Abnormal morphology

The thoracic spine is prone to the usual range of degenerative and maturation changes that affect other areas of the spine, plus some that principally affect this region. With age the thoracic kyphosis tends to increase, a process that is accentuated by reduced physical activity, postural habit and female gender (Singer 2004). A number of specific pathologies, some asymptomatic, can exacerbate this these include ankylosing spondylitis, Scheuermann's disease, diffuse idiopathic skeletal...

About the Authors

Robin McKenzie was born in Auckland, New Zealand, in 1931 and graduated from the New Zealand School of Physiotherapy in 1952. He commenced private practice in Wellington, New Zealand in 1953, specialising in the diagnosis and treatment of spinal disorders. During the 1960s, Robin McKenzie developed new concepts ofdiagnosis and treatment derived from a systematic analysis of patients with both acute and chronic back problems. This system is now practised globally by specialists in physiotherapy,...

Alternative positions for Procedure 1 Retraction

Retraction in standing should be performed as described for retraction in sitting. It is a useful position as it allows the patient the opportunity to perform retraction regularly throughout the day. Retraction in supine with pillow support The patient should lie supine on the treatment table. In very acute cases and during the initial treatment session, one or two small pillows may be placed under the neck and head to allow for any deformity (Photo 25). The patient should be instructed to...

Alternative positions for Procedure 2 Retraction and extension

Retraction and extension with rotation in supine The patient should be instructed to lie supine over the end of the treatment table so that the head, neck and shoulders are unsupported down to the level of the third or fourth thoracic vertebra. The patient places one hand under the occiput to provide assurance and stability (Photo 44). The patient then fully retracts the head (Photo 45) and is instructed to continue the movement by slowly and steadily tilting the head backwards as far as...

Alternative positions Procedure 5 Rotation

Patient lies supine on the treatment table. The head may be supported on a pillow if necessary. Placing a piece of shiny paper under the occiput allows a better rotation movement to be performed. The patient turns the head, generally towards the side ofthe pain (Photo 73). The position is maintained for one or two seconds, and then the head is returned to the neutral position. The movement is repeated about ten times. Rotation in supine with patient overpressure Ifa progression of force is...

Ankylosing spondylitis

Ankylosing spondylitis is an inflammatory systemic disease that can affect the whole spine. It usually commences with sacral and lumbar pain, but may involve the thoracolumbar spine early on (Singer 2000). Once the thoracic spine is involved, due to involvement of the costal joints, respiration may become impaired. Later on the disease causes ankylosis of joints and ossification of ligaments leading to an immobile, fused spine and structural deformity, such as a fixed thoracic kyphosis....

Application of retraction

Retraction is the essential preliminary procedure for the reduction of posterior derangements in the lower cervical spine. It is also used for the treatment of extension dysfunction in the lower cervical spine. Retraction is an essential precursor to other movements required to effectively treat the cervical spine. Some movements, apparently ineffectual or even aggravating to the patient, can become effective when their application is preceded by repetitive retraction of the head and neck....

Application

Flexion procedures are rarely used therapeutically in the thoracic spine. The most common use of flexion procedures in the thoracic spine is provocative testing of posterior derangements or non-mechanical problems. Flexion procedures may help to establish the force direction that worsens the patient, therefore helping to establish what improves their condition. Worsening with all test movements highlights unsuitability for mechanical therapy and the need for further investigation. Flexion...

Categories of dysfunction

Dysfunction affects peri-articular, contractile or neural structures (McKenzie 1981, 1990 McKenzie and May 2000, 2003). In an articular dysfunction, end-range movement in one or more directions that puts tension or compression on the affected structure provokes the pain. In a contractile dysfunction, pain is experienced during active or resisted movement that loads the affected tissue. Contractile dysfunction occurs predominantly in tendons muscle tissue, being well vascularised, in general...

Centralisation

Centralisation refers to the phenomenon by which distal limb pain emanating from the spine is abolished in response to the deliberate application of loading strategies (Figure 7.4). The phenomenon is characteristic of derangement syndrome, and its high prevalence rate, reliability of assessment and value as a prognostic indicator has been established in a review (Aina et al. 2004). The review highlights the limited documented evidence about centralisation in the cervical spine. Werneke et al....

Cervical anatomy

Cervical anatomy is described in detail elsewhere (for instance, Taylor and Twomey 2002 Oliver and Middleditch 1991 Bland 1998), and it is not the intention to replicate that material in this text however, it is important to note certain key features. Between the occiput and first thoracic vertebra there are eight cervical motion segments. Cervical motion segments are not simply smaller versions of lumbar motion segments. Anatomical differences include the absence of intervertebral discs at...

Cervical anatomy and the McKenzie conceptual model

The anatomy of cervical morphology has been used to disparage certain pathological concepts regarding the cervical spine. With knowledge of the fibrosed state of the adult cervical intervertebral disc, it is stated that it is generally impossible to herniate the nucleus as there is none (Bland 1998). This statement is misleading, suggesting that disc herniations are always of nucleus material, whereas in the lumbar spine they are clearly not, being nucleus, annulus and endplate, or some mixture...

Conclusions

In this chapter some of the key characteristics of cervical anatomy have been mentioned. It is important for the clinician to be aware of some of the unique aspects of the cervical spine, especially if manual therapy is being contemplated. The unique structure of the upper cervical spine, the uncinate processes, the vertebral arteries, and the particular way in which the cervical spine goes through the ageing and degenerative process are all important pieces of background knowledge that the...

