Improving Low Back Pain Care: A Paradigm Shift….Finally

December 21, 2011

First, I’d like to wish everyone a very Merry Christmas and may 2012 be a year of prosperity: physically, spiritually, emotionally, and financially.

I have advocated the benefits of making a mechanical diagnosis in individuals with back and neck pain since I first learned about how this was done 30 years ago. It was so impressive to see Robin McKenzie use his spinal movement testing methods to identify what proved to me over subsequent years to be very common patterns of pain response. These patterns enabled the classification of most patients into mechanical subgroups for which there were distinct and predictably effective solutions.

The truly astonishing observation was that these assessment methods revealed that most acute and a large percentage of chronic painful disorders are rapidly reversible, meaning they can be quickly corrected. To accomplish this first requires the precise identification of the mechanical characteristics of the disorder, which is possible in most cases. This needs to be followed by the appropriate mechanical patient education to enable them to carry out the required self-treatment strategies and bring about their own recovery.

Remarkably, this could be done in most patients, and that proved to be a career-changing realization for me. I had just completed the most up-to-date orthopedic training residency, but was never taught that painful spinal pathology “worked” like this, nor that so many could be so quickly and simply treated.

My mentors knew nothing about these dynamic mechanical behaviors. And now, thirty years later, despite an abundance of scientific studies documenting these clinical phenomena, most low back pain clinical guideline panelists still have no knowledge of these methods of care.

To be able to intentionally and rapidly centralize and eliminate the pain of most back and neck pain was quite astonishing. That ability gradually compelled me to turn my focus onto this large patient population and I have not been able to let go of my advocacy for this form of care. It is now commonly called Mechanical Diagnosis & Therapy (MDT), or just McKenzie care.

The scientific literature includes many reliability studies documenting that those who are well-trained in the MDT methods can examine the same patients and agree on their mechanical diagnosis. Further, many prospective observational cohort studies show that patients who demonstrate a rapidly reversible condition (called a “reducible derangement” and pain centralization in MDT jargon) and are then treated with mechanical strategies guided by the assessment findings have far better outcomes than those who are not in this subgroup. So the MDT assessment is able to identify those who can get better rapidly and how to make that happen, as well as those who cannot recover rapidly. Those are hugely important distinctions.

What’s really amazing is that those same studies document that this subgroup of reducible derangements comprises 80-90% of acute and 50% of chronic low back pain. That means that the great majority of low back pain patients, acutes and chronics, axial pain and sciatica, have a rapidly reversible problem.

Further, there are now eight randomized controlled trials that all show superior outcomes with MDT care for this large subgroup while other common low back pain treatments fall far short of producing those good/excellent results.

What primary care doc or spine specialist would not be attracted to a form of care that enables the majority of their patients to recover quickly, safely, and inexpensively by empowering them to treat themselves and learn how to prevent recurrences? That’s a very attractive package to provide your patients.

So why is it taking so long for MDT to gain recognition amongst spine care clinicians? In the Forward to my book “Rapidly Reversible Low Back Pain”, Kevin Spratt, Ph.D. wrote:

“it seems safe to say that the medical community as a whole sends too many patients down the more costly, invasive, and not necessarily more efficacious surgical path than the far less costly, non-invasive, and usually more efficacious MDT path. This is understandable in the case of the surgeons, and maybe even for general practitioners who might feel safer in sending patients down the more traveled path, but for payers to be willing to spend so much more for care, with no strong evidence that patients will benefit more, is hard to understand.”

Physicians may click here to review opportunities to learn more about MDT.  As Dr. Spratt writes, payers should especially be interested in how to substantially decrease their costs of low back and neck pain care. They may click here to visit the Payers area on the SelfCare First website to learn more.

2 Responses to “Improving Low Back Pain Care: A Paradigm Shift….Finally”


  1. […] is now substantial health plan and employer claims data documenting that a specific and unique mechanical form of clinically evaluating and diagnosing most musculoskeletal disorders (excluding fractures, dislocations and infections) can identify patient-specific non-pharm, […]


  2. […] and validating subgroups should be our top research focus.  But that requires more than RCTs. A new research paradigm(5) is needed that begins with reliability studies to demonstrate that both subgroup members and […]


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