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To comply with professional boards/associations standards:• I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•PESI and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 105: The Power of Directional Preference: Unique Treatment Approach for Musculoskeletal Pain
Margaux Lojacono PT, DPT, MS, OCS, FAAOMPT, Cert. MDT
Financial: Margaux Lojacono has an employment relationship with Niagara Falls Memorial Medical Center. She receives compensation from McKenzie Institute USA. Dr. Lojacono receives a speaking honorarium from PESI, Inc.Non‐financial: Margaux Lojacono is a member of the American Physical Therapy Association and the American Academy of Orthopaedic Manual Physical Therapists.
To comply with professional boards/associations standards:• I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•PESI and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 105: The Power of Directional Preference: Unique Treatment Approach for Musculoskeletal Pain
Joe Lorenzetti PT, DPT, MS, OCS, FAAOMPT, Cert. MDT, MTC
Financial: Joe Lorenzetti is an adjunct professor at Bryant & Stratton College and Daemen College. He receives compensation from McKenzie Institute USA. Dr. Lorenzetti receives a speaking honorarium from PESI, Inc.Non‐financial: Joe Lorenzetti is a member of the American Physical Therapy Association and the American Academy of Orthopaedic Manual Physical Therapists.
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Session Objectives
• Analyze the similarities and differences between the Maitland‐Australian Approach (MAPS), Movement System Impairment Syndromes (MSI), Treatment Based Classification (TBC), and Mechanical Diagnosis and Therapy (MDT) systems
• Define centralization and discuss implications for treatment
• Discuss classification processes used in MDT and Treatment Based Classification (TBC) model
• Synthesize examination findings to determine categorization of patients into directional preference, mobilization, manipulation, and stabilization categories, centralization vs. non‐centralization and patient response methods for assessment
• Recognize the evidence regarding patient response methods as a means of classifying patients with low back pain, and how MDT and the TBC model can be integrated
INTRODUCTION
Why Classification Is Important
• “Low Back Pain” is a heterogeneous condition: majority of patients have no patho‐anatomical cause for symptoms
• Determine appropriateness of physical therapy interventions• Identify red flags and non‐organic signs/symptoms
• Identify patients likely or not likely to benefit from intervention• Patients receiving interventions matched to classification demonstrate improved outcomes than those
receiving unmatched interventions
• Patients with fewer than 3/5 criteria for the lumbar spine manipulation CPR have only a 7% probability of success, indicating the need for alternative treatment
• Centralization phenomenon has prognostic value related to pain and functional disability
Long 2004, Brennan 2006, Fritz 2003, Childs 2004
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Patient Response Methods
• Maitland Australian Approach – patient response to passive mobilizations
• Movement System Balance (Sahrmann) – patient response to active limb movements
• MDT (McKenzie)– patient response to repeated end range movements
“Patient response methods…
…require dedicated communication between clinician and patient for clinical decisions, without necessarily requiring a pathology based diagnosis.”
• Cook C, Ramey K, Hegedus E. Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature. J Man Manip Ther. 2005;13(3):152‐62.
Cook 2005
Traffic Light Guide
RED • Symptoms are produced/increased/peripheralize and remain worse
• Loss of AROM/strength/function
YELLOW• Symptoms are produced/increased but no worse
• Symptoms are decreased but do not remain better
• No change in AROM/strength/function
GREEN• Symptoms abolish/centralize/decrease and remain better
• Improved AROM/strength/function
Adapted from McKenzie 2003
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Comparison of Classification Systems
• Maitland‐Australian Approach (MAPS)• Geoffrey Maitland
• Movement System Impairment Syndromes (MSI) • Shirley Sahrmann
• Treatment Based Classification (TBC)• Anthony Delitto, Richard Erhard, Richard Bowling
• Mechanical Diagnosis and Therapy (MDT)• Robin McKenzie
Maitland‐Australian Approach (MAPS)
• Assesses the patient response to passive mobilizations to confirm the source/specific tissues potentially at fault
• Treatment principles include physiological and accessory passive mobilization techniques
• Interventions are performed to restore normal movement and mechanics of stiffness dominant disorder, or to reduce/eliminate the patient’s pain dominant disorder
www.ozpt.com
Movement System Impairment Syndromes (MSI)
• Assesses the patient response to active limb movements
• Identify faulty alignment, movement patterns, and muscle imbalances using observation of movement as well as muscle length and strength testing
• Patients are classified by the alignment and/or movement direction that most consistently causes pain and is impaired
• Emphasis on self‐ treatment, patient education, and avoidance of therapist dependency
• Treatment principles focus on correcting the movement impairments in order to alleviate symptoms
Sahrmann 2002
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Treatment Based Classification (TBC)
• Initially designed for treatment of acute low back pain
• Uses specific algorithms and decision rules to classify patients and guide management
• Classification criteria and recommended interventions modified periodically based on emerging research
• Recommended interventions specific to each subgroup classification
Mechanical Diagnosis and Therapy (MDT)
• Assesses patient response to loading strategies, including repeated and sustained end range movements
• Focus on identifying centralization and directional preference
• Classification of patients into subgroups based on symptomatic and mechanical responses
• Emphasis on self‐ treatment, patient education, and avoidance of therapist dependency
• Combination of exercise and therapist intervention as necessary
Centralization
What is it and how do we get it?