Differential diagnosis

The prevalence figures suggest that the differentiation between the different headache types is straightforward, uncontroversial and simple to make, but this is not the case. One problem is the use of different diagnostic criteria. For instance, Haldemann and Dagenais (2001) list five different criteria for cervicogenic headache, which have certain consistent features, but each includes distinctive characteristics. The most extensive classification criteria produced by IHS has been criticised...

Dysfunction syndrome

In dysfunction syndrome, the mobility or function of soft tissues is reduced because of structural impairment. It is a painful disorder caused by loading or stretching tissue that is imperfectly repaired or has become adaptively shortened (McKenzie 1981, 1990). Structurally impaired tissue gives rise to pain with normal mechanical loading. In the thoracic spine dysfunction may develop because of trauma, derangement, long-term poor postural habits or pathologies that affect the region, such as...

Effect of movement on structures

Movements of the head and neck have effects on both the soft and bony tissue in and around the cervical spine (Edwards et al. 2003 Farmer and Wisneski 1994 Kramer 1990 Magnaes 1982 Nuckley et al. 2002 Butler 2000 Yoo et al. 1992 Ordway et al. 1999 Lentell et al. 2002 Kitagawa et al. 2004). Protrusion has the following effects flexion of the lower cervical spine. displacement of intradiscal matter posteriorly enlargement of intervertebral foramen enlargement of spinal canal tensioning effect on...

Evidence

Documented evidence for preventative interventions for neck pain is very limited. A systematic review (Linton and van Tulder 2000) on preventative interventions for back and neck pain concluded that there is consistent evidence that back schools are not effective in preventing neck and back pain level A evidence (strong -consistent findings from multiple randomised controlled trials) there is consistent evidence that exercise may be effective in preventing neck and back pain level A evidence...

Exploring frontal plane movements

A large proportion of patients will respond to sagittal plane movements, even in the presence of unilateral or asymmetrical symptoms. Mostly sagittal plane forces achieve symptom and mechanical change more rapidly and effectively than frontal plane movements. However, in the event that there has been no conclusive symptomatic or mechanical response from the sagittal plane tests outlined above, then it becomes necessary to explore the response to movements in other planes. If after several sets...

Extension principle

Can be performed sitting, standing, supine or prone I Photos 2 J, 22 Retraction from erect sitting posture. I Photos 2 J, 22 Retraction from erect sitting posture. In this text, retraction means to move the head backwards as far as possible from a protruded position so that it is positioned more directly above the spinal column. Throughout the movement the head must remain horizontal, facing forward, and be inclined neither up nor down. For instruction, the patient is initially seated on an...

Health careseeking

As with those who have lumbar back pain, not everyone with neck pain seeks health care. In the Netherlands, just over 50 of those with neck-shoulder-upper back pain had contact with a Gp, specialist or physiotherapist (Picavet and Schouten 2003). In the US, in two studies with a mixed population of neck and or back pain, 25 to 66 had sought health care from a complementary or conventional provider (Cote et al. 2001 Wolsko et al. 2003). In the UK, 69 consulted a health professional, mostly their...

History

Taking a history from patients with headache is much the same as patients with other symptoms. The site of symptoms is recorded, the initial onset, history this episode, aggravating and relieving factors, frequency, history of headache, and history and effect of medication. It is important to have a clear understanding of the frequency history, how often and for how long the headaches last, as this may help in evaluating clinical response. As in other parts of the spine, the aggravating and...

Horners syndrome

Horner's syndrome occurs as a result of interference to the sympathetic nerve supply to the eye in the central or peripheral nervous system (Berkow et al. 1992 Walton and Buono 2003). It comprises the following symptoms variable drooping of upper eyelid - ptosis constriction of the pupil - miosis ipsilateral loss of sweating - anhydrosis recession of eyeball into the socket - enopthalmos. This may result from central nervous system lesions or damage to the cervical sympathetic chain or...

Identifying responders

Certain aspects of the history provide clues as to the likely responsiveness to mechanical diagnosis and therapy Especially suggestive of a good response is a history of intermittent symptoms and variable pain behaviour in response to different postures and activities. Intermittent symptoms indicate that there are times during the day when, as a result of being in certain positions or performing certain activities or for no apparent reason, the patient has no pain. Even in those patients who...

Introduction

This chapter is an introduction to some of the key elements of cervical movement and biomechanics it is not a thorough analysis of the topic. For a fuller discussion, consult other texts (for instance, Oliver and Middleditch 1991 Penning 1998 Bogduk 2002). The aim of this chapter is to draw attention to certain aspects of clinical anatomy that are relevant to an understanding of the cervical spine and are relevant to mechanical diagnosis and therapy as applied to the cervical spine. Sections in...

Management of central and symmetrical symptoms

A loss of thoracic extension can sometimes be difficult to distinguish. Rather than there being a loss of range of movement, the patient may have full range of movement, but pain at end-range. In more severe cases, both flexion and extension can be clearly limited and painful. Rather misleadingly, some patients with thoracic derangement find relief of symptoms in the flexed posture, whilst extension increases pain, usually centrally. This may give the mistaken impression that the patient's...

