The Greatest Discovery EVER in the Management of Low Back and Neck Pain

March 19, 2015

For centuries, many with a fever died before we ever knew what an infection was. Fever was often attributed in those days to things like immorality or weakness of faith.  But with so many dying, a wide range of treatments were desperately tried.

In hindsight, there is little doubt that the cause of fever and associated deaths across those centuries was commonly an infection.  But not until diagnostic innovations like the microscope, culturing techniques, and sensitivity testing once antibiotics were invented could a very precise diagnosis of infection be made, followed by the delivery of what became predictably effective antibiotic treatment.

Similarly, low back pain (LBP) and neck pain (NP) have been described throughout the history of mankind.  Hippocrates (c. 460 BCE – c. 370 BCE) was the first to use a term for sciatic pain and low back pain. Through the medieval period, folk medicine practitioners provided a wide range of treatments for back pain to address what they believed were bad spirits, not unlike the early theories about fever.  A psychosocial label seems to be a common default explanation when there is an inability to make a clear medical diagnosis.

Treatments included a diverse array of non-surgical methods until Mixter and Barr performed the first surgery in 1938 to remove some herniated nucleus pulposus.  Since then, both surgical and non-surgical decision-making and treatment remain highly variable and drive very expensive care tied directly to each care provider’s educational background and practice preferences.

Yet even today, it is commonly believed that the underlying diagnosis for these non-specific symptoms of LBP and NP is unknown in 85% of patients with a common belief that psychosocial issues play a prominent role when pain persists.

Directional Preference: the greatest discovery in the history of LBP?

Though the term “directional preference” (DP) was not introduced until 1991 (1), that clinical phenomenon was first observed by Robin McKenzie in the mid-1950s.  Since then, thousands of healthcare practitioners worldwide, mostly physical therapists, have been trained in McKenzie’s methods of clinical evaluation (also known as Mechanical Diagnosis & Therapy or MDT) by completing the educational curriculum and credentialing process offered by the McKenzie Institute International.

Such a high level of interest in this paradigm of care stems directly from the importance and value of identifying DP.   Quite simply, a DP found during an MDT evaluation identifies that the underlying pain-generator is “rapidly reversible“(2) and can be corrected in most cases by some simple exercises and posture modifications that can be performed entirely by the individual experiencing the pain.

Why is DP the greatest discovery in LBP history?

After centuries of having little insight into and no solution for these non-specific symptoms, there is now extensive documentation (2) that validates the importance of DP.  This documentation reports that:

  • the pain-generator for the majority with LBP and NP has a DP: 70-89% of recent-onset pain and at least 50% in those with chronic symptoms.
  • these patients can correct their own problem using the findings of this simple, inexpensive, safe, non-invasive diagnostic process.
  • since there is no need for invasive care, there is no need to identify the anatomic pain source nor to pursue any imaging or EMGs in this very large subgroup.
  • there is no need for medications, prolonged physical therapy or chiropractic care, ER visits, specialty referrals, injections, or surgery.
  • to achieve their recovery, these patients first learn how to eliminate their own symptoms, then how to prevent them from returning, and finally how to prevent future episodes by independently implementing the same self-treatment strategies either proactively or else promptly in reaction to any symptom or sign of a recurrence.

In many studies, DP has been tied to a pain-generating intervertebral disc disorder(2), whether the pain is primarily axial or tied to nerve root compression.  In either case, and regardless of whether the pain is acute or chronic, and regardless of what prior treatments have already been unsuccessful, a DP finding has an excellent prognosis if treated with matching directional strategies.

Given the centuries, including the last 50 years and the present, of how poorly LBP and NP have been managed, these are astonishing and game-changing facts. This DP discovery means that only 10-15% of patients still deserve the label of “non-specific” LBP or NP. Rather, the pain for the great majority with a DP appears to be directly tied to disc pathology.

So just as victims of fever across many centuries never had the benefit of diagnosing their infection and receiving specific antibiotic therapy, neither did LBP and NP victims have access to MDT diagnostics that would have identified the reversibility of their pain source.  Just what the microscope did for diagnosing the cause of most fever, Robin McKenzie’s diagnostic innovation dramatically contributed to the understanding and successful management of these very common and very expensive spinal disorders.

The tragedy is that, more than 50 years after McKenzie’s discovery, and despite the extensive DP publications over the past 25 years, most LBP and NP patients are still deprived by their doctors of the opportunity to undergo this MDT evaluation.  Most have a rapidly reversible disorder that is routinely undiscovered and routinely mis- or over-treated.  There’s also no reason to believe that most LBP and NP in the decades to come will not have a DP, whether or not it is discovered during each patient’s clinical evaluation.

The only remaining question is how long will today’s spine specialists remain fixed on their current status quo of care that appears to serve their own clinical preferences more than their own patients.  I believe clinicians get away with continuing their self-serving care preferences because, unlike treating fever, patients with LBP and NP aren’t dying if incorrectly treated.

As always, I welcome your thoughts and questions. Please leave a comment or question below.

1. Donelson R, Grant W, Kamps C, Medcalf R. Pain response to repeated end-range sagittal spinal motion: a prospective, randomized, multi-centered trial. Spine. 1991;16(6S):206-12.

2. Donelson R. Rapidly reversible low back pain: an evidence-based pathway to widespread recoveries and savings. Hanover, NH: SelfCare First, LLC; 2007.


3 Responses to “The Greatest Discovery EVER in the Management of Low Back and Neck Pain”

  1. Kailash tupe Says:

    may i ask you a question is it possible that patient suffers /pain aggravates in both flexion and extension movement? because one disc bulg (say for exp L4-5) triggers pain during flexion movement and another disc bulg (L5-S1) triggers pain during extension movement.
    if yes then in that case how MDT specialist can help this patient?

    • Thank you Kailash for your great question. Not only can two discs likely become painful in opposite directions, but it is also possible for a single disc to become painful with both flexion and extension. These are difficult cases but an MDT specialist would determine the best treatment based on further details that emerge from their assessment. One common solution is to temporarily avoid both flexion and extension in hopes that one direction will begin to stabilize/recover so that same direction then becomes available and useful to help treat the opposite direction. It requires careful, meticulous work but it can be effective in achieving recovery.

  2. KAILAS TUPE Says:

    thank you doctor for valuable guidance

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