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Definition of TermsCentralization
Directional Preference
Peripheralization
Definition of Terms: Centralization
• The phenomenon by which distal pain originating from the spine is progressively abolished in a distal to proximal direction
• Occurs in response to a specific repeated movement and/or sustained position and this change in location maintained over time until all pain is abolished
• During centralization, there is often a significant increase in the central back pain
• Local back pain moves from a widespread to a more central location and is then abolished
McKenzie 2003
Definition of Terms: Centralization
• Centralizing:• During the application of loading strategies distal pain is being abolished
• The pain is in the process of becoming centralized but this will only be confirmed once the distal pain remains abolished
• Centralized: • As the result of the application of the appropriate loading strategies the patient reports that all distal pain has abolished and now the patient only has back pain
• The central back pain will then continue to decrease and abolish
McKenzie 2003
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Characteristics of Centralization
• Occurs in response to repeated or sustained loading strategies
• Is usually a rapid and always lasting change in pain location
• Has demonstrated excellent interrater reliability
• Hallmark feature of Derangement Syndrome (MDT)
• Required to classify patient for Specific Exercise Classification (TBC)
McKenzie 2003, Fritz 2000
Definition of Terms: Directional Preference• The clinical phenomenon where postures or movements in one direction result in a clinically relevant improvement in either symptoms and/or mechanics
• Symptoms may decrease, abolish, though not always centralize; motion limitations often improve
• Postures or movements in the opposite direction often cause symptoms to worsen
• It is an essential feature of MDT Derangement Syndrome
• Pain intensity and ROM changes are the most prevalent constructs when centralization is not found during initial examination
McKenzie 2003, Yarnzbowicz 2018
Definition of Terms: Peripheralization
• The phenomenon by which proximal symptoms originating from the spine are progressively produced in a proximal to distal direction
• Occurs in response to a specific repeated movement and/or sustained position and the change in location maintained over time
• May also be associated with a worsening of neurological status
McKenzie 2003
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Definition of Terms: Peripheralization
• Peripheralizing:• During the application of loading strategies distal pain is being produced
• The pain is in the process of becoming peripheralized but this will only be confirmed once the distal symptoms remain
• Peripheralized:• As the result of the application of the inappropriate loading strategies the patient reports that the distal symptoms that have been produced now remain
McKenzie 2003
Visualization of Centralization
https://mckenzieinstituteusa.org/PatientFlyer‐MDTasFirstStep.pdf
Differences between Centralizationand Directional Preference• Directional preference encompasses a broader range of responses than centralization
• Directional preference results in a lasting improvement of symptoms AND/OR mechanics, not always a change in location
• Centralization refers to the lasting change in the location of pain as a result of loading strategies
• All centralizers have directional preference, but not all those with directional preference experience centralization
McKenzie 2003
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How Centralization Is Tested Determines How Frequently It Is Elicited
• Pain Pattern Classification:• Centralization• Non‐ Centralization: sx do not move proximally, do not change, or move further away from spine
• Not Classified: no symptoms @ rest
• Strict definition and overlay tool can aid in classification of centralization, non‐CEN or not classified
• Presence of centralization was associated with treatment outcome at discharge and patient improvement during rehabilitation
Werneke 2008
How Centralization Is Tested Determines How Frequently It Is Elicited• Prevalence of Pain Pattern Classification
• Centralization: 43%• Non‐ Centralization: 39% • Not Classified: 18%
• Prevalence of Centralization in patients meeting pragmatic CPR for manipulation (13% of patients)
• 89% classified as MDT derangement, 68% centralized
• Prevalence of centralization in patients meeting CPR for stabilization (7% of patients)
• 83% classified as MDT derangement, 80% centralized
Werneke 2010