Management of Derangements Cha Ter Twenty 339 Unilateral or Asymmetrical Symptoms Below the Elbow

(Previously Derangements 5 and 6) Introduction This chapter describes the management of patients with symptoms in the forearm that are referred from the neck. These symptoms may be pain anc Jor paraesthesia and may be accompanied by pain in the arm, shoulder, scapular region or neck. These patients are those previously classified as Derangements 5 and 6, and comprise up to 20 of the neck pain population (McKenzie 1990). Specific cervical pain with clear aetiology is more likely in this group as...

Mechanical diagnosis and therapy and clinical reasoning

Clearly elements of the classical description of clinical reasoning are as relevant to the McKenzie Method as any other. Data-gathering, knowledge base, clinical experience and thought processes during the clinical interaction are all central to mechanical diagnosis and therapy. However, there are limitations and problems with the process of clinical reasoning as described. The list ofwhat knowledge base is needed is considered incomplete, as knowledge from other areas can be required also...

Mechanical syndromes

Derangement, dysfunction and postural syndromes are all found in the thoracic spine. Their presentations are more fully described in Chapter 6, and are only briefly outlined here. Derangement syndrome is most common and is characterised by a varied clinical presentation and typical responses to loading strategies. Pain may be central or symmetrical or radiate laterally around the chest wall, or even present with patches of pain on the anterior chest wall. Worsening or peripheralisation of...

Mechanically determined directional preference

Mechanically determined directional preference describes the situation when postures or movements in one direction centralise, abolish or decrease symptoms and lead to an improvement in mechanical presentation. Very often postures or movements in the opposite direction cause symptoms and signs to worsen, although in part this is a response to the length of exposure to the provocative loading. The phenomenon of mechanically determined directional preference is characteristic of derangement...

Mid and lower thoracic Sustained prone lying in extension

The patient lies prone on the treatment table, leaning on their elbows. The patient relaxes in this position, allowing the spine to sag, which applies a passive overpressure to the thoracic spine. The position is sustained for a maximum of three minutes and then the patient returns to the prone lying position. Photo 1< < 3 Sustained supine lying over rolled towel for mid-thoracic spine. I Photo 104 Sustained prone lying I in extension. I Photo 104 Sustained prone lying I in extension.

Morphology function and pathology

Unsurprisingly, the structure of the cervical vertebral column affects function. The unique anatomy of the axis, with its cranially projecting odontoid peg or dens around which the atlas rotates, permits the greatest range of movement -frontal rotation -of any motion segment in the spine (Oliver and Middleditch 1991). The development of the uncovertebral joints and the posterior cleft may facilitate rotation, but the cranially projecting uncinate processes as well as the facets of the...

Natural history

A number of studies suggest that, like lumbar back pain, the natural history of neck pain is frequently protracted and episodic. In two long-term follow-ups of over 250 patients with neck pain, nearly 60 reported on-going or recurrent problems (Lees and Turner 1963 Gore et al. 1987). In those who had on-going symptoms, just over half reported them to be moderate or severe (Gore et al. 1987). Retrospectively, 42 of a general population sample of nearly four thousand reported an episodic history...

Other categories

As in other spinal regions, once serious pathologies have been excluded, an extended mechanical evaluation within three to five sessions will demonstrate one of the mechanical syndromes in the majority of patients. Failure to demonstrate a mechanical response might lead to the consideration of other possible conditions. For these 'Other' categories to be included, however, it is essential that force progressions and force alternatives are fully but safely explored to exclude a mechanical...

Other examination procedures

It is generally unnecessary to add further examination procedures than those outlined above. It should be remembered that once a positive symptomatic or mechanical response is gained, further testing is unnecessary at that point. If test movements have so far failed to generate a conclusive symptomatic or mechanical change, there is no guarantee that extra tests will do so - in fact, they are more likely to generate confusion. Palpation adds very little to a mechanical evaluation and is rarely...

Pain

Pain of recent onset of less than seven days. Will include some with pain ofan inflammatorynature, but manywill have pain ofa mechanical nature due to derangement. Sub-acute Pain that lasts between seven days and seven weeks. In some this may represent an interface between inflammatory and mechanical pain, but again, mechanical factors are likely to predominate. Pain that lasts for longer than seven weeks. In the majority this will be mechanical in nature, and non-mechanical in a minority. Pain...

Patient review Extension principle

When the patient returns for review they will be improved, worsened or unchanged. Ensure that the status reported by the patient is their true state. Patients may report their symptoms to be worse when widespread pain has centralised to the middle of the spine they may report themselves to be unchanged when in fact pain that was constant has become intermittent. Some patients, keen to please and to get better, report an improvement that is difficult to confirm. See Chapter 12 for details of how...

Physical examination

Poor posture may be noted, with protruded head posture most common. When posture and spondylosis are the cause of dysfunction, there may also be an exaggerated cervico-thoracic kyphosis, the so-called 'Dowager's Hump', especially when there is a major loss of extension. There is always reduced movement in spinal dysfunction. When dysfunction results from some discrete past event such as an accident or derangement, movement loss may be asymmetrical. When dysfunction results from poor postural...

Postsurgery

There is limited documented evidence about the best rehabilitation approach following cervical surgery. The emphasis of examination and management depends on when the patient is seen after surgery and what type of surgery has been performed. There is much greater variety of surgical procedures than at the lumbar spine. Cervical disc herniations are commonly treated by microdiscectomy with or without fusion, and instability or trauma by fusion and possibly fixation. Spinal surgeons may have...

