The document provides an overview of the McKenzie method for assessing and treating musculoskeletal pain. It describes the key concepts of centralization and peripheralization and how patients' pain responses to specific movements can help classify their condition as a postural syndrome, dysfunction syndrome, or derangement syndrome. Treatment generally involves repeated movements and positioning to encourage centralization of pain. Precautions are taken to avoid worsening a patient's pain. The McKenzie method examines both spinal and extremity issues through detailed mechanical diagnosis and management.
Concept given by Shacklock (modern concept) and Butler (old concept), a method of assessment as well as treatment of peripheral neurological system by physiotherapists.
Part-I: The current slideshow: theoretical aspect of neurodynamics.
Part-II: Assessment of peripheral nervous system on the basis of neurodynamic concepts: Date: 01/04/2020
Part-III: treatment part: Date: 03/04/2020
Part-IV: Self neurodynamics: 05/04/2020
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Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Concept given by Shacklock (modern concept) and Butler (old concept), a method of assessment as well as treatment of peripheral neurological system by physiotherapists.
Part-I: The current slideshow: theoretical aspect of neurodynamics.
Part-II: Assessment of peripheral nervous system on the basis of neurodynamic concepts: Date: 01/04/2020
Part-III: treatment part: Date: 03/04/2020
Part-IV: Self neurodynamics: 05/04/2020
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
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This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
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This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
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Normalization of muscle tone
Use of Developmental sequences.
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This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Basic Introduction about Joint Mobilisation and Manipulation, This article gives clear notes for the students to understand the Mobilisation techniques.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
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(zaid hijab) 4th stage
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small correction in slide number: 10
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
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Stay informed, stay safe, and get your flu shot today!
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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
2
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)
3
4. HISTORY
Accidental discovery by Robin Mckenzie by making a patient
sleep for 20min in prone sustained extension position and
finding it to recover the pain with centralization
4
5. Principles of McKenzie
Centralization: Pain travelling back to the originating
part
Peripheralization: pain travelling away from the
originating part
Note: Robin Mckenzie quoted the aspects of
centralization and peripheralization initially on the
basis of spine. He thought pain originates from spine.
Later, on deeply studying the theory of extremities; it
was quoted that both centralization and
peripheralization mechanism belong to originating
source of pain or root cause not restricting itself to
the spine.
5
6. 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.
Pain in the extremity moves sequentially back to the centre
i.e. spine.
Occurs in derangement syndrome
Increase in localized central pain
Reliable predictor: for improvement due to therapy
6
7. PHENOMENON OF PERIPHERALIZATION
As a result of certain repeated movements/ adoption of
certain postures, radiating symptoms originating from the
spine are referred.
Pain in the spine moves sequentially to the lower extremity
through the course of the nerve.
Occurs in derangement syndrome
Increase in radicular/peripheral pain
Reliable predictor: for poor therapy or need of therapy the
earliest
7
8. Uses of McKenzie
1. Mechanical diagnosis of thoracic, lumbar and cervical
spine problems.
2. Treatment of thoracic, lumbar and cervical spine
problems.
3. Self treatment component.
4. Non-specific mechanical spine disorders are treated at
best.
8
9. In this approach mechanical forces are applied to the patient in such
a way that, it causes a therapeutic changes in presenting syndrome.
These forces can be divided into 3 types:
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
9
McKenzie Concept
10. Force alternatives:
1. Starting position: loaded or unloaded.
2. Direction of loading strategies: sagittal/frontal plane
movements.
3. Sagittal force: flexion or extension.
4. Lateral force: lateral flexion or rotation.
5. Lateral direction: towards pain or away from pain.
6. Time factor: sustained positioning or repeated movements
10
McKenzie Concept
11. Principles of Treatment:
1. Extension principle: all extension maneuvers of McKenzie
performed can be also clubbed with Retraction
Note:
A. Retraction mobilisation is useful in lower Cx extension
dysfunction.
B. Retraction extension and rotation is useful in posterior
derangement syndrome.
2. Lateral principle: all the lateral flexion to be performed
Note: used usually in lateral and posterolateral derangement
3. Rotation principle: all rotation maneuvers to be perfromed
4. Flexion principle: all flexion maneuver to be performed
11
McKenzie Concept
12. Increased intradiscal pressure due to abnormal
biomechanics of lifting, or bending.
Increased compressive force placed on the spine: by
abnormal biomechanics of bending suddenly.
Shearing force on the spine.
Overstretching of ligament and capsules surrounding the
spine.
12
Biomechanical Factors responsible for deformation of the
intervertebral disc are:
Biomechanical Factors responsible for deformation of the
intervertebral disc are:
Causes of pain in spine:Causes of pain in spine:
•Specific vs non-specific.
•Mechanical
•Traumatic
•Tissue deformation
•Postural stress
•Abnormal forces on the intervertebral joints.
•Age related changes of the spine.
13. Repetitive minor stress or strain interfere with normal
physiology and causes further damage and deformation.
Degeneration of the intervertebral joints and the vertebral
bodies due to age related changes.
