In response to Sam's, Karen's and AMV's statements and questions:

The way I read it, there is a chance this patient will end up with a
permanently absent tendon reflex. So, before conservative treatment
(whatever that will consist of) is prolonged, one has to find out whether
there is a real chance things will get better with that conservative
treatment. This regarding, Donelson et al found that "[n]onoccurrence of
centralization accurately predicts poor treatment outcome and was a helpful
early predictor of the need for surgical treatment" while "[i]ts occurrence
during initial mechanical evaluation is a very accurate predictor of
successful [conservative-]treatment outcome" (1), and found that the
McKenzie assessment distinguishes between competent and incompetent discs
(reversible and irreversible derangements) better than MRI (2).


More specifically:

Sam: "There are many therapists out there with no McKenzie credentials who
would treat this patient using best available knowledge of pain mechanisms
and do an excellent job."
FC: Apparently, that's not as easy as you make it believe. Hofstee et al
found that "regular" physio-manipulative therapists (who were not
McKenzie-trained) did not do better with their method than just bedrest, or
just continuation of ADLs without treatment (3).

Sam: "How is he supposed to learn if every time he gets an interesting
patient he refers them on?"
FC: By attending the first (few) visit(s) to the McKenzie-trained therapist.
I suggest we not advise PTs to try to invent the wheel every time
themselves.

Karen: "There is very little evidence on the efficacy of McKenzie therapy in
the treatment of LBP with neuro signs."
FC: McKenzie is substantiated by more evidence than any other PT method,
even though, due to a lack of high-quality, practical-outcome research, a
definite recommendation could not be given. See
http://www.mckenzieinstitute.co.uk/research.htm. That list of references
includes quite a number of studies on the effect of the McKenzie
method/McKenzie-developed aids & tricks on radiating LBP.

Karen: "There's a very good article in the newsletter of the Physiotherapy
Pain Association in Dec 2002 challenging the fear avoidance behaviour
encouraged by the McKenzie approach."
FC: Does that article offer any evidence? It's a good thing McKenzie is
challenged with research, but with just hypothetical concepts all methods
can be criticised unfoundedly.

McKenzie's rule is: "First, teach the patient
to heal himself as much as possible". Let's take a typical example of a
McKenzie treatment in cases like the one we're talking about. Let's assume
the pt. is an extension-responder with normal side-gliding. The pt. is prone
on the couch with radiating LBP. PT teaches the pt. to do passive extension.
It hurts a lot. PT tells pt. not to get scared by it, and to do it a couple
of times. The pt. (reluctantly) does it, but to his surprise the radiation
centralises with a number of repetitions. He gets off the couch and the
centralisation remains. PT tells the pt. to do this exercise 6 times a day,
gives the pt. (a) lumbar support(s), with which further reduction can be
achieved (4-6), and teaches the pt. how to lift with a straight spine and to
avoid early-morning loaded lumbar flexion. Result: the pt. gets control over
his complaints, and can get to work earlier. Once the complaints have
stabilized, the PT teaches the pt. to also include flexion exercises in a
safe manner, which is a standard procedure in the McKenzie treatment of
derangements.

This is a typical McKenzie approach. If you wanna call the McKenzie method
an encouragement of Fear Avoidance Behaviour, you'll have to come with hard
evidence, or I'll reject your notion and think you're biased to a high
degree.

AMV: "We need to learn as many as possible, apply the appropriate treatment
to each case  and treat these patients."
FC: The McKenzie method consists of specific exercises, posture control,
spinal mobilization and manipulation, and neural mobilization (and traction
in select cases). Just about all the methods used by PTs, with the exclusion
of modalities. What makes the method unique is that it offers shortcuts as
to the question "When should one apply what?", by using a specific
algorithm. As such, it offers shortcuts in the learning process. Again:
there is no use in letting a (junior) PT go through the process of inventing
the wheel.

Three studies looking at the methods used by PTs found that the vast
majority those PTs appreciate the McKenzie approach, if not favour it (7-9).
The reason why I advised Ben to refer to a <credentialled> McKenzie
therapist is that I don't know anyone personally in London. Therapists often
call themselves McKenzie therapists or state "McKenzie Therapy" in the
yellow pages, while many have taken only part A and could even have
virtually slept through it. There is no test taken after separate course
parts.


References:
1. Donelson R et al, Centralization phenomenon. Its usefulness in evaluating
and treating referred pain. Spine 1990 Mar;15(3):211-3.
2. Donelson R et al, A prospective study of centralization of lumbar and
referred pain. A predictor of symptomatic discs and anular competence. Spine
1997 May 15;22(10):1115-22.
3. Hofstee DJ et al, Westeinde Sciatica Trial: randomized controlled study
of bed rest and physiotherapy for acute sciatica. Journal of
Neurosurgery:Spine 2002; 96(1).
4. Williams MM et al, A comparison of the effects of two sitting postures on
back and referred pain. Spine 1991 Oct;16(10):1185-91.
5. Van Poppel MN et al, Lumbar supports and education for the prevention of
low back pain in industry: a randomized controlled trial. JAMA 1998 Jun
10;279(22):1789-94.
6. Jellema P et al, Feasibility of lumbar supports for home care workers
with low back pain. Occup Med (Lond) 2002 Sep;52(6):317-23.
7. Gracey JH et al, Physiotherapy management of low back pain: a survey of
current practice in northern ireland. Spine 2002; 27(4):406-411.
8. Foster NE et al, Management of nonspecific low back pain by
physiotherapists in Britain and Ireland. A descriptive questionnaire of
current clinical practice. Spine 1999; 24(13):1332-1342.
9. Battie MC et al, Managing low back pain: attitudes and treatment
preferences of physical therapists. Physical Therapy 1994; 74(3):219-226.


R.,
Frank

F.J.J. Conijn, PT
Editor, Physical Therapist's Literature Update
The Internet Journal of Updates for Clinicians in Non-Operative Orthopaedic
Medicine
www.ptlitup.com



----- Oorspronkelijk bericht -----
Van: Sam Bowden
Aan: [log in to unmask]
Verzonden: vrijdag 24 januari 2003 13:02
Onderwerp: Re: LBP & neuro signs dilemma


Frank

Why on Earth would you say that these problems are best treated by McKenzie
trained physiotherapists? I can't understand that at all...is there a new
piece of evidence I don't know about? It sounds like the advice given is
very sensible and I am aware of no reason to send the patient on anywhere
at present! There are many therapists out there with no McKenzie
credentials who would treat this patient using best available knowledge of
pain mechanisms and do an excellent job.

How is he supposed to learn if every time he gets an interesting patient he
refers them on? (anyway who would get the credit if this patient
spontaneously resolves)?

sam bowden