Lecture 2a Lx Symptom Modulation

Lecture 2a – Treatment Based Classification
Symptom Modulation
Integrated Orthopedic Management

PHTH-560
Isabelle Pearson
Patrick Ippersiel
© SPOT, McGill University
©
Learning Objectives
• Understand and explain an assessment and treatment approach

based on the TBC system
• Understand and explain assessment and treatment procedures
based on the symptom modulation classification
• Apply these concepts to simple case studies
• Recall best practice principles for treatment of LBP

What is low back pain?
LOW BACK PAIN

LOW BACK PAIN
Red flag or systemic Radicular syndrome

NSLBP (90%)
pathology (1-2%) • No clear (5-10%)
• Malignancy pathoanatomical • Radicular pain
• Fracture diagnosis • Radiculopathy
• Systemic • Stenosis
inflammatory
disorder
Symptom Movement Functional
• Infection Modulation Control Optimization
• Cauda equina
*NSLBP = Non-specific low back pain; SLBP = Specific low back pain
What is low back pain?
LOW BACK PAIN

LOW BACK PAIN
NSLBP (90%)
• No clear
pathoanatomical
diagnosis
Symptom
Modulation
*NSLBP = Non-specific low back pain; SLBP = Specific low back pain
TBC – Symptom Modulation
Alrwaily et al., Phys Ther. 2016;96(7):1057-66
SYMPTOM MODULATION
•Acute LBP (<4 weeks) or acute on
chronic/recurrent issue
KEY FEATURES
• Moderate to high pain & disability
level
• Moderate to high irritability
• Volatile/ Changing symptoms
• Back pain > leg pain
(5)
• Rx Goal: Pain reduction

Some Important Definitions / Concepts

Directional Preference
(as defined by the MDT approach)
• Clinical phenomenon where a specific direction of repeated

mvt and/or sustained position results in a clinically relevant
improvement in symptoms.
• This improvement is usually accompanied by an ↑ in function,

or mechanics, or both.
• Its presence and relevance is generally determined over 2-3

visits.
• It is an essential feature of the derangement syndrome
© SPOT, McGill University ©

Centralisation & Peripheralisation
Centralisation
❑ Phenomenon by which distal pain originating from the spine is
progressively abolished in a distal to proximal direction.
❑ Occurs in response to repeated mvts and/or sustained positions

❑ The change in pain location is maintained over time until it’s completely
abolished
❑ As the pain centralises, the intensity of central pain may increase.
❑ If only spinal pain present, the pain becomes more central
Peripheralisation
❑ Phenomenon by which proximal symptoms originating from the spine
are progressively produced in a proximal to distal direction.

Centralisation & Peripheralisation
Centralisation/peripheralisation phenomenon
Only occurs with the derangement syndrome
(2)

Background Information –
Symptom Modulation

The McKenzie Method in Mechanical Diagnosis
and Therapy (= MDT)
• Developed in the 1960’s by Robin

McKenzie, pht in New Zealand
• “Mr Smith” story (1956)

(1)
• Robin McKenzie then noticed that

most people with LBP have a
directional preference
(3)

Some classic myths about MDT
• « McKenzie, it’s only for the spine »
• « McKenzie, it’s only for disc problems »
• « McKenzie, it’s Lx extension »
• « With McKenzie you don’t touch pts – there is no

hands-on »

The McKenzie Method in Mechanical Diagnosis
and Therapy (MDT)
• Evaluation, classification and treatment system of the entire

musculoskeletal system
• Distinguishing assessment feature

– Uses repeated mvt testing / sustained position testing
– 1 repetition of a mvt = tells you minimal information
– Multiple reps = tells you a lot more!
• Is this mvt good or not for the patient?
• Is this mechanical or not?
mechanical=movement affects pain

Some evidence on the MDT approach
• Well researched in the spine > extremities

• Good reliability by trained clinicians
(Garcia et al. 2018, Razmjou et al. 2000, Clare et al. 2005, Abady et al. 2014)
• The concept of DP and centralisation is integrated in most

lumbar clinical practice guidelines

• Four systematic reviews on DP & centralisation

(Aina et al. 2004, May and Aina 2012, Surkitt et al. 2012, May et al. 2018)
• High prevalence in LBP

