While the term “McKenzie care” is very familiar to most physicians, it is a greatly misunderstood form of care. Because family physicians and internists play such an important role in initiating care for back and neck pain, it’s important for them in particular to understand just what McKenzie care is. So let me briefly cover ten things that all health care practitioners, but family docs in particular, should know about McKenzie spine care. Read the rest of this entry »

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. Read the rest of this entry »

In their excellent book about health care reform entitled “The Innovator’s Prescription”, Christiansen, et al provide some very practical insight into the challenge of diagnosing and treating low back and neck pain. The authors describe three sequential eras or phases of medicine: Intuitive, Empirical, and Precision medicine. Read the rest of this entry »

Millions worldwide are struggling with low back and neck pain and many of these are frustrated by having tried numerous treatments without success.  Of great importance is how few know that most low back and neck pain is rapidly reversible. That means that the underlying painful condition can be corrected and the pain turned off fairly quickly, often as fast or faster than it turned on. Many can learn how to turn their pain off, and keep it off, in just 1 or 2 sessions.  That includes those with acute and chronic pain, those with neck or back pain only as well as those whose pain radiates away from the spine and down the arm or leg.  But how to reverse the problem differs from person to person.

What is truly amazing is just how common rapidly reversible back or neck pain is.  Numerous studies document that nearly 90% of those with recent onset (acute) and 50% of longstanding (chronic) low back pain can be rapidly reversed.  Unfortunately, most people don’t know these things and, even worse, neither do most doctors.

How do you know if your back or neck pain is rapidly reversible?
To answer that question requires a special form of examination of your back or neck. For that,
you need to be examined by someone with special training in how to perform this evaluation. There are several studies that show that lesser trained clinicians cannot reliably implement this type of examination. If that examination demonstrates that your pain is reversible, it also reveals what is needed to reverse it so you can quickly recover.

That so many people are not being examined in this way means that many are suffering unnecessarily.  Most are prescribed medications that aren’t needed, given unnecessary MRIs, and many undergo spinal injections and even surgery that is simply not needed.  All players in the spine care community, including patients, need to learn more about this as well as the many scientific studies that validate the use of this type of care.

This form of care will have tremendous impact on the costs of managing individuals who seek care for their back or neck pain. In the U.S., nearly $90 billion is spent each year on the problem of low back pain alone! There is still-unpublished data documenting the staggering savings by utilizing this form of care.

In other blog entries, I discuss these savings available to employers and health plans frustrated with paying for so much unnecessary and very expensive care.

You can read more about that examination process and rapidly reversible back and neck pain at www.selfcarefirst.com and especially in my new book entitled: “Solving the Mystery: The Key to Rapidly Reversing Most Back and Neck Pain”.

Ron Donelson, MD, MS

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

Musculoskeletal (MS) conditions account for the majority of lost work and bed days due to health conditions. According to a report by the Bone & Joint Decade commission, they are the leading cause of disability and health care cost, as well as the most common health condition in the U.S.  The total U.S. cost of MS treatment and lost-wages in 2004 was estimated to be $849 Billion, or 7.7% of GDP.

In this large and very expensive MS arena, numerous studies show that many disorders can be resolved quite easily and quickly using some simple-yet-precise movements and positions of the painful joints that somehow actually correct the underlying problem and eliminate the pain.  The really good news is that, if you’re the one in pain, you can usually perform these movements and positions yourself.  But this requires your provider to first determine which movements, if any, will correct the problem and then teach you what to do.  This specific form of self-care, known as Mechanical Diagnosis & Therapy (MDT), empowers you to take control of, and eliminate, your own painful problem.

Unfortunately, these painful conditions are rarely treated in this way. Only a small percentage of individuals with MS conditions are provided the opportunity to be evaluated by a clinician with MDT training. Consequently, the painful conditions too often persist, even worsen, despite undergoing other extensive, expensive, sometimes even risky treatments. But most importantly, these treatments are all unnecessary for those who can recover using self-care first and MDT principles.

I wanted to advocate for this first type of MDT self-care across the spine care community in order to help individuals avoid these other ineffective and expensive treatments. I therefore founded Self-Care First in 2002. This blog is part of that effort. So whether your condition can be eliminated easily with MDT care or not, the best way to find out is to be evaluated by a practitioner trained in MDT.  In other words, first explore the potential and value of self-care.  Therefore…..self-care first.

