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 4 Lateral flexion

The patient lies supine on the treatment table. The head may be supported on a pillow if necessary. Placing a piece of shiny paper, such as a magazine, under the occiput allows a better lateral flexion movement to be performed. The patient is asked to laterally flex the head and neck towards the side of pain so that the ear approximates the shoulder (Photo 63). It is important for the patient to look straight upwards and avoid rotating the head. The movement is usually performed towards the...

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

Slouch-overcorrect is used to educate patients how to attain correct posture and demonstrates to them the difference between good and bad postures. Patients are often unaware of their body posture, and this procedure, practised regularly, helps them to become conscious of their poor sitting habits. Once the patient is able to attain the correct posture, they are then able to maintain the correction for increasing periods of time. As well as using slouch-overcorrect to retrain postural 'habit',...

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...

Chronic pain state

persistent widespread symptoms all activity increases symptoms mistaken beliefs and attitudes about pain and movement. Thoracic outlet syndrome diffuse neck shoulder arm symptoms of pain paraesthesia provoked with raised arm activities positive concordant pain response to at least two TOS provocation tests. Abdi S, Datta S, Lucas LF (2005). Role of epidural steroids in the management of chronic spinal pain a systematic review ofeffectiveness and complications. Pain Physician 8.127-143....

Clinical presentation

If radiculopathy persists beyond about twelve weeks and is now felt intermittently rather than constantly, it is possible for the symptoms to arise from two causes 2. the development of nerve root adherence or fibrosis. If after surgery symptoms recur, adherence as a result of surgical scarring may be the cause. Fibrous repair following disc herniation or protrusion can cause adherence of the nerve root dura complex to the disc wall, which in turn limits the mobility of the root itself. Any...

Conclusions

This chapter has described the classification system used in the thoracic spine. The first duty of the clinician is to detect patients who have serious spinal pathology A series of 'red flags' might indicate the presence of serious pathologies, and any such patients should be referred for further investigation - these are detailed in Chapter 8. It should be remembered also that thoracic pain may result from visceral disorders, although ascribing visceral disease to thoracic musculoskeletal...

Determining the appropriate loading strategy

A variety of management strategies and responses are not uncommon in this group. For instance, treatment in an unloaded position is more common responses are sometimes slower, and traction may be required to enable retraction to be performed. At all times careful monitoring of symptom and mechanical response is essential to ensure the appropriate management strategies are being selected. If nerve root signs and symptoms are present, special caution should be exercised when testing movements and...

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...

Distinguishing chemical and mechanical pain

As the cause of pain is an important determinant of the appropriateness of mechanical therapy, it is vital to distinguish between mechanical and chemical sources ofnociception (McKenzie 1981, 1990). We can begin to distinguish between these types of pain by certain factors gained during the history-taking and largely confirm this impression during the physical examination. A key characteristic that indicates the possibility of pain of chemical origin is constant pain. Not all constant pain is...

Dysfunction syndrome

Pain from the dysfunction syndrome is caused by mechanical deformation of structurally impaired soft tissues. This abnormal tissue may be the product of previous trauma or degenerative processes and the development of imperfect repair. Contraction, scarring, adherence, adaptive shortening or imperfect repair tissue become the source of symptoms and functional impairment. Pain is felt when the abnormal tissue is loaded. A distinguishing set of characteristics is found during the history-taking...

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...

Examination of movement

It is important that movement testing is done from a standardised start position that allows proper evaluation of movement. Movement whilst in a slouched sitting posture, for instance, is limited and may be uncomfortable, and so does not present a true picture of someone's movement ability. Failure to correct the starting position can cause incorrect conclusions regarding the presenting symptoms. Equally, we want the patient to be in a position that is easy to replicate on the next occasion...

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

This is the most common mechanically determined directional preference displayed by cervical derangements, with well over 60 responding to these forces (McKenzie 1990). Whether the patient has symmetrical, asymmetrical or unilateral symptoms in the neck, arm or forearm, it is still necessary in most instances to explore sagittal plane movements first. Very often extension and flexion are the only movements to be examined, at least initially. There are, however, times when lateral forces must be...

