International Journal of Mechanical Diagnosis and Therapy

Transkript

1 International Journal of Mechanical Diagnosis and Therapy 26 Branches Worldwide Americas Region Argentina Brazil Canada United States Asia/Pacific Region Australia Japan New Zealand Nigeria Saudi Arabia European Region Austria Benelux/Netherlands Croatia Czech Republic Denmark Finland France Germany Hellas/Cyprus Hungary Italy Norway Poland Slovenia Sweden Switzerland United Kingdom 2006 Volume 1, No. 1 Danish version The McKenzie Institute International Center for Postgraduate Study in Mechanical Diagnosis and Therapy

2 On the Cover: The Bronze Lady: The McKenzie Institute International Extension Award, awarded to an individual/ or individuals for outstanding contribution to education or research in the field of Mechanical Diagnosis and Therapy. Since 2001, the award has been publicly awarded in conjunction with our MII Conferences. Visit our website for a list of past recipients:

3 International Journal of Mechanical Diagnosis and Therapy Editor Allan Besselink, PT, Dip. MDT Editorial Review Board Helen Clare, PT, PhD, Dip. MDT Stuart Horton, PT, Dip. MDT Sinikka Kilpikoski, PT, Dip. MDT Stephen May, PT, Dip. MDT Julie Shepherd, PT, Dip. MDT Mark Werneke, PT, Dip. MDT Contributors Ann Carlton, PT Production The McKenzie Institute USA Nancy Morden, Executive Asst. McKenzie Institut Danmark Ansvarshavende redaktør Camilla Nymand, PT, Dip. MDT Formand Uffe Lindstrøm, Dip. MDT Næstformand Martin Melbye, Dip. MDT Sekretær Anne Juul Sørensen, Dip. MDT Kasserer Eva Hauge, Dip.MDT Bestyrelsesmedlemmer Merethe Fehrend, Cert.MDT Charlotte Krog, Dip.MDT Suppleanter Troels Balskilde, Dip.MDT Michael Rømer, Cert.MDT Webmaster Jesper Rasmussen 2006 The McKenzie Institute 2006 The McKenzie Institute

4 I n d h o l d Volume 1, Nr. 1 Marts 2006 Artikler International Journal of Mechanical Diagnosis and Therapy Editorial Review Board Helen Clare, PT, PhD, Dip. MDT [email protected] Stuart Horton, PT, Dip. MDT [email protected] Sinikka Kilpikoski, PT, Dip. MDT [email protected] Stephen May, PT, Dip. MDT [email protected] Julie Shepherd, PT, Dip. MDT [email protected] Mark Werneke, PT, Dip. MDT [email protected] Contributors Ann Carlton, PT [email protected] Production The McKenzie Institute USA Nancy Morden, Executive Asst. [email protected] & McKenzie Institut Danmark 8 Non-specific low back pain are we any nearer a structural diagnosis? Stephen May, PT, Dip. MDT 18 Low back care Advice is plentiful but is it worth taking? Richard Rosedale, Reg. PT, MCPA 20 Getting your back back to work: pain relief where to start? Timothy J. Caruso, PT, MBA, MS, Cert. MDT and David J. Pleva, PT, MA, Dip. MDT 30 A personal journey on the MDT path Eva Novakova, PT, Cert. MDT 34 Variance in manual treatment of nonspecific low back pain between Orthomanual Physicians, Manual Therapists, and Chiropractors Elise A. van de Veen, MSc, Henrica C.W. de Vet, PhD, Jan J.M. Pool, Wouter Schuller, MD, Annemarie de Zoete, DC, and Lex M. Bouter, PhD 59 Mekanisk Inkonklusiv Behandling og Rehabilitering (artikel 3/3) Camilla Nymand, Dip. MDT & Martin Melbye, Dip.MDT 67 Klassifikation af skulderpatienter ad modum McKenzie, et intertester reliabilitetsstudie Camilla F. Lauridsen, Helene Olsen, Line Martley Jensen & Mette Brøndum Spalter 3 Mission, Policies and Editorial Calendar 4 Nyt fra formanden Uffe Lindstrøm, Dip. MDT 5 Et kig indenfor, redaktionen Camilla Nymand, Dip. MDT 43 Clinical Viewpoint Clinical Reasoning: Stuart Horton, Dip Phty, DMPhty. Dip. MDT 47 Case Reports 1. Aidan Sylvester, BSc Physio, PG Dip Phty. MDT 2. Chris Littlewood, BHSc(Hons), MSc, Dip. MDT 54 Literature Reviews Reviewed by Stephen May, PT, Dip. MDT 58 Diploma Dialogue McKenzie Institut Danmark 6 Generel info fra McKenzie Institut Danmark 2006 The McKenzie Institute 7 Credential Update / Tillykke med bestået Credential Evaluering 69 Kursusoversigt / 10. Internationale McKenzie Konference New Zealand 2007 Volume 1, No. 1 March 2006 IJMDT 2

5 Mission Statements & Submission Guidelines International Journal of Mechanical Diagnosis and Therapy The McKenzie Institute International Headquarters: 1 Alexander Road Raumati Beach, Kapiti Coast, New Zealand Postal Address: PO Box 2026 Raumati Beach 6450 New Zealand Telephone: Facsimile: [email protected] International Center for Postgraduate Study The worldwide mission of The McKenzie Institute International is to further the philosophies for spinal disorders developed by Robin A. McKenzie of Raumati Beach, New Zealand. The philosophies and treatments are know internationally as the McKenzie Method of Mechanical Diagnosis and Therapy. The mission will be achieved by: Educating health care providers in the principles and practical application of Mechanical Diagnosis and Therapy, as developed by Robin Anthony McKenzie. By research and study of spinal disorders and back care treatment generally, and in particular in reference to the McKenzie Method. To promote and support research that will advance the knowledge, skill and treatment of mechanical disorders of the spine. To make known to the medical profession and other related parties, the concept and the benefits of the McKenzie Method of Mechanical Diagnosis and Therapy. IJMDT Mission: The International Journal of Mechanical Diagnosis and Therapy (IJMDT) is a collaborative effort of the worldwide branches of The McKenzie Institute Institute (MII) emphasizing scientific study, clinical relevance and education related to Mechanical Diagnosis and Therapy (MDT). Editorial Calendar Submission deadline*: January 15 May 15 September 15 Mail date: March 15 July 15 November 15 *unless the date of publication is important to the nature of the material, we welcome submissions throughout the year. General Policies The MII IJMDT seeks original material of clinical, educational or professional relevance by physical therapists and members of all related health professions. Once the submission is accepted, the material becomes the property of MII and cannot be reproduced elsewhere without permission from the Chief Editor. We reserve the right to edit for style and content and/or cut articles to fit our space requirements. Significant modifications will be discussed with the author. The author will be notified by mail or of the status of the submission. The views and opinions in the IJMDT are those of the authors and not necessarily of MII. Submission Guidelines* Articles preferred by or mailed on disk in MS-Word (.doc) format using 10pt Arial font. PDF files are also acceptable. Hard copy submissions should be typed, double-spaced on standard letter-size paper with 1 inch margins on all sides and each page numbered. A title page must be included and the name of the author(s). Degrees, professional titles and current position should be included, along with an address and daytime telephone and fax numbers where the author(s) can be reached. All statements based on published findings or data should be referenced appropriately. *Please visit our website for examples of reference styles, additional details and the most up-to-date submission guidelines as the publication advances in the future: Submit via to: Allan Besselink, Chief Editor [email protected] Nancy Morden, Executive Asst [email protected] Or mail disk or hard copy to: Ms. Nancy Morden, Executive Asst The McKenzie Institute USA 126 N. Salina Street, 4th Floor Syracuse, New York IJMDT is published annually March, July and November by The McKenzie Institute USA. All rights reserved. Contents are not to be reproduced or reprinted without permission of publisher. [email protected] or fax request to (315) Volume 1, No. 1 March 2006 IJMDT 3

6 Nyt fra formanden Velkommen til denne første udgave af International Journal of MDT Med udgivelsen af den første udgave tager vi et stort skridt fremad med hensyn til en endnu mere målrettet og omfangsrig kommunikation om MDT og relaterede emner. IJMDT vil sikre at langt flere, som beskæftiger sig med muskuloskeletale problemer, meget hurtigere får centrale informationer om MDT og relaterede emner. Informationerne vil, med bidrag fra hele verden, blive alsidige og den videnskabelige kvalitet høj og væsentligt. Samtidig bevarer vi enhver mulighed for at bibeholde lokale nyheder og lokalt stof. Vor tilknytning til McKenzie Institute International har mange fordele, herunder ikke mindst når det massiv vidensdeling. Fra andre muskuloskeletale tilgange tales der for tiden en del om i hvor stor udstrækning man tilhører et koncept eller om man foretager konceptuelle valg og om man er konceptuel afhængig. Det er vel en overvejelse værd at fundere lidt over om MDT et koncept og om vi er konceptuelle afhængige? Det korte svar på begge spørgsmål er NEJ. MDT er en dynamisk undersøgelses- og behandlingsstrategi, som hviler på et fagligt rationale. Det er dynamisk fordi det kontinuerligt bliver udviklet og tilpasset i forhold til hvad videnskabelige undersøgelser viser. Indgangsvinklen til hvorledes vi som klinikere vælger at håndtere vore patienter kan være forskellige, men lukkede koncepter og dogmatiske holdninger til hvorledes vi hver især håndterer muskuloskeletale problemer ser ikke ud til at have det store potentiale. Derimod vil dynamiske undersøgelses og behandlingstrategier som MDT, der hviler på et fagligt rationale, på sigt - tror jeg vise sig at bidrage til en bedre forståelse af og dermed en mere effektiv håndtering af de muskuloskeletale problemer. Et fælles træk - for de skabende områder indenfor det muskuloskeletale felt i dag og i tiden der kommer - er at de arbejder med subgruppering af de muskuloskeletale problemer. Evidens begrebet er centralt for de som arbejder med muskuloskeletale problemer. Udfører vi med MDT evidensbaseret praksis? Det korts svar er JA. MDT er beskrevet at fysioterapeuten Robin McKenzie. Med fokus på patienternes symptomatiske og mekaniske respons på belastningstrategier, samlede McKenzie data ind fra sine patienter over en periode på 20 år. Med udgangspunkt i den indsamlede data beskrev han sine undersøgelsesog behandlingsstrategier - MDT. Dele af disse strategier er gennem de sidste ca. 15 år afprøvet i videnskabelige forsøg verden over. Alle dele af MDT er ikke belyst endnu, men meget mere er undervejs. I sin fokus og bestræbelse på at benytte sig af evidensbaseret behandling, må man som kliniker ikke overse, at der i evidensbaseret praksis indgår tre elementer. Nemlig en intervention, der tager sit udgangspunkt i de bedste tilgængelige forskningsresultater sammenholdt med klinikerens egen erfaring og patientens ønsker. De bedste hilsener som altid! Uffe Lindstrøm, Dip MDT Formand IMDT Volume 1, No. 1 March 2006 IJMDT 4

7 Et kig indenfor Kære Læsere Større og mere omfangsrigt, en betydelig øget kvalitet og en stor mulighed for at give Jer et input fra hele verden dét er formatet af International Journal of MDT. McKenzie Institut International udvikler sig: flere og flere lande indtegnet på verdenskortet, til stadighed flere der sigter efter at øge deres kompetenceniveau indenfor MDT og årlige internationale og amerikanske konferencer med en bred vifte af interessant klinisk stof og opdateringer på nuværende viden. Danmark er på verdenskortet med et relativt stort antal credential terapeuter, og muligheden for at tage den kliniske del af diplomuddannelsen i Danmark er nu også en realitet. Derfor er det meget glædeligt at vores ansigt udadtil, nyhedsbladet bliver konverteret til en International Journal dét projekt glæder jeg mig over at være en del af. Der er mange ting at glæde sig over. Dét dagligt at møde patienter præsentere sig med adskillge typer af muskuloskeletale problemer som håndteres efter MDT s principper, er en stadig kilde til begejstring og entusiasme. Og lige i kølvandet kommer uundgåeligt en taknemmelighed over at have mødt nogle ekseptionelle mennesker, der har formået at give denne viden og dette buskab videre på en inspirerende og gribende måde. Jeg husker min mentor, Mark Miller, sige: Du vil opleve det øjeblik, hvor du pludselig fanger ideen og mærker flow giv mig et kald når det sker, derfra begynder det først at blive rigtigt sjovt. Det er altid en udsøgt fornøjelse, suppleret med nogen udfordring, at diskutere hvad MDT egentligt er for noget. Det er ikke usædvanligt at McKenzie hos nogle er forbundet med de her bagoverbøjnings-stræk-øvelserfor-lænderyggen. Heller ikke ret mærkeligt, når man tænker over det. Extension er ikke noget dårligt valg af strategi hvis man kun måtte vælge én ting. Knap halvdelen af kronikerne og 2/3 af de akutte og subakutte har en retningspræference, af disse vil lidt mere end 80% have ekstension som den gavnlige retning. Dertil kan man lægge pænt mange af de mekanisk inkonklusive og overvejende psykosociale problemstillinger der uden tvivl vil respondere favorabelt på at bevæge sig - også når valget falder på extension. Så man er faktisk pænt godt kørende med bare extension i rygsækken. Og så er der også nogle der allerede hár gennemskuet at McKenzie umuligt kun kan dreje sig om én enkelt øvelse, for det kan man da ikke holde 5 kurser + en diplomuddannelse + skrive artikler og designe avancerede studier om -igen og igen i flere og flere år. Rigtigt. Og så er det smart at have en god basis at tale ud fra. Det har vi i tiltagende grad. Mange aspekter af MDT i flere veldesignede studier giver en god basis og hjælp i diskussionerne. Et godt kendskab til konceptet giver viden om dets styrker og de udfordringer og forhindringer man støder på i designet af gode kvantitative studier der belyser konceptet såvel fra dets diagnostiske, som fra dets behandlende og forebyggende potientiale. At MDT er mere end lumbal extension er en smal sag at bevise bring blot en nakkepatient på banen! De fleste med blot et basalt kendskab til MDT vil kaste sig over det uden et sekunds tøven. Og er den helt gal, kan der altid trækkes kaniner op af hatten med en ekstremitetspatient her skal man næsten være uheldig for ikke at finde enten et derangement eller en dysfunktion, og det vil de fleste kaste sig over indenfor maksimalt 2 sekunders tøven. Oplevelsen af hvad MDT er, kommer for alvor til sin ret når principperne anvendes på ekstremitetsproblemer uanset problemets oprindelse og strukturelle baggrund. Der er ikke behov for hokus-pokus, raketvidenskab eller uopnåelige palpatoriske evner, og det gør slet ikke så meget at være lidt fummelfingret, bare man kan ligge trykket geografisk rigtigt når situationen kræver lidt ekstra pres. Logisk tænkning, fornuftig klinisk ræsonnering og evner til at uddanne patienterne i deres problem er gode redskaber at fylde i værktøjskassen. Med et kig på denne værktøjskasse, og sammenholdt med budskabet i såvel MTV rapporten og de europæiske guidelines, synes MDT at befinde sig et fornuftigt sted. Det tror jeg i høj grad kan betragtes som et lyspunkt. Ikke blot kan det bekræfte den enkelte kliniker i at være på rette spor, men i endnu højere grad være et stort potientiale for at udvikle tættere samarbejdsrelationer med vores lægelige kollegaer uden tvivl til stor gavn og fornøjelse for alle. Jeg håber I får glæde af denne første udgave og jeg ønsker Jer alle en rigtig god start på foråret. Camilla Nymand, Dip. MDT Ansvarshavende redaktør McKenzie Institut Danmark Volume 1, No. 1 March 2006 IJMDT 5

8 Generel info fra McKenzie Institut Danmark International Journal of Mechanical Diagnosis and Therapy NYT FRA SEKRETÆREN Kursusaktivitet I 2006 afholdes vores kurser fortrinsvis på Rygcentret, Hans Knudsens Plads i København og på fysioterapeutskolen i Århus. Der er dog enkelte afstikkere, som kan ses enten på sidste side i dette blad eller på hjemmesiden under kurser. Både refresherdagen og credentialevaluering afholdes fortsat både i København og i Århus. Har du eller din arbejdsplads brug for et kursus er du/i velkomne til at ringe eller skrive til IMDT. Venteliste Hvis du har været på venteliste til et af vore kurser, skal du være opmærksom på, at du ikke automatisk overføres til næste kursus. Derimod skal du henvende dig til kursussekrtær Eva Hauge Rasmussen og vælge det kursussted, der passer dig bedst. Adresseændring og registrering Vi får i IMDT en del breve retur og nogle medlemmer modtager ikke bladet som forventet. For at undgå dette bedes du meddele adresseændring til IMDT via hjemmesiden Referat fra bestyrelsesmøder Fra 2. okt er det muligt at læse referat fra betyrelsens møder på hjemmesiden Medlemskontingent & Told & Skat Husk at indberette CPR nummer hvis du ønsker medlemskontingent opgivet til told og skat ECTS POINT En del medlemmer har henvendt sig til IMDT vedrørende ECTS points for vores kurser. ECTS point er imidlertid ikke en standard, som gælder for alle uddannelser. Der skelnes f.eks. mellem ECTS for diplom niveau, bachelor niveau eller master niveau. Uddannelser, som er underlagt en bekendtgørelse fra et ministerium, har således en fastlagt ECTS point skala som f.eks. fysioterapeutuddannelsen, mens alle efteruddannelses kurser selv fastsætter niveauet for ECTS point. ECTS point for MDT kurserne fastsættes derfor af IMDT selv ud fra kriterier om timeantal, forberedelsesgrad, supervison, studiebelastning, undervisernes uddannelsesniveau o.s.v. Ved en eventuel ansøgning til en anden uddannelsesinstitution er det denne, der afgør, om ECTS points givet for kurser i MDT er relevante til netop aktuelle uddannelse. IMDT samarbejder med DFFMT (Danske fysioterapeuters forum for muskuloskeletal terapi) i udarbejdelsen af et passende niveau for fastsættelse af ECTS point for kurser. Der vil være løbende information på vores hjemmeside når der er nyt. Eventuelle spørgsmål kan henvendes til undertegnede. Anne Juul Sørensen Sekretær i IMDT [email protected] Husk at tilmelde dig nyhedsmail på THE EVIDENCE MOUNTS Ønsker du et uforglemmeligt input og samtidig både en faglig og personlig oplevelse så ligger muligheden der under den 10. internationale McKenzie Konference i Queenstown New Zealand marts Der er mulighed for at søge McKenzie Institut Danmark om støtte på 5000 kr. til 4 ansøgere til dækning af rejseudgifter/konferenceudgifter. Credentialterapeuter har fortrinsret. Send en motiverende ansøgning til McKenzie Institut Danmark ([email protected]) inden 15. november th International Conference in Mechanical Diagnosis and Therapy Honorary Chairman: Robin McKenzie, CNZM, OBE, FCSP (HON), FNZSP (HON), DIP MDT Key Note Speakers: Nikolai Bogduk, Peter Croft, Richard Deyo, Paul Hodges, Susan Mercer, Barry Vernon-Roberts Conference Venue: / Queenstown, New Zealand: Bookmark our Conference page for more info: Volume 1, No. 1 March 2006 IJMDT 6

