Dr. Joe Lorenzetti and Mechanical Diagnosis and Therapy

Dr. Joe Lorenzetti and Mechanical Diagnosis and Therapy 

By Carley Swanson

Not every intervention and rehabilitation method can be used for every single person. Yet, there is still a reason that Dr. Joe Lorenzetti uses Mechanical Diagnosis and Therapy first in his approach to physical therapy. Dr. Joe Lorenzetti is a well-known physical therapist from Buffalo, New York, who has been practicing for many years. Along with many other titles, Dr. Lorenzetti is a Doctorate of Physical Therapy, a Fellow of the American Academy of Orthopedic Manual Physical Therapist, and a diplomat of MDT. He currently works as a clinical spine specialist with Catholic Health System Spine Program and is also the fellowship and residency mentor at the McKenzie Institute. In his practice, he uses a unique method of assessment and treatment called Mechanical Diagnosis and Therapy (MDT). MDT is a method of assessment and treatment that was developed by New Zealand physiotherapist Robin McKenzie in the 1950s. The overall goal of MDT is to empower the patient to self-manage their condition through education and exercise. MDT aims to systematically evaluate the patient's condition and identify the specific mechanical factors that contribute to the patient's pain and dysfunction. Once the mechanical factors have been identified, specific mechanical loading techniques can be applied to alleviate the pain and restore function. 

MDT has a way of classifying low back pain into four main categories, including derangement, dysfunction, posture, and other. Derangement is the most common category and is characterized by a variable clinical pattern that may arise gradually or suddenly. Patients may experience constant or intermittent pain that increases or decreases with movements and postures. The mechanical presentation of derangement always includes a diminished range of motion or obstruction of movement and may include temporary deformity. Dysfunction is characterized by intermittent pain that occurs only when loading structurally impaired tissue. It can affect articular structures, leading to painful restriction or end-range movement. However, with dysfunction, the pain disappears when the loading is ceased. Dysfunction usually lasts for 6 to 8 weeks and is intermittent and localized, except in the case of Adherent Nerve Root (ANR). Patients with dysfunction experience consistent pain with movement. Posture-related low back pain is not due to any pathological conditions, but it is only caused by prolonged static loading of normal tissue. This category of low back pain is rare and mainly affects young patients. It always produces local pain and is caused by prolonged sitting. Posture correction often helps abolish the pain and the physical examination usually appears normal. Posture-related low back pain can be acute, subacute, or chronic. The fourth category of low back pain is all-encompassing, and  it includes conditions that do not fit into the other three categories, such as spinal stenosis, spondylolisthesis, or tumors. The approach to treating "other" conditions may vary depending on the specific situation. The MDT approach emphasizes the importance of identifying the specific mechanical presentation of a patient's low back pain, enabling clinicians to provide personalized treatment tailored to which movements and postures can centralize pain. 

Centralization refers to the phenomenon in which peripheral or radiating pain is abolished or reduced and the symptoms rapidly change. This lasting change can occur in both acute and chronic patients, particularly those with obstruction to movement, and can be observed with end-range movements or posture correction. Centralization is most commonly seen with extension and less commonly with lateral movements or flexion. It is an indication of directional preference in the body. It can be reliably assessed by healthcare professionals, and failure to observe centralization may indicate a poor prognosis. It is important to note that centralization only occurs in derangement syndrome, the most common classification of low back pain. Research has shown that centralization is a reliable predictor of good or excellent treatment outcomes. In one study of 87 patients, centralization occurred in 87% of cases, and 100% of patients who experienced centralization had excellent outcomes. MDT therapists use centralization as a tool to help identify the source of the patient's pain and to guide treatment decisions. By observing the patient's response to various movements and postures, therapists can develop a better understanding of the underlying cause of the patient's pain and develop a treatment plan that is tailored to their specific needs. 

Treating a client with MDT involves more than just addressing the patient's physical symptoms. The social-emotional aspect of the patient-provider relationship is also important in promoting healing and recovery. Dr. Lorenzetti emphasizes the importance of active listening; fully engaging with the patient, being present in the moment, and showing a genuine interest in their concerns. This involves not only hearing what the patient says, but also understanding their feelings and emotions-  if you listen closely , they will tell you exactly what has caused them pain and how to treat it. Dr. Lorenzetti also highlights building a bond with clients to understand their concerns and provide personalized care. With trust and positive perception, it is proven that they will do better in rehabilitation. Studies have shown that psychological and social factors can have a significant impact on the patient's response to treatment. Cognitive aspects such as perceptions of illness, catastrophizing, fear, low self-efficacy, and hypervigilance can negatively affect the patient's response to rehabilitation. Patients' beliefs and expectations about their condition and the efficacy of treatment may decrease their motivation to engage in the treatment process and their willingness to engage in physical activities. Emotional barriers such as anger, anxiety, depression, and distress can also affect the patient's response to rehabilitation and ultimately, their outcome.Contextual factors such as relationships, work environment, work attitudes, cultural beliefs, family history, and attitudes of friends can also affect the patient's response to rehabilitation. Patients who feel supported by their family and friends may have better emotional and functional outcomes. Threat and fear/avoidance of exercise and rehabilitation can also affect the patient's response to treatment. Patients who are fearful of exacerbating their pain or causing further injury may avoid engaging in physical activities, impeding their progress in the rehabilitation process, when in fact, physical activity will do the complete opposite of their thoughts. Therefore, it is important for healthcare providers to consider the social and emotional factors that can affect the patient's response to rehabilitation. Building trust and improving communication with a patient through active listening can improve patient engagement in rehabilitation. Additionally, addressing patients' emotional and psychological needs can improve their motivation and compliance with treatment. By considering these factors, healthcare providers can develop a comprehensive treatment plan that addresses the physical, emotional, and social needs of the patient. 