Prevalence of Procedures Utilized to Achieve Directional Preference and Centralization• Preliminary study of procedures used to achieve centralization (n=19 patients)
• 13 required single plane movement
• 4 patients required complex movement
• Types of end range procedures used were not significantly associated with outcomes
Stowell 2018
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Prevalence of Procedures Utilized to Achieve Directional Preference and Centralization
• Prevalence of centralization and directional preference: systematic review (21 studies, n=5135 patients)
• Centralization: 39.5%
• Directional Preference: 26%
• Neither: 33.5%
• Prevalence of plane of movement of directional preference: systematic review (5 studies)
• Extension: 80%
• Lateral: 10‐14%
• Flexion: < 10%
May 2018
Procedures Utilized to Achieve Directional Preference and Centralization: MDT• Repeated movements
• Sustained postures
• Positions: standing, seated, lying, kneeling
• Directions: sagittal, frontal, coronal single plane and combinations
• Patient generated forces
• Clinician generated forces (overpressure, mobilization, manipulation)
McKenzie 2003
Results of Repeated Movement Exam/Sustained Postures: MDT
Response During Testing
• Produced
• Abolished
• Increased
• Decreased
• Centralizing
• Peripheralizing
• No Effect
Response After Testing
• Worse
• Better
• No better
• No Worse
• Centralized
• Peripheralized
• No Effect
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Procedures Utilized to Achieve Directional Preference and Centralization: TBC• Delitto, Erhard, Bowling. 1995
• Repeated and sustained movements sagittal and frontal plane
• Fritz, et al. 2006• Repeated Movements: extension standing, flexion seated: 10 repetitions• Sustained Positions: extension in prone, 30 seconds
• de Oliveira, et al. 2018• Extension: prone, different loading strategies in sagittal plane• Flexion: supine, 4‐point kneel, sitting• Lateral shift: standing • Used 10‐40 repetitions in each test position
Delitto 1995, Fritz 2006, de Oliveira 2018
Results of Repeated Movement Exam/Sustained Postures: TBC Response After Testing
• Improves: pain or paresthesia is abolished or moves from the periphery toward the lumbar spine (centralizes)
• Worsens: paresthesia is produced or the patients pain or paresthesia moves distally from the lumbar spine (peripheralizes)
• Status quo: pain or symptoms may increase or decrease in intensity but do not centralize of peripheralize
Delitto 1995
Treatment Based Classification
The Classification Process
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TBC 1995: Delitto, Erhard, Bowling
• First‐Level Classification: determine appropriateness of physical therapy
• Second‐Level Classification: stage the patient
• Third‐Level Classification: interventions to address impairments
Delitto 1995
First‐Level Classification:Determine appropriateness of physical therapy
• Cannot be managed with PT, requires referral to another health care practitioner
• Medical, psychological, surgical (red flags)
• Patient managed independently with Physical Therapy
• May be managed with PT, in addition to consultation with another provider
• Medical (inflammatory process), psychological (yellow flags)
Delitto 1995
Second‐Level Classification: Staging the Patient
• Stage I: inability to perform basic tasks of sitting, standing, walking• Primary focus: pain modulation
• Stage II: can perform ADLs but not functional ADLs• Primary focus: pain modulation, elimination of physical impairments that may predispose to recurrence
• Stage III: returning to high physical demand activities• Primary focus: focus on improving tolerance to demands without exacerbation of symptoms
Delitto 1995
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Third‐Level Classification: Determining Interventions: Stage 1 Patients• Specific exercise: extension, flexion, lateral shift
• Traction
• Mobilization
• Immobilization
• Goal: modulate symptoms to allow for progression to Stage II interventions
Delitto 1995
Updates to TBC
Summary of Updates and Research 2000‐2013• Research studies using TBC during this period began to incorporate clinical prediction rules and include research involving lumbar stabilization
• Classification criteria and recommended interventions were updated
• A clinical algorithm was developed and demonstrated acceptable reliability
• Centralization used as a screening tool to aid in classification
Brennan 2006, Fritz 2006, Fritz 2007
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Subgrouping Patients with Low Back Pain: Evolution of a Classification System Approach to Physical Therapy• Julie Fritz, Josh Cleland, John Childs. J Orthop Sports Phys Ther, 2008.
