Quote of the Week

"We are seeing a revolution growing out of the old orthopedic concept of the 'dynasty of the disc' into a more integrated biopsychosocial model of back pain."

-Alf Nachemson MD, 1998

I just had a conversation with a newly-trained McKenzie practitioner this week. He told me all about lateral and posterolateral componenets of disc pathology responsible for peripheral pain and the mechanical diagnostic process. It makes me wonder, where's the revolution?  Any comments?

Comments

[John Goodrich]

To the extent that it's relevant to the question, in the most recent edition of Spine, Ozawa, et al, draw the following conclusions: "Almost all of the nociceptive nerve fibers in the human intervertebral disc are peptide-containing nerve fibers, similar to the rat disc, suggesting that nerve fibers related to inflammation may transmit pain originating from human degenerated discs." I am not a McKenzie trained therapist, so I'm not going to go there. I believe that what Nachemson is referring to is what the evidence clearly shows, that what is seen on imaging studies has little if anything to do with treatment strategies (personally I think Nachemson and others have overstated the biopsychosocial model as a stand-alone explanation for back pain, but that's another discussion). I think studies such as this (Nachemson is the first reference by the way) indicate that the disc, as a pain source, is not irrelevant. That leaves us to determine if and how this information impacts our clinical decision making, and to what extent it matters.

[Jason Silvernail]

Thanks, John.

I guess I was less interested in any evidence indicating that the disc has nerve tissue subject to mechanical or chemical stimulation (of course it does) and more interested in whether the revolution's most important point that you brought up (imaging findings do not equal symptoms).

If it's true that disc bulges and herniations are often present without pain, why is it that this practitioner has been taught that? (consider this a general and mostly rhetorical question)

I think, as we find that spinal manipulation is not about alignment and stuck facets and really about a neurophysiological mechanism, why this sort of orthopedic meme persists in other paradigms as well.

In other words, isn't it just as ridiculous to say a patient has an posterolateral disc bulge after exam as it is to say they have an ERS/FRS or Type I/II dysfunction?

Aren't these "diagnoses" grounded in theories that have been refuted for some time now?
Where's the revolution?

J

[John Goodrich]

I think that the "revolution," such as it is, is limited to researchers and a relatively small percentage of practitioners, and the research is far outpacing clinical reality. If it is true that evidence based practice is a focal point in the DPT programs, then our profession is well positioned to "universalize" if you will this concept (eg, reducing practice variability). As was alluded to in a PTConnect post, we often find ourselves at odds with both physician referral sources and colleagues. That should not suggest we hold a moral high ground, but we do have a great deal of work to do in terms of education. At the same time, the "new" constructs are still largely theoretical, particularly in terms of clinical application, so that also needs to be taken into account.

[John Ware]

Jason,
I don't know that it's been proved yet that manipulation may not in some instances "unlock" a facet. Certainly the evidence does show that there is a neurophysiological effect from manipulation, but facet-locking is a biologically plausible possibility-even if it hasn't been shown to be reliably diagnosable. Let's not overstate what the current evidence tells us.
John

[Jason Silvernail]

John G- Thanks, I agree.

John W - Re: locking facets - I will first say that it's not possible to prove a negative, but the fact that a facet block has never actually been demonstrated is I think an important thing to think about.
Like you, I have seen a few things that really seemed to me to be a true mechanical problem, and I can't be sure that in some rare cases, it isn't. I can think of a few SIJ cases I've seen for example.

But the the evidence at this time points toward a neurophysiological rather than mechanical answer, so that's the basket I'm puttin' my eggs in at the moment.
That's also the direction I think we should be heading, as far a research and practice goes.
Jason.

[Michael DuPriest]

We love our gurus and respect their opinions often more so than the evidence. We also love mechanistic explanations of why things work, rather than do they actually work in some particular condition.

This is not to say we should abandon research directed toward the "why" and I know the individuals who previously posted know where I am coming from when I say this.

I still occasionally get the question, "what kind of technique do you use?"
This whole way of thinking has existed for years and is engrained and actually propagated. Recently I participated in a survey from a PT school on regarding OCS practices. One question concerned itself with whether you do Maitland, McKenzie, Grimsby, or other. As this point in my career I am not really sure what I do, other than change an impairment and observe how it effects function.

Mike d

[John Ware]

Jason,
I just re-read Bogduk's anatomical study of the lumbar facet "meniscoid," (Spine 5: 454-60) and he did indeed suggest that an intra-articular meniscoid as a cause of acute "locked back" was probably overstated, but certainly possible. While I agree that trying to devine FRS's is futile, I still think we shouldn't put ALL our eggs in the neurophysiological theory "basket."
John

[Jason Silvernail]

Mike-
I couldn't agree more, and this is the sort of thing I'm trying to get at.