Flexion principle

The flexion principle is rarely required in the treatment of cervical derangement it is used in less than 5 of all patients (McKenzie 1990). However, flexion forces are commonly required in the management of headache and dysfunction (see appropriate chapters). In cervical derangements requiring flexion, symptoms will be symmetrical or asymmetrical around the mid- to lower cervical spine, possibly also with anterior or antero-lateral symptoms around the throat. There may also be pain on...

Flexion principle previously Derangement

There may be certain clues found during the history-taking and physical examination that suggest the flexion principle should be used, which are listed in the previous chapter. The patient might report that they have anterior as well as posterior neck pain and that they have pain or problems with swallowing. Such derangements can result from road traffic accidents. On examination there will be marked loss of flexion, but full-range pain-free extension. This presentation is relatively rare....

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...

Introduction

Headache is a commonly reported symptom with a variety of causes, both serious and benign. Some headaches arise secondary to a neck problem with the primary complaint in the neck - such patients should be classified with one of the mechanical syndromes and managed in the same way as described elsewhere in the book. Some patients attend primarily with the complaint of headache, although there may be some secondary neckache - this chapter addresses this group. Headache means pain anywhere in the...

Management lateral component with lateral deviation wry neck or acute torticollis

These patients, few in number, are identified by the obvious lateral deviation of their head and neck. The patient is fixed in flexion, lateral flexion or rotation, or a combination of these. The patient cannot laterally flex, rotate or extend normally. The pain and deformity is usually of very recent onset. The patient may in some cases be able to bring their head back to mid-line, but is unable to maintain this correction. This deformity is termed a contralateral shift if away from the...

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...

Management of postural syndrome

Once patients are made aware of the link between their posture and their pain, most find it relatively easy to self-manage this syndrome. However, it is vital that this correlation between their position and symptoms is made apparent to them. If the patient is finding this difficult to accept, positioning them in a sustained posture so that symptoms are provoked is usually sufficient to convince them of the cause. Once the link is well established, they need advice on correcting posture and...

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 nociception

Pain may be produced in the absence of actual tissue damage by excessive mechanical strain or tension upon collagen fibres. This is thought to be the result of the deformation of collagen networks so that nerve endings are squeezed between the collagen fibres, with the excessive pressure perceived as pain (Bogduk 1993). No damage to the tissues need have occurred, and when the stress is removed the pain abates. Me weakened, damaged or abnormal tissues. If the excessive strain is so great as to...

Mechanical syndromes Derangement

This will be the conclusion in the majority of patients for instance, in a sample of seventy-eight neck pain patients, sixty-two (79 ) were classified as derangement (May 2004a). Once it is determined that a derangement is present, the key management decision concerns the mechanically determined directional preference. The movement that centralised, decreased or abolished the symptoms during the examination is the one chosen for the patient to perform. The movements that the patient reported to...

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...

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...

Neurological examination

If a neurological examination is deemed necessary, this is a suitable time before the examination of repeated movements so that the effect of exercises on nerve root signs and symptoms can be monitored. A neurological examination should be conducted if nerve root involvement is suspected. Table 11.1 Conducting a neurological examination paraesthesia in the upper limb weakness in the upper limb arm or forearm symptoms, especially in a radicular pattern. Neurological examination may involve four...

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...

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 standing

Patients rarely report cervical postural pain that occurs in standing, presumably as this position allows greater postural variety and they escape sustained end-range postures. Occasionally someone who works standing in a position of sustained neck flexion or protruded head posture may present. For management, the same principles apply. If sustaining the causative posture can reproduce symptoms, the effects of resuming a more neutral posture are quickly established. If symptoms cannot be...

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 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 5c Rotation mobilisation in sitting

The patient sits upright in a chair with the hands resting on the top of the thighs, The clinician stands behind the patient with one hand resting lightly on the patients shoulder with the fingers anteriorly and the thumb firmly placed against the spinous process at the desired level on the side opposite to the pain, The clinician cradles the patient's head with the right hand and places the ulnar border of this hand Photo 71 Overpressure is applied via the occiput and the spinous process,...

