Directional Therapy Works, But How Do You Explain This to Patients
Directional therapy is an evaluation and treatment strategy that was initially employed by physical therapists. However, due to the abundance of research and reproducible clinical results, directional therapy has become more popular and has transcended to multiple professions. Chiropractic utilization has grown to a point requiring its own branch within the McKenzie Institute.
Evidence-Based practitioners recognize the importance of CLASSIFYING mechanical joint disorders before applying a treatment or exercise prescription. All evidence-based chiropractors must first understand WHAT tissue is injured and WHY it was injured regardless of our technique or evaluation process. Classification allows for a reproducible identification of WHAT and WHY.
Watch Dr. Steele explain why patients respond to directional therapy exercises.
Directional preference therapy is commonly associated with the treatment of disc lesions, however, classification of low back pain is not specific to any single diagnosis and is also useful for stenosis, degeneration, spondylolisthesis, facet syndrome, intersegmental joint dysfunction, and others.
One of the key tenants of directional therapy is to determine if symptoms centralize or peripheralize upon repeated end range loading. Centralization is the retreat of radiating complaints in a proximal direction, while peripheralization describes an increase or progression of distal symptoms. Centralization suggests recovery, while peripheralization indicates that the condition is being aggravated.
Radicular symptoms in the lower extremity will typically respond to either extension or flexion exercises, but not usually both. (Playing the averages, most younger patients centralize with simple extension exercises when classified with a derangement syndrome.)
Directional exercises and postures may impact the position of the nucleus pulposus. A paper by Takasaki et al. 2010 demonstrated the shift in the nucleus through directional therapy treatment (i.e. extension squished the nucleus forward). (1) But new information has created doubt in the theory of nucleus migration via directional therapy treatment and exercises. Abdollah V, et al. (2018) found:
“Little evidence was found supporting the hypothesis that press-up exercises affect disc fluid content and distribution. Novel parameters reflecting fluid distribution detected similar or larger effects of the extension than MSI. (Mean Signal Intensity) If such exercises are effective in reducing symptoms, it is likely through other mechanisms than by changing fluid content or distribution.” The anterior shift of the signal intensity observed with extension at the L4-5 level in our study likely indicates a more fluid concentration in the anterior part of the disc after the exercises. This was consistent with our hypothesis that extension increases the pressure on the posterior part of the disc and drives fluids anteriorly.” (2)
How do you explain this new information to patients?
Most patients do not understand clinical terms and are unfamiliar with the anatomy of the lumbar spine. The process of educating patients must be short, clear, and concise so they can relay that information to their family, friends and other healthcare providers.
Research drives the vast majority of treatments provided in chiropractic offices. There has been a positive trend in chiropractic schools over the last several years to promote evidence-based learning leading to a new generation of chiropractors focused on one goal – resolving complaints efficiently and effectively. This mission requires a toolbox of evaluations and treatments because every patient is a case study of one.
Evidence-based chiropractors are challenged with providing world-class care for every patient on every visit. Treatment has evolved from solely spinal manipulation to a multifaceted approach that crosses professional lines to incorporate whatever is best for the patient. Depending on the patient presentation and goals, there is utility for spinal manipulation, directional therapy, exercises, injections, surgeries, medications, nutritional advice, and more. The modern chiropractor must know the right treatment for the right patient at the right time.
We do not typically include opinions on this blog, but…. we highly recommend learning more about McKenzie Directional Therapy (MDT). And our recommendation is supported by research, including recent clinical practice guidelines (3) that endorse directional preference testing for the differential diagnosis of LBP (specifically to help rule in disc lesions and to rule out facet complaints). McKenzie classes provide invaluable information, transformative patient results, and a better understanding of the difference between pathoanatomical and pathophysiologic sources of pain. Learn more about the chiropractic division of MDT here. * ChiroUp is an unpaid and formally unaffiliated promoter of this widely accepted system.
As always, you check out ChiroUp.com to review more up-to-date research on patient education, rehabilitation, and treatment techniques. ChiroUp is developed and maintained by practicing chiropractors. We are dedicated to helping evidence-based chiropractors become the vocal majority. Learn more HERE.
- Hiroshi Takasaki Et al. Nucleus pulposus deformation following application of mechanical diagnosis and therapy: a single case report with magnetic resonance imaging. J Man Manip Ther. 2010 Sep; 18(3): 153–158.
- Abdollah V, Parent EC, Battié MC. MRI evaluation of the effects of extension exercises on the disc fluid content and location of the centroid of the fluid distribution. Musculoskelet Sci Pract.2018 Feb;33:67-70. https://www.ncbi.nlm.nih.gov/pubmed/29180112
- Peterson T, Laslett M, Juhl C. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskeletal Disorders. May 12, 2017, 18:188