Directional preference of the extremity: a preliminary investigation

Cervical contribution in musculoskeletal shoulder pain. A review of the literature

Shoulder pain is the third most common cause of musculoskeletal pain and the primary cause of non-traumatic pain in the upper limb. Accurately diagnosing this condition remains a challenge for clinicians due to the lack of consistency and uniformity in the existing diagnostic labelling and the criteria used. In this regard, current scientific evidence does not consistently support pathoanatomical models, as imaging tests and orthopaedic examinations might not provide relevant information for diagnosing shoulder pain. Therefore, it may be necessary to carry out subclassification-based diagnosis of patients who share reliably reproducible characteristics. In this context, shoulder pain might be, at least, partially attributed to a cervical contribution. Nevertheless, this potential diagnosis is poorly considered and often misdiagnosed in clinical practice. This might lead to an erroneous decision-making process and poor patient management, compromising both treatment and prognosis. Consequently, this review presents the neurophysiological, biomechanical and clinical reasoning-related characteristics that justify the pertinence of the cervical contribution in musculoskeletal shoulder pain.

Cervical Spine Screening Based on Movement Strategies Improves Shoulder Physical Variables in Neck-Related Shoulder Pain Patients: A Secondary Analysis from an Observational Study

Background: It is important to consider the cervical spine as a potential contributor to shoulder pain, indicating the paramount importance of screening the cervical spine in patients with shoulder pain. Objectives: To study the immediate effects of cervical spine screening (CSS) on the shoulder active range of motion, isometric strength and self-reported function in patients with neck-related shoulder pain. Methods: A secondary analysis was conducted on data from a previous study. A cervical contribution was considered if a ≥30% shoulder symptom modification of pain intensity (Numeric Pain Rating Scales) was recorded during the most painful shoulder movement after CSS. Pre-post measurements of the shoulder active range of motion (inclinometer) and shoulder isometric strength (dynamometer) were recorded in a single session. Self-reported shoulder function (Shoulder Pain and Disability Index) was assessed at a 1-week follow-up. Results: Among 60 participants, statistically significant changes were found for those with a cervical contribution (n = 30) for shoulder flexion and the abduction range of motion (p < 0.001), with a medium size effect (r = 0.55), and in internal rotation (p = 0.02) and external rotation at 0° abduction (p = 0.008), with a small size effect (r = 0.3 and 0.34, respectively). The self-reported shoulder function in those without a cervical contribution significantly declined from the pre to post measurements (p = 0.002), with a small size effect (r = 0.4). No statistically significant changes were found for the isometric strength in either group. Conclusions: In patients with shoulder pain classified as having a cervical contribution, CSS produces intrasession improvements in the active shoulder range of motion but not in the shoulder isometric strength or self-reported shoulder function.

The application of directional preference for chronic non-specific knee pain: A pragmatic, controlled, randomized clinical trial

Functional disability and chronic knee pain are frequent in combats sports participants. The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a system for specific function examination and intervention for spinal and extremity musculoskeletal disorder. This clinical trial aimed to investigate the effectiveness of MDT, through Directional Preference, for specific function disability in Brazilian Jiu-Jitsu practitioners (BJJPs) experiencing chronic non-specific knee pain.

METHODS

Sixty-five BJJPs with chronic non-specific knee pain were evaluated and classified according to the MDT system. Following classification, 28 BJJPs were randomized pairwise into intervention (IG) and control (CG) groups. The procedures were consistent with the principles of DP and the intervention period was 6 weeks and follow up was included. The primary outcome was specific functional disability evaluated using the Patient Specific Function Scale (PSFS) and the secondary outcomes were pain intensity and fear-avoidance in utilizing the symptomatic limb. Data were analyzed with a two-way analysis of variance (ANOVA) and repeated measures for the outcome factor were performed (p < 0.05).

RESULTS

For the specific functional disability, ANOVA revealed significant differences between groups based on group interaction and treatment factors (F (2, 52): 162,015; p < 0.001; η2: 0.208). The BJJPs allocated to the IG achieved significant improvements in specific functional disability, a mean difference of -4.36 (-5.01 to -3.72) post-interventional and -4.80 (-6.07 to -3.53) follow-up in the PSFS. Improvements in pain intensity and fear-avoidance were also achieved post-intervention and follow-up.

