Introduction
Mechanical Diagnosis and Therapy (MDT) utilizes the symptomatic and mechanical responses to loading strategies to determine treatment. We often speak of force progressions to achieve reduction, but at times, doing so is a disservice to the patient. A client's involvement is not only key to reduction, but is essential for their understanding of how to prevent and deal with future occurrences. Robin McKenzie claims that a client can, with proper guidance, achieve resolution of the condition, while avoiding therapist dependence.

If there is the slightest chance that a patient can be educated in any method that enables him to reduce his own pain and disability using his own understanding and resources, he should receive that education. Every patient is entitled to the information, and every therapist should be obliged to provide it (McKenzie 1989).

This case study describes the use of patient education, coupled with an MDT assessment to reduce a Lateral Shift Deformity. Please refer to the completed assessment form.

Case
A 76 year old male presented to the clinic with a three week history of intermittent symptoms into the left back/thigh following bowling. He reported being unable to fully stand erect or walk any significant distance. His prescription stated "Spinal Stenosis" and he reported having two total knee replacements that had not been fully rehabilitated. No other significant health findings were indicated. The client demonstrated an antalgic gait and a visually significant Right Lateral Shift Deformity. Attempts at correction of the shift in standing were unsuccessful, but the client noted a decrease in symptoms, as well as, the ability to ambulate further, following sustained Right Rotation in Flexion. The client was educated on the centralisation phenomenon and the importance of adjusting position in response to the most distal symptom. An initial exercise program of sustained Right Rotation in Flexion for 5-10 minutes every hour was instructed.

At follow-up 48 hours later, the client noted that walking had improved significantly. He was still unable to perform standing shift correction, but could now lie prone without increased symptoms. Attempts at achieving further extension in lying resulted in a Produce or Increase/No Worse response. Various alternate loading strategies and therapist techniques were attempted without success.

The client was educated that a temporary increase in symptoms was acceptable, as long as the distal symptoms did not remain worse as a result, or peripheralise. He was also informed that the ultimate goal of correction of the shift would be achieved through full restoration of extension. He was, therefore, encouraged to continue Right Rotation in Flexion, as needed, and to increase time lying prone in extension. The client was informed of the expectation that a temporary increase of symptoms would occur and to follow the rules on symptom response at all times.

Four days later, the client returned noting that he was now able to lay prone on elbows, without aggravating his symptoms. He reported that the first couple of days created a temporary Increase but No Worse response, but he persisted since this was an acceptable response.

He was very happy to find that he could work further toward extension in lying. We reviewed acceptable symptom responses and the goal of achieving full extension. Self-correction of lateral shift in a doorway was now tolerable, although he was only able to initiate performance in some degree of lumbar flexion. The client was sent away with attempting further extension in lying with the use of pillows (the client was unable to perform REIL secondary to an unrelated shoulder injury) and exploration of lateral shift correction in a doorway. He was encouraged to focus on achieving full overcorrection of his shift before attempting to perform lateral shift correction in more extension.

Upon each visit, the client was able to demonstrate the ability to gain further range without aggravation into movements that, at his prior visit, either resulted in an increase or peripheralisation of symptoms. Therapist techniques were unsuccessful with reduction. The client was routinely educated on the expected symptomatic responses, the appropriate adjustments in the loading strategy, and the performance of his exercise as the most therapeutic intervention. By the third visit, he was able to initiate self-correction of lateral shift in a doorway with slight adjustments in hip angle and by the fifth visit he was able to perform REIS, without increasing symptoms. At that time, he was further educated on the importance of maintaining lordosis, achieving end-range extension throughout the day, and ensuring that he could perform pain free SGIS to the Left several times a day. He continues to demonstrate a slight Right Lateral Shift, but it is no longer relevant and he has begun a restoration of function program in the gym to address his bilateral total knee replacements and secondary right shoulder condition (a derangement that is responding very well to patient produced forces).

Discussion
This case demonstrates that, in this instance, a significant lateral shift deformity with multiple co-morbidities responded best to patient produced force progressions. At times, one will find that the desire to "speed up" the process will, in fact, only result in unwanted symptomatic responses. When we are presented with such a presentation, we must take a step back and remind ourselves that the most therapeutic loads will be those that can be self administered by the client 24 hours a day. These loading strategies may initially result in an INCREASE/NW response. A temporary increase in symptoms is not a sign to STOP a particular loading strategy. Throughout treatment, the above client would go home to explore the INCREASE/NW response and return with a clear BETTER response a few days later. Success was achieved by ensuring that the client had a clear understanding of "Why do I need to do these exercises? How do I perform them? What should I expect as a result?" By utilizing McKenzie's logical assessment process and achieving a consultative process with the client, the clinician is able to answer these three questions sufficiently so that the patient is empowered and the desired therapeutic response occurs.

Reference: McKenzie RA (1989). A perspective on Manipulative Therapy. Physiotherapy, 75(8), 440-444.

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