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Re: McKenzie Thread
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Re: McKenzie Thread - November 26, 2006 4:12:00 AM
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rv36116
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and SJBird, you keep referring to 30-40%... Is this coming from Charle's comment of
[QUOTE]I have found no people who have gone all the way through the McKenzie educational system who feel that every patient is a derangement who must centralize, or else. It is simply a powerful system to recognize which patients will respond rapidly to certain movements and forces, and gives relevant guidelines on treating the other 30-40 percent.[/QUOTE]?
Do you know what the 30-40% represents, or are you just saying that is the number he's giving for those who are "inconclusive"? I think you're grabbing something you're not understanding...but I wanted to get your observation and assumption about that number before going forward.
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Re: McKenzie Thread - November 26, 2006 5:53:00 AM
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mcap56
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Rob:
You are operating under a number of misconceptions. You really, really, really need to read the literature on low back pain. If you did, I think you would be reluctant to make absolute statements.
1. The SIJ is distinct from lumbar derrangments. Yes, the SIJ is not a classification under McKenzie proper. But, when you have one of the original McKenzie diplomats - Mark Laslett who knows more than you, I, or anyone you are working with come up with a system for diagnosing SIJ joints that 1. Is based on McK and special test 2. Has outstanding sensitivity and specificity 3. Makes theoretical sense 4. Is substantiated by pain staking research - don't you think you ought to read the article instead of just telling us to force SIJ patients into one of the derrangements or call them inconclusive?
2. As SJ and Duffy say, most McK practicioners work in places where they must see and treat any mechanical low back pain problem. Any mechanical low back pain patient is appropriate for PT. If they don't improve, referral is warranted. But not simply after an eval.
Read the back pain revolution by Waddell. If you take a patient and tell them they can't be helped, you have contributed to the fear avoidance cycle, the over medicalization of the patient and helped along a very destructive cascade of events. Psychosocial factors are far more predictive of outcome in patients with LBP.
3. I am glad you are enthusiastic about McK. But please refrain from lecturing me about it. I am a believer in the system. I am credentialed and I have taught it a several schools. I have no shortage of friends who use the method and I use to lead the NYC study group. Any system however, needs to be viewed in context. Taking a narrow view of low back pain is not appropriate.
4. You need to cite literature about the long term benefits of McK. Is there any study, for example, that demonstrates a reduction in recurrance rates, over long periods, close to what Richardson and Jull found in their study? If not, don't you owe it to your patients to use segmental stabilization?
To answer your question SIJ, all of the patients I see, whether inconclusive, derangement or whatever, as long as they are mechanical get at least:
segmental stabilization
aerobic exercise
reactivation
posture/ergonomics
And education, education, education. I spend a ton of time discussing back pain in general and how they way they think about their problem plays in.
Respectfully,
mcap
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Re: McKenzie Thread - November 26, 2006 7:53:00 AM
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SJBird55
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Rob, yes, it is coming from Charlie's comment.
You alluded to the frequency that "inconclusive" occurred over in that knee thread, but you didn't give any specific number - how am I supposed to interpret this?? quote:
...you want me to give you a ballpark figure, maybe about 2 per month, last week I evaluated about 13 patients, treat about 10-12 patients per day...quote:
Do you determine "inconclusive" after the evaluative process? then if you always evaluate 13 patients/week in a month you'd have about 45.5 patients, which if there is about 2/month that are "inconclusive" that equates to about 3-4%. Seems like a kind of low figure, especially after reading Charlie's response and the types of diagnoses that are not considered "mechanical."
Charlie's figure of 30-40% actually seems quite realistic and believable and isn't charged with emotion. Also, historically, Charlie has done a pretty darn good job at presenting material and ideas such that he's pretty consistent in his arguments and beliefs. I guess, I tend to view him as being a credible source. Charlie responded to my question about the frequency of "inconclusive" in a manner that is easily understood. Rob, you happened to bring up the whole topic of "inconclusive" and you still haven't been able to address it any further than stating that patients in that category need to be referred on to someone who can treat them or giving a generalized exercise program. Are you following yourself and your comments in this discussion? You instead want to argue about everything else that is more personal in nature (I'm not McK certified, I haven't worked along side you, I'm making erroneous assumptions) versus discussing the actual topic.