66% of LBP pts have a DP (40% centralisation)
More common in acute LBP (77%) than subacute (50%) & chronic (40%)
• Centralisation is associated with good prognosis
• Large treatment effect sizes in some high-quality studies

• Some studies demonstrating that MDT alone (Rasmussen et al. 2005) or

MDT combined with transforaminal injections in “non-centralising” patients
(van Helvoirt et al. 2014) can reduce surgery rate in the spine
• Donelson et al. 2019, reported 51.5% cost-savings when using the MDT
approach compared to usual community care
• MDT has an association with improving fear-avoidance beliefs, pain

self-efficacy, depression, and psychological distress (Kuhnow et al.
2020)
• In summary, MDT versus other interventions

– Some evidence demonstrating better outcomes
– Some evidence demonstrating same outcomes
– No studies showing that it is less effective than other interventions

Concepts from the MDT approach used in
NSLBP Symptom Modulation Category
• The concept of the derangement syndrome
• The repeated movement/ sustained position

assessment
– To establish if a directional preference or centralisation of
symptoms is present

What is it and what can I do about it in terms of assessment?
SYMPTOM MODULATION

Symptom Modulation
What is it? NSLBP causing significant symptomatic feature
Definition of derangement: Clinical presentation which demonstrates

Directional Preference in response to loading strategies and is typically
associated with mvt loss. A common feature in the spine is Centralisation.
• Classification is based on: History/subj eval (mechanism of injury, pain site,

pain type, pain pattern) and objective examination
• Recall, this is non-specific LBP – meaning we cannot confidently identify a

structure responsible for their pain
– Disc, loose bodies, meniscoid structures in the joint, synovial folds, any
other articular tissue (fat pads, etc.) causing a mvt obstruction
Think: Tissue obstructing movement

Derangement Syndrome
• Key: Ax & Rx based on symptomatic and mechanical

responses, not on pathoanatomical hypothesis or MRI findings
• Repeated mvts / sustained positions assessment is used to identify

its presence
• Derangement hallmark: rapid, sustained changes in Sx and/or

mechanical response
Reminders
– Directional preference is an essential feature
– Centralisation/peripheralisation of Sx may occur

Symptom Modulation Subclassification
Symptom
modulation
Directional No directional
preference preference
Derangement Derangement Derangement

Derangement
DP extension DP flexion DP combined (e.g. ext +
DP lateral lat, flex + lat)

Patient Assessment Framework
Screen for Mandatory Questions /

Red flag? Referral
complexity Subjective
Acute injury? Proceed to joint specific aspects

of scan/biomechanical ax
Lower quadrant scan
Spinal or Peripheral ?
Lumbar Ax Peripheral joint

biomechanical Ax
Referral?
Lumbar Biomechanical Ax
No
Yes
Treatment Improving? Proceed

Symptom Modulation
Biomechanical assessment for symptom modulation
• Repeated movement testing
• Sustained position testing
• Other assessment techniques prn (e.g. PAG)

Short in-class group activity
• Provide some specific examples of daily activities,

movements or positions that patients would report
pain with if they have problem/pain with:
– Lumbar extension?
– Lumbar flexion?

Symptom Modulation
Hx & S/A
Mechanism of injury:
• New / recent injury
• Acute flare up of chronic / recurrent issue
• MOI is variable & often sudden onset

DP extension DP flexion DP lateral
MOI May be associated May be associated May be associated
with flexion with extension with lateral or
activities: activities: rotational activities:
E.g. E.g. E.g.
• Bending • Landing in • Twisting mvt
• Bending & lifting gymnastics during lifting

Symptom Modulation
Hx & S/A
Pain type:
– Constant or intermittent
– Referred pain (somatic) may be present
Pain site:
– Back pain > leg pain (referred NOT radicular pain)
– Variable in location
– If DP present: Location and intensity of pain can rapidly or
progressively worsen or improve
Pain site • Central/ • Central/ • Unilateral/
symmetrical symmetrical asymmetrical
• Unilateral/ • Unilateral/
asymmetrical asymmetrical
Symptom Modulation
Hx & S/A
Pain pattern:
– Often painful in all directions or high level of pain in one or a few
specific directions
– Pt avoids postures or movements that are provocative
– Pt with no DP: unclear pain pattern / variable pain pattern