9 Credential Update Udviklingsmuligheder for credential terapeuter International Journal of Mechanical Diagnosis and Therapy Credential Update med Grant Watson, Dip.MDT, Dip.MT, Int. Faculty & Charlotte Krog, Dip. MDT Rygcenteret, Hans Knudsens Plads, København En workshop for Credential terapeuter som ønsker udvikling. Workshoppen giver en blanding mellem teori og praksis og vil udfordre dig I forhold til klinisk ræsonnering og problemløsning. Workshoppen finder sted 7. Juni for Credential terapeuter MED Part E og 8. juni for Credentialterapeuter UDEN part E. Kursusafgift 950 kr. For medlemmer og 1300 for ikke medlemme. Betalingen opkræves, når du har modtaget bekræftelse på deltagelse. Ved afbud senere end 1. maj opkræves et administratinsgebyr på kr Tilmelding via hjemmesiden: eller via til [email protected] Tidligere på året besluttede bestyrelsen at ændre rammerne for Credentialforum. Vi har aldrig været i tvivl om at der er et behov og ønske om kursus- og udviklingsmuligheder for de af vores medlemmer som har taget credentialprøven. I løbet af efterår og vinter har vi været i dialog med McKenzie Institute International samt branches i andre lande, for at blive inspireret til alternativer til det hedengangne Credentialforum. Resultatet er blevet, at vi kører to eksklusive kurser, som vi kalder Credential Update. Der bliver et kursus, som henvender sig til de credentialterapeuter, der har gennemført ekstremitetskurset (Part E) og et andet kursus for dem, som udelukkende har credentialniveau. Tillykke! Bestået Credential Evaluering 5. November 2005 Anners Bilbenberg, Viborg Karen Elisabeth Christensen, Hørning Jannie Degn Andernsen, Hvide Sande Jannick Idas Johansen, Odense SV. Tina Junge, Odense SV Brian Knørr Skov, Aalborg Lasse Lindgren Holmstrøm, Vodskov Rikke Linding Christensen, Ulfborg Sanne Mortensen, Århus Karsten Møller, Holstebro Michael Seiger Kristiansen, Hedensted Jesper Skov, Århus Lise Skovbo Almind, Ry Marie Louise Stitz Hansen, Hovedgaard Mette Stubkjær, Ringkjøbing Berit Sønderby Kortbek, Vissenbjerg Finn Zachariasen, Sønderborg Maria Duminski Björkman, Gilleleje Anne Gøtzsche, Ringsted Jackie Lolk Rasmussen, Svendborg May-Britt Lund, Aalborg Henrik Bjarke Madsen, Odense Jesper Ottosen, Lyngby Morten Graversen, Holstebro Volume 1, No. 1 March 2006 IJMDT 7

10 Non-specific low back pain are we any nearer a structural diagnosis? Stephen May, PT, Dip. MDT Introduction The diagnostic triage is a well accepted classification of back pain (CSAG 1994, Waddell 2004). This distinguishes serious spinal pathology (< 2%), nerve root pathology (5-10%), and non-specific or mechanical back pain (>90%). Because patho-anatomical or structural diagnoses of low back pain by clinical examination have lacked validity and assessment tools have lacked reliability non-specific or mechanical back pain has been the preferred nomenclature for several decades (Spitzer et al. 1987, CSAG 1994). However it has been argued by some that a structural diagnosis can be established in non-specific back pain in over 60% of patients using double articular anaesthetic blocks or discography (Bogduk et al. 1996). Injections must be performed under fluoroscopic control to ensure accurate placement. Double blocks are necessary as single blocks are associated with a rate of false positive responses (Manchikanki et al. 2004). The equivalent control in discography is concordant pain produced at one segmental level, with no pain at an adjacent level (Laslett et al. 2005a). Such diagnostic injections have been termed reference or criterion standards (Laslett et al. 2005a). Such studies provide the theoretical framework for understanding the prevalence of different structural diagnoses in mechanical back pain; however their specialist and intrusive nature makes them unacceptable or unavailable for the majority of patients with back pain. The use of a clinical examination to determine a pathoanatomical diagnosis has in the past proved ineffective, but some new studies have attempted to locate more useful clinical tools to determine a structural diagnosis. The article will briefly review previous clinical studies relating to non specific low back pain, then more recent ones, some of which are described in detail at the end. The article will look at the diagnosis of discogenic back pain, but will not include the specific diagnosis of nerve root pathology associated with disc herniation or spinal stenosis. Thus the aim of the review is to examine the value of the clinical examination to make specific structural diagnoses in patients with non-specific low back pain as determined by reference standards. The review will summarise the value of clinical findings under the following headings: discogenic pain sacroiliac joint pain zygapophyseal joint pain prevalence of different entities Review of some recent studies Discogenic pain This section will discuss primary discogenic back pain, and does not include consideration of nerve root pain caused by disc herniation. The criterion standard for discogenic pain is discography that provokes concordant pain at one level, with an adjacent level being pain free; this is sometimes followed by anaesthetic injection at the painful level to confirm the diagnosis, and axial CT scan to gain an image of the pathological disc. Discography remains controversial with its proponents claiming it to be the only valid and reliable method to detect primary discogenic pain, and its detractors claiming it to have poor specificity and be of limited clinical value (Laslett et al. 2005a, Manchikanti et al. 2001). One study found no clinical features, from history or physical examination that correlated with discogenic pain (Schwarzer et al. 1995d). However a mechanical evaluation, noting centralisation or peripheralisation, was found to correlate with discography findings (Donelsen et al. 1997). Of the 31 patients who demonstrated centralisation 74% had a positive discography, 91% showed a competent annular wall. Of the 16 patients who demonstrated peripheralisation 69% had a positive discography, with 54% showing a competent annular wall. Of the 16 patients demonstrating no change in pain only 12.5% had a positive discography. The data from this study has been re-calculated to provide sensitivity, specificity, and positive likelihood ratio estimates for discogenic pain as follows (Bogduk and Lord 1997): centralisation 92%, 64%, 2.5 peripheralisation 69%, 64%, signs combined 92%, 52%, 2.0 Patients with discogenic pain have been found to be more likely to have pain at or above L5, obstruction to movement, change in movement loss, and centralisation/ peripheralisation (Young and Aprill 2000). Significant association between discogenic pain and pain when rising from sitting and centralisation have been noted (Young et al. 2003). Centralisation had low sensitivity (47%), but high specificity (100%) for predicting discogenic pain. The most recent study (Laslett et al. 2005a) reported similar results; with sensitivity of centralization to predict discogenic pain being poor (37%), but specificity good (90%) and extremely good in patients without severe distress or disability (100%). This study is described in detail later. These latter studies would suggest that centralisation by itself is of limited value in identifying all patients with discogenic pain; many patients with discogenic pain will not demonstrate centralisation at initial assessment. As the specificity is very Volume 1, No. 1 March 2006 IJMDT 8

11 Non-specific low back pain are we any nearer a structural diagnosis? good the mnemonic SpPin (Sackett et al. 1997) is relevant: with high Specificity, Positive test, rules in the diagnosis: thus when centralisation does occur discogenic pain is the likely cause of pain. However Donelson et al. (1997) reported good sensitivity, but weak specificity; and it is unclear why the conclusions are so different though this may be related to different samples or slightly different definitions of centralisation. If sensitivity is very good the mnemonic SnNout (Sackett et al. 1997) is relevant: with high Sensitivity, Negative test, rules out the diagnosis - thus when no centralisation discogenic pain is unlikely. Centralisation/peripheralisation appear to be strongly correlated with discogenic pain, but from the evidence to date it is unclear if this correlation can be used to rule in or rule out the diagnosis. Sensitivity and specificity have a seesaw relationship with each other, as one goes up the other comes down; further research is needed to determine if it is sensitivity or specificity that is most stable. Sacroiliac joint (SIJ) problems. The reference standard for establishing SIJ pain is fluroscopically guided, contrast enhanced intraarticular anaesthetic blocks (Laslett et al. 2005c). However as in zygapophyseal joint injections there is a false-positive rate to single joint injections, estimated for SIJ injections to be between 8% and 20% (Laslett et al. 2005c). The literature on the reliability and validity of SIJ clinical diagnostic tests was summarised in two systematic reviews (van der Wurff et al. 2000a, 2000b). Regarding reliability, SIJ tests that used palpation and attempted to detect movement abnormalities were consistently found to have poor levels of reliability; whereas SIJ tests that were based on pain provocation of the patient s concordant symptoms were found to have moderate levels of reliability, though not consistently (van der Wurff et al. 2000a). For reliable pain provocation tests see Laslett and Williams (1994), and Kokmeyer et al. (2002). In terms of validity, compared with a SIJ injection no provoking or relieving movements or positions have been found that were unique or especially common to SIJ pain, either in the history or the physical examination (van der Wurff et al 2000b); and pain provocation tests were not validated against criterion standards (Dreyfuss et al. 1996, Scwarzer et al. 1995, Maigne et al. 1996, Slipman et al. 1998). Although the most common pain pattern is over the buttock and posterior thigh, pain patterns were found to be highly variable (Slipman et al. 2000). In a review entitled Using published evidence to guide the examination of the sacroiliac joint region Freburger and Riddle (2001) summarised the literature at that point in time. They noted that movement at the joint was too small to detect, and that there was no evidence to support the use of symmetry or movement tests, whereas some pain provocation tests may be useful, as well as certain descriptions of the pain pattern - namely absence of pain in the lumbar region, pain below L5, pain around the posterior superior iliac spine, and pain in the groin area (Freburger and Riddle 2001). They also noted the general lack of validity for clinical examination in detecting SIJ problems as verified by intra-articular injections. There was some concern about injections as gold standards ; with possible, but unknown rate of false positives and the possibility of leakage of anaesthetic. The use of multiple tests has been shown to be more reliable than single tests (Kokmeyer et al. 2002, Cibulka and Koldehoff 1999, Laslett et al. 2003, Young et al. 2003), and false positive SIJ tests are common in populations without confirmed SIJ pathology (Laslett 1997). Thus the diagnostic accuracy of the clinical examination is enhanced if lumbar spine patients are first excluded - detected using a mechanical evaluation, noting centralisation or peripheralisation; following which three positive pain provocation tests are used to determine SIJ problems (Laslett et al. 2003). Sensitivity is 91%, specificity 87%, and the positive likelihood ratio improves from 4.2 to 7.0 with the exclusion of lumbar spine patients. In a study in which 81 patients with chronic back pain were given a number of injections to determine a structural pathology; findings on clinical examination were correlated with different criterion standards (Young et al. 2003). Positive SIJ injections were associated negatively with mid-line pain and pain above L5, and positively with unilateral pain, pain produced or aggravated when rising from sitting, and three or more positive pain provocation tests. The latter was very strongly correlated (P <0.001), with an odds ratio of 28.0 (Young et al. 2003). In another study (Young and Aprill 2000), findings in patients with SIJ and zygapophyseal joint (ZJ) pain were similar with lack of both obstruction to movement initially and change in movement loss following repeated movements, and lack of centralisation/ peripheralisation. Patients with SIJ pain were likely to have no pain at or above L5, and likely to have pain on rising from sitting and three or more positive pain provocation SIJ tests when compared with ZJ patients. In the study described later (Laslett Volume 1, No. 1 March 2006 IJMDT 9

12 Non-specific low back pain are we any nearer a structural diagnosis? et al. 2005c) multiple pain provocation tests have been directly compared with criterion standard tests. This study evaluated the collective value of different tests and found three or more positive pain provocation tests to have a sensitivity of 94%, specificity of 78%, and positive likelihood ratio of 4.3. The authors (Laslett et al. 2005c) suggest the following diagnostic algorithm is used: no centralisation/ peripheralisation / directional preference during mechanical evaluation pain in buttock area distraction / thigh thrust tests applied if positive assume SIJ if negative apply compression / sacral thrust tests if two positive tests assume SIJ if all tests negative rule out SIJ. In conclusion, it does seem SIJ problems are open to diagnosis using clinical examination, but only if a staged differential diagnostic process is used involving mechanical evaluation and pain provocation SIJ tests. Demonstration of centralisation, peripheralisation or directional preference denotes a lumbar spine problem, and discounts the need to examine for SIJ pathology it should be noted that this may not occur at the initial assessment, but subsequently (Werneke and Hart 2003). In the absence of a positive symptomatic or mechanical response to end-range repeated lumbar movements, and in the presence of unilateral pain over the buttock pain provocation SIJ tests should be used in the order outlined above. When three of these tests produce concordant pain a SIJ problem is likely; when all tests are negative a SIJ problem can be ruled out. Zygapophyseal pain The criterion standard for identifying zygapophyseal joint (ZJ) pain needs are controlled comparative local anaesthetic blocks, as single blocks are associated with at least 27% false positive response in the lumbar spine (Manchikanti et al. 2004). Earlier studies failed to link any clinical features of history or physical examination with ZJ problems (Schwarzer et al. 1994a, 1994b, 1994c); and specifically ruled out certain features that had been suggested might be diagnostic (Fairbank et al. 1981, Helbig and Lee 1988). More recently Revel et al. (1992, 1998) proposed a set of clinical criteria that might be relevant (5 of 7 were necessary): age > 65 years pain relieved in supine lying absence of pain aggravated by coughing absence of pain aggravated by flexion absence of pain aggravated by return from flexion absence of pain aggravated by extension absence of pain aggravated by extension-rotation. However, more recent work has found there to be a lack of correlation between these clinical features and criterion standards (Manchikanti et al. 2000, Laslett et al. 2004). Sensitivity of Revel s criteria was shown to be low (13% to17%), though specificity was higher (84% to 93%). Similarly low sensitivity was shown in the study detailed later (Laslett et al. 2005b). However centralisation was never found and lack of pain on rising from sitting was significantly associated with patients with positive ZJ pain (Young et al. 2003). In another study (Young and Aprill 2000), findings in patients with SIJ and ZJ pain were similar with lack of both obstruction to movement and change in movement loss following repeated movements, and lack of centralisation/peripheralisation. Patients with ZJ pain were likely to have pain at or above L5, and unlikely to have pain on rising from sitting, or three or more positive pain provocation SIJ tests compared to SIJ patients. At this point in time, compared to criterion standards, it does not seem possible to identify ZJ pain using clinical criteria with any accuracy. It appears most likely to be a diagnosis by exclusion rather than one by positive identification. Patients with centralisation/ peripheralisation or directional preference have discogenic pain; those without, but with 3 or more positive pain provocation SIJ tests have SIJ pain; others may have ZJ pain. Prevalence of different entities According to reference or criterion standard the estimated prevalence of discogenic pain is about 39%, the prevalence of zygapophyseal joint pain is about 15%, and the prevalence of sacroiliac joint pain is about 12% (Bogduk et al. 1996). Estimates obviously vary but discogenic pain is usually the pathoanatomical structure that appears to be the principal pain generator. In 92 patients, 36 patients (39%) had a positive discography at least at one level, eight (9%) had a positive response to a double anaesthetic block at the ZJ, and only three responded to both (Schwarzer et al. 1994d, 1995d). In 216 patients who received 137 structural diagnoses, as well as additional classifications of illness behaviour and indeterminate, pathoanatomical diagnosis by reference standard was as follows (Laslett et al. 2005b): discogenic pain 70 (51%), nerve root pain 32 (23%), ZJ pain 14 (10%), spinal stenosis 10 (7%), hip pain 6 Volume 1, No. 1 March 2006 IJMDT 10

