In the rehabilitation world, we always look for the quick answers first.
Getting someone out of pain as soon as possible is the main goal for us, and definitely for the patient.
There are many ways this can be accomplished (i.e. manual therapy, dry needling, education, medicine, etc).
But one of the best ways is determining what exact movement provokes and relieves this symptoms.
Often times this is a ying and yang. Bending over hurts, arching back helps. Reaching outward hurts, reaching inward helps. It’s a mechanical thing.
It sounds easy. And sometimes it is. But sometimes it requires a very thorough assessment and trial and error to get it right.
What is this process called?
It’s been called many things and continues to be innovated by organizations selling continuing education classes. Some call it finding neutrality, some call it rapid responder, some call it a phase shift.
However, the originator was Robin McKenzie, the founder of Mechanical Diagnosis and Therapy (MDT). He coined the outcome of this process “Directional Preference”.
Directional Preference
Directional preference is a clinical phenomenon observed during assessment where a specific direction of repeated movement or a sustained position consistently leads to an improvement in the patient's symptoms and/or mechanical presentation.
This improvement can manifest as:
Reduction or abolishment of pain: The pain may decrease in intensity or completely disappear.
Centralization of symptoms: If pain is radiating (e.g., sciatica or pain down an arm), it moves from a distal (further away from the spine) location to a more proximal (closer to the spine) or central location, eventually being abolished in the extremity and then potentially in the back/neck. This is a highly favorable prognostic sign.
Increased range of motion (ROM): The ability to move the affected body part improves.
Improved function: The patient can perform activities that were previously difficult or painful.
Essentially, it means that moving in one specific way (e.g., repeated lumbar extension, cervical retraction, or shoulder internal rotation) makes the patient feel better, while moving in the opposite direction might worsen symptoms.
Theoretical Basis and Mechanism in MDT
While the precise mechanisms of directional preference are still debated and researched, the MDT theory suggests that most musculoskeletal pain is "mechanical" in origin. This means the pain is a result of abnormal forces or mechanics in the tissues, rather than a serious pathology like cancer or infection.
For the most common MDT classification, Derangement Syndrome, directional preference is believed to be related to the "derangement" of articular (joint) tissue. While originally hypothesized to involve a "reductive force" on displaced disc material (e.g., a herniated disc), the theory has evolved to acknowledge that directional preference can occur even without clear disc displacement.
Here's how it generally works in the MDT framework:
Assessment: The clinician takes a detailed history of the patient's symptoms and how they behave. Crucially, the assessment involves performing a series of repeated movements (e.g., bending forward and backward, or side-bending) and sustained postures. The clinician carefully observes how the patient's pain and range of motion respond to these movements.
Identification of DP: If a specific direction of movement consistently improves symptoms and/or mechanics, that direction is identified as the patient's directional preference.
Classification: Based on the assessment, the patient is classified into one of the MDT syndromes (Derangement, Dysfunction, Postural) or an "Other" category. Directional preference is a hallmark of the Derangement Syndrome.
Treatment: The treatment then focuses on prescribing exercises and postural advice that align with the identified directional preference. The patient is actively involved in performing these specific, repeated movements at home to self-treat their condition. The goal is to rapidly reduce or abolish symptoms and restore function. In some cases, manual techniques by the clinician may be used if the patient cannot achieve the desired effect on their own.
Key Points about Directional Preference in MDT:
Active Patient Involvement: MDT emphasizes empowering the patient to self-treat and prevent recurrences through education and self-management strategies.
Individualized Treatment: There is no generic "McKenzie exercise" prescription. Treatment is tailored to the individual's specific directional preference and symptom response.
Prognostic Indicator: The presence of a directional preference, especially when accompanied by centralization, is often associated with a better prognosis and more rapid recovery in patients with spinal and extremity pain.
Beyond the Spine: While widely known for spinal pain, directional preference is also identified and utilized in the assessment and treatment of extremity problems (e.g., shoulder, knee, ankle).
Summary
Directional preference is about finding the specific mechanical loading strategy (a movement or posture) that reduces or abolishes pain and improves function, thereby guiding the patient's self-treatment and promoting recovery.
In my 15+ year career, finding directional preference has been the most powerful variable in quickly reducing someone’s pain.
As mentioned above, it can be a complex process, but once a directional preference is found, the rest of the journey becomes much easier for me and the patient