Thursday, December 10, 2009

The Facts about MRI’s

We have noticed an aggressive trend of increase MRI studies on low back patients over the past year. It is important to note that the false positive rates for lumbar MRI’s are quite high. Several studies or investigations have been conducted looking at groups of people who have never experienced back pain and had MRI’s taken. These asymptomatic individuals presented with disk bulges, protrusions, and extrusions. We see this often in the clinic as many patients come in with MRIs that show pathology on the opposite of involvement and we are quick to point out the importance of these false positive rates.

The McKenzie method or mechanical diagnosis and therapy (MDT) utilizes a phenomenon known as “centralization” which has been shown to be a more accurate indicator as to successful outcome for discogenic problems. Studies by Donelson have reported that referred symptoms to the buttock, thigh or leg in 89% of patients with acute pain, centralized during mechanical assessment. Of this centralization group, 91% have excellent outcomes resulting in complete relief of pain and restoration to function.

Some insurance plans are now requiring an MDT assessment be done prior to MRI studies to avoid the problematic issue of false positives and excessive cost. Of those patients that do centralize, we not only reduce their pain and restore function, but they also learn a valuable tool on how to prevent recurrent episodes.

Monday, December 7, 2009

Back to the basics

This past month, we have seen an increase in the number of patients with pain or parathesia that travels into the lower extremity. Back in 1990, a study was published “The centralization phenomenon: It’s usefulness in evaluating and treating referred pain”. In this study of 87 patients, 87% of all acute, sub- acute and chronic patients exhibited centralization. 81% of the centralizers and even 33% of the non-centralizers had good or excellent outcomes. Of this group, only 4 were surgical patients and were also non-centralizers and did quite well with surgery as well. The conclusion is that centralization is that it occurred commonly and its present or absence was a strong predictor of treatment outcome and present or absence of surgical disk pathology.

Very often our patients in these times are very eager to obtain an MRI study of their spine which will indicate a history of what condition their spine has been in and is not always conclusive to the source of pain. Centralization has proven to be a very valid predictor of treatment and outcomes and should still be considered the gold standard before more invasive procedures are tried. We will be compiling studies which have supported the importance of mechanical diagnosis and therapy and the issue of centralization in hope educational white paper or pamphlet which will help guide decision making for diagnostic decision making among our patients.

Friday, November 6, 2009

Anterior derangements

The anterior derangement which is classified as symmetrical or asymmetrical pain usually across L4/5 with or without buttock and/or thigh pain has a deformity of an accentuated lumbar lordosis. This is a rather rare condition that we see but of course since I started this blog, just about every type of derangement has surfaced.

We had a patient with a long standing recurrent history of back pain (8 years) which was originally described to us by his wife and it took several recurrent episodes before she dragged him in to see us. The most enlightening piece of information was the dramatic lordosis (swayback) and the fact that he could not bend forward nor could he reverse the curve. He was then put through the appropriate testing which in these types of derangements usually reverses rather rapidly allowing for full forward flexion to occur.

This again emphasizes the importance of a good mechanical exam and also the importance of patient generated referrals. Even though this patient had medical care in the past, it was his wife that researched the McKenzie method and made the appropriate referral.

Friday, October 30, 2009

Time does not matter

I recently saw a patient with a one year history of pain into the right lower extremity below the knee which was becoming progressively worse. She had already had MRI’s, EMG studies, several injections and trials of medications without any lasting change in symptoms. Her subjective history and objective examination were somewhat puzzling. However, the one constant was that we could find a centralization that would centralize her leg pain. By the time she came for her second visit, she reported movement of her pain that had been present for over one year and reported intermittent right low back and buttock pain only. Within the next visit, this moved further into the back until all symptoms had abolished.

She has since been able to progress to recovery of flexion and resumed all functional activities without symptoms returning. Her only complaint was of how long it took to have this problem assessed correctly and that all the testing that was done was irrelevant to her problem.

The moral of the story is that centralization should be used as guide for all of us who evaluate low back and neck pain.