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Re: McKenzie Thread - November 26, 2006 8:20:00 AM
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rv36116
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Mr. Sheets, what does the 30-40% represent that you mentioned?
Marc, apparently you think I'm referring the patient somewhere else after eval? I wish everyone would quit making assumptions. I'm glad you teach it, great.
[QUOTE]3. I am glad you are enthusiastic about McK. But please refrain from lecturing me about it. I am a believer in the system. I am credentialed and I have taught it a several schools. I have no shortage of friends who use the method and I use to lead the NYC study group. Any system however, needs to be viewed in context. Taking a narrow view of low back pain is not appropriate. [/QUOTE]I'm not lecturing you about it, but I will point out differences about your ideas on McKenzie. To summarize, your teaching of segmental stabilization afterwards is the polar opposite of McKenzie. Did you have instructors who taught that to you? Did you test the joint prior to initiating those 4 activities to ensure the derangement was fully reduced? Because you teach it doesn't mean there are no shortcomings in your approach. E-mail Robin McKenzie and ask if he'd support teaching the patients stabilization and reactivation afterwards, and let me know what he says.
Just out of curiosity, are you able to see a good caseload of patients at the same time you work as a professor?
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Re: McKenzie Thread - November 26, 2006 11:27:00 AM
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certMDT
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SJ, you're asking some good questions, and I think the trouble is that there isn't an understanding of what "mechanically inconclusive" means within the McKenzie system.
Mechanically inconclusive is more a diagnosis of exclusion. The criteria, per the second edition of the Lumbar text, are:
Symptoms affected by spinal movement
No loading strategy consistently decreases, abolishes or centralizes symptoms, nor increases or peripheralizes symptoms
Inconsistent response to loading strategies
This is a fairly narrowly defined category, and it's not unreasonable that only 2-5% would fall into this group, as Rob said. Remember, this does not include SIJ, spondylolisthesis, stenosis, chronic pain, posture, dysfunction, or nerve entrapment, all of which would make up the 30-40% that I alluded to. That 30-40% came from a grouping of studies looking at the frequency of centralization; they aren't people who can't be treated, they are simply those that don't respond rapidly (ie centralize, abolish) with mechanical testing. One category that might get referred out is irreducible derangement or chemical pain, in which case a pathology is suspected that may be better treated by a surgeon or someone with the right drugs, respectively. The recognition of irreducible derangement is acually the strongest part of the McKenzie system to me, and the primary reason I went through the Diploma program - it gives the ability to get a patient to the appropriate person, recognizing that conservative care is likely not the answer.
Perhaps a few examples will help clarify:
Patient comes in with low back and leg pain for two weeks. Reports pain better walking and standing, worse sitting and bending. Friend said to do backbends, but doesn't because it hurts his back. Evaluation shows that extension centralizes his pain to his buttock and back (worse back, abolishes leg), he is sent home to do this knowing (Werneke and Hart) that he will do well. This is a posterior derangement, everyone is happy, this falls into the 60% that we can improve rapidly.
Another patient comes in with leg pain for the past 6 months, had really bad pain about 8 months ago, now only feels it in his leg when he bends over to tie his shoes or put on his pants. No other pain provocation. Examination shows no pain at rest, flexion in standing immediately produces pain in his leg to his ankle each time (with limited range), no change with repetition. No other motions have any effect (although a slump test/straight leg raise would likely reproduce the symptoms). After testing with flexion for a few days to make sure this is stable, we know this is an adherent nerve root, a form of dysfunction. Treatment for this patient is to continue stretching the nerve, with understanding that over 6-8 weeks this will remodel and the pain will resolve. This would fall into the 30-40% that we can treat, but will not resolve rapidly.
A third patient comes in with a six month history of back and leg pain, worse with prolonged sitting, bending, prolonged standing. Tends to feel better lying down. Examination shows a slight decrease in pain with posture correction. Motion testing shows no significant obstruction to motion. All endrange repeated motions increase pain, without producing an obstruction to movement. Pain doesn't remain significantly worse after movement, but it does gradually get worse as testing continues. There is no peripheralization or centralization of pain. Pain is relieved again with sitting with lumbar support.