Hi John W-
Ever hear of Bertrand Russell's teapot story? It goes like this - let's say I think there's a china teapot in close orbit around the sun. While we'll never be able to prove that there's not a teapot there, we know that we've never seen a teapot any other place in space, and given what we know of the physics of space, the likelihood of that teapot being there is so infinitesimal that it's really not worth talking about.
How does this relate? Well, I'm willing to concede that there may indeed be a few cases where people actually have a soda machine problem (meaning the can won't drop and you have to bang on it to get your soda). But what seems quite obvious from the research into pain and human physiology is that those examples or teapots, if they even exist, are extremely rare. And probably not worth teaching our students or residents or colleagues about.

Neurophysiology is a much more plausible research and study area to explain our patients in pain. So it's not that those mechanical things aren't possible, it's just that they are so rare and so unlikely that it may not yeild much to discuss them. Kind of like sacral torsions and such.

BTW, if you ever demonstrate or find an actual facet block, please let us know. And call Ripley. :)

Jason.

[John Ware]

Jason,
The teapot analogy is pretty cool, and very logical, but irrelevant to the point I'm making. Whether or not there's a teapot orbiting the sun is of no consequence to any particular individual's experience. The concept in philosophy, I believe, is referred to as "pragmatism" or "instrumentalism." That is, is the phenomenon your trying to explain of any importance to anyone in particular? I think whether or not the effects of spinal manipulation are purely neurophysiological, entirely mechanical OR A COMBINATION OF BOTH is an important and momentous question for those who suffer with it and for the society that pays so dearly for its costly effects. Teapots orbiting the sun are, of course, inconsequential. Furthermore, I believe Bertrand Russell was more a believer in the scientific method than the immediate application of empirical findings. Did he not believe that empirical, scientific findings were tentative, and a piecemeal process of understanding the truth? I think he would advise against drawing hasty conclusions based on a few RCTs. Understanding is more important than Predictability.
John

[sean]

Hi all,
I just wanted to say that I've seen a large number of patients in my career who had a disc bulge (whether confirmed by MRI or not) that was remedied in part by the McKenzie method. In addition, I have seen even more sacral torsion patients who I was able to help by using methods which I've described in other posts.
All of my techniques fit in with the neurophysiological theory. I don't understand the problem with McKenzie and how anyone can think that it does not fit the theory perfectly. The same goes for sacral torsions. While the SI joint may not be the source of pain, its dysfunction creates a chain of events which leads to a person's c/o pain.
My point is that posterlateral disc bulges do create symptoms in many cases, as do sacral torsions. In those cases, if the root cause is not successfully treated, the pt will never fully recover.

[Jason Silvernail]

Oh boy, there's so much to address in that last one...

John W-
I agree with the thrust of your post, which if I read it correctly is that there may be both mechanical and neurophysiological effects of manipulation. I'm willing to believe that's possible. To my knowledge, mechanical effects have never been demonstrated. Not that there haven't been attempts.
Russell did believe in the tentative nature of empirical findings, which I believe supports my point more than yours.

Far from basing my opinion on "a few RCTs" - I am basing it on a wide variety of empirical and theoretical studies which not only fail to show any mechanical effects of manipulative therapy, but illustrate the nature of pain as a neurophysiological entity. I love our good discussions, man.

sean-
A few questions:
You mentioned that you've seen people in your career with disc bulges not confirmed by MRI but improved with McKenzie treatment. How do you know they had a disc bulge without an MRI? Is this just assumed because that's what Robin McKenzie said the evaluation process ends up with?

You mentioned sacral torsions and "While the SI joint may not be the source of pain, its dysfunction creates a chain of events which leads to a person's c/o pain". Is there any reason to think this is true? What is the incidence of "sacral torsion" in an asymptomatic population? If it's anywhere near the rate of disc bulge, then I would say your argument is not holding up very well.

If indeed disc pathology causes pain (and I beleive it can, but does not always), the reason why is not mechanical but neurophysiological. Pain will arise when the mechanical or chemical stimulus is greater than the tissue's ability to tolerate it. This can happen with or without disc pathology, so to ascribe pain to disc pathology and treatment to reducing the disc problem and therefore eliminating the problem is just plain wrong and a flawed argument. Yet this is precisely what my McKenzie colleague parrots to me.
It just doesn't make sense.