Postural syndrome

The postural syndrome is characterised by intermittent pain brought on only by prolonged static loading of normal tissues. Time is an essential causative component, with pain only occurring following prolonged loading. However, the loading period required to induce symptoms may decrease with repeated exposure over time. Patients with the postural syndrome experience no pain with movement or activity. Neither do they suffer restriction of movement. No pathological changes occur in this syndrome....

Postural syndrome aggravating factor lying

Individuals frequently awake with neck pain, presumably arising from end-range or awkward positions of the head and neck assumed and maintained during sleep. Derangements can arise in this way and symptoms will persist for a few days or more and be accompanied by restricted painful movements. Pain from cervical postural syndrome fades away once the individual gets up, and there are no effects on movements. However, this may occur regularly if the person sleeps in an awkward position that...

Postures involved

Sitting is the most frequent cause of pain of postural origin, and many patients name this as the only provoking factor. They may complain that pain is produced after spending a certain time, for instance quarter of an hour or so, in any sort of chair or when driving. Others may complain that the pain only comes on after working at the computer for a while. During prolonged sitting when the relaxed posture is assumed, spinal muscular activity decreases (Harms-Ringdahl 1986 O'Sullivan et al....

Preventative strategies

It is reasonable to advise patients about aspects of the epidemiology of neck pain. Not everyone with neck pain has future episodes, but a considerable proportion have future or persistent episodes. Warnings regarding the natural history of neck pain, which is commonly episodic or persistent, thus represent a responsible aspect of management. Most patients are interested in prognosis and clinicians are responsible for providing this information. Two main aspects should be discussed what can be...

Procedure 1 a Extension in lying with patient overpressure

The patient lies prone on the treatment table with the hands palm down alongside the shoulders as for extension in lying for the lumbar spine. The top half of the body is pressed upwards by straightening the arms while the lower half of the body is allowed to sag with gravity. The top half of the body is then lowered to the starting position. The exercise is then repeated ten to fifteen times. After a few repetitions it is important that the arms are fully straightened and the patient sags the...

Procedure 1 a Extension in sitting with patient overpressure

The patient sits in an upright chair with the hands clasped behind the neck for support. The patient then extends the thoracic spine by lifting the elbows upwards as far as possible using the top of the chair as a fulcrum. The position is maintained briefly before the patient returns to the starting position. The movement is repeated up to ten times, with each repetition increasing the range to maximum. I Photo 97 Overpressure for tnid-I thoracic spine using a chair

Procedure 1 b Extension in sitting with clinician overpressure

The patient sits on the treatment table with hands clasped behind the neck for support. The clinician stands to the side of the patient with one arm under the patients elbows and the heel of the other hand against the spinous process at the appropriate level. The patient then actively extends the upper thoracic spine as far as possible. By lifting the patient's elbows with one hand and applying pressure to the appropriate level with the heel of the other hand, extension overpressure is applied...

Procedure 1 c Extension mobilisation

An adjustable-height treatment table is preferred to perform this procedure most effectively.It should be at a level that allows the clinician to be positioned directly over the patient so as to deliver the mobilising force perpendicular to the spine. The patient lies prone with their arms by their side and near the edge of the table. The clinician stands beside patient and places the hands and arms as described for extension in lying with clinician overpressure. Once the hands are positioned...

Procedure 1 c Extension mobilisation in sitting

The patient and clinician positions are as described above. The manoeuvre is essentially the same as that described for clinician overpressures except that the patient remains relaxed throughout. The clinician lifts the patient's elbows and applies resistance overpressure with the heel of the hand to the spinous process at the appropriate Photos 100 and 101 One arm stabilises the patient at end-range thoracic extension while the other hand applies extension mobilisation to the thoracic spine....

Procedure 1 Extension in

I Photos 95 and 96 Extension or mid-thoracic spine. sitting) The patient sits on the treatment table with hands clasped behind the neck for support. The patient then extends the thoracic spine lifting the elbows upwards as far as possible. The extended position is maintained briefly before the patient returns to the starting position. The movement is repeated about ten times, witheach repetition increasing the range to maximum. I Photos 95 and 96 Extension or mid-thoracic spine. sitting) I...

Procedure 2 Posture correction

Photos 108, 109, 110 From slouched position (108), gentle pressure at spine and sternum restores the lordosis (109). Gentle pressure at chin and thoracic spine corrects the head posture (110). Symptom response is monitored before and after. Photos 108, 109, 110 From slouched position (108), gentle pressure at spine and sternum restores the lordosis (109). Gentle pressure at chin and thoracic spine corrects the head posture (110). Symptom response is monitored before and after....

Procedure 2 Retraction and extension

Can be performed in sitting, supine or prone. Retraction and extension in sitting Head and neck retraction and extension are the movements of retraction, followed immediately by movement of the head and neck into the fully extended position. Although there are two movements involved, they should appear to blend smoothly into one continuous motion until finally the neck is fully extended. This procedure can be commenced once the patient is proficient in performingbasic retraction and a good...

Procedure 3 Postural correction

Photos 54, 55, 56 Extreme of poor posture (54) extreme posture correction (55) followed by slight relaxation mU (56). Slouch-overcorrect and posture correction Sitting over the end or side of the treatment table, the patient is instructed to adopt a relaxed slouched posture with the lumbar and thoracic spine flexed and the head and neck protruded (Photo 54) . The patient then smoothly moves into the extreme of the erect sitting posture with the lumbar spine in maximum lordosis and the head and...

