Mckenzie Mechanical Diagnosis: Lumbar Flashcards
What are the five critical questions you need to ask when assessing the lumbar spine?
- Onset of Symptoms
- Cause of symptoms
- location of symptoms
- are symptoms constant or intermittent
- Does anything change the symptoms
Symptoms less than 6 weeks rules out?
- dysfunction
- ANR
symptoms greater than 6 weeks can indicate?
- dysfunction
- derangement
- postural
anything
sudden cause of onset means:
NO dysfunction
often derrangement
gradual onset means
any cause
Post surgical/ trauma usually means
dysfunction
location of symptoms localized to spine
any
symptoms radiating to extremity
- NO Postural
- NO standard dysfunction
- YES adherent Nerve Root Dysfunction
- OFTEN Derangement
If symptoms are constant
No Postural
NO Standard Dysfunction
NO ANR
YES Derangement or Other
If symptoms are intermittent
any
If anything changes the symptoms what are the possible causes
YES derangement
YES postural
rules out function
if nothing changes symptoms
Dysfunctional
severe derangement
what components make up objective assessment
- asses posture
- neuro screen (if extremity symptoms)
- Myotomes/Dermatomes/Reflexes
- Neural Tension
- AROM assessment (1 rep each)
- Repeated motion testing
- Static positional testing
Posture rules
- never ROM loss
- never has neuro signs
- never has produced or increased pain with repeated motion testing
- always intermittent pain
- always pain local to spine
- pain is produced with static hold
Dysfunction rules
- ALWAYS:
- intermittent
- has ROM loss
- onset > 6 weeks
- will have pain only at end range of restricted ROM - NEVER will have symptoms that change with repeated motion or static testing
- ALWAYS local pain with rare exception of adherent nerve root
Derangement rules
- Variable presentation- CHANGE
- symptoms CHANGE with position, repeated motion
- Directional Preference
- Concordant Signs
- Peripheralizing or Centralizing symptoms
What to asses with posture
- standing & seated
- look for lateral shift deformity, treat IMMEDIATELY if RELEVANT
- assess normal spinal curves
- look for altered weight bearing
- assess discretely if possible
- assess effect of postural correction on current symptoms
- SLOUCH/OVERCORRECT technique
if you see a lateral shifted deformity what should you do first?
ask if it is relevant, if it is, fix it!
When do you have to do a neuro assesment
if symptoms are below the knee
Neuro test components
- myotomes, dermatomes, reflexes
- neural tension
- make useful concordance signs to retest and see if treatment is effective
ROM
- one active rep of each: flexion, extension, lateral flexion
- acts as baseline measure
- in standing if possible
Repeated motion
- must start in sagittal plane 1st
- flexion or extension (slow)
- may use subjective info to guide choice
- reproductive to treat or provocative to confirm diagnosis
- often needs 20-30 reps to change
- CHANGE LOAD 2nd (trial prone, supine or seated)
- assess lateral last if needed
how many reps are needed to see change?
20-30
what motions should you start with first in the sagittal plane?
flexion and extension
when checking repeated motion what do you do first and second
first: motion in sagittal plane
second: load
Descriptors used during motion
centralizing peripheralizing increase decrease no effect produce abolish
terms used to describe symptoms following motion or reps
- centralized
- peripheralized
- better
- no better
- worse
- no worse
- no effect
how do repeated motions affect postural?