13
Pathophysiology of the spine pain
14. 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.
14
15. MECHANICAL DIAGNOSIS
1. Postural syndrome
2. Dysfunctional syndrome
3. Derangement syndrome
Syndrome ?
A characteristic group of symptoms & pattern of happenings
typical of a particular problem.
( Chamber’s dictionary)
15
17. POSTURAL SYNDROME
Definition: it’s a syndrome where soft tissues deform
mechanically due to sustaining end range postures and
positions.
FEATURES;
No pain with movement
No pathological changes occur in this syndrome
Common example: slouched sitting which produces a
protruded head: upper Cx may be extended and the lower
Cx is in a position of flexion. {McKenzie Book}.
On progression of this syndrome derangement syndrome
is encountered. 17
18. POSTURAL SYNDROME
Mechanism of pain:
Prolonged static loading of soft tissues within/adjacent to
spine
Causes overstretching & mechanical deformation
Ligamentous followed by muscle fatigue
Eg: Slouched sitting and Bent finger syndrome
18
19. Types of POSTURAL SYNDROME
i. Rotational positional fault: if a single
or 2-3 vertebraes are rotated
towards one side such that the
spinous process does not follow the
alignment.
ii. Extension positional fault: if one or
some vertebraes are stuck in
extension and do not glide forward
during flexion.
iii. Flexion positional fault: if one or
some vertebares are stuck in flexion
and do not glide backwards during
extension.
19
20. DYSFUNCTION SYNDROME
Definition: shortened tissues are mechanically deformed by
overstretching at end range
FEATURES;
The patient feels pain when they mechanically deform
previously shortened structures surrounding and within their
spine on attempting normal end range movements.
Pain from the dysfunction syndrome is caused by mechanical
deformation of structurally impaired tissues. This abnormal
tissue may be the product of previous trauma, or inflammatory
or degenerative process. These events leads to contraction,
scarring, adherence, adaptive shortening or imperfect repair.
Pain is felt when the abnormal tissue is loaded. 20
21. DYSFUNCTION SYNDROME
Mechanism of pain:
When soft tissue within and around the spinal segment are
shortened
(Adaptive shortening, scarring, contracture, adherence/
fibrosis)
Decreased elasticity and extensibility of soft tissues
Decreased spinal mobility
On Static/ dynamic loading in end range
Mechanical stress are imposed on these abnormal soft tissues
Causes Mechanical deformation
Pain
Causes: trauma, degeneration, posture/ derangement
21
22. Types of Dysfunction SYNDROME
Extension dysfunction: Patient lacks end range
extension which produces symptoms.
Flexion dysfunction: lacks end-range flexion which
produces symptoms.
Side flexion dysfunction: Same as above
Rotational dysfunction: Same as above
22
23. DERANGEMENT SYNDROME
Definition: disruption or displacement of structures within
the intervertebral segment
Mechanism of pain
Unequal loading of Intervertebral Disc
Nucleus pulposes in eccentric position
Asymmetric compression of the Disc
Disruption in normal resting position of vertebrae
Discomfort
Pain
23
24. Types of Derangement SYNDROME
Anterior
Posterior
Para central disc bulge.
Lateral
Postero-lateral.
24
25. Phases of PIVD
Instability: due to the tear of surrounding ligaments there will be loss of
stability to the IV disc thus leading to bulging.
Dysfunction: due to maintained bulge and maintained posture in order
to avoid pain, there is muscle imbalance occurring to guard the disc
from further bulging.
Restabilization: these muscles guard undergoes spasm thus, also the
ligamnets undergo calcification thus restabilizing the disc.
25
26. Stages of PIVD
Prolapse: Bulging out of disc.
Protrusion: bulging out of the disc still in contact with
the parent nucleus.
Extrusion: contact lost with parent nucleus.
Sequestration: complete rupture of the annulus leading
to split of the disc and move out of the inter-vertebral
space.
26
28. Quebac Task Force**
Activity related spinal disorders:
1. Pain without radiation.
2. Pain with radiation to extremity proximally.
3. Pain with radiation to extremity distally.
4. Pain with radiation to either upper extremity on lower
extremity + neurological signs.
5. Presumptive nerve root compressive on a single X-ray.
6. Compression confirmed by imaging technique.
7. Spinal stenosis
8. Post-op status 1-6months after intervention.
9. Post-op status >6months after intervention
10. Chronic pain.
11. Other diagnosis.
28
31. Uses of McKenzie
Acute, subacute, chronic Low back ache.
Slowly or sudden occurrence and sharp
pain.
With/without radiation over the buttock or
slightly down the leg.
Recurrent syndrome.
Intermittent sciatica without neurological
deficits.
31
32. AIMS OF Physical examination
1. Usual posture: sitting, standing, also measure
leg length discrepancy.
2. Symptomatic response to posture correction:
3. Deformities/ asymmetries related to episode
4. Neurological examination: sensation, muscle
power, reflexes, nerve tension test.