Procedure 3c Rotation mobilisation in prone extension

To perform this procedure most effectively, an adjustable-height treatment table is recommended. This should be at a level that allows the clinician to be positioned directly over the patient to enable delivery of the mobilising force perpendicular to the spine. The relaxed patient lies prone with their arms by the side and head turned to one side near the edge of the treatment table. Photo 1133 Clinician overpressure is applied anteriorly and posteriorly at both shoulders. Photo 1133 Clinician...

Procedure 3d Rotation manipulation in prone extension

Rotation manipulation in prone extension is used if a favourable response has previously been generated with unilateral rotation mobilisation in extension, but symptoms have subsequently returned. The patient and clinician start positions for this procedure are the same as those described in the previous procedure. The clinician stands on the side opposite that which is to be mobilised. Place one hand on top of the other to perform the mobilisation on one side force is directed anteriorly and...

Procedure 4b Lateral flexion in sitting with clinician overpressure

(Right lateral flexion for right-sided pain is described.) Photos 60, 61 Overpressure is applied by the clinician Ihrough bofh bands, one < m Ibe side of the bead and the other thumb on the spine. Photos 60, 61 Overpressure is applied by the clinician Ihrough bofh bands, one < m Ibe side of the bead and the other thumb on the spine. Patient position is as described above. The clinician stands behind the patient with the patient's head resting lightly on the clinician's chest. The tip of the...

Procedure 4c Lateral flexion mobilisation in sitting

Patient and clinician positions are as described above. The clinician, with one hand, laterally flexes the patient's head towards the side of pain to the available end-range. While the head is held in lateral flexion, the clinician applies pressure through the thumb of the otherhand on the lateral aspect ofthe spinous process (Photo 62). An alternative is for the clinician to apply the pressure with the metacarpophalangeal junction of the index finger of the right hand against the lateral...

Procedure 6a Flexion in sitting with patient overpressure

Photos 79,80 Flexion with patient overpressure, directed at lower (79) and upper (80) cervical spine. Photos 79,80 Flexion with patient overpressure, directed at lower (79) and upper (80) cervical spine. If the response to the exercise is inadequate, the following progression should be applied to ensure that maximum range of motion is achieved. The patient should be instructed to interlock the fingers of both hands behind the upper neck and occiput and repeat the movement as described above. On...

Procedure 6c Flexion mobilisation in supine

Patient and clinician positions are as described above. The clinician flexes the patient's head and cervical spine by raising the forearms and the patient's occiput, and at the same time applies counter-pressure with the hand on the patient's shoulder. At the end-range of flexion the shoulders are stabilised and a flexion mobilisation force is applied to the occiput. The force may be applied either sagittally or to either side of the mid-line, depending on the location of pain. The position is...

Range of movement

Sagittal plane movements are available at all segments and are a combination of sagittal translation and sagittal rotation. Normal ranges of translation in individuals without symptoms maybe as high as 4-5mm, depending on the segmental level, although there is considerable individual variation (Reitman et al. 2004). Flexion and extension are initiated in the lower cervical spine (C4 - C7). Most rotation occurs at C1 - C2 motion segment, with much less rotation available at all other segments...

Reduction of derangement

Reduction describes the process by which the derangement is progressively lessened. Improving symptomatic and mechanical presentations is a way of monitoring reduction of derangement. This is recorded by centralisation of pain or abolition or decrease in symptoms, and recovery of full range of movements. This may occur on day one or take several sessions. Following the history and physical examination, a treatment principle win be decided upon to achieve reduction of derangement. The treatment...

Repeated movements

The repeated movement part of the physical examination provides the mostuseful information on symptom response and is the ultimate guide to the management strategy to be applied (McKenzie 1981, 1990). A decrease, abolition or centralisation of pain is a reliable indicator of which movement should be chosen to reduce mechanical deformation. An increase or peripheralisation of pain is just as reliable to indicate which movements should be avoided. This, the cumulative effect of the movement,...

Repeated movements or sustained postures

Procedures can be used as either repeated movements or as sustained positions. Repeated movements are used most commonly. The optimum number of movements is about ten repetitions in one 'set' however, the exact amount can vary depending on the patient's tolerance, response and so on. In certain instances, several sets of exercises may be done in succession. The number of times in a day that the series of exercises should be done varies according to the mechanical syndrome, the severity of the...

Repeated test movements Protrusion sitting

The patient is reminded to remain sitting upright with their bottom to the back of the chair. Prior to test movements the patient is asked to report the location of any present pain, especially the most distal. The patient is then instructed to extend their chin as far forward as possible, so the neck is outstretched, with the head remaining horizontal and not inclining up or down. Then they return to the neutral sitting position, and the effect this has on their symptoms is recorded. The...

Retraction mobilisation

Procedure 1 c - Retraction mobilisation in sitting Patient and clinician positions are as described for retraction with clinician overpressure (sitting). The clinician's hand on the patient's mandible stabilises the head at endrange ofretraction and the clinician applies a postero-anterior force with the heel of the hand on the spinous processes of the upper thoracic Can be performed in sitting, supine or prone. Photo 36 One hand stabilises the head at end-range retraction, and the heel of...