J

[Jon Newman]

I agree with Jason. Stuck facets and malalignment may exist but it would seem that many more people benefit from our interventions than those with detectable malalignment or stuck facets. Thus, having those things is not a requisite for getting better using the techniques.

On teapots and circular motion: Carolyn Porco (look her up) reminds us that there are in fact billions of teapots orbiting the Sun. They just happened to be affixed to the earth.

[sean]

Jason,
you stated, "...the reason why is NOT MECHANICAL but neurophysiological. Pain will arise when the MECHANICAL or chemical stimulus is greater than the tissue's ability to tolerate it." Ummmmmmmm, how is it mechanical, yet not mechanical at the same time?
Regarding the McKenzie method: In my post I'm using the best evidence available. If there are studies out there that are better constructed, and offer greater evidence, I'd love to see them. I'm not sure how else you can explain peripheralization, and centralization of radicular symptoms, in a dermatome, other than by McKenzie's methods.
RE MRI: there is another study that showed McK. certifed PTs were accurate in predicting the exact level of a disc bulge prior to MRI.
When I said "confirmed by MRI or not" I was referring to patients who did not have one, did have traditional dermatomal referral patterns, and resolved as expected using repeated motions.
Re sacral torsions: I'm going based on my experience of easily 100 patients in the last 2 years. Most common findings for these people include: pain below the belt, none above; intermittent/constant buttock pain, hamstring, and/or ITB pain; tenderness to palp. over some or most of the muscles listed above and 1 or both SI joints; in addition to the most common finding of all - equal leg length with one medial malleolus and corresponding ASIS higher than those on the contralateral side.
Upon evaluation, self-mobilization and stretching exercises provide immediate relief, improved gait, and less pain with transfers. My theory: lack of SI stability -> SI dysfx -> m. spasm/guarding -> deformation of nervous tissue -> pain, tingling.
Treatment protocol: self-mobilization if needed -> stretching which upon initial testing provided significant symptom relief immediately afterward -> progress to stabiliztion activities to promote dynamic stabilization while the pt's theoretically unstable static stabilizers lay down collagen and get stronger.
Course of treatment before discharge 4-6 weeks depending on the pt's ability to avoid exacerabating activities. The worst of which is a torsional force such as getting up from the floor (lunge style).
Sorry about the long post but it's not possible to answer the question without giving an in depth explanation.

John,
One question, if you find no clinically significant problems, how do you select your manual treatment techniques. What is the clinical reasoning process used when mobilizing someone without a ROM deficit, or at least pain when moving into that motion?

[Jon Newman]

Hi Sean,

What does "pain below the belt, none above" mean?

I don't understand why a simultaneous pain experience, in the shoulder or neck for instance, would change the outcome. Especially if you detected and fixed what was wrong.

Jon

[sean]

John,
From my experience with SI people, if they have pain above the belt, it is not ONLY the SI involved, if at all, and therefore the posted explanation would not accurately represent my treatment strategy.
Did you see the question I asked you in my previous, long-winded post?

[Jon Newman]

Hi Sean,

Based on the context of your question and the spelling of John (i.e. not Jon), I thought you were referring to John G. or possibly John W.

I'm not much for passively mobilizing joints unless active movment is contraindicated.

[sean]

Jon,
It's funny you mention that. I pride myself on prununciation and spelling of my patients' (dozens of diff. countries of origin) names, and then I can't even spell your somewhat typical name correctly.
Anyhow, when you wrote "our interventions" I was under the impression you were speaking of mobilization interventions. Your comments make more sense now.
That being said, what's your take on my SI interventions, reasoning, flow chart, and seeming success?
In addition, for people with similar symptoms, do you utilize similar/different protocols? Jason, any input would be greatly appreciated.
The fact is that no matter where I've worked, I've seen patients from co-workers and competitors with back and neck pain that were poorly mismanaged with usually poor results. In contrast, once working with the same pt's, I was able to help them achieve much more favorable outcomes.
I'm in this forum strictly to learn and help other colleagues learn better interventions and practice patterns. Enlighten me please.

[Jon Newman]

Hi Sean,

No problem. I'm a moron with names (among other things).

"Our interventions" referred to the large variety of movements and modalities PTs use with their patients.

I think most every PT can claim to have seen patients from co-workers and competitors who had poor results. In fact, having a poor result is almost a pre-requisite of seeing a co-worker's or competitor's patient. They're the numerator, not the denominator.

My take on SI stuff: I don't see the value of assessing SI alignment and trying to fix it.