“I want the majority of the treatment to be myofascial release as I have been told that is the only way my back is going to get better,” said a patient (we will call him Sam) that I had treated for a recurrence of low back pain with a history of a multi-level lumbar fusion. Despite our good rapport, Sam, an elderly gentleman, eventually decided that his expectations for manual-based treatment didn’t align with what was being provided; a more exercise-based McKenzie Method approach. The rationale for exercise-based treatment in assessing for a derangement classification was discussed (more on what that means later). Eventually, both he and I agreed to discontinue treatment after two sessions. Despite best efforts, a treatment partnership was not able to be formed secondary to differing expectations by both patient and therapist.
The above may sound familiar to clinicians who are utilizing primarily exercise-based approaches. Research has shown equal if not better results for exercise-based treatment compared to manual therapy or manual therapy combined with exercise, particularly for low back pain. Part of the reason for support for exercise-based treatments is the prevalence of a diagnostic classification known by physical therapists as derangement. It doesn’t matter if you are a high-level athlete of any age or an affable older gentleman like Sam, who wanted to get back to walking. If you want to get rid of your pain quickly, stop worrying, and save yourself money, you should care about derangements in your physical therapy examination and treatments.
What Is A Derangement?
As a physical therapist, explaining what a derangement is and how it is related to your musculoskeletal pain to a patient or a physician doesn’t have to be complicated. Based on the McKenzie Method (MDT) a derangement is an obstruction to either the spine or any of the joints of your upper limbs and lower limbs that leads to pain and decrease movement; kind of like the pain and frustration of having to stop in traffic for an obstructing train when you’re late for work. The obstruction can be a disc, a tiny broken piece of cartilage, a torn meniscus, tiny articles of bone, really any tissue found within a joint loosened or compromised from life’s activities. An obstruction causes the supporting structures (ligaments of a joint or outer layer of your disc) to be irritated from being stretched and stressed beyond pain-free capacity. It would be like having an eyelash becoming separated from your eyelid and being lodged on the surface of your eye. It may appear to be insignificant and small but it can cause a lot of irritability; a discomfort we want immediately taken away. The one positive about a derangement is that if it is present, rapid alleviation of pain and rapid improvement of restricted motion is observed within the first 1-3 treatment sessions.
What The Research Says
The concept of derangements has been around for at least 60 years, first published for public consumption 42 years ago in 1980 through Treat Your Own Back, by Robin McKenzie. There are roughly 230,000 physical therapists in the United States and only less than 2500 of them are certified in the McKenzie Method (cert. MDT) or are higher trained Diplomates of Mechanical Diagnosis and Therapy (Dip. MDT). Both types of clinicians have been trained to identify and treat a derangement quickly in the spine, upper limbs, and lower limbs. With many different schools of training across the United States in physical therapy, medical doctors having little exposure and knowledge to what the capabilities are for physical therapists in musculoskeletal examination and treatments, and no unified system of assessment, it is no surprise there is a lack of awareness about the concept of derangements today in the medical field.
Now, what if I were to say that a derangement, either of your neck, midback, low back, or in the joints of your upper and lower extremities, oftentimes was the cause of your pain (74% of the time causing low back pain, 29% to 71% of the time causing pain in your shoulder, hip, and knee)?3-6 What if I were to say that you could resolve a lot of your pain issues quickly in 1-3 physical therapy visits with specific self-treating active movement exercises and postures (labeled as directional preference movements or postures). Examples of this would be repeated backward bending in standing for some cases of low back pain or repeated straightening of your knee for some cases of knee pain. All you would have to do is perform those very easy and short one or two exercises, every two to three hours, over one to two weeks. THESE SOLUTIONS WOULD BE MORE NUANCED THAN THAT BUT ULTIMATELY, YOU WOULD HAVE THE CONTROL OVER HOW QUICKLY YOU GOT WELL.
Is having control over what makes you well something that you would find appealing? That would make common passive treatments such as myofascial release, lasers, massage, e-stim, massage guns, inversion tables, etc. being alternative options but not essential. Would that make you think, “This guy or group is passing off information that is made up. It just sounds too simple.” If you are a physician, are you asking yourself, “Can this guy or any other clinician who is promoting this content be trusted, because I have never heard of such a thing?”
Maybe these are not your exact words but perhaps some of those thoughts run through your mind at first blush as a patient or as a physician. Frankly, it’s human nature to be skeptical and I certainly don’t take offense to you for thinking those initial thoughts. You are not acquainted with me or the other couple of thousands of clinicians in the United States expressing the above information to the patients we are treating and seeing results with. But maybe what I and another couple thousand clinicians stateside are saying has validity and should be considered. A clinical presentation called a derangement that is treated with directional preference exercises or postures, has been proven time after time to be able to help people overcome their acute or chronic spine and extremity pains. As a physical therapist, it is very important to me to educate the public on effective treatments that ultimately save you time, save you worry, and save you money.1,2
So Why Should You Care?