Retraction mobilisation in prone

Patient and clinician starting positions are described in retraction with clinician overpressure (prone). The clinician, with the hand on the mandible, stabilises the head at end-range of retraction. The hand on the spinous processes of the upper thoracic segments applies a postero-anterior force, which achieves an extension movement of the upper thoracic segments (Photo 38). The movement should be repeated five or six times, and then the head returned to the resting position on the clasped...

Review

When the patient returns for review they will be better, unchanged or worse. Ensure that the status reported by the patient is their true state. Patients may report their symptoms to be worse when widespread pain has centralised to the middle of the spine they may report themselves to be unchanged when in fact pain that was constant has become intermittent. Some patients, keen to please and to get better, report an improvement that is difficult to confirm. If there is improvement in the...

Role of palpation

The ability of clinicians to agree on findings obtained from palpation of motion abnormalities or segmental levels has not been substantiated in the lumbar spine (McKenzie and May 2003) nor in the cervical spine (see Table 9.1). Inter-practitioner agreement on the presence of a finding actually constitutes a test of internal validity and is not simply a measurement of reliability only (Nansel et al. 1989). If interrater reliability is poor the clinical phenomenon may not exist, and certainly...

Serious thoracic spinal pathology

Thoracic spine pain is often found in lists of 'red flags' indicating serious spinal pathology (CSAG 1994 Waddell 2004). Not all pain originating in the thoracic spine is serious, and much of it is normal mechanical pain. However, as there is a much lower prevalence rate of thoracic pain compared to lumbar and cervical, proportionately there is a higher incidence of serious pathology in this region. A range of serious pathologies can occur in the thoracic spine, some more commonly in this...

Sources of neck pain and cervical radiculopathy

Any structure that is innervated is a potential source of symptoms. In and around the cervical spine the follOwing structures meet this criteria muscles, ligaments, zygapophyseal joints, intervertebral discs, anterior and posterior longitudinal ligaments, the atlanto-occipital and atlantoaxialjoints and their ligaments, the blood vessels and the dura mater (Bogduk et al. 1988, 2002b McLain 1994 Mendel et al. 1992 Groen et al. 1988, 1990). Posterior structures receive innervation from the dorsal...

Spinal cord

Spinal cord lesions may result from different lesions in the cervical and thoracic spines most commonly these are degenerative changes producing stenosis in the cervical spinal canal disc lesions in the thoracic spinal canal. In the cervical spine some authors make a distinction between mechanical and vascular causes of myelopathy, and whether it is combined with radiculopathy (Ferguson and Caplan 1985). Signs and symptoms vary due to different spinal levels being involved. At surgery in the...

Spinal infection

Infection in the cervical spine is a very rare occurrence, being the most uncommon spinal region affected, and in the thoracic spine still rare but less so. Although the cervical region is not affected as frequently as the thoracic and lumbar spine, it is suggested that cervical infections have the highest rate of neurologic compromise and the greatest potential for causing disability (Currier et al. 1998). The proportion of spinal infections diagnosed in each region of the spine has been...

Symptomatic presentation

Pain is usually the main complaint of patients with musculoskeletal problems, although paraesthesia, numbness or weakness may also be relevant. Pain as an outcome measure is criticised as 'soft' data, which lacks objectivity. However, whilst pain is by its very nature a subjective experience, it can be recorded and assessed in a reliable way, especially when using serial measurements of pain taken from a single individual (Sim and Waterfield 1997). For any therapeutic intervention whose goal is...

The Cervical Thoracic Spine Mechanical Diagnosis Therapy

CNZM, OBE, FCSP (Hon), FNZSP (Hon), Dip MDT, Dip MT Spinal Publications New Zealand Ltd Raumati Beach, New Zealand The Cer'ical Thoracic Spine Mechanical Diagnosis Therapy First Edition first published in 1990 by Spinal Publications New Zealand Ltd Second Edition first published in April 2006 Reprinted February 2007, March 2008 by Spinal Publications New Zealand Ltd PO Box 2026, Raumati Beach, New Zealand Email enquiries spinalpublications.co.nz All rights reserved. No pan of this publication...

Thoracic biomechanics

Serious study of movement and biomechanics of the thoracic spine is very limited, consisting mostly of cadaver studies or unvalidated research techniques (Mercer 2004b). The ribcage and the complex interaction between spineandribcage present significant methodological problems in the study of thoracic biomechanics and movements (Edmondston 2004). Most reports of range of movement appear to be based on one early cadaver study, and whilst coupled movements seem to occur, report of coupling is...

Thoracic epidemiology

Understanding of thoracic pain epidemiology is handicapped by two major drawbacks the lack of good quality literature and the problem of definition of thoracic pain. The literatureinvestigating the epidemiology of thoracic spine pain is very limited. In one of the few relevant population-based studies of 35- to 45-year-olds, 66 reported spine pain in the previous year, 15 reported pain in the upper back compared to 56 in the low back and 44 in the neck (Linton et al. 1998). This equates to a...

Thoracic Outlet Syndrome

There is still controversy about the existence of Thoracic Outlet Syndrome (TOS), mainly because of the lack of reliable and valid diagnostic criteria (Rayan 1998 Huang and Zager 2004). Part of the controversy lies in the fact that it is detected and treated by surgeons more often in some countries than in others (Lindgren 1993). Whilst not uncommon in the US, it is reported to be unknown in Australia and seldom diagnosed in England and Europe (Lindgren 1993 Schenker and Kay 2001). Reported...