13 Non-specific low back pain are we any nearer a structural diagnosis? (4%), and SIJ pain (4%). In 120 patients who were put through an algorithm-type diagnostic process, which meant that not all patients had all structures tested, the following diagnoses were made with precision diagnostic blocks (Manchikanti et al. 2001): ZJ pain 40%, discogenic pain 26%, and SIJ pain 2%. Discogenic pain by itself has been found in 57% of 63 patients (Donelson et al. 1997), and 75% of 144 patients, and such patients were more likely to have distal leg symptoms than non-discal pain (Ohnmeiss et al. 1997). Estimates of lumbar zygapophyseal joint pain have varied from 31% of 397 patients (95% CI, 27% to 36%) (Manchikanti et al. 2004), to 40% (95% CI, 27% to 53%) of 57 patients (Schwarzer et al. 1995). Prevalence decreases if a stricter definition is applied, such as total abolition of pain, to 12% (Schwarzer et al. 1995). Estimates of the prevalence of SIJ pain have varied from 13% of 100 consecutive patients (Schwarzer et al. 1995a), to 53% of 85 patients selected with suspicion of SIJ involvement (Dreyfuss et al. 1996). However, both these studies used only single anaesthetic blocks, which have been associated with a 53% false positive response Maigne et al. 1996). In a sample of 54 patients selected on suspicion of SIJ involvement, 18% responded to two injections (Maigne et al. 1996). The wide range of possible prevalence rates should be noted, and that possible biases exist that weaken the validity of these estimates chiefly relating to the patients involved in these studies and the nature of the reference or criterion standard. Most pain populations examined in these studies are very chronic, often with high levels of disability, and all were seen in tertiary care; obviously it is only this type of population who are likely to be offered the invasive interventions. For instance, some patients had a mean duration of pain exceeding eight years, and 50% had a traumatic onset (Manchikanti et al. 2004), whilst others had a mean Roland Morris score of 18.5/23, worst pain intensity of 88/100, traumatic onset 73%, and 29% had previous lumbar surgery (Laslett et al. 2005b). This means that generalisability may be questionable to other populations, such as in primary care or pain of shorter durations. Secondarily is the question of whether double articular anaesthetic blocks and discography are absolutely valid as gold standards in making a structural diagnosis. Theoretically, these interventions might register false negatives under certain circumstances. For instance, discogenic pain that emanates from a lesion of the outer annulus fibrosus that is not connected to the inner nucleus where the needles are placed, or SIJ pain that is related to extra-articular ligaments rather than intra-articular contents where the needle is placed. In contrast, theoretically there maybe instances when false positives are registered; for instance, if there is leakage of anaesthetic beyond the joint space or in the presence of abnormal pain behaviour. Review of some recent studies Laslett M, Oberg B, Aprill CN, McDonald B (2005a). Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal Objective A previous study has suggested that the phenomenon of centralization is an indicator of discogenic pain. The aim of the study was to estimate the diagnostic accuracy of centralization for disc pain using discography as the reference standard. Furthermore, to determine the influence that patients distress and disability might have on the diagnostic process. Design A prospective, blinded, concurrent reference standard-validated study design. Setting Specialist private radiology spinal diagnostic clinic Louisiana, USA. Patients Consenting consecutive patients with chronic LBP referred for further investigations between May 2001 and October 2002 when the physiotherapist was present, which was in blocks of 4 to 8 weeks. Patients were excluded if they had a normal MRI, severe degeneration associated with spondylolisthesis, contraindications for discography, unwillingness to cooperate, fear avoidance, or excessive incapacity. 118 patients were initially included, 11 were excluded for technical discography reasons, and a further 38 failed to undergo or complete a physical examination; so the final study population numbered 69 (58.5%) who underwent both discography and a full mechanical evaluation. However, the physical therapist partially or fully examined and offered an opinion on 83 patients. Patients who had had previous spinal surgery were included and most patients had failed previous conservative treatment. Those who failed to undergo a full physical examination had significantly higher pain scores, greater disability, higher depression scores, and more surgery. For all patients mean values were as follows: age 43, duration of back pain over three years; Volume 1, No. 1 March 2006 IJMDT 11

14 Non-specific low back pain are we any nearer a structural diagnosis? time off work two years; pain VAS (best / worst) 59% (33% / 88%); Roland-Morris disability questionnaire score 19/24; previous surgery 30%; distressed (DRAM) 56%. Intervention Highly skilled and experienced radiologist and physical therapists undertook the different interventions and were blinded to each others findings. The reference standard was discography, with positive discography defined as follows: concordant pain response with injection of one disc, with no pain invoked at an adjacent disc. Physical examination included a mechanical evaluation, noting symptomatic response to repeated movements, as well as nerve function, SIJ and non-organic pain behaviour tests. Centralization was defined as the abolishment or significant reduction of most distal pain; peripheralization as the production or substantial worsening of distal symptoms that could not be subsequently decreased or centralized. Once a clear symptom response was generated this portion of the physical examination was terminated. Main outcome measures Prevalence of test results; concordance between reference standard and full or partial mechanical evaluation; and affect of distress and disability using sensitivity, specificity, and likelihood ratios for positive and negative tests (plus 95% confidence intervals). Distress was measured using DRAM, disability by Roland-Morris disability questionnaire. Main results The prevalence of positive discography was 75%; the prevalence of centralisation was 32%. Following a full mechanical evaluation centralization had a likelihood ratio of 6.9 in predicting discogenic pain. Sensitivity of centralization to predict discogenic pain was poor (37%), but specificity was reasonably good (90%) and extremely good in patients without severe distress or disability (100%). The number of true (centralization & positive discography) and false (centralization & negative discography) positive centralization responses; true (non-centralization & negative discography) and false (non-centralization & positive discography) negative centralization results; sensitivity (centralization // positive discography); specificity (non-centralization // negative discography); and Likelihood Ratios are listed in Table 1. Conclusions The ability of centralization to predict discogenic pain, as predicted by positive discography was calculated. Positive correlation between centralization and discogenic pain (sensitivity) was weak (35% to 46%). Positive correlation between non-centralization and nondiscogenic pain (specificity) was strong (80% to 100%). Comments In this group of patients centralization was not a good predictor of disc pain; many patients with discogenic pain did not demonstrate centralization. However, when centralisation does occur, especially in the absence of distress or high levels of disability, discogenic pain is highly likely. Several features may have deleteriously affected the diagnostic accuracy of the clinical examination. The patients were very chronic, disabled, distressed, with long term sick leave and about a third had had lumbar surgery. Only 6% of patients were DRAM normal and only 10% had no or minimal disability. All these features may have obscured the mechanical responses, and patient s intolerance led to premature termination of the clinical examination on a large number of occasions. Furthermore, mechanical evaluation was conducted on only a single occasion, whereas in a more normal LBP population 60% of those who initially were noncentralisers centralised on a subse- Table 1. Prevalence and diagnostic performance of centralization compared to reference standard of discography Outcome N All N=83 Full MD 69 DRAM neg 38 DRAM pos 31 RMDQ < RMDQ > True / false pos (N) 23 / 2 21 / 1 11 / 0 10 / 1 9 / 0 12 / 1 True / false neg (N) 20 /38 16 / 31 8 / 19 8 /12 10 /17 6 / 14 Sensitivity 37% 40% 37% 45% 35% 46% Specificity 90% 94% 100% 89% 100% 80% LR incalculable 4.1 incalculable 3.2 LR incalculable 0.6 incalculable 0.6 Full MD=mechanical evaluation; DRAM=distress risk assessment method: neg= normal or at risk, pos= depressed or somatic ; RMDQ= Roland Morris Disability Questionnaire; LR=likelihood ratios. Incalculable as zero in a cell. Volume 1, No. 1 March 2006 IJMDT 12

15 Non-specific low back pain are we any nearer a structural diagnosis? quent occasion (Werneke and Hart 2003). The low prevalence rate of centralisation in this study (32%), compared to other chronic low back pain populations (52%) (Aina et al. 2004) should be noted. It is important to note the effects of distress as measured by DRAM and disability on the accuracy of the mechanical evaluation. With high disability sensitivity fell from 100% to 80%, whereas with positive DRAM compared to negative it fell from 100% to 89%. Donelson et al (1997) found a sensitivity of 92% and specificity of 64% for centralisation to predict discogenic pain; in contrast, this study found a high specificity and weak sensitivity. The authors suggest this is due to the nature of the patient sample, and the slightly different definitions of centralisation used. Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B (2005b). Agreement between diagnosis reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disorders 6:28 Available at: Background/Objective The tissue origin of low back pain (LBP) can be identified frequently using advanced imagery and discography, zygapophyseal (ZJ) or sacro-iliac joint (SIJ) provocation or anaesthetic blocks (reference standards). These methods are invasive, require specialist clinicians, and are not commonly available. Clinical examination in contrast is non-invasive and commonly available, but to date single clinical tests have proven to lack validity when compared to injections. However in clinical practice single tests are rarely used to classify or diagnose. The objective of the study was to compare multiple clinical tests with reference standards to quantify their diagnostic acumen. Design A prospective blinded validity design was used. Results from the clinical examination undertaken by a physiotherapist were compared to reference standards. Physiotherapist and radiologist were blind to each others results. Setting Specialist private radiology spinal diagnostic clinic Louisiana, USA. Clinical Diagnosis discogenic (IVD) ZJ pain SIJ pain nerve root (NR) spinal stenosis (SS) hip pain instability illness behavior (IB) other Patients Consenting consecutive patients with chronic LBP between May 2001 and October 2002 when the physiotherapist was present, which was in blocks of 4 to 8 weeks patients were seen at the clinic in the period, 296 when the physiotherapist was present; 78 were excluded most commonly because of lack of consent (53), no pain on day (10) and time constraints (9); so that 216 patients were included. Details of 216 patients: mean age 44; mean duration of LBP about Criteria centralisation / peripheralisation / directional preference in response to repeated movements; OR midline pain (1) absence of (1) above + Revel s criteria (see main article) absence of (1) above + 3 positive pain provocation tests (PPT) (2) referred pain provoked by nerve tension tests neurogenic claudication relieved by sitting / flexion passive hip test provoke concordant pain more readily than 1 or 2 above lack of specific criteria patient s behavior / responses to question / examination suggested psychosocial distress other uncommon causes of pain indeterminate (none) no conclusion could be reached three years; mean time off work over two years; mean pain intensity today/best/worst 58 / 33 / 88; mean Roland-Morris 18.5 / 23; DRAM scores 12% normal, 37% at risk, 44% depressed, 6.5% somatic. Intervention The clinical examination was undertaken by two very experienced physiotherapists over minutes immediately after the reference standard diagnostic tests. Clinical examination proceeded through these stages: The reference standards used in the structural diagnosis by the very experienced radiologist mostly employed provocation or anaesthetic block injections under fluoroscopic guidance. Spinal stenosis and other used CT or MRI imaging; instability used paradoxical motion of flexion/extension radiographs; illness behaviour, as above was based on clinical opinion; and indeterminate was as above. Not all reference standard diagnostic procedures were carried out with all patients Volume 1, No. 1 March 2006 IJMDT 13

16 Non-specific low back pain are we any nearer a structural diagnosis? Main outcome measures Exact agreement was when clinical examination agreed with reference standard entirely, including multiple diagnoses. Clinical agreement was when the clinical examination was included within the reference standard multiple diagnoses. Main results The radiologist came to a single diagnostic conclusion in 144 cases (66%), two in 72 cases (34%), and three in 2 cases. The physiotherapist reached a single diagnosis in 163 cases (76%) and two conclusions in 53 cases (Table 2). Exact agreement (95% confidence interval) was 32% (26%, 38%); clinical agreement was 51% (45%, 58%). Regarding only structural pathologies agreement was 57% (48%, 64%); kappa statistic was 0.31 (0.18, 0.44). Conclusions Reference standards identify a structural source of pain in many patients. Clinical examination agrees with the reference standard more often than chance. Comments According to the reference standard the most common structural diagnosis was discogenic pain (50% of all structural diagnoses, excluding IB and indeterminate). Of the rest of the 205 structural diagnoses 18% were nerve root, 12% ZJ, 7% spinal stenosis, other and hip were both less than 5%, and 3% SIJ. Twentytwo patients (10%) received two patho-anatomical diagnoses. However additionally, illness behaviour was recorded in 79 patients and indeterminate conclusion was made in 84 cases. Thus about 44% of patients fell into one of these categories. The authors conclude that the diagnosis made by the physiotherapist s clinical examination was better than expected by chance when compared to the reference standard; however agreement was generally weak with low kappa values and sensitivity. Identification of hip and discogenic pain was most accurate with sensitivity about 55%, which increased to 83% and 74% when IB and indeterminate was excluded. Clinical identification of other structural pathologies was generally much weaker. The population in which these examinations occurred was extremely chronic, disabled, and distressed; nearly a third had had lumbar spinal surgery. This has several implications; this was not a normal LBP population and there is a problem with generalisability. Furthermore the nature of the sample may have helped cause the high prevalence of patients diagnosed with illness behaviour or indeterminate, which in turn probably affected the ability of the reference standard to reach a single conclusion and the accuracy of the clinical examination. Table 2. Reference standard / physiotherapy diagnoses Reference standard IVD ZJ SIJ NR Hip SS Other IB None Totals IVD P H Y S I O T H E R A P Y ZJ SIJ NR Hip SS Other IB None Totals * Bolded numbers are counts of agreement; for abbreviations see bullet points on previous page; *total N = total number of multiple diagnoses Volume 1, No. 1 March 2006 IJMDT 14

17 Non-specific low back pain are we any nearer a structural diagnosis? Laslett M, Aprill CN, McDonald B, Young SB (2005c). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy Background / Objective Earlier studies of single pain provocation tests have shown these to lack validity against reference standard diagnostic tests. Clinically it is common to use multiple tests to confirm a diagnosis. The objective was to determine the diagnostic accuracy of single and various combinations of multiple SIJ pain provocation tests against SIJ anaesthetic injections. Design A prospective blinded validity design was used. Results from the clinical examination undertaken by a physiotherapist were compared to reference standards. Physiotherapist and radiologist were blind to each others results; both were highly experienced. Setting Specialist private radiology spinal diagnostic clinic Louisiana, USA. Patients Patients were not consecutive. Inclusion criteria: buttock pain +/- other pain; exclusion criteria: lack of consent, midline / symmetrical pain; clear signs of NR pathology; too frail. 62 agreed to participate and were examined by physiotherapist and radiologist; exclusions were unable to tolerate the exam (3), pain free (2), or had a technical failure of / or no injection (9); leaving 48 patients. Mean age was 42 years; mean symptom duration 32 months; mean off work 18 months; mean Roland-Morris score 76%. Intervention Positive reference standard, using fluoroscopically guided injection, was provocation of familiar pain followed by 80% or more pain relief, followed by a confirmatory anaesthetic block combined with corticosteroid. Positive physical examination was pain provocation tests that produced or exacerbated concordant pain. The following pain provocation SIJ tests were used: distraction (1), compression (2), rightsided thigh thrust (3), right (4) and left-sided (5) Gaenslen s, and sacral thrust (6) numbers relate to Table 3 below. Main outcome measures Prevalence of test results; and concordance between reference standard and physical examination procedures using sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative tests (plus 95% confidence intervals). Main results 16 / 48 (33%) had positive reference standard tests. Positive physical exam tests ranged from 31% to 50%; false positive tests were common (range 19% to 31%); 11 patients (34%) with negative reference standards had two or more positive exam tests. Results for individual tests are in Table 3 the thigh thrust is the most sensitive and the distraction test the most specific. When tests were combined the optimum combination was 3 or more positive tests with a sensitivity of 94%, specificity of 78%, and likelihood ratios of With 1 / 2 or more positive tests sensitivity remained high, but specificity decreased to 44% / 66%. With 4 / 5 positive tests specificity increased, but sensitivity decreased to 60% / 27%. The best combination of tests was distraction, thigh thrust, compression and sacral thrust; with Gaenslen s adding little to accuracy. Table 3: Prevalence, sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and likelihood ratios (LR) for individual SIJ provocation tests Test results* Outcome RS Prevalence 33% 32% 44% 50% 37% 31% 37.5% Sensitivity 60% 69% 88% 53% 50% 63% Specificity 81% 69% 69% 71% 77% 75% PPV NPV LR LR *RS = reference standard, numbers refer to physical exam tests in intervention section above Volume 1, No. 1 March 2006 IJMDT 15

18 Non-specific low back pain are we any nearer a structural diagnosis? Conclusions Combination of SIJ pain provocation tests improve diagnostic acumen for SIJ problems over single tests with most accuracy being gained with 3 or more positive pain provocation tests. When all six tests do not provoke familiar pain the SIJ can be discounted as a source of back pain. Comments The results of this study contrast with earlier studies that failed to demonstrate diagnostic accuracy of history or physical examination items (Dreyfuss et al. 1996, Scwarzer et al. 1995, Maigne et al. 1996, Slipman et al. 1998) and a systematic review (van der Wurff et al. 2000). The authors suggest the greater accuracy found in this study may relate to the greater force applied by physiotherapists when using the tests. Patients involved in the study were not consecutive and were exceedingly chronic, disabled and with a long duration of sick leave consequently the results are not generalisable. However the authors maintain, from anecdotal clinical experience, that in a more normal clinical population the assessment process is more straightforward and the results if anything understate the diagnostic accuracy of multiple tests. The patient population used also means that prevalence of SIJ pain in the back pain population cannot be inferred from the data. The criterion validity, gold standard or reference standard for SIJ pathology was provocation of familiar pain, plus appropriate timed relief of 80% or more, with relief from a confirmatory anaesthetic block that also contained corticosteroid. As false positive responses do occur with single anaesthetic blocks of SIJ joints (Schwarzer et al 1995, Maigne et al 1996) the additional use of corticosteroid is a minor confounder in the reference standard. Furthermore intra-articular injections are only likely to identify intraarticular pathology, but not periarticular pathology, such as to ligaments. As the pain generating mechanism of SIJ pathology is not understood the relevance of this is unknown. References Aina A, May S, Clare H (2004). The centralization phenomenon of spinal symptoms a systematic review. Man Ther Bogduk N, Derby R, Aprill C, Lord S, Schwarzer A (1996). Precision diagnosis of spinal pain. In: Pain 1996 An Updated Review. Ed. Campbell JN. IASP, Seattle. Bogduk N, Lord S (1997). A prospective study of centralization of lumbar and referred pain: a predictor of symptomatic disc and annular competence: commentary. Pain Med J Club Cibulka MT, Koldehoff R (1999). Clinical usefulness of a cluster of sacroiliac tests in patients with and without low back pain. JOSPT CSAG (1994). Clinical Standards Advisory Group: Back Pain. HMSO, London. Donelson R, Aprill C, Medcalf R, Grant W (1997). A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine Dreyfuss P, Dreyer S, Griffin J, Hoffman J, Walsh N (1994). Positive sacroiliac screening tests in asymptomatic adults. Spine Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine Fairbank JCT, Park WM, McCall IW, O Brien JP (1981). Apophyseal injection of local anesthetic as a diagnostic aid in primary lowback pain syndromes. Spine Freburger JK, Riddle DL (2001). Using published evidence to guide the examination of the sacroiliac joint region. Physical Therapy Helbig T, Lee CK (1988). The lumbar facet syndrome. Spine Kokmeyer DJ, van der Wurff P, Aufdemkampe G, Fickenscher TCM (2002). The reliability of multitest regimens with sacroiliac pain provocation tests. J Manip Physiol Ther Laslett M, Williams M (1994). The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine Laslett M (1997). Pain provocation sacroiliac joint tests: reliability and prevalence. IN Movement, Stability & Low Back Pain. The essential role of the pelvis. Eds Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, Churchill Livingstone, New York. Laslett M, Young SB, Aprill CN, McDonald B (2003). Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocations tests. Aus J Physio Laslett M, Oberg B, Aprill CN, McDonald B (2004). Zygapophysial joint blocks in chronic low back pain: a test of Revel s model as a screening test. BMC Musculoskeletal Dis /5/43 Laslett M, Oberg B, Aprill CN, McDonald B (2005a). Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B (2005b). Agreement between diagnosis reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disorders 6:28.: Laslett M, Aprill CN, McDonald B, Young SB (2005c). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy Maigne J-Y, Aivalikilis A, Pfefer F (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine Manchikanti L, Pampati V, Fellows B, Baha AG (2000). The inability of the clinical picture to characterise pain from facet joints. Pain Physician Manchikanti L, Singh V, Pampati V et al (2001). Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD (2004). Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders 6: Volume 1, No. 1 March 2006 IJMDT 16