Tuesday, October 27, 2009

The Amazing Thoracic Spine

Although the literature states that thoracic spine derangements are relatively rare and are usually disguised as cervical derangements it is important to perform a thorough mechanical diagnosis and therapy assessment to rule these out. I had a recent patient with a three week history of intermittent left upper thoracic pain that did not radiate and was only affected when lying on the left side and when raising the left arm or lifting. Her symptoms were basically in the left upper trapezius region and she could have essentially been either a cervical or shoulder derangement as well. The importance of finding concordant signs and then assessing repeating movement testing is critical to determine the effective exercise. Although I initially focused on the cervical spine due to major limits with cervical retraction, upon the patient’s second visit no significant change in symptoms or functions were noted. It was at that time that we further explored the thoracic spine and found a directional preference of flexion which is a rather rare direction of preference but response to movement is what dictates where we go.

The patient returned on their third visit with all symptoms abolished and all range of motion restored to within normal limits with one simple thoracic flexion exercise. I had nothing else to offer as she could not provoke any pain with any direction of movements or with any resistance and she could lift as much weight as she wanted. She was discharged with home exercise program.

Just when you think you’ve seen every type of mechanical derangement in the spine, there is always something new to test your evaluation abilities.

Monday, October 19, 2009

Irreducible low back derangements

So far our blog has consisted of success stories of those with reducible derangements. The question that is raised “what do we do when a person is irreducible?” Irreducible simply means that at the current time there is no “directional preference”. This means that with all movements, symptoms increase or travel further into the leg. This past month, I have had two such cases, both involving the lumbar spine and pain throughout the leg with weakness. Both had lateral shift deformities and were unable to bear full weight on the involved extremity.

“Time, time, time is on my side, yes it is.” These are lyrics from the Rolling Stones 1964 hit. This holds true with the treatment of irreducible derangements. In both cases, we instructed the patients on the importance on not aggravating the condition and were instructed in very gentle mid range lumbar spine movements that would never increase leg pain. This eventually resulted in enough of a reduction of their constant pain and both became mechanical responders. In both cases, all the extremity pain has centralized to the lumbar spine and they are now undergoing a recovery of a reducible derangement.

The main difference between reducibles and irreducibles are that the reducibles rapidly respond and the irreducible may respond but will require a longer period of time.

Friday, October 9, 2009

Right posterior thigh pain

Right posterior thigh pain- was it back or was it hip? I had a patient present with right sided posterior thigh pain who reported pain with sitting and rising. She was unable to raise her right hip secondary to pain and was unable to squat. We initially evaluated the lumbar spine and could not come up with a conclusive mechanical diagnosis and then evaluated the hip. Essentially, we wound up treating both the lumbar spine and hip into extension.

This resulted in complete abolishment of all symptoms including pain, weakness, and inability to raise her weight against gravity and squat. This involved two directions of preference for this patient as we were unsure whether we were treating a stubborn low back derangement or a hip derangement. The only consequence to the patient is she needed to do two exercises instead of one but the outcome was good in just 5 visits.

Tuesday, October 6, 2009

"Course F?"

Please do not go to the McKenzie website looking for Course F because it does not exist. I had the wonderful opportunity to sit in on an introductory seminar held by Orthopedic and Sports Physical Therapy in Tallahassee, Florida. Several of the Mechanical Diagnosis and Therapy faculty and researchers gathered at this meeting to discuss the development of a Mechanical Diagnosis and Therapy network known as Integrated Mechanical Care. This particular clinic was able to show a 79% improvement in pain scores and 54% improvement in function scores for its members at Capital Health Plan in Tallahassee, Florida.

A fantastic article was written in the Manage Care magazine in June 2008 by Dr. Charles Tomlinson, who was vice president at Capital Care from 2000-2008. The results were so promising that all members of this health plan must now utilize Mechanical Diagnosis and Therapy specialist in physical therapy before surgery, injections or MRI’s are considered. Significant reductions in the percentage of surgeries, injections and MRI’s have also been noted as a result as the implementation of Mechanical Diagnosis and Therapy.  It was quite exciting to see the recognition of Mechanical Diagnosis and Therapy addressed by those outside our profession.