Pain ↑ Flexion: Extension: one lat/rot direction
• Bending • Prone and often worsens
• Sitting • Standing with activities in flex
• Curve reversal • Walking & ext
after prolonged
sitting or bending
Pain ↓ Extension: Flexion: opposite lat/rot

• Prone • Bending direction
• Standing • Sitting
• Walking
Symptom Modulation
Objective Ax
Observation:
– Slow guarded mvt & trunk bracing
– Muscle spasm (15)
– A deformity may occur with the onset of pain

Deformity – Kyphotic Lordotic Lateral shift*
If present (pt is unable to correct it
voluntarily or can’t maintain
correction)
*R lat shift = shoulders are moved to the R side in relationship to the pelvis
When present, 9/10 pts will shift away from the painful side/leg (contralat)
Functional mvt: Change of sitting posture (posture correction)

– Response is variable but change in posture generally affects Sx for sagittal plane
derangements (DP ext, DP flex)

Symptom Modulation
Objective Ax
ROM:
– Mvt loss or obstruction present
• Likely in multiple directions but may also present with a major loss in one
specific direction

ROM – Typically, loss of Typically, loss of Typically,
Most consistent mvt extension flexion asymmetrical loss
loss or mvt obstruction of side glide with
more loss in one
direction
Neuro exam:
• Likely (-)ve

Patient Assessment Framework
Screen for Mandatory Questions /

Red flag? Referral
complexity Subjective
Acute injury? Proceed to joint specific aspects

of scan/biomechanical ax
Lower quadrant scan
Spinal or Peripheral ?
Lumbar Ax Peripheral joint

biomechanical Ax
Referral?
Lumbar Biomechanical Ax
No
Yes
Treatment Improving? Proceed

Symptom Modulation
*Would get the same outcome
Objective Ax on sustained position testing
Repeated mvt testing (sustained position* may be needed):

– Pt subclassified as no DP: the result will demonstrate a mechanical presentation with no DP
– If derangement is present, will display a DP
– Response for derangement is variable based on subcategory and if pain present at rest or not

Rep ext – Better or Worse or Generally worse or
After testing Centralised** Peripheralised Peripheralised
(Sx & mech) ** But may have more LBP
Rep flex – Worse or Better or Generally worse or

After testing Peripheralised Centralised Peripheralised
(Sx & mech)
Rep side glide – Usually not tested Usually not tested One direction:
After testing Worse or
(Sx & mech) Peripheralised
Opposite direction:
Better or
Centralised

Symptom Modulation
Objective Ax
• P/A (from Lx Ax) & PAG (from biomechanical Ax)

– May help identify the most symptomatic segment
– May help identify the most relieving segment

How do I perform repeated mvt testing and/or sustained position
testing?
SYMPTOM MODULATION

Repeated mvt / Sustained position Ax principles –
Detailed
• Identify a comparable sign/funct baseline before repeated mvt or sustained position

testing (Sx & mechanical baseline)
• Ensure that you record baseline Sx at the beginning and when there is a change in
position (e.g. standing vs supine)
• Repeated mvt testing can start with different mvts depending on different factors:
– Pt Hx & S/A
– Can start with potentially reductive vs provocative (if few painful baselines) directions
– Can start with the mvt with the most loss of mvt from your ROM assessment
• Start with 1 set of 10 reps for the selected mvts (may need to perform less or more
based on pt’s response)
• If yellow light is present, the general recommendation is to perform 3 sets of 10 reps
• Ensure that you get info regarding Sx and mech response during and after testing
• Follow the Traffic Light Guide principles
– Use force alternative (red light) and force progression (yellow light) based on
pt’s response
• Use of sustained positions may be necessary
• Need to eventually get to the EOR of the mvt – but may take a few visits
©
Repeated mvt / Sustained position Ax principles –
Summary
• Identify and record the symptomatic and mechanical

(functional) baseline
• Select & get the pt to perform one repeated mvt (or

sustained position) to start with based on what makes the
most sense for your patient (based on Hx & S/A)
• Based on the symptomatic and mechanical response of the

pt to the chosen mvt, use the traffic light guide principle to
guide you in selecting the most appropriate follow-up mvt
until you get a green light
– Use force alternative principle with red light and force
progression principle with yellow light

