MDT for Cervical Spine Flashcards
1
Q
What are the cardinal features of MDT (mechanical diagnosis and therapy)
A
- Classification of subgroups
- Focus on centralization
- Self-treament & patient education
- Progression of forces
2
Q
How does MDT differ from other treatment approaches
A
- Repeated movements used to assess & manage condition
- Patient independence
- Avoids dependence on therapist
- Minimal intervention/least amount of force used to treat
- Directional preference exercises used for pain relief
3
Q
What are the MDT classifications
A
- Derangement
- Dysfunction
- Posture
4
Q
What is postural syndrome
A
- Intermittent pain brought on only by prolonged static position
- Rarely seen in clinic
- Pain is localized
- No pain with movement
- No ROM deficits
- Posture correction abolishes symptoms
- Exam is normal and only has pain in the painful posture and once corrected it goes away
5
Q
Describe management of postural syndrome
A
- Education on link b/w posture & pain
- Education on link b/w lumbar & cervical postures
- Education on posture correction: attain posture & maintain posture
- Education on avoidance of aggravating postures
- Posture correction
- Slouch-Overcorrect
- Can implement use of lumbar posture support and/or cervical night roll
6
Q
Describe dysfunction classification
A
- Pain caused by mechanical deformation of structurally impaired soft tissue: contracture, scarring, adherence, adaptive shortening of tissue
- Intermittent pain that oNLY occurs at end range of the restricted movement
- Gradual onset due to lack of use or 6-8 wks post-trauma
- Pain is localized (except in case of adherent nerve root)
- Symptoms do NOT persist after repeated movement testing
- Named for the ROM deficit
- Recovery can take 6-8 wks
7
Q
Describe management of dysfunction
A
- Long recovery
- Perform the restricted movement 10-15 reps every 2-3 hrs
- Exercise must produce their pain every rep
- Pain should subside following exercise within 10 min
- If pain persists, overstretching has occurred or maybe you have exposed an underlying derangement
- Maintenance: once ROM restored & without pain perform 1-2 times daily
8
Q
Describe adherent nerve root
A
- Hx of radiculopathy or spine surgery
- Intermittent symptoms into arm/forearm
- Consistent reproduction of symptoms with loading: typically shoulder abd, elbow extension, wrist extension with contralateral cervical lateral flexion or cervical flexion
- No rapid change & no lasting reproduction of distal symptoms
9
Q
Describe management of adherent nerve root
A
- Cervical flexion
- Cervical flexion with patient overpressure
- Cervical lateral flexion (away from the pain)
- Cervical lateral flexion with patient overpressure
- Elbow ext. in shoulder ABD with lateral rotation
- Elbow ext. in shoulder ABD/lateral rotation with wrist extension
- Elbow ext. in shoulder ABD/lateral rotation with neck flexion/lateral flexion
- Will take several wks at least for recovery
- With each movement perform the opposite C-spine movement to expose underlying derangement if present
10
Q
What is derangement
A
- Most common classification
- Onset can be gradual or sudden
- Somatic, radicular, or combination
- Symptoms are variable & inconsistent
- Pain can change sides, move distal/proximal = CENTRALIZATION & PERIPHERALIZATION
- Movement can increase/decrease symptoms
- Sustained postures can increase/decrease symptoms
- Temporary deformity may be present: wry neck or kyphosis
11
Q
What are the hallmarks of derangement
A
- Centralization
- Peripheralization
- Rapid change
- Variable symptoms
- Mechanically determined directional preference
12
Q
What is a mechanically determined directional preference
A
- Postures or movements in one direction decrease, abolish, or centralize & restore movement
- Postures & movement in opposite direction can worsen/peripheralize & reduce ROM
13
Q
Describe pain
A
- Sensory, cognitive, & emotional components
- Nociception is how our body detects & processes painful stimuli
- Nociceptors are activated by thermal, mechanical stress, & chemical/inflammatory
- Innervated structures of lumbar spine that can produce pain: facet joint capsule, outer layer of annulus fibrosis of intervertebral disc, vertebral bodies, dura mater, nerve root sleeve & connective tissue of nerves, spinal musculature
14
Q
What are the different types of pain
A
- Somatic: MSK structures, when referred is deep ache, vague
- Radicular: nerve root pain, follows dermatomal pattern
- Central: pain related to abnormal CNS problem
- Visceral: organs
15
Q
Describe the McKenzie pain phases and their identifiers
A
- Chemical: constant, acute onset, signs of inflammation (swelling, rumor, color, tenderness), all movements are painful, & no movement reduces Sx
