One of the philosophical and practical differences between MDT and other approaches is the use of exercise for rapid and lasting pain relief.
It is not uncommon for patients to successfully decrease or abolish their symptoms with only one or two exercises, which simplifies the management program for both patient and clinician.
The two studies below, focus on the use of MDT in the cervical spine. They add further evidence to the clinical utility of testing patients with headache and / or neck pain for directional preference, without necessarily needing to make a pathoanatomical diagnosis.
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Peter Schoch, Faculty
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Lan Lin Pu, Eric Miller & Ronald Schenk
Journal of Manual & Manipulative Therapy, Published online: 01 Jun 2023
https://doi.org/10.1080/10669817.2023.2217592
Background/Purpose
Headaches are among the most common complaints requiring medical care, and annual expenditures for this condition are estimated to be 14 billion US dollars. The International Headache Society (IHS) describes cervicogenic headache (CGH) as a secondary type of headache emanating from the cervical spine which may be referred to one or more regions of the head and/or face. Mechanical Diagnosis and Therapy (MDT) is an approach shown to be effective in the management of spinal musculoskeletal disorders; however, there is limited evidence as to its efficacy in the management of CGH. The purpose of this case series was to examine the MDT approach in the assessment, classification, and management of a sample of patients experiencing cervicogenic headache.
Case Description
This study was a prospective case series. Following IRB approval, 15 patients meeting the study inclusion criteria were recruited from a hospital-based outpatient physical therapy clinic. All subjects received a physical therapy examination by a Diploma trained MDT clinician which included but was not limited to patient self-report forms and the testing of repeated end range movements. The Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Index (HDI), Yellow Flag Risk Form (YFRF), Cervical Flexion Rotation Test (CFRT), and the Craniocervical Flexion Test (CCFT) were administered at the initial visit, 5th visit, and 10th visit or discharge, whichever occurred first. The NPRS, NDI, and HDI were re-administered at a 3 month follow up. Following the initial examination, patients were classified into the MDT categories of derangement, dysfunction, postural, or ‘other’ and then received intervention based on directional preference.
Outcomes
Fifteen subjects (mean age, 45.9 years; F = 11, M = 4; symptom duration, 44.3 months; average visits, 8.8) received an examination and intervention and completed follow-up outcome measures. Based on MDT classification criteria, all 15 subjects in this case series were classified as derangements. A non-parametric Friedman test of Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation differences among repeated measures was conducted on all outcome measures revealing statistically significant improvements in NPRS (p < .01), NDI(p < .01), and HDI (p < .01) scores at visit 10 and 3 month follow up. The mean change scores exceeded the minimal clinical important difference (MCID) for NPRS (4.2), NDI (7.6), and HDI (28.5). CCFT scores improved significantly from the initial examination to visit 5 (p < .01) and YFRF scores improved significantly between visits 5 and 10 (p < .01).
Discussion/Conclusion
The diagnosis of CGH is difficult to determine based on pathoanatomical assessment. This case series suggests that the patient’s response to repeated end range movements may indicate a directional preference for manual procedures and exercises which may be used in management of musculoskeletal conditions such as CGH.
Hiroshi Takasaki & Chisato Yamasaki
Journal of Manual & Manipulative Therapy
Published online: 13 Apr 2023
https://doi.org/10.1080/10669817.2023.2201918
Background
Selective deep neck flexor muscle activation through craniocervical flexion exercises has been considered to be different from cervical retraction exercises.
Objective
To compare the immediate analgesic effect of craniocervical flexion versus cervical retraction exercises in individuals with nonacute, directional preference (DP) for cervical retraction or extension
Methods
A two-arm, assessor-blinded, pretest-posttest randomized experiment was conducted. Participants were randomly assigned to either craniocervical flexion or cervical retraction exercises and those who were confirmed at the post-intervention examination to have a DP for cervical retraction or extension were analyzed. The primary outcome measure was pressure pain thresholds at the C2 and C5-C6 levels.
Results
A total of 10 (mean age = 20.6 years) and nine participants (mean age = 19.4 years) undertook craniocervical flexion and retraction exercises, respectively. One-way analysis of variance demonstrated no statistically significant (p > 0.05) interaction effect regardless of the neck level. In the pre-post change percentages, retraction exercises provided greater analgesic effects compared to craniocervical flexion exercises at the C2 (Hedges’ g = 0.679) and C5-C6 levels (g = 0.637).
Conclusion
This study showed a comparable or greater immediate neck analgesic effect from cervical retraction exercises compared to craniocervical flexion exercises in individuals with a DP for cervical retraction or extension.