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Mitch -> SPINAL MECHANICS PRIOR TO MFR OR THE LIKE WITH SPINAL PAIN (August 4, 2003 9:05:00 PM)
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MFR Case Study – MFR Publication – Chapter 23 T. Juett – Low Back Strain
The following reprents one in many examples as to why a mechanical evaluation prior to MFR is always called for. Quite often, one will obtain the desired results without having to add MFR at all. However, one would not know this if one does not first start with a mechanical evaluation. While the many MFR treatments might provide various benefits, it’s not the first evaluative approach to use with regard to spinal pain.
Patient: 33 y/o Female; Strained LB while picking up a 38-pound child & could not straighten up
Mitch: Question: Why couldn’t this patient straighten up? What happens when she tries to do so?
Continued…
Patient received Moist Heat, Ultra Sound, Intermittent traction to 110 pounds for 3 months, no improvement.
Mitch: Question: How did the patient define ‘no improvement’? Sometimes increased pain is desired. This therapist would like to have this clarified. I notice that no mechanical evaluation or treatment was provided (i.e., a la McKenzie).
Continued…
Examined by MFR practitioners: Subjectively patient c/o pain over sacrum, intermittent pain in posterior left leg to the knee and into the low back above the sacrum. Worse: Sitting, lifting, bending forward, sleeping on a soft mattress. No longer able to ride her horse or do household activities such as mopping and vacuuming.
Mitch: Was the pain over the sacrum constant or intermittent? With regard to intermitten pain, what position(s) and/or movement(s) produced the pain? This would tell us a lot about how the pain generator is influenced by positions and movements / ADL’s. While further clarification of the patient symptoms is called for, we are still provided with a lot of good mechanical information. However, no where in the case study do we see how these ADL’s may correlate with the persons problem. They appear to be recorded as nothing more than a measure to compare with after treatment has been rendered over some time period. In the McKenzie assessment, this information provides the examiners with their first sense of the patient’s problem, however, nothing is indicated in this regard. The information provides definitive correlation with the McKenzie categorizations and gives us the ‘first’ insights into how specific positions may be of benefit and which may be detrimental. Such movements and positions are incorporated into the patient’s home program and go beyond the standard postural and body mechanic instruction. The true meaning of this information is being missed in the evaluators assessment.
Note: Sitting, lifting, bending forward, mopping and vacuuming are all flexion type of activities which give us relevant information regarding the nature of this patient’s problem, yet, this hasn’t been addressed anywhere. This information appears to have been included as nothing more than comparative variables, the progress of which to be noted after receiving treatment(s). However, no where in the case study are these specifically indicated ADL’s even mentioned again.
Continued…
Assessment: Normal Achilles and patellar reflexes, tenderness over piriformis bilaterally, no tenderness over psoas
Bilaterally.
Mitch: After treating thousands of back pain patients, involvement of the piriformis is quite rare. The examiner’s note tenderness over the piriformis and the poas, however, no information is provided to the reader as to what this is suppose to inform us. It it’s being reported in a case study, it would appear to have some relevance, however, this is not related to us. A mechanical evaluation will reveal the relevance of investigating the piriformis to begin with.
Continued…
Active trunk ROM not painful…
Mitch: I’d like to know whether full end-range was truly attempted, pain responses can frighten practioners who don’t truly know how to read symptoms and a mechanical eval teaches one just how to read them. Even trained McKenzie practitioners have had problems knowing how far to move someone until they learn to trust themselves. It is therefore, quite likely that the spine was not fully moved towards it’s available end-range of motion. This is also more likely as no information is provided to the reader as to what exactly limited the ROM. This is further clarified in the next paragraph.
Continued…
Active trunk ROM Limited in extension, side bending bilaterally, and left rotation . . .
Mitch: Did pain limit the ROM? What did the patient experience during and/or at the end-range of the movements? Was this limitation(s) a result of obstruction or restriction? This information would provide important evaluative distinctions. All that is indicated is that the ROM was limited. What did the patient experience while trying to stand erect? Was there an obstruction or restriction to the limited movement(s)? There is a difference between ‘obstruction’ and ‘restriction’ .
Continued…
Patient treated 3 times /wk for 17 treatments. Began feeling better & increased her activity level after the first and each succeeding treatment. Trunk ROM returned to full flexibility in all motions. Treatment only included myofascial release and a slow progression of stretching and strengthening exercises.
Mitch: Perhaps the treatment did in-fact help, however, there are no mechanical considerations noted. While the focus of treatment was on fascia, muscle and apparently the ‘dural tube’, there is no consideration as to how said procedures, and perhaps the position the patient is in during said procedures, may influence the spinal mechanics. Important symptomatic influences, or lack thereof, while the patient assumed positions on the treatment table conducive for the applied treatment procedures, are not mentioned, therefore, they are left unconsidered.
Also to consider:Rember the patient had treatment for 3 months elsewhere. Note the following:
Approximately 44% of patients with low back pain are better in one week, 86% within one month, and 92% within two months. (Dixon, A.St.J. (1976), “Diagnosis of low back pain”, in: “The lumbar spine and back pain” Ed. M. Jayson; McKenzie, The Lumbar Spine, Mechanical Diagnosis and Therapy"; Waikanae, New Zealand,. Spinal Publications Ltd.; 1989, p. 2). Waddell, G. found that 90% of all low back pain will resolve within six weeks (Waddell G, A new clinical model for the treatment of low back pain. Spine 12:632-644, 1987). Kuslich, MD, St. Crouix Orthopedics, Stillwater, MN, also corroborates self resolution of back pain (The McKenzie Institute, USA, Educational Update and Second General Membership Meeting, Minneapolis, MN, July 15, 1995). Perhaps the added treatment of MFR helped things along, however, considering the natural history of spinal pain, this patient’s problem may have also had quite a bit of help from mother nature.