• Clinical commentary citing rationale for updates based on work by Fritz, Brennan, et. al. (2006)
• Updated symptomatic classification criteria and interventions based on emerging research
• Utilized a simplified hierarchical decision‐making algorithm for classification of patients
• Specific Exercise
• Manipulation
• Stabilization
Fritz 2007
Classification Criteria: Manipulation
• Duration of symptoms <16 days
• At least one hip with less than 35° of internal rotation
• Lumbar hypomobility
• No symptoms distal to the knee
• FABQ work subscale <19
Fritz 2007
Classification Criteria: Stabilization
• Age <40 years
• Greater general flexibility (postpartum, average straight leg raise >91°)• Aberrant movements present during trunk flexion/extension AROM
• Positive prone instability test
• Post‐partum patients:• Positive posterior pelvic pain provocation, and positive active SLR and modified Trandelenberg tests
• Pain provocation with palpation of the long dorsal sacroiliac ligament or pubic symphysis
Fritz 2007
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Classification Criteria: Specific Exercise
• Extension• Symptoms distal to the buttock• Symptoms centralize with lumbar extension• Symptoms peripheralize with lumbar flexion• Directional preference for extension
• Flexion• Older age (>50 y/o)• Directional preference for flexion• Imaging evidence of lumbar stenosis
• Lateral Shift• Visible frontal plane deviation of the shoulders related to the pelvis• Directional preference for lateral translation movements of the pelvis
Fritz 2007
Classification Criteria: Traction
• Traction Classification:
• Signs and symptoms of nerve root compression
• No movements centralize symptoms
Fritz 2007
Classification Decision‐Making Algorithm 2007
Adapted from Fritz 2007
Does the patient 1. Centralize with 2+ movements in the same direction (ie, flexion or extension)OR2. Centralize with a movement in 1 directionand peripheralize with an opposite movement
Does the patient1. Have recent onset of symptoms <16 daysAND2. No symptoms distal to the knee
Does the patient have at least 3 of the following?1. Average SLR ROM >91°2. Positive prone instability test3. Positive aberrant movements4. Age <40y/o
Specific Exercise
Manipulation
Stabilization
YES
YES
YES
NO
NO
NO
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Which Subgroup does the Patient Best Fit?
For patients who do not clearly meet the subgroup criteria additional criteria is provided to aid in classification
Fritz 2007
Which Subgroup Does the Patient Best Fit?
Manipulation Stabilization Specific Exercise
Which Subgroup does the Patient Best Fit?
Fritz 2007
Manipulation
Factors Favoring Factors Against
• More recent onset of symptoms
• Hypomobility with spring testing
• LBP only (no distal symptoms)
• Low FABQ scores (FABQW scores <19)
• Symptoms below the knee• Increasing episode
frequency• Peripheralization with
motion testing• No pain with spring testing
Which Subgroup does the Patient Best Fit?
Fritz 2007
Stabilization
Factors Favoring Factors Against
• Younger age• Positive prone instability test• Aberrant motions present• Greater SLR ROM• Hypermobility with spring
testing• Increasing episode frequency• 3 or more prior episodes
• Discrepancy in SLR (>10°)• Low FABQ scores (FABQPA<9)
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Which Subgroup does the Patient Best Fit?
Fritz 2007
Specific Exercise
Factors Favoring Factors Against
• Strong preference for sitting or walking
• Centralization with motion testing
• Peripheralization in direction opposite centralization
• LBP only (no distal symptoms)• Status quo with all
movements
Recommended Interventions
• Manipulation Classification:• Manipulation of the lumbopelvic region
• Active ROM exercises
• Specific Exercise Classification:• Extension:
• Extension exercise, avoidance of flexion
• mobilization to improve extension
• Flexion:• mobilization/manipulation of the spine and/or lower extremities
• exercises to address impairments in strength/flexibility
• body‐weight supported treadmill
• Lateral shift: exercises to correct lateral shift
Fritz 2007
Recommended Interventions
• Stabilization Classification:• Promoting isolated and co‐contraction of deep stabilizing muscles (transverse abdominus, multifidus)
• Strengthening for large spinal stabilizing muscles (erector spinae, oblique abdominals)
• Traction: (not included as classification)• Mechanical or auto‐traction
• Authors stated traction was not an appropriate intervention for most patients with LBP, therefore should not be widely used (based on research interpretations)
Fritz 2007
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Evaluation of a Treatment‐Based Classification Algorithm for Low Back Pain: A Cross‐Sectional Study (2011)
• Prevalence of subgroups using classification criteria: • Specific Exercise: 44.8%; Manipulation: 35.2%• 49.6% met criteria for one subgroup only• 25% of patient met classification for more than one subgroup• 25% of patients did not meet the criteria for any subgroup
• Prevalence of subgroups using hierarchical algorithm• Manipulation: 42.0%; Specific exercise: 30.8%• Clear classification: 66% • Unclear classification: 34%
• Reliability: acceptable using comprehensive algorithm
• Authors stated hierarchical algorithm is required to prioritize classification when overlap occurs.