Exploring self-care first is especially important in the many disorders that do recover, only to recur days, weeks, or months later. Low back and neck pain are common examples of conditions that frequently recur. Many treatments for these conditions are described as “passive”. That means your practitioner performs the treatment on your behalf, doing something TO you.  They may apply ice, heat, ultrasound, or diathermy to your painful area, or use their hands to massage, mobilize or manipulate your spine and other joints. But they are performing the treatment for you.  You are passive.

Even if effective in decreasing your pain, the pain usually returns again soon.  When it does, your experience tells you to return to get that same relief again for that same passive treatment from your practitioner.  So you seek that type of care again, and again, and again, that cycle repeating itself sometimes many times.  But you meanwhile learn nothing about how to treat yourself or how to prevent your own pain from returning.  You instead develop a dependence on your provider and this passive care while gaining no insight into why it keeps returning nor how to prevent it.  Some practitioners will deepen your dependency on them by recommending you return for treatment even after your pain has gone away in order to prevent your painful condition from returning.  But no data has ever shown that such treatment lowers the chance of having another episode.

Alternatively, if you had learned methods of self-care first that enabled you to eliminate your own pain, you would have also learned how to prevent your pain from returning, a necessary part of your recovery from your current episode as well as for preventing it over the weeks and months ahead.  And if or when your pain does return, you already know how to get rid of it by yourself, because what worked before usually works just as well now.  You have been empowered to be independent of your practitioner using the know-how learned earlier to quickly and effectively treat yourself.

There’s one other point that illustrates the importance of pursuing self-care first (MDT care).   In other blog postings, I described studies documenting that as many as 50% of individuals with back pain that had been considered disc surgery candidates, when finally provided this MDT evaluation, found out they had a rapidly and easily reversible problem all this time that would quickly resolve using self-care.  This enabled these individuals to avoid what would have been unnecessary surgery.

The overwhelming message for patients, clinicians, employers and health plans is to pursue MDT and self-care first.  To locate a practitioner near you that is trained to provide you with this form of care, click here.

Here are some books you may wish to read about MDT and self-care for low back, neck, and shoulder pain:

Treat Your Own Back, by Robin McKenzie

Treat Your Own Neck, by Robin McKenzie

Treat Your Own Shoulder, by  Robin McKenzie

Solving the Mystery: The Key to Rapid Recoveries from Most Back and Neck Pain, by Ronald Donelson

Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings, by Ronald Donelson

Dr. Ron

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

In my book “Solving the Mystery: The Key to Rapid Recoveries from Most Back and Neck Pain”, I included the stories of two individuals, one with disabling neck pain and the other disabling back pain, both persisting for more than two years despite actively seeking care.

I was present when Peter was first examined for his chronic neck and arm pain.  It was a demonstration to attendees at an international spine conference of how the MDT evaluation identifies rapidly reversible conditions and then guides rapid recoveries.  References to “Figures” below pertain to illustrations in the book.

PETER’S HISTORY
Peter is a 38 year-old adventure guide and instructor who was on his honeymoon when the car he was driving was hit from behind while stopped. He passed out at the scene and was taken by ambulance to the hospital where no severe injuries were identified. He was discharged, given Tylenol, and told to see his doctor when he returned home.

Severe headaches soon started that kept him from sleeping at night as well as pain and numbness progressing down his left arm to his hand. His physician at home sent him to physical therapy that he continued for 18 months.

His pain forced him to stop working because he couldn’t rotate his head when kayaking nor look upward when leading rock-climbing groups.

A neck MRI showed bulging/prolapsed discs at his C5-6 and C6-7 levels that were pressing against his nerve causing the pain and tingling in his left arm.

He was referred to a neurosurgeon who offered him surgery to relieve the pressure on the nerve.  He was told there was a 50% chance of improvement, 40% chance of being the same, and a 10% chance of worsening as a result of the surgery. Because he didn’t like those odds, he decided against surgery.

