age 40
THE MCKENZIE INSTITUTE LUMBAR SPINE ASSESSMENT
Spinal Case Study
Referral: GP / Orth / Self / Other
Work: Mechanical Stresses Administration
Sitting++
Leisure: Mechanical Stresses Stand/walk > sitting
Functional Disability from present episode Cannot sit >2-3 mins
Functional Disability score RM: 19/24, Fear Avoid:14/24 (act)
VAS Score (0-10) 9/10
Spinal Case Studyclinical reasoning
• Derangement
• Posture
D f ti
• Hip
• Spinal stenosis
R d fl
Possible hypotheses?
• Dysfunction
• SIJ
• Chronic Pain
• Trauma
• Red flag
• Spondylolisthesis
• Mechanically inconclusive
Present Symptoms
Present since Yesterday Improving / Unchanging / WorseningCommenced as a result of
Doing the “bow” in yoga Or no apparent reason
Symptoms at onset: back / thigh / leg
Constant symptoms: back / thigh / leg
Intermittent symptoms: back / thigh / leg
Worse bending Sitting / rising standing walking
lying
am / as the day progresses / pm when still / on the move
other
Spinal Case Studyhistory
Better bending sitting standing walking lying
am / as the day progresses / pm when still / on the move
other
Disturbed Sleep Yes / No Sleeping postures: prone / sup / side R / L Surface: firm / soft / sag
Previous Episodes 0 1-5 6-10 11+ Year of first episode
Previous History 1 episode 7 years ago, resolved in 1 month…nothing since
Previous Treatments none
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Cough / Sneeze / Strain / +ve / -ve Bladder: normal / abnormal Gait: normal / abnormal Medications: Nil / NSAIDS / Analg / Steroids / Anticoag / Other Robaxacet, Ibuprofen
General Health: Good / Fair / Poor Imaging: Yes / No
Spinal Case Studyspecific questions
Imaging: Yes / No Recent or major surgery: Yes / No Night Pain: Yes / No
Accidents: Yes / No Unexplained weight loss: Yes / No
Other:
McKenzie Institute International ©2005
Spinal Case Study
• Chronic pain
• Trauma
• Dysfunction
• Hip
What have we ruled out?
• Red flags
• Posture
• Spinal stenosis
Spinal Case Study
• Derangement
• SIJ
Extension
Flexion
Lateral
What’s left?
SIJ
• Spondylolythesis
• Mechanically inconclusive
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POSTURE Sitting: Good / Fair / Poor
Standing: Good / Fair / Poor Lordosis: Red / Acc / Normal Lateral Shift: Right / Left / Nil
Correction of Posture: Better / Worse / No effect Relevant: Yes / No
Other Observations: NEUROLOGICAL Motor Deficit Reflexes
Sensory Deficit Dural Signs
Spinal Case Studyexamination
MOVEMENT LOSS
Maj Mod Min Nil Pain
Flexion * LBP (No loss of lordosis)
Extension * LBP
Side Gliding R * LBP
Side Gliding L * LBP
Spinal Case Studytest movements
Describe effect on present pain – During: produces, abolishes, increases, decreases, no effect, centralising, peripheralising. After: better, worse, no better, no worse, no effect, centralised, peripheralised.
Symptoms During Testing Symptoms After Testing Mechanical Response
Rom RomNo
Effect
Pretest symptoms standing: LBP
FIS
Rep FIS
EIS Increase LBP
Rep EIS Increase LBP W * Pretest symptoms lying: NIL y p y g
FIL Produce LBP
Rep FIL Produce LBP B in F
EIL Produce LBP
Rep EIL Produce LBP W In F
If required pretest symptoms:
SGIS – R
Rep SGIS - R
SGIS - L
Rep SGIS- L STATIC TESTS
Sitting slouched Sitting erect
Standing slouched Standing erect
Lying prone in extension Long sitting
OTHER TESTS
Spinal Case Studyprovisional classification
Derangement Flexion Principle
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Spinal Case Studyprinciple of management
• Flexion: RFIL x 10 / 1‐2 hours
• Posture: Neutral (sit and stand)
• Avoid extension
Spinal Case Studyfollow-up (4 days later)
• Hx:
– “85% better,” much less pain, moving well
• Exam:Exam:
– Movement loss:
• Flexion: No loss (full reversal of lordosis)
• Extension: No loss
Spinal Case Studyfollow-up (4 days later)
• Pre: No symptoms
• RFIL: NE
• Rx:
– Decrease frequency RFIL to 3‐4x/day
– Review posture
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Spinal Case Studyvisit 3 (2 days later)
• Hx: Only experiencing odd twinge; otherwise pain‐free, moving fully
• Exam:
– No movement lossNo movement loss
– No baseline pain
• Rx: Review prophylaxis
– Resume all previous activities
– Review posture…..D/C
Spinal Case Study1-month follow-up
• Pain‐free: 0/10
• Roland Morris score: 0/24
• Resumed all activities, including yoga
Extremity Case Study
34‐year‐old female with long history of
left knee painleft knee pain
http://images.teamsugar.com/files/upl1/1/12981/18_2008/runners‐knee.jpg
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Extremity Case Studyhistory
• 4‐year Hx of intermittent left knee pain.
