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RE: Extension exercices in geraitric population
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RE: Extension exercices in geraitric population - April 18, 2008 7:02:03 AM
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rwillcott
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supender,
There is plenty of evidence to support the use of a treatment based classification system and the use of directional preference.
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RE: Extension exercices in geraitric population - April 18, 2008 10:46:53 AM
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ptim
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supender
In the majority of cases, directional preference is determined by centralization.
Centralization occurs in the majority of patients, and has plenty of evidence to support it
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RE: Extension exercices in geraitric population - April 18, 2008 12:39:19 PM
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cclem2000
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Why do we have to assume that these pts are stenotic because of their age? I agree with the posters who go through a mechanical eval and look at subjective/objective throughout with continuous reassessment
In one of my McKenzie courses, the insructor noted that he finds a good many "older" people who have actually been responding to extension in standing over a fulcrum (i.e treatment table)
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RE: Extension exercices in geraitric population - April 18, 2008 1:09:59 PM
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TexasOrtho
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quote:
ORIGINAL: ptim
supender
In the majority of cases, directional preference is determined by centralization.
Centralization occurs in the majority of patients, and has plenty of evidence to support it
Really? I'm pretty suprised at this statement. I am no McKenzie specialist by any stretch so my definition may be different than yours, but I have found centralization as I've seen it defined to be a rare phenomenon in certain populations. I would like to see your evidence to support this statement.
I do agree with the concept of directional preference, but I have used it in the context of intensity and location of symptoms as opposed to centralization alone. I am probably just fuzzy on the true McKenzie definition of centralization however and just mincing words again.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Extension exercices in geraitric population - April 18, 2008 2:13:12 PM
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jesspt
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I can't say that I agree that centralization occurs in the majority of cases. From my understanding of the phenomenon, in order for centralization to occur, a patient needs to have distal symptoms, and I don't see that many LBP patients who have symptoms distal to the gluteal fold. Those who do have distal symptoms do seem to exhibit the phenomenon a fair bit, but I still don't think I see it as often as some of my colleagues have told me they experience in their caseload. Of course, this could just be differences in our patient population.
If anyone has a few spare hours, they can peruse a thread over at MyPhysicalTherapyspace:
http://myphysicaltherapyspace.leveragesoftware.com/group_discussion.aspx?DiscussionID=9be327d581834d9a85d985df8946d91c
It hashes out, Ad infinitum, the McKenzie method, the liklihood of the disc as a pain generator, and also goes over the definitions of directinal preference and centralization.
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Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
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RE: Extension exercices in geraitric population - April 18, 2008 4:28:40 PM
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ptim
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Rod
Audrey Long et al; Does it matter which exercise? Spine 2004, found directional preference in 74% of subjects, acute, subacute and chronic
Aine et al; Manual Therapy 2004 70% prevelence in sub-acute and 52% chronic
Donelson, Spine 1990, 87% prevelence(acute-chronic)
Sufka et al; Jour. Ortho sport 1998 70% prevelence
Werneke et al; several studies showing the majority of patients demonstrate centralization.
The common theme is using MDT trained therapist.
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RE: Extension exercices in geraitric population - April 18, 2008 6:55:17 PM
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TexasOrtho
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I'll need to take a look at those articles. I'd like to see what common characteristics there are in the roughly 30% who do not demonstrate centralization. The majority of patients I see demonstrate directional preference regardless of age, but the concept of centralization as I've seen it defined, occurs more in younger populations. There was a recent article in JOSPT (I believe) which supports this observation.
I'm not a MDT trained therapist, so that must be the missing link. 
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Extension exercices in geraitric population - April 18, 2008 8:07:31 PM
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jlharris
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That's a good question. ptim, you seem to use "centralization" and "directional preference" interchangably. Is this the way MDT uses it? In my mind, centralization in reduction of symptoms distal to proximal and directional preference has more to do with movement preference which may or may not include centralization.
Again, like Rod, I'm not MDT trained so don't have all the insights you (or other MDT gurus) may have.
Thanks.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Extension exercices in geraitric population - April 18, 2008 10:14:58 PM
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TexasOrtho
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Ptim. I just looked at the most recent Werneke article in JOSPT (March 2008). In this study, he found centralization prevalences of 15% and 17% respectively for cervical and lumbar cases out of a total of 418 cases. The highest prevalence of centralization was 31.9% in the 18-44 age range. Lower prevalence rates were seen in patients between 65-74 (8.3%) and >75 years of age (1.3%). Chronicity of symptoms also played a role in determining centralization. This does not support your statement that centralization occurs in the majority of cases.