As there is nothing specific to help categorize this patient, a next step could (depending on the patient and the attitude of the therapist) be to have the patient flex for a few days to determine if flexion will significantly worsen symptoms, revealing a posterior derangement. If not, treatment will likely consist of midrange postures, postural education, and pain education. A re-check can be performed periodically to determine if a directional preference will show itself. This patient falls into the category of mechanically inconclusive. It falls within the 30-40% - certainly treatable, but nothing that we expect to improve rapidly. It further falls into a smaller category (as Rob was saying), probably anywhere from 5-30% depending on the therapist's caseload (ie more chronic vs. acute).
This is the type of patient with whom Marc would go through lumbar stabilization, and as he says, there is some evidence to back it up. Personally, the findings of O'Sullivan on the increase in TrA and multifidus in erect sitting posture justifies just hammering at posture and slouch/overcorrect, as well as frequent position change. To me, going through all of the stabilization exercises tends to overmedicalize things, but I've certainly done my share of stabilization training in the past, and still do it from time to time, although more along Stuart McGill's general bracing versus Richardson and Hides' specific stabilization. I know an excellent McKenzie Diplomat who loves his real-time ultrasound machine, and I'm looking forward to checking it out sometime. We can take that up on another thread.
Thanks for inviting me to contribute. I can better list those references if you want.
Charlie
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Charles Sheets PT OCS Dip MDT
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Re: McKenzie Thread - November 26, 2006 2:21:00 PM
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SJBird55
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Thank you, Charlie. I was comprehending the 30-40% statistic accurately. The mechanically inconclusive appear to be a subgrouping of patients that probably will not improve with interventions that focus on repeated movements to eliminate symptoms of pain. (And I know I'm simplifiying my thought processes.) And I certainly agree that we do need to know when to treat and when to refer, but in reading what Rob posted and his interpretation of "inconclusive" and the clinical decisions that he proported to occur in McK just didn't make any clinical sense and also didn't appear to be realistic, in my opinion. Your first example would be my interpretation of a classical response with McK intervention for a responder. The second example seems to have more neurodynamic issues. The third example is the type of patient that any medical practitioner has difficulty treating successfully - no matter what approach. It is highly probably that that type of patient will fall into the "plateau" category at discharge and we cross our fingers and hope he/she continues to improve independently because he/she isn't improving at a quick enough rate to satisfy third party payors either by the amount of improvement or the number of visits or the duration of time allowed for physical therapy services.
So, technically, it appears to me that the amount of value McK has to offier may be dependent on the timeframe in which the majority of patients are referred for physical therapy services. The approach may not necessarily be as successful for patients with symptoms for 6-12 months after onset. Have there been any studies on the timeframes of acute, subacute and chronic that indicate the probability of success with the approach?
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Re: McKenzie Thread - November 26, 2006 3:17:00 PM
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certMDT
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I don't remember the exact statistics, but Audrey Long's study (Spine 2004) looked at directional preference and response in acute and chronic patients.
To be clear, there are plenty of patients who fit the response of patient one, who have had the pain for 3-6 months or longer. I was just trying to keep that example as simple as possible, sort of the "classic McKenzie patient."
Charlie
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Charles Sheets PT OCS Dip MDT
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Re: McKenzie Thread - November 26, 2006 9:04:00 PM
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rv36116
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[QUOTE]Thank you, Charlie. I was comprehending the 30-40% statistic accurately.[/QUOTE]Actually, I still think you're off base SJ...I'm going to try and clear this up as best as I can so we can get on the same track, if it doesn't work, ok, I tried... if it does help, excellent, we'll be on the same page.
1st you're assuming that 30-40% are inconclusive, as you mentioned the following earlier in the conversation:
[QUOTE] if 30-40% of patients might be "inconclusive" within the McK system, one has to do something for that patient.[/QUOTE]...to which Charles just described that the 30-40% you are speaking of as being "inconclusive":
[QUOTE]This is a fairly narrowly defined category, and it's not unreasonable that only 2-5% would fall into this group, as Rob said.