Traffic Light Guide
Pt response What to do
AFTER testing
Red light Pt is worse Force alternative

or peripheralised
Yellow light No change Force progression

i.e. NB, NW, NE
Green light Pt is better Continue same

or centralised

©
Forces Alternatives
• When you get a red light

– Loaded vs unloaded positions
– Sustained vs repeated (time factor)
– Change in direction of the loading strategy
• Sagittal vs frontal vs combined directions
• Change in the angle of mvt or position
• Add traction
– Force regression (too fast, too soon)

©
Force Progression
• When the light is yellow

• While keeping the same
Manipulation
loading direction
Mobilisation
Clinician OP
Pt OP
Pt
generated
forces
Independent Dependent

©
Force Progression
• Other options of force progression when you get a

yellow light
– Mid-range progression to end-range positions

– Increase in frequency of ex’s in the HEP
– Increase number of repetitions
– Increase velocity (extremities only)

©
Derangement Syndrome & Repeated mvt /
sustained position testing
• Typical response to repeated mvt / sustained position testing

– Varies depending if reductive or provocative mvt direction (multiple
combinations possible)
• DP will be found in one plane (opposite direction may make them worse)
– Pain During Movement (PDM) and/or End Range Pain (ERP)
– Lasting change
• Explore sagittal plane 1st except if presence of lateral shift where it always
needs to be corrected 1st
• Majority of pts respond to extension principles (~70%), followed by lateral

(~25%) than flexion (~5%)
(May & Rosedale 2019, Otéro & Bonnet 2014, May & Aina 2012)
• Remember: 2-3 visits may be necessary to determine confidently the DP

Repeated Mvt / Sustained Positions testing
Terminology
Symptomatic response DURING loading or rep mvt testing

Terminology Definition Example
(pre → during)
Produce (P) Creates Sx that were not present prior to testing 0/10 → 4/10
Abolish (A) Abolishes Sx that were present prior to testing 4/10 → 0/10
Increase (↑) Sx already present increase in intensity 4/10 → 8/10
Decrease (↓) Sx already present decrease in intensity 4/10 → 1/10
Peripheralising Moves the pain more distally 0/10 (thigh),
(PE’g) 4/10 (buttock) →
6/10 (thigh),
2/10 (buttock)
Centralising Moves the most distal pain proximally 6/10 (thigh),
(CE’g) 2/10 (buttock) →
0/10 (thigh),
4/10 (buttock)
No effect (NE) No effect on symptoms during testing 4/10 → 4/10
Terminology
Symptomatic response AFTER loading or rep mvt testing
Terminology Definition Example
(pre→during→post)
Worse (W) Sx produced or ↑ remain aggravated post-test 0 → 4 → 4/10
No Worse (NW) Sx produced or ↑ return to baseline post-test 0 → 4 → 0/10
Better (B) Sx abolished or ↓ remain improved or Sx 8 → 4 → 4/10
produced but ↓ on reps remain better post test
No Better (NB) Sx ↓ or abolished return to baseline post test 8 → 4 → 8/10
Peripheralised Distal pain produced remains post test 0/10 (thigh),
(PE’d) 4/10 (buttock) →
during & post:
6/10 (thigh),
2/10 (buttock)
Centralised Distal pain abolished remains abolished post 6/10 (thigh),
(CE’d) test 2/10 (buttock) →
during & post:
0/10 (thigh),
4/10 (buttock)
No effect (NE) No effect on symptoms post test 4 → 4 → 4/10
Terminology
• Mechanical response AFTER loading or repeated

movement testing
– Increase (↑) – improvement in the mechanical functional baseline
– Decrease (↓) – loss in the mechanical functional baseline
– No effect (NE) – no effect on the mechanical functional baseline

Charting repeated mvt testing – Example
Repeated mvt/sustained position testing:

Mechanical baseline and/or functional tests: EIS (refer to ROM section)
Baseline symptoms :
Standing : P1 6/10 before 1)
Prone : P1 3/10 before 3)
Supine : N/A
Repeated mvt (symptoms during, symptoms after, mechanical response):

1) Rep FIS, 10 reps: ↑, W (P1 8/10), ↓ ROM EIS
2) Rep EIS, 3 X 10 reps: ↑, NW (P1 8/10), NE
3) Rep EIL, 2 X 10 reps: ↓, B (P1 1/10), ↑ ROM EIS
Static positions (symptoms during, symptoms after, mechanical response):

