The use of Mechanical Diagnosis and Therapy (MDT) in patients with lower urinary tract symptoms (LUTS): case series

Inter-rater reliability of Mechanical Diagnosis and Therapy (MDT) in evaluating and classifying chronic pelvic pain syndrome

INTRODUCTION

Chronic pelvic pain syndrome (CPPS) involves complex interactions between the musculoskeletal system, nervous system, and psychosocial factors. A major challenge in managing CPPS is the lack of reliable assessment and classification systems. The Mechanical Diagnosis and Therapy (MDT) is a widely used and reliable classification system for assessing and managing painful musculoskeletal conditions affecting the spine and extremities. This study's primary objective was to assess the inter-rater reliability of the MDT assessment in diagnosing CPPS using clinical vignettes. Secondary objectives included determining the prevalence of MDT classification categories.

METHODS

Five MDT clinicians classified clinical vignettes into three categories: 1) Spinal Derangement, 2) Pelvic Floor Contractile Dysfunction, or 3) MDT OTHER subgroups. The vignettes were developed from the McKenzie Pelvic Pain Assessment Form. Inter-rater reliability among clinicians was calculated using the Fleiss kappa statistic with 95% confidence intervals, and Cohen's kappa examined reliability between pairs of raters.

RESULTS

A total of 76 vignettes were developed (40 females and 36 males). Good inter-rater reliability was found among clinicians (Fleiss kappa = 0.616, 95% CI = 0.598-0.633, p < 0.001). Inter-rater reliability was higher when classifying female vignettes (Fleiss kappa = 0.658, 95% CI = 0.634, 0.682) than male vignettes (Fleiss kappa = 0.546, 95% CI = 0.519, 0.573). The most common classification was Spinal Derangement (57%), followed by MDT OTHER subgroups (26%) and Pelvic Floor Contractile Dysfunction (17%).

CONCLUSIONS

The study indicates good inter-rater reliability among MDT clinicians in classifying pelvic pain syndrome. However, clinical vignettes may not fully capture the complexities of real participant interactions, potentially inflating agreement. Future studies should incorporate direct observation of real participant encounters alongside clinical vignettes to improve validity.

A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

BACKGROUND

Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms.

CASE DESCRIPTIONS

Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated.

OUTCOMES

Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management.

DISCUSSION

These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into 'Mechanical Pelvic Syndrome' is proposed. Level of Evidence: 4.

Centralization and directional preference: An updated systematic review with synthesis of previous evidence

BACKGROUND

Centralization and directional preference are common management and prognostic factors in spinal symptoms.

OBJECTIVE

To update the previous systematic review.

DESIGN

Systematic review to synthesis multiple aspects of centralization and directional preference.

METHOD

Contemporary search was made of multiple databases using relevant search terms. Abstracts and titles were filtered by two authors; relevant articles were independently reviewed by two authors for content, data extraction, and quality.

RESULTS

Forty-three additional relevant articles were found. The quality of the studies, using PEDro for randomized controlled trials, was moderate or high in six out of ten RCTs; moderate or high in six out of 12 cohort studies. Prevalence of centralization was 40%, the same as the previous review. Directional preference without Centralization was 26%; thus Centralization and directional preference combined was 66%, which was very similar to the previous review. Neither clinical response was recorded in about a third of patients. Centralization and directional preference were confirmed as key positive prognostic factors, certainly in patients with low back pain, but limited evidence for patients with neck pain. There was no evidence that these might be important treatment effect modifiers. One study evaluated reliability, and found generally poor levels, despite training.

CONCLUSIONS

Centralization and directional preference are worthwhile indicators of prognosis, and should be routinely examined for even in patients with chronic low back pain. But they do not occur in all patients with spinal problems, and there was no evidence that they were treatment effect modifiers.