Mechanical Treatment

for the Cervical Spine

 Introduction to McKenzie MDT
 How McKenzie developed his initial concept
 McKenzie courses and benefits to practice
 Addresses weaknesses of our schooling
 Great tool for new therapists to develop
confidence and evaluation skills
 Mainly patient generated forces
 Promotes client independence
 Success where many other approaches fail
 Introduction to McKenzie MDT
 Based on determining a directional
preference and mechanical response to
repeated movement
 Seeks to determine structure(s) responsible
for symptoms
 Seeks to classify the problem based on its
response to testing
 Classification based on symptom location and
positional / postural findings
 Indications
 Nerve root problems
 Mechanical neck pain (i.e. the pain varies
with physical activity and / or over time)
 Cervico-dorsal, scapular, shoulder and arm
pain
 + / - neurological symptoms
 Patient is generally well
 Cervical headache
 Contraindications for MDT
 Serious spinal pathology
 Cord Signs
 Cancer
 Infections
 Fractures
 Widespread neurological deficit
 Non-mechanical neck pain
 Caution : Vertebral artery / VBI – testing (5D’s)
 Caution : RA, AS, Acute Whiplash, chronic steroid
use (ligament laxity), pregnancy, Down’s Syndrome
 Syndromes
 Postural: Caused by deformation of soft
tissues through excessive load (time)
 Derangement: Damage to or
displacement of annular tissue with or
without nuclear displacement, or
mechanical pain from soft tissues
 Dysfunction: Chronic movement loss or
adherence of nerve roots
 Classification of Derangement
 D1 – Central, symmetrical - 35%
 D2 – Central, symmetrical (kyphotic deformity) -
3%
 D3- Asymmetrical, above elbow – 39%
 D4 – As per D3 with wry neck – 2%
 D5 – Asymmetrical below elbow – 15%
 D6 – As per D5 with deformity – 6%
 D7 – Anterior derangement, symmetrical,
possible “choking” feeling – 4%
 Recent Changes
 In recent years, classification has been
shifted to clinical impression > movement
response > symptom location
 Example : Posterior lateral derangement,
lateral responder, asymmetrical
 Planes of Movement
 Sagittal: Movements in the plane of
flexion and extension, protrusion and
retraction
 Coronal: Movements in the plane of side
flexion
 Axial: Movements in the plane of rotation
 Definitions in MDT
 Peripheralization: Production or increase of more
distal symptoms after repeated movement
testing
 Centralization: Production of more proximal
symptoms or a decrease in peripheral symptoms
after repeated testing
 Directional preference: Centralizing response of
symptoms to a specific repeated movement
 Mechanical reponse: Change in range of motion
in the tested movement or its opposing
movement during or after repeated movement
 Definitions (con’t)
 Increase: Augmentation of pain
 Decrease: Reduction of pain
 No Worse (NW): Increase in pain that is not maintained
post testing
 No Better (NB): Decrease in pain that is not maintained
post testing
 Worse: Maintained increase in symptoms or
peripheralization
 Better: Maintained decrease in symptoms or
centralization
 Produce: Creation of a pain that was previously not
present
 Abolish: Disappearance of a pain that was previously
present
 Definitions (con’t)
 Peripheralizing (Ping): Peripheralization of symptoms DURING
repeated testing
 Peripheralized (Ped): Peripheralization of symptoms maintained
POST repeated testing
 Centralizing (Cing): Centralization of symptoms DURING repeated
testing
 Centralized (Ced): Centralization of symptoms maintained POST
repeated testing
 These definitions apply most reliably to PAIN
 Current nomenclature refers mainly to symptoms post repeated
testing
 Changes are named in comparison to prior symptoms, not initial
symptoms
 Disc Forces
 Most frequently, compressive forces are
applied to the anterior annulus
 These forces cause a posterior migration
of the nucleus on to the annular wall
 Very few occasions in a given day where
posterior forces are applied
 Example: sitting
Anatomy
 Deformities
 Wry Neck
 Forward head Posture
 C0-1-2 Malposition can contribute to “Cervical
Headache”
 Relevent Shift: Indicates a need to address shift
in order to address symptoms
 Relevent Lateral Compartment: Used to name a
derangement requiring non-sagittal movements
Wry Neck
Forward Head Posture
Postural Issues
 Wry Neck
 There is a clear tilt of the head to one side
 Often below the age of 15, due mainly to
underdeveloped unco-vertebral joints
 Onset of wry neck came on with neck pain
 Patient is often unable to self-correct
 Correction can cause centralization or
worsening of peripheral symptoms
 Red Flags
 Hx of cancer
 Unexplained weight loss
 Constant, progressive, non-mechanical pain, worse at
rest or at night
 Systemically unwell
 Persisting severe restriction of cervical movement (Acute
MVA)
 Widespread neuro deficits
 History of significant trauma (i.e. fractures, dislocations)
 No movement or position centralises, decreases or
abolishes pain.
 5 D’s – Who knows them all?
 The 5 D’s
 Dysphagia
 Disarthria
 Drop Attack
 Diplopia
 Dizziness
 Other concerns – nystagmus, nausea,
tinnitus
 CORD SIGNS
 Upper Motor Neuron
 Bilateral / quadrilateral P&N
 Bilateral / quadrilateral Weakness
 Csp: 4 limbs; Tsp: 2 limbs; Lsp: 2 limbs
 Hyper-reflexia
 Increased sensation
 Spastic “key muscles” (i.e. Myotomes)
 Positive Babinski / clonus
 Ataxic / wide base gait
 Fine coordination may be affected (i.e. writing, buttons,
zippers)
 L’Hermitte’s sign (Csp flex: Positive for Csp if P&N 4 limbs;
Positive for Tsp if 2 lower limbs)
 Extremely rare, but we need to be vigilant – NO EVAL
 Movement loss
 ROM
 Is it pain or stiffness that stops the
movement?
 Is there any deviation to one side?
 Is the patient confident and willing to
move?
 Is there a curve reversal?
 Repeated movements
 Always take their baseline, i.e. What are you feeling right now?
 Protrusion, Retraction, Flexion, Retraction/Extension (all repeated as
required)
 Repeated Side Flexion or Rotation as needed
 What is happening during the movement?
 Is it Cing, Ping, ↑, ↓, PROD, ABOL, NE

