Mechanical Diagnosis & Therapy

1. Mechanical Diagnosis & Therapy Advanced Cervical and Thoracic Spine & Extremities – Upper Limb

2. Course Goals • Identify and discuss common problems encountered in the application of Mechanical Diagnosis and Therapy for the cervical and thoracic spine. • Analyse and discuss the MDT assessment and how it assists with patient classification. • Discuss the application of clinician forces, and how they fit with McKenzie’s ‘Progression of Forces’ concept.

3. Course Goals 4. To perform clinician techniques for the cervical and thoracic spine at an advanced level and to identify problems with their application. 5. Analyse case studies of patients presenting with cervical / thoracic symptoms and determine their classification.

4. Course Goals 6. Describe and discuss the current evidence base for the use of MDT for upper limb musculoskeletal disorders. 7. Describe the characteristics of Derangement, Dysfunction and Postural syndromes as they present in upper limb musculoskeletal disorders. 8. Perform MDT assessments for upper limb musculoskeletal disorders and determine the presenceof McKenzie syndromes.

5. Course Goals 9. Design appropriate management programs for patients who present with Derangement, Dysfunction and Postural syndromes in the upper limb. 10. Analyse case studies of patients presenting with upper limb symptoms and determine their classification.

6. About the course C P R Content Participation Review

7. Mechanical Diagnosis and Therapy Advanced Cervical and Thoracic Spine

8. Module One Cautions and Contra-indications

9. Review of the pre-manipulative stages in Mechanical Diagnosis and Therapy

10. ABSOLUTE CONTRA-INDICATIONS Looking at the assessment forms, indicate where you would be alerted to the presence of these contra-indications

11. RELATIVE OR QUALIFIED CONTRA-INDICATIONS Looking at the assessment forms, indicate where you would be alerted to the presence of relative or qualified contra-indications

12. CLINICAL RECOGNITION OF CONTRA-INDICATIONS

13. Non-Mechanical Sources / Causes of Pain

14. Module Two Problem Areas and Problem Solving Guide

15. Problem Areas Assessment • History • Physical Examination Classification Management • Educational Component • Mechanical Component

16. Problem Areas Reassessment Force Progressions Procedures • Patient procedures • Clinician procedures Other problem Areas

17. Module Three Cervical Spine Workshop

18. Review Of Force Progressions • Patient Generated Force • Patient Generated Overpressure • Clinician Overpressure • Clinician Mobilization • Clinician Manipulation

19. Review Of Force Progressions Remember: • The goal of applying external force is? • When do you add force diagnostically? • When do you add force therapeutically?

20. Review Of Terminology • Define deformity • Define lateral shift • Define relevant lateral shift • Define relevant lateral derangement • What words describe effect during loading? • What words describe effect after loading? • Describe centralization pattern in the cervical/thoracic spine

21. TABLE OF CERVICAL PROCEDURES

22. Extension Principle Procedure One - Retraction Can be performed in sitting, standing, supine, prone 1a. Retraction with patient overpressure 1b. Retraction with clinician overpressure 1c. Retraction mobilisation

23. Procedure Two - Retraction / Extension Can be performed sitting, supine, prone • 2a. Retraction and extension with rotation • 2b. Retraction and extension with rotation and clinician traction (supine) Procedure Three - Postural Correction

24. Lateral forces Lateral forces are considered when the sagittal plane has been exhausted. • Describe what it means to exhaust the sagittal plane • What must be found in order to consider relevant lateral? • What are the typical loading strategies employed for cervical derangements with a lateral deformity?

25. Lateral Principle In the cervical spine, lateral involves either lateral flexion or rotation. • Indicate why you would choose one versus the other.

26. Lateral Principle Procedure Four – Lateral Flexion Can be performed sitting, or supine • 4a. Lateral flexion with patient over-pressure • 4b. Lateral flexion with clinician over-pressure • 4c. Lateral flexion mobilisation • 4d. Lateral flexion manipulation

27. Lateral Principle Procedure Five – Rotation Can be performed sitting or supine • 5a. Rotation with patient over-pressure • 5b. Rotation with clinician over-pressure • 5c. Rotation mobilisation • 5d. Rotation manipulation

28. Flexion Principle Procedure Six – Flexion Can be performed sitting or supine • 6a Flexion with patient over-pressure • 6b Flexion with clinician over-pressure (supine) • 6c Flexion mobilisation (supine)

29. Recovery of Function • What is evidence of full reduction? • When to and how to test for recovery of function? • Is it necessary to recover function in the cervical spine?

30. Differential Diagnosis

31. Upper cervical spine Self-treatment procedures for the upper cervical spine are: • Retraction • Flexion • Rotation • Combination flexion / rotation • Combination extension / rotation

32. Module Four Thoracic Spine Workshop

33. Thoracic Spine • Do not assume that symptoms arise from the thoracic spine simply based on location of symptoms. • Cloward 1950 demonstrated that structures in the lower cervical spine could refer to the lower angle of the scapula. • The actual incidence of true thoracic problems is quite low. • Look for clues in the history.

34. Thoracic Spine • Rule out cervical/lumbar involvement before examining the thoracic spine. • Attempt to target loading to the thoracic spine while minimizing load in the lumbar/cervical. This may be accomplished through attention to detail with the thoracic techniques. • The thoracic spine will often require higher levels of force such as over-pressure, mobilization, and sustained loading.

35. Thoracic Spine What sub-classifications are rarely seen in the thoracic spine?

36. Table of Thoracic Procedures

37. Extension Principle Procedure One ‑ Extension Can be performed sitting (mid thoracic), supine (upper thoracic), prone (mid and lower thoracic). • 1a. Extension with patient over-pressure • 1b. Extension with clinician over-pressure • 1c. Extension mobilisation • 1d. Extension manipulation in prone

38. Extension Principle Procedure Two ‑ Posture Correction

39. Lateral Principle Procedure Three ‑ Rotation • 3a. Rotation with patient over-pressure • 3b. Rotation with clinician over-pressure • 3c. Rotation mobilisation in sitting or in prone • 3d. Rotation manipulation in prone

40. Flexion Principle Procedure Four ‑ Flexion • 4a. Flexion with patient over-pressure

41. Module Five Reflective learning

42. Module Six Case Studies

43. MECHANICAL DIAGNOSIS AND THERAPY EXTREMITIES – UPPER LIMB

46. Module Seven: Epidemiology / Evidence Base for MDT in the Upper Limb

47. Site of the problems – % general population (Badley 1992)

48. Site (N = 522)

49. Evidence Base for MDT in the Upper Limb Surveys of: • Prevalence rate of mechanical syndromes in extremity patients • 27% derangement • Prevalence rate of derangement varied quite widely across different surveys and different joint sites.

50. Evidence Base for MDT in the Upper Limb Two surveys have assessed reliability • Pilot study using 11 patient vignettes and 3 Credentialed therapists there was 82% agreement with a kappa value of 0.70 (Kelly et al 2008). • 25 patient vignettes and 97 therapists with MDT diploma status worldwide there was 92% agreement, with a kappa value of 0.83. (May and Ross 2009).