***Remember, this does not include SIJ, spondylolisthesis, stenosis, chronic pain, posture, dysfunction, or nerve entrapment, all of which would make up the 30-40% that I alluded to.***
That 30-40% came from a grouping of studies looking at the frequency of centralization; they aren't people who can't be treated, they are simply those that don't respond rapidly (ie centralize, abolish) with mechanical testing.[/QUOTE]The starred part is what I'm trying to get through to you about, most of that 30-40% he's speaking of, and what I see, are largely dysfunctions (mckenzie defined dysfunctions),with chronic pain patients, entrapments, soft tissue stenosis, posture syndrome and SIJ occurring pretty much in that order of frequency just in a quick estimation of what I see in the clinic. These ARE treated mechanically using MDT, but they take more time than the usual derangement treatment. I do not send these patients away.
You mentioned it again, saying that the 30-40% were not treated but referred out:
[QUOTE]now if there is a 30-40% of patients that may fall into the "inconclusive" category (and I'm strictly talking patients without any red flags or with issues outside of our scope of practice), and a physical therapist had that high of a frequency of referring out[/QUOTE]I am not sending the 30-40% out. The 30-40% are those that don't fall into the 'derangement' category. Those who have the diagnosis and categories that Charles mentioned, are still treated, with much success if the patient is consistent with the remodeling process or posture correction (with dysfunctions/entrapments and posture syndromes, respectively).
The % that I send out and initially estimated are those who have something chemically dominant or something PT will not address, as I mentioned previously in another post:
[QUOTE]"Inconclusive" which means, it won't be helped by this approach, means get them to someone who can help them...[/QUOTE]and as Charles said in detail:
[QUOTE]One category that might get referred out is irreducible derangement or chemical pain, in which case a pathology is suspected that may be better treated by a surgeon or someone with the right drugs, respectively.[/QUOTE]SJBird, from your comments, you have a completely different idea about what "inconclusive" is and how it's handled in the McKenzie system.
Hopefully this will answer some fogginess you were having about the 30-40% number and don't see that number as the percent that McKenzie sees and sends away, but rather the % that doesn't fall into the "derangement" category.
4 main categories, 1 inconclusive.
1-derangement
2-dysfunction
3-posture syndrome
4-entrapment
5-***inconclusive (this is the part I've mentioned as my "inconclusive", about 2-5%, as Charles mentioned, would be about average of what I see (just me, not saying this is everyone).
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Re: McKenzie Thread - November 27, 2006 1:10:00 AM
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SJBird55
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Rob, I did understand Charlie correctly. There are approximately 30-40% of patients that aren't going to quickly respond to a directional preference which would be like SIJ, spondylolisthesis, stenosis, chronic pain, posture, dysfunction, or nerve entrapment. The semantics of your posts originally led me to believe that if no directional preference was established then the situation was a hard and fast "inconclusive" in which you had said you either refer on to someone who can treat them or provide general exercise. That just did not make clinical sense and wouldn't be realistic in a clinical environment. Charlie did a great job in clarifying what you had posted previously.
Charlie, thanks on the response with chronic... so, by any chance, has literature looked into FABQ in the chronic and the response with directional preference?
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Re: McKenzie Thread - November 27, 2006 2:29:00 AM
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certMDT
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SJ -
I think you've got it. Actually, this line "The mechanically inconclusive appear to be a subgrouping of patients that probably will not improve with interventions that focus on repeated movements to eliminate symptoms of pain" summarizes it far better than I did.
To answer your other question, I would take a look at the letter to the editor in the December JOSPT. The discussion and references would give you a great starting point to answer your question.
Charlie
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Charles Sheets PT OCS Dip MDT
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Re: McKenzie Thread - November 27, 2006 3:15:00 AM
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SJBird55
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Charlie, I don't have my JOSPT yet... I'll check it out when I get it. Thanks again.
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Re: McKenzie Thread - November 27, 2006 4:21:00 AM
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certMDT
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Sorry, that was from 2005. Typing a little too fast.
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Charles Sheets PT OCS Dip MDT
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Re: McKenzie Thread - November 27, 2006 3:42:00 PM
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mcap56
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SJ:
There was a study recently that compared McK and stabilization therapy in chronic patients. I don't have the results, or the study on hand however. Perhaps Rob or Charles has the reference handy...
Marc
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