1) N/A

Terminology – Short Group Activity
Scenario 1 Scenario 2
P1 = central LBP P1 = central LBP
Baseline pain: at rest P1 3/10 Baseline pain: at rest P1 0/10

During repeated mvt: P1 5/10 During repeated mvt: P1 2/10
After repeated mvt: P1 3/10 After repeated mvt: P1 2/10
Terminology to chart: Terminology to chart:
During?: ______________ During?: ______________
After?: _______________ After?: _______________

Symptom Modulation
Charting your PT diagnosis for the nature of the condition
E.g., …symptom modulation with a derangement with DP extension…
E.g., …symptom modulation with a derangement with DP flexion…
E.g. …symptom modulation with a derangement with DP lateral…
E.g. …symptom modulation with no DP identified…

Treatment Concepts
SYMPTOM MODULATION

Symptom Modulation
• Overall treatment options for this classification

– Education and re-assurance
• Condition & management
• Active rest: advice to stay active (*within reason)
– Use the traffic light guide principle to provide advices on
activities to do and to limit
– Directional preference ex’s / management principles
of derangement – Key when DP present
– Manual therapy (manipulation vs mobilisations)
– Traction or Soft tissue techniques (STT) (if not
responding to the above 2)

Symptom Modulation: Explanation to patient
Pht: “So, you have a derangement...”

Pt: “What, I am deranged???”
(12)

Symptom Modulation: Explanation to patient
• What’s my injury?
• If DP: tissue obstructing movement
• If no DP: likely a muscle strain or joint sprain
• Not serious. In general, expect good recovery in a reasonable time-frame
• Two categories of pts
1. Those that recover faster (DP) and
2. Those that takes more time to recover but for which we still expect good
recovery (no DP).
By testing some very specific ex’s, I want to see if you are in the faster category.
• Extreme pain not indicative of extreme damage
• May be inflammatory response depending on MOI
• Main goal of treatment is pain reduction
• Then we can get more specific with treatment if needed.
• How do treatments work?

• Specific exercise can restore balance in the joint by taking pressure off of
sensitive structures
• Use techniques and exercises that can help control your pain and help
you become more functional
Symptom Modulation – Directional Preference
Rx for Derangement
Initial stage: Education

• Posture (lumbar roll in sitting prn)
• Mvt(s)/position(s) to limit for a short period of time
• Mvt(s)/position(s) to adopt to help control Sx (6)
• Traffic light guide

• Centralisation/peripheralisation phenomenon
(7)

Rx for Derangement
Initial stage: DP exercise

– If lateral deformity is present, correct it 1st (refer to lab notes)
– Prescribe exercise(s) in DP generally for a few weeks

• Extension principles
• Flexion principles
• Lateral principles
– It is important to eventually achieve the EOR of the DP (i.e.

progress forces when indicated)

Management of Derangement
Flexion Principle
• Flexion principle – some options

(dynamic: repeated mvts)
– Flexion in lying
– Flexion in sitting
(9)
– Flexion in standing
– Flexion in lying with clinician OP
Parameters: each rep is maintained 1-2 sec

and generally 10 reps every 2-3 hours but
adjust based on pt’s response

Extension Principle – Sustained Positions
• Extension principle – some options (sustained

positions)
– Lying prone (C)

• May need to start in Lx flexion for severe cases
– Lying prone in extension (D)
– Sustained extension with adjustable table or pillow
• Gradual increase in extension ROM
Parameters: each position generally

maintained for ~ 3 min but
adjust based on pt’s response
© SPOT, McGill University (8)

Extension Principle – Repeated mvt
• Extension principle – some options (dynamic: repeated mvts) (8)
– Extension in lying (E)

• Progressive increase in ROM
– Extension in lying with pt OP
• Pt locks elb in ext and sags pelvis with exhale
– Extension in lying with clinician OP
– Alternate options for OP
• Extension in lying with towel OP
• Extension in lying with bedsheet OP
• Extension in lying with belt fixation
– Extension in standing (force alternative)
Parameters: each rep is maintained 1-2 sec and generally 10 reps every
2-3 hours but adjust based on pt’s response
Lateral Principle
❑ Lateral principle (sustained vs rep) – some options

❑ Pure lateral component
❑ Manual correction of lateral shift
❑ Self-correction of lateral shift/ side gliding against a wall
❑ Parameters:
❑ Sustained: generally sustained for ~ 3 min but adjust based on pt’s response
❑ Rep mvt: each rep is maintained 1-2 sec and generally 10 reps every 2-3 hours but adjust
based on pt’s response

