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Jordan Nolan-McKenzie Classification System in the Extremities

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Jordan Nolan

on 18 September 2012

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Transcript of Jordan Nolan-McKenzie Classification System in the Extremities

McKenzie Classification System
in the Extremities Jordan Nolan, SPT Learning Objectives By the end of this presentation, you will be able to: -Differentiate between an anatomical diagnosis and a mechanical diagnosis -Understand the four McKenzie classifications for the extremities and recognize what symptoms and mechanical responses each classification displays -Utilize the McKenzie guidelines to create treatment plans for patients with extremity pathologies. 2. "Diagnostic accuracy of clinical test for SLAP lesions: systemic review" 1. "Interexaminer Reliability of orthopedic special tests used in assessment of shoulder pain"
Invalid and unreliable test lead to suspect diagnosis and treatment protocol Postural Syndrome Intermittent pain of normal tissue brought on ONLY by prolonged static loading. Dysfunction Syndrome Derangement Syndrome Other Don't conduct repeated movement testing in all directions because it may aggravate the problem and give invalid symptomatic responses during the rest of the evaluation
Signs spine is involved:

Peripheral joint pain associated with proximal pain.
Ex: Scapular region or buttock

Numbness/Tingling

Symptoms felt in the extremity but unaffected by mechanical testing of the local joints and muscles Negative repeated movement results.

Only specific posture causes pain. Correcting poor postural habits Displacement within the joint preventing movement and causing pain. Common to occur suddenly in the joints of the extremities. Repeated movements: No affect or produce a lasting increase in pain, and movement may become more difficult Rapid and lasting changes Common causes:
menisci in knee and TMJ
loose bodies from degeneration of articular cartilage and bony fragments
Impingement of synovial membrane
Tears and catching of the labrum McKenzie Examination General Guidelines Anatomical Diagnosis Many standard orthopedic tests used to make anatomical diagnosis in musculoskeletal disorders in the extremities are:

NOT reliable(reproducible)

NOT valid(measure whats intended) The Following 4 research studies highlight issues with Anatomical Diagnosis 3. "Reliability of measurement obtained with four tests for patellofemoral alignment" 4. "Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis" Classify patients concentrating on syndrome identification Mechanical Evaluation- Examine the symptomatic and mechanical response of patients to different repeated movements or static forces Patient's are classified into 4 broad categories rather than "tissue-specific diagnoses" Identification of a disease by means of its signs and symptoms Syndrome-"characteristic group of symptoms, and pattern of responses characteristic of a particular problem." McKenzie Mechanical Diagnosis McKenzie system mainly used to classify and treat patients with mechanical spinal disorders.

Recently applied to patients with musculoskeletal disorders in the extremities. Unable to classify patient into one of the three mechanical syndromes. They are considered to be non-mechanical. Ex: Post-Op, inflammatory disorder, chronic pain syndrome PRICE, general graduated exercise program, and densitization Repeated movement testing: Pain only when structures are mechanically loaded Articular Dysfunction Contractile Dysfunction Intermittent pain

Restriction of END RANGE movement in one or more directions Intermittent pain only during MOVEMENT OR LOADING of the structural impairment

Contract or stretch musculotendinous unit Ex: Joint capsule or adjacent supporting ligaments. Pain and decreased ROM persist until remodeling of affected structures has occurred. Remodeling process must affect both the tissues' ability to contract, as well as to be stretched. This can take months Contractile and articular dysfunctions can occur together Complete McKenzie Extremity Assessment Sheet Order of Examination:
Active Movements
Passive Movements
Resisted Movements
Repeated movements
Sustained postures Management of Derangement Acceptable for an increase of pain while doing reductive movements; However, afterward the joint should feel better and movement should be easier Temporarily avoid aggravating positions/movements and do the reductive movements regularly Time frame: Days to a few weeks, elbow could be less 10 reps 3-4 times daily for first few days.
Progress to every 2 hours Initially patient applies repeated active exercise to end range Direction of preference needed for reducing peripheral derangement varies at different joints