PETER’S MDT EXAMINATION
He was finally given the opportunity to be examined by a physical therapist with extensive training in Mechanical Diagnosis & Therapy (MDT). At that time, he reported he had improved only 10% over his 18 months of physical therapy. He had pain, numbness and tingling into his left palm and fingers as well as tension and tightness in his neck and aching in his left arm. He did report some improvement in those symptoms four months earlier when he changed his job and stopped climbing and kayaking.

Attempts to bend his neck in any direction seemed to increase his neck and arm pain, including bending his head and neck backward. But a special variation of neck extension (bending the neck backward) noticeably decreased the arm and hand tingling that then didn’t return, which he stated was a “huge difference” from his last 18 months. With more neck extension movements, his hand and arm symptoms improved substantially and remained better, which greatly impressed Peter.

PETER’S MDT EDUCATION AND SELF-CARE INSTRUCTIONS
The therapist told Peter that something was pressing on the nerve and they were perhaps learning that that “something” might be able to be withdrawn from the nerve so his pain and tingling would go away.

He was instructed to perform 10-12 repetitions of the cervical extension exercises 5-6 times/day.  He was shown how to perform them standing, sitting and lying down. He was shown how his forward head position when sitting aggravated his condition and was given a lumbar roll to use behind his lower back, especially in the car, to enable him to sit more erectly with his head positioned much better to keep from aggravating his condition while sitting (Fig. 22.6).

FOLLOW-UP
Using this self-care strategy, the tingling in his arm and hand disappeared almost immediately despite having been present for 18 months.  His headache, neck and arm pain progressively decreased over the next four weeks to where he no longer had any pain. He reported three months later that he was pain-free as long as he did his exercises. He admitted to only doing them 1-2 times per day and if he stopped those exercises for more than two days, his headaches would return very slightly which reminded him to return to his exercises.

He was able to return to all of his work and had even taken up snowboarding as a new sport that he could now include in his work.

SUMMARY
In hindsight, Peter had an undiscovered rapidly reversible problem all this time. Like so many with motor vehicle whiplash injuries, his neck and arm pain didn’t begin until many days after his accident. He then underwent 18 months of useless physical therapy and almost accepted an unnecessary surgical procedure because neither he nor his physicians knew his underlying problem was actually rapidly reversible all this time. Fortunately, Peter finally found someone trained to evaluate and treat him using MDT principles of care.

Peter Is Not An Unusual Patient! There are published data indicating that half of chronic back and neck pain patients respond similarly. While not unusual, sudden and rapid recoveries like this are not widely known, which is why I have written my books and created this blog.  Unfortunately, and most importantly, such dramatic recoveries are also unfamiliar to most health care providers, payers and policy makers who do not provide their back and neck patients with this Mechanical Diagnosis & Therapy (MDT) form of evaluation.

From a cost perspective, every one of these patients who have an undiagnosed rapidly reversible condition costs tens, if not hundreds, of thousands of dollars in direct medical costs and lost productivity,……..all unnecessarily! It only requires a thorough MDT evaluation at the outset of their care to identify them early and guide their rapid recovery to avoid nearly all of that unnecessary expense.

Peter’s actual initial MDT evaluation at this conference can be viewed on DVD available at http://www.optp.com/A-Day-with-McKenzie-DVD_914DVD.aspx. The therapist on the DVD who assessed Peter is Robin McKenzie himself, who developed the MDT method of care.

Dr. Ron

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

 

A very common complaint patients with back or neck pain have is that their doctor doesn’t provide them with a clear diagnosis or explanation of their pain.23,79

That complaint is quite understandable because the conventional examination used by most doctors, along with the best imaging procedures available, are unable to identify the precise cause of most back and neck pain. That does not mean there isn’t a cause; it just can’t be found in most cases using those methods of evaluation.

Nevertheless, back and neck pain often go away on their own in a few days or weeks, regardless of what treatment you pursue.21,59,81,82 Therefore, the underlying problem, whatever it is, is somehow often able to recover, even without formal treatment.

Unfortunately, even though it goes away, it often returns a few weeks or months later.21,59,81,82 Each time it returns, it is referred to as a new “episode”. Each episode ends when the pain goes away again for a few more weeks, months, or maybe even years. Unfortunately, it is all too common for back pain to return several times each year and continue to do so for many years.