Stanton 2011
What Characterizes People Who Have An Unclear Classification Using A Treatment‐based Classification Algorithm For Low Back Pain? A Cross‐sectional Study.
• Stanton TR, Hancock MJ, Apeldoorn AT, Wand BM, Fritz JM, Phys Ther, 2013.
• Prevalence of unclear classification: 34%
• Characteristics of patients with unclear classification using algorithm:
• Longer duration of symptoms
• Previous episodes of LBP
• Fewer fear avoidance beliefs
• Less LBP related disability
Stanton 2013
Treatment‐Based Classification System for Low Back Pain: Revision and Update• Arlwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. Phys Ther, 2016.
• Recognized strengths and limitations of prior versions
• Significant revisions to categories
• Three rehabilitation categories• Symptom modulation: interventions to modulate symptoms: manual therapy, directional preference, traction or immobilization
• Movement control: interventions to include quality of movement, e.g. stabilization exercises
• Function optimization: interventions to maximize physical performance
Alrwaily 2016
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Treatment‐Based Classification System for Low Back Pain: Revision and Update• Determine the appropriate management approach
• Medical Management• “red flags,” leg pain with progressive neurological deficit, medical co‐morbidities precluding
rehabilitation
• Rehabilitation Management• Medium to high psychosocial risk status
• Low psychosocial risk status with predominantly leg pain
• Minor or controlled comorbidities
• Self‐Care Management • Low psychosocial risk status
• Predominantly axial low back pain
• Minor or controlled medical comorbidities
Alrwaily 2016
Symptom Classification:Symptom Modulation Approach
Clinical findings: Disability: high, Symptom Status: volatile, Pain: high to moderate
Interventions: active rest, traction, directional preference exercises, manipulation/mobilization
Adapted from Alrwaily 2016
Is the patient irritable and inflamed?
Does the patient peripheralize with extension and flexion or have positive crossed SLR?
Does the patient centralize with
extension or flexion
Does the patient no longer centralize and have no symptoms distal to the knee?
Address inflammation by active rest
Prescribe traction
Prescribe specific exercises that centralize symptoms
Prescribe manipulation
RESOLVED
Symptom Classification:Movement Control Approach
• Clinical Findings: • Disability: moderate
• Symptom Status: stable
• Pain: moderate to low
• Interventions: • Sensorimotor exercises
• Stabilization exercises
• Flexibility exercises
Alrwaily 2016
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Symptom Classification: Functional Optimization• Clinical Findings:
• Disability: low
• Symptom Status: controlled
• Pain: low to absent
• Interventions:• Strength and conditioning exercises
• Work‐ or sport‐specific related tasks
• Aerobic exercises
• General fitness exercises
Alrwaily 2016
Prevalence And Reliability Of Treatment‐Based Classification For Subgrouping Patients With Low Back Pain• Isadora de Oliveira, Rodrigo de Vasconcelos, Bruna Pilz, et al. J Man Manip Ther, 2018.
• 429 patients presenting with LBP assessed by 13 physical therapists
• Classification Criteria only, no algorithm
• Patients classified and treated for 12 weeks, re‐evaluations every 4 weeks, and transitioned to functional recovery stage when appropriate (NPRS<3 pts, ODI <20%)
• Assessed prevalence of subgroups and examined interrater reliability
de Oliveira 2018
Prevalence And Reliability Of Treatment‐Based Classification For Subgrouping Patients With Low Back Pain
Treatment Subgroup Classification Criteria
Manipulation (4/5 present) Duration of symptoms <16 daysAt least one hip with less than 35° of internal rotationLumbar hypomobilityNo symptoms distal to the kneeFABQ work subscale <19
Stabilization Age <40 yGreater general flexibility (SLR >91°)Aberrant movement present+ prone instability testHypermobility of lumbar spineHigh frequency of recurrence
Traction Age >30Positive neurological signsNo movements centralize symptomsCentralization with manual traction+ Laseque’s or Cross‐Laseque’s sign
de Oliveira 2018
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Prevalence And Reliability Of Treatment‐Based Classification For Subgrouping Patients With Low Back Pain
Treatment Subgroup, cont.
Classification Criteria, cont.
