McKenzie Flashcards
(100 cards)
1
Q
At least 7 million out of work due to LBP.
LBP is the most common cause of occupational disability
.
From studies that McKenzie quotes LBP begins at age____
Of those who have the LBP: ___ get sciatica, ___ become recurrent LBP problems
LBP is not necessarily consequence of degenerative process—there are other reasons for problems with the low back
No obvious relationship between degenerative changes and LBP.
A
At least 7 million out of work due to LBP.
LBP is the most common cause of occupational disability.
From studies that McKenzie quotes LBP begins at age 35
Of those who have the LBP: 35% get sciatica, 90% become recurrent LBP problems
LBP is not necessarily consequence of degenerative process—there are other reasons for problems with the low back
No obvious relationship between degenerative changes and LBP.
2
Q
Is there a relationship between degenerative changes and LBP. ?
A
No obvious relationship between degenerative changes and LBP.
3
Q
Difference in frequency of LBP in people with sedentary occupations as those doing heavy labor
A
Nachemson: LBP occurs with about the same frequency in people with sedentary occupations as those doing heavy labor
4
Q
McKenzie
CAUSE OF LBP
A
believes that a common denominator exists in production of LBP (lifestyle):
There must be some inherent fault in our lifestyle to cause such a wide spread problem
Almost all LBP is aggravated and perpetuated, if not caused by POOR SITTING POSTURES in both sedentary and manual workers
5
Q
Goal of McKenzie Tx
A
Mckenzie: difficulty does not lie in treating a particular episode, but in PREVENTING FUTURE EPISODES
6
Q
___of patients Improve in 1 week
A
44%
7
Q
___% of patients Improve in 1 month
A
86% of patients Improve in 1 month
8
Q
__% of patients Improve in 2 months
A
92% of patients Improve in 2 months
9
Q
McKenzie Aims of the Therapist
A
Patient Education
Teaching Prophylactic Methods
10
Q
Patients likely to benefit from McKenzie
4
A
Acute, Subacute, or Chronic LBP = slowly or suddenly occurring rather SHARP PAIN with or without radiation over buttocks or slightly down leg and RESTRICTIONS OF MOTION
Patients who respond:
In addition are, patients who have INTERMITTENT SCIATICA WITHOUT neurological deficit
There must be time in the day when the patient feels neither sciatic pain nor paraesthesis
11
Q
Patients not benefit from McKenzie
2
A
- Those patients where there is NO POSITION or movement that can REDUCE or CENTRALIZE the pain
- Patients with CONSTANT severe sciatica WITH NEUROLOGICAL deficit
Reassess to see if the condition changes
12
Q
Predisposing Factors: to LBP
A
doing flexion, losing extension
- Bad SITTING POSTURES causes end range overstretch and enhances and perpetuates problem
Frequency of flexion inherent in our lifestyle, we spend too much time in FLEXION - LOSS OF EXTENSION RANGE after injury, there is always some extension restriction
- With healing, ADAPTIVE SHORTENING occurs (changes in soft tissues: joints, capsules, muscles will have shortening)
13
Q
LBP: Precipitating Factors:
A
- Movement: unexpected and unguarded movement
- Lifting: produces a strain
McKenzie believes that lifting should be with lordosis
14
Q
McKenzie: how should spine be for lifting?
A
lordosis
15
Q
nociceptive receptors: what causes them to be in pain ?
A
Nociceptive Receptor System:
Most tissues in the body possess system of nerve endings (nociceptive receptors) which are particularly sensitive to tissue dysfunction
pain from : PRESSURE, STRETCH, MALALIGNMENT
16
Q
Nociceptive Receptor System Lumbar Region:
9 places they exist
A
1) Skin
2) Subcutaneous tissue
3) Fibrous capsule of all synovial apophyseal joints
4) Longitudinal Ligaments, especially PLL
5) Ligamentum Flava
6) Interspinous ligament
7) Vertebral bodies
8) Fascia
9) Dura
17
Q
What is chemical pain?
- -When does it occur?
- -When?
- -Constant vs intermittent
- -How can pain be reduced?
A
Chemical Pain: due to inflammatory process
produced by chemical irritation
Occurs first 10-20 days following trauma
Constant
Pain will NOT be reduced by movement or position
18
Q
Mechanical Pain
What is it?
