Mechanical Diagnosis & Treatment of the Spine: A Look at the Mckenzie Method

hello everybody hello hi so hello Winnie how many of you have experienced neck or back pain in the past I figured it would be the majority of the room um I'm going to talk to you today about one particular type of spine treatment uh that I have my certification in and several of the other therapists here have learned a lot from me in terms of how to treat people with this approach and so um our Clinic as a whole does a pretty good job of utilizing this as one of our tools uh next to the common cold low back pain is the most common reason that individuals visit their doctor's office and I think you guys represented that pretty well since just about everyone raised your hand uh billions of dollars in medical expenses um are spent on uh this condition and McKenzie is a method that provides a benefit to both you and your practitioner it helps to eliminate the need for some expensive and invasive procedures that might have to take place it's a problemsolving approach that we use clinically to determine what movements and directions and postures create your pain and which take them away so I'm going to talk to you a little bit more about kind of the whole assessment procedure and how it is used in terms of treatment and how you can apply it to your life moving forward the McKenzie method was developed in the 1960s by a physical therapist in New Zealand named Robin McKenzie there are about 2900 MDT therapists in the US and only 19 in New Hampshire at this point McKenzie stumbled upon his theory quite by accident um he had a patient one day who was complaining of low back pain with symptoms going down his legs and he had his assistant bring Mr Jones into the treatment room and and told the assistant to have Mr Jones lie on the table um the table had been propped up at one end from the previous patient and the assistant did not realize this is not how Mr McKenzie wanted it to be the patient laid on the table on their stomach so they were way propped up in this backwards Direction because that's what they were told to do was like on the table on their stomach so when Mr McKenzie came into the room and found the patient lying in that position he was actually quite startled and was afraid that he may have done something to harm the patient inadvertently he asked the patient how he was and the patient said this is the first time I've had no pain in my leg or my back in over three months Robin McKenzie thought hm that's interesting because at that point in time the general theory was that we should not do extension of our spine to an extreme motion because that could be harmful but he started to think maybe that wasn't so harmful if this person is first time painfree in 3 months so I'm going to explore this a little bit further that was the end of the treatment session for the day the patient felt better he got sent home he came back a few days later and reported that he continued to lie on his stomach and he continued to have no pain they proceeded through a a little bit more problem solving procedure to make sure he had that full range of motion and the patient later reported you know several months down the road at the grocery store or whatever it may be that he never had a return and his symptoms and it was that simple to solve it now it's not that simple for everybody but it's part of what set him down his path to kind of do some problem solving and figure out why did this work for this person most spinal pain is believed to be mechanical in nature and most responders will show patterns of response to pain and function based on a certain direction of movement and that allows us to classify them a certain way we're going to talk about that in a little bit pain of mechanical origin occurs when um The Joint between two bones has been placed in a position that over stretches the surrounding ligaments or other soft tissues so some people who have heard about McKenzie and the McKenzie method uh have an untrue belief that it's only for treating disc problems and that's not the case it's for treating any kind of mechanical pain in the back that often send symptoms radiating into the leg so I'm going to do a little demonstration with you guys I want you all to put your palm your hand Palm up and I want you to bend your index finger back until you just start to feel some strain okay that's the point where there's some strain on the tissue but there's no damage being done and if you continue to bend your finger back you're going to hit the point where you get to pain and you think I'm not so keen on this I don't really want to do it anymore and if you were I don't know masochistic enough and kept bending it backwards you would create damage okay so this gives a little demonst ation about uh kind of the way mechanical pain develops initially we have a situation where there's strain we may move in and out of a position with our back or our neck where we feel some strain but we move out of that position and the pain goes away if we keep moving into that so we're U maybe hauling wood all day long it becomes less than strain it becomes pain because we've repeated that over and over and pushed it a little bit further and the potential for damage then is increased because the more we push that limit the more chance we have to overstretch some of the structures the soft tissues once soft tissues are damaged the pain will be felt until the healing is complete and the function is fully restored so a good way to kind of picture this is if you have a cut on the top of your knuckle when you first cut your finger every time you bend your finger until the scab develops you have the potential for kind of reopening that cut or recreating the damage once you leave it bandaged long enough and leave it alone for a few minutes so that the the scab can develop you create a situation where you then can bend your finger and you still have a scab there but it's it you have freedom of motion without that scab coming open again well of course in the spine it takes