• Progressively worsened over years.
• Night pain.Night pain.
• Unable to squat at all, run and pain/unsteadiness with walking.
• Pain with ascending/descending stairs.
Extremity Case Studyhistory
• Injection 2 years ago: no help.
• Scope left knee 5 months ago.
• Continued pain post‐scope, “worse than pre‐surgery.”
Extremity Case Studypost-scope diagnosis
• Scope:
– Removal lesion and debridement
– Partial lateral menisectomy
• “Osteochondral lesion from lat femoral condyle, unrepairable displaced chronic bucket handle tear of the lateral meniscus.”
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Extremity Case Studypost-scope MRI findings
• Complete absence of normal lateral meniscus, “flipped” with multiple fragments in joint space.
• Thickening of patellar tendon, consistent with partial teartear.
• Suspected partial tear of quad tendon and ITB.
• Osteochondral injury and fragmentation of the subchondral region with fragment (1.1x1.7cm).
• Joint effusion and Baker’s cyst.
Extremity Case Study
What’s the prognosis?
Extremity Case Studyexamination
• Knee flexion 135 degrees: painful lack of 5‐8 degrees.
• Full and pain‐free extension.
• Squat painful and less WB on left.
• Resisted strength strong, painless.
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Extremity Case Studyrepeated movement exam
• Repeated flexion produced knee pain, but no worse symptomatically.
• Mechanically
– Increased range.
– “50% less pain” on squatting.
Extremity Case Study
? D t
What’s the classification?
? Derangement
Extremity Case Studytreatment
• The classification of derangement determines the treatment of a specific directional exercise.
• In this case, it is end‐range repeated knee flexion, 10‐15 repetitions 5‐6x per day.
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Extremity Case Studyprognosis
• The classification also determines the prognosis.
hi h l ifi i f• In this case, the classification of a derangement would predict a rapid and successful outcome.
Extremity Case Studyoutcomes
• 24 hours:
– “Walking is much better, best it’s been in the past few months.”
– Jogging on treadmill with
• 1‐week follow‐up:
– “80% better since initial visit.”
– Full range knee movement.
Pain free squat (still WB lessJogging on treadmill with no pain.
– Pain‐free squat.
– Pain‐free squat (still WB less on left).
• 3‐week follow up:
– Full squat.
– “Not experiencing pain.”
Extremity Case Studypost-scope MRI findings
• Complete absence of normal lateral meniscus, “flipped” with multiple fragments in joint space.
• Thickening of patellar tendon, consistent with partial teartear.
• Suspected partial tear of quad tendon and ITB.
• Osteochondral injury and fragmentation of the subchondral region with fragment (1.1x1.7cm).
• Joint effusion and Baker’s cyst.
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Section 5
Summary
Summary
• Comprehensive system
• Spine and extremities
• Principles are based on sound scientificsound scientific rationale
• Identifies those that are appropriate for therapy
Summary
• Meticulous assessment/reassessment of patient
• Emphasis on
Patient ed cation &– Patient education &
– Training in self‐management
• Use and timing of treatment and progressions
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Summary
• Reliability
Research is extensiveand growing:
• Validity
• Prognostic value
Summary
Effective andEffective and efficient use of MDT is dependent upon the level of clinical training of the practitioner.
A Day With McKenzie
The following video clips were taken during a live presentation at the
2007 McKenzie Institute Conference, with highlights of Robin McKenzie g g
assessing actual patients.
While time constraints do not allow the entire assessment process to be shown, these are two
great patient examples.
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A Day With McKenziepart three
A Day With McKenziepart four
Peter Hitchman, outdoor education instructor18 months of intense pain and neurological deficit
A Day With McKenziepart five
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A Day With McKenziepart six
Clare Field and Peter Hitchman, 4 months after attending the Spine Symposium.
Summary
Thank you for participating!
www.mckenziemdt.org
Special thanks to the MI International Education Committee under the direction of Helen Clare, Ph.D., FACP, MappSC, Dip. Physio, Dip. MDT
for material contributions for this course.
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