19 Non-specific low back pain are we any nearer a structural diagnosis? Ohnmeiss DD, Vanharanta H, Ekholm J (1997). Degree of disc disruption and lower extremity pain. Spine Revel ME, Listrat VM, Chevalier XJ et al (1992). Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil Revel M, Poiraudeau S, Auleley GR et al (1998). Capacity of the clinical picture to characterize low back pain relieved by facet joint injection. Proposed criteria to identify patients with painful facet joints. Spine Sackett DL, Richardson WS, Rosenberg W, Haynes RB (1997). Evidence-based Medicine. How to Practice & Teach EBM. Churchill Livingstone, New York. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994a). The falsepositive rate of uncontrolled diagnostic blocks of the lumbar zygapophyseal joints. Pain Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994b). Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Is the lumbar facet syndrome a clinical entity? Spine Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N (1994c). Pain from the lumbar zygapophyseal joints: a test of two models. J Spinal Dis Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994d). The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine Schwarzer AC, Aprill CN, Bogduk N (1995a). The sacroiliac joint in chronic low back pain. Spine Schwarzer AC, Wang S, Bogduk N, McNaught P, Laurent R (1995b). Prevalence and clinical features of lumbar zygapophyseal joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1995d). The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E (1998). The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil Slipman CW, Jackson HB, Lipetz JS, Chan KT, Lenrow D, Vresilovic EJ (2000). Sacroiliac joint pain referral zones. Arch Phys Med Rehabil Spitzer WO, LeBlanc FE, Dupuis M et al (1987). Scientific approach to the activity assessment and management of activityrelated spinal disorders. Spine 12.7.S1-S55. Van der Wurff P, Hagmeijer RHM, Meyne W (2000a). Clinical tests of the sacroiliac joint. A systematic methodological review. Part 1: reliability. Manual Therapy Van der Wurff P, Meyne W, Hagmeijer RHM (2000b). Clinical tests of the sacroiliac joint. A systematic methodological review. Part 2: validity. Manual Therapy Waddell G (2004). The Back Pain Revolution (2nd Edition). Churchill Livingstone, Edinburgh. Werneke M, Hart DL (2003). Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomic pain patterns. Spine Young S, Aprill C (2000). Characteristics of a mechanical assessment for chronic facet joint pain. J Manual Manip Ther Young S, Aprill C, Laslett M (2003). Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine Journal If its good enough for royalty... Volume 1, No. 1 March 2006 IJMDT 17

20 Low Back Care: Advice is plentiful, but is it worth taking? Richard Rosedale, Reg. PT, MCPA International Journal of Mechanical Diagnosis and Therapy Back pain is a significant health problem in western society and a major cause of disability; in fact it is the most frequent cause of work related disability in those younger than 45 years old. 1 As a result, much research has been conducted attempting to provide some answers to the challenges of prevention, treatment and reducing recurrences. As yet there are few definitive answers but enough good information to allow the establishment of evidence-based guidelines in many countries and by many institutions throughout the world. The message promoted by these guidelines is fairly consistent and provides some simple advice for those with back pain and those trying to prevent occurrences. The following would be a fairly representative sample of the information: Back pain is common and rarely due to serious disease Most people recover quickly Many will have recurrent episodes It is best to stay active and at work Regular exercise is helpful Passive treatment modalities (e.g. ultrasound) are not recommended One of the goals of these guidelines is to reduce anxiety and concern regarding back pain and its consequences. Certainly, when these guidelines are adhered to, individuals tend to experience a better recovery from an episode of low back pain. 2 However, these guidelines may not be that accessible to the general public, the advice can be fairly general in nature and some people are looking for more specific help. Many people may turn to other sources of accessible information: articles in magazines and newspapers, many Internet sites and dozens of books are available on the topic, many claiming to offer people solutions to the problem of back pain. But how much of this is useful, based on current evidence, and how much is outdated or misleading? The Internet is one of the sources that people are turning to in increasing numbers, however the information people can access may have dubious value. In a recent study it was found that most web sites on back pain provided poor quality information, some of which was seriously misleading. 3 In another article, 74 websites were reviewed; only 9 were ranked as being high quality. It was noted that most web sites available for back pain information could be classified as advertising and it would be difficult for people to get useful information. 4 Although there appear to be no thorough reviews, the same might be said for the books, magazine and newspaper articles on back pain available to the public. Not needing the scrutiny of peer review, authors are potentially able to make many unsubstantiated claims and give advice which may not be consistent with current knowledge. Consumers certainly need to be wary and discriminating with the information to which they may be exposed. A prudent first step is to check that any claims made are substantiated with a reference. This reference should state the source of the evidence on which the claim is based. If the source is a peerreviewed scientific journal, the information is likely to be more credible. If the advice being given has not been supported by evidence then this should also be stated. Everyone is of course at liberty to give opinions, provided it is stated as such and does not give the reader the impression that it has been validated. Advice leading consumers to purchase expensive products or services should be viewed with the greatest of caution, especially if backed only with personal endorsements or testimonials (these should not be considered as evidence ). If this advice is also inconsistent with some of the general guidelines outlined above, there would be even more reason for concern. For instance, the recommendation of a totally passive form of treatment, one encouraging dependency on a provider, is very suspect. An emphasis on self-care and giving the back pain sufferer the responsibility in the management of their problem would be much more inline with current evidence. Low back pain is now known to be a recurrent and persisting problem that can be present on and off throughout alifetime. 5 With this in mind it is logical that people should be instructed in strategies that will help them not only to manage their present symptoms but also to know what to do with future episodes and how to attempt to prevent those recurrences. People need advice that will keep them independent from healthcare providers, not dependent upon them. This can also make a difference to the individual on another level: It is now well established that many of the most influential factors that contribute to the transition of pain from being acute to becoming prolonged and chronic are more psychosocial than physical in nature. People s coping mechanisms, their attitudes, their fears and beliefs can all make a significant difference to how well or poorly they do when they have back pain. 6 Empowering people, giving them the responsibility to control their episode of pain and disability, can po- Volume 1, No. 1 March 2006 IJMDT 18

21 Low Back Care: Advice is plentiful, but is it worth taking? International Journal of Mechanical Diagnosis and Therapy tentially have a beneficial effect on these factor sand will hopefully help to prevent the transition from acute to chronic pain. This obviously makes sense not only for the individual but also for a system that is heavily burdened by the significant costs associated with longstanding pain and disability. Another example of a recommendation that is inconsistent with the evidence would be the advice that someone suffering with back pain should be on bed rest. Although traditionally a mainstay of care for back pain, it has now been shown that bed rest is rarely justified, 7,8 will certainly contribute to a fairly rapid deterioration in physical fitness, and can lead to other health problems. Though some people with low back pain may actively seek out information from these sources, many will rely on the advice given by health care professionals. Evaluating this advice can be even more challenging, especially when back pain sufferers see more than one professional and find the advice given is conflicting. To evaluate this information we must again compare it to the established guidelines: Is it reassuring and does it ease anxieties? Is education a key component? Does it promote activity and its early resumption? Does it guide people towards independence rather than dependency? Does it encourage a positive attitude? Does it promote staying at work or an early return to work? This last point is one of particular contention as it is so vital in influencing the long-term outcome of an episode of back pain. 5 The inclination of the back pain sufferer may be to think that rest and being off work are best and that one should not be working in pain. Unfortunately, sometimes this may be reinforced by the health care professional who then unintentionally becomes complicit in allowing an acute episode to become chronic and disabling. The longer someone is off work, the more difficult it becomes for them to return. Those that have been off work for 4 to 12 weeks have a 10-40% risk of still being off work at one year; after 1-2 years of absence it is unlikely they will return to work in the foreseeable future. 5 There are, however, many unknowns in regards to back pain. The evidence will take us only so far. Some interventions have been studied fairly extensively; others have never been examined. Ensuring that advice is consistent with the established guidelines is a start. Hopefully we can become even more discerning in the future as the research continues to be published and guidelines updated. Until then, it s important to know that some advice and information on back pain may be useful but some may not be. Distinguishing between the two is the challenge. References 1. Nachemson AL, Johsson E., Neck and Back Pain (Philadelphia: Lippincott, Williams and Wilkins, 2000). 2. Mcguirk B et al., Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care, Spine Vol. 26, No.23 (2001). 3. Butler L, Foster N., Back pain online. A cross-sectional survey of the quality of web-based information on low back pain, Spine Vol. 28, No.4 (2003) 4. Li L et al., Surfing for back pain in patients. The nature and quality of back pain information on the Internet, Spine Vol. 26, No.5 (2001) 5. Faculty of Occupational Medicine of the Royal College of Physicians, Occupational health guidelines for the management of low back pain at work: evidence review and recommendations, (March 2000) [available on-line at: BackPain.htm] [cited May 13, 2004] 6. Fritz J, George S., Identifying psychosocial variables in patients with acute work-related low back pain: The importance of fear-avoidance beliefs, Physical Therapy Vol 82, No.10 (Oct 2002). 7. Waddell G, Feder G, Lewis M., Systematic reviews of bedrest and advice to stay active for acute low back pain, Br. J. Gen Pract 1997, Oct, 47 (423) 8. Hagan KB et al., The Cochrane review of advice to stay active as a single treatment for low back pain and sciatica, Spine 2003, Mar 1, 28 (5) Roland, Waddell et al., Clinical guidelines for the management of acute low back pain (Royal College of General Practitioners, 2000). Reprinted from The Safe Angle, Perspectives on Health & Safety from the Health Care Health & Safety Assoc of Ontario, Vol 6, No 2, Now online pdf format MII Assessment Forms Copyright of the forms will remain with MII and the actual form itself must not be changed in any way, however it will be acceptable for a hospital etc. to incorporate their logo or name at the top of the form and requisite format for patient identification. This option is for convenience however you may find it more expensive than buying the pads from OPTP or the other Spinal Publications Limited agents who carry stock. Volume 1, No. 1 March 2006 IJMDT 19

22 Getting your back back to work: pain relief where to start? Timothy J. Caruso, PT, MBA, MS, Cert. MDT, and David J. Pleva, PT, MA, Dip. MDT Abstract Dental health care workers are vulnerable to back and neck pain resulting from poor occupational posture. While numerous choices exist for treatment, this article will provide them with a practical approach to seeking out appropriate care for this common malady. The McKenzie treatment approach is discussed and recommendations for its application are presented to provide the reader with a starting point for treatment. For the dental health care worker experiencing pain and dysfunction of the back and/or neck, as more than half will during their careers, this article will seek to provide an overview of potential causes while creating a roadmap for seeking the most appropriate conservative antidote for their care. Orthopedic research has shown that 70 percent to 80 percent of the population will experience transient neck or low back pain during the course of their lives. 1,2 Studies have found that 23 percent to 79 percent have symptoms that persist or recur. 3-6 A majority of dentists and hygienists have musculoskeletal complaints related to the back and neck. 7-9 Although dental practice changed from standing to sitting postures in the mid-1960s, ostensibly to decrease the incidence of back and neck problems, a decrease in the prevalence of reported discomfort has not been observed. 10 Numerous choices exist for treatment of spinal ailments including but not limited to: massage, acupuncture, chiropractic, yoga, Rolfing, Pilates, physical therapy, osteopathic, orthopedics and surgery. While there is not a one-sizefits-all approach to caring for back pain, with the proper training and advice, the majority of dental health care workers with pain can learn to treat their condition independently. Classification systems may be a clinically relevant way to characterize different sub-groups of back and neck pain and thereby to offer pain management strategies while excluding serious spinal pathology This article will present a classification system for the treatment of spinal pain created by physical therapist Robin McKenzie. According to McKenzie, the majority of low back pain appears to be mechanical in nature, having been initiated by excessive mechanical forces. Such an event may result from bending down to pick something up, or getting items out of a car trunk after prolonged sitting. 15 Mechanical pain is thought to involve injury to soft tissue. There is no single reason for mechanical low back pain, but the gamut of possible causes is vast considering the number of structures in the spine that have a nerve supply and are therefore capable of producing pain. 16 The benefit of the McKenzie approach lies in identifying the movement preference of an individual with back or neck pain in order to alleviate the symptoms. The approach has had favorable clinical acceptance among therapists and patients and offers a conservative alternative to treating back and neck pain. The article will provide an overview of the McKenzie approach, in order to provide the reader with back/neck pain basic information to determine the most appropriate course of action for conservative treatment of their disorder. The benefit of the McKenzie approach lies in identifying the movement preference of an individual with back or neck pain in order to alleviate the symptoms. The approach has had favorable clinical acceptance among therapists and patients and offers a conservative alternative to treating back and neck pain. The article will provide an overview of the McKenzie approach, in order to provide the reader with back/neck pain basic information to determine the most appropriate course of action for conservative treatment of their disorder. The McKenzie physical examination assesses four areas of relevance: 1) sitting and standing postures; 2) range of movement; 3) neurological testing assessing strength, sensation, reflexes, and dural status; and 4) directional movement preference testing. The repeated movement testing is a series of dynamic movements and loading strategies that attempt to determine a directional preference. This preference is determined by assessing the effect of the movements on pain. McKenzie advises that self-treatment should not be performed by individuals with the following complaints: 17 A first episode of back pain that persists for more than 10 days Bowel and bladder symptoms associated with back pain Back or neck pain caused by trauma Leg pain with symptoms below the knee including numbness, tingling or weakness Malaise Pain that disturbs sleep In the event of any of these symptoms, treatment must be administered by a qualified medical professional. 17 The treatment for mechanical pain involves identifying the correct direction to move the spine and alleviating the symptoms while limiting movements and activities that aggravate the symptoms for a period of time. In the McKenzie assessment scheme, mechanical pain is characterized by: 1) pain that can be constant or intermittent, 2) limited Volume 1, No. 1 March 2006 IJMDT 20

23 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy range of motion of the back or neck that improves as symptoms diminish, and 3) movements in certain incorrect, or exacerbating directions increases the pain while simultaneously decreasing range of motion in the opposite direction. The treatment for mechanical pain involves identifying the correct direction to move the spine and alleviating the symptoms while limiting movements and activities that aggravate the symptoms for a period of time. As symptoms improve, activities are reintroduced that may have been previously limited until all activities have returned to normal. For example, a patient may present with low back pain along with referred symptoms into the thigh. Following the performance of extension exercises, the thigh symptoms are abolished and remain better following completion of the exercises. This demonstrates mechanically produced pain that responds to the performance of the exercise in the correct direction. According to McKenzie, in most cases, the pain one experiences, at least initially, will have a combination of chemical and mechanical components. He proposed three nonspecific mechanical syndromes posture, dysfunction and derangement syndromes, which are now widely used in the musculoskeletal care of the spine. 18 These three separate syndromes can be identified by their unique clinical presentations and through assessment of a specific sequence of loading strategies. Each syndrome responds to repeated and/or sustained end-range loading in different ways. Within these three syndromes we can identify and diagnose the vast majority of nonspecific spinal problems 18. Postural Syndrome Postural pain syndrome is thought to be due to poor seated or standing posture, which stresses soft tissue structures at their end range of movement without any actual pathology. This poor posture position, if held over time, tends to decrease the blood supply to the area and overloads the supporting soft tissue structures, thus causing back pain. The hallmark of postural syndrome is that once the poor posture is corrected and the end-range stress is removed, the pain resolves. McKenzie gives the example of stressing one s finger by pushing it into an over extended position toward the wrist and holding it (Figures 1 and 2). As this position is held, pain begins to develop and tends to worsen with time. Once position is released, the pain subsides. In many cases the treatment is just as simple as that, once again enforcing what our mothers always told us, to sit up straight. In the case of the dental health care worker, poor posture is defined as forward head with rounded shoulders, flexed thoracic and lumbar spine, with the pelvis posteriorly Figure 1. Overextending a finger Figure 3a. Slouching posture tilted; also called slouching (Figure 3). Whether due to training, habit, or fatigue, slouched posture appears to be a regular part of the working day in the dental clinic. The ill-effects of poor seated posture are coming to light in the literature. Recently published studies have confirmed that slouched sitting causes the spinal musculature to diminish its activity and place increasing stress on the posterior ligamentous structures of the spine resulting in increased length or creep. 19 Bogduk defines creep as a constant force, that if left applied for a prolonged period to collagen tissue will result in further movement or length of the ligamentous tissue. 16 This creep phenomenon when combined with diminished muscular activity is thought to result in an imperceptible increase of unprotected movement of the lumbar spine and thought to place it at greater risk of injury. He went on to say that sustaining a flexed posture also reduces the resistance of the spinal ligaments. Figure 2. Overextending a finger Figure 3b. Slouching posture Volume 1, No. 1 March 2006 IJMDT 21