As with many modalities, there are misconceptions. One of the most pervasive misconceptions about MDT is that it is only about derangements. Although this is the most common classification, MDT is not limited to derangements alone. It includes other classifications such as dysfunction, posture, and other mechanical presentations, as I have stated before. Each classification requires different approaches to management, and MDT provides a structured way to identify and treat the various presentations. Another common misconception about MDT is that it is solely focused on extension exercises. While extension exercises are often used, as the cause of most low back pain is due to over excessive flexion in the low back from sitting all day, it is not the only type of exercise used. Treatment plans are tailored to each individual patient's specific mechanical presentation and may include a variety of exercises and manual techniques. Another misconception is that MDT is only for the spine. While MDT was initially developed for the assessment and treatment of spinal disorders, it can also be applied to other musculoskeletal conditions such as shoulder, hip, and knee pain. The same principles of mechanical diagnosis and treatment can be applied to other joints to achieve effective outcomes. Lastly, there is a common misconception that MDT does not include manual therapy or manipulation. Manual therapy is an important component of MDT, and it is often used in conjunction with exercise therapy to address mechanical dysfunction.MDT practitioners are trained to use a variety of manual techniques including mobilization, manipulation, and soft tissue mobilization to improve patient outcomes. 

Because MDT is a patient response system, it heavily relies on a traffic light system of how exercising has affected their pain levels: red may be pain increased worse or produced worse, amber may be increased no worse, decreased no better or abolished no better and green may be decreased, better or distal pain abolished/decreased better. Similar measures are taken during the history assessment: a red flag can indicate symptoms such as progressive neurological deficit, saddle anesthesia, incontinence, night pain, unexplained weight loss, and a history of cancer. These symptoms may indicate serious conditions such as spinal cord compression, cauda equina syndrome, or cancer metastasis to the spine. It is important for the therapist to recognize these symptoms and refer the patient to the appropriate medical specialist for further evaluation and management. Yellow flags, on the other hand, refer to psychosocial factors that may affect the patient's response to treatment. These factors can include anxiety, depression, fear/avoidance behavior, job dissatisfaction, and low levels of physical activity. Identifying these factors allows the therapist to tailor the treatment plan to address not only the physical symptoms but also the psychological and social aspects of the patient's condition. 

There are many goals of doing a history assessment, one of them being the presence of these different flags. We also assess the site of pain. Is it central, unilateral, symmetrical or asymmetrical? Is the pain in the back, thigh or below the knee? We also determine the stage of the disorder, whether it is acute, sub-acute or chronic. Lastly is the status of the condition, whether it is improving, worsening or remaining unchanged. Establishing a baseline creates measurements of the symptomatic and mechanical presentations against which improvements can be judged. It provides physical evidence to those patients who may have doubts that they truly are improving and getting better. Another way toguide future management is to determine factors that may aggravate or relieve the problem: standing vs. sitting vs. walking. vs. laying down. 

Dr. Joe Lorenzetti's integration of MDT into his medical practice has provided patients with a unique approach to the treatment of musculoskeletal conditions. The systematic evaluation process and specific mechanical loading techniques of MDT provide personalized care for each patient, and the goal of empowering patients to self-manage their condition through education and exercise aligns with a patient-centered approach to care. By emphasizing the importance of active listening, building a bond with clients, and evaluating social-emotional aspects of treatment, Dr. Lorenzetti is able to provide comprehensive care for his patients. While there are common misconceptions about MDT, the efficacy and reliability of the method have been demonstrated in many research studies. Overall, MDT provides a promising approach to the treatment of musculoskeletal conditions that should continue to be explored and integrated into medical practices. Dr. Joe Lorenzetti's use of Mechanical Diagnosis and Therapy (MDT) has provided a unique approach to the treatment of musculoskeletal conditions. The principles and techniques of MDT, including the classifications of treating low back pain and the importance of centralization, provide a systematic approach to personalized care.