S - Dr. Gary Jacob

McKenzie Method Cervical & Thoracic
Gary Jacob, DC, LAc, MPH, DipMDT
garyjacob.com
Back Black Box
SL →
S:
L:
R:
M:
S:
→ R M+ R S
stimulus
load (movement &/or positioning)
response
mechanical
symptomatic
Back Black Box:
Observation vs. Explanation
SL →
→ R M+ R S
SL → R M + R S
= phenomenology
= what
= mechanism
= why
The conceptual models… may eventually alter…effectiveness of the procedures will not change
R McKenzie, Cervical Spine Intro p. xxiii
SL →
→RM+RS
= chemical v. mechanical?
Chemical (C) = Inflammation
 Better with rest, better upon awakening
 Lack of, or negative, response to movement
 Tends to be constant, intermittent if slight
 Mechanical (M)
 Worse/no response from rest, worse upon awakening
 Positive response to movement, manipulation
 Tends to be intermittent, constant if severe
Intermittent vs. Constant
Intermittent:
“mechanical” more likely
Constant
mechanical
chemical
psychophysiological
internal/systemic/organic
SL → R M + R S Mechanical Patterns
3 (SL →
→ R M + R S) Patterns
3 Patterns Amenable To Mechanical (Movement & Positioning) Therapy
= Posture
stabilization
= Dysfunction
short tissue
= Derangement
subluxation
stabilization
Posture Syndrome
Sitting
Root of Most Postural Spinal Evil
Cause, perpetuator, aggravator
Upper cervical extension
Cervico-thoraco-lumbar flexion
Shoulder int. rotation & adduction
Hip flexion
Knee flexion
McKenzie Slouch – Overcorrect - Back off 10%
McKenzie Slouch – Overcorrect - Back off 10%
McKenzie Slouch – Overcorrect - Back off 10%
Jacob Sit Like you Stand
Postural Syndrome Protocols
Postural Syndrome Treatment
Common for children
Uncommon for adults
Derangement Treatment
Children
Cervical
Adults
Cervical or Lumbar
Masaccio Expulsion from the Garden of Eden c. 1424-28
St. Francis in the Desert
Giovanni Bellini c. 1430 -1516
DYSFUNCTION
The Myth of Muscle Spasm
ODE to SPASM
violent, involuntary,
sustained contraction
that
prohibits joint motion
in the direction opposite
the afflicted muscle’s action
Myth of Muscle Spasm
Loss of Lordosis = paravertebral spasm?
 radiology’s greatest myth
 paravertebral muscle spasm would do the opposite!
 in other words it is impossible…
Normal, Loss & Reversed Lordosis
Normal lordosis
Loss of lordosis
Reversal of lordosis
Loss of Lordosis due to
Paravertebral Muscle Spasm?
Normal lordosis
Increased lordosis!
Loss of Lordosis due to
Paravertebral Muscle Spasm?
Normal lordosis
Loss of lordosis
Reversal of lordosis
Coming to Terms With Short Tissue
 Spasm
 Adaptive Shortening
 Hypertonic
 Hyperactive
 Tight
 ≠ Spastic
 Contracted
 Scar
 Dysfunction (McK)
 Myofascial?
 CNS disorder
Short Muscle Expectations
Motion loss and symptom provocation . . .
 Consistent with muscle claimed to be short
 In direction opposite action of culpable muscle
 Rx: muscle stretch to recover motion
Motion loss and symptom provocation . . .
 Inconsistent with muscle claimed to be short
 Consider resistance to intra-articular compression
 Rx: intra-articular compression to recover motion
Short Muscle Behavior
Muscle Short
Paravertebral
Suboccipital
Upper trapezius
SCM
Levator scapulae
Motion loss & Symptoms Expected
Flexion of the involved spinal area
C flexion, lat flexion to opposite side
Lat flexion to opposite, rot same side
Cervical extension, rot to same side
Cervical flexion, rot to opposite side
Scalenes
Upper Trap Myofascitis
Upper Trapezius
Myofascial Release with Movement
Neural “Mobilization”
dysfunction behavior and treatment rules
McK: adherent nerve root
Increasing root tension: spinal flexion &:
Cervical
Cervical flexion, Shoulder depression
Cervical contra lateral flexion
Decreasing root tension: opposite of above
“Flossing”:
backing tension off @ the last moment
 giving “slack,” “letting out the line”
When Neural Mob May Be OK
 Dysfunction M & SR:





Behaves like short tissue
Intermittent
ER only
Does not remain worse after provocations
Old & Cold vs. Young & Hot
UE Neural Mobilization
Median N.