24 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy This reduction in resistance makes the spinal support structures weaker and thus, increases the chance of injury. In animal studies, it was found that the amount of time to cause the creep phenomenon to occur was as little as 20 minutes. Recovery took more than 24 hours and never returned to the original resting tissue length. It has been theorized that the combination of diminished muscle activity, combined with ligamentous creep may, in fact, lead to musculoskeletal cumulative trauma disorders over time as the amount of soft tissue damage exceeds the rate of repair and recovery in humans. It may also explain why individuals may experience ongoing or chronic low back pain over time with no apparent pathological condition with radiographic and other special studies. 19 Clinically, individuals with back pain may seek treatments that only address their symptoms and do not get at the cause of the problem. Having a one-hour massage may alleviate the discomfort for that particular day, while returning to the same slouched seated posture the next day causes a return of the symptoms. McKenzie theorized that the behavior of the lumbar discs mimics that of a soap cake between one s palms, wherein squeezing the palms backwards, the soap moves forward and squeezing the fingers together, the soap moves toward the wrist. This being the case, it can be seen that compressing the anterior aspect of the disc during forward flexion of the spine will cause the nucleus to migrate posteriorly and stretches the posterior annulus With spinal flexion, the vertebral canal is lengthened and this places tension on the spinal cord and peripheral nervous tissues. Flexion causes an increase in intradiscal pressure of up to 80 percent. 24 Conversely, extension of the spine compresses the posterior aspect of the disc moving the nucleus anteriorly The intradiscal pressure is decreased up to 35 percent with extension. 24 Andersson identified changes in intradiscal pressure with changes in posture in an historical publication. Slouched seated posture with weighted upper extremities demonstrated the highest intradiscal pressure of all postures measured. He found that in the unsupported sitting position, the highest level of myoelectric activity was in anterior sitting and the lowest in posterior sitting. Both myoelectric activity and disc pressure were found to decrease when the back was supported, particularly as the lumbar support was increased and armrests were used. 25 Anatomically, it is known that the posterolateral aspect of the disc is the weakest point of the structure with less radius, not as firmly attached to the vertebral end-plate, and not covered by the posterior longitudinal ligament. 26,27 If the creep phenomenon evidenced above holds true, recovery takes up to 24 hours irrespective of the load. Dentists and hygienists have been observed to assume a notably forward flexed posture greater than 50 percent of the time that they are working with their patients. 28 When a flexed posture is maintained, the stress of holding this position will fatigue the posterior annulus of the disc, overcoming its strength. If overstretching of the annulus exceeds 4 percent, irreversible damage will result. 29 As dental health care workers, sitting in this relatively poor position for extended periods of time is a natural part of the working day and may, in fact, lead to debilitating spinal disorders. When back pain sufferers are evaluated, measurement of their back strength has been found to be diminished The question of whether the weakness is a result of By adjusting the chair and oneself in a good, balanced, seated posture where the spine has assumed its natural curves, surviving the stresses of the work day becomes much easier. the back pain, or the back pain is a result of the weakness remains to be answered. There is, however, evidence to show that isolated strengthening of the back extensor muscles had a positive effect on complaints of low back pain Clinically, we often see significant weakness of the back extensor and posterior scapular musculature with an associated tightness of the anterior chest and shoulder musculature in individuals having back and neck pain. Additionally, we find weak abdominal musculature and tightness of the suboccipital soft tissue structures. If we were to combine the effects of weakness with limited mobility, stress, and fatigue in the working day, it is easy to see how this scenario can become problematic. For dental health care workers, good posture is a key ingredient to successful practice. For the purpose of clarity, we will define good posture as that position which places the ear over the shoulder, the shoulder over the hip, while the legs are supported and parallel or slightly inclined (knees lower than the hips approximately 5 degrees) with the feet supported on the floor (Figure 4). In a recent article by Figure 4. Good posture. Note the ear, shoulder and hip are in line Volume 1, No. 1 March 2006 IJMDT 22

25 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy Figure 5. A balanced spine Pynt et al., the authors concluded that lordosed seated posture, regularly interspersed with movement, is the optimal seated posture and assists in maintaining lumbar postural health and preventing low back pain. 33 Balancing the spine while seated provides a more stable base from which to work with less stress. McKenzie promotes the use of a lumbar roll in order to re-establish and support the natural lordosis of the spine and a cervical roll for sleeping to support the neck. He theorized that one of the main culprits causing low back pain is the loss of this lordosis in the lumbar and cervical spine, combined with excessive flexion of the spine throughout the day. In speaking with the average dental practitioner, they report not using the back of the operator chair regularly. In fact, some report not adjusting the chair prior to beginning their treatments. As a simple preventive strategy, adjusting one s chair prior to beginning work may counteract the illeffects of poor seated posture. By adjusting the chair and oneself in a good, balanced, seated posture Figure 6. A balanced spine with back support where the spine has assumed its natural curves, surviving the stresses of the work day becomes much easier. With the spine balanced, the head is over the shoulders and the natural spinal curvature is returned (Figures 5 and 6). For back pain of postural origin, the act of sitting up straight consistently through out the working day and while driving, alleviates symptoms entirely. As a dental health care practitioner, tuning into good posture, while adding a few general chairside exercises, may ease the day-to-day stiffness and discomfort experienced during a typical working day. While there is sparse support in the dental literature, at least one publication has identified the benefits of exercises performed by video display unit operators. 34,35 It was found that exercises performed while working at the video display resulted in short-term decreases in both musculoskeletal discomfort and postural immobility. 36 Another study found limited evidence based on randomized trials and epidemiological studies that exercises to strengthen back or abdominal muscles and to improve overall fitness, can decrease the incidence and duration of low back pain episodes. 37 So, where does one start? Family practitioner, orthopedist, chiropractor, physical therapist, massage, acupuncture? How about doing it yourself? Try the McKenzie approach. McKenzie recommends selftreatment exercises under the following conditions: 15 Periods in the day when you have no pain Pain is confined to areas above the knee Symptoms are generally worse with sitting for prolonged periods and better with standing or walking Symptoms are worse with bending or stooping and with inactivity If symptoms are better with lying face down Several episodes of back/neck pain have been experienced over the past few years As a general rule to follow for the McKenzie exercises: If pain does not centralize, decrease, or otherwise improve with the exercises; if pain was getting worse before starting the exercises and does not improve after the first two days; or if symptoms worsen following performance of the exercises and remain worse, seek advice from a medical doctor as this program may not be appropriate. 18 As a first step, correct poor seated posture by way of a technique called slouch-overcorrect. In this procedure, one assumes an extreme, slouched position. From this position one rises into an exaggerated, lordotic posture (Figures 7 Volume 1, No. 1 March 2006 IJMDT 23

26 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy Figure 7. An extreme slouched posture. good seated posture. This is the key to ongoing success. Extension in standing is another exercise used for counteracting poor postural habits. It requires one to stand with feet apart, shoulder width; placing hands in the small of your back or at the top of your buttocks; bending your trunk backward as far as possible while keeping the knees straight, and using the hands as a fulcrum (Figure 9). Repeat the process eight to 10 repetitions. This exercise can also be repeated four to six times throughout the day or as often as needed to counteract the stresses of forward flexion. In the case of neck pain of postural origin, good seated posture is the first activity to master. One can choose from several other movements to perform. Included are neck flexion, extension, and retraction. Since cervical flexion and extension are quite common, retraction will be discussed. While sitting up straight, retraction consists of moving the head posteriorly on the neck and shoulders as if someone is pushing your face gently backward (Figure 10). The movement itself reverses the cervical lordosis Figure 9. Extension in standing. and opens up the suboccipital space. A feeling of pulling or pressure in the cervical region at the end range of movement with no pain is normal. Retractions can be performed eight to 10 repetitions throughout the working day. The beauty of the postural syndrome is that the exercises to relieve it fit very neatly into the work day. Even though the postural syndrome is an entity in its own, poor posture also plays a significant role in the next two syndromes described by McKenzie. The sitting posture of individuals identified with dysfunctions and derangements must also be addressed in order to effectively resolve their conditions. Dysfunction Syndrome McKenzie theorized that the dysfunction syndrome is thought to occur when structural changes affect the joint capsules or adjoining soft tissues. Pain is experienced when the end range of movement is attained in one or more directions. Analogous to the dysfunction syndrome is a Colle s fracture of the wrist. Once the cast is removed from the wrist, movement of the wrist causes the shortened soft tis- Figure 10. Cervical retraction. Figure 8. An exaggerated lordotic posture. and 8). One can repeat this procedure 10 times and then reposition oneself back into a good seated posture with appropriate lumbar lordosis. This can be repeated throughout the working day as a simple chairside exercise. Repeat the process eight to 10 times throughout the day. After completion of the slouch-overcorrect maneuver, make sure to resume the Volume 1, No. 1 March 2006 IJMDT 24

27 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy Figure 11. Flexion in lying. Figure 12. Extension of the neck. sues to stretch and produce pain. As movement improves, pain decreases. Dysfunctions can be described in a variety of ways such as shortened, contracted, adhered, scarred, or fibrosed. Dysfunctions result from poor posture, trauma or surgery and the lasting effect of imperfect healing. Dysfunctions are time dependent and take at least six to eight weeks after the onset of injury to develop. 18 The pain from dysfunction is intermittent in nature and felt locally, in the neck or low back regions without extremity symptoms. The symptoms from dysfunctions are only produced when the shortened tissues are placed on stretch, and cease when the loading has stopped or decreased. Additionally, movement of the spine will be limited in the direction of the pain. The pain one feels from dysfunction syndrome will persist until full range of motion of the spinal segments has been recovered, and remodeling of the affected soft tissue structures has been achieved. In order to remodel a dysfunction, the soft tissues need to be stressed regularly throughout the day in order to return them to their normal resting length and full function. In dysfunction syndromes, the direction of movement in which this syndrome is treated is the one that causes discomfort. An initial pain that wears off gradually as you complete more repetitions is appropriate, whereas pain that is increasing with each repetition or moving distally is not, and one should stop the exercise. For example, if flexing forward causes discomfort confined to the back, without any symptoms into the buttocks or extremities, and improves as you increase the number of repetitions, then flexion in lying is the exercise of choice (Figure 11). Flexion in lying is performed while in a supine, hook lying position with the knees bent and the feet flat on the floor. Gently bring the knees up toward the chest until a feeling of pull or stretch is felt in the back. Repeat these exercises in sets of eight to 10 repetitions until Figure 13a. Extension in standing. the feeling of stretch subsides or until the knees reach the chest easily with no discomfort. Once the knees are brought to the chest easily, the progression is to flexion in sitting and standing. In the cervical spine, if extension of the neck is limited and a feeling of pulling, stretching or pressure confined to the neck is felt with no other symptoms; extension in sitting is the exercise of choice (Figure 12). Extension in sitting consists of raising the chin upward while extending the neck. The head is extended back until a feeling of pulling, stretching or pressure in the neck is felt. Return to the starting position, rest and repeat eight to 10 times throughout the day. As the exercise progresses, range of movement will tend to improve with less feeling of pulling or pressure. Several points of caution need to be made. It is known that the spinal discs hydrate during the night and that excessive flexion early in the morning may place individuals at risk for injury. 18 Snook et al. found that controlling lumbar spine flexion in the early morning was an effective form of self-care with potential for reducing nonspecific low back pain. 20 McKenzie recommended that flexion exercises always be followed by extension exercises, either extension in standing or lying (Figure 13). He theorized that performing extension after flexion could restore any distortion caused by flexion exercises. In the cervical Figure 13b. Extension in lying Volume 1, No. 1 March 2006 IJMDT 25

28 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy spine, known pathology such as arthritic conditions, abnormal signs or symptoms, such as dizziness, disorientation or confusion with performing extension of the cervical spine is an absolute indication to stop and seek medical advice. Derangement Syndrome The second condition McKenzie described is the spinal derangement syndrome. As previously mentioned, self-treatment for individuals with derangements is ill-advised and potentially dangerous. This discussion of derangement syndrome is for informational purposes only in order to provide readers with a conservative alternative to be considered prior to undergoing a potential surgical procedure for pain of discogenic origin. According to McKenzie, spinal derangements are the most commonly seen clinical condition. 18 A displacement or disturbance in the normal resting position of a spinal motion segment is the cause of derangement. The disruption will be pain provoking until it is reduced. In regard to the spine, this disruption can be anywhere in the motion segment, which is defined as the vertebrae above and the vertebrae below including the disc and soft tissues associated with this joint. This disruption can lead to a loss of one or more movements in the cervical or lumbar regions with associated pain. Derangements have varying clinical presentations, but usually respond to specific loading strategies. Symptoms can be felt locally in the spine, distally in the extremities or both. The hallmark of treating the derangement syndrome is called centralization. Centralization only occurs in derangements and is characterized by the identification of a movement that reduces the distal symptoms with a concomitant increase in local neck or back pain. With this decrease in symptoms, one will notice a dramatic, simultaneous increase in range of motion of the cervical or lumbar spine. The opposite occurs when a movement worsens symptoms or peripheralizes them into the extremities. Centralization includes the restoration of full movement with reduction or abolishment of symptoms. 18 For those facing a possible surgical intervention, this represents a reasonable treatment to try prior to undergoing more invasive treatments. Clinically, the majority of patients with a derangement respond to the extension principle of movement, however the treatment strategy for derangements is based strictly on identifying a directional preference. In other words, directional preference is determined by identifying the direction that decreases, abolishes or centralizes the symptoms while simultaneously increasing the lost range of motion of the spine. Donelson et al. reported that directional preference is guided by centralization. 38 Long-term correction of this condition is also dependent upon eliminating poor postures, whether sitting, standing or lying, which can be a contributing or underlying causative factor in the persistence of this condition. Research has shown centralization to be a reliable indicator in determining which patients will have a good prognosis Eighty-seven percent of the patients who centralized had good or excellent outcomes when compared to those who did not centralize. 38 In the chronic back pain population, 47 percent centralized and of the group that did centralize, 68 percent returned to work versus 52 percent of the noncentralizing group. 42 Donelson et al. reported that centralization most often occurs with extension. 43 In the case of the centralization phenomenon described by McKenzie, the pain can be a bit unnerving to individuals who may report feeling a worsening of their symptoms while experiencing it. A thorough explanation of symptom identification, understanding of potential pain behavior and location allows individuals to monitor and control their pain. Individuals must be assured that increasing central low back pain is desirable if distal, radicular symptoms in the arm or the leg are resolving or abolished. Once a treatment regimen has been established, ongoing postural education and awareness is a key ingredient to a successful treatment program. Derangements can be summed up as a condition that is inconsistent and rapidly changing. 11,18 To support the concept of sitting in lordosis with the derangement population, Williams took patients with back and referred pain and divided them into two groups. One group was to sit in lordosis, and the other group was instructed to sit in kyphosis for 24 to 48 hours. The group that sat in lordosis had their back and leg pain significantly reduced versus the kyphotic group. 39 When experiencing symptoms consistent with the derangement or dysfunction syndromes, seeking professional guidance by an experienced practitioner initially during your care will assure a successful recovery. Having a complete McKenzie evaluation may allow one to more accurately direct one s own care and the return to pain-free, daily activities in a timely manner. With the McKenzie system, individuals beyond the scope of conservative treatment can often be identified within a reasonable number of visits (three to six), rather than an extended period of time. If successful conservative intervention cannot be achieved, individuals can be referred to the appropriate practitioner with a written report in order to make an educated decision about Volume 1, No. 1 March 2006 IJMDT 26

29 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy more invasive treatment options. In the cases where surgery is indicated, returning to a McKenzietrained practitioner following a surgical procedure can facilitate a return to pain-free function. Prevention Prevention as a result of exercise has not been strongly supported in the literature, however; there is ample evidence that healthier, stronger individuals are at significantly less risk of health-related maladies including musculoskeletal disorders. One study has suggested that good dynamic trunk extension performance may protect against backrelated permanent work disability. 44 Weakness of the spinal musculature in individuals with low back pain has been identified in the literature, and general poor health has been associated with back/ neck pain in older individuals. 45 Spinal extensor musculature has been shown to have large potential for strength increase. 44 Medx is one particular treatment strategy utilizing a frame which specifically isolates the lumbar spine in order to strengthen back extensor musculature and has met with good results. 30 Lastly, the benefit of good working posture cannot be overstated. Poor seated posture may be a result of the combination of equipment choices and training. 46 (See Dr. Allan Jones article on Page 137.) Marklin noted that poor seated posture is quite prevalent among dentists and hygienists. 28 While the cause of poor seated posture is often difficult to pinpoint, several theories have been proposed including equipment selection, muscle weakness and debilitation, training techniques, work habits, workload, years in practice or some combination of these factors. Suffice to say, there is not one simple solution to this multifactorial problem. The addition of exercise alone to the dental health care worker s daily routine is only part of a complete solution. Several exercises have been recommended, however having a specific program customized for one s specific needs is the most appropriate approach to beginning an exercise program, particularly if there is underlying pathology. Having a complete musculoskeletal evaluation by a trained practitioner is a great place to start. Choosing an ergonomically designed workspace and properly fitting equipment may further reduce the risk associated with some of these causative factors. Denis et al. found that EMG activity of dental hygienists upper trapezius musculature was significantly reduced with the elbows supported by armrests on the operator stools during the working day. 47 Reducing this type of stress is one part of the resolution. Looking at the layout of the clinic is a good place to start and analyzing the specifics of your dental practice. Answering the following questions may be informative: Is scheduling helping or hindering the work flow? Is needed equipment within easy reach while working with patients? Can you get close to the patient? Do you have them move to accommodate your needs? How is the lighting in the operatory? Do you use magnification? Does it help? Are you using fitted gloves of the appropriate size? Is your chair adjustable? Is it comfortable? Does it provide you the support to assume a good seated posture? Have you had your posture observed or have you observed others in your office? Are you able to take a small break between patients to perform a few simple exercises? Are you stressed during the day? Have you had to modify your work hours/techniques due to discomfort or pain? Take a picture of your seated work posture. What does it look like? Being aware of the things we can control is extremely important. The concept of caring for our most important instrument, our body, is invaluable. Becoming aware of our aches, pains and general health is a vital part of attaining and maintaining a pain-free life. For years, dental health care workers have been constrained by the limitations of their own work environment and have paid the price physically. Equipment that does not work properly, adjust properly or limits lighting and visibility, along with increasing workloads, and poor ergonomic awareness and training, may all play a role. Fitting the worker to the work can have significant physical costs. Working with discomfort can only negatively impact the profitability of a dental practice. Likewise, career satisfaction, from quality of work to patient satisfaction, can also be greatly affected. It is often advantageous to have an objective third party perform a practice analysis to determine if the work environment is to blame for musculoskeletal aches and pains. Conclusion Given the numerous exercise routines and recommendations for treating back pain along with the countless health care practitioners available to seek advice from, it s always an advantage to be able to help yourself. There is an old proverb that goes something like this: Feeding an individual a fish takes care of their hunger, while teaching them to fish allows them to survive Volume 1, No. 1 March 2006 IJMDT 27