A
due to a motion or position : stress on irritated tissue causes pain, when no stress on irritated issue no pain
Produced by application of mechanical forces
Pain produced by applying forces to stress or deform the ligamentous and capsular structures
Pain is intermittent
Increases when movement is performed in one direction
Decreases when movement is performed in opposite direction
Pathology need not exist
No chemical cure available
19
Q
Which pain is intermittent? Which pain is constant ?
A
Chemical = constant
Mechanical = intermittent
20
Q
What causes mechanical pain?
A
Produced by application of mechanical forces
Pain produced by applying forces to stress or deform the ligamentous and capsular structures
21
Q
How to reduce mechanical pan?
A
due to a motion or position : stress on irritated tissue causes pain, when no stress on irritated issue no pain
22
Q
Is mechanical pain caused by pathology?
A
Pathology need not exist
23
Q
Is there a cure to chemical pain?
A
No chemical cure available
24
Q
What kind of disc derangement responds to extension?
A
posterior lateral
25
Postural Syndrome
what is it
Caused by mechanical deformation of the soft tissue as a result of postural stresses
Pain is INTERMITTENT : mechanical deformation in soft tissue causes postural stress causing intermittent pain
Changing the alignment will relieve pain
26
What is caused by mechanical deformation of the soft tissue as a result of postural stresses?
Postural Syndrome
27
What type of pain is experienced in Postural Syndrome?
Pain is INTERMITTENT : mechanical deformation in soft tissue causes postural stress causing intermittent pain
Changing the alignment will relieve pain
28
Dysfunction Syndrome:
what is it
Caused by mechanical deformation of soft tissues affected by adaptive shortening
Prolonged positioning or prolonged bad posture: when mechanically deformed soft tissue that has adaptive shortening it registers as pain
The step beyond the postural syndrome
29
What is caused by mechanical deformation of soft tissues affected by adaptive shortening ?
Dysfunction Syndrome:
30
What causes pain in Dysfunction Syndrome?
Prolonged positioning or prolonged bad posture:
when mechanically deformed soft tissue that has adaptive shortening it registers as pain
31
What is caused by prolonged positioning or prolonged bad posture?
Dysfunction Syndrome:
Prolonged positioning or prolonged bad posture: when mechanically deformed soft tissue that has adaptive shortening it registers as pain
The step beyond the postural syndrome
32
Derangement Syndrome:
What is it ?
Caused by mechanical deformation of soft tissues as a result of internal derangement of disc
Have internal derangements of the discs that is impeding the movements that are having the problems
33
What is caused by mechanical deformation of soft tissues as a result of internal derangement of disc ?
Derangement Syndrome:
34
Which syndrome can centralization phenomenon be used?
Derangement Syndrome
35
Centralization Phenomenon:
1. Occurs only in derangement syndrome
- ->Moving disc material from a point where it is putting a lot of pressure on a nerve to a point where it is putting less pressure on the nerve
2. Decrease pain peripherally as centralization of pain develops
3. Increase in central pain permissible
- ->The central pain may be more intense, that is ok, as long as it is not peripheral
36
What is happening when pain is centralized?
Occurs only in derangement syndrome
-->Moving disc material from a point where it is putting a lot of pressure on a nerve to a point where it is putting less pressure on the nerve
37
What to do on McKenzie Subjective
```
Present Pain
How long present
Commenced as a result of..
Constant / intermittent
Better/worse - sitting, standing, walking, lying
Sleep
General health
Medications
Accidents
PMH
Recent surgeries
Recent x-rays
```
38
What to do on McKenzie Objective
POSTURE sitting: supported / unsupported
Posture standing lordosis: reduced/ accentuated
LATERAL SHIFT:
Are scapula girdle and pelvis in a straight line
LEG LENGTH DISCREPENCY
MOVEMENT RANGE and observe DEVIATION during movement and RETURN from the movement
- Flexion
- Extension
- Side Glide Left
- Side Glide Right
39
Deviation In Flexion:
DERANGEMENT (disc) : in general, deviation AWAY from the painful side as long as there is no sciatic nerve root irritation
DYSFUNCTION: with adherent sciatic nerve root-deviation TOWARDS side of the root irritation
40
Deviation in Extension:
DERANGEMENT (disc) : in general, deviation AWAY from the side of the pain
DYSFUNCTION: usually NOT a significant deviation due to the facet apposition
41
Deviation in Side Gliding:
When a lateral shift is present plus some unilateral loss of side gliding, then the lateral shift is a significant finding
DERANGEMENT (disc) may have lateral shift and unilateral side gliding issues
DYSFUNCTION may show limited side gliding but not necessarily lateral shift
42
Side Glide: What we can learn
Pain bend to painful side,
1. intra-articular dysfunction
2. disc protrusion lateral to the nerve root.