More planes of motion at a joint the more directions that may need to be tried to reduce the derangement Always choose the most painful movement first Progression of Forces apply overpressure at the end range of the active movement and evaluate symptomatic and mechanical response if you get a "yellow light" with therapist overpressure, that is a good indication to progress with mobilizations in this direction Force Alternative 1. Change starting position 2. Lateral component Use when movements in the sagittal plane are not effective Some derangement show a painful arc but no obvious obstruction to movement. Apply resistant in the direction of movement that is most painful. Derangement Management:
Hip Extension>IR>ER>Flexion Derangement Management:
Knee Extension>Flexion Derangement Management:
Ankle DF>PF>EV>IV DF: active, add towel for overpressure, squat in WB PF: active, sit on feet(knees flexed) Typically need reduction in WB Derangement Management:
Shoulder Extension>IR>Horizontal Adduction (if Ext. and IR are full) ALWAYS try and get internal rotation ROM full before attempting external rotation! If patient is limited in extension and IR and isn't responding to functional internal rotation try functional external rotation. Derangement Management:
Elbow Extension>Flexion Can add valgus or varus force Try supination first then pronation Derangement Management:
Wrist Usually Extension can include radial or ulnar glide with distraction aka Tendinopathy Management of Articular Dysfunction Patient MUST move affected joint towards restriction until pain is felt Try to go farther with each repetition with the goal of reaching end range Initially repeat movement 10-12 reps 3-4 times a day.

If symptoms are no worse after the exercise increase to every 2 hours Most joints need the addition of overpressure to get to end-range
Ex: Full hip flexion or full knee flexion is impossible to obtain by active movement only

Overpressure may sometimes be necessary from day one Usually movement will improve as symptoms do, but this is not always the case Hip Articular Dysfunction Extension>IR>ER>Flexion Multi-directional dysfunction start with one direction until significant improvement-then begin another direction Two types:
1. Articular Dysfunction
2. Contractile Dysfunction Add medial or lateral rotation 3. Apply Resistance
"A survey of the McKenzie Classification System in the Extremities: Prevalence of Mechanical Syndromes and Preferred Loading Strategies" Mechanical deformation of structurally impaired tissue due to
Previous trauma
Inflammation process
Degenerative process
These events cause contraction, scarring, adherence or adaptive shortening. Determine prevalence rates of MDT syndromes in extremities

30 MDT certified therapists
Data gathered on 388 patients

Classification categories:
37% Derangement
36% other (20% was post-surgery or post trauma)
17% Contractile Dysfunction
10% Articular Dysfunction Management of Contractile Dysfunction 1. Resisted mid-range loading

2. End-range stretches in the opposite direction from its contractile role. Pain at end range every time Longer time to heal because tissue has to remodel. Slow turnover of collagen (weeks/months rather than days) Traumatic or insidious onset

Severe symptoms in the past for several months; patient has improved some but pain is persisting and improvement is plateauing unlike articular dysfunctions, this is usually short of end range "TARGET ZONE": Apply static or dynamic loading in Target zone Studies show eccentric loading is extremely useful in rehabilitation of chronic tendon problems.

Eccentric loading accelerates recovery and hastens strength gains. Initially repeat movement 10-12 reps 3-4 times a day. Progress exercise to every two hours Management of Contractile Dysfunction What If patient has increased pain that remains worse long after exercise? Option 1: exercise in the least painful range. static holds well away from the target zone If no change may need to increase the degree of loading temporarily to irritate the tissue
Need to re-trigger healing process


Procedure: Patient actively performs the movement and at the same time applies static overpressure/compression at the site of maximum tenderness


Continue with the compression and movement until the condition is stirred up so that constant aching has been achieved


Aching should only last a 1 or 2 days following which active range of motion and later resisted exercise should be initiated to rehabilitate the structure Multiple case studies have been published demonstrating the success of MDT on extremity pathologies Case Study 1: Shoulder Pathology Demographics:
cervical spine cleared Flexion, extension, and adduction were wnl and had no effect on symptoms.