30 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy Table 1. NONSPECIFIC MECHANICAL SYNDROMES for life. The benefit of having a custom-tailored home program based on your particular needs will allow you to be proactive with your back/ neck pain. In most cases, nipping it in the bud before an annoying pain becomes more chronic and selflimiting is an obvious advantage. The authors have attempted to summarize the characteristic symptoms of mechanical back/neck pain, along with providing a logical approach for seeking the most appropriate conservative care. As an ongoing treatment strategy, the McKenzie approach fits very nicely into a regular workout routine and can be advanced to include a complete strength and conditioning program. McKenzie creates a framework within which one can perform all of their daily activities as well as their nightly activities safely, without pain. The ultimate success of the program combines the expertise of the trained health care practitioner including postural awareness, compliance of the patient and his/her self-treatment strategies. Making a conscious effort to include these components into daily and nightly activities will generally assure a much greater level of success. In general, being tuned in to how you feel will make a significant difference in your life, your staff, and in the lives of your patients. (Table 1). Footnote: It is strongly encouraged you seek the advice of a trained health care provider when experiencing low back or neck pain prior to beginning any type of exercise program to rule out serious pathology. If experiencing symptoms consistent with dysfunction or derangement syndromes it is advised to have these evaluated under the guidance of a trained professional. References 1. Spratt KF, Lehmann TR, et al, A New Approach to the Low Back Physical Examination: Behavioral Assessment of Mechanical Signs. Spine 15: , Kelsey JL, White AA, Epidemiology and Impact of Low Back Pain. Spine 5: , Toroptsova N, Benevolenskaya L, et al, Cross-Sectional Study of Low Back Pain among Workers at an Industrial Enterprise in Russia. Spine 20: , Croft PR, Macfarlane GJ, et al, Outcome of low back pain in general practice: a prospective study. British Med J 316: , Carey TS, Garrett JM, et al, Recurrence and care seeking after acute back pain. Results of a Long Term Follow-up Study. Medical Care 37: , van den Hoogen, Koes BW, et al, On the Course of Low Back Pain in General Practice. A one-year follow up study. Ann Rheumatol Disab 57: 13-9, Oberg T. et al, Musculoskeletal Complaints in Dental Hygiene: A Survey from a Swedish Country. J Dent Hyg 67 (5): , Murphy D. editor, Ergonomics and the Dental Care Worker. American Public Association, Ariens, GAM, et al, Are Neck Flexion, Neck Rotation, and Sitting at Work Risk Factors for Neck Pain? Results of a Prospective Cohort Study. Occupational Environmental Medicine 58: 200-7, Rundcrantz BL, Pain and Discomfort in the Musculoskeletal System Among Dentists. Lund Sweden: Department of Physical Therapy, University of Lund, 3-59, McKenzie R, The Lumbar Spine: Mechanical Diagnosis and Therapy. Spinal Publications, McKenzie R, The Cervical and Thoracic Spine: Mechanical Diagnosis and Treatment. Spinal Publications, Spitzer WO, LeBlanc FE, et al, Scientific Approach to the Activity Assessment and Management of Activity- Related Spinal Disorders. Spine 12(7): S Delitto A, Erhard RE, Bowling RW, A Treatment-Based Classification Approach to Low Back Syndrome: Identifying and Staging Patients for Conservative Treatment. Physical Therapy 75: , Nachemson A, Jonsson E, Jonsson editors. Neck and Back Pain. Lippincott, Williams and Wilkins, Philadelphia, SYNDROME SYMPTOMS STRENGTH SPINAL RANGE OF MOTION TREATMENT Posture Local, intermittent +/- weakness of trunk No limitation Postural correction General strengthening Dysfunction Local, intermittent +/- weakness of trunk Limited, painful at end range Derangement Local / distal / both Radicular pain Possible sensory changes, motor deficits, bowel/bladder symptoms +/- weakness of trunk / extremities Limited, painful during range of movement and/or at end range End range stretch in direction of pain throughout the day General strengthening Rule out serious pathology with physician. Determine directional preference under trained practitioner. Exercises performed throughout the day Centralization Volume 1, No. 1 March 2006 IJMDT 28

31 Getting your back back to work: pain relief where to start? International Journal of Mechanical Diagnosis and Therapy 16. Bogduk N, Twoomey L, Clinical Anatomy of the LumbarSpine. Churchill Livingstone, New York, McKenzie R, Kubey C, Seven Steps to a Pain-Free Life: How to Rapidly Relieve Back and Neck Pain. Plume/ Penguin Publishing, New York, McKenzie R, May S, The Lumbar Spine: Mechanical Diagnosis and Therapy 2nd edition Spinal Publications, Solomonow M, et al, Biomechanics and Electromyography of a Common Idiopathic Low Back Disorder, Spine 28 (12): Snook SH, et al, The Reduction of Chronic Non-specific Low Back Pain through Control of Early Morning Lumbar Flexion, Spine 23: , Shah JS, Hampson W, Jayson M, The Distribution of Surface Strain in the Cadaveric Lumbar Spine. J Bone Joint Surg 60B: , Sheppard J, Rand C, Knight G, et al, Patterns of Internal Disc Dynamic, Cadaver Motion Studies. Orthopedic Transcripts 14: 321, Sheppard J, In vitro study of segmental motion in the lumbar spine. J Bone Joint Surg 77B(Suppl 2): 161, Edmondston SJ, Song S, MRI Evaluation of Lumbar Spine Flexion and Extension in Asymptomatic Individuals. Man Therapy 5: , Andersson BJ, et al, The sitting posture: An electromyographic and discometric study. Orthoped Clin N Am, 6 (1): , Adams MA, Biomechanics of the Lumbar Motion Segment. In Grieve s Modern Manual Therapy. (2nd Ed). Eds. Boyling JD, Palastnaga N. Churchill Livingstone, Edinburgh, Edwards WT, Ordway MS, Peak Stresses Observed in the Posterior Annulus. Spine 26: 17539, Marklin R., Cherney K, Working Postures of Dentists and Dental Hygienists, in press. 29. Hickey DS, Hukins DWL, Relation between the Structure of the Annulus Fibrosis and the Function and Failure of the Intervertebral disc. Spine 5(2): 106, Sini M, MEDX Clinical Data, Kerlin- Jobe/HealthSouth Clinic, Los Angeles, California. 31. Shirado O, et al, Trunk Muscle Strength during Concentric and Eccentric Contraction: A Comparison between Healthy Subjects in Patients with Chronic Low Back Pain. J Spinal Dis 5: , Leggett S, et al, Restorative Exercise for Clinical Low Back Pain: A Prospective Two Center Study with One-Year Follow-up, Spine 24: , Pynt J, et al, Seeking the Optimal Posture of the Seated Lumbar Spine. Physiotherapy Theory and Practice 17: 5-21, Shugars D, Managing Dentistry s Physical Stresses: Chair Side Exercises for Dentists & Dental Auxiliaries. NC Dent Rev 2(2), Valachi B, Valachi K, Preventing Musculoskeletal Disorders in Clinical Dentistry: Strategies to Address Mechanisms Leading to Musculoskeletal Disorders. J Am Dent Assoc 134, December Fenety A, Short-Term Effects of Workstation Exercises on Musculoskeletal Discomfort and Postural Changes in Seated Video Display Unit Workers. Physical Therapy (82)6:57889, Pollock M, et al, Effect of Resistance Training on Lumbar Extension Strength. Am J Sports Med 17(5), Donelson R, Grant W, et al, Pain Response to Sagittal End-Range Spinal Motion: A Prospective, Randomized Multi-Centered Trial, Spine 16(6S): S206-S12, Williams MM, Hawley JA, et al, A Comparison of the Effects of Two Sitting Postures on Back and Referred Pain, Spine 16(10): , Karas R, McIntosh G, et al, The Relationship between Non-organic Signs and Centralization of Symptoms in the Prediction of Return to Work for Patients with Low Back Pain. Physical Therapy 77(4): , Long A. The centralization phenomenon. Its usefulness as a predictor of outcome in conservative treatment of chronic low back pain, Spine 20(23): , Sufka A, Hauger B, et al, Centralization of low back pain and perceived functional outcome. JOSPT 27: , Donelson R, Murphy K, Silva G. Centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine 15(3): 2113, Rissanen A. et al, Does Good Trunk Extensor Performance Protect Against Back Related Work Disability? J Rehab Med 34: 62-6, Hartvigsen J, et al, Back and Neck Pain May Exhibit Many Common Features in Old Age: A Population-Based Study of 4486 Danish Twins Years of Age. Spine 29: , Jones A, et al, Functional Training for Dentistry: An Exercise Prescription for Dental Healthcare Personnel. In press. 47. Denis M, et al, Reducing Musculoskeletal Strain with the Use of Movable Elbow Supports in a Dental Clinic. Proceedings Article Self-ACE Conference - Ergonomics for Changing Work, Reprinted with permission from CDA Journal, Vol 33, No 2, Pgs , February Photos property of Timothy J. Caruso and reprinted by permission. All rights reserved. Questions, not answers, are the seeds of success. Someone focused on answers says, "This is the way." Someone focused on questions asks, "Is there a better way?" Questions force you to explore - to stretch, to learn, to grow, and to be creative. Answers let your mind go to sleep. You get lazy when you think you've found the answer. You haven't. And you never will because things always change. To stay vibrant and relevant, keep living the questions. - Author Unknown Volume 1, No. 1 March 2006 IJMDT 29

32 A Personal Journey on the MDT path Eva Novakova, PT, Cert. MDT International Journal of Mechanical Diagnosis and Therapy Dear colleagues, I would like to share with you some of my personal experiences with the McKenzie Method. My first contact with the McKenzie Method was in Prague in 1995, when Scott Herbowy introduced this method to Czech physiotherapists and doctors at a Part A course. After this first contact, many of us were disappointed, confused and most did not want to accept this new diagnosis and therapy of lumbar spine. I must admit that I was among those who could not accept a new method of diagnosis and therapy. When I returned to my office, I decided to try this methodology with the approval of the appropriate doctors, though I was convinced that this method would not work. Surprisingly for me after a few months, I realised that 90% of my patients had responded to this new therapy and their recovery was quicker and better that with other PT modalities. After six months following my initial experience with McKenzie, I took a Part B course, also in Prague. Now I was sure I knew everything that there was to know about the McKenzie Method ( foolish me! ). I continued to increase my clinical experience with the McKenzie Method, having great success with therapy and diagnosis. I also found that I was quite alone in the use of the McKenzie Method in my country after the two parts offered. For the next three years, I continued my own research and treatment with great success. I began to present my successful findings at many conferences. After a long while, some colleagues began to question me and visit my office to observe my use of the McKenzie Method. As a result, I decided I had to learn more about McKenzie. I asked Stacey Lyon from the USA branch of MII, who I only knew via the internet, if she could help me to continue my McKenzie studies. Fortunately, she was a big help to me. Stacey arranged my attendance at a Part C and D course as well as observation of David Pleva Dip. MDT at Weiss Memorial Hospital in Chicago. As a result of these experiences, I realized that I had much more to learn-which continues today and probably forever. Even if my successful treatment was obvious, I still made a lot of mistakes during an assessment, for example: It was difficult to strictly follow the assessment form and to formulate a logical McKenzie conclusion. I was not able to compare the frontside of the form with the backside in many details. It took some time, then I realised that the protocol is created in such a way that all items of the protocol have a relationship with each other. We can t do the movement loss section if we do not take the consequences from the worse/ better section, or the repeated movements. The worse/better section gives us already an idea of the presence/absence of a loading component. We must use this information in all other sections. (That is why our McKenzie instructors can sometimes look like very well educated PTs or crazy PTs, because their conclusion of diagnosis is obscure for many students who do not know how to compare these sections of the assessment sheet). I had a problem complying with the McKenzie system. I wasn t patient. If I didn t get a good result immediately, I combined McKenzie principles with other techniques - PNF, etc. I had a problem with understanding how to comply with the progression of forces described in the book. Now this is, for me, a logical frame work of progression of mechanical loading as a result of the symptom response of the patient. This was completely opposite knowledge from what I was taught in my country. It also took some time before I understood that I have to be certain of the reaction of the patient to different loading strategies, etc. Nico de Bruine from Benelux and Ela Wierchzon from USA helped me a great deal with these above items. In addition to many other items which I failed to note, I am sure that without their help I never could have passed the McKenzie exam. It is really difficult to live in a non-english speaking country like the Czech Republic and be the only one using the McKenzie Method. Now I am the administrator of the McKenzie Czech branch and organize McKenzie courses with the kind support of MII from New Zealand. Unfortunately just now my country is not in a good economic position. I think it will take ten or more years before the Czech economic system will be able to compete with other western countries. Even though our financial situation is not very good, I am hopeful that now I will not be the only one in my country using the McKenzie method. In comparison with my knowledge from before, now students or participants can learn much more about the McKenzie courses. Although they receive a lot of information, without clinical practice and sharing their experiences with each other, they will remain at a Volume 1, No. 1 March 2006 IJMDT 30

33 A Personal Journey on the MDT path International Journal of Mechanical Diagnosis and Therapy poor level. Also they will think that the McKenzie Method doesn t work. They must go through this specific process of theoretical and clinical practice. As I have already realised the learning is forever. My last comment is to Lawrence Dott from MII NZ: I would really like to express my thanks to him for all his help to me and to our Czech students who now are attending the McKenzie courses in the Czech Republic. I know they will be able to take care of Czech patients in a better way. Case Study The following is a case that I had before I took the McKenzie exam in Nico debruine provided the following comments on my mistakes made (which you can see on the assessment sheet): Are the relevant symptoms (= the symptoms the patient presents today) exactly the same as on the bodychart?? The bodychart gives all!!!! symptoms during this episode. By carefully asking the present symptoms, and the smptoms during the whole episode, you get an idea of the change in location of the symptoms (indication derangement/dysfunction). Symptoms at onset: when did the symptoms in the foream start? Previous history: did all symptoms in previous episodes abolish? If not, it could be possible that in the meantime he was developing gradually a dysfunction. Movement loss: keep comparing the result of all sections. McKenzie = dynamic evaluation of the symptoms behaviour due to loading strategies. Not a basket with all different isolated tests. Repeated movements: why start in loaded position with such a big loading problem (see worse/ better section!!!) The most left part of the repeated movement section: PDM/ERP. Here you only tick either Pain During Motion or End Range Pain. Why give him, as result of all tests, posture correction in sitting/ standing? With such an enormous loading factor. The first therapy you do with him is unloading = lying. The PNF I already mentioned. No McKenzie!! Even if my examination was not perfect, the treatment which I used for this patient was successful. Since 2002, I see him every year. His posture is very good. He has not noted any problem. He still works in sitting position, he does exercise regularly 2-3x per day retraction and extension in sitting, 3x per week exercise for the whole spine. He started to go swimming and hiking. If he works in sitting position too much, he sometimes feels a stiffness in his neck, but never in his arm and hand etc. He usually changes his position and exercise retr.+ ext. and stiffness goes away. Eva Novakova Chairman of McKenzie Institute CZ Stochovska Praha 6 Czech Republic PH : FAX : [email protected] website: Volume 1, No. 1 March 2006 IJMDT 31

