Mechanical Diagnosis And Therapy Classification Research Articles

Predictors of 1-Year Perceived Recovery, Absenteeism, and Expenses Due to Low Back Pain in Workers Receiving Mechanical Diagnosis and Therapy: A Prospective Cohort Study.

This multicenter prospective cohort study aimed to preliminarily explore statistically relevant modifiable and predetermined factors for 1-year perceived recovery, absenteeism, and personal expenses in workers who received Mechanical Diagnosis and Therapy (MDT) for low back pain (LBP). Three stepwise multiple regression models were explored with 42 independent variables, including (1) socio-demographic factors; (2) risk stratification; (3) pain-related variables, psychological variables, and behavioral variables at baseline and changes after a month; (4) therapeutic alliance and exercise adherence at 1-month follow-up; and (5) MDT classification and therapist levels. Data from 58 participants were analyzed, after which a model with a medium effect size was developed for 1-year perceived recovery only. Consequently, patients with derangement syndrome were expected to have improved 1-year perceived recovery, with expected predetermined prognostic factors including shorter symptom duration, self-management skills to lead a healthy life, and less pain catastrophization at baseline. A stronger therapeutic alliance between patient and therapist during the 1-month MDT intervention was identified as an expected modifiable prognostic factor. It may be difficult to accurately predict the annual absenteeism and personal expenses due to LBP given the weak to low effect sizes of the developed models.

Mechanical diagnosis and therapy in patients with extremity problems: A Systematic review

Background: Mechanical Diagnosis and Therapy (MDT) is used in the treatment of extremity problems. It is an effective approach in cases of spinal conditions for target population. Availability of the reliable data like RCT and systematic review is a key factor to determine the precise clinical problem and to direct an appropriate intervention. Objectives: The primary aim of this systematic review is to assess the methodological quality of well-designed RCTs related to the MDT classification and treatment for extremity problems. Design: Systematic review. Method: Electronic search on various data bases was done. The level of evidence was determined considering the methodological quality of the studies. Results: 1 RCT was included and it met the criteria for high quality. After the assessment of RCT according to the CONSORT guidelines it was found that out of 25 checklist points; 4 methodological faults were found in assessed RCT. Those were; a) sample size determination, b) Blinding after assessment c) Generisability of the trial findings d) Where the full trial protocol can be accessed. Conclusion: The current systematic review found strong evidence of benefits of MDT approach for extremity problems (knee joint). But there was limited evidence in other extremity joints.

Mechanical diagnosis and therapy and Morton’s neuroma: a case-series

ABSTRACTObjectives: Morton’s neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for MN are sparse, and utility of physical therapy (PT) is unknown. Mechanical Diagnosis and Therapy (MDT) is a classification system utilizing direction-specific treatment for orthopedic conditions based on mechanical and symptomatic response to repeated end range movements. The purpose of this case series is to describe the management of three patients with a medical diagnosis of MN using the MDT classification system.Methods: Three female patients aged 54–75 years with unilateral plantar forefoot pain for 6 weeks to 8 years were referred by a podiatrist following positive clinically accepted diagnostic criteria for MN including radiological imaging and provocation testing. Patients were evaluated and treated utilizing MDT assessment and treatment principles. The intervention consisted of repeated movements matched to the patient’s directional preference at either the lumbar spine (1 patient) or distal extremity (2 patients).Results: Immediate and one-year outcomes were excellent, demonstrating rapid and lasting improvement. Following discharge, the patients have been asymptomatic or able to self-manage without seeking additional medical intervention for this condition. Total visit frequency per patient averaged 2–3 visits total across 8–16 days.Discussion: Responses to repeated end range movements testing allowed for classification and prescription of exercise to rapidly improve symptoms and function in three patients referred to PT services with medically diagnosed MN. This series provides preliminary evidence that MDT may be effective in classifying and treating patients with MN.