 Change in ROM

 What happens after?

 Is it Ced, Ped, B, W, NB, NW, NE

 Maintained change in ROM

 May need to send client home with a repeated movement in order to

evaluate its effect on symptoms
 Watch for loss of ROM in opposing direction or temporary pain relief with
loss of ROM
 History taking
 A good history allows the therapist to guide the
evaluation towards helpful movements quickly
 As an example: “I have severe arm pain when I read
in bed with a pillow behind my head” – client has
already told you flexion/protrusion peripheralizes the
pain
 AM stiffness may require additional questioning on
sleeping habits/position – Night Roll
 Carefully evaluate client’s activities and daily postures
 Use posture as a test (sit unsupported)
 Sustained posture
 When NE with repeated movements
 Derangement that is very difficult to expose
(stable)
 When patient is too acute to perform repeated
movements
 With certain deformities (i.e. wry neck)
 May require time +++
 To educate the patient, i.e. when you stay in
this position, you worsen…
 Neuro Testing
 Key Muscles “Myotomes”
 Dermatomes
 Reflexes
 Neural tension (i.e. NDT)
Dermatomes
 Education
 Most important treatment that can be done on day one
 Essential to ensure patient motivation and compliance
 Anatomy review and explanation of forces on
structures can be helpful
 Need to implicate patient as much as possible
 Postural correction +++
 Sleeping position / pillow / work station
 Need to see client soon after eval for follow-up (acute
1-3 days)
 Key Factors
 ROM testing prior to repeated testing (baselines)
 “Scared Stiff”
 Correct for protrusion pre-testing
 Exhaust Sagittal before going lateral, but get back to Sagittal
 Get to end of ROM before progression (what is max ROM today,
may not be true end of ROM)
 Goal is to progress into WB exercise
 Maintenance (pain was their motivator)
 Recovery of Function (no reproduction of pain, maintain ROM)
 Postural exercises / strengthening as prophylaxis and
maintenance
 Benefits of our other services for prevention / maintenance
Patient Techniques (Repeated)
Sagittal Techniques
Retraction in Sitting (WB)
Retraction / Extension (WB)
Retraction in Supine
Retraction / Extension in Supine
Flexion
Retraction / Flexion

(Belts/towel or hand support can be used – “heavy head”)

Lateral Techniques
Retraction with Side Bending (WB)
Retraction with Rotation (WB)
Retraction with SB / Rot (WB)
 Therapist Techniques
 Traction / Retraction
 Traction / Retraction / Extension
 Retraction mob (supine or sitting)
 Extension mob (prone)
 Rotation mob (supine or sitting)
 Side bending mob (supine or sitting)
 Upper Cervical Flexion Mob (supine)
 Lower Cervical Flexion Mob (supine)
 Additional Techniques
 Cervical Traction
 Soft Tissue Mobilization
 Suboccipital Release
 Elevated / Depressed First Rib
 Thoracic Traction
 Thoracic Extension
 Frontal Lift for Headache
 Muscle Energy (future IPD)
 Additional Concerns
 Posture +++ and work station
 Lumbar support
 Scapular Control
 Stress and fatigue
 Lung or breathing issues
 Poor technique at home or at work
 Thoracic pain above T7 is often neck
related
 Myth Busters
 Most often, cervical spine will respond to heat
despite mild inflammatory responses
 Lumbar rolls will not damage the spine if used for a
prolonged period
 Neck braces are not a viable long-term solution to
any condition – they actually promote protrusion!
 Traction is not a maintained relief and no research
exists to suggest reduction
 Transient / faint numbness or P&N is not normally
considered peripheralization (release phenomenon
Questions?