Derangement of the temporomandibular joint; a case study using Mechanical Diagnosis and Therapy

Directional preference of the extremity: a preliminary investigation

Background: Mechanical diagnosis and therapy (MDT) is a specific classification-based musculoskeletal examination and intervention system that uses repeated end range and sustained movement to classify patients into mechanical syndromes. Research has recently demonstrated increased prevalence, reliability, and efficacy of MDT syndromes in varied peripheral musculoskeletal populations. There is currently no research analyzing if predictive variables exist for establishing directional preference in peripheral joints, other than the wrist. The aim of this study was to examine the clinical application of predictive variables for establishing directional preference and spinal referral in patients with isolated peripheral joint pain. Case Description: Thirty-seven consecutive patients with isolated peripheral pain were evaluated and classified using MDT assessment. Secondary analysis of predetermined variables was performed for association with directional preference and identification of spinal referral in Derangement syndrome. Results: All 37 patients were classified using MDT assessment. Thirty-three (89.2%) were classified as Derangement syndrome: 17 as spinal Derangement (45.9%) and 16 as peripheral Derangement (43.2%). One peripheral derangement also had an underlying Articular Dysfunction. Additionally, there were four patients classified as Other (10.8%). Discussion: Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference or spinal referral. Mechanical stress was found to be the most associated factor in predicting directional preference. No peripheral movement loss, paresthesia, and constant pain were more associated with spinal referral. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes. Level of Evidence: 4.

Provider reliability with interventions for knee impairments: a preliminary investigation to facilitate development of an MDT-based knee intervention taxonomy

Objectives: The lack of a standardized intervention taxonomy in comparative effectiveness research trials has led to uncertainty regarding the management of individuals with knee impairments. Inconsistently and poorly defined interventions affect frontline-care providers' abilities to understand and assimilate research findings into practice. An intervention taxonomy could help overcome the lack of treatment specificity commonly found in research trials. Methods: In the present study, we aimed to develop a Mechanical Diagnosis and Therapy (MDT)-based taxonomy and test the levels of reliability between providers who currently manage individuals with knee impairments in a rehabilitation setting. A total of 182 participants accessed the study during the study period, in which 180 consented to participate and 59 completed the survey (98.9% participation rate; 32.7% completion rate). Results: A total of 89.8% of the participants who completed the survey were physical therapists. Fleiss kappa values for the primary, secondary, and tertiary categories were 0.90, 0.89, and 0.71, respectively. The results of our investigation suggest substantial to almost perfect levels of reliability for identifying diverse MDT-based knee interventions displayed in video and vignette format within a sample population primarily of physical therapists who currently manage individuals with knee impairments in a rehabilitation setting. Discussion: Our findings show acceptable levels of reliability and provide support for using this standardized MDT-based intervention taxonomy as a way to improve intervention specificity and generalizability in comparative effectiveness research. Level of Evidence: 5.

The application of Mechanical Diagnosis and Therapy to the ankle-foot complex: a case series

Background

Pain at the ankle-foot complex is a common musculoskeletal condition that can lead to dysfunction. Mechanical Diagnosis and Therapy (MDT) is an orthopedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained movement. There has been no investigation of the association between MDT and patients diagnosed with ankle-foot complex pain.

Case description

This report presents four patients with a primary complaint of pain in the ankle-foot complex. Three patients had a medical diagnosis while the other was self-referred through direct access. All received classification and treatment by clinicians trained in MDT solely utilizing MDT principles.

Outcomes

Short- and long-term (4-12 months) outcomes were excellent, demonstrating rapid abolishment of symptoms and return to prior levels of function in an average of six visits over 21 days (4-8 visits over 14-33 days) without the use of modalities, strength, or proprioceptive training. The patients demonstrated the ability to prevent and manage re-occurrence of symptoms independently without seeking further health care at long-term follow-up.