Lateral Principle
• Lateral principle (sustained vs rep) – some options

– Combined presentation (frontal + sagittal planes)
• Manual correction of lateral shift with extension
• Self-correction of lateral shift/side gliding with extension against a wall
– Parameters:
• Sustained: generally sustained for ~ 3 min but adjust based on pt’s response
• Rep mvt: each rep is maintained 1-2 sec and generally 10 reps every 2-3 hours but adjust
based on pt’s response

Rx for Derangement
Later stage: Recovery of function

• Recovering ROM in direction opposite of DP when appropriate
– Only start once the derangement is stable (does not rapidly/easily
worsen)
• Rep mvt testing of the provocative direction: after = NW or NE +
mechanical response should be unchanged
– Prescribe ex’s in the direction that used to be provocative while finishing
each ex’s session with one set in the reductive direction
– Important that all mvts are full and pain-free at the end of the rehab
• Address all other deficits as needed (str, motor control,

endurance, proprioception, etc)
– Can be started as soon as pain is under control
– Ensure Sx are not worsening with these additional ex’s

©
Recovery of Function
LOW BACK PAIN

LOW BACK PAIN
Red flag or systemic Radicular syndrome

NSLBP (90%)
pathology (1-2%) • No clear (5-10%)
• Malignancy pathoanatomical • Radicular pain
• Fracture diagnosis • Radiculopathy
• Systemic • Stenosis
inflammatory
disorder
• Infection Modulation Control Optimization
• Cauda equina

Rx for Derangement
Before discharge: address prevention of recurrence

• Continue ex’s program for DP (likely at ↓ frequency) as
needed
• Continue ex’s program to address other deficits as needed
(str, motor control, etc)
• Education
– Limit certain sustained postures (if necessary) + balance of mvts
in daily activities
– Posture (e.g. lumbar roll prn) / good ergonomics
– Importance of general fitness
– Use of same exercises if recurrence of LBP, if doesn’t work
come back

©
Symptoms Modulation – Directional Preference
Other Treatment Options
• Other management strategies to consider for Sx

modulation
– Manual therapy treatment techniques (e.g. PAG and PPIVM)
for their neurophysiological effects
• It is recommended to confirm 1st if DP present & in what
direction
– May attempt to use techniques biasing the DP while keeping
in mind the limitations of the biomechanical effects of MT
techniques
• E.g. for extension (A)
• E.g. for flexion (B)
KEY IS TEST-RETEST
A B
What if there is no DP or DP ex’s are not working anymore but
patient is still experiencing pain ++?
SYMPTOM MODULATION

Symptom Modulation – No Directional Preference
• Education regarding condition & active rest

– Principles of painfree activities or
produce/increase but no worse after
(8)
• Mobilisation techniques (PAG, PPIVM) –
for their neurophysiological effect
• Manipulation (non-specific gap) – if no
symptoms distal to the knee
• Traction could be tried if not responding to
other Rx (manual vs mechanical vs
positional) (10)
• STT, dry needling, ms energy techniques

could also be tried
• Once pain settles, do they need to go into
motor control or functional optimization Modulation Control Optimization
category before D/C?

Questions?

References
• Abady, A. H., Rosedale, R., Overend, T. J., Chesworth, B. M., & Rotondi, M. A. (2014).
Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in
assessing patients with shoulder pain. Journal of Manual & Manipulative Therapy, 22(4),
199-205.
• Abady, Afshin Heidar, et al. "Consistency of commonly used orthopedic special tests of the
shoulder when used with the McKenzie system of mechanical diagnosis and
therapy." Musculoskeletal Science and Practice 33 (2018): 11-17.
• Aina, A., May, S., & Clare, H. (2004). The centralization phenomenon of spinal
symptoms—a systematic review. Manual therapy, 9(3), 134-143.
• Alrwaily, M., Timko, M., Schneider, M., Stevans, J., Bise, C., Hariharan, K., & Delitto, A.
(2016). Treatment-based classification system for low back pain: revision and
update. Physical therapy, 96(7), 1057-1066.
• Carragee, E., Alamin, T., Cheng, I., Franklin, T., van den Haak, E. and Hurwitz, E., 2006.
Are first-time episodes of serious LBP associated with new MRI findings?. The Spine
Journal, 6(6), pp.624-635.
• Chou, R., Qaseem, A., Owens, D.K. and Shekelle, P., 2011. Diagnostic imaging for low
back pain: advice for high-value health care from the American College of
Physicians. Annals of internal medicine, 154(3), pp.181-189

