RD & Dr.Sood

Dr. Ron and Dr. Sarveshwar Sood of India

In my last blog posting, I was heading to Dubai to give a presentation at the World Congress on Low Back and Pelvic Pain.  This conference is considered by many to be “the place” to hear the latest and greatest research from the world’s top spine and pelvic researchers. Attendees include clinicians (doctors, physical therapists, and chiropractors mostly) and researchers – both clinical and basic science. The Congress is held every three years in a different, and always attractive, city.  More than 1,000 attended this four-day conference from 58 countries. The conference venue was outstanding and Dubai a fascinating city.

I’m sure most considered the presentations to be excellent research, yet so many were in fact only lectures about myofascial and musculature anatomy and physiology of the spine and pelvis, but no clinical data. The rationale for these presentations?… these structures are essential to spine movement and stability, ergo, they must in some way be deficient in painful individuals and therefore in need of strengthening or stretching.  So many presenters offered no explanation for how pain is generated related to these structures and their deficiencies, nor did they present any data as to the beneficial impact when people perform exercises that theoretically address these alleged deficiencies. In other words, so what?  Interesting anatomy and physiology, but where’s the clinical relevance?

One positive and significant program feature for me was the final half-day that focused on the topic of subgrouping: why is it important, how to validate subgroups, and examples of subgrouping efforts.

The final talk of that final day by Hanne Albert, PT, PhD from Denmark, was especially well-received.  She is an excellent presenter who reviewed her research in identifying and validating a new, but very small, subgroup within the chronic low back pain population whose pain appears to be due to an infection within a disc that was previously herniated and now has Modic 1 changes in the adjacent vertebrae.  Her RCT reports that this small subgroup does quite well with antibiotic treatment vs. being treated with a placebo medication.

What is remarkable is that identifying and preliminarily validating this subgroup is being hailed as a major breakthrough by the spine care world, despite only one RCT.  Further, even if this is all true, it is still only about 1% of the LBP population.

Meanwhile, my presentation, described in some detail in my last posting, preceded Dr. Albert’s.  It focused on two cases of radiculopathy and how both became completely pain-free in just 30 min. and were able to avoid scheduled surgery.  They both then fully recovered within days, and remained pain-free when last checked two years later.  All this happened because of their mechanical (MDT) assessment followed by performing some simple, safe exercises without risk or side-effects.

But then I additionally presented a great deal of published evidence that these rapid recoveries are actually very common, occurring in 70-89% of acutes, 50% of chronics and radiculopathies, most axial neck and low back pain, as well as a good percentage of stenotics and spondys.

Of course, most researchers have never, or have rarely, seen a patient evaluated or treated, so they have no appreciation for the rapid and rather dramatic rate and ease of eliminating these patients’ severe pain, sensory loss, and tension signs, while simultaneously restoring normal movement and reducing the size of their disc herniations – all within their 30-minute first session!

Just one question was addressed to me during the subsequent discussion. I was asked how the status of a painful disc’s hydrostatic mechanism influences whether the pain can be centralized or not. I responded with the results of our study published in 1997 that compared the findings of the MDT evaluation in patients who promptly underwent discography that identified the status of the anulus and hydrostatic mechanism in centralizers, peripheralizers and those who had no change in pain with their MDT assessment.

Not surprisingly, conference participants without any MDT training were described by one as “spellbound” because, on one hand, these two patients’ presentations were very familiar to them, yet they had no idea that such severe disc pathology could be turned around so quickly and easily.  One U.S. physiatrist also noted that I was the only speaker to present so much data in my literature overview.

Nevertheless, my sense was that Dr. Albert’s presentation caused the greater buzz, by far.  So why was that?

On one hand, even if we assume that her Modic infection subgroup is validated, that still only represents a very small portion of non-specific chronic LBP patients.  Furthermore, treatment consists of 100 days of oral antibiotics that routinely creates GI side-effects, an occasional temporary blackening of teeth, and some treatment failures of course.  Pain relief doesn’t begin until weeks into the treatment and then often does not resolve completely.  Nevertheless, even this small validated subgroup is worthwhile identifying for those with this infection who otherwise would continue in pain.

On the other hand, the “reducible derangements” (dir. pref. and centralization) that I described account for 70-89% of acutes, 50% of chronics and sciaticas.  The treatment is simple, safe, routinely brings complete pain relief, usually in minutes, hours or a few days, and commonly leads to long-term freedom from pain for patients who perform very simple exercises on a regular basis and guard their posture a bit.