Discussion

The rapid speed of recovery and return to functional activities demonstrated in this case series, raises questions about whether or not the pathologies traditionally associated with the etiology of ankle-foot injuries are actually at fault or understood. Moreover, it demonstrates that specific movements can rapidly worsen or improve symptoms challenging the current generalized rehabilitation protocols. This report provides preliminary evidence that MDT may be capable of providing more effective short-term outcomes in the management of ankle-foot complex injuries.

Level of Evidence

4.

The application of mechanical diagnosis and therapy on hip osteoarthritis: A case report

Background: The prevalence and cost of hip osteoarthritis (OA) is rising. Mechanical diagnosis and therapy (MDT) is an orthopedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained end-range movements. There has been no investigation of the association between MDT and patients diagnosed with hip OA. Case Description: This case report presents a 71-year-old female diagnosed with hip OA and matching the currently accepted clinical prediction rule (CPR) for symptomatic hip OA. The patient was classified and treated by a Diplomat of MDT and co-examiner using MDT. Outcomes: Short- and long-term (13 months) outcomes were excellent, demonstrating rapid abolishment of symptoms and improvement in function in 5 visits over 21 days. The patient demonstrated the ability to prevent and manage reoccurrence of symptoms independently; nevertheless, she received a total hip replacement which was not in accordance with current guidelines and recommendations. Conclusion: This case report raises questions about whether or not pathologies traditionally associated with the etiology of hip OA are actually at fault. Moreover, it raises questions about the utility of special tests and CPRs typically utilized to identify those structures. The case report provides preliminary evidence from one patient that MDT may be capable of providing effective short- and long-term outcomes in the management of hip OA.

February 2017 Letter to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "Regarding the Complexity of Low Back Pain" with Authors' Response J Orthop Sports Phys Ther 2017;47(2):126-129. doi:10.2519/jospt.2017.0201.

The application of mechanical diagnosis and therapy in lateral epicondylalgia

BACKGROUND

lateral epicondylalgia (LE) is a musculoskeletal diagnosis that causes pain and dysfunction in the lateral aspect of the elbow. Mechanical diagnosis and therapy (MDT) is an orthopaedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained end-range movement. There has been no investigation of the association between MDT and patients diagnosed with LE.

CASE DESCRIPTION

this report presents three patients matching the currently accepted diagnostic criteria for LE, two with a diagnosis of lateral epicondylitis (tennis elbow) from a medical doctor. These patients were classified and treated by a diplomat of MDT and two third-year doctoral students of physical therapy using MDT.

OUTCOMES

short- and long-term (one year) outcomes were excellent, demonstrating rapid abolishment of symptoms and return to prior levels of function in 3-6 visits between 11-59 days. Patients demonstrated the ability to prevent and manage reoccurrence of symptoms independently without seeking further health care.

DISCUSSION

this case series raises questions about whether or not the pathologies traditionally associated with the aetiology of LE are actually at fault. Moreover, it raises questions about the utility of special tests typically utilized to identify those structures. The series provides preliminary evidence that MDT may be capable of providing effective short- and long-term outcomes in the management of LE.

LEVEL OF EVIDENCE

4.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

OBJECTIVE

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

METHODS

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

RESULTS

There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

DISCUSSION

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

Clinical decision-making in the management of cervical spine derangement: a case study survey using a patient vignette

BACKGROUND

Neck pain is one of the most common, potentially disabling, and costly musculoskeletal conditions seen in outpatient physical therapy (PT). Clinical decision-making involves referral or the selection of intervention based on the results of the PT examination. Despite evidence that suggests that treatment based classification is most efficacious, it is hypothesized that examination and intervention may be heavily influenced by post-graduate training experiences.

PURPOSE

The purpose of this study was to analyze which tests, measures, and interventions are most commonly selected by physical therapists (PTs) holding a credential from the McKenzie Institute and those holding the McKenzie credential plus the credentialc of Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT). Their responses were based on a simulated case vignette involving a patient with a presentation of cervical spine disk derangement.