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36 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors Elise A. van de Veen, MSc, Henrica C.W. de Vet, PhD, Jan J.Mm Pool, Wouter Schuller, MD, Annemarie de Zoete, DC, and Lex M. Bouter, PhD ABSTRACT Objective The aim of the study was to identify differences in the diagnosis and treatment of nonspecific low back pain among 3 professional groups in the Netherlands: orthomanual physicians, manual therapists, and chiropractors. Methods Information was obtained from training materials from professional groups, literature searches, and observation of selected practitioners at work. Results In The Netherlands, there are differences in education between the 3 professional groups. The focus of orthomanual medicine is on abnormal positions of components of the skeleton and symmetry in the spine. Manual therapy focuses on functional disorders of the musculoskeletal system. Chiropractic focuses on the musculoskeletal and nervous systems in relation to patients' health in general. Orthomanual medicine considers inspection and palpation the most important diagnostic tools. Manual therapists and chiropractors additionally perform tests to determine functional disorders and manual therapists evaluate psychosocial influences. Chiropractors take radiographs if necessary. Orthomanual physicians apply mobilization techniques using fixed protocols. Manual therapists and chiropractors use various manipulation and mobilization techniques and their manipulation techniques differ in amplitude and velocity. Conclusions Diagnostic techniques and treatment methods of the 3 professional groups differ considerably. For more accurate reporting of the efficacy of manipulative and mobilizing therapies, the characteristics of treatments should be described in more detail when reported in studies such as randomized clinical trials. Pain in the low back is very common. Approximately 70% to 90% of adults suffer from low back pain (LBP) at some time during their lives, whereas 5% to 10% suffer for a long period. 1,2 Nonspecific LBP manifests itself as pain, muscle tension, or stiffness; localized below the costal margin and above the inferior gluteal folds; with or without leg pain; and is not attributed to recognizable pathology. 2 It is classified as acute, subacute, and chronic, lasting less than 6 weeks, 6 to 12 weeks, or more than 12 weeks, respectively. 2 In general, the aim of conservative treatments of LBP is to relieve pain, to improve functional ability (including return to work), and to learn to cope with pain. 3 For acute LBP, guidelines for general practitioners aim at preventing unnecessary dependency on medical care. The guidelines for subacute and chronic LBP concentrate on preventing or diminishing dysfunction. 4 This paper is focused on manipulation and mobilization therapies as treatment methods for patients with nonspecific LBP by different professional groups in the Netherlands. Literature shows various definitions of the concepts mobilization and manipulation. In general, manipulation is characterized by a thrust with high velocity, beyond the physiological limits of the range of motion of the joint and beyond the control of the patient. Mobilization encompasses low-velocity passive movements within or at the limit of joint range of motion. 5 The concept of mobilization comprises a wide range of techniques. In the course of time, several comprehensive systematic reviews on the efficacy of manipulation and mobilization therapies suggest evidence for short-term efficacy of manipulative and mobilizing treatment of chronic LBP and limited or conflicting evidence for short-term efficacy of manipulative and mobilizing treatment of acute LBP. 3,6 Longterm efficacy is rarely studied. 3,6 A recent meta-analysis showed that manipulative/mobilizing therapies are more effective than placebo and other ineffective therapies, but not more effective than other effective therapies for acute and chronic LBP. 7 In the above study, they tried to distinguish between different forms of manual therapy. Trials that used manipulative therapy solely or predominantly were studied separately, and this was also done for trials in which the profession of the manipulator was chiropractic. The results of these subsets of trials did not differ from the other trials. 7 However, we question whether the treatments have been classified properly, as the characteristics of treatments under study are usually poorly described in method sections of randomized clinical trials and many professional groups apply a combination of manipulation and mobilization techniques. Furthermore, the term manipulation is often used when mobilizations are also performed. Therefore, it remains unclear whether the inconsistency in the results of various randomized clinical trials should be partially attributed to the different manipulative or mobilizing treatments used in those studies. Only a more systematic and detailed description of the manual techniques applied can shed more light on potential differences in efficacy. Comparison of international guidelines for LBP shows differences in the recommendation of manipulative and mobilizing therapy. 4 In most countries these therapies are recommended, mostly for acute LBP. In none of the guidelines a preference is given for a specific manipulative or mobilizing treatment method. 4 This lack of preference is possibly because of poor descriptions in the literature about the type of treatments under study. The purpose of our paper is to describe the treatment methods of 3 professional groups in the Netherlands who provide manipulative or mobilizing treatment methods, orthomanual physicians, manual therapists, and chiropractors, and examine whether there are differences in the diagnosis and treatment of nonspecific LBP among them. If the efficacy of a certain drug is studied in a randomized clinical trial, the dose, frequency of administration, and duration of the treatment are presented to characterize Volume 1, No. 1 March 2006 IJMDT 34

37 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors the intervention. But when manual therapy is the intervention, the information is usually minimal. Often references to descriptions in articles, handbooks, or professional documents are missing. This prohibits not only the distinction between different forms of manual therapy, but also prohibits the application and implementation of the interventions, which are shown to be effective in clinical practice. Therefore, adequate descriptions of the manual therapeutic interventions are urgently needed. These considerations led to our initiative to describe the concepts, contents, and practicalities of the treatments of 3 major professional groups involved in manual therapy in the Netherlands. Because there might be international differences, we only focused on the way Dutch practitioners perform their treatments. METHODS The professional groups in the Netherlands were asked to supply information and training material. A profession profile or job profile was obtained from each group, as well as additional information such as patient profiles. Furthermore, books advised by training colleges were perused, and web sites of the professional groups were checked for additional information. This information was supplemented by articles found in international literature. To check whether the profiles correspond to daily practice, a small group of practitioners were observed while at work. These professionals were chosen by the project team as typical and pure representatives of their disciplines, without applying combinations of therapies from different professional groups. They often were involved in training and education of their professional group in the Netherlands and all were experienced. Visits lasting half a day were made by one of the authors (EAvdV) to 3 orthomanual physicians, 3 manual therapists, and 4 chiropractors. RESULTS Description of the Professional groups Orthomanual medicine. Orthomanual medicine is a medical profession practiced by physicians who have an additional 3 years of fulltime study in practicing orthomanual diagnostic and therapeutic techniques. As a basic principle, orthomanual medicine assumes the symmetrical development of the skeleton. The central idea is that misaligned positions of skeletal components can result in movement limitations and pain. 8 Emphasis of the orthomanual examination is on the 3-dimensional positions of the vertebrae, pelvis, and ribs in relation to each other. 9 The pelvis is considered to be the fundamental part of the vertebral column and abnormal positions are assumed to have an impact on the skeleton in its entirety. A declined position of the pelvis is denoted as a pelvis distortion. If the distortion is a recent development, it causes misalignments of the above-located vertebrae. If the distortion persists more than 5 years, those vertebrae fixate in rotated and lateroflexed positions. 8 Orthomanual medicine denotes a fixed displacement as a misaligned position. 10 Different positions are distinguished, based on the most striking misalignments. These positions form patterns with empirically established regularities. The objective of the orthomanual treatment is to adjust the misaligned positions and thus to diminish the complaints. The treatment goal is an improved position of the skeletal components, in which misaligned positions are no longer present (source: training manual of orthomanual medicine with no publisher or author known). Furthermore, the pelvis as well as the ribs must be in an optimum symmetrical position. Typical of this treatment is that corrections are made in a specific order. When the correct sequence is used not much force is needed and no levers are used. Manual therapy. The emphasis of manual therapy is on dysfunctional joints in the broadest sense of the word. According to the International Federation of Orthopaedic Manipulative Therapies, manual therapy is a specialization within physical therapy. In the Netherlands an additional 4 years of part-time training (24 weekends a year) of the theory and practice of manipulation and mobilization techniques is followed after graduation as a physical therapist. The diagnostic examination and treatment of manual therapy are aimed at pathoneurophysiology and pathokinesiology, as well as the recognition and interpretation of tissue and organ-specific dysfunctions on a local and segmental level. 11,12 During the diagnostic examination, the individual movement system is analyzed while accepting asymmetrical morphology and function, and respecting the related individual preference of function. A biomechanical assessment is used to obtain detailed information of the relevant joints, muscles, and surrounding soft tissue and to determine whether manual therapy will be beneficial. 13 The assessment includes 3-dimensional tests within or at the limit of the range of motion of the joints. Manual therapists correlate their findings of the examination with the nature and distribution of the offending symptoms to arrive at a diagnosis and proceed to select a course of treatment. Treatment Volume 1, No. 1 March 2006 IJMDT 35

38 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors aims at stimulating natural recovery and adaptive processes in relation to functionality of movement in a biopsychosocial perspective. Furthermore, objectives of the treatment are to diminish pain, to influence and increase the level of activities and participation of the patient, and to prevent recurrences. 11,14 Chiropractic. The treatment of disorders of the neuromusculoskeletal system is the heart of chiropractic. 15 The chiropractor completes a 6- year full-time education in chiropractic college to become a doctor of chiropractic. The emphasis is on manual techniques, including joint adjustment (chiropractic manipulation). Moreover, the curriculum includes substantial education in the use of radiography. 15,16 The profession, defined by the World Federation of Chiropractic as a health profession, is concerned with the diagnosis, treatment, and prevention of disorders of the musculoskeletal system and the effects of these disorders on the function of the nervous system and general health. 15 This implies a broad scope, comprising the etiology, pathogenesis, diagnostics, therapeutics and prophylaxis of functional disturbances, pathomechanical states, pain syndromes, and other neurophysiologic effects. 17 For a treatment plan, guidelines or standards from literature will be used when relevant The chiropractor works toward normalization of disturbed physiology, recognizing that health problems can occur because of psychosocial, physiological, and mechanical factors from inside or outside the body. Another objective is to enable the body to use its capacity for self-recovery. The therapeutic approach may incorporate dynamic manual treatments, designed to release joint restrictions directly or indirectly (reflexively), and other procedures designed to enhance the healing process. These procedures include reflex techniques, exercise, physiological therapeutics, nutritional supplementation, and counseling about exercise, posture, diet, relaxation, and stress reduction. 17 History taking for LBP The 3 professional groups use the regular method of taking a history with standard questions. Contraindications and other pathologies, which can influence the treatment or need for other treatment, are examined. To some extent, there is a difference in emphasis and extensiveness of the history taking between the professional groups. Patients who visit a manual therapist are referred by their general practitioner or other health care provider, whereas for treatment by chiropractic and orthomanual physicians no referral is needed. Thus, these professionals have a broader diagnostic scope to distinguish nonspecific LBP from other disorders. Orthomanual physicians concentrate on nonspecific and specific disorders of the musculoskeletal system, particularly of the spine. Manual therapists strongly focus the history taking on the functioning of the musculoskeletal system including possible psychosocial influences. Chiropractors focus on the neuromusculoskeletal system in relation to the patients' health in general. Diagnostic examination for LBP Orthomanual medicine. The practitioner uses palpable points of reference for the orthomanual examination, such as the posterior inferior iliac spine and anterior superior iliac spine, the iliac crest, margins of muscles, spinous processes of the vertebrae, and others. The anatomical axes and planes serve as a frame of reference and are used to describe the positions and possible malpositions of the vertebrae, pelvis, and ribs, with regard to their normal anatomical position and their normal range of movement. The results of the examination are recorded in a notational system specific to orthomanual medicine (source: training manual, unknown publisher or author). For inspection and palpation, the predominant position is when the patient sits on the table in a forward bent position. This enables palpation of points of reference in a posture in which surrounding muscles are relaxed, without disturbance from possible discrepancies in leg length. A prone or supine position is used for additional information or verification. For the assessment of the position of the pelvis, the level of the iliac crest and the positions of the iliac spines are palpated, and it is noted whether or not the pelvis is raised on one side. The examination of the spine and ribs is carried out by 2-sided, simultaneous palpation of the spinous and transverse processes and ribs. Misaligned positions of vertebrae can cause deviations of ribs relative to a horizontal line, resulting in different intercostal spaces and a high or low position of those ribs. Options for additional tests are active, passive, and resistance tests; passive movements through the range of motion; extensive neurologic tests or medical tests; and imaging techniques for underlying or other problems. Different combinations of misalignments of vertebrae and ribs may point to different malpositions in vertebral joints, costotransverse or costocorporal joints. Some malpositions can only be diagnosed after the correction of other malpositions. Volume 1, No. 1 March 2006 IJMDT 36

39 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors Manual therapy. The diagnostic examination focuses on joint function, stability, movement patterns, range of movement, and the severity of disorders. The skills and disabilities of the patient and the relationship between stress on the body of the patient and its ability to endure stress are also assessed. 11 As any structure innervated by pain fibers can be a potential source of symptoms, a biomechanical assessment of tissues that either underlie or refer to the symptomatic areas is performed. 13 The position of the joints is considered to be essential to the performance of diagnostic tests. Manual therapists use different basic positions, such as standing, sitting, supine, prone, or side posture. 11 The joints are tested and treated from these positions in a position different from neutral. Palpation is directed to specific pain locations such as tender points, myofascial trigger points, and tendomyosis. 11 Techniques are static palpation of the paraspinal tissue and osseous structures, and palpation of passive accessory and passive intervertebral movements. The results yield information as to tenderness (pain), restricted intersegmental motion (stiffness), and spasm (muscle tension). 13 The extensive amount of neurologic tests used can be grouped into tests for syndromes, sensibility, and segmental function. In practice, manual therapists do not perform a complete neurologic evaluation, but choose appropriate tests. The biomechanical assessment includes general, regional, and segmental techniques. 20 General techniques consist of the execution of active movements with instruction. Regional and segmental assessments comprise several techniques. Guided active, resistance, and provocative tests are carried out. Provocative tests consist of the execution of spring action with gapping and compression; traction in the cervical region; and rotatory tests in the thoracal and lumbar regions. 20 Manual therapists use specific combinations of techniques such as rolling/gliding and traction / translation. 14,20 Objectives of the assessment are determination of abnormal maneuvers in a movement pattern, resistance and quality of end-feel, joint play, and effects on other segments. In this way, information on willingness to move, strength, coordination, and pain is obtained. Chiropractic. The standard physical examination is conducted to establish a clinical diagnosis from a differential diagnosis and to determine whether chiropractic care is indicated for the patient's complaint. First, the patient's general health is examined with tests that include blood pressure, gait analysis, standing balance, and neurologic tests. Then, the chiropractor looks at the area of the complaint(s). This comprises inspection; observation; palpation; active and passive range of motion; provocation tests; and orthopedic, neurologic (eg, reflexes, pin-wheel testing), and vascular examination. 21 The components of the physical examination, which are not related to the musculoskeletal system, are only practiced when necessary. 16 Testing of the low back is carried out with the patient standing, seated on a motion palpation stool, prone, and supine. The patient is seated to stabilize the pelvis or in a standing position with the shoulders or neck stabilized by the chiropractor. The examination of joint play is customary. Joint play can be defined as the degree of passively allowed distension, which cannot be achieved through voluntary effort. 17 The patient is not able to influence this small accessory movement within the joint. Besides standard chiropractic procedures, motion palpation is used to detect restricted joint play and the end-feel per segment. 17,22 This examination for limited motion is done by carrying the segment through its normal range of motion. The palpating fingers should be on the active and at least 1 adjacent segment. Then, movements are carried out on the spine by using various parts of the hand or fingers. The movements consist of pushing and releasing pressure, which gives an impression of the mobility of vertebrae during flexion, extension, rotation, and lateral flexion. A similar procedure can be performed on the sacroiliac joint with the patient standing or in prone position. The use of imaging techniques, such as radiographs, computed tomography scan or MRI, and blood tests is additional to the diagnostic examination. Radiographs can be taken by the chiropractors themselves. 23 Radiographs are used for the examining for (contra)- indications for chiropractic treatment or for predicting the prognostic outcome of treatment and for localization and type of treatment. 3,16 Often it is possible to use previously taken radiographs requested from the general practitioner or medical specialist. Treatment of nonspecific LBP Treatment of a patient with LBP comprises several sessions. In orthomanual medicine, usually 4 to 6 sessions of treatment are needed, once a week at maximum. 8 The Dutch guidelines for manual therapy state a number of 6 sessions per indication to be sufficient for recovery of function of the joint. 14 Chiropractors use 4 to 12 sessions of treatment before the practitioner switches to maintenance care or Volume 1, No. 1 March 2006 IJMDT 37

40 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors the prevention of recurrences, if indicated. 16 The length of time in between sessions is not prescribed for manual therapy or chiropractic. In practice, 1 session per week is customary, although there is a large variation between practitioners. Orthomanual medicine. The positioning of the patient is focused on the relaxation of muscles, opening of the joint, or a slight form of traction. Most frequently used is a prone position or side posture, with the head on a pillow and both knees pulled up or one knee pulled up, and the other leg stretched out. 9 Variations and slightly different positions are practiced for treatment of a specific location or to create traction or a force in a desired direction. Orthomanual medicine practitioners label their therapeutic actions as manipulation. However, according to the standard definitions of manipulation and mobilization it should be labeled as mobilization. It can be described as a direct force, used on an osseous structure of the spine with a malposition or malfunction, using a short lever within a segment in the direction of the natural position or function. The force applied is pulsating or with a fast impulse. Orthomanual physicians do not apply high-velocity thrusts (HVTs). The length of time spent on orthomanual mobilizations during a treatment session is considerable and almost no other techniques are used. Some practitioners use rocking movements or vibrations preceding the mobilization. The mobilization is carried out by pushing with the thumb, forefinger, or hypothenar against a spinous or transverse process. 10 While adjusting the pelvis or ribs, different parts of the hand are used. Orthomanual physicians use different forms of mobilization: with the fingers, with other parts of the hand, with a drift or by pushing the vertebra in the wrong direction, resulting in a spontaneous replacement. The use of the drift supplies an axial force; the use of the thumb or other fingers supplies a more radially directed force. The treatment sequence per session of pelvis, vertebrae, and ribs is set down in strict, experience-based guidelines. In practice, there is a limit to the number of adjustments possible in one session. 9 Seldom will the practitioner decide to deviate from the guidelines. The guidelines prescribe the moment of treatment of a skeletal component in a particular session out of the series, the sequential relation to other skeletal components, and the number of vertebrae or ribs that can be treated per session. Manual therapy. The patients' positioning is focused on obtaining a nonneutral joint position. 11,14 Most positions are used to create space in the joint. Sometimes traction is performed. Manual therapists use a multitude of techniques. Customary are myofascial techniques, stretching, instructions, exercises, and advises in activities of daily living. Manual techniques specific for manual therapy are predominantly mobilizations. 11 Mobilizations attempt to recover the full, painless functioning of joints by rhythmic, repeated passive movements. 24 There are 2 principal mobilization techniques: passive oscillatory movements within the restricted physiological range of the joint, and sustained stretching with or without oscillations at the limits of the range. 13 The techniques consist of traction, translation, rolling, rocking, gliding, and spinning movements, tilting movements, and compression. 11 Characterizing features of mobilizations are the movement section, range of motion, number of repetitions, velocity of action, rhythm, and handling of the body. Variability in the use of these parameters results in variation of intensity of the treatment. During the application of mobilizing techniques, patients can report on the effects, thereby putting the action within their control. Manipulation is a passive maneuver in which a specifically directed force is applied to vertebral articulations. It is a precise, single, and fast movement with small amplitude and a regional or localized effect, dependent on the positioning of the patient. The movement is not necessarily forceful and is finished before the patient can stop it. 24 The lack of the ability to stop the application by the patient is a difference between mobilization and manipulation. A manipulation can be delivered in 2 forms: long-lever manipulations and short-lever manipulations. Long-lever manipulations consist of a high-velocity force exerted on a point of the body some distance away from the area where it is expected to have its beneficial effect. Short-lever manipulations are HVTs directed specifically at an isolated joint. 13 In a survey, the use of one or more HVT techniques was reported by 36% of the practitioners during every session and intermittently by 40%. 25 Manual therapists use neuromuscular techniques as well. These muscle energy techniques use contractions at various intensities from controlled positions in specific directions against a distinctly executed counterforce. Proprioceptive neuromuscular facilitation uses specific manual contact to enhance the direction, strength, and coordination of a motor response. 13 In general, manual therapy is directed primarily to the complaints, particularly the main complaint. In Volume 1, No. 1 March 2006 IJMDT 38