Classification by pain pattern for patients with cervical spine radiculopathy

ABSTRACT Objectives A prospective observational cohort study was conducted to (1) report the prevalence of Mechanical Diagnosis and Therapy (MDT) classifications, Centralization (CEN), and Non-CEN among patients with Cervical Spine Radiculopathy (CSR), and (2) describe the association between classification via CEN and Non-CEN and clinical outcomes at follow-up. Methods Data were collected from 680 consecutive patients who presented to outpatient, orthopedic physical therapy clinics with primary complaints of neck pain with and without radiculopathy; thirty-nine patients (6%) met the physical examination inclusion criteria for CSR. First examination and follow-up data were completed by 19 patients. Results Seventy-nine percent of patients’ conditions were classified as Reducible Derangement at first examination and 21% were classified as either Irreducible Derangement, Entrapment, or Mechanically Inconclusive. The prevalence of CEN and Non-CEN was 36.8% and 47.4%, respectively. All patients treated via MDT methods made clinically significant improvements in disability, but not pain intensity, at follow-up. The magnitude of change in clinical outcomes was greatest for patients who exhibited CEN; however, the changes in disability and pain intensity at follow-up were not statistically significant compared to patients who exhibited Non-CEN at first examination. Patients who exhibited CEN were discharged, on average, ten days earlier and had one less treatment visit compared to patients who exhibited Non-CEN. Discussion The findings of this study show that patients with CSR can be classified and treated via MDT methods and experienced clinically significant improvements in disability, but not pain intensity, at follow-up. Providers should consider MDT classification and treatment to improve clinical outcomes for their patients affected by CSR.

A prospective study of patients with shoulder pain and Mechanical Diagnosis and Therapy (MDT)

ABSTRACTObjectives: A prospective observational cohort study was conducted to (1) determine the prevalence of Mechanical Diagnosis and Therapy (MDT) syndromes for patients with shoulder impairments and (2) report the interaction between MDT classification and clinical outcomes, including pain intensity and disability, at discharge.Methods: Clinical outcome measures were completed at intake and discharge by 115 patients. A two-way mixed model analysis of variance with subsequent pairwise comparisons was done to examine differences in clinical outcomes between the following MDT classifications: Shoulder Derangement, Shoulder Dysfunction, and Other.Results: The primary findings were that (1) 44.3 (35.3, 53.4), 40.0 (31.0, 48.9), and 15.6 (9.0, 22.3) percent of patients’ conditions were classified as Shoulder Derangement, Shoulder Dysfunction, and Other, respectively, (2) all groups managed via MDT methods made clinically significant improvements in disability and pain intensity at discharge, (3) a statistically significant difference in pain intensity at discharge was observed between the Shoulder Derangement and the Shoulder Dysfunction classifications (p = 0.01), and (4) patients with the Shoulder Derangement classification were discharged, on average, 35.3 days earlier than the Shoulder Dysfunction classification and 28.3 days earlier than the Other classification.Discussion: This study confirms previous reports that the Shoulder Derangement and Shoulder Dysfunction classifications are common and represent distinct clinical trajectories when assessed and managed via MDT methods.

The most common classification in the mechanical diagnosis and therapy for patients with a primary complaint of non-acute knee pain was Spinal Derangement: a retrospective chart review

ABSTRACTObjectives: To preliminarily investigate in patients with a primary complaint of non-acute knee pain for ≥ 1 month: 1) the proportion of patients with non-acute knee pain classified by Mechanical Diagnosis and Therapy (MDT) as Spinal Derangements, 2) the number of sessions taken to identify the concluding classification, and 3) the ability of MDT classifications, demographics, and symptomatic baselines to predict pain reduction at 1-month follow-up.Methods: This study reviewed data from outpatients managed with MDT. For modeling knee pain reduction at the 1-month follow-up, 3 MDT provisional or concluding classifications (Spinal Derangement, Knee Derangement, and Non-Derangement) and the following variables were included: 1) gender, 2) symptom duration, 3) presence of low back pain (LBP), 4) the Japanese Knee Osteoarthritis Measure, 5) average pain intensity at the initial session using a 0–10 numerical rating scale, and 6) the Kellgren–Lawrence grade.Results: Data from 101 patients were extracted. The percentage of patients with the concluding classification of Spinal Derangement was 44.6%. This was greater in those patient’s reporting concomitant LBP (p = .002) and without radiographic findings of knee osteoarthritis (p < .001). A concluding classification was determined by the fourth session in 80% of patients. Multiple regression modeling demonstrated that only the concluding classification significantly predicted the knee pain reduction at the 1-month follow-up.Discussion: These findings suggest the importance of careful screening assessments of the lumbar spine and the importance of detecting Derangements throughout the follow-up sessions for patients with a primary complaint of knee pain.