Thoracic pain

As mentioned above, there is ample room for confusion between symptoms that emanate from the thoracic and cervical spines. Several studies have indicated that pain around the scapular and shoulder region commonly arise from cervical discogenic or zygapophyseal joint disorders (Cloward 1959 Smith 1959 Whitecloud and Seago 1987 Grubb and Kelly 2000 Dwyer et al. 1990 Aprill et a .1990). However, stimulation of thoracic structures has also caused pain in the chest and scapular region (Bogduk...

Types of pain

One proposed pain classification system has suggested the following broad categories of pain (Woolf et al. 1998) transient pain, which is of brief duration and little consequence. Tissue injury pain relates to somatic structures, whilst nervous system injury pain includes neurogenic or radicular, as well as pain generated within the central nervous system. An example of transient pain is that produced in postural syndrome. The other source of pain that occasionally must be considered in the...

Upper cervical biomechanics

At the occiput - C1, maximum movement occurs in the sagittal plane - nodding the head. During flexion the occipital condyles roll forward and translate backwards on the lateral masses of the atlas and the atlas translates backwards relative to the occiput (Oliver and Middleditch 1991). The atlas tilts upwards at the same time so that the posterior arch of the atlas and the occiput are approximated. During extension the reverse occurs. There is controversy about whether axial rotation occurs at...

Upper cervical instability

A generally accepted definition of instability does not exist (Swinkels and Oostendorp 1996). Concerns about instability at upper cervical levels relate to systemic conditions, such as rheumatoid arthritis (RA) or cervical trauma (Aspinall 1990 Bland 1994). There may be a discrepancy between the degree of destruction or instability and the symptoms. Patients with slight instability may have major neurological problems, whereas others may have significant laxity without neurological symptoms...

Upper thoracic Retraction and extension in supine

The head and neck and lowers the head towards the floor into a fully extended position. If tolerable, the supporting hand may be removed and the head, neck and upper thoracic spine allowed to hang relaxed. After two or three seconds the patient should return the head to the starting position by lifting the head with the supporting hand and at the same time tucking in the chin. Care should be taken to avoid actively raising the head by using the neck musculature. The retraction and extension...

Epidemiology of headache

Headaches are extremely common in the general population and a very common reason for seeking health care. The literature on the prevalence of headache in forty-four studies was summarised in 1999 (Scher et al. 1999). At age 40 there was an estimated prevalence in males of 25 in Europe and just over 60 in North America, and in females of 70 - 80 in both these areas (Scher et al. 1999). It is unclear why there is such a marked difference between European and North American males. Lifetime...

Surgery for cervical and thoracic problems

Indications for cervical surgery are said to be instability, often secondary to rheumatoid arthritis or trauma, radiculopathy, myelopathy and tumour Qones 1998). In the thoracic spine, thoracic disc herniations causing progressive myelopathy, trauma that may cause spinal cord lesions, and progressive deformity that fails to respond to conservative measures are said to be indications for surgery (Findlay and Eisenstein 2000). If treatment is considered for thoracic scoliosis deformity, this may...

Management of dysfunction syndrome

The treatment of adhesions, contractures or adaptive shortening as in an articular dysfunction essentially requires the application of movements that encourage the process of remodelling. Only with the application of such loading strategies will normal tissue function be re-established. Ideally such movements commence during the stages of repair and remodelling in the weeks after an injury (Evans 1980 Hardy 1989 Hunter 1994 Barlow and Willoughby 1992). If appropriate and graded tension is...

Stephen may

THE CERVICAL & THORACIC SPINE MECHANICAL DIAGNOSIS & THERAPY This book is essential reading for any health professional involved in the management of patients with cervical or thoracic pain. Described within are the mechanical measures required for the diagnosis and treatment of these common problems. The precise identification and management of subgroups in the spectrum of mechanical cervical and thoracic disorders has been said to be a priority if we are to improve our methods of...

Instructions to all patients with dysfunction syndrome

Patients will be attending the clinic with pain. To be told that they must go away and regularly cause the pain that they are complaining about needs a very good explanation to gain their adherence to the programme. As long as patients are given a good justification for performing the exercises, most will follow the advice that is given. Most will understand the idea of scar tissue that needs to be 'stretched' to recover full movement that stretching the scar hurts, and on releasing the stretch...

Treatment pathways in derangement

Derangement Thoracic Spine

Description of the management of derangement is based on two considerations. The numbering system is no longer used, but the management is based on familiar concepts. The first consideration is the location of pain the next is the extent of distal symptoms. These issues are decided by the patient's report of present symptoms, which is defined as the pain that is their present problem. This applies to all symptoms being experienced even if not actually present at the time of assessment....

Cervical and thoracic zygapophyseal joint pain

Zygapophyseal or facet joint pain somatic dysfunction is a common diagnostic label used by manual therapists (Maitland 1986 Trott 2002 Gatterman 1998 McClune et al. 1998). This section explores what is documented, rather than speculated, about this syndrome in terms of diagnosis and treatment. Zygapophyseal joints are involved in the normal ageing process of cervical spondylosis, but changes such as anterior and posterior osteophytes, bony hypertrophy and foraminal stenosis are commonly found...

