Summary and Perspective of Recent Literature
This prospective multi-center study assessed the prevalence of Derangement, Dysfunction, Postural Syndrome, OTHER subgroups, Centralization and Directional Preference (DP) as well as their consistency over five visits (Otéro & Bonnet, 2016). 293 patients with nonspecific neck pain of any duration were classified by 34 Certified MDT therapists working in a variety of clinical settings in France.
At the initial visit, the proportion classified is shown below. As can be seen, the proportion of patients classified as Derangement is encouragingly high, despite the fact that more than 40% of the patients had a history of greater than three months. (Note: the ‘Irreducible Derangements’ (now known as Mechanically Unresponsive Radiculopathies) found in the study are included in the OTHER category).
For Derangements, Extension was the most frequent DP at 83.6%. Of these, 49.2% were Retraction responders, 31.6% Retraction-Extension, and 2.7% Extension responders. A lateral principle was reductive in 13.7% and a DP for flexion was observed in only 2.7%.
During the initial visit, Centralization was observed in 52.9% and ‘partial’ Centralization in 21.9%.
Concerning the consistency of classification over five visits, only 3.51% of Derangements were reclassified in another subgroup, mostly OTHER subgroups (77.77%). On the other hand, 34.28% of OTHERs were reclassified, all of them as Derangements. The proportions by the fifth visit are shown below:
For the consistency of observation of DP, the overall prevalence rates varied only marginally over the five visits. However, the DP changed from one spinal movement to another in a total of 41.4%. The authors describe a total of 23 such changes; the most common change was, in fact, a progression (rather than a change in direction) from Retraction to Retraction-Extension (38.8%) and then there was a change from Retraction to Lateral Flexion (10.7%). In 9.9%, no DP changed to a DP, and, conversely, in another 5.8% with a DP changed to no DP.
Concerning the prevalence of centralization, by the fifth visit, the breakdown is shown below. The incidence of Centralization changed between the 1st and the 5th visit from 52.9% to 76%.
So, what are the implications for the MDT clinician? While this study confirms the prevalence rates observed in other studies, the prevalence rates of the various reclassifications and their detailed descriptions adds interesting new information to the current literature and informs clinical practice. It substantiates the importance of continuous re-assessments in order to confirm a provisional diagnosis and to guide management. Indeed, clinicians should not hesitate to test and confirm appropriate management over a few visits in order to thoroughly assess challenging clinical presentations.
The most compelling finding, though, is the overwhelming proportion of Derangements reported and the large percentage of those that demonstrate Centralisation. The implications are clear; most patients with neck pain who see a MDT clinician, have the potential to treat themselves with simple end range exercise and the prognosis is excellent.
Our inclination is to think that these patients will respond to Directional Preference exercises and posture correction better than to any other intervention, but we desperately need trials to confirm or contradict this inclination. In the meantime, surveys like this give us some encouragement that we can provide simple solutions to the majority of our patients in the hope that it will empower them to manage current and future episodes.