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MCKENZIE APPROACH
RADHIKA CHINTAMANI
1
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
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
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
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
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
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
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
 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
 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
 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
 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.
 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
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
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
FOR SPINE
16
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
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
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
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
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
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
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
Types of Derangement SYNDROME
 Anterior
 Posterior
 Para central disc bulge.
 Lateral
 Postero-lateral.
24
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
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
27
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
Quebac Task Force**
Indications:
1,2,3- most indicated for McKenzie.
7,8,9,10 relatively indicated.
4,5,6 not suitable, i.e. contraindication.
29
Contraindications
Malignancy
TB spine.
RA
AS
CNS Dysfunction.
Fracture of anterolesthesis/retrolesthesis
Instable spine
Vascular abnormality like vestibulo-basilar
insufficiency
Advance diabetes mellitus.
30
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
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
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
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
CONCLUSION
1. Syndrome classification
2. Appropriate therapeutic loading strategy
3. Appropriate testing loading strategy
35
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
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.
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
Management
Derangement syndrome
39
Stages Rx
Reduction
Manitenance of
reduction
Recovery of function
Prophylaxis
Extension
Flexion
Lateral flexion
Combined movements
Irreducibe
FOR EXTRIMTIES
40
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
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
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
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
PREDISPOSING AND PRECIPIATING
FACTORS
Predisposing: Precipitating:
 Prolonged sitting - Movements
 Frequency of flexion - trauma
- lifting
- lateral flexion or rotation
45
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
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
McKenzie- PracticalMcKenzie- Practical
48
PROCEDURES
CERVICAL SPINE
1. Retraction
2. Retraction with extension (sitting/ standing)
3. Retraction with extension (lying/prone)
4. Retraction with extension with traction or rotation
5. Extension mobilization (lying prone/ supine)
6. Retraction and lateral flexion
7. Lateral flexion mobilization and manipulation
8. Retraction and rotation
9. Retraction mobilization and manipulation
10. Flexion
11. Flexion mobilization
12. Traction
49
50
51
THORACIC
 Erect sitting flexion
 Extension in lying
 Extension mobilization/ manipulation
 Erect sitting rotation
 Rotation mobilization/ manipulation
52
53
LUMBAR
1. Lying prone
2. Lying prone in extension
3. Extension in lying
4. Extension in lying with belt fixation
5. Sustained extension
6. Extension in standing
7. Extension mobilization
8. Extension manipulation
9. Rotation mobilization in extension
10. Rotation manipulation in extension
11. Sustained rotation/ mobilization in flexion
12. Rotation manipulation in flexion
13. Flexion in lying
14. Flexion in step standing
15. Correction of lateral shift
16. Self-correction of lateral shift
54
55
56
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
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
 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
59
60
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
61
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
62
 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
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.
64

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Meckenzie approach

  • 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
  • 27. 27
  • 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
  • 29. Quebac Task Force** Indications: 1,2,3- most indicated for McKenzie. 7,8,9,10 relatively indicated. 4,5,6 not suitable, i.e. contraindication. 29
  • 30. Contraindications Malignancy TB spine. RA AS CNS Dysfunction. Fracture of anterolesthesis/retrolesthesis Instable spine Vascular abnormality like vestibulo-basilar insufficiency Advance diabetes mellitus. 30
  • 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
  • 35. CONCLUSION 1. Syndrome classification 2. Appropriate therapeutic loading strategy 3. Appropriate testing loading strategy 35
  • 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
  • 39. Management Derangement syndrome 39 Stages Rx Reduction Manitenance of reduction Recovery of function Prophylaxis Extension Flexion Lateral flexion Combined movements Irreducibe
  • 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
  • 45. PREDISPOSING AND PRECIPIATING FACTORS Predisposing: Precipitating:  Prolonged sitting - Movements  Frequency of flexion - trauma - lifting - lateral flexion or rotation 45
  • 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
  • 49. PROCEDURES CERVICAL SPINE 1. Retraction 2. Retraction with extension (sitting/ standing) 3. Retraction with extension (lying/prone) 4. Retraction with extension with traction or rotation 5. Extension mobilization (lying prone/ supine) 6. Retraction and lateral flexion 7. Lateral flexion mobilization and manipulation 8. Retraction and rotation 9. Retraction mobilization and manipulation 10. Flexion 11. Flexion mobilization 12. Traction 49
  • 50. 50
  • 51. 51
  • 52. THORACIC  Erect sitting flexion  Extension in lying  Extension mobilization/ manipulation  Erect sitting rotation  Rotation mobilization/ manipulation 52
  • 53. 53
  • 54. LUMBAR 1. Lying prone 2. Lying prone in extension 3. Extension in lying 4. Extension in lying with belt fixation 5. Sustained extension 6. Extension in standing 7. Extension mobilization 8. Extension manipulation 9. Rotation mobilization in extension 10. Rotation manipulation in extension 11. Sustained rotation/ mobilization in flexion 12. Rotation manipulation in flexion 13. Flexion in lying 14. Flexion in step standing 15. Correction of lateral shift 16. Self-correction of lateral shift 54
  • 55. 55
  • 56. 56
  • 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 59
  • 60. 60
  • 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 61
  • 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 62
  • 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. 64