We will keep you updated on further developments with other insurance companies following this same plan.

Thursday, September 24, 2009

Plantar fasciitis or not?

I recently had a patient that I was evaluating and treating for a completely unrelated problem, a two year history of plantar fasciitis. I spent most of my time assessing her current complaint but continued to question her about how her diagnosis of plantar fasciitis was made and what had been done over the past two years. The amount of treatment and assessment was rather extensive without there being any change in her symptoms. Typically, the primary complain of this condition is difficulty walking when getting up out of bed or after prolonged sitting. The patient described hobbling around for 10-20 minutes until the pain subsided and this occurs on an everyday basis.

I simply explained that it may not even be plantar fasciitis but perhaps an internal derangement in the ankle/foot complex. The patient had excellent concurrent signs. Every day when they wake up, they have “searing pain” for 15-20 minutes. They were given one corrective exercise that is common for derangement in the ankle/foot complex and was to perform this exercise 10 times every hour. Upon return, the patient quite happily responded that today was the first time that they had gotten out of bed and walked without any pain in their foot in two years.

The patient has continued with the one corrective exercise and is able to function without pain or limitations. The moral of the story is that diagnosis labels can often be misleading. We basically need to prove that derangements do not occur before accepting some of these clinical diagnoses.

So, plantar fasciitis or not? I think not.

Thursday, September 17, 2009

Shoulder extremity pain

The McKenzie method or “mechanical diagnosis and therapy” which is currently being used has expanded beyond neck and back pain. It now includes all the extremity joints. Some of the findings in treating extremities have been quite dramatic. In most cases it is important to rule out the cervical or lumbar spine as a source of referred pain which is easily done with history taking and a quick screen of the spinal motions. I had a recent patient with constant upper arm pain which persisted for 6 months and was not improving. She was unable to lie on this shoulder or lift her arm secondary to pain and did not respond to over the counter medications or rest. She had an x-ray which was negative and her cervical spine was cleared out of the source of her symptoms. She also presented weakness in the shoulder.

After only 4 visits, almost all of her arm pain was gone and a significant increase in motion was noted. Within 7 visits, her range of motion was within normal limits and now she is being seen periodically for strength training to improve strength and prevent any reoccurrence of these symptoms. The most interesting observation is that all of this was performed with simple “mechanical diagnosis and therapy” testing and treatment without the need for a MRI study, surgery or even injections. The patient was quite amazed how rapidly her symptoms could change and only wished she could’ve started her treatment much sooner. The extremity joints particularly the shoulder do present some difficult variables as there are so many ranges of motion in this joint and we essentially use our shoulders everyday for most of our functional activities.

We will continue to keep your updated with various spine and extremity stories that have responded successfully to mechanical diagnosis and therapy.

Thursday, September 10, 2009

Cervical Headaches

Robin McKenzie’s first “Mechanical Diagnosis and Therapy of the Cervical/Thoracic Spine” text published in 1990 sites that the specific epidemiological data on the subject of cervical headaches was rather sparse. He references a study by Frykholm that of all headaches in practice, headaches of cervical origin were the most frequent. This certainly holds true in our practice. With the increase use of laptops and computerized workstations, forward head postures and loss of the ability to retract the cervical spine and extend the thoracic spine certainly contributes to mechanical derangement of the upper cervical region.

I am once again amazed by the rapid reversal of cervical headaches as I had a patient this week with a two and a half week history of constant headache which was simply relieved with a sustained cervical retraction position. With the use of joint mobilization and exercise to increase her flexibility, she is able to keep her symptoms abolished with relatively simple posture correction and exercise.

How many people out there suffer from cervical induced headaches that continue to rely on medications which do not resolve mechanical headaches?