References
• Clare, H. A., Adams, R., & Maher, C. G. (2005). Reliability of McKenzie classification of
patients with cervical or lumbar pain. Journal of manipulative and physiological
therapeutics, 28(2), 122-127.
• Cleland JA, Koppenhaver S. Netter’s Orthopaedic Clinical Examination. An Evidence-
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• Delitto A, George SZ, Van Dillen LR, et al; Orthopaedic Section of the American Physical
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• Donelson, R., Spratt, K., McClellan, W. S., Gray, R., Miller, J. M., & Gatmaitan, E. (2019).
The cost impact of a quality-assured mechanical assessment in primary low back pain
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• Dutton M. Orthopaedic Examination, evaluation and intervention. 4th edition McGraw Hill.
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• Edmond, S. L., Cutrone, G., Werneke, M., Ward, J., Grigsby, D., Weinberg, J., ... & Hart,
D. L. (2014). Association between centralization and directional preference and functional
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References
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References for pictures
All pictures from personal collection except:

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• 9: Active Solution Physiotherapy, used with permission
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• 15 (retrieved in 2021): https://www.youtube.com/watch?app=desktop&v=OqznIRxbE7w

Lecture 2a Lx Symptom Modulation

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Lecture 2a Lx Symptom Modulation

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Lecture 2a – Treatment Based Classification

Integrated Orthopedic Management

• Understand and explain an assessment and treatment approach

© SPOT, McGill University

LOW BACK PAIN

Red flag or systemic Radicular syndrome

LOW BACK PAIN

© SPOT, McGill University

© SPOT, McGill University

• Clinical phenomenon where a specific direction of repeated

• This improvement is usually accompanied by an ↑ in function,

• Its presence and relevance is generally determined over 2-3

• It is an essential feature of the derangement syndrome

© SPOT, McGill University ©

❑ Occurs in response to repeated mvts and/or sustained positions

© SPOT, McGill University ©

© SPOT, McGill University

© SPOT, McGill University

• Developed in the 1960’s by Robin

• “Mr Smith” story (1956)

• Robin McKenzie then noticed that

© SPOT, McGill University

• « McKenzie, it’s only for the spine »

• « McKenzie, it’s only for disc problems »

• « McKenzie, it’s Lx extension »

• « With McKenzie you don’t touch pts – there is no

© SPOT, McGill University

• Evaluation, classification and treatment system of the entire

• Distinguishing assessment feature

© SPOT, McGill University ©

• Well researched in the spine > extremities

• The concept of DP and centralisation is integrated in most

© SPOT, McGill University

• Four systematic reviews on DP & centralisation

• High prevalence in LBP

• Centralisation is associated with good prognosis

• Large treatment effect sizes in some high-quality studies

© SPOT, McGill University

• Some studies demonstrating that MDT alone (Rasmussen et al. 2005) or

• MDT has an association with improving fear-avoidance beliefs, pain

• In summary, MDT versus other interventions

© SPOT, McGill University

• The concept of the derangement syndrome

• The repeated movement/ sustained position

© SPOT, McGill University

© SPOT, McGill University

What is it? NSLBP causing significant symptomatic feature

Definition of derangement: Clinical presentation which demonstrates

• Classification is based on: History/subj eval (mechanism of injury, pain site,

• Recall, this is non-specific LBP – meaning we cannot confidently identify a

Think: Tissue obstructing movement

© SPOT, McGill University

• Key: Ax & Rx based on symptomatic and mechanical

• Repeated mvts / sustained positions assessment is used to identify

• Derangement hallmark: rapid, sustained changes in Sx and/or

© SPOT, McGill University ©

Derangement Derangement Derangement

© SPOT, McGill University

Screen for Mandatory Questions /

Acute injury? Proceed to joint specific aspects

Lower quadrant scan

Lumbar Ax Peripheral joint

© SPOT, McGill University

Biomechanical assessment for symptom modulation

During?: During?:

After?: _ After?: _