a little bit longer than a few minutes like the finger analogy but that gives you a sense for um why we're going to talk about avoiding certain directions of movement when we get into some of the um techniques that we use once the healing has completed it is important to move into the direction that you were previously avoiding to ensure that you regain your full range of motion and we'll talk about that as well when tissues heal they tend to form scar tissue and this tissue is less elastic than normal tissues it tends to shorten over time and G give a sense of stiffness which can also be part of what creates pain and as I said appropriate exercises need to be performed to restore that normal tissue Mobility one of the C natural tenant of the McKenzie method is that self-healing and self- treatment are important for the patient pain relief and Rehab um in a truly purely McKenzie Clinic we would not use modalities like heat ultrasound cold um Hands-On stuff massage none of that he truly believed that it was based on patient movement patient education and patient carrying out what had to happen to make them better at Cha fryan Associates we tend to use a little bit more of an Eclectic approach so so we certainly want to teach you what to do how to do it when to do it but we tend to use other things to help the process along some you know things like massage and heat and ultrasound and the dry needling and all the other things we do we tend to picture the Mackenzie as a little bit more of one piece of our toolbox and use as many tools as we need to get you better as fast as we can the McKenzie approach can help to centralize a patient pain so in the example I gave you of Mr Jones and Rob McKenzie it brought the pain out of his leg into his back and that allows us then to treat the source of the pain rather than the symptom so lots of times a patient coming in complaining of leg pain will often you know think it's a little bit funny that their doctor has sent them for therapy on their back because they don't have an understanding that the leg pain is actually coming from their back or their arm pain is coming from their neck and what the McKenzie method does is works on centralizing it to the place it came from and then taking it away so this is an example of centralization of uh lower extremity pain so it may start in the foot and as we're working on treatment the patient might start to tell me you know I never have symptoms below my knee anymore but it's really getting quite intense in my back and I never want to say that's good because I don't want someone to have more pain anywhere but actually it's good because we're bringing it up to the center where it's started from and the last place we take it away from is the spine and then this is a a similar diagram of what it looks like when we're centralizing arm pain interestingly I've also seen um diagrams related to the mzi treatment that talk about head pain so headaches can also be referred um from the spine and some of the McKenzie treatment can treat that as well once the directional preference is found the McKenzie exercise treatment begins with exercises that are directly related to what we discovered inside the treatment so the goal is to centralize that pain and to teach you how to do it so in 2004 uh there was a review of 14 studies that had been published uh over that series of years and the prevalence of at least partial centralization of symptoms through this directional movement approach which is what the MDT or McKenzie approach is was 70% in 731 Subacute back pain patients and 52% in the chronic back pain patients now in terms of medical treatment and physical therapy treatment those are actually pretty good statistics for decreasing someone's pain uh in another study 11 patients with confirmed MRI disk prolapses or herniations uh over half of those people also had weakness or sensory loss in their leg were treated with repeated end range movement which is what McKenzie uses re-evaluated after five treatment sessions and centralization of that pain had occurred in eight of 11 patients the interesting thing is is that there was no change on their MRI so if we looked at the disc bulge on the MRI we and took note of the patient symptoms We performed the treatment the symptoms reduced but the MRI didn't change and so that's a good piece of information for patients to have the Imaging the X-ray the MRI doesn't always tell the whole picture we might see something that looks nasty on the MRI and patients lose hope and think I'm never going to be out of pain but there's lots of things that can be done to decrease pain even though the Imaging may not change and so just because there's a positive finding on an image doesn't mean it has to be the source of your pain and vice versa we can have people with pain that has Imaging that shows nothing so it's only part of the picture so the assessment procedure uses a systematic progression of Applied mechanical forces and mon the patient's response to those forces this allows us to classify the patient into one of these types of subgroups that I'm going to go through here next so he came up with three classifications one is the postural syndrome in the postural syndrome the patient has full range of motion they have pain when they're in a particular position so let's say I have a patient who comes in and says every time I'm sitting I have back pain okay and they're sitting in a slumped posture but as soon as we pull them out of that posture they say well I don't have any pain as long as I sit up straight what we need to work on in that situation is more patient education and strengthening getting their muscles to be able to support them in a proper posture there really isn't any structural problem going on it's just that they're resting at that point of strain which causes discomfort over time the next classification is the dysfunction there's um shortened structure shortened tissues so the patient may come in and I'll have them bend backwards and they say I have pain right when I get to there and I