The two therapists performing the assessments were MDT trained (one diplomat and one credentialed). It seems that even those adequately trained may not observe the centralization phenomenon that frequently. This data is consistent with my observations in the clinic.
An interesting finding was that patients who did demonstrate centralization reported lower pain scores at discharge than those who didn't. I need to read more into Werneke's explanation of this, but there could be a few plausable explanations.
Bottom line for me: The use of centralization may not be an appropriate assessment or outcome measure for older adults.
With some varation of course, I have observed that older patients have more of a directional preference away from loading the posterior elements of the spine (ie flexion). This would seem to be consistent with the physiologic changes we often see in this population.
Werneke MW et al, (2008). Centralization: Prevalence and Effect on Treatment Outcomes Using a Standardized Definition and Measurement Method. Journal of Orthopedic and Sports Physical Therapy, 28(3), 116-125.
< Message edited by TexasOrtho -- April 19, 2008 12:22:24 AM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Extension exercices in geraitric population - April 20, 2008 9:37:29 AM
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supender
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ptim,Thats what I wish to say directional preference and centralization principles are often confused with each other.Lack of standardised operational definition has been one of the causes of vastly different prevalence rate(17% to 89%),MDT or no MDT.I even think having a subgroup of specific exercise by directional preference and specific exercise by centralization in the TBC and studying otcome would also optimise our practice.
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RE: Extension exercices in geraitric population - April 21, 2008 8:49:43 AM
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Shill
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From: Madison WI USA
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In skimming this study, what is interesting to me is that so far, they analyze only abolition of distal symptoms, not necessarily improvement in distal symptoms. It is my clinical experience that on the way to abolition, there is often improvement. Perhaps monitoring for improvement, on the VAS should be considered, as opposed to pure abolition.
"Based on available data, the systematic review concluded that documentation of centralization should focus on (1) measuring changes in pain location observed during physical examination without consideration of symptom intensity and (2) measuring changes in pain location using pain diagrams and a numeric overlay template tool."
To me, this does not make much sense, and could explain the 17% prevalence. However, I would actually expect the prevalence to be lower than 17% if abolition were the sole requirement needed for centralization. Location is crucial, but intensity is not irrelevant.
I may back track as I read on...
Nope. No backtracking.
"The operational definition of centralization required a reduction in
pain location score of at least 1. If pain location score increased or remained
the same after repeated movement tests, the pain response noncentralization was recorded."
The location score increasing should indeed be a non-centralizing finding, but a lack of location improvement, again in what I think is most clinically applicable, may not necessarily be a non-centralizing occurrence. Symptoms could improve from a 9/10 to a 1/10, and would still be classified as non-centralizing. I truly believe, in case it isnt obvious, that realistically, expecting abolition for grouping is non-optimal. This is where the definition confusion needs to be hashed out, as tossing in the towel or changing approaches when intensity drops, but location has yet to change seems quite silly.
< Message edited by Shill -- April 21, 2008 9:08:25 AM >
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Steve Hill PT
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RE: Extension exercices in geraitric population - April 21, 2008 11:39:40 AM
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ptim
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Rod
I've not had a chance to look at Werneke's recent study yet, did he give an explanation as to why their prevelence was lower than the other studies? I'm interested to see his operational definitions and methodology within this study.
As for my previous statement, I'll rephrase it, I see directional preference in the majority of these patients, less than the younger population, but still present.
As to which direction, I still see more patients with a DP of extension than flexion, though again less than the younger population. I think too many therapists either assume extension will not be beneficial or do not appropriately explore it, too far to fast, or not reading the symptom/mechanical response to this direction correctly and then abandoning it.
Jason
Centralization is purely a symptom response to loading, movement/aboliton of most relevant symptom form distal to proximal.
Directional preference is the direction that produces centralization, though is not dependent on it. DP may be determined by improved mechanical response to loading and therefore DP would be seen more frequently than centralization.
Supender
Operational definitions are one of the big issues, I think every other author uses a slightly different definition, and therefore you see varience even within the MDT community.
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RE: Extension exercices in geraitric population - April 21, 2008 7:13:20 PM
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TexasOrtho
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Steve. That is a really good point. I need to investigate that further. I guess it does go back to the operational definition of "centralization". You'd have to think, with your more inclusive definition of centralization, the prevalence of would most likely have gone up.
Ptim. I'm going to read the article more closely tonight and I'll get back to you on Werneke's explanations. I get what you are saying about directional preferences and we seem to agree. As with many of these types of discussions, it does help to be all on the same page with respect to defining these phenomenon. I think Steve brings an exellent point into the discussion about severity and location of symptoms. Not being MDT certified, I would not have picked up on that.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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