Many report that, when their pain returns, it’s even worse than before.30,83,84 Perhaps you have had a few episodes.  Is your pain now more intense, more disabling, lasting longer than in your early episodes? Has it now spread into your arm or leg and require more care than in the past? Often, after many episodes, your pain finally just doesn’t recover again. When it persists for three months or more, it is usually referred to as “chronic”. Once symptoms become chronic, the underlying problem is often much more difficult to solve.

Sometimes back or neck pain become so severe that it prevents you from doing things you want and need to do: you can’t work, take care of your home and family, or participate in the fun things in life. If you are just not improving, your doctor may offer a referral to another doctor for spinal injections or to a spine surgeon to consider an operation.

Besides being no fun, these procedures are risky. They are not always successful, may make your pain worse, cause new symptoms, and also limit future treatment choices. In most circumstances, these risks are unlikely, but they are certainly possible. Unfortunately, it is not unusual to end up with long-term, even permanent, disabling pain.

But these procedures can also be helpful for many. But who are they? There is no way to figure that out ahead of time. And unfortunately, even those who improve are often still unable to return to their former level of activity or work.

So are there any better solutions? Yes, thankfully, for most there are.

The above is a chapter excerpted from my book entitled “Solving The Mystery: The Key to Rapid Recoveries for Most Low Back and Neck Pain.”  This book, my first book (“Rapidly Reversible Low Back Pain“), the SelfCare First website, and many posts on this blog are all devoted to spreading the message:  yes, thankfully, there are better solutions.  In fact, most back and neck pain is rapidly reversible using simple-but-specific exercises and posture modifications. Keep reading these resources. (Numbered references in this excerpt cite specific scientific articles listed in this book.)

Dr. Ron

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

During these critical times of economic challenge and intense debate over health care reform, finding ways to reduce the cost of health care is central to solving our financial dilemma.  Many feel that both the quality and cost of health care are greatly influenced by how providers are reimbursed because their actions and interactions are understandably tied to their need to earn, protect, and even grow their own incomes.

Reducing the Cost of Care
In an effort to reduce costs, there are five ways commonly discussed for doing so.  Four of them are tied to changes in how services are reimbursed: 1-just lower fees in the current fee-for-service system; 2-transition to a pay-for-performance model where fees are based on quality and value of the service; 3-combining payments for distinct episodes of care (fee-bundling); and 4-creating global payment systems, such as capitation.  The fifth is to simply restrict access to, or ration, certain forms or quantities of care.

Let’s look at and compare the first two of these reimbursement methods and how they influence providers in their role in determining both the quality and cost of health care.

Fee-For-Service Reimbursement
Fee-for-service reimbursement is currently our dominant payment method.  It rewards providers for prescribing more treatment, not less, with the same financial benefit for a superior treatment outcome as for an inferior one.  An inferior one even requires more treatment, which of course can mean more income.  So the more services a provider carries out and the higher the price of those services, the more money that provider makes.

This volume-driven system creates considerable conflict for providers, many of whom understandably develop an economic bias in favor of treatments that pay better, sometimes even if they are unproven, without necessarily even considering what’s best for their patient. That widely held economic bias moves providers toward delivering as much treatment as possible, rather than providing treatment only as needed for recovery.

So to merely reduce fee-for-service reimbursement fees as a major cost-cutting strategy will only provide very short-term savings as neither patients nor providers have any incentive to reduce levels of utilization or to maximize the quality of care.  To the contrary, it is predictable from past experience that reducing those fees will only motivate more treatment to compensate for the lost income from lower fees. Since delivering high quality care is not rewarded financially, it therefore is very often not the provider’s primary objective.

Pay-For-Performance Reimbursement
Alternatively, the intent of a pay-for-performance, or value-based, system is to reward high quality and value in the care provided.  It does this in large part by eliminating providers’ conflict so their financial incentives match their patients’ priorities.  Providers are therefore rewarded for the quality of their work, not its quantity.

There are two fundamental challenges within this system however.  The first is how to accurately define and establish some standard of quality and value and then how to measure its delivery in a reliable, meaningful manner.

If Value = Quality/Cost, then value increases by improving the quality of the outcome, by decreasing the cost of care, or, ideally, both.  The current reality, especially in spine care, is that costs keep rising, rather dramatically in the case of injections and surgery, with little, if any, evidence that patients’ outcomes are improving as a result.  For all the technological innovations in spine care over the last two decades, the value of that care has actually decreased.