know that their full range would be here so they have pain before what would be considered normal range because they're bumping into tightness or restriction in a tissue and so we need to work on improving that mobility and then moving into the strengthening and control and making sure we get them learning how to control their body in the new range of motion that we help them develop and the last classification is derangement in derangement there's an anatomical disruption so this might be a discarnation or bulge it might be a ligament tear or something like that and so what we need to do in this situation is figure out how to keep the patient out of whatever movement or position they perform that creates pain teach them how to work on staying out of that movement or position to allow the healing to happen if we go back to the analogy about the cut finger if we stay out of the trouble range of motion long enough we can produce an environment that allows healing and then we can move the patient back into the range of motion that once cause pain without them having their symptoms all three of those syndromes that I just talked about occur in the neck the midback or the thoracic region and the lombar region and when we get into talking about derangements there tend to be two categories that McKenzie uses there's reducible derangements and irreducible derangements in a reducible derangement we're able to produce a change in the clinic we're able to perform a movement we're able to have the patient say you know it's not in my foot anymore it's only at my knee it's not in my knee anymore it's only in my buttocks and clearly there's it's not I'm not sure maybe it's a little better it's this is definitely making a difference we're able ble to centralize it and we're able to maintain the centralization the patient is able to come back in and say you know I haven't had it to my foot since I left here I do still sometimes get it in my thigh and we need to keep pressing on at that point but we're able to centralize it and keep it there there's patients who are irreducible their symptoms are so intense or the pressure on the nerve or whatever structure it is that's causing their pain is so severe that we can't reduce it um or we I mean we can't centralize it or if we centralize it we can't keep it there so we might centralize it while they're laying on the table performing a certain exercise as soon as they get up the symptoms are right back repeat the exercise as soon as they get up the symptoms are right back and it doesn't matter how much problem solving we do but we can't get it to stay reduced typically he says three to five sessions of problem solving is the maximum that he would allow in order to kind of label someone irreducible and those may be the patients who eventually become surgical candidates or need other types of therapy to help their situation he talks about some severity indicators generally if a patient comes in and has Central or symmetrical type symptoms they're easy to centralize and easy to maintain the centralization if they have unilateral symptoms that only go down to the knee that's also pretty easy to solve usually when those patients come in I think at two or three visits and we're going to have this pain significant L reduced when the symptoms go all the way down to the foot doesn't mean we can't centralize it just takes longer a little bit more effort a little bit slower process because the the damage to whatever tissue um is causing the problem has been more significant so it takes more time to heal that tissue so when we take you through a mckenzi evaluation we're trying to determine your directional preference or the principle of management that we're going to use part of that comes from just an interview with you you're going to come in and tell me something like every time I sit my back is killing me every time I stand up or walk it feels so much better i' take that bit of information and think about what does that mean for your spine when you're sitting your spine is in flexion so it's rounded okay when you're standing your spine is relatively in extension so it's bent backwards to some small degree and so there you're already building a story for me that says this patient is probably going to respond to extension but we're going to problem solve and see okay and there there are other directions of movement lateral and some combined movements as well that could be used so these are some examples of the directional preference movements that we might use so in the lumbar region we're working on a motion called a press up which is producing that position that the patient was lying on on the table where their chest was propped up inadvertently and we McKenzie saw a reduction in the leg Sy symptoms and this is the same exercise in standing uh only because lying down isn't always incredibly useful people have work and jobs and things to do where they can't lie down so we have to give them another option um in the neck uh one of the main things we find is people present with what we call a forward head posture so the head is jutted forward and as we all become more computer oriented we're actually seeing more of that because we sit in this position all day typing on our computers so the motion we work on is called traction so it's pulling the head back trying to align the ear with the tip of the shoulder and that's working on some extension in part of the spine as well this is an example of a lateral movement so sometimes there has to be a sideways component to what happens so we're Shifting the hips to the side working on unloading the structure that may be damaged so from A to Z the way it would work is you would come in and we would do the evaluation to determine the directional preference of of reducing your symptoms we would talk to you about those findings and then we would instruct you into how to stay out of the position that creates your pain and repeat movements into the direction that decrease your pain we'll continue with those directional preference movements until