So how much ‘buzz” did my presentation create?  Only a handful came up to me at the gala dinner that night to comment.  So my sense is that it did not cause as much stir as Dr. Albert’s work. Was that because those dramatic recoveries I showed were viewed by some as too-good-to-be-true? Or perhaps these highly prevalent rapid recoveries were just too disruptive to clinicians’ rigid perception of back pain’s pattern of slow recovery.

Regardless, the evidence indicates that every patient with neck or low back pain should undergo an MDT assessment and every clinician should be obliged to provide such an assessment for their painful spine patients. The strong possibility of such rapid, simple, and safe recoveries should be made available to all.

As always, I welcome feedback and questions. Please be sure to click on “Like” if this was useful and enlightening, or “Leave a Comment” by clicking on “Comment” below. Have a wonderful week everyone.

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

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

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 neck pain and the other back pain, both disabled for more than two years despite actively seeking care.

I was present when Clare was first examined as a demonstration to attendees at an international spine conference of how the Mechanical Diagnosis & Therapy (MDT) evaluation identifies rapidly reversible conditions and then guides rapid recoveries. References to “Figures” below pertain to illustrations in the book.

CLARE’S MDT HISTORY
Clare was 52 years old when she developed a sore back after moving some furniture. When her pain worsened, she saw her family doctor who sent her to physical therapy, but that was not all that helpful. During treatment, her pain even began to spread down her left leg. Her doctor and therapist nevertheless felt she should continue physical therapy and was also given anti-inflammatory medications.

With more and more flare-ups, she was referred to an orthopedic specialist. An MRI was ordered but she was told it didn’t show very much. She was told to continue physical therapy even though it didn’t seem to be helping her.

She saw a second orthopedic specialist who also felt it would simply take more time and she needed to become more fit. Physical therapy was continued but now her left leg pain had become constant and so painful she was unable to continue working.

A second MRI higher up in her back showed some herniated discs in her thoracic (chest portion) spine but those were not considered responsible for her pain.

One of her orthopedic surgeons discussed the option of surgery and referred her to a neurosurgeon who found nothing to operate on and labeled her as having “chronic pain”.

She was sent to a pain specialist who told her she would have to learn how to live with her pain and manage it with drugs. She was evaluated by a “specialty team” consisting of an occupational medicine physician, physical therapist, and psychologist who developed a plan that would include an intense rehabilitation program.

She had now been in pain for two years. It had become constant with shooting pain down her left leg and she was too painful to work.

Through another contact, she was finally given the opportunity to see a physical therapist well-trained in Mechanical Diagnosis & Therapy (MDT).

She stated that prolonged sitting would consistently bring on or worsen her leg pain.

CLARE’S MDT EXAMINATION
The therapist observed that she sat very slouched. By having her sit very erectly, Clare reported that the intensity of her leg pain promptly decreased. When she repeatedly extended her lower back (bent backward), her leg pain decreased more and more until it disappeared. Slouched sitting would bring the pain back again but she found she could decrease and eliminate her leg pain with backward bending while standing or sitting but was especially effective when lying facedown performing a series of press-ups (Fig. 22.2).

CLARE’S INITIAL EDUCATION
The therapist explained that her pain had clearly “centralized” (come out of her leg) with low back extension test movements and this was a very good sign. She likely had a bulging disc that was irritating a nerve causing the pain, numbness, and tingling in her leg. The longer she sits slouched, the more it bulges and the pain increases. But extension (backbending) likely decreases that bulge by putting the displaced disc material back in its place that then takes the pressure off the nerve.

It was important to find out whether she would be able to stop her pain and keep it from returning using these extension exercises and very erect sitting posture. Could she now prevent the leg pain from returning and eliminate whatever low back pain was still present?

CLARE’S INSTRUCTIONS & TREATMENT
She was given a lumbar roll to place behind her lower back whenever sitting (Fig. 22.6) to help her avoid the slouch and she was to perform 10-12 press-ups (Fig. 22.2) 5-6 times per day for the next several days. She needed to be seen for another 2-3 visits to be sure that this was working.

With considerable hope that something useful had been found, Clare began to work diligently on her sitting posture and performed her exercises as instructed. By doing so, when she returned two days later, she reported she was able to stop her leg pain herself and even keep it from returning.

She was encouraged to keep up the same self-care efforts. She soon found herself pain-free and off all medications. She was also able to become much more active and soon was able to return to work with no pain.

SUMMARY
In hindsight, despite two years of worsening pain, seeing numerous physicians, therapists, and a psychologist, despite having had two MRIs, lots of medications, and nearly two years of physical therapy, it is clear that Clare had a rapidly reversible problem all that time that simply had never been evaluated adequately or discovered. Unfortunately, none of her physicians or physical therapists ever provided the MDT evaluation nor sent her to someone who could.