- no baseline symptoms due to need to SUSTAIN load to bring on symptoms
- no effect during repeated movements
- mo effect following repeated movements
- postural always asymptomatic with motion
- no ROM loss
how do repeated motions affect dysfunction
- no symptoms baseline resting position
- one or more motions restricted ROM
- produces local pain at end range only
- no worse/ no change with repetition
- all on / all off
what causes pain at end range only
Dysfunction
what has one or more motions restricted
dysfunction
dysfunction ANR
what gets no worse with repitition
dysfunction
dysfunction ANR
what has no change with repetition
dysfunction
no symptom baseline in resting position
dysfunction
dysfunction ANR
what has ALL ON or ALL OFF
dysfunction
what has ON/OFF
dysfunction ANR
what has positive neural tension
Dysfunction ANR
what produces pain in extremity only at end range of restricted motion
Dysfunction ANR
may or may not have symptoms baseline in resting position
derangement
symptoms will worsen or improve, centralize or peripheralize either during or following repetition
derangement
may or may not have ROM restriction
derangement
What indicates a red light
perpipheralized, worse, worsening, concordants
what indicates yellow light
produced increased decreased no worse no better no effect
what indicated green light
centralized
better
abolished
improved concordants
STOP!``
decrease force or change direction
Caution!
progress reps
force in current direction
closely monitor for change
Go!
progress reps
force in current direction until abolished
if there is no relevant lateral shift, when should you do lateral shift exercises on a patient
ONLY if the sagittal planes both worsen or fail to improve symptoms
What are the principles of treatment?
extension
flexion
lateral
Force progressions:
- begin unloaded (laying) then progress to loaded (standing)
- change reps, then load, then principle
- begin with patient generated force and progress to therapist generated force
- Always progress to end range unless you get RED LIGHT
- if no change with dynamic testing/ treatment trial static
- Always try to get back to sagittal patient generated forces
when doing force progressions how is a person first situated?
- Laying (unloaded)
2. standing (loaded)
what do you start with for force progression
patient generated
Patient generated extension principle
- prone
- prone on elbows
- extension in lying
- extension in lying with self over-pressure
- extension in standing
Therapist generated Extension
- extension in lying with therapist over pressure
- extension mobilization
- extension manipulation
if you have a posterior/posterior lateral derangement or extension disfunction which exercises feel better
extension principle
Extension mobilization/manupilation guidelines:
- SLOW
- take 10 or more reps to get to end range
- never manipulation with out mob testing
Flexion principle patient guided
- supine
- hook lying
- flexion in lying
- Flexion in sitting
- flexion in standing
- sustain flexion
what must be corrected first or other treatment with not be effective?
lateral shift
lateral shifts must be?
relavant
what makes a lateral shift relevant
easily noticeable and related to recent symptoms
how are lateral shifts named?
in the direction of where the upper body are shifted to
fixed shift
pt cannot correct it
unfixed shift
can correct it
how many reps do you do to get to end range of self standing side glide
10 reps, shift into the direction that it will be corrected if doesn’t work go contralateral
Lateral principle patient generated?
- prone lying hips off center
- extension in lying hips off center
- standing self lateral glides
- extension in lying with lateral over pressure
lateral principle therapist generated
- standing lateral shift correct
- rotation in extension mobilization
- rotation in flexion mobilization
- rotation manipulation
hand pressure on lower segment and pelvis are shifted which way in lateral principle?
- directed away from the pain
ex: pain on right, push hips left
hand pressure above the lesion is directed which way in lateral principle?
- directed toward pain
ex: pain on right, hand up top push to right
HEP for derangement
- 10-15 reps, every 1-2 hours to reduce deranged material
- avoidance of directions that RED LIGHT
- maintenance of proper posture
- follow up with PT in 2 days
- Encourage self reliance, pt active participant in their own recovery
- reassess, reassess, reassess
- prevent recurrence, modify work, home, posture to avoid repeated or sustained provoking forces
treatment for postural syndrome
- education
- ergonomics/activity modification
- posture correction
- posture slouch-overcorrection
- tapping
- lumbar roll
treatment of dysfunction
- 15 reps intro restricted/painful motion
- ANR needs flexion in standing SLR or flexion in sitting with leg extended (slump)
- follow with 15 extension in laying (if not extension dysfunction)
- repeat every 2 hours
- must produce pain at end range, but not remain worse > 15 min post exercise
- education (4-6) weeks
how long does it take for tissue to remodel to correct dysfunction?
4-6 wks