Pain bends away of from the painful side
1. muscular or ligamentous lesion (which will cause tightening of the muscle or ligament)
2. The patient may also have a disc protrusion medial to the nerve root.
43
Test Movements:
(Symptoms: centralize, peripheralize, no change/increase, decrease ROM or no effect)
what are they
FIS: Flexion in Standing
Repeated FIS:
EIS: Extension in Standing
Hand behind buttocks, arch your back backwards, hold
Repeated EIS:
Hand behind buttocks, arch your back backwards, repeat
FIL: Flexion in Lying (knees to chest)
Repeated FIL:
EIL: Extension in Lying (prone press up)
Repeated EIL:
SGIS R: Side-glide in standing Right
SGIS L: Side-glide in standing Left
Repeated SGIS R:
Repeated SGIS L:
44
Repeated Movements : effect on pain
Postural vs Derangement vs Dysfunction
Postural Syndrome: no symptoms produced
Derangement:
repeated movements in direction which increases accumulation of nuclear material will increase derangement and peripheralize pain
repeated movements in the opposite direction will result in reduction of derangement and centralize pain
45
Repeated Movements
Postural
Postural Syndrome: no symptoms produced
46
Repeated Movements
Derangement
= Mechanical deformation of soft tissue as result of internal derangement of DISC
PERIPHERALIZE: repeated movements in direction which increases accumulation of nuclear material will increase derangement and peripheralize pain
CENTRALIZE:
repeated movements in the opposite direction will result in reduction of derangement and centralize pain
47
Repeated Movements
Dysfunction
Dysfunction:
mechanical deformation of soft tissue affected by ADAPTIVE SHORTENING
-->repeated movement in the direction in direction which stretches adaptive shortened structures will produce pain at END RANGE
but repetition DOES NOT make the patient worse
48
Will repeated movements make pain worse in derangement or dysfunction?
Derangement (disc)
PERIPHERALIZE: repeated movements in direction which increases accumulation of nuclear material will increase derangement and peripheralize pain
CENTRALIZE:
repeated movements in the opposite direction will result in reduction of derangement and centralize pain
49
McKenzie: 2 types of pain
Chemical pain:
Sedate with modalities, grade 1 or 2, but do not aggravate it
Mechanical pain:
restore the faulty mechanics whether postural, dysfunction at facet joint level, disc pathology, derangement
50
Postural Syndrome:
1. What causes it?
2. type of pain
Mechanical deformation of the soft tissue as a result of POSTURAL STRESSES
Pain is intermittent
pain in bad posture, less pain or no pain out of bad posture
51
Progression
Postural --> Dysfunction --> Derangement
Old injury that doesn't heal well:
Postural -->
tissue can begin to scar/ bind down and cause adaptive shortening—in the postural syndrome where joints were mobile,
now in the DYSFUNCTION syndrome not freely mobile,
then in derangement at the disc level the mechanics are messed up because the disc is not sitting where it is supposed to (the nuclear material)
52
Dysfunction Syndrome
what is it
caused by a mechanical deformation of soft tissue affected by ADAPTIVE SHORTENING
53
Derangement syndrome
what is it
disc level : caused by mechanical deformation of soft tissues as a result of internal DERANGEMENT of DISC
54
Centralization phenomenon
what it is
Occurs only in derangement syndrome
Decrease pain peripherally as centralization of pain develops
Increase in central pain permissible
55
McKenzie Objective Exam
4 things we must assess
1. Posture: sitting: supported/unsupported
2. Posture: standing lordosis: reduced/accentuated
3. Lateral shift
4. Leg Length Discrepancy
56
DERRANGEMENT: Deviation in Flexion
Derangement – in general, deviation AWAY from the painful side as long as there is no sciatic nerve root: get away
- ->Patient deviates from the painful side, getting away from the painful structure
- ->There is no sciatic nerve root irritation
57
DYSFUNCTION: Deviation in flexion
WITH ADHERENT SCIATIC NERVE ROOT: DEVIATION TOWARD SIDE OF ROOT IRRITATION
one side doesn’t move but the other side moves fine so it looks like a deviation TOWARD the stuck side
Facet may or may not be messed up, but also the dura and neurolemma are stuck in the opening so it is adherent —deviation towards the painful side ==> Nothing to get away from, just that the right side not moving, left side moving fine
Right side stops, left side keeps going so it looks like you’re getting deviation to the “stuck” side
Either a dysfunction or an adherent nerve root
58
Deviation in Extension: Derangement
in general, deviation AWAY from the side of the pain
59
Deviation in Extension: Dysfunction
usually NOT a significant deviation due to facet apposition (position)
May have an extension dysfunction and be already extended so extend from the rest of their spine if already extended and so wont see the limitation , if they have a flexion dysfunction (?)