Saving yourself time, worry, and money in finding solutions for your pain is usually incentive enough to care. There have been countless patient cases where derangements have been identified and resolved quickly throughout my and many others’ careers. I will focus on several instances that come to mind. There was one female patient of mine who had off and on pain of her low back for 40 plus years after suffering from an early adult traumatic accident. Both thoracic and lumbar spine derangements were identified quickly and the patient had full resolution of pain and return to her desired functional goals in three visits through directional preference movements. Another patient, a middle-aged male, was having right shoulder and low back pain that had been limiting his daily activities for five years after being in a vehicular crash. A neck and low back derangement was quickly identified. He became pain-free for only the second time throughout his five-year ordeal in less than 1.5 weeks. It took three visits using directional preference movements to achieve that status. An elderly woman I treated last year had issues for several years negotiating steps and getting up and down from a chair. She was diagnosed with osteoarthritis pain in her knee and had nearly accepted that surgery was her best option. Despite having osteoarthritis of variable grade, she ended up having derangements in her low back and her right knee. She was back to the full preinjury pain-free capacity of climbing stairs and rising from a chair in six visits with again, directional preference movements.
Now, will everyone have a derangement? No. But years of research as well as the evidence collected anecdotally using the McKenzie Method, show a very good possibility that you may have one to two derangements that are contributing to your pain and your limitations to living fully. If your musculoskeletal clinician does not know how to identify and treat derangements for spine pain or pain in your upper and lower extremities, YOU MAY BE MISSING THE CHANCE FOR RAPID RECOVERY 25%- 74% OF THE TIME.3-6 Even more worrisome, you may be prematurely jumping to a surgical solution for supposedly an unresolvable pain condition, that CAN be successfully treated through physical therapy.
In Order To Become Independent Again You Must Be Willing To Move
There are different ways to get from point A to point B. There are different strokes to swim across an ocean. You are not going to be able to help all the Sam’s of the world because their predetermined expectations do not match your examination and treatment methods of identifying derangements quickly. A lot of patients think of treatment consisting of passive modes (myofascial release, lasers, massage, e-stim, massage guns, inversion tables, etc.) as the “premiere” ways to achieve full movement and pain-free function. What if the key to moving fully and pain-free function was actively moving joints in the directions that weren’t moving well, to begin with? Isn’t that the goal, to normalize movement and be independent? What if directional preference movements are found (seen 25% to 74% of the time with a spine, upper extremity, or lower extremity pain) and pain-free status rapidly is achieved in 1-3 visits?3-6) Would passive modes of treatment still be a go-to choice?
As a patient, by putting in a little bit of work, there is a good chance you attain the results you want in regards to pain and function in the quickest way possible according to the research. Sometimes in life, much like physical therapy treatment for a derangement, all that needs to be done to get a bothersome eyelash out of your eye is simply to be ACTIVE and WILLING to move repeatedly by blinking. To not move ensures you have less of a chance to get where you want to go. In the case of all patients, that’s being pain-free and staying pain-free.
If you are seeking to learn how to proactively take control of your pain and achieve pain-free independence as quickly as possible, schedule an appointment here today!
Jeff Lum PT, MPT, OCS, Dip. MDT is a physical therapist and owner of Mobile Spine Specialist serving the North Austin Texas communities, including Cedar Park, Round Rock, Georgetown, Leander, and Pflugerville. You can learn more about how he helps individuals overcome pain and improve mobility. To make a connection, reach out to him.
1. Agarwal, V., Schenk, R., Ross, M., 2020. Primary care management of patients with pain complaints and the influence of physician training in mechanical diagnosis and therapy. J Public Health (Berl.).
2. 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 care. Journal of Manual & Manipulative Therapy 27, 277–286.
3. Heidar Abady, A., Rosedale, R., Chesworth, B.M., Rotondi, M.A., Overend, T.J., 2017. Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study. Journal of Manual & Manipulative Therapy 25, 235–243.
4. Long, A., Donelson, R., Fung, T., 2004. Does it Matter Which Exercise?: A Randomized Control Trial of Exercise for Low Back Pain. Spine 29, 2593–2602.
5. Rosedale, R., Rastogi, R., May, S., Chesworth, B.M., Filice, F., Willis, S., Howard, J., Naudie, D., Robbins, S.M., 2014. Efficacy of Exercise Intervention as Determined by the McKenzie System of Mechanical Diagnosis and Therapy for Knee Osteoarthritis: A Randomized Controlled Trial. J Orthop Sports Phys Ther 44, 173-A6.
6. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins S, A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS), J Man Manip Ther., published online, 2019.