Flexion Age > 50Symptoms centralize with lumbar flexionSymptoms peripheralize with lumbar extensionDirectional preference for flexion in ADLsImaging evidence of lumbar stenosisNeurogenic claudication signs during gait
Extension Symptoms centralize with lumbar extensionSymptoms peripheralize with lumbar flexionDirectional preference for extension in ADLsDistal symptoms to the buttock
Lateral Shift Visible frontal deviation of shoulders to the pelvisDirectional preference or centralization for lateral movements of the pelvis
Combined At least two criteria of each subgroup associated with centralization phenomena or directional preference
de Oliveira 2018
Prevalence And Reliability Of Treatment‐Based Classification For Subgrouping Patients With Low Back Pain
• Prevalence of subgroups:• Specific exercise 27%:
• extension 15%, flexion 11, lateral shift .47%
• Stabilization 22%
• 66% of patients met criteria for one subgroup
• 21% of patients met criteria for more than one subgroup
• 13% of patients did not meet any treatment subgroup
• Interrater Reliability: 66% between raters, kappa value 0.62(substantial agreement)
de Oliveira 2018
Prevalence And Reliability Of Treatment‐Based Classification For Subgrouping Patients With Low Back Pain: Results and Discussion
• Low prevalence of manipulation subgroup
• Specific exercise/centralization• Single plane repeated movements in standing, sitting, prone lying, supine
and 4 point kneeling
• Recognized absence of coronal plane movements (e.g. rotation, extension with hips off center)
• Clear classification of specific exercise required centralization, not directional preference
• Higher numbers of patients able to be classified compared to prior research
• PTs with previous experience with TBC criteria
• Knowledge of involvement in prevalence study‐ greater inclination to classify
• Ability to use principles of classification with clinical judgement without use of algorithm
de Oliveira 2018
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TBC Summary
• Individual subgroup criteria and hierarchical algorithms to guide classification
• Advocates specific interventions matched to classification
• Centralization is prioritized in algorithm over other subgroup classifications
• Most research limited to assessment of centralization to single plane movements
• Most research does not include directional preference as component of specific exercise subgroup
TBC and MDT: Traffic Light Guide
Fritz 2003
Manipulation and exercise
Stabilization exercises
Activities to Promote
Centralization
Specific Exercise Stabilization Traction
Classification Criteria
Classification Criteria
Classification Criteria
Classification Criteria
Mechanical/ auto-traction
Manipulation
Exhausting the Specific Exercise Category Mechanical Diagnosis & Therapy
The Classification Process
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Patient ClassificationsPostural Syndrome
Dysfunction Syndrome
Adherent Nerve Root (ANR)
Derangement Syndrome
Other
MDT Classification: Postural Syndrome• Common Symptoms Reported:
• Local• Intermittent • Associated with prolonged time in specific posture
• Exam findings:• Movement loss (‐), no pain/symptoms reported
• Results of Repeated Movement Testing:• No effect• Symptoms only produced by sustained loading in relevant position, no worse after moving from that posture
• Management Strategies:• Posture education• Posture correction
McKenzie 2003
MDT Classification: Dysfunction Syndrome• Common Symptoms Reported:
• Chronic symptoms• Local pain• Intermittent• Consistent reproduction with activities
• Exam findings:• Movement loss (+), pain reported at end range into restriction• Neurological exam (‐)
• Results of Repeated Movement Testing:• Produced/No Worse into restriction, no effect in opposite direction
• Named by the direction of restriction (ex: extension dysfunction)
• Management Strategies:• Progressive tissue remodeling into the direction of restriction
McKenzie 2003
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MDT Classification: Adherent Nerve Root• Sub‐Classification of Dysfunction Syndrome‐ nerve is the restricted tissue
• Common Symptoms Reported:• Chronic• Intermittent leg symptoms • Consistent reproduction during certain activities which are no worse when ceasing activity
• Exam findings:• Movement loss (+) lumbar flexion• Symptoms reproduced at end range, no worse
• Results of Repeated Movement Testing:• Symptoms will be produced, no worse when nerve is tensioned, no effect when slackened (example: RFIS‐ Produced/NW; RFIL: NE)
• Management Strategies:• Progressive tissue remodeling of restricted nerve
McKenzie 2003
MDT Classification: Derangement Syndrome• Common Symptoms Reported:
• Constant/intermittent
• Local, referred, radicular
• Acute, subacute, chronic
• Variable throughout the day and with activity
• Exam findings:• Kyphotic or lateral shift (+/‐)
• Movement loss (+), pain/symptoms reported during motion/end range