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 6b Flexion in supine with clinician overpressure

The patient lies supine with the head at the extreme end ofthe treatment table. The clinician stands at the end of the table and holds the occiput in the palm of one hand with the finger and thumb cradling the atlas and axis. The clinician's other hand is passed under the wrist or forearm and rests palm down on the patient's shoulder (Photo 83). The patient is asked to flex the chin towards the chest while the clinician raises both forearms, lifting the patient's occiput, and at the same time...

Procedure S Rotation

Can be performed in sitting or supine. I Photos. 67, 68 From neutral upright posture (67) to rotation. (68). I Photos. 67, 68 From neutral upright posture (67) to rotation. (68). As with the other cervical procedures, this manoeuvre starts from a position of retraction, which must be retained during the movement of rotation. The patient sits erect in a straight-backed chair. The patient first retracts (Photo 67) and then rotates the head towards the side of pain (Photo 68). After a second in...

Procedure Sa Rotation in sitting with patient overpressure

Should the response be inadequate, it may be necessary to add more pressure. The patient retracts the head and places the hand of the non-painful side behind the head with the fingers over the ear on the painful side. The palm of the other hand is placed against the chin on the opposite side (Photo 69) With the head still retracted, the patient turns the head towards the side of pain as far as possible and accentuates the movement by applying overpressure with both hands (Photo 70). After a...

Prognostic factors

Various studies, generally of poor quality, have tried to identify factors that are associated with persistent symptoms, and a wide range of potential prognostic factors have been considered (Hohl 1974 Deans et al. 1987 Hildingsson and Toolanen 1990 Norris and Watts 1983 Watkinson et al. 1991 Maimaris et al. 1988 Gargan and Bannister 1990 Hartling et al. 2001 Stovner 1996 Allen et al. 1985 Olney and Marsden 1986 Mayou and Bryant 1996 Pennie and Agambar 1991 Gargan et al. 1997 Radanov et al....

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 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 in supine

Patient and clinician starting positions are described in retraction with clinician overpressure (supine). The clinician, by bending the knees, moves the patients head and neck to the end-range ofretraction (Photo 37). The pressure is released and then repeated five or six times before the head is returned to the neutral position. It is important to ensure that the patient's head is kept in the horizontal plane. Some degree of traction may be applied during the procedure. Pboto 37 Patient's...

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...

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...

Symptoms this episode

Where have you had symptoms this episode Have you had any pins and needles, tingling or numbness Have you had any weakness in the arm Where are you still having symptoms All the symptoms that have occurred during the present episode should be accurately marked on the body chart. To ensure accuracy this can be shown to the patient and checked by them. The relevant symptoms are those that have been felt in the last few days and are still a problem - these are noted on the line below. Baseline...

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...

Vertebrobasilar artery

The right and left vertebral arteries arise from the subclavian arteries they then pass up through the foramen transversarium of C6 - Cl. After the foramen transversarium of C1, they turn from a vertical to a nearly horizontal direction, Finally, the right and left vertebral arteries enter the foramen magnum, merge and become the basilar artery, which joins the Circle of Willis (Grant 2002), The vertebral arteries contribute about 11 of total blood supplied to the brain asymmetry between right...

Treatment pathways in derangement

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...

Identification of serious spinal pathology

It is recommended that the same 'red flags' used to provide clues as to the existence of serious spinal pathology in patients with back problems be applied to patients with neck pain (Nachemson and Vingard 2000 Honet and Ellenberg, 2003). The recommendation exists because there is a lack of evidence with regard to 'red flags' for the cervical spine (Nachemson and Vingard 2000 Honet and Ellenberg, 2003). Minimal work has been done to evaluate the diagnostic accuracy, incidence or...

Mechanical diagnosis and therapy and headaches

Patients who attend musculoskeletal specialists with a primary complaint of headaches may be suitable for mechanical diagnosis and therapy. Patients who have a secondary complaint of headache, but a primary complaint of neck pain, are managed as explained in other parts of the book. Amongst those with primary headache it must be remembered that the symptom can indicate serious pathology, although rare, and such patients must always be screened for the existence of other 'red flag' features...