Diagnosis of cervical and thoracic musculoskeletal spinal pain receptive to mechanical movement strategies: a multicenter observational study

ABSTRACTBackground: The McKenzie’s Mechanical Diagnosis and Therapy (MDT), which uses a combination of repeated movements and sustained positions to affect signs and symptoms, is commonly used for the conservative evaluation and management of cervical and thoracic spinal conditions.Objective: Report a consecutive cohort of neck and thoracic pain patients managed using MDT and to record their classifications and physiotherapy management strategies.Methods: Therapists provided demographic data on themselves and the patients, clinical data on the patients, and Neck Disability Index scores at baseline and final visit.Results: Sixteen therapists collected data on 138 patients at baseline, of who 120 (87%) were followed up three to five visits later; these were patients with 131 cervical and seven thoracic problems. The therapists and patients are described. Regarding MDT classifications 83% were recorded as cervical and 100% as thoracic Derangement; there was a Directional Preference for extension in 80% of cervical spine patients, and 100% of thoracic spine patients. In addition, 13% of cervical spine patients were classified as OTHER, for which specific classifications were given. Classifications remained stable between initial and discharge sessions in 94% of patients. Neck Disability Index scores reduced from a mean of 24–12 at discharge (P < 0.001).Conclusions: Routinely collected data can describe both therapists and patients involved, demonstrate the MDT classification clinical utility in terms of prevalence and stability between visits, provide information on the clinical course of this patients’ population, which could help establish treatment efficacy. Randomized controlled trials are needed to test for efficacy.

Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy

BackgroundShoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests. ObjectivesTo investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment. MethodsAn international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications. ResultsThe overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs (P values > 0.05). ConclusionThe lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study

Objectives: The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification.Methods: International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed.Results: The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The Derangement and Spinal classifications had significantly higher UEFI scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The frequency of discharge at week 2 was 37% for both Derangement and Spinal classifications, with no discharges for the Dysfunction classification at this time point. The frequency of discharge at week 4 was 83, 82 and 15% for the Derangement, Spinal and Dysfunction classifications, respectively.Discussion: Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.Level of Evidence: 2b

Agreement of Mechanical Diagnosis and Therapy Classification in People With Extremity Conditions.

In the McKenzie system of mechanical diagnosis and therapy (MDT), a reliable system for the management of spinal problems, classifications are used to guide management strategies. For the classification of extremity disorders, interexaminer agreement has not been investigated with patients. The study objective was to investigate interexaminer agreement for provisional MDT extremity classification with patients. This was a reliability study with examiner masking. A therapist with an MDT credential observed the assessments made by 2 therapists with MDT diplomas, who successively performed MDT assessments for 33 patients with extremity pain on the same day. Immediately after each evaluation, all 3 therapists assigned the most appropriate MDT classification from 15 categories; they were unaware of each other's selection. The observed agreement and the Cohen kappa were calculated for the MDT classifications. The observed agreement for the 15 MDT categories of classification between the therapist with an MDT credential and the first therapist with an MDT diploma was 78.8%. The Cohen kappa was .72 (95% confidence interval=.54, .89), indicating good agreement. However, the observed agreement between the 2 therapists with MDT diplomas when the patient was assessed separately was 42.4%. The Cohen kappa was .21 (95% confidence interval=.01, .41), indicating poor agreement. Study limitations included convenience sampling of patients, the small number of examiners, and the limited extremity experience of the therapists with MDT diplomas. Interexaminer agreement for provisional MDT extremity classification was good when the examiners were seeing the same patient concurrently but poor when the patient was seen successively. Further studies are needed to establish which factors, including study method, are responsible for the divergent results of the MDT assessments of extremity disorders.

Attitude Towards the Use of Mechanical Diagnosis and Therapy and Reliability of Classification Extremity Problems by Credentialed Therapists

ObjectiveThe purpose of this study was to investigate attitudes towards Mechanical Diagnosis and Therapy (MDT) for extremity problems and inter-examiner reliability of classifying extremity problems into MDT subgroups by credentialed practitioners in MDT (Cred.MDT) in Japan. MethodsA cross-sectional survey was used and all 120 Cred.MDT practitioners registered in the McKenzie Institute International Japan branch were asked about their attitude towards MDT for extremity problems and were asked to select the most appropriate MDT subgroup for each of the 25 extremity patient vignettes. Model classifications were used to investigate accuracy of classification. Percent agreement and Kappa analyses were examined. ResultsSixty practitioners (50%) participated in this study. For the management of patients with extremity problems, the majority did not use MDT most of the time (53%) due to a lack of confidence in using MDT in the extremities (78%). The overall accuracy for their MDT classification for extremity problems was 87% (Fleiss's κ=0.78). ConclusionsThe majority of the Cred.MDT practitioners in Japan did not use MDT frequently and were not confident to use MDT with extremity patients. However, accuracy and inter-examiner agreement of their MDT classification from the information on the assessment sheet was good.

Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series

The McKenzie method, also known as Mechanical Diagnosis and Therapy (MDT), is primarily recognized as an evaluation and treatment method for the spine. However, McKenzie suggested that this method could also be applied to the extremities. Derangement is an MDT classification defined as an anatomical disturbance in the normal resting position of the joint, and McKenzie proposed that repeated movements could be applied to reduce internal joint displacement and rapidly reduce derangement symptoms. However, the current literature on MDT application to shoulder disorders is limited. Here, we present a case series involving four patients with chronic shoulder pain from a duration of 2–18 months classified as derangement and treated using MDT principles. Each patient underwent mechanical assessment and was treated with repeated movements based on their directional preference. All patients demonstrated rapid and clinically significant improvement in baseline measures and the disabilities of the arm, shoulder, and hand (QuickDASH) scores from an average of 38% at initial evaluation to 5% at discharge within 3–5 visits. Our findings suggest that MDT may be an effective treatment approach for shoulder pain.

A Survey of the McKenzie Classification System in the Extremities: Prevalence of Mechanical Syndromes and Preferred Loading Strategies

Classification of patients with extremity problems is commonly based on patho-anatomical diagnoses, but problems exist regarding reliability and validity of the tests and diagnostic criteria used. Alternatively, a classification system based on patient response to repeated loading strategies can be used to classify and direct management. The purpose of this study was to investigate the prevalence of McKenzie's classification categories among patients with extremity problems and the loading strategies used in their management. This was a prospective, observational study. Thirty therapists among 138 invited (response rate=22%) with a Diploma in Mechanical Diagnosis and Therapy (MDT) were identified from the McKenzie Institute International registry and recruited worldwide to complete an e-mailed questionnaire. They provided data about their age, years qualified, years since gaining a diploma, and practice, and prospectively provided data on anatomical site and categorization for 15 consecutive patients with extremity problems. Data were gathered on 388 patients; classification categories were as follows: derangement (37%); contractile dysfunction (17%); articular dysfunction (10%); and "other" (36%), of which 20% were postsurgery or posttrauma. Exercise management strategies and syndrome application varied considerably among anatomical sites. Classification categories remained consistent in 85.8% of patients over the treatment episode. These findings are not generalizable to therapists who are not experienced with use of MDT in the extremities. This study demonstrates that trained clinicians can classify patients with extremity problems into MDT classifications and that these classifications remain stable during the treatment episode. Further work is needed to test the efficacy of this system compared with other approaches, but if derangements are as common as this survey suggests, the findings have important prognostic implications because this syndrome is defined by its rapid response to repeated movements.

Management of Low Back Pain

To the Editor: I was interested to read the recent article by Maluf et al titled “Use of a Classification System to Guide Nonsurgical Management of a Patient With Chronic Low Back Pain” (November 2000). The authors correctly stated that there are “potential benefits to using a classification approach to guide identification and treatment of symptom-provoking movements and postures.” However, given the widespread recognition of a very similar, but more comprehensive, classification system proposed by McKenzie 20 years ago,1 I would question how Maluf and colleagues' proposal contributes further to our current understanding. McKenzie's Mechanical Diagnosis and Therapy (MDT) model1 first demonstrated the value of utilizing symptom-provoking-and-relieving movement and posture testing in assessing and classifying painful spinal disorders. Additionally, the major elements of both the MDT assessment and classification system have already been shown to yield measurements with interexaminer reliability.2–7 Both philosophies recognize that daily repetition of direction-specific postures and movements contributes to the development and recurrence of mechanical low back pain. Maluf et al recommended limiting motion in those directions identified as aggravating, but they did not discuss the possibility that exploring repeated motion in the opposite direction or another direction may also be beneficial in decreasing or eliminating pain. There is abundant literature reporting that patients not only have a directional “vulnerability” (to flexion most commonly), they also have a directional “preference” that can be identified with the MDT examination, namely the use of repeated end-range loading of the symptomatic spine while monitoring the symptom response.8–15 The patients' pain typically centralizes and abolishes when they perform therapeutic movements and postures that honor and match their directional preference found during their assessment. While Maluf et al reported that their patient's pain “localized” to the spine during treatment, they avoided the term …