Abduction wnl but pain increased in her shoulder from 150° to end range

External rotation limited to 70° and increased pain at end-range

FIR was the most symptomatic and limited of all movements. She could only touch her buttock and had increased pain at end range
Passive Shoulder ROM:
some caused mild discomfort, but no single test reproducing concordant symptoms. *What movement would you decided to explore first in repeated movement testing?
Repeated Movement Results: FIR got easier and range of motion increased. After 2 sets she had no pain at rest and all symptoms had been abolished What classification does she fall under? Case Study 2: Shoulder Pathology 57 year old male

Occupation-printer, required regular transfer of print screens of various weights and dimensions. Repetitive lifting is required at both above and below shoulder level.



Resisted Testing: What classification does this gentlemen fall under? Answer: Derangement Syndrome Study Highlighted Issue 1. Postural Syndrome

2. Dysfunction Syndrome
Articular
Contractile

3. Derangement Syndrome

4.Other RULE OUT SPINE FIRST!! Syndrome Identification: Management: Syndrome Identification: Management: Syndrome Identification: Pain during AROM and PROM but not resisted testing Syndrome Identification: Ex: Active movements, static resisted movements, and concentric and eccentric loading. sufficient to generate the patient's pain, but ceases when the load is removed. Option 3: change the starting position.
Ex: Shoulder exercises may be aggravating in standing can be done lying Option 2: exercise in non-painful range for a week or two Two week trial Chronic Contractile Dysfunction Syndrome Identification: Increasing symptoms in one direction Decreasing symptoms in the other Instructions for patient Patient overpressure upper extremity use healthy hand and use both hands in lower extremity. Potentially an article of furniture Therapist overpressure Mobilization Syndrome Identification: Management: 38 year old female Subjective anterior right shoulder pain present for 2 months
Insidious onset
Symptoms intermittent and aggravated by all movements of shoulder and by sleeping on right side
Pain gets worse during course of day with normal work and ADL's Objective
Active Shoulder ROM: replicated active movements and was prevented by patients pain rather than a physical limitation. Resisted tests: Answer: FIR Demographics:
Pain affecting his left shoulder and upper arm for the past 12 months

Insidious onset and unchanging symptoms Subjective: Objective: Shoulder ROM:
Full active and passive ROM of left shoulder

Arc of pain provoked between 80°-120° with abduction and end range pain produced with lateral rotation and FIR.

These responses did not alter with repetition, or with increased load using a small weight. Thus these tests produced pain with movement but were no worse as a result of the movement. Repeated Motion Testing: Cervical spine clear Pain provoked during isometric abduction and lateral rotation were the most symptomatic. Repeated isometric testing of abduction and ER similarly provoked pain at the shoulder that was no worse following the test. Contractile Dysfunction What would his "Target Zone" be? NOT Reliable NOT Valid NOT Reliable NOT Reliable Work Citied 2. McKenzie R (2011). Advanced Cervical & Thoracic Spine and Extremities(upper limb). McKenzie Institute: Part D. 53-81. 3. McKenzie R (2011). Advanced Lumbar Spine and Extremities(lower limb). McKenzie Institute: Part C. 69-104. 4. Cadogan A, Laslett M, Hing et al (2010). Interexaminer reliability of orthopaedic special tests used in the assessment of shoulder pain. Manual Therapy 16. 131-135. 5. Dessaur WA, Magarey ME (2008). Diagnostic Accuracy of Clinical Tests for Superior Labral Anterior Posterior Lesions: A Systemic Review. JOSPT 38. 341-352. 6. Fitzgerald G, McClure P (1995). Reliability of measurement obtained with four tests for patellofemoral alignment. 7. Shcotlen RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Family Pract 2003; 52:689-694. Answer: 80°-120° of abduction 1. McKenzie R, May S (2000).The Human Extremities Mechanical Diagnosis & Therapy. New Zealand: Spinal Publications New Zealand Ltd. 8. Aina A, May S. A shoulder derangement. Manual Therapy 10 (2005); 159-163. 9. Littlewood C, May S. A contractile dysfunction of the shoulder. Manual Therapy 12 (2007); 80-83. 10. Kaneko S, Takasaki H, May S. Application of Mechanical Diagnosis and Therapy to a Patient Diagnosed with de Quervain's Disease: A Case Study. J Hand Ther. 2009;22:278-284. Pain decreases with each repetition Pain increases while doing movement but gets better after Pain increases and remains worse after the repeated movement Green Light: Yellow Light: Red Light: Traffic Light
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