What is the Directional Preference? | Modern Manual Therapy Blog

What is the Directional Preference?

This post was inspired by the usual twitter nonsense. Some physiotherapist had never heard of MDT and unilateral loading loss, so he proceeded to ask other physios, known skeptics, and I believe UK's equivalent of either the AAOMPT or the APTA if I was basically full of it or not.

I basically told him I did not have enough time to explain it on twitter, and that he should either read McKenzie's Text or take one of the courses for a better understanding. Also, he was taking one part of an entire system (the repeated motion exam) out of context.

I thought it would be a great chance to write a quick review of the directional preference or DP (not to be confused with dysfunctional and painful from the SFMA). Anyone who is not considering using MDT as a framework for evaluation and does not have a system may as well be a blue pill!

The directional preference is the motion in any area of the body that needs to either be repeated loaded or the position sustained in NWB or partial WB, often to end range to improve several things

  • ROM
    • the improvements with repeated end range loading are often too drastic to be purely mechanical
  • pain
    • intensity
    • location 
      • centralization: when Sx move from distal to proximal
      • research shows finding the DP and centralizing Sx is an excellent prognosticator of successful outcomes
      • remember to explain to the patient that if distal Sx are abolished, it is still ok if the proximal Sx are produced in an area that did not have Sx before, or make proximal Sx temporarily worse
      • the temporarily is key here, it is still centralization if the hand or forearm pain/paraesthesia is gone, but now there is neck pain on the same side
  • DTRs
  • strength
  • function
The DP is often the direction that the patient has avoided, or has moved away from. Here are several common patterns. Notice that the patterns are devoid of Dx, which does not matter in most cases as this is non pathoanatomical, and purely movement based.

Right Hip Pain
  • the patient has difficulty WB on the right LE
  • they have decreased stance on the right
  • the often sit and stand unloading the right
  • this causes a unilateral loading loss on the right
  • repeated sidegliding in standing (SGIS) will show often pain during the motion, that increases, and may or may not remain worse to the LEFT
  • SGIS to the right may or may not be painful, but will often be limited
  • the limited side is the side that NEEDS to be loaded
Left Shoulder Pain
  • the patient has intermittent left shoulder pain with elevation
  • the upper traps ipsilaterally often "feel tight" (for many reasons, compensation, concurrent cervical pain... etc)
  • the patient often "stretches" or unloads to the opposite direction
  • but like the above case, if this has been happening for several months or longer, we know that if the body/mind is going to resolve a condition on its own, it will have in 6-8 weeks
  • this case when loaded in cervical retraction will likely show full and possibly painful SB to the right, and limited, and possibly painful SB to the left
  • if cervical retraction and SB to the left is limited (ipsilateral side), this is the DP and this should be instructed to the patient or you may perform it passively for them to show them end range
One thing that must be stressed here is that these are extreme shortcuts based on my experience with MDT. Regular readers of my blog know that I am not a fan of provocation tests. Repeated loading in the direction that is most likely going increase their pain, and have it remain worse is something I do not often try. Any good PT exam includes a detailed history. If there is one thing McKenzie taught us was to listen to the patient. The activities they say that make their complaints worse (sitting, reading, texting) and better (lying, walking, sitting upright) give us clues on where to take their repeated motion exam.

What I listed above are the patterns that I teach for unilateral screens. Absolutely you may start the repeated motion exam for the cervical spine with repeated cervical protraction, or lumbar with repeated flexion. I do not, knowing that most patients are doing these motions already 1000s of times a day. 

I start with either
  • cervical retraction with overpressure for central/bilateral complaints
  • cervical retraction with rotation and overpressure for upper cervical/HA complaints
  • cervical retraction with SB and overpressure for mid/lower cervical and radiating/radicular complaints
    • this is performed to the side of most distal complaints
    • i.e. right side upper trap, left side hand pain, most likely the retraction/SB left will be limited, so that is the DP
  • lumbar extension in standing for central/bilateral complaints
  • SGIS for unilateral complaints
    • the SGIS is perform to the side of the most distal complaint
    • i.e. bilateral LE pain, left side radiating to buttock and right side has foot paraesthesia, the SGIS will most likely be limited to the right and not the left
In the end, what I am trying to do is show the shortcuts I have learned over the years to help your classify your patients according to DP, which cuts down on clinical decision making and reduces this


Because that is how I feel most special tests are perceived by the patient. In the end, MDT is a very logical an step by step system to direct your education and treatment. It has built in testing and because of the stop light rule, it is unlikely you will harm a patient if the steps are followed.

Keeping it Eclectic!

6 comments:

  1. Dr. E, I especially liked your "go to" directions for specific cervical pain complaints. I have a plethora of radiculopathy patients down the arm for some reason and have been using several of these techniques.

    ReplyDelete
  2. Thanks Dan, it does work really well, which seems to be quite often given the right caseload. It's also a very simple screen that rules out cervical or lumbar involvement.

    ReplyDelete
  3. Hi Dr. E I am considering signing up for your channel after my exams are finished. Do you discuss DP further in your videos?

    ReplyDelete
  4. Thank you! Yes I discuss it and also there are lots of live cases where I use it on patients.

    ReplyDelete
  5. CM, the information on Dr E's channel is well worth the subscription.

    ReplyDelete
  6. Thanks for the plug Michael, have a great day!

    ReplyDelete