- Mechanical: intermittent but can also be constant, certain repeated movements reduce or abolish/centralize Sx, & movements in one direction may lessen Sx whereas Sx in another direction may increase Sx
- Chronic: may not be influenced by mechanics alone, need to account for psychosocial factors, length of time present does not mean mechanical assessment & treatment are not beneficial, may take longer than pts that are not chronic, & chronic pain may not respond to treatment
16
Q
Contraindications to MDT
A
- Spinal cord lesions
- Fractures & ligamentous instability
- Tumors
- Spinal infection
- Dizziness
- Vertebrobasilar insufficiency
- Gait/upper limb abnormality
- Bilateral UE & LE symptoms
- Hyperreflexia, bowel/bladder, spasticity
- Recent surgery: fusion 3 mo to 1 yr for good stabilization, discectomy no concerns
17
Q
Red flag clues
A
- Age >55
- Hx of CA (cancer)
- Unexplained weight loss
- Constant, progressive, non-mechanical pain, worse at rest
- Systemically unwell
- Persisting severe restriction of lumbar flexion
- Widespread neurological deficit
- Prolonged steroid use
- Hx of intravenous drug use
- Hx of significant trauma enough to cause fracture or dislocation (X-rays will not always detect Fx)
- Hx of rival trauma & severe pain in potential osteoporotic individual
- No movement or position centralizes, decreases, or abolishes pain
18
Q
Physical exam using MDT
A
- Assess posture & effects of posture correction
- Neuro exam if paresthia in UE, weakness in UE, or radicular symptoms
19
Q
What is wry neck
A
- Lateral deviation
- Significant if occurs with onset neck pain
- Unable to correct voluntarily
- If able to correct cannot maintain
- Right deviation = vertebra above has laterally flexed to right
- Left deviation = vertebra above laterally flexed to left
- Contrtalateral = head shifted away from painful side
- Ipsilateral = head shifted toward painful side
20
Q
Describe the different upper limb tension tests
A
- Ulnar: “eye hole” with thumb & index finger
- Median: scapular depression, shoulder ABD, ER, elbow ext., supination, wrist ext.
- Radial: scapular depression, shoulder ABD, IR, elbow ext. pronation, & wrist flexion
21
Q
Describe repeated movement testing
A
- Assess mechanical baselines before movement
- Pain after performing repeated movement
- Is pain during movement? (PDM)
- Is pain only at end range? (ERP)
- Reassess mechanical baselines
- Sagittal plane movements have greatest effect
- Lateral movements used initially with wry neck, sagittal plane will not be tolerated
- Testing in sitting is easier but this is loaded position & may not be tolerated
- Once a repeated movement decreases, abolished, or centralizes pain further testing of movements is not always necessary
22
Q
Describe static testing
A
- Indicated when repeated movements do not effect symptoms
- Indicated if pt only reports symptoms with prolonged position: postural classification, intermittent derangements
23
Q
Terminology during movement
A
- Increase: Sx already present increase in intensity
- Decrease: Sx already present decrease in intensity
- Produce (P): Sx produced that were not present
- Abolish (A): No longer have Sx after testing
- Centralizing: Movement of pain from distal to proximal
- Peripheralizing: Movement of pain from proximal to distal
- No effect (NE): Movement has no effect during testing
24
Q
Terminology after testing
A
- Worse (W): Sx produced or increased w/ movement & remain aggravated after testing
- Not worse (NW): Sx produced or increased w/ movement return to baseline after testing
- Better (B): Sx decreased or abolished during movement remain better after testing
- No better (NB): Sx decreased or abolished during movement or loading return to baseline after testing
- Centralized: Distal pain abolished by movement that remains abolished after testing
- Peripheralized: Distal pain produced during movement testing remains after testing
- No effect: Movement or loading has no effect on Sx after testing
25
Q
What does LCDF stand for
A
- Location: differentiate peripheral site pain vs radicular
- Classification: derangement, dysfunction, postural syndrome, mechanically inconclusive, other
- Direction: choosing the direction that best fits the assessment
- Force: patient generated, loaded or unloaded, patient overpressure, clinician overpressure, clinician mobilization, manipulation
- Build your care starting at L
- Modify your care starting at F
26
Q
What is failure to classify
A
- Classification should be confirmed within 3-5 visits
- Recent neck trauma: whiplash associated disorder
- Other conditions: stenosis, mechanically inconclusive, chronic pain state, shoulder
27
Q
Extension principle clues from the history (~60%)
A
- Onset related to flexion task
- Flexion activities worsen
- Extension activities decrease or abolish
28
Q
Extension principle clues from the examination (~60%)
A