Above horizontal
Below horizontal
Radial nerve
Waiter’s tip
Ulnar nerve
Hear no evil
Median Nerve Mobilization
above the horizontal
Median Nerve Mobilization
below the horizontal
Cervico-Brachial Mobilization
Establish UE Tension & Roll Lateral
Ulnar Nerve Mobilization
Radial Nerve Mobilization
Short Adductors & Int Rotators
Pect Stretch
DERANGEMENT
Derangement M & SRL
features not present in other syndromes
Quick changes persist after loading ceases
ERL in one direction affects another
Response during arc of motion
Centralization <> Peripheralization
Derangement M & SRL
Response to loading in direction of detriment
M&SR during motion arc & at ER
Symptom Peripheralization
Mechanics (ROM) obstructed in another direction
i.e. mechanical impedance in other direction
Derangement M & SRL
Response to loading in direction of correction
M&SR at ER only
Symptom Centralization
Mechanical obstruction diminishes
Provocation diminished in direction of detriment
Direction of Correction, an educational term here,
is known in the literature as Directional Preference
Derangement M & SRL
“McKenzie Reflex”
Promoting instability in one direction
promotes obstruction in another
Diminishing obstruction in one direction
diminishes instability in another
Kyphotic Antalgia
Posterior Derangement
Flexion:
- possible
- pain during motion
- end range pain
Sustained or dynamic flexion results in:
- peripheralization
- increased pain
- further loss of extension
Kyphotic Antalgia
OBVIOUS posterior derangement
Extension:
- obstructed
- no pain during motion
- end range pain
Sustained or dynamic extension results in:
- centralization
- diminished pain
- recovery of extension
- less pain with flexion
Symptomatic Response
a closer listen
Monitor for symptomatic responses
During motion (mid range)
Peripheralization
Centralization
After ER
AT End Range
Cervical Kyphotic Antalgia
OBVIOUS Posterior Derangement
 Monitor symptomatic response
 Traction: maintained throughout
 Retraction: flexes upper, extends lower C spine
 Retraction  let go of retraction to extend
 Mini-rotations at ER to extend more
Traction
Traction- Retraction
Traction-Retract (let go)-Extension
Cervical Posterior Derangement
self-treatment
 Correcting sitting posture
 Overcorrect - relax
 Stand - sit
 Cervical retraction
 Cervical retraction, extension
 Retraction, extension, mini-rotation
 Sitting vs. supine
 Towel, belt
Extension from Protruded Position
Extension From Neutral Position
Extension From Retracted Position
Extension from protruded
Extension from neutral
Extension from retracted
McKenzie Prayer
Posterior Derangement Mgmt.
 Two main factors for success or failure
1. Maintenance of Lordosis
 Sitting, ADLs & transitions, Sleeping
 Avoid flexion: “cut finger”
 Counteract flexion with extension ERL
2. Achieve Extension End Range Loading
the 3-Rs Recap
Posture syndrome
RE-EDUCATE
Dysfunction syndrome
RE-MODEL
Derangement Syndrome
REDUCE
Torticollic/Scoilotic Antalgia
OBVIOUS posterolateral derangement
Right Lateral Flex/Rot:
- obstructed
- end range pain
Sustained or dynamic contra Lateral Flex/Rot:
- centralization
- decreased pain
- recovery of contra LF/R
Then proceed as for ”Fixed Kyphosis”
Cervical Disc Horizontal Clefts
Von Luschka 1858
Develop during childhood
 Level of uncinate, progress medially
 Regular physiologic findings
 Not degenerative
 Attempt to adapt to functional demands
 Weakens lateral containment of nucleus
Cervical Disc Horizontal Clefts
Von Luschka 1858
Torticollis: Supine Mob
 Monitor symptomatic response
 Traction – maintained throughout
 Step-wise recovery of lateral flexion
Rotation in same direction if not tolerated
To unlock lateral flexion
 Unilateral technique
Self treatment strategies
Therapist
 Progress to kyphotic protocols
Retraction – Lateral Movements
Torticollic/Scoliotic Mgmt.
 Avoid sagittal ERs; find lordotic “magic spot”
 Push nucleus to middle, then forward
 Sagittal extension ERL after coronal correction
 Checks for elimination of “relevant lateral component”
 i.e. need to avoid loading in sagittal plane
 Once extension benefits, treat as fixed kyphosis
 Flexion ER after period of preclusion evaluates for:
 Persisting derangement
 Adaptive shortening from avoiding flexion
Lordotic Antalgia
OBVIOUS anterior derangement
Extension:
- possible.
- pain during motion.
- end range pain
Sustained or dynamic extension results in:
- peripheralization
- increased pain.
- further loss of flexion.
Lordotic Antalgia
OBVIOUS anterior derangement
Flexion:
- obstructed.
- no pain during motion.
- end range pain.
Sustained or dynamic flexion results in:
- centralization
- decreased pain
- recovery of flexion
- less pain with extension.
Cervical Anterior Derangements
not obvious
 Antalgia not visible – hidden
 Maybe associated with dysphagia
 retropharyngeal hemorrhage vs. ?
Monitor symptomatic response
Supine or sitting flexion maneuvers
Spinal Lordotic Antalgia Mgmt.
 Avoid extension ER
 Lose lordosis
 Flexion ERL
 Later: introduce extension ER to eval for
 Elimination of anterior derangement
 Adaptive shortening
Cervico-Cephalic
Summary: Obvious Derangements
 Antalgias (obvious derangements)
 Easy to recognize
 Easy to fix
 Mechanics dictate
 reverse the mechanics
 Symptoms corroborate
 respect centralization
No Obvious Derangement?
What to do?
 Absent antalgia, detective work required
 search to find “hidden” derangement
 employ antalgia based criteria (“ABC”)
 recall simple antalgia M & SRL patterns
 choose antalgia M & SRL best fit
as if recovering from, or headed to, which antalgia?
 apply tx protocols of best fit
Jacob’s Postulate
The utility
of McKenzie derangement protocols
is proportional
to the degree that
Mechanical & Symptomatic Responses to Loading
resemble
kyphotic, torticollic or lordotic
antalgia patterns
Mechanical Responses
a closer look
ROM loss?
Maintain intended direction?
 Asymmetry vs. Curve reversal?
Standardized McK C Spine Eval
 ERL history
 Order of motions tested
 Sitting: protrusion, retraction, retract  extend
 Supine: retraction, retract  extend
 “If needed”: Lateral flexion, rotation, flexion
 Tactics
 Single ROM – loss?, curve reversal?
 Dynamic loading: monitor symptoms
 If needed: sustained static loading
Especially protrusion/retraction for HA
factors
sitting
bending
walking
a.m.
post-a.m.
p.m.
stationary
moving
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