• Posture correction may affect symptoms
• Neurological exam (+/‐)
McKenzie 2003
MDT Classification: Derangement Syndrome
• Results of Mechanical Exam:• Produce/increase/worsen/peripheralize
• Abolish/decrease/better/centralize
• Named by presentation of symptoms and response to loading strategies
• Central/Symmetrical
• Unilateral/Asymmetrical above the knee
• Unilateral/Asymmetrical below the knee
McKenzie 2003, McKenzie Institute 2016
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MDT Classification: Derangement Syndrome‐ Management• Reduce derangement: determine directional preference, work towards centralization
• Identify treatment principle that centralizes/reduces/abolishes symptoms and restores function
• Extension principle
• Flexion principle
• Lateral principle
McKenzie 2003
MDT Classification: Derangement Syndrome‐ Management• Progression of forces
• Based on symptomatic and mechanical responses
• Only necessary if improvement ceases• Repeated movements
• Sustained postures
• Positions: standing, seated, lying, kneeling
• Directions: sagittal, frontal, coronal planes, combinations
• Continuum of forces‐ built‐in safety mechanism• Patient generated forces
• Clinician generated forces (overpressure, mobilization/manipulation)
McKenzie 2003
Traffic Light Guide
RED • Symptoms are produced/increased/peripheralize and remain worse
• Loss of AROM/strength/function
YELLOW• Symptoms are produced/increased but no worse
• Symptoms are decreased but do not remain better
• No change in AROM/strength/function
GREEN• Symptoms abolish/centralize/decrease and remain better
• Improved AROM/strength/function
Adapted from McKenzie 2003
26
MDT Classification: Derangement Syndrome‐ Management• Maintain reduction
• Regular performance of reductive exercise
• Postural correction
• Avoidance of aggravating postures/positions/movements
• Regular interruption of sustained postures
• Recovery of function• All motions are full and pain free
• Patients should be made confident to bend and perform other normal activities
• Systematic restoration of flexion movements
McKenzie 2003
MDT Classification: Derangement Syndrome‐ Management
• Prevention of recurrence • Beware of sustained postures
• Continuance of exercise program for as long and as frequently as needed to maintain full mobility
• Balancing flexion with extension
• Importance of general fitness
• Use of lumbar roll
• Resumption of reductive exercise if stiffness/motion loss or LBP returns
McKenzie 2003
MDT Classification: Other
• Chronic Pain Syndrome
• Inflammatory
• Mechanically Inconclusive
• Mechanically Unresponsive Radiculopathy
• Post‐Surgery• Sacro‐Iliac (SIJ)/Pregnancy Related Pelvic Girdle Pain (PGP)• Spinal Stenosis• Structurally Compromised
• Trauma/Recovering Trauma
McKenzie 2003
27
Prevalence of MDT Syndromes
• Prevalence Of Classification Methods For Patients With Lumbar Impairments Using the McKenzie Syndromes, Pain Pattern, Manipulation, and Stabilization Clinical Prediction Rules. J Man Manip Ther, 2010.
• MDT syndromes: 72% patients classified, 28% other• Derangement: 67%
• Dysfunction: 5%
• posture: 2%
• Pain Pattern Classification• Centralization: 43%
• Non‐ centralization: 39%
• Not classified: 18%
Werneke 2010
Reliability of Classification: “The MDT system…
… appears to have acceptable interrater reliability for classifying patients with back pain into main and sub‐syndromes when applied by therapists who have completed the credentialing examination, but unacceptable reliability in other therapists.”
Garcia 2018
Evidence Supporting Centralization
28
Orthopedic Section of APTA Clinical Practice Guideline for Low Back Pain
• Clinicians should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain
• Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits
• Recommendation based on strong evidence
Delitto 2012
Centralization Has Been Shown To Have Prognostic Capabilities
• Patients with chronic pain demonstrate the ability to centralize
• Patients with chronic LBP with partial or complete centralization demonstrate measurable improvements in physical performance over 10 weeks
• No association between type of disc lesion on MRI and ability to achieve DP/CEN at baseline
May 2018, Al‐Obaidi 2013, Albert 2012
Centralization Has Been Shown To Have Prognostic Capabilities
• Pain Pattern Classification is important for predicting functional status and pain intensity at discharge from rehabilitation
• Patients who fail to achieve centralization are at higher risk for delayed recovery and development of chronic symptoms
• Physical signs of non‐CEN is associated with non‐organic signs, overt pain behaviors, fear of work activity, and somatization
Yarznbowicz 2017, Werneke 2001, Werneke 2005
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Preliminary CPR For Centralization
• Initial Pain And Disability Characteristics Can Assist The Prediction Of The Centralization Phenomenon On Initial Assessment Of Patients With Low Back Pain. J Man Manip Ther, 2019.