Clare had been unnecessarily doomed by all her care-givers to a life of “chronic pain” while her true problem, when finally fully evaluated using MDT principles, was actually a rapidly reversible derangement that she was able to easily correct herself and then able to maintain that correction and get back to work and her life.

Clair Is Not An Unusual Patient!
There are published data indicating that half of chronic back and neck pain patients may respond similarly.  While not unusual, sudden and rapid recoveries like these, after so long, 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.

Clare’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 Clare is Robin McKenzie himself, who developed the MDT method of care.

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

We’ve all read about individuals who have had near-death experiences.  But what about a “near-surgery experience” (and rescue) for someone in excruciating back and leg pain?

Last week, I had dinner with a good friend and reminisced about his “near-disc surgery” experience three years ago and how grateful he was to have avoided his scheduled operation.  He had developed severe back and leg pain and numbness in his foot that all started as just back pain after carrying some heavy equipment, falling on the ice three weeks later, and then cutting firewood for two hours.

Because he also developed some thigh pain, he was initially misdiagnosed by his family doc as having a hamstring tear.  But his pain became severe, interfering with his recreational, work activities, and simply walking.  Over the next 4-5 months, he saw a massage therapist, a chiropractor, a Reiki therapist, had cranio-sacral therapy, and treatment by a physical therapist while also trying Advil, Prednisone, Hydrocodone, Vicodan, Percocet, Neurontin, muscle relaxants, and had two epidural injections. But his pain and ability to function just kept worsening.

An MRI eventually showed a bulging disc compressing a nerve in his lower back.  Because of his excruciating pain and lack of improvement with all these treatments, he felt he had no choice and reluctantly consented to be scheduled for disc surgery.  Only then was he finally examined by a physical therapist trained in Mechanical Diagnosis & Therapy (MDT).

That unique examination revealed that certain movements and positions began to take away his lower leg and foot symptoms, indicating that his disc pain was possibly reversible and correctable, without surgery. As directed, he continued these specific pain-relieving movements/exercises and some posture changes at home. When his leg pain continued to improve, he decided to at least postpone his surgery.  His continued improvement also enabled him to progressively discontinue his numerous medications.  His foot numbness soon disappeared and his ability to walk and bend his lower back in all directions also progressively improved.

I also had given him a copy of my newly published book “Rapidly Reversible Low Back Pain” that he still says was “powerful” in helping him recover and understand what he was going through and why no one had introduced him to this kind of care long ago.

Six weeks after starting his MDT care, he was able to return to work and was soon pain-free.  He continued his simple exercises to keep his pain from returning.  He was elated to have complete recovery from this extremely painful disc problem while also avoiding the pain, apprehension, risk, and uncertainty of undergoing surgery.

At dinner, now three years later, he told me he remains pain-free, doing everything, including being a very active recreational athlete.  He had one brief, mild episode of back pain two years ago that he quickly eliminated using the same methods that helped him recover from his bad episode.

He is very grateful that he was finally taught how to eliminate his own pain that enabled him to dodge that surgical bullet that was about to strike him. He knows that if he hadn’t run into MDT care, and read that book, that he would certainly have undergone surgery.  He also realizes that his surgery, even if it had have been successful, would have been unnecessary.

One more thing.  He knows how many different clinicians prescribed and provided ineffective and even misdirected care.  If he had just been referred for evaluation and treatment with someone well-trained in MDT principles at the outset of his care-seeking, he would have recovered much earlier, much faster, avoided all those useless and expensive treatments and drugs, and not had to miss work and all his family and recreational activities for all those months.

My friend’s experience is not unusual, both from the standpoint of being treated with useless remedies but finding that even the most severe back problem can often be reversed easily with some simple-but-precise exercises.  There are at least four published studies all showing that 50% of those who are considered by their doctors to be candidates for disc surgery can still recover, usually much more quickly than my friend, when MDT methods of evaluation and treatment were properly implemented.

In fact, just like my friend, many other studies show that most back and neck pain sufferers can rapidly recover using self-care exercises and posture changes, providing they are evaluated properly using MDT methods.  Maybe your back or neck pain will respond rapidly like this too.

To find out more about how you, your patients, or your employees might be able to recover early and quickly from both simple and severe back and neck pain, come to www.selfcarefirst.com

Dr. Ron

Ronald Donelson, MD, MS

President
SelfCare First, LLC
Blog: selfcarefirstblog.wordpress.com

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