So what does a quality outcome look like? Ideally, it is best defined by those seeking care: the patients.  A survey of physicians, low back pain patients, many of whom were out-of-work because of their pain, treating staff members, and third-party payers (including employers) asked which of six treatment objectives they valued most.  Physicians and patients valued pain control most, while the treating staff and payers valued return-to-work the most. Fortunately, these two objectives often improve together.  In fact, pain relief and functional improvement have become fairly standard measures of quality spine care.

What is Effective Care?
There is a second challenge: there is little convincing evidence that most forms of treatment provide any higher quality and savings than others.  Many interventions remain controversial: opioid therapy, epidurals, physical therapy, chiropractic, facet blocks, discectomy, fusion, and kyphoplasty/vertebroplasty.  The evidence supporting the reimbursement for much of this care is unfortunately not convincing.

Perhaps the most important reason these treatments are so controversial is not because they are ineffective, but because we simply don’t know how to determine who will benefit from each and who will not.  Each likely has the potential to provide benefit, but only for certain patients. We just don’t know how to determine who they are.  Some researchers are working on how to best determine this.

Improving Health Care Requires Innovation in Patient Assessment and Classification
As long as we continue to reimburse health care using a fee-for-service, i.e. volume-driven, reimbursement system, we will not substantially improve the quality of care.  This system offers providers no incentive to improve their outcomes nor to find innovative ways to select patients better.  Who cares if the patient will benefit or not, if reimbursement is the same either way?

We must first learn how to make better treatment decisions but, again, there’s no incentive to develop that know-how or innovation until there’s some financial reward for doing so.  The greatest financial reward targets high-priced invasive treatments rather than innovation in how to excel in patient selection for those procedures.  So both quality care and innovation are stifled by fee-for-service.  Regina Herzlinger writes: “it’s only innovation that’s going to control our health care costs: innovation is insurance, in the way health care is delivered and in technology.”  Meanwhile, Clayton Christiansen, in his book “Innovative Prescription”, describes fee-for-service reimbursement as a “perverse regulator” of health care and a strong deterrent to innovation.  Innovation is a key component of health care progress and volume-based reimbursement is obstructing its development.  He also predicts that diagnostic innovation will become the higher paying form of care.

Despite these challenges, both the quality and cost of care can be improved when treatments are provided that predictably deliver sufficient benefit that the patient needs no further care AND is able to function well, long-term, so no, or very little, care is needed again.

It is the availability of high quality, low cost care for back, neck and musculoskeletal pain that SelfCare First wants to bring to the attention of everyone dealing with these conditions: patients, providers, employers, health plans, and even researchers. The data being generated by health plans and employers in terms of cost-savings, both short- and long-term, for the use of MDT is very impressive. You can read more about this in my other blog postings and at our SelfCare First website.

Please visit us and let us know how we can help you, via email or leave your comment or question below.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: blog.selfcarefirst.com

This past weekend, I made a presentation to a group of 20 or more spine surgeons on the topic of “Improving Your Surgical Outcomes With Better Patient Selection”.  This was at the New England Spine Study Group meeting in Springfield, MA.  That’s also the home of the Basketball Hall of Fame where our meeting was actually held, in their lovely auditorium.  After the meeting adjourned, I had the afternoon to tour the H. of F., which was great fun for this long-time basketball fan.

My 30-min. presentation focused on the rationale and benefit of utilizing a special form of clinical evaluation of low back and neck pain patients developed by Robin McKenzie and often referred to as “Mechanical Diagnosis and Therapy” (MDT).  My intent was to make the case for incorporating that assessment somewhere along the care pathway leading up to the surgeon’s decision.  Happily, rather than focusing on the potential loss of surgical cases, surgeons instead expressed their appropriate concerns about not wanting to perform unnecessary surgery.

You can learn more about those MDT methods in some of my other postings and in my books, found at www.selfcarefirst.com.

I told them about four published studies (see references below) that all document that this form of assessment can identify patients who would otherwise have undergone unnecessary surgery if not provided the opportunity to identify that their condition could still recover using non-surgical care.  Whether this form of evaluation is offered at the fairly late point of surgical decision-making, or much earlier in a patient’s care, it is extremely important for both recovery and cost outcomes.