60
Deviation in Side Gliding
Derangement
may have LATERAL SHIFTt plus UNILATERAL SIDE GLIDING ISSUES
(Something blocking from disc level that makes it difficult for them to get back over
look to see if there is a unilateral loss to side gliding they may come in already with a unilateral side glide but when ask them to glide the other way there is pain due to disc level blocking that side glide
)
61
Deviation in Side Gliding
Dysfunction
may show LIMITED SIDE GLIDE but not necessarily lateral shift
(May be generally stiff but may not walk in with a lateral shift)
62
McKenzie
Test Movements: WB vs non-WB
In a WB position and NWB position, what is happening to the pain
```
FIS: flexion in standing
Repeated FIS
EIS: extension in standing
Repeated EIS
FIL: flexion in lysing
Repeated FIL
EIL: extension in lying
Repeated EIL
SGIS R: side glide in standing right
SGIS L: side glide in standing left
Repeated SGIS R
Repeated SGIS L
```
63
How: Testing Side-Glide:
stabilize pelvis and have them side glide their thorax
can be done actively and stabilize the pelvis but also can do it this way
If they want to go into that painful side, stabilize their thorax with our shoulder and we draw their pelvis toward us – 2 point pressure system
64
Repeated Movements
DERANGEMENT
Repeated movement in direction which increases accumulation of nuclear material will increase derangement and peripheralize pain
Repeated movements in opposite direction will result in reduction of derangement and centralization of pain
65
Repeated movements in derangement: what will centralize pain?
Pain peripheralize: nuclear material moving towards side of the problem
Pain centralize: nuclear material moving away from the side of the problem
66
Repeated Movements
DYSFUNCTION
Repeated movements in direction which stretches adaptive shortened structures will produce pain at end range but does not make the patient worse
we may hit painful barrier but repetition may not necessarily make it worse
67
Repeated Movements
POSTURAL
no symptoms produced
68
Diagnose
The movement that causes pain have static pain or make it same each time (not worse or better) and opposite movement is pain free
Dysfunction
Flexion dysfunction if cannot flex, extension dysfunction if cannot extend
69
Diagnose
one direction is painful and the other direction relieves it on repeated motion testing
derangement: go one way and have relief in other way,
dysfunction: keep going and can be the same, opposite no issue
70
FIL not painful and FIS was: what does this mean?
if suspect adherent nerve root and FIL not painful and FIS was: think about the NR
FIL – flexion takes place from below up
bottom up approach
removal of gravity in lying
FIS – flexion takes place from top down approach
Puts more stretch on sciatic nerve in FIS so do both FIL and FIS
FIS – the sciatic nerve is lengthened and stretched
71
Difference between flexion in standing vs lying?
FIL – flexion takes place from below up
bottom up approach
removal of gravity in lying
FIS – flexion takes place from top down approach
Puts more stretch on sciatic nerve in FIS so do both FIL and FIS
72
Difference between extension in standing vs lying?
BOTH are top down approach
EIL doesnt have gravity
--more extension range because of weight of pelvis/abdomen
=> BETTER REDUCTION OF DISC
EIS does have gravity
--compressive forces
73
Better reduction of disc: extension in standing vs lying?
extension in lying has better reduction of disc
74
For treatment to reduce a disc and bring it back into place, use EIS or EIL due to the gravitational forces?
