This was a secondary analysis of a prospective, observational cohort study. The current study examined the directional preference (DP) framework used by MDT practitioners with cervical spine patients in routine clinical practice. Its aim was to investigate the presence of DP constructs in the absence of centralization in this particular patient population, and determine the association between DP constructs and clinical outcomes (pain intensity (NPRS) and NDI score) at discharge.

Spinal DP with/without centralization represent distinct diagnostic categories, with differences in prevalence and prognostic validity. No studies to date have investigated the criteria used to establish a spinal DP without the presence of centralization with regard to outcome.

Data was collected from 718 consecutive patients with complaints of neck pain. Inclusion criteria: non-specific neck pain +/- radiation into the upper extremities, with classification of “DP, non-centralizing” or “DP non-classifiable”. Of those who met inclusion criteria (384), there was a 97% completion rate for those completing first assessment data collection, and a 54% completion rate for those who completed first assessment and discharge data. Patients with younger age and less health insurance were cited as primary reasons for the lower completion rate. All 10 clinicians collecting data had advanced training (certified MDT or diploma MDT). Average time to discharge was 35 days.

DP was considered present at the time of assessment if any of the following occurred. Prevalence of these findings at assessment:
1. reduction in the most distal pain by 2+ points -15%
2. increase in cervical ROM (bubble inclinometer utilized) - 32.5%
3. patient reported improvement in ROM – 79.5%
4. improvement in neuro signs – 6%
5. improvement in pain with functional task by 2+ points – 5%
**Constructs #4 and #5 were not analyzed further due to the unexpected low occurrences

The DP constructs were developed through focus group meetings with certMDT and DipMDT practitioners, all working in Certified McKenzie clinics. The framework for DP constructs was adopted from McKenzie.

The effects of DP constructs on disability and pain intensity at discharge were analyzed. All DP groups met the MCID for disability change, and all DP groups met the MCID for pain intensity change except for the group that did not show an increase in cervical ROM. No statistically significant difference in disability change or pain intensity change was observed between the groups.

Cervical spine ROM analysis revealed 28.5% of patients exhibiting an increase into extension, and 6.5% of patients exhibiting an increase into flexion post repeated movements at first assessment. Statistically significant differences existed between the cervical spine extension groups for differences in pain, and between the cervical spine flexion groups for differences in disability. The author advises interpreting with caution on the latter, as the number of patients observed with flexion groups was quite low.

Take Home Messages for the McKenzie clinician assessing patients with cervical spine pain in the absence of centralization:

1. The most prevalent DP constructs at assessment included (a) patient reported improvement in ROM (b) increase in spinal ROM (c) pain intensity change.
2. All DP groups improved and met MCID for pain and disability except those not demonstrating an increase in ROM (re: pain intensity improvement only) at the time of assessment
3. There was no DP construct demonstrating a clinically significant difference in either pain intensity or disability at discharge. This would indicate that each construct is comparable within the patient’s treatment, exhibiting similar outcomes at discharge with regard to pain and disability. The author suggested possible further investigation to determine if particular constructs were associated with more rapid improvements in outcomes at particular time points within the treatment plan.
3. The MDT paradigm with regard to DP aligns quite closely with this study’s constructs of pain and ROM, including not only the measurement of ROM but also the patients reported reduction in pain during ROM, which was the most common construct reported in this study.
5. A consensus on a comprehensive set of DP constructs has not been met, but with ongoing research, developing this would be beneficial for all practitioners utilizing this method regularly. This study outlined the common DP constructs that will be seen in clinical practice (referenced in first point above), and their relationship to outcomes at discharge of pain intensity and disability this patient population.

Cervical: Observational studies