Diagnostic Approaches to Low Back Pain - Comparing Maitland, McKenzie and Movement Impairment Syndromes
Original Editor - Katherine Portas, Lea Cobham and Anj Leung as part of the Nottingham University Spinal Rehabilitation Project
Top Contributors - Kathryn Priest, Katherine Portas, Angela Hiu-Wai Leung, Kim Jackson, Lea Cobham, Lucinda hampton, Admin, Candace Goh, 127.0.0.1 and Evan Thomas
Introduction
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Physiotherapists use a range of techniques to assess and diagnose low back pain. The most commonly used in the UK are those of Geoffrey Maitland (mobilisations), Robin McKenzie (derangement, dysfunction) and Shirley Sahrmann (movement impairment). (For extensive details on each approach, please see the links above for the relevant Physio-pedia pages. A short summary will be provided for each below).
Determining which approach is best to use, in what circumstances and with which patients, can be confusing, especially for students and newly qualified clinicians. Furthermore, clinicians rarely use just one approach, and can often use these in combination with other modalities such as acupuncture or massage (Gross et al, 2010)[1].
This page aims to clarify each of the systems, to suggest their benefits and contraindications (? pros and cons - what's the long-hand of this?), and compare them using a generic case study. This will hopefully enable the reader to begin to make up their own mind, based on the evidence and the experiences of practising professionals.
Basic Concepts and Summary of Techniques[edit | edit source]
Maitland's Mobilisations[edit | edit source]
Geoffrey Maitland first described his concept of mobilisations and manipulations in 1965[2]. It is a passive mechanical approach that aims to move synovial joints ("passive arthro-kinematic motion"; literally 'joint-moving')[3] and their surrounding tissues. This can be applied both to the spine and to the extremities, with the goal of reducing pain and stiffness and restoring correct alignment and function (REF).
A mobilisation is a controlled oscillatory repeated movement of the joint (REF). Mobilisations are set at five grades, varying in amplitude of movement and force against resistance.
Grade I - Small amplitude movements at the beginning of range of movement, against no resistance (pain gating effect[4])
Grade II - Large amplitude movements, through range up to a feeling of resistance(also pain-gating effect)
Grade III - Large amplitude movements, shallowly into resistance but not to the full feeling of restricted movement
Grade IV - Small amplitude movements, deep into resistance to begin to increase the range of motion of the joint
Grade V - High velocity, low amplitude thrust to a joint, beginning at the end point of resistance of the joint with decreased range (commonly called a 'manipulation' as opposed to a 'mobilisation').
Although these grades appear quite specific, Maitland himself wrote, as recently as 2005, that adaptations to technique will always need to be made as every patient is different and presents with different symptoms[6].
Suggested sections (please comment on):
- Any controversy - In a systematic review of 27 randomised controlled trials, seeking to find whether manipulations or mobilisations had significant positive effects on pain and function, Gross et al (2010) found that any ill effects were transient and benign, such as radiculopathy, headache or localised neck pain. Incidence of stroke or serious adverse effects were not reported in any of the trials.
- Relevance, the usual patient that this suits?
- Anatomy - diagrams, pics etc to illustrate the concept?
- Pros
- Cons
- Any discussions you've found online / elsewhere that have a good debate going!
- Further resources:
- Further reading:
- References
The McKenzie Approach[edit | edit source]
Kat Portas to complete
Movement Impairment Syndromes[edit | edit source]
Lea Cobham to Complete
Suggested things to include (please add to): Anj to Complete? [edit | edit source]
- Case Study to suit and COMPARE all approaches
- interviews with proponents of each style- to gain pros and cons and interesting viewing
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
References will automatically be added here, see adding references tutorial.
- ↑ Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. ManipulationfckLRor Mobilisation for Neck Pain. Cochrane Database of Systematic Reviews 2010, Issue 1.
- ↑ Banks, K. Geoffrey D. Maitland, 1924–2010, Physical Therapy March 2010 vol. 90 no. 3 326 http://ptjournal.apta.org/content/90/3/326.full [accessed online 03/01/2014]
- ↑ Heiser R, O’Brien V, Schwartz D. The use of joint mobilization to improve clinical outcomes in hand therapy: A systematic review of the literature, 2013, Journal of Hand Therapy Vol 26, 297-311
- ↑ Dickenson, A H. Editorial I: Gate Control Theory of pain stands the test of time British Journal of Anaesthesia, 2002, Vol 88 (6): 755-757
- ↑ Maitland Mobilization Grades Available on YouTube at http://www.youtube.com/watch?v=MNVLNP18dTA [accessed 03/01/2014]
- ↑ Maitland G. Maitland's Vertebral Manipulation. 7th ed. Philadelphia, PA. Elsevier. 2005