EIL (NO GRAVITY)
75
EIL vs EIS
Both EIL and EIS are a top down approach
GRAVITY IS DIFFERENT
EIS – adds compressive forces
EIL
weight of pelvis/abdomen causes increase of extension range
better extension range, better picture of arc of motion in EIL (body is stabilized)
*Better reduction of disc in EIL*
For treatment: to reduce a disc and bring it back into place, use EIL due to the gravitational forces
76
What needs to be cleared on exam for McKenzie (3)
Examination: (have to clear all these)
Neurological
Hip joints
SI joints
77
Postural Syndrome:
| 9 symptoms
1. Prolonged stress to soft tissues
2. Intermittent pain
3. Pain reproduced by prolonged positioning
4. Pain relief by position change
5. Some pain free days
6. Poor sitting or standing posture
7. No loss of movement
8. No signs of pathology
9. No neurological signs
78
Dysfunction Syndrome:
| 8 symptoms
1. Adaptive shortening and loss of mobility
2. Caused by poor posture, trauma, derangement
3. Intermittent pain (because there will be a posture that isn't painful)
4. Pain reproduced end range where shortened structures are stretched (usually symptoms are at the end range where the tissues are on stretch)
5. Pain alleviated when stretch is removed
6. Loss of movement or function
7. Pain reproduced by movement into position where tightness is present
8. Not irritated by test movements
[Because it is adaptive shortening, considering it to be long term thing, not necessarily hot joint (but could be)]
79
Derangement Syndrome:
10 signs
1. Change in position of fluid nucleus creates abnormal joint mobility (change in ROM)
2. Usually CONSTANT pain (chemical nature to the pain)
3. Certain movements/positions which are REPEATED or SUSTAINED increase symptoms
4. Other movements/positions which are REPEATED or SUSTAINED decrease symptoms
5. WORSE: sitting, sit to stand, bending
- ->If nuclear material is protruding posterior or posterior lateral they will have trouble sitting for a long period of time: into flexion: moves the disc material posteriorly
- ->Bending will be painful for them because loading and flexing, material getting pushed back
- ->But don’t forget there can be anterior derangements—don’t like to be standing which puts into extension and pushes the disc material forward
6. BETTER: walking and lying
- ->better because it is a more extended position- postural it keeps the dic material centered
7. Repeated recurrences
8. Usually a POSTURAL DEFORMITY – lateral shift, kyphosis
9. MOVEMENT LOSS
10. May see NEUROLOGICAL SIGNS
80
Adherent Nerve Root:
- what is it used for
- what to put in the HEP
Used to sub-categorize patient presentation
Careful customized home program needed for controlled stretch of the adherent nerve
81
TREATMENT
Postural Syndrome
1. PATIENT EDUCATION – body mechanics, posture, ADL
2. STRETCH tight structures
3. STRENGTHEN weak muscles (ie scapular protractors, ie like Sahrmann approach)
4. HEP
82
TREATMENT
Dysfunction Syndrome:
1. PATIENT EDUCATION
2. STRETCH (it is ok to be a little painful to stretch adaptive shortening, painful on stretch, shouldn’t aggravate too much)
3. JOINT MOBILIZATION: to improve mobility
- ->P/A, P/A with flexion
- ->PA with extension
- ->Augment with active movements – flexion or extension in lying or standing
4. POSTURE RE-EDUCATION if need
General Rule
In treatment of dysfunction, we choose movement that produces that pain since this movement results in stretching and lengthening of contracted soft tissues
83
TREATMENT
is it bad to treat dysfunction with position that creates pain?
General Rule
In treatment of dysfunction, we choose movement that produces that pain since this movement results in STRETCHING and lengthening of contracted soft tissues
84
TREATMENT
Derangement Syndrome
1. REDUCE THE DERANGEMENT
- ->first reduce the lateral shift before do doing the movement that they are having difficulty with: once centralized, go into extension to centralize the dic
2. MAINTAIN THE REDUCTION (once it is reduced: Cant do the offending movement for a while otherwise it’ll cause the problem again, need to maintain the reduction)
3. RECOVERY OF FUNCTION
4. PATIENT EDUCATION self management
General Rule:
In treatment of derangement, we choose movement that RELIEVES pain since this movement reduces the derangement
Find the thing that makes it better and use that
85
TREATMENT
is it bad to treat derangement with position that relieves pain?