the centralization is consistent I don't want someone to come in and say my symptoms have been centralized for a few hours now I'm looking for someone to say I really haven't had any of my leg or arm symptoms for a few days and when we get into that point we're ready to move into the strengthening and the functional activities is to start getting you back to your normal life your normal things that you want to be doing and then we introduce movement into the once avoided Direction so to use a really simple example someone a very common finding for low back patients is they come in they have more pain when they're sitting or bending they have less pain when they're standing or walking so we may find that that press up motion is their their movement that centralizes their symptoms and interestingly most patients who have back pain are a little bit nervous about doing that direction of movement when I first asked them to because they think that's crazy that's really going to hurt my back they're often pleasantly surprised to find how quickly it reduces their like symptoms and how simple it is to make themselves feel better so once we determine that movement we're going to educate them on active involvement they need to take responsibility and owner ship for decreasing these symptoms because the more we can keep the stress off of the damaged structure the sooner we can allow it to heal and the sooner we can allow the patient to feel better so the goals are to decrease the pain quickly restore the function and Independence and do it in a minimum number of visits Hands-On techniques are applied if the patient can't manage the symptom reduction on their own so if a patient is working on that press up motion and they're thinking you know it feels pretty good my symptoms are quite a bit better but it's still down here in my buttock it's it's not all the way into my spine the therapist can add some extra techniques to help improve how much Mobility is happening at those segments in the back and further reduce or centralize the symptoms learning how to self treat their problem lets a patient gain Hands-On knowledge as to how to minimize any recurrence that's one of the things I like best about the McKenzie approach is is there's so much patient education the patient leaves here feeling pretty confident that should they ever have another episode of this in the future they're going to know what to do to minimize it as rapidly as possible um there have been lots of attempts by different researchers and therapists to identify a consistently effective intervention for back pain and they've been largely unsuccessful some patients get better with rest some patients get better with this or that and it's been difficult to find something that works for patients across the board Who present with a certain set of symptoms um there's a there's a process that happens called the development of clinical prediction rules these are tools that are designed to assist clinicians in decision-making when they're caring for their patients so we might have a set of a certain group of symptoms or things to look for that a patient might present with and if they present with a certain number of those things the clinical prediction rules would guide us toward a certain type of treatment spinal manipulation has been identified as one of the more successful spinal treatment techniques and because of that a clinical prediction rule has been established regarding that manipulation in a study conducted by the University of Washington it was shown that one month after completing treatment patients receiving the Mackenzie method improved to the same degree as patients receiving manipulation but most importantly the patients treated by the McKenzie method required fewer treatments to achieve the same amount of improvement and it's also you know notedly important that it's a treatment the patient can do to themsel when you're not in the clinic how can you help yourself if you can't perform a manipulation on yourself so this is another possible tool for you to use to self-manage once you learn about it there was another case study in 2010 um a patient met four out of five of the clinical pred rules for manipulation he failed to respond to two sessions of manipulation but then did respond to the repeated movements of the McKenzie approach so there has not been a clinical prediction rule developed for the McKenzie approach but what they're starting to do is do some problem solving to see okay we have these prediction rules that say manipulation will work if that fails does this work trying to find ways to guide the physical therapy community and delivering the best care for the patient the references are here if anyone needs them I will be happy to email them to you um and that's my information on Mckenzie if anyone has any questions I would be happy to answer them yeah when you say manipulation what do you mean chiropractors um chiropractors certainly do do manipulation they're they call their manipulations adjustments physical therapist do a type of manipulation as well it's mobilization we grade it uh through a different grading scale and so a grade one mobilization would be something very gentle and a grade five mobilization would include include a Thrust movement which would be similar in idea to what a chiropractor does anyone else yes if the source of the pain is a post crust vertebra in the lumbar region is what across the vertebra they cross verra this normal happens un normal does this system R something of that nature or is right well obviously we can't change the fact that the vertebra is crushed but what we can do is set up that region of the spine um for the best possible biomechanics so let's say vertebrae number three is crushed in the lumbar spine okay vertebrae number one is crushed right so your body may have because of that developed a certain movement pattern that makes you move some segments or vertebrae more or less than others to help you avoid pain so you might have excess motion above or below that and then decreased