- Poor posture
- Posture correction affects Sx
- Loss of multiple movements
- Greatest loss of extension
- Extension may be obstructed or painful
- Lateral movements less limited than sagittal
- Repeated flexion worsens mechanical presentation & Sx
- Retraction/extension decreases, abolishes, or centralizes
- Repeated retractions improves extension ROM
- Presence of kyphotic deformity (fixed in protrusion/flexion)
29
Q
Lateral principle clues (~20%)
A
- Unilateral or asymmetrical Sx
- Flexion & extension aggravate Sx
- Directional preference for rotation or lateral flexion
- Lateral movement is asymmetrical with major loss in one direction
- Sx improve with lateral movements
- Peripheralization or worsening of peripheral Sx with flexion/extension
- Presence of wry neck (clinically relevant lateral deviation of the spine)
- Sx unchanged with trial of sagittal plane
30
Q
Flexion principle clues (~5%)
A
- Symmetrical or asymmetrical Sx
- Anterior/anterolateral Sx
- Pain or problems with swallowing
- Recent MVA
- Pain on neck flexion
- Major loss of flexion
- Pain free full extension
- Repeated flexion increases ROM & decreases Sx
31
Q
What are the stages of management of derangement
A
- Reduction
- Maintenance of reduction
- Recovery of function
- Prevention of recurrence
32
Q
Describe reduction of derangement
A
- Establish treatment principle that centralizes, abolishes, or decreases Sx & restores function
- Regular performance of pain alleviating exercises
- Posture correction
- Force progressions if indicated
- Ongoing re-evaluation of treatment principle if improvement ceases
33
Q
Describe maintenance of reduction for derangement
A
- Avoidance of aggravating postures, positions, & activities: use of postural supports
- Regular performance of directional preference exercise
34
Q
Describe recovery of function for derangement
A
- restorre all movements once reduction is maintained ~5 days
- Recovery of flexion “5 X 5 X 5”: 5 reps of flexion, 5 reps of extension, 5 times per day, progress force to self overpressure after 5 days, produce central pain not worse response is okay
- Lateral flexion utilized in C-spine more than L-spine & therefore recovery of contralateral lateral flexion may be needed
- Recovery of function not needed in anterior derangement
35
Q
Describe prevention for derangement
A
- Continue with daily ORM to maintain full mobility
- Avoid prolonged sustained postures
- Lifelong use of lumbar support roll
- maintain healthy active lifestyle
36
Q
What are the stages of force progerssion
A
- Patient generated
- Patient overpressure
- Therapist overpressure
- Mobilization
- Manipulation
37
Q
Describe static patient generated force
A
- Mid range
- End range
38
Q
Describe dynamic patient generated force
A
- Repeated motion mid range
- Repeated motion to end range
- Repeated motion end range with patient overpressure
39
Q
Describe clinician force
A
- Patient motion in mid range with clinician overpressure
- Patient motion to end range with clinician overpressure
- Mobilization
- Manipulation
40
Q
Describe force alternatives
A
- Loaded vs unloaded position
- Loading strategy in sitting may peripheralize/worsen Sx, however performing in supine may decrease & centralize Sx
- Change direction: remember coupling of lateral flexion & rotation, one motion may be tolerated better
41
Q
Describe extension principle for retraction
A
- Retraction
- Retraction w/ pt overpressure ( have the patient rotate/”wiggle” their head a little)
- Retraction w/ clinician overpressure
- Retraction mobilization
- Can be performed sitting, standing, supine, or prone
- May need to perform on pillows & progress to no pillows
42
Q
Describe extension principle for retraction/extension
A
- Retraction & extension
- Retraction & ext. w/ rotation
- Retraction & ext. w/ rotation & clinician traction (supine only)
43
Q
Describe lateral principle for lateral flexion
A
- Can be performed sitting or supine
- Lateral flexion
- Lateral flexion w/ pt overpressure
- Lateral flexion w/ clinician overpressure
- Lateral flexion mobilization
- Lateral flexion manipulation
44
Q
Describe lateral principle for rotation
A
- Can be performed sitting or supine
- rotation
- Rotation w/ pt overpressure
- Rotation w/ clinician overpressure
- Rotation mobilization
- Rotation manipulation
45
Q
Describe flexion principle
A
- Can be performed sitting Orr supine
- Flexion
- Flexion w/ pt overpressure
- Flexion w/ clinician overpressure
- Flexion mobilization
46
Q
How do you fill out the McKenzie form
A
- Circle activities/symptoms that are always there or always aggravate/alleviate Sx
- Underline those that occur sometimes
- Cross out those that never occur
47
Q
Progression of forces for least to greatest
A
- Patient generated
- Patient overpressure
- Clinician overpressure
- Mobilization
- Manipulation