In treatment of derangement, we choose movement that RELIEVES pain since this movement reduces the derangement
86
Extension Principle
WHEN IS IT APPLIED (2)
Derangement
Dysfunction
1. POSTERIOR DERANGEMENT: extension REDUCES mechanical deformation
We use those movements which centralize the pain = It may make pain worse, but it will be centralized
2. DYSFUNCTION, extension principle is applied when extension PRODUCES mechanical deformation
We use those movements which produce pain during the examination: To treat extension dysfunction: use extension
87
When is extension principle applied in derangement?
POSTERIOR DERANGEMENT:
extension REDUCES mechanical deformation
We use those movements which centralize the pain = It may make pain worse, but it will be centralized
88
When is extension principle applied in dysfunction?
DYSFUNCTION, extension principle is applied when extension PRODUCES mechanical deformation
We use those movements which produce pain during the examination
To treat extension dysfunction: use extension
89
Flexion Principle:
WHEN IS IT APPLIED (2)
Derangement
Dysfunction
In ANTERIOR DERANGEMENT, flexion principle is applied when flexion REDUCES mechanical deformation
ie knees to chest in lying, flexion in standing
In DYSFUNCTION, flexion is used when this PRODUCES mechanical deformation and pain
To treat flexion dysfunction: use flexion
Can use joint mobilizations
90
When is flexion principle applied in derangement?
In ANTERIOR DERANGEMENT,
flexion principle is applied when flexion REDUCES mechanical deformation
ie knees to chest in lying, flexion in standing
91
When is flexion principle applied in dysfunction?
In DYSFUNCTION, flexion is used when this PRODUCES mechanical deformation and pain
To treat flexion dysfunction: use flexion
Can use joint mobilizations
92
McKenzie Tx Positions
```
Lying prone
Lying in prone extension
Extension in lying
Extension in lying with belt
Sustained extension
Extension in standing
Extension mobilization
Extension manipulation
Rotation mobilization in extension
Rotation manipulation in extension
Flexion in lying (Knee to chest)
Flexion in standing (Bending forward)
Flexion in step standing (Stretch out a nerve over your hip and add some flexion on top of that and get more stretch, and can adjust the step)
```
93
What must be treated first in McKenzie?
Treat the lateral shift first!
Apply EXTENSION Principle AFTER treating the lateral shift to maintain correction in cases of posterior or posterolateral derangement
Apply FLEXION principle AFTER treating the lateral shift to maintain correction cases of anterior or anterolateral derangement
94
What is the order of treatment in a posterolateral derangement?
Treat the lateral shift first!
Apply EXTENSION Principle AFTER treating the lateral shift to maintain correction in cases of posterior or posterolateral derangement
95
What is the order of treatment in anterolateral derangement?
Treat the lateral shift first!
Apply FLEXION principle AFTER treating the lateral shift to maintain correction cases of anterior or anterolateral derangement
96
Why might a patient be laterally shifted to the right?
**if laterally shifted to the right: can be trying to get away from disc on the left that is lateral to NR on left, or trying to get away from medial NR on the right. create space away from irritated nerve.
We need to reduce this deviation to get the disc material to where it is supposed to be
97
Butler approach to interventions
when to do the slider? tensioner?
do the slider in the more acute phase, do the tensioner in the not so acute phase. If I don't trust patient on HEP to do tensioner then give them the slider.
Mobilization of the tissue along the course of the nerve – soft tissue techniques
Mobilize the nerve via active motion:
TENSIONER – stretch over BOTH ends of the nerve (whole tract or just part of the track)
SLIDER – stretch over ONE end of the nerve course and release – then stretch over the opposite end of the nerve – alternate back and forth
98
LATERAL SHIFT: Self correction
(Lateral shift = thorax has moved over pelvis)
Mechanically getting pelvis under the thorax
Prop arm against wall – now there is a space between pelvis and wall
-Elbow at 90
-Gently nudge pelvis toward the wall
With the other hand
-Get pelvis into a better position
-Follow up with repeated extension in standing
Correction of lateral shift
99
Peripheral vs Localized Annular Bulge
Peripheral annular bulge – squishing the jelly donut, like love handles
Not through the fibers yet
Localized annular bulge – annular material bulging onto spot and aggravating a nerve but not enough to cause major neuro signs
Annulus is intact but its pouching out in one direction
100
LATERAL SHIFT: correction
my shoulder to her thorax, my hands around opposite ilium (move the thorax over the pelvis)