• 90 pts with LBP
• 31% classified as centralizers
• CEN more likely to occur in lower levels of disability (ODI<33%), leg pain less than back pain, intensity of most distal symptom less than 6/10
Rabin 2019
Putting it all together
Case Study
Patient History
• Age: 35 y/o female, employed in a hospital as a RN. Leisure: generally active, enjoys gardening, walking
• Symptom onset: 3 weeks ago, NAR
• Location: 3/10‐7/10; constant “aching” across lower lumbar spine, intermittent tingling posterior right buttock to the knee
• Better/worse: made worse with prolonged standing >10 min., sitting> 30 min; ease with prone lying; worse in the morning and evening.
• Prior episodes: recurrent LBP related to lifting injury 10 years ago, no prior leg symptoms, treated by chiropractor in past with good results
• PMH/PSH: none
• Medications: IB 600, prn pain
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Physical Exam
• Posture: slouched in unsupported sit
• Correction increases LBP, decreased tingling in leg
• Standing posture: fair, no evidence of acute deformity
• Single movement tests: • Flexion: mod loss, increased LE sx
• Extension: mod loss, increased LBP
• SGIS left: min loss, NE
• SGIS right: mod loss, increased LBP
Physical Exam
• Hip Internal rotation: left: 45°, right 35°
• Spring testing lumbar spine: + concordant pain L4
• SLR: left: 70° right: 50° with c/o “stretch” posterior knee
• LS dermatomes/myotomes: equal/intact
• DTR’s: 2+ bilateral Achilles, patella
Repeated End Range Movement Testing
• Repeated extension standing: increased RLE/worse
• Repeated lumbar flexion sitting: increased RLE/worse
• REIL (repeated extension lying): increased RLE/no worse
• Sustained lumbar extension, prone x 30 sec: increased RLE/worse
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How would you classify this patient?
Exhausting Specific Exercise: Force Alternatives
• REIL hips off‐center left: increased LBP/NE leg pain
• REIL hips OCL, PT overpressure (extension): increased RLE/Worse
• REIL hips OCL, PT overpressure (lateral): abolished RLE, decreased LBP 2/10. improved SLR to 60°.
How would you classify this patient?
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How would you classify this patient?
MDT: Derangement, asymmetrical above the knee
TBC: unclear classification‐ best fit: specific exercise
Pain Pattern Classification: Centralizer
Integration of Treatment Approaches
• Prevalence of MDT: Other Classification : 28% other
• Prevalence of TBC: not classified: 13‐25%
• How do we provide effective treatment for patients not classified with MDT/TBC?
Other Classifications
• Chronic Pain Syndrome
• Mechanically Inconclusive
• Mechanically Unresponsive Radiculopathy
• Sacro‐Iliac (SIJ)
• Spinal Stenosis
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Chronic Pain Syndrome
• Pain generating mechanism influenced by psychosocial factors or neurophysiological changes
• Symptoms:• Persistent widespread pain
• Aggravation with all activities
• Disproportionate pain response to mechanical stimuli
• Inappropriate beliefs and attitudes about pain
Mechanically Inconclusive/Mechanically Unresponsive Radiculopathy
• Unknown musculoskeletal pathology.
• Symptoms affected by positions or movements BUT no recognizable pattern OR inconsistent symptomatic and mechanical responses on loading.
• Radicular presentation consistent with a currently unresponsive nerve root compromise.
• There is no centralization and symptoms do not remain better as a result of any repeated movements, positions, or loading strategies.
Sacro‐iliac (SIJ)
• Pain‐generating mechanism emanating from the SIJ or symphysis pubis
• Three or more positive SIJ pain provocation tests having excluded the lumbar spine and hip
• Thigh Thrust
• SI Distraction
• SI Compression
• Sacral Thrust
• Gaenslen’s Test
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Spinal Stenosis
• Symptomatic degenerative restriction of spinal canal or foramina
• Lumbar spine: older population, history of leg symptoms relieved with flexion activities and exacerbated with extension, longstanding loss of extension
• Cervical Spine: arm symptoms consistently produced with closing foramen, abolished or decreased with opening
Summary
• Exhausting the specific exercise category is necessary to help ensure proper classification
• Centralization/directional preference guide patient management in both TBC and MDT systems
• Patients not matching classifications of MDT or TBC should be treated with other appropriate interventions
• Goal is to provide efficient treatment, empower self‐management of symptoms
Questions?