As a mechanical evaluation hasn’t been performed, we don’t truly know what the status of the patient’s injuries are. Note: Van Wijmen reports that repeated movement testing is essential to determine the stability of repair following tissue damage by derangement or trauma. This applies not only to spinal structures but also to soft tissue elsewhere in the body. During the healing process natural tension applied to the repair is necessary to prevent the development of a painful and weak scar resulting from cross linkage of collagen (Evans 1980)
Continued…
After the first session of MFR of the dural tube and sacrum, she felt better than she had at any time since the injury
Mitch: I would appreciate this author describing what the patient interprets is better versus what the therapist interprets as better. As one should realize, increased pain is not necessarily indicative of something worsening, nor is decreased pain indication of something improving. Location of symptoms tells a lot regarding the pain generator, as does influences related to movements and positions. Perhaps indeed the patient felt much better and was improving, however, for the sake of properly communicating one’s problem, we need to have this information clarified.
Continued…
Most of the treatments emphasized MFR of the dural tube and sacrum . . .
Mitch: What mechanical influences would one suppose said treatments might have upon the underlying mechanics of the spine? What effects might the position assumed during said treatments have? Perhaps improvement occurred as a result of unconsidered mechanical influences of said procedures, however, we won’t know that, as a mechanical assessment was not provided in the initial stages.
If the reader will recall, the patient suffered a strain upon the lifting of a child. Her symptom c;o’s and the suddenous of the pain points toward tissues other than fascial restrictive involvement or the like. Note that her symptoms started while in flexion while lifting the child. This is a classic cause of derangement, however, we still only theorize and then we confirm via the entire evaluative process. Now note the following study:
Adams and Hutton: Cadaveric lumbar spine, hyperflexion and compression combined produced disk derangements that are similar to the disturbances known to occur in living spines and that simulated repeated flexion produces a “gradual prolapse may explain the way in which disk lesion develop over days or months. (Adams MA. Hutton WC: Gradual disc prolapse. Spine 1985; 10: 524-531; Laslett, Mark: Use of Manipulative Therapy for Mechanical Pain of Spinal Origin; Orthopaedic Review, Vol. XVI No. 8, August 1987, p. 67)
Now, consider that the patient’s pain occurred while lifting a child! Certainly a full mechanical evaluation is required to determine the potential for derangement, however, the spinal mechanics (i.e., disc, spinal motion segment, etc..) are more likely to be the primary cause of the patient’s problem and might have been addressed just fine with independent mechanical procedures, with the addition of hands-on only as proven needed as an adjunct. However, we won’t know this because the practitioners decided to add hands-on from the get-go. While MFR procedures might have influenced the spinal mechanics in beneficial ways, these influences were left unconsidered. This patients problems may have been adequately treated with fewer treatments rather than 17 visits if the mechanical influences were addressed initially, but we won’t know that now because the evaluative process wasn’t used initially as it should have. The reader will note that prior treatment only consisted of moist heat, ultra sound & traction. This treatment does not follow mechanical principles of treatment. However, the MFR treatments do influence spinal mechanics, however, the practitioner who isn’t mechanically trained (i.e., McKenzie) does not realize this and will ultimately ascribe benefits to there own theoretical models.
Continued…
Because of a 20-year history of “migraines” three to four times a week and lasting a day at a time, dural tube releases were also done from the occiput. In addition, cranial base release was done. Follow up with this patient 10-weeks after her final treatment she reported having had no back pain despite doing stressful activities, such as horseback riding and wood splitting. She was back to her preinjury activity level and felt that she had full flexibility. She had no more migraines.
Suspicion was that an old trauma had created her chronic headaches and dural tube restrictions. This provided enough drag on the distal dural tube and the contiguous fascia to prevent relaxation and recovery of the low back soft tissue from the initial injury.
Mitch: What soft tissues are we speaking of? No problem with theorizing, however, theorizing is limited because a mechanical evaluation wasn’t performed initially.
The preexisting fascial tightness would also have predisposed this individual to a greater likelihood of strain.
Mitch: How about preexisting postural and body mechanic stresses over the years? How about the stresses this applies to annular tissues, ligaments, etc.. Again, theorizing is fine, perhaps one can theorize preexisting fascial tightness related to poor posture however, all that is noted is preexisting fascial tightness. The basic consideration of postural and body mechanic, movement and positional influences upon the spinal structures are ignored. Fascia is being treated as though the most important tissue of focus with most musculoskeletal problems, however, research thus far has told us otherwise. If anything, perhaps it is involved secondarily, not primarily. The use of MFR, in my view, can be quite useful as an adjunct, however, there are many who have kept outcome studies over a number of years which demonstrate positive long term outcomes without the use of MFR. In any event, if one is to use it, at least first evaluate for it’s potential value by evaluating via mechanical processes first. This case study delineates no findings relative to a mechanical evaluation.
Response from Frank Previte who reviewed my critique of the aforementioned case study:
Mitch,
I finally read through your consideration of this "case study." What can I say but well done. If a passive MFR approach to care is solely administered the patient exists the process without knowledge of self-treatment and prophylactic principles to hopefully minimize the odds of recurrence. I think you gave the readers some things to consider but whether they will or not
is to be seen. . . . Happy New Year! Frank
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