Having studied under Craig Liebenson for quite some time, I have developed a better appreciation for the McKenzie Mechanical Diagnosis and Therapy system. Seeing Dr. Liebenson relentlessly "audit" his patients, and understanding that this audit forms the foundation of McKenzie principles, the reassessment has become a cornerstone in the management of my patients.
As such, and to gain a better understanding of this system, I decided to host McKenzie "A" - The Lumbar Spine at my clinic.
It truly is more than centralization.
Apparently, this was the first course held in Canada that combined physical therapists and chiropractors as delegates. To me this was significant as I have always held the belief that who you are is more important than what you are.
Now the key take away from this course was perhaps the first statement made by our instructor, Audrey Long.
"It's about applying the right thing to the right patient"
To me, the above statement means conducting a thorough and accurate assessment, applying the appropriate management strategy, and reassessing to confirm the effectiveness of that strategy. So it was clear to me that McKenzie MDT was more of an assessment method than a treatment method.
The second principle learned from this course was another "Craig-ism"...the importance of self-care. That it is very important that we first utilize an active, hands off, approach in order to allow the patient to learn about the treatment experience. Taking this approach promotes independence and a better understanding (by the patient) that they have the power to "make themselves feel better".
Now it is still considered manual therapy, better decision making is just employed to determine when and when not to put one's hands on the patient.
One important key to a thorough assessment is the patient history, and understanding why they got there in the first place. Quite often it is what they didn't do, rather than what they did, but it is also likely related to their tendencies. Do they sit all day? Do they stand all day? Are they constantly bending? Are they constantly twisting? Or...do they have faulty movement patterns?
While the philosophy that surrounds this method of treatment lies in the clinical audit process, there is no question that most therapists equate McKenzie MDT to discogenic pathologies. And for good reason.
However, quite often such pathologies, especially of the acute variety, present with pain induced sympathetic overload and/or faulty core function secondary to high threshold strategies.
For the latter, often the patient presents with antalgia and obvious signs including, but not limited to, guarding, sweating, fear of movement, etc. In such cases, for me to put them through repeated movement testing from the get go, may not be the best approach. Some therapists will often use ice, IFC and e-stim, but for me, I would rather unwind the system that's on lockdown. And by that I mean, decreasing the threat.
Patrick Ward recently wrote about the Parasympathetic Nervous System. For me, the methods I often use are crocodile breathing, gentle perturbations rib cage and hip mobilizations, soft bracing as per Stu McGill, reactive neuromuscular training and reflex stimulation...all dependent on patient presentation. And ALL with appropriate (read reassuring) communication.
I will also groove proper hip hinging and thoracic uprighting. But following that, and when appropriate, I would then implement centralization methods. Likely on the first visit but always with respiratory control.
Ultimately though, my goal aside from the above history, would be to understand why the individual mechanically sustained the injury to begin with. And this is where the SFMA fits in...to respect the high threshold strategy. This is also where Stuart McGill's strategies come in. Sometimes prior to calling off security, and sometimes after. But definitely always.
I admit that I am still having difficulties with my understanding of McKenzie methods. Not only because this method "tissue-fies" many pain presentations, but also because I believe there may be more appropriate ways to assess and "treat" with repeated movement in very acute conditions. Our instructor suggested that, "we should stick with McKenzie and not mix systems (i.e. stability and muscle imbalances)" and to me, this may not be the best approach. I truly believe that the patient should take priority over the method and therefore, I will continue to do what I feel is most appropriate.