Consequences of postural neglect

The effects of postural habits have long-term implications on the human shape (McKenzie 1981, 1990). The commonly observed posture of protruded head, rounded shoulders and flattened spine may become habitual. As age advances, permanent postural 'set' may occur - head protruded, shoulders rounded, dowager's hump, loss of lumbar lordosis and the erect posture replaced by a slight stoop. This is likely to be accompanied by considerable soft tissue adaptations. Positions that are frequently...

Contents

CHAPTER Management of Derangement - Principles 289 Stages of Management Treatment pathways in CHAPTER Management of Derangement - Central and Symmetrical EIGHTEEN Symptoms (previously Derangements 1,2 and 7) 311 Extension Deformity of kyphosis (previously Derangement 2) 316 Flexion principle (previously Derangement 7) 318 CHAPTER Management of Derangement - Unilateral and NINETEEN Asymmetrical Symptoms to Elbow (previously Derangements 3, 4 and Assessment - determining the appropriate strategy...

Classification

Mechanical headaches are classified as derangement, dysfunction or postural syndrome. It should be recognised that mechanical syndromes may behave atypically when symptoms are primarily headache, which may be due to the unique anatomy of the upper cervical region. For instance, with derangement headache symptoms can be abolished, but not always easily reproduced. For this reason the original description involved a separate headache syndrome (McKenzie 1990). However, despite atypicality, certain...

Nineteenasymmetrical Symptoms to Elbow

(previously Derangements 3, 4 and Assessment - determining the appropriate strategy 322 Identification of lateral Management - lateral component, no lateral deviation 329 Management - lateral component, with lateral deviation, wry neck or acute Flexion CHAPTER Management of Derangements - Unilateral or TWENTY Asymmetrical Symptoms Below the Elbow (previously Derangements 5 and Differential Determining the appropriate loading Management when deformity is Non-responders to mechanical diagnosis...

Postural syndrome aggravating factor sitting

Sitting is the most common cause of pain in the posture syndrome. The individual with posture syndrome is exposed to long hours of sitting due to occupation, study, unemployment or hobby The postural habit when sitting for a period of time, and the effect this may have on symptoms, is best observed if the patient is seated without a back support as on the examination couch, rather than in a chair. Posture in sitting is often slumped, with no attempt to maintain an upright position actively The...

Effect of posture on symptoms in normal population

Harms-Ringdahl (1986) explored the effects of sustained slumped postures in volunteers without current or past neck symptoms. They maintained a posture of lower cervical and thoracic flexion and extreme upper cervical extension that is seen in a typical protruded head posture. All ten volunteers began to perceive pain within two to fifteen minutes, which increased with time, eventually forcing them to discontinue the posture after sixteen to fifty-seven minutes. Once they discontinued the...

Failure to remodel repair tissue

Following tissue damage, an important factor in the physiology of repair is the phenomenon of contracture of connective tissues. A characteristic of collagen repair is that it contracts over time. Recently formed scar tissue always shortens unless it is repeatedly stretched, this contracture occurring from the third week to the sixth month after the beginning of the inflammation stage. Contracture of old scar tissue may in fact occur for years after the problem originated (Evans 1980 Hunter...

Example of clinical reasoning process

In the following illustration some examples of the clinical reasoning process are given in italics. In this clinical example not all possibilities are explored the main emphasis is on trying to establish a mechanical diagnosis and appropriate management. The data gathered was relevant to this end and another clinician with an alternative perspective could have focussed on other aspects of the case. It should also be noted that the patient initially displayed a number of poor coping responses to...

Osteoporosis

Osteoporosis is the most common metabolic disorder affecting the spine. The suggested World Health Organisation definition is bone mineral density more than 2.5 standard deviations below the mean of normal young people (Melton 1997). According to this definition, approximately 30 ofpost-menopausal white women in the USA have the condition, and 16 have osteoporosis of the spine. Prevalence is less in non-white populations. Bone density decline begins in both sexes around 40 years of age, but...

Yellow flags

Term used to describe psychosocial risk factors for developing or perpetuating long-term disability or sick leave as a consequence of musculoskeletal symptoms. They include factors such as the attitudes and beliefs of the patient about their problem, their behavioural responses to it, compensation issues, inappropriate health care advice, information or treatment, emotions such as depression, anxiety and fear of movement, and relations with family and work. Adherent nerve root classification...

Management of mechanical cervical headache

If it has been established that the headache is cervical in origin and mechanical in nature by the previous test movements, management usually consists of postural advice and an exercise component. The exercise involves the movement thathasbeenfound to abolish or decrease symptoms for derangement and reproduce symptoms for dysfunction, whilst for postural syndrome, posture correction is the key component. The sequence below describes the normal force alternatives and force progressions that may...

Sustained loading and creep

Mechanical diagnosis and therapy makes use of the concept that different sustained postures (and movements) cause symptoms to decrease, abolish, centralise, produce, worsen or peripheralise. Certain therapeutic loading has a favourable effect on symptoms and should be encouraged, whilst other loading has an unfavourable effect on symptoms and should be temporarily avoided. Clues about this are gained during the history-taking, and these provide important pointers to management. The...

Fractures and dislocations

Fractures of the cervical or thoracic spine or ligamentous instabilities of the upper cervical spine may be caused by a variety of traumatic events, such as motor vehicle accidents, diving into shallow water, falling from a high place or a number of athletic activities. The thoracolumbar junction is reported as the most common site for non-osteoporosis-related spinal column fractures (Huler 1997). Fractures ofthe ribs may be caused by repeated muscular contractions. There are more reports...