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Directional preference and low back/leg pain- what does it mean?
So, I think we all can either think of someone who has or have personally have had an episode of low back pain in our lifetime. The research shows that 80% of the population will experience an episode of low back pain at some point in the course of their life. Low back pain is the second most common cause of disability in the U.S and the utilization of healthcare services for low back pain has increased significantly in the last twenty years.
In addition to low back pain, it is also common to have radicular pain/symptoms into one or both legs. This could be burning, shooting, numbness, or tingling. Pain is a sensory, cognitive, and emotional experience (this will need a whole other blog post!).
There are numerous structures in the spine that have been shown to be a source of pain and many studies have shown that the disc, which sits between the vertebrae in your spine, is a possible and common source of back pain (Kuslich et al, 1991). The conceptual model of the McKenzie MDT approach, which directional preference is a huge part of, is based on the theory of the disc as a source of back pain. I have completed Part A of the McKenzie courses which includes examination and treatment of the lumbar spine (i.e. low back) and have found this approach extremely beneficial for individuals with low back pain and/or radicular symptoms into the legs.
Some indications to utilize the McKenzie mechanical diagnosis and therapy (MDT) approach include nerve root problems and mechanical back pain. Mechanical back pain typically occurs in individuals ages 20-55 years old and pain is located in the lumbosacral region, buttocks, and thighs. These individuals complain of pain that is “mechanical” in nature, meaning the pain varies with physical activity and over time.
So, what is the goal with this approach? And, what would someone expect to go through during the assessment?
The goal with this approach when examining a patient is to try and find a directional preference, which is defined below.
Directional preference: phenomenon where a specific direction of repeated movement and/or sustained position results in a clinically relevant improvement in symptoms or mechanics.
So, what this means is that by either staying in a sustained position or doing what we call repeated movements (where you would do one specific movement for at least 10-20 repetitions), symptoms improve or there is a noticeable increase in range of motion or strength, etc.! Sometimes a change is noticed almost immediately and other times it takes longer. For example, the patient may need to do the exercise consistently every 2 hours throughout the day for a few days to ensure we have found their direction of preference!
Here are some things included in my assessment:
Lumbar spine active range of movement
Strength/Muscle testing of the legs
Assessing sensation and reflexes
Any special tests that help me diagnose the problem
Gait assessment (i.e. watching you walk)
Posture assessment
Throughout this assessment, I take people through some repeated movements of the low back in various directions in attempt to determine their direction of preference. Determining the direction of preference is based on how their pain/symptoms change throughout. In addition, some of the things listed above that are included in the assessment are tested before and after doing the repeated movements to determine changes. This helps guide the assessment!
Once we have found their direction of preference, I prescribe the specific exercise as their home exercise program to be performed every 2 hours throughout the day and whenever their pain comes back. The instructions are to “Do as many repetitions as are necessary until the pain is gone!” Thus, in this way, the exercise acts as your ‘pain medication.’
A study done by April, Medcalf, and Donelson in 1997 showed that a Mechanical Diagnosis and Therapy (MDT) evaluation was more accurate than an MRI! SAY WHAT?! Now, this study was only done on 63 patients, but still that’s a pretty cool finding!
Do you have back pain or nerve-related pain that is limiting you from doing all the things you love? Is it hindering your workout routine? Is it affecting your work life or your social life?
The McKenzie Mechanical Diagnosis & Therapy (MDT) Approach is meant to help you take control over your pain and symptoms and be able to manage them independently!!
I can help you determine the best treatment for you! Call 614-437-9002 or Email khartley@grandviewprimarycare.com today to schedule! :)
References
Freburger JK, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009; 169(3): 251-258.
The McKenzie Institute Part A: Lumbar Spine. McKenzie method of mechanical diagnosis and therapy. 2016.