Chronic pain interpretation of symptomatic responses

With chronic pain, peripheral tissue and central nervous system elements may be sensitised and deconditioned to normal movement the criteria of symptom response needs to be different. Under these circumstances normal mechanical stimuli can produce pain, repeated movements may have a 'wind up' effect on pain production, there may be a spread of painful areas, and there may be ectopic nociceptive signals (Dubner 1991 Johnson 1997). These changes make the interpretation of mechanically produced...

By Robin McKenzie And Stephen May

This book is essential leading for any health profesional involved in the management of patients with ceivical 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 management of back and neck problems. This latest book in the series by...

Assessment of the mechanical presentation

Neck pain has traditionally and anecdotally been viewed as being less dramatic in its effect on function thanback pain. Nonetheless, restrictions in normal function and range of movement are common in neck pain patients, especially if acute. Decreased movement compared to healthy controls and interference with usual activities of living and working are commonly reported in neck pain patients (Jordan et al. 1997 Hermann and Reese 2001 Hagen et al. 1997b Chiu and Lo 2002). Changes in these...

Tissue repair process

Following tissue injury, the process that in principle leads to recovery is divided into three overlapping phases inflammation, repair and remodeling (Evans 1980 Hardy 1989 Enwemeka 1989 Barlow and Willoughby 1992). No inflammation no repair is a valid dictum (Carrico et al. 1984). In fact, each part of this process is essential to the structure of the final result. Connective tissue and muscle do not regenerate if damaged, but are replaced by inferior fibrous scar tissue (Evans 1980 Hardy...

What is whiplash

Whiplash is a familiar term to patients and clinicians. It generally denotes neck symptomatology that has commenced during or shortly after a motor accident. Strictly, the causal event for a true 'whiplash' injury is said to be a rear-end collision at a modest speed into a stationary vehicle in which the victim is facing forwards (Bogduk 1986). In practice, anyone involved in a car accident that develops symptoms is likely to be considered to have 'whiplash'. Neck pain that develops after a...

Cervical spine and vertebrobasilar insufficiency VBI Background

Traditionally a series of movements or positions thought to test the integrity of the vertebrobasilar arteries have been advocated prior to manipulation or mobilisation of the cervical spine (Maitland 1986 Grant 1994a McKenzie 1990). Such cervical procedures have sometimes been associated with complications, very rarely of a serious nature, such as death or cerebrovascular accident. The aim of the test movements and certain direct questions is to try to identify patients for whom this type of...

Cervical radiculopathy

Cervical radiculopathy is a specific lesion affecting the cervical nerve roots in which neck pain is accompanied by upper limb pain and possibly neurological symptoms and signs (Radhakrishnan et al. 1994). This section presents some details about the epidemiology, pathology and recognition of cervical radiculopathy. For its management refer to Chapter 20, where it is included in the derangement category with referred arm pain below the elbow. The radiculopathy is most often attributed to...

List of Figures

1.1 Severity and disability grading of neck pain (N l lOO) 9 2. 1 Patterns of referred pain produced by stimulating cervical zygapophyseal joints in normal 2.2 Patterns of referred pain produced by discography at symptomatic 2.3 Cervical dermatomes derived by symptom provocation 24 2.4 Matching the stage of the condition to management 37 3.1 Sketch of the adult cervical 5.1 Initial management pathway - key categories, estimated prevalence in neck pain 6.1 Classification algorithm for cervical...

Neuroanatomy of cervicogenic headache and experimental evidence

Ironically, despite remaining controversies regarding diagnosis, the neuroanatomical mechanism for cervicogenic headaches is one of the best understood (Bogduk 2001). Cervicogenic headache appears to be a form of referred pain from the upper three cervical segments (Bogduk 1994 Pollman et al. 1997) The mechanism for this is the 'trigeminocervical' nucleus in the upper part of the spinal cord (Bogduk 1994). Within this area, terminals from the trigeminal nerve and the upper three cervical nerves...