1. The McKenzie Method An Overview Mechanical Diagnosis & Therapy of the Spine: A Dynamic System of Examination, Diagnosis, Intervention and Prevention By: Amrish Patel, MD, PT

2. Who am I?? Went to PT school (long time ago) Practice McKenzie based therapies for 4 years Got tired of doctors telling me what to do so I went back to Medical School Became a Physiatrist (Kessler Institute for Rehab) with fellowship in Sports and Interventional Spine (UPMC) Still use MDT type evaluation for spine patients to find directional preference

3. NO FINANCIAL DISCLOSURES None, I am broke!

4. Overview Epidemiology of low back pain History: Who is Robin McKenzie? Who is Robin McKenzie? What is MDT? What is MDT? McKenzie Method Misconceptions MisconceptionsBenefitsClassificationsTreatmentsQuestions

5. Questionsto answer What is McKenzie Therapy? What is MDT? Does McKenzie Therapy = extension Is it only for radiculopathy Is it all hands off? Is there any evidence for McKenzie therapy?

6. Epidemiology 50-80% population experience back pain Peak prevalence 40-50 years of age and tapers after that C-spine -Women tend to be affected more men L-spine – Men tend to more affected than women First episodes of symptoms start in the 20’s w/ reoccurrence rates between 39-71% Majority (80-90%) of low back disorders occur at the L4/5 and/or L5/S1-

7. Who is Robin McKenzie?

8. History MDT Robin McKenzie Physiotherapist from New Zealand Physiotherapist from New Zealand Dr. James Cyriax Dr. James Cyriax strong influence on McKenzie's initial training strong influence on McKenzie's initial training considered the framework for MDT considered the framework for MDT Clinical experience Clinical experience Mr. Smith 1956 – 2 weeks of radicular sx then serendipitous surprise Exploration of End Of Range - some improved, while others worsened

9. History - cont What McKenzie learned from his accidental discovery is that most back and neck pain has a directional preference. Most spinal pain can diminish with backward bending positions/movements and a small percentage will diminish with more twisting or tilting movements.

10. History continued…. Over next 20 years developed approach Began teaching approach 1977 Rancho Los Amigos McKenzie Institute formed in 1982 >26 branches around the world Currently there are approximately >30,000 MDT therapist in US.

11. Enough History??

12. Common Misconceptions of McKenzie Therapy Compliments of McKenzie website www.mckenzieinstitute.org

13. Common Misconceptions McKenzie therapy=extension exercises to centralize symptoms only Only about Centralization: The process by which the pain radiating from the spine is sequentially abolished,distally to proximately, in response to specific therapeutic positions or movements. Only addresses reduction and abolition of spinal pain.

14. Reality

15. McKenzie Method Realities More than exercises, MDT is a system of evaluation and creating a treatment paradigm From history: is problem mechanical, medical, biopsychosocial or a combination From history: is problem mechanical, medical, biopsychosocial or a combination Develop Differential Diagnosis Develop Differential Diagnosis Classify/Stratify: if mechanical is it dysfunction, derangement, postural or other (not all and only about radiculopathy!) Classify/Stratify: if mechanical is it dysfunction, derangement, postural or other (not all and only about radiculopathy!) PE helps confirm or refute DDX PE helps confirm or refute DDX

16. Evaluation

17. McKenzie Classification Three Syndromes PosturalDysfunctionDerangement

18. MDT cont’d During assessment: All planes of motion are used in the assessment and to help guide treatment All planes of motion are used in the assessment and to help guide treatment Direction of treatment is based on patient’s symptomatic and mechanical response to repeated or sustained movements Direction of treatment is based on patient’s symptomatic and mechanical response to repeated or sustained movements Movements are done in progression from mid range to end range, not all just at end of range Movements are done in progression from mid range to end range, not all just at end of range

19. MDT Classification Postural: Prolonged end range stress on normal structure (e.g. sitting posture) Prolonged end range stress on normal structure (e.g. sitting posture)Dysfunction: End range stress or over stretching of shortened structure. (scarring, fibrosis, nerve root, adherence). End range stress or over stretching of shortened structure. (scarring, fibrosis, nerve root, adherence).Derangement: Anatomical disruption and displacement within motion segments (I.V.D) (this is the syndrome where centralization is more likely to occur). Anatomical disruption and displacement within motion segments (I.V.D) (this is the syndrome where centralization is more likely to occur).

20. MDT cont’d “ “MDT is not reliant on a patho-anatomical diagnosis but is based around a sound research proven classification system” and this helps to guide clinical management MDT does use mobilization techniques (not hands off therapy), but “MDT’s focus is primarily on education and self-directed treatments in order to reduce dependency on the clinician and to empower the patient to control their symptoms.”

21. Classification All three mechanical syndromes, postural, dysfunctional and derangement occur in the cervical as well as thoracic and lumbar regions of the spine. 2 categories of Derangements: -reducible (able to centralize and maintain the centralization). -reducible (able to centralize and maintain the centralization). -irreducible (at least 3-5 sessions of treatment before can lable it) -irreducible (at least 3-5 sessions of treatment before can lable it)

22. Derangements Severity indicators: - central and symmetrical symptoms. - central and symmetrical symptoms. - unilateral and asymmetrical symptoms to the knee. - unilateral and asymmetrical symptoms to the knee. -unilateral and asymmetrical symptoms to below the knee. -unilateral and asymmetrical symptoms to below the knee.

24. Derangements Directional preference or principle of management: Extension Extension Flexion Flexion Lateral Lateral Combination Combination Goal: abate symptoms (centralization)

25. Centralization of lower extremity pain

26. McKenzie Exercises Figure 3. Lying Prone Figure 4. Progress to elbows Figure 5. Full press up Figure 1. Seated Figure 2. Standing http://www.Spine-Health.com

27. More McKenzie Exercises Figure 6. Lying Supine Figure 10. Flex to Floor Figure 7. Knees bent Figure 8. Knees to Chest Figure 9. Flex with hands behind seat http://www.Spine-Health.com

28. Examples of lateral directional preferences

29. Benefits

31. MDT benefits MDT provides a system of assessment, diagnosis and subgrouping or classifying to help guide treatment. Provides ability for patient prognosis based on response to treatment in a few sessions Emphasis on self treatment provides the patient independence in long term management of their back pain Can help them prevent severe reoccurrences by being independent

32. McKenzie System Truths/Summary Based on good history taking Based on good observations Is logical if you understand it’s basic concepts and concepts of tissue healing Based on repeated motions, but not all extension Based on end range loading of tissue, but progresses through all ranges of motion Based on appropriate/ progressive loading of tissue, to help symptoms and mechanical changes Is a movement based system – is a mechanical based system Is involved in treating movement based problems Sprained ankles ; painful shoulders ; knee pain and dysfunctions ; can be used for acute or chronic problems Sprained ankles ; painful shoulders ; knee pain and dysfunctions ; can be used for acute or chronic problems Used world wide Used world wide

33. Questions answered? What is McKenzie Therapy? Method of classification and treatment What is MDT? Mechanical Diagnosis and Treatment Does McKenzie Therapy = extension? No Is it only for radiculopathy? No Is it all hands off? No Is there any evidence for McKenzie therapy? Yes

34. THE END GO DAWGS!!!