CONCLUSION

Intervention in accordance with DP promoted resulted in favorable outcomes for clinical effects on specific functional disability pain intensity, and symmetry index of the lower limbs. These findings suggest that intervention based on DP may be effective in the management of chronic knee pain in BJJPs.

The influence of directional preference on lateral patellar dislocation: a case report

BACKGROUND

There is little consensus on the conservative management of lateral patellar dislocations (LPD). Mechanical diagnosis and therapy (MDT) is an established classification system in the spinal and extremity population. This case report describes the use of MDT in the management and classification of a patient with LPD.

CASE DESCRIPTION

The patient was a 20-year-old female with a 3-month history of left knee pain precipitated by a lateral patellar dislocation. The patient described pain and a feeling of instability with standing and walking and limitations in work and recreational activities which involve lifting, squatting, and running. Based on the patient's response to repeated end range knee movements, the patient was found to have a directional preference (DP) for knee extension and instruction in performance of knee extension DP exercises was provided.

OUTCOMES

The patient's knee examination and subsequent intervention included her responses to repeated end range knee movements. Her knee pain was abolished, and strength, function, and motion were fully restored in five visits. A minimal clinically important difference (MCID) was achieved on the Lower Extremity Functional Scale (LEFS). At discharge, the patient was able to independently manage symptoms and perform all work and recreational activities at a pre-injury level and these improvements were maintained at a 9-month follow-up.

DISCUSSION

There are various management strategies for lateral patellar dislocation. This case demonstrated the use of classifying, subgrouping, and treating a patient with lateral patellar dislocation using the principle of DP.

CONCLUSION

The patient's outcomes suggest that MDT may be used in the nonoperative management of people with LPD who present with a DP.

Exploring indicators of extremity pain of spinal source as identified by Mechanical Diagnosis and Therapy (MDT): a secondary analysis of a prospective cohort study

OBJECTIVE

To explore indicators that predict whether patients with extremity pain have a spinal or extremity source of pain.

METHODS

The data were from a prospective cohort study (n = 369). Potential indicators were gathered from a typical Mechanical Diagnosis and Therapy (MDT) history and examination. A stepwise logistic regression with a backward elimination was performed to determine which indicators predict classification into spinal or extremity source groups. A Receiver Operating Characteristic (ROC) curve was constructed to examine the number of significant indicators that could predict group classification.

RESULTS

Five indicators were identified to predict group classification. Classification into the spinal group was associated with the presence of paresthesia [odds ratio (OR) 1.984], change in symptoms with sitting/neck or trunk flexion/turning neck/when still (OR 2.642), change in symptoms with posture change (OR 3.956), restrictions in spinal movements (OR 2.633), and no restrictions in extremity movements (OR 2.241). The optimal number of indicators for classification was two (sensitivity = 0.638, specificity = 0.807).

DISCUSSION

This study provides guidance on clinical indicators that predict the source of symptoms for isolated extremity pain. The clinical indicators will allow clinicians to supplement their decision-making process in regard to spinal and extremity differentiation so as to appropriately target their examinations and interventions.

Shoulder Pain of Spinal Source in the Military: A Case Series

Musculoskeletal injury (MSI) presents the greatest threat to military mission readiness. Atraumatic shoulder pain is a common military MSI that often results in persistent functional limitations. Shoulder orthopedic evaluation presents many diagnostic challenges, due in part to the possibility of a spinal source of symptoms. This case series outlines the use of mechanical diagnosis and therapy to screen the cervical and thoracic spine in active duty (AD) service members (SMs) with a chief complaint of unchanging or worsening shoulder pain. All three SMs previously received shoulder-specific diagnoses from experienced clinicians, yet repeated movements revealed a possible spinal nociceptive driver that guided targeted intervention. Treatment directed only at the cervical spine resulted in a clinically important improvement within an average of 10 days from the initial evaluation, return to duty (RTD) within an average of 32 days, and continued resolution at 3 months. SMs can independently complete the screening process with guidance from healthcare providers, ultimately shaping the treatment strategy and possibly facilitating self-management of future recurrence. This case series demonstrates that identification of shoulder pain of spinal source in the military population may be an important step in facilitating timely RTD. These cases also highlight the use of a standardized, systematic method to screen the cervical and thoracic spine that concurrently reveals the indicated treatment. Further research to determine the prevalence of shoulder pain of spinal source in the AD population and its impact on RTD rates has the potential to reduce the substantial burden of MSI in the military.