Clinical Viewpoint: To Progress or Not Progress

In its most basic form, the McKenzie approach is about understanding symptoms in terms of a direction and a force. We use loading strategies to find the right direction and apply the force required. The directions available are in the sagittal, frontal and horizontal planes and the forces available are patient generated or therapist generated. The ultimate goal is to direct the patient to the most effective self management strategy possible.

"Force progression is considered when the previously employed technique increases or decreases symptoms during the procedure but afterwards they are no worse or no better." (McKenzie and May 2003, pg 447). It must be remembered however, that failure to progress could arise from any of the following reasons:

1. The patient self applied loading strategy is insufficient to fully reduce the derangement.
2. The patient may not be exercising correctly.
3. The patient may not be achieving end range.
4. The patient may not be exercising frequently enough.
5. The patient may have unwittingly or inadvertently caused recurrence of the derangement.
6. Our classification/diagnosis may be incorrect.

Before applying force progression, particularly the application of therapist technique, consider carefully the purpose of the progression. In management of derangement a key question you must ask yourself clinically is: Is this a problem of reduction or a problem of maintenance? This will be determined by thorough questioning at follow-up evaluations. If the problem is the latter then force progressions should never be used. For example in management of posterior derangement, more force is no substitute for inadvertent flexion or loss of lordosis when sitting (point 5 above). However, if you have excluded other possible causes, particularly exercise technique, achieving end range and frequency (points 2,3,4,) for non-improvement it is reasonable to conclude that therapist technique is required to aid reduction before self treatment procedures will become effective again (point 1).

Confirmation of correct diagnosis (point 6) is also achieved through re-evaluation. Differentiation between derangement and dysfunction is important, or the lesion may be anterior rather than posterior, or it may be non mechanical. It should be remembered that within this system, therapist technique is only indicated in the clinical management of just two syndromes: derangement and dysfunction. It is not justified to implement these procedures if the diagnosis of derangement or dysfunction has not been made. Further repeated movement testing should help to clarify the situation. Also a review of the initial history may help.

Remember:
Dysfunction history does not change mechanically during the course of a day, a week but may change over a month. The same limited movements or prolonged positions that cause pain do not change and occur whenever those movements or positions are performed. There are no exceptions.

Derangement history is for regular change in pain frequency, intensity, and location and there will be good days and bad days. There will be a day when a particular movement causes pain and the following day may be pain free. Apart from severe derangements with constant and unremitting pain the most common history is one of variables in both pain and mechanical presentation.

Do not instigate clinician technique unless it is clear that improvement cannot be achieved by any other means. I encourage my students to explore force alternatives within the patient generated procedures in the first instance, particularly on Day 1.

Some examples can include: ensuring patients are achieving end range (+/-OP) with their exercise, utilise more repetitions, increase frequency of exercise, use sustained positioning, test the opposite direction, try combinations of planes of movement, try loading or unloading. It is often wise to give the patient twenty four hours of trial exercising before any progression, as over time, things may change with frequency and repetition. Sometimes use of therapist overpressure is warranted to clarify a clinical picture and confirm direction, particularly when the response is produce/increase and no worse. In this case 'more pressure-less pain' indicates the correct direction.

Force progression should not be viewed as a recipe approach where you must do this…then this…followed by this. It is a reasoning process which requires understanding and interpretation of a patient's symptomatic and mechanical responses to loading strategies. In essence there are many patient generated forces in loaded and unloaded positions to explore before clinician techniques are usually required. An exception would be the presence of an acute lateral shift which needs clinician technique immediately. When clinician forces are required they have a clear purpose, and that is to progress the patient to again effectively self manage.

Reference
McKenzie RA, May S; The Lumbar Spine. Mechanical Diagnosis and Therapy. (Vol. 1 and 2) Spinal Publications, Waikanae, New Zealand; 2nd Edition, 2003.

Reprinted with permission from The McKenzie Institute USA
Spineline, 2006, Vol. 10, No. 2
Clinical Viewpoint-To Progress or Not Progress.pdf
http://www.mckenziemdt.org/spineline.cfm