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, 2014). 349 patients with nonspecific low back pain of any duration were classified by 36 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: With the recent change in terminology, ‘irreducible derangements’ are now termed Mechanically Unresponsive Radiculopathies (MUR).)
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Concerning the consistency of classification over five visits, only 5.57% of Derangements were reclassified in another subcategory, mostly MUR (26.5%) and OTHER (20.6%). On the other hand, 50% of MURs were reclassified, most of them as Derangements (29.4%). The proportions by the fifth visit are shown below:
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For Derangements, extension was the most frequent DP (79.5%), followed by lateral (15.1%). A DP for flexion was observed in only 5.4%. During the initial visit, centralization was observed in 50.1% and partial centralization in 20.3%.
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 26.5%. The authors describe a total of 24 such changes; the most common change was from a DP for pure sagittal extension to a DP for extension with hips off center (18.7%). In 9.9% no DP changed to a DP for extension, and conversely, in another 9.9% a DP for extension changed to no DP.
Concerning the prevalence of centralization, by the fifth visit, the breakdown is shown below:
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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.