You see, in each of those pre-surgical studies, as many as 52% of patients were able to rapidly diminish and eliminate their own pain, and thereby avoid surgery. One study reported that just over half of the individuals with full sciatica and neurologic deficits were able to eliminate all their pain themselves within 2-5 days after their MDT evaluation was finally performed just prior to being scheduled for surgery.  They eliminated their pain using only some simple “disc-correcting” exercises.

In an earlier blog posting, you can also read about a friend of mine who was scheduled for surgery when finally provided the opportunity to be evaluated with MDT principles.  His response during the initial evaluation was very encouraging and he consequently cancelled his scheduled surgery and was able to completely recover using some simple exercises and other self-care strategies.  He only wished his family physician, or anyone else for that matter, had referred him for that evaluation many months before when he would have recovered even more quickly but, most importantly, he would have avoided all those months of pain and disability, along with all that unnecessary cost to his health plan.

Such rapidly reversible cases are especially common in those whose back or neck pain is of recent onset, generally referred to as “acute”.  Studies report that 70-89% of acute back and neck pain patients have this rapidly reversible kind of condition that can only be identified by using this form of MDT evaluation.  Unfortunately, whenever this assessment is delayed, many of these individuals’ pain becomes chronic and that percentage whose pain is rapidly reversible drops to 45-55%.  Even though that’s still a sizable percentage of chronic pain that remains rapidly reversible, it also means that many back conditions lose their ability to rapidly reverse that they had when they were acute.  This sizable subgroup of patients has lost its window of opportunity to rapidly reverse the underlying painful condition before it deteriorated and became irreversible.  The solution to their problem, if there still is one, is often much more complex, sometimes even requiring surgery that could have been prevented.  For so many, an early assessment using MDT methods avoids so much pain, disability and cost.

One of the spine surgeons who heard my presentation caught the importance of educating family physicians about the value and importance of providing this assessment early for their back and neck pain patients.  He expressed interest in developing an educational effort for the family physicians in his community.

I believe there will be a point in the next few years when the standard of care for acute and subacute back and neck pain will become the provision of this special form of assessment.  The prevalence data speaks clearly that, if this assessment is not implemented in time, patients with either acute back or neck pain can lose that window of opportunity, finding themselves instead on a slippery slope, in danger of sliding into long-term (chronic) pain at considerable expense to themselves, to society, and to employers who are paying the tab.

Unfortunately, most family physicians remain unfamiliar with MDT and all its benefits to them and their patients.  All the scientific studies that validate MDT have been published in spine care-related journals that are unread my family physicians.  We need to establish educational opportunities to influence their education on this topic.  One way I’ve attempted to help is by writing two books entitled “Rapidly Reversible Low Back Pain” and “Solving the Mystery”.  Family physicians who have read them have found them extremely enlightening.

Some hospital and physician networks have expressed interest in educating their primary care docs in order to improve both the quality and the cost of spine care in their communities.  That is an excellent step and we need expand that to a much broader scale across the family medicine practicing and academic profession, as well as within the curriculum of their training programs.

Please leave comments and your input regarding ways to deliver this education so we can substantially halt the flow of acute to chronic back or neck pain.  You may visit www.selfcarefirst.com for more information.

1. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain: A predictor of symptomatic discs and anular competence. Spine. 1997;22(10):1115-22.

2. Kopp J, Alexander A, Turocy R, Levrini M, Lichtman D. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus, a preliminary report. Clinical Orthopedics. 1986;202:211-8.

3. Laslett M, Öberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. The Spine Journal. 2005;5:370-80.

4. Rasmussen C, Nielsen G, Hansen V, Jensen O, Schioettz-Christensen B. Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine. 2005;30:2469-73.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: blog.selfcarefirst.com

Robin McKenzie developed the evaluation and treatment approach to managing back and neck pain known as “Mechanical Diagnosis & Therapy” (MDT).  I had the good fortune of meeting Mr. McKenzie in 1981 when I was first in private orthopedic practice.  A good friend and physical therapist dragged me to a four-day course McKenzie was teaching in Syracuse, NY.  I think I only attended one of the days but I saw some remarkable things there that planted a seed that slowly grew and changed my entire professional focus over the next thirty years. During the 80’s, I transitioned from my sports medicine, orthopedic surgical, small town practice to a research-oriented, non-surgical, large medical center spine practice.  But that’s a story for another day.