Criteria to conduct a neurological examination is:
5. Paraesthesia in the upper limb,
6. Weakness in the upper limb,
7. Arm or forearm symptoms,
8. Especially in a radicular pattern.
32
33. Typical signs and symptoms associated with nerve root involvement.
33
Root level Typical area of
sensory loss
Common motor
weakness
Reflex
C4 Top of shoulder Shoulder
elevation
C5 Lateral arm Shoulder
abduction
Biceps
C6 Thumb Elbow flexion Biceps
C7 Middle finger Elbow extension Triceps
C8 Little finger Thumb extension
T1 Medial aspect of
forearm
Finger abduction/
adduction
34. AIMS OF Physical examination
5. Baseline measures of mechanical presentation: all movements
possible at the spine, like, flexion, extension, side flexion towards
right and left, and right and left rotation. Movement in relation to
pain are also assessed in sleeping and standing posture.
6. Symptomatic & mechanical response to 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. 34
36. Clinical picture of 3 syndromes
Postural Dysfunction Derangement
Age: <30yrs >30yrs 20-55 or 12-55yrs
Occupation:
Sedentary occupation
Past h/o trauma or
derangement, poor
posture
Onset: Insidious and
gradually worsens
Gradual Sudden
Pain character:
Local, intermittent and
symmetrical
Intermittent pain at end
range
Assymetrical
Radiating
symptoms
Non-radiating Non-radiating pain Pain alters and
differs
Active pain free
movements
Reduced spinal mobility:
assymetrical movement
loss
Painful ROM
Worsens at the end of
the day
Early morning stiffness Constant pain
Associated with
headaches for Cx
Structural deformities Structural
deformities
36
37. Management
Postural syndrome
37
Stages Rx
1. Poor posture
2. Constant stage of
maintaining poor
posture
3. Pain in
musculoskeletal
structures
1. Correction of posture
2. Prevention or
avoidance of the poor
posture.
3. Posture education.
38. Management
Dysfunction syndrome
i. Process is lengthy & measured in
week/months.
ii. Exercises performed repeatedly every 2-3
hours
iii. Each session of 10-15 stretches.
iv. Do not strain and cause micro trauma
v. If pain persist after treatment:
vi. Overstretching
vii. Micro trauma
viii. Wrong diagnosis
ix. Pain is mandatory but subsides after 10 mins 38
41. POSTURAL SYNDROME
Definition: Pain caused by mechanical deformation/
vascular deprivation of soft tissues due to prolonged
postures
Affects articular structures / contractile tissues,
tendons / periosteul insertions
41
42. POSTURAL SYNDROME
1. It usually affects articular structures / contractile tissues,
tendons / periosteal insertions, Joint capsule/ligament
Pain
Prolonged end range position
2. Contractile tissue pain
Prolonged static mid range loading
Leads to CTDs. [connective tissue disease]
42
43. DYSFUNCTION SYNDROME
Definition: Pain cause 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.
1. capsule/ligaments affected-painful restriction at end-range
2. Contractile tissues affected-pain during resisted movements/
loading at any point of range
3. Articular structures-restricted end range & intermittent pain
4. Pain in contraction & stretching 43
44. 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 which leads to deformation of the capsule &
periarticular ligaments thus, causing pain .
44
46. 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.
46
47. RED FLAGS
Cauda equina syndrome
Possible cancer
Inflammatory disorders
Stenosis
Serious spinal pathology
Hip pathology
Symptomatic SIJ
Symptomatic spondylolisthesis
Mechanically inconclusive
Chronic pain state
47
57. EXTREMITIES
1. POSTURAL SYNDROME
Education in self management
Exercises 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
57
58. 2. DYSFUNCTION SYNDROME
a) 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
b) 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 58
59. 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
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61. 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:
1) Static
2) Dynamic
3) Therapist generated
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62. SUMMARY
Force alternatives:
1. Starting position: loaded or unloaded.
2. Direction of loading strategies: sagittal/frontal plane
movements.
3. Sagittal force: flexion or extension.
4. Lateral force: lateral flexion or rotation.
5. Lateral direction: towards pain or away from pain.
6. Time factor: sustained positioning or repeated movements
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63. Principles of Treatment:
1. Extension principle: all extension maneuvers of McKenzie
performed can be also clubbed with Retraction
Note:
A. Retraction mobilisation is useful in lower Cx extension
dysfunction.
B. Retraction extension and rotation is useful in posterior
derangement syndrome.
2. Lateral principle: all the lateral flexion to be performed
Note: used usually in lateral and posterolateral derangement
3. Rotation principle: all rotation maneuvers to be perfromed
4. Flexion principle: all flexion maneuver to be performed
63
SUMMARY
64. REFERENCES
Robin Mckenzie, Stephan May; The lumbar spine: mechanical
diagnosis & therapy. Volume I, II. 2nd edition, Spinal
publications.
Robin Mckenzie, Stephan May; The cervical & thoracic spine:
mechanical diagnosis & therapy. Volume I, II. 2nd edition,
Spinal publications.
Robin Mckenzie, Stephan May; Human extremities: mechanical
diagnosis & therapy. Volume I, II. 2nd edition, Spinal
publications.
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