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A 36-year-old male construction worker self-referred to an outpatient physical therapy clinic with a complaint of low back pain and pain radiating from his posterior left hip all the way to his lateral foot. He first experienced pain 3 weeks ago while doing a home maintenance project. The onset of pain occurred when he attempted to lift an air conditioning unit. He reports that as he bent over to lift the unit, he experienced an intense, stabbing pain and immediately fell to the ground. He required assistance from his wife to walk back into the house. For the first 24 hours after the incident, he rested prone on a couch or on his bed. Over the past 3 days, he reports an improved tolerance to walking and standing for short periods. However, he rates his current pain level 5 out of 10 on the visual analog scale and he continues to experience radiating pain distal to his knee. Signs and symptoms are consistent with a lumbar herniated disc. His goal is to return to work as soon as possible.

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Based on the patient's suspected diagnosis, what do you anticipate may be the contributing factors to his condition?

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What examination signs may be associated with this diagnosis?

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What are the most appropriate physical therapy interventions?

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What are possible complications that may limit the effectiveness of physical therapy?

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CENTRALIZATION: Phenomenon in which distal limb pain emanating from the spine is immediately or eventually abolished in response to deliberate application of loading strategies; peripheral pain progressively retreats in a proximal direction, sometimes associated with simultaneous development or increased proximal pain; centralization is described by McKenzie1 to occur in the derangement syndrome

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DIRECTIONAL PREFERENCE/MECHANICAL DIAGNOSIS THERAPY: Preference for postures or movement in one direction (characteristic of the derangement syndrome); describes when postures or movements in one direction decrease, abolish, or centralize symptoms and postures or movements in the opposite direction often cause symptoms to worsen1

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LOADING STRATEGIES: Dynamic or static movements, positions, or loads applied in order to stress particular structures; dynamic loads are repeated movements and static loads are sustained postures; significant loading strategies, postures, and repeated movements are those that alter symptoms1

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  1. Understand the anatomy of the lumbar disc and its mechanical response to different directional movements of the spine.

  2. Describe the McKenzie or Mechanical Diagnosis and Therapy (MDT) classification system.

  3. Describe the McKenzie evaluation process and how the objective findings determine the classification system of the syndromes.

  4. Describe how the objective findings from the examination determine the treatment approach for the syndromes.

  5. Prescribe appropriate interventions for each phase of the condition—from acute injury to full restoration of function.

  6. Describe the evidence for the efficacy of using the McKenzie approach in the treatment of lumbar spine disorders.

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