METHODS

A survey administered through Survey Monkey was sent to 714 members of the McKenzie Institute who are certified or hold a diploma in mechanical diagnosis and therapy (MDT) or these credentials with the addition of Fellowship credentialing (MDT+FAAOMPT). Of the 714 surveyed PTs, 83 completed the survey for a response rate of 11.6%. As the PTs were given further information regarding the patient, they were asked to progress through a clinical decision-making process by indicating their sequence of examination techniques, and then indicating which interventions would be performed based on the results of the examination.

RESULTS

A descriptive analysis was conducted to determine the most common sequences chosen by the PTs based on their training. To perform the analysis, only respondents who completed the survey were included: clinicians with MDT credentials, (n = 77), and clinicians with both the MDT and FAAOMPT credentials (MDT+FAAOMPT), (n = 6). Initially, the most common examination chosen regardless of credential was postural analysis. After receiving additional information regarding the patient's posture, the majority of clinicians in each of the three groups then chose active range of motion (AROM). However, after additional information was given, the majority of the MDT group chose repeated end range cervical movements as their next examination measure, and the FAAOMPT group varied. The majority of the FAAOMPT group continued to assess the patient through an entire examination sequence, while the majority of the MDT group discontinued testing. A descriptive analysis of the intervention sequences depicted a trend toward direction of preference (DP) exercises for the MDT group (80.3%), and passive movements or mobilization exercises for the FAAOMPT group.

CONCLUSION

The results of this study suggest that PTs with post-graduate training through the McKenzie Institute or through Orthopaedic Manual Physical Therapy (OMPT) Fellowship training may demonstrate an inherent bias toward their advanced training in the assessment and treatment of acute cervical derangement. Although no significant findings can be reported secondary to sample size limitations, future studies may be performed to further explore this topic.

Use of orthopedic manual physical therapy to manage chronic orofacial pain and tension-type headache in an adolescent

Temporomandibular dysfunction (TMD) is frequently associated with multiple headache types. While the efficacy of orthopedic manual physical therapy (OMPT) intervention for TMD with/without headache symptoms has been investigated, it has received less attention than other musculoskeletal conditions. This case describes the OMPT treatment and outcome of a 14 year-old female with a 2-year history of facial pain surrounding the right temporomandibular joint (TMJ), and bilateral occipital and temporal tension-type headaches (TTHs). Intervention included manual mobilization of the TMJ and surrounding cervical/facial soft tissue structures, postural re-education, and patient/family education on prevention, self-treatment, and postural adaptations. Outcomes included pain free and maximal mouth opening (MMO), pressure pain threshold (PPT) over the masseter muscle belly, fear avoidance beliefs questionnaire-physical activity subscale (FABQ-PA), jaw pain and function questionnaire (JPFQ), visual analog pain scale (VAS) for facial pain, and headache frequency, duration, and intensity on a VAS. Results included increased pain free and MMO by 22 mm, improved PPT bilaterally by 403.05 kPa on the affected, and 360.88 kPa on the unaffected side, and decreased reported headache frequency, duration, and intensity. Score decreases of 5 points on VAS with MMO, 8 points on FABQ-PA, and 5 points on JPFQ were also noted. Further research is warranted to investigate the effects of OMPT on pain processing and functional outcomes in patients with TMD and headache.

Treatment of shoulder pain utilizing mechanical diagnosis and therapy principles

This case report describes the effectiveness of mechanical diagnosis and therapy (MDT) in the management of a patient referred with a diagnosis of shoulder tendonitis. The patient was a 56-year-old male with a 3-month history of left anterior shoulder pain. Upon initial assessment, he presented with a positive open-can test, lift-off test, and Hawkins-Kennedy impingement test. A MDT assessment quickly ruled out cervical involvement and identified a loss of end-range shoulder mobility and pain during active shoulder movement. After the patient underwent a repeated movement examination and treatment based on responses to end-range movements over three visits, his shoulder pain was abolished and motion was fully restored. Despite having positive rotator cuff and impingement signs, this patient was effectively treated with repeated end-range movements over a short period of 2 weeks. This case demonstrates that treatment based on MDT sub-classification principles may be an effective way to manage shoulder pain as it is in the spine.