Time does not matter

I recently saw a patient with a one year history of pain into the right lower extremity below the knee which was becoming progressively worse. She had already had MRI’s, EMG studies, several injections and trials of medications without any lasting change in symptoms. Her subjective history and objective examination were somewhat puzzling. However, the one constant was that we could find a centralization that would centralize her leg pain. By the time she came for her second visit, she reported movement of her pain that had been present for over one year and reported intermittent right low back and buttock pain only. Within the next visit, this moved further into the back until all symptoms had abolished.



She has since been able to progress to recovery of flexion and resumed all functional activities without symptoms returning. Her only complaint was of how long it took to have this problem assessed correctly and that all the testing that was done was irrelevant to her problem.


The moral of the story is that centralization should be used as guide for all of us who evaluate low back and neck pain.

The Amazing Thoracic Spine

Although the literature states that thoracic spine derangements are relatively rare and are usually disguised as cervical derangements it is important to perform a thorough mechanical diagnosis and therapy assessment to rule these out. I had a recent patient with a three week history of intermittent left upper thoracic pain that did not radiate and was only affected when lying on the left side and when raising the left arm or lifting. Her symptoms were basically in the left upper trapezius region and she could have essentially been either a cervical or shoulder derangement as well. The importance of finding concordant signs and then assessing repeating movement testing is critical to determine the effective exercise. Although I initially focused on the cervical spine due to major limits with cervical retraction, upon the patient’s second visit no significant change in symptoms or functions were noted. It was at that time that we further explored the thoracic spine and found a directional preference of flexion which is a rather rare direction of preference but response to movement is what dictates where we go.


The patient returned on their third visit with all symptoms abolished and all range of motion restored to within normal limits with one simple thoracic flexion exercise. I had nothing else to offer as she could not provoke any pain with any direction of movements or with any resistance and she could lift as much weight as she wanted. She was discharged with home exercise program.

Just when you think you’ve seen every type of mechanical derangement in the spine, there is always something new to test your evaluation abilities.

Irreducible low back derangements

So far our blog has consisted of success stories of those with reducible derangements. The question that is raised “what do we do when a person is irreducible?” Irreducible simply means that at the current time there is no “directional preference”. This means that with all movements, symptoms increase or travel further into the leg. This past month, I have had two such cases, both involving the lumbar spine and pain throughout the leg with weakness. Both had lateral shift deformities and were unable to bear full weight on the involved extremity.



“Time, time, time is on my side, yes it is.” These are lyrics from the Rolling Stones 1964 hit. This holds true with the treatment of irreducible derangements. In both cases, we instructed the patients on the importance on not aggravating the condition and were instructed in very gentle mid range lumbar spine movements that would never increase leg pain. This eventually resulted in enough of a reduction of their constant pain and both became mechanical responders. In both cases, all the extremity pain has centralized to the lumbar spine and they are now undergoing a recovery of a reducible derangement.


The main difference between reducibles and irreducibles are that the reducibles rapidly respond and the irreducible may respond but will require a longer period of time.

Right posterior thigh pain

Right posterior thigh pain- was it back or was it hip? I had a patient present with right sided posterior thigh pain who reported pain with sitting and rising. She was unable to raise her right hip secondary to pain and was unable to squat. We initially evaluated the lumbar spine and could not come up with a conclusive mechanical diagnosis and then evaluated the hip. Essentially, we wound up treating both the lumbar spine and hip into extension.

This resulted in complete abolishment of all symptoms including pain, weakness, and inability to raise her weight against gravity and squat. This involved two directions of preference for this patient as we were unsure whether we were treating a stubborn low back derangement or a hip derangement. The only consequence to the patient is she needed to do two exercises instead of one but the outcome was good in just 5 visits.

"Course F?"

Please do not go to the McKenzie website looking for Course F because it does not exist. I had the wonderful opportunity to sit in on an introductory seminar held by Orthopedic and Sports Physical Therapy in Tallahassee, Florida. Several of the Mechanical Diagnosis and Therapy faculty and researchers gathered at this meeting to discuss the development of a Mechanical Diagnosis and Therapy network known as Integrated Mechanical Care. This particular clinic was able to show a 79% improvement in pain scores and 54% improvement in function scores for its members at Capital Health Plan in Tallahassee, Florida.

A fantastic article was written in the Manage Care magazine in June 2008 by Dr. Charles Tomlinson, who was vice president at Capital Care from 2000-2008. The results were so promising that all members of this health plan must now utilize Mechanical Diagnosis and Therapy specialist in physical therapy before surgery, injections or MRI’s are considered. Significant reductions in the percentage of surgeries, injections and MRI’s have also been noted as a result as the implementation of Mechanical Diagnosis and Therapy.  It was quite exciting to see the recognition of Mechanical Diagnosis and Therapy addressed by those outside our profession.



We will keep you updated on further developments with other insurance companies following this same plan.