Motion in the segments right near it or or whatever combination it may be and the McKenzie technique can help to kind of equalize the amount of motion that takes place across the vertebrae to decrease the stress or the load to that segment of your spine so yes it can help with decreasing symptoms for that thank you yes um your presentation of the M Kenzie method seems very logical and well thought out if you were given the book describing it and given all the instructions do you feel that's enough and someone were to read it allow give you enough but treat your own backbook or treat your own neck book um I just read it you know it's interesting I looked at that as part of my preparation to see like what would a patient be reading and how can I incorporate that into what I'm presenting I think it would give people a general sense of of what to do but not not to the degree of actually being able to solve their problem without a little bit more instruction okay what if you were given this by a physical therapist who gave you instruction or just handed you the book handed you the book then again I don't think it would be as useful as a a full full evaluation and treatment session of McKenzie would be I think you could apply the principles to some degree but I don't think you would see as quick of a response and as as broad of a response as you could with a few sessions of kind of guided or directed treatment can I make a comment on that having just um tried to help my husband with a disc problem for months and months and you know telling things over and over again and then I finally bought him the book right it has helped a lot to reinforce what I told him all along which but you know I do find it a helpful tool for patients to look at and read after I've educated them because lots of times you get so much information in an appointment you leave with your head swimming and you think I don't even remember what she said at the beginning of the appointment and the the book does a very good job of kind of taking people through the concept step by step thank you mhm yes so what if your pain is intermittent you have to get in here for the evaluation while you're in pain um it's helpful but not necessary because a a large portion of determining which category of of this you fall in has a lot to do with your history what movements produce the pain when do you have the pain in what postures and positions and then once we also do some of the screening to determine any range of motion issues that can also kind of point us in the direction even if you're not currently having the pain I will certainly do this problem solving with people who don't have the pain at the moment they're sitting there telling me I had the pain yesterday but I don't have it right now and all I can do during that session is give them I hate to use the word guess but my best educated guess about what movement is going to be their problem solver and I tell them when you go home the next time you have the symptoms I need you to do this and then you need to come back and tell me what the response was because I can't problem solve you right there in the moment because you don't have the symptoms but I can give you some tools to be able to problem solve it and come back and give me more information so I can take you to the next step anyone else yep getting back to the idea of being told uh more information than you can actually retain yes um are there now given the internet given YouTube given the ability to actually see the movements properly do you have that resource so that you would say you should do this this and this and they're either in this book that I give you or you can go to this website either produced by you or somebody and allow you to see that motion again to remind yourself how to do it properly right um I always hand out handouts when the patient is here so they leave with papers that describe everything to do that includes photos and repetitions and all that information we also do have the books here the mckenzi books um I let people borrow my personal version if they don't want to buy one and we sell them also so there's a couple options there um certainly When I Was preparing I was looking at things on the internet and there are pictures and and and videos and things but um it's a good suggestion because we could certainly put some of that just reflecting backwards you know I had some exercise with your shoulder and and there were certain angles and you had these two dimensional pictures and you know you do it and then you come back and say geez I can't remember exactly what I what direction I was supposed to be moving these rubber bands you y so we could put some of that up on our website that's a great suggestion yes um so are there McKenzie exercises to prevent back pain from happening in the future if you if you don't have it yet if you've never had it or okay um probably it's going to depend on how your spine presents and what your Mobility looks like but most likely when a a patient who's anyone over a teenager comes in we're going to find some anomalies and range of motion and strength and than that have become kind of altered over the course of years and so if we can remedy those things through some of these movement patterns and make a better balance then the theory would be that we're going to prevent pain because we're allowing your spine to function in a normal capacity and that's what we would do in our posture and flexibility evaluation that we're giving away this evening good anyone else well if you think of anything else uh when you're not here with me um you can always email through our website and I'll be happy to answer any basic questions you have but if you have a more significant issue and want um evaluation then that would require an imperson visit so thank you

Channel: Cioffredi & Associates Physical Therapy

Views: 91,531

Keywords: McKenzie Method, McKenzie, Back, Pain, Stretches, Therapy, Spine, Ortho, injury, rehab

Id: KRiBYHtpfqM

Length: 31min 28sec (1888 seconds)

Published: Thu Nov 14 2013