Today I want to focus on Robin McKenzie and what he has contributed that is of such great importance.  He is world-renowned in the field of spine care for his unparalleled contribution to evaluating and treating back and neck pain.  The methods he developed and investigated for more than two decades starting in the mid-1950’s in his own New Zealand clinic determined that a high percentage of back pain is caused by a condition that is usually rapidly and quite easily reversed or corrected.  He was decades ahead of anyone else in determining that most people could rapidly reverse their own problem using simple-yet-very-specific pain-eliminating exercises and posture modifications that could only be identified for each individual using his unique form of clinical examination.

McKenzie’s contribution has not so much been about how to treat back or neck pain, but how to evaluate it.  He developed some simple but very special clinical tests that became the focus of his routine office examination.  Specifically, his most important contribution was to have individuals bend their lumbar spines repeatedly to end-range, meaning as far as they can comfortably bend, testing one direction at a time, doing so both while standing (loaded) and then while lying down (unloaded). By monitoring how their pain responded during, and as a result of, this type of testing, very important features of the underlying condition were revealed.

Why is that so important?  Because most physicians, whether its your family practitioner or the spine expert in the Medical Center’s Spine Institute, only have their back and neck pain patients bend their spines once in each direction, to see how limited their movement is.  However, McKenzie has taught us how incredibly informative performing these bending tests repeatedly can be.

Here’s the difference.  If an individual with low back pain performs a standing back bend only once (see below), what most doctors routinely request, that single movement often causes the pain to briefly increase.  For many doctors, that increase promptly suggests that the pain may be coming from one or more facet joints.  Those are small joints located in pairs in the back of the spine that are loaded or compressed with backward bending.  Too often, doctors conclude from that increase in pain that back bending should be avoided, figuring that it may be aggravating the underlying problem.

A standing backbend is one of many valuable spinal bending tests, if performed repeatedly.  For many, it can also become a very helpful pain-eliminating treatment exercise.

However, if patients are then directed to perform this same backbend test repeatedly, each time bending as far back as they can, this very same movement, as it’s repeated, often becomes progressively less painful.  Many also have pain radiating into their buttock, thigh, or lower leg. These test movements often begin to eliminate the furthest-away pain first and, with even more repetitions, the rest of the pain subsides until only midline back pain remains.  Additionally, their ability to bend backward progressively increases.  If more repetitions completely eliminate the back pain, the ability to bend backward will be completely restored as well.

So the very direction of testing that increased the pain on just the first try ended up progressively eliminating the pain with more repetitions.  This testing teaches both the clinician and the patient how to quite easily eliminate the pain.  Of further importance, if the pain returns again, whether in the car, at home, or at work, the patient can promptly return to this same movement and eliminate their own pain again.  So what began as a test ended up being a very effective self-care tool for the patient.

So McKenzie’s greatest contribution was to discover that the results of a common spine-bending test movement, if performed only once, often leads clinicians to draw an incorrect conclusion: in this case that extension should be avoided.  But when that same test is performed repeatedly, just the opposite is true.

I cover this in greater depth, including why this happens, in both of my books that can be found at www.selfcarefirst.com.

Pain that can be eliminated so rapidly in this way, and then its return prevented the same way, means that the underlying painful condition was dynamic, easily changeable, and, most importantly, reversible. Specifically, it somehow benefits from a single direction of repeated end-range movements, very often by bending the lower back backward.

While most people with back or neck pain can learn how to eliminate their pain and then keep it from returning again, there is a small percentage whose pain does not respond in this way.  When tested in this same way, their pain is either unaffected or even temporarily irritated.  But that is also important information for those individuals who need to undergo other forms of evaluation and treatment.

So the big question for everyone suffering from back or neck pain, and for their doctors: is there a way to rapidly reverse this condition to bring about a rapid recovery?  An evaluation using the principles Robin McKenzie has brought to us can determine that.

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: blog.selfcarefirst.com

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