41 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors the Dutch guidelines, the treatment sequence of disorders is not prescribed. 12 In practice, techniques with a neuroreflexive effect will be used first, followed by mobilizations with increasingly specific effects. 14 Chiropractic. Patients are treated in supine position, side posture, prone position, with or without the use of pads or supports to open the joints. 26,27 Chiropractic treatment comprises manipulation, mobilization, exercises, and instructions for rehabilitation, as well as advice, preventive instructions, and information. 15 In the Netherlands, chiropractors also often use Cox flexion-distraction technique, trigger point therapy, and traction. Indirect functional approaches, such as cutaneous reflex techniques, vibration, isometric or isotonic contractions, or massage, are often used when the cause for fixation is determined to be essentially muscular or when any form of manipulation would be contraindicated. 17 Manipulation or HVT technique is the most characteristic action of chiropractors. 15 This technique is the application of a specific pressure or force in a specific guided direction on a blocked joint. It is a short, direct, thrusting movement, acting on a spinous or transverse process, which is used as a lever. 15 Chiropractors report the use of the HVT technique often to always in a session. 16 In the practices observed for this study, HVT is applied singularly or only a few times per session. There is an extensive amount of variation of manually or mechanically applied interventions within the range of manipulation and mobilization techniques. Various parameters characterize the techniques, such as applied force (low, medium, high), duration of the force (brisk or sustained), amplitude or distance of articular motion (short, medium, long), and direction of drive (straight, oblique, or curving to the articular plane). Furthermore, techniques have a slow, moderate, or abrupt thrust onset. 17 Several different thrusts are practiced by chiropractors. Recoil thrusts are performed with the use of the spring support of the table, in which the tension is released and the hands recoil away from patient's spine. For a body-drop thrust, the adjuster uses his body weight in a dropping movement. Multiple thrusts have a gradual increase in force and permit the application of a force equal to or greater than used in a single thrust. Extension thrusts are a distraction of joint surfaces and elongation of soft tissues, so that articular pressure is reduced to a minimum at the moment of joint movement. Rotatory thrusts apply a lateral force on the contralateral side of a lateral flexion fixation. Leverage moves use counterpressure or contralateral stabilization. The main complaint will be treated first if the patient presents with several disorders. Treatment of remaining complaints follows in order of priority or, if possible, simultaneously. 15 Active and passive care in relation to the participation of the patient is included. Active care, such as exercises, rehabilitation, and lifestyle adaptation, is completed along with passive care focused on relaxation, reduced muscle tension, and relief from pain. DISCUSSION The 3 Dutch professional groups in this study resemble each other with their strong emphasis on diagnosis, the explicit construction of a treatment plan, and the practice of a number of manipulative or mobilizing techniques during treatment. The differences become apparent when looking at the basic principles and objectives of the professions. Orthomanual physicians primarily focus on the abnormal positions of components of the skeleton, and then the realization of optimal symmetry in the spine. Manual therapists aim at disorders of the musculoskeletal system and accept asymmetry and an individual preference of function. Chiropractors focus on the musculoskeletal system as well as the nervous system in relation to the patients' health in general. The differences between the 3 professional groups in the history taking are less than in the techniques of diagnostic examination (Table 1). Orthomanual medicine considers inspection and palpation as the most important diagnostic methods, focused on determination of malpositions of vertebrae and other osseous structures. Manual therapy focuses the diagnostic examination on determining disorders in function of anatomical structures and joints. The diagnostic examination of the chiropractors resembles that of manual therapy to a large extent, but chiropractors focus on the patients' health in general, using a medical diagnosis where relevant, in part for the exclusion of contraindications. Table 1 presents the aspects of the methods and techniques. Orthomanual physicians practice mainly the orthomanual mobilization technique as described by the professional group. Manual therapists and chiropractors practice multiple manual techniques. Consequently, orthomanual therapists spend a relatively large amount of time in a session on orthomanual mobilization, whereas the time spent by manual therapists or chiropractors on HVT techniques may not be considerable. Those latter groups differ in the frequency of application of the HVT technique, chiropractors use HVT to a greater extent than manual therapists. There are distinct dif- Volume 1, No. 1 March 2006 IJMDT 39

42 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors Table 1. Comparison of characteristics of manual treatment by 3 professional groups Orthomanual therapy Manual therapy Chiropractic therapy Primary focus Symmetrical development of the skeleton Disorders of function of the musculoskeletal system, including psychosocial influences Disorders of function of neuromusculoskeletal system and patients health in general Education Three years of training in mobilization skills and background of spinal disorders after graduation as medical doctor Four years in manipulative and mobilizing skills and background after graduation as physical therapist Six-year training in chiropractic college focused on medical knowledge, emphasis on manual techniques. X-ray use is trained. Diagnostic Examination 1. Objectives 1. Three-dimensional positions of vertebrae, pelvis, ribs 1. Joint function, stability, movement patterns, range of movement, and the severity of disorders 1. Patients health in general and area of complaint 2. Patients positions 2. Sitting forward bent position, prone or supine 2. Standing, sitting, supine, prone or side posture; joints in nonneutral position 2. Standing, sitting, supine, or prone 3. Palpation joints 3. Osseous structures 3. Palpation of pain locations 3. Motion palpation 4. Palpation techniques 4. Two-sided simultaneous palpation 5. Biomechanical assessment 4. Static palpation and palpation of passive accessory and intervertebral movements 5. Little or no functional assessment 5. General, regional, and segmental techniques with and without activity of the patient and provocative tests. 4. Joint play and end-feel 5. Test for joint function 6. Additional tests 6. Active, passive, and resistance tests, passive movements, extensive neurologic tests, medical tests, imaging tech niques. 6. Neurologic tests 6. Orthopaedic, neurologic, and vascular examination and radiography Treatment 1. Objectives 1. Adjustment of deflecting positions of components of the skeleton 2. Patients positions 3. Manipulation techniques 4. Mobilization techniques 2. Prone or side posture with traction 1. Adjustment of dysfunctional joints; stimulating natural recovery and adaptive processes 3. No manipulations 3. Long-and short-lever HVT techniques, variable force 4. Mobilizations of osseous structure using fingers, hand or drift, with a low and often pulsating force 1. Normalization of disturbed physiology, release joint restrictions, stimulating self-recovery 2. Nonneutral position 2. Supine, prone, or side posture, to open joint 4. Passive oscillatory movements and sustained stretching; traction, translation, rolling, gliding, spinning movements, tilting, and compression 5. Scale of use 5. Only orthomanual mobilzations 5. Predominantly mobilizations, HVT to a moderate extent 6. Neuromuscular techniques 7. Treatment sequence 8. Number of sessions 6. Not used 6. Regularly 6. Incidentally 7. Set down in experience based guidelines 3. HVT techniques: recoil thrust, bodydrop thrust, extension thrust, rotatory thrust, variable force 4. Various techniques, for example, Cox flexion-distraction technique, trigger point therapy, traction, cutaneous reflex techniques, vibration, massage, and various other techniques 5. One or a few HVT per session, in 95% of all sessions 7. Main complaint with priority 7. Main complaint with priority, others simultaneously if possible 8. Four to six sessions, once a week 8. Six sessions 8. Four to twelve sessions 9. Protocol 9. Fixed protocol 9. Protocol is mostly used, argued deviations 9. Protocol is used where relevant, therapy patient-adapted Volume 1, No. 1 March 2006 IJMDT 40

43 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors ferences between manual therapists and chiropractors in the frequency of applying other techniques. 16 The professional groups state appropriate guidelines in their training material concerning features and application of manipulation and mobilization. These guidelines describe the patients' positioning for treatment, the positioning of the hands of the practitioner, the part of the hand used for pressure, the osseous structure of the spine to work on, and the amplitude, direction, and velocity of force. 13,17,18,20 The positioning of patients for diagnosis and treatment differs, particularly concerning the purpose of the position. The goal of the position is accessibility of the process of the vertebrae, some opening, and traction of the joint. Patients' positions for manual therapy and chiropractic are aimed at opening of the joint with or without traction. Considerable differences in manipulation and mobilization techniques are found in amplitude and velocity. Orthomanual physicians practice the least amplitude by pushing against a vertebra without using a movement section. Their concept of velocity applies to the application of force or pressure and implies the use of an impulse. It is a pulsating technique applied a multiple of times. It is not a HVT technique. Variation in the orthomanual mobilization is obtained by nuances in force and direction of application. The HVT technique of manual therapy and chiropractic is a singularly applied technique where the thrust may vary in amplitude but applied with high velocity. There are a number of different techniques and the chosen HVT technique can be different within manual therapy and chiropractic. The chosen technique depends to a large extent on the preferences of individual practitioners. Apart from the manipulations and mobilizations, considerable difference in the application of remaining interventions between orthomanual medicine compared to manual therapy and chiropractic is noted. In addition to the techniques used, the chosen sequences during the treatment contribute to the contrast between the professional groups. Orthomanual physicians use fixed sequences and procedures for treatment. Manual therapists initially treat the main complaint, but the methods of treatment, the chosen mobilizations, manipulations, or other interventions depend on the degree of disorder and the way the patient is handling the complaint. Chiropractors treat the main complaint with priority and other disorders sequentially or more or less simultaneously. CONCLUSIONS In summary, we conclude that there are relevant differences in diagnostic techniques between orthomanual medicine compared to manual therapy and chiropractic in the Netherlands. No substantial differences between manual therapy and chiropractic are found between available diagnostic tests and techniques, although there is a difference in the extent of their use. However, the treatment techniques are clearly different between the 3 professions. Most systematic reviews of the efficacy of manipulative and mobilizing therapy have paid little attention to diagnosis and treatment methods applied in the included studies. This might be due to the inadequate description of the protocol and the interventions reported. 28 To properly document the effective component in each study, detailed descriptions of the diagnosis and treatment methods should be included. We invite other professional groups and manual therapists in other countries to describe their treatments in similar detail. Through an appropriate description of the interventions used in research studies on manual therapy, a better examination and understanding of the differences in the efficacy of manipulative and mobilizing therapies can be achieved. References 1. Waddell G. A new clinical model for the treatment of low back pain Spine 1987;12: Nachemson AL, Waddell G, Norlund AI. Epidemiology of neck and low back pain In Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis and Treatment, eds A. Nachemson, E. Jonsson. Philadelphia: Lippincott Williams & Wilkins; p Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic non specific low back pain. A systematic review of randomized controlled trials of the most common interventions Spine 1997;22: Koes BW, Van Tulder MW, Ostelo RW, Burton AK, Waddell G. Clinical guidelines for the management of low back pain in primary care. An international comparison Spine 2001;26: Ottenbacher K, DiFabio RP. Efficacy of spinal manipulation/mobilization therapy. A meta-analysis Spine 1985;10: Koes BW, Assendelft WJJ, Van der Heijden GJMG, Bouter LM. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials Spine 1996;24: Assendelft WJJ, Morton SC, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A metaanalysis of effectiveness relative to other therapies Ann. Intern. Med. 2003;138: Jorritsma W, Brouwer R, Molenaar J, Jansen MPL. Beroepsprofiel en - eindtermen van de (ortho)manuele geneeskunde Professional profile and final attainment levels of the (ortho) manual medicine Ulrecht: Federatie Nederlandse Vereniging Artsen Manuele Geneeskunde; Volume 1, No. 1 March 2006 IJMDT 41

44 Variance in Manual Treatment of Nonspecific Low Back Pain Between Orthomanual Physicians, Manual Therapists, and Chiropractors 9. Sickesz M. Orthomanipulatie Orthomanipulation Alphen a/d Rijn: Stafleu; Albers JWB, Keizer ED. Een onderzoek naar de waarde van orthomanuele geneeskunde An evaluation of orthomanual medicine Delft: Eburon; Baumgarten K, Hoppenbrouwers GCJ, Van der Wurff P, Oostendorp RAB, Heerkens YF. Functieprofiel Manueel Therapeut, versie 1.0 Functional profile manual therapy Amersfoort: Nederlands Paramedisch Instituut; Heijmans WFG, Hendriks HJM, Van der Esch M, Pool-Goudzwaard A, Scholten- Peeters GGM, Van Tulder MW. NVMT richtlijn lage rugpijn Dutch manual therapy guidelines for low back pain Amersfoort: Nederlands Paramedisch Instituut; Gross AR, Aker PD, Quartly C. Manual therapy in the treatment of neck pain Rheum. Dis. Clin. North Am. 1996;22: Aalberse R, van de Esch M, Groeneweg R, Van Helvoirt JNJ, Oostendorp R, Scholten-Peeters GGM. Landelijk functie opleidingsprofiel Manuele Therapie Educational profile manual therapy Amersfoort: Nederlands Paramedisch Instituut; Liefhebber S, Van den Berg G. Beroepsprofiel chiropractor Professional profile for chiropractics Ulrecht: Nederlandse chiropractoren associatie en NIZW; Assendelft WJJ. Chiropractic in the Netherlands Diagnosis and Effects of Treatment, Amsterdam: EMGO Institute; Schafer RC, Faye LJ. Motion palpation and chiropractic technique: Principles of dynamic chiropractic Huntington Beach (Calif): Motion Palpation Institute; Bergmann TF, Peterson DH, Lawrence DJ. Chiropractic technique: Principles and procedures New York: Churchill Livingstone Inc.; Haldeman S, Chapman-Smith D, Peterson DM. Guidelines for chiropractic quality assurance and practice parameters In, eds Gaithersburg (Md): Aspen Publishers; Van der El A. Manuele diagnostiek wervelkolom Manual therapy diagnostics for the spine Rotterdam: Manthel; Souza TA. Differential diagnosis for the chiropractor: Protocols and algorithms Gaithersburg (Md): Aspen Publishers, Inc.; Leboeuf-Yde C, Van Dijk J, Franz C, Hustad SA, Olsen D, Pihl T. Motion palpation findings and self-reported low back pain in a population-based study sample J. Manipulative Physiol. Ther. 2002;25: de Zoete A, Assendelft WJJ, Algra PR, Oberman WR, Vanderschueren GMJM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists and medical radiologists Spine 2002;27: Grieve PG. Common vertebral joint problems Edinburgh: Churchill Livingstone; Van Berkel L, Van Ravensberg D, Storm I, De Visser D, Oostendorp RAB, Pool J. Profiel patiëntpopulatie manuele therapie Patient profile Manual therapy Amersfoort: Nederlands Paramedisch Instituut; Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for low back conditions: Characterizing the literature J. Manipulative Physiol. Ther. 2001;24: Cramer GD, Tuck NR, Knudsen JT, Fonda SD, Schliesser JS, Fournier JT. Effects of side-posture positioning and side-posture adjusting on the lumbar zygapophysial joints as evaluated by magnetic resonance imaging: A before and after study with randomization J. Manipulative Physiol. Ther. 2000;23: Assendelft WJJ, Koes BW, Van der Heijden GJMG, Bouter LM. The efficacy of chiropractic manipulation for back pain: Blinded review of relevant randomized clinical trials J. Manipulative Physiol. Ther. 1992;15: Reprinted from Journal of Manipulative and Physiological Therapeutics, Volume 28, Pgs , 2005, with permission from The National University of Health Sciences ANNOUNCING... Establishment of an Independent Research Foundation The Chairman of the Institute's International Board of Trustees, Dan Kelley, and CEO, Lawrence Dott, are proud to announce that "The International Mechanical Diagnosis and Therapy Research Foundation" has been formally established. The Mission Statement of the Foundation is: "To fund original research worldwide that contributes to the body of evidence related to the usefulness and limitations of Mechanical Diagnosis and Therapy". The Foundation has been registered as a not-for-profit organization in the United States of America, operating on a worldwide basis independently from the McKenzie Institute International. The Board of Directors comprise: Ted Dreisinger, PhD as Chairman, Betty Sindelar, PT, PhD, Mark Werneke, PT, Dip. MDT, Uffe Lindstrom, PT, Dip. MDT, and Stephen May, PT, Dip. MDT. The McKenzie International Institute Research Committee has now been disbanded. However, all donations to date made to the Institute for research will continue to be held in escrow until 1 July 2007 when funding of research projects as determined by the Foundation will commence. In the interim, research donations can now be made to the Foundation and mailed to the Institute's Head Office who will administer for the Foundation until such time as the Foundation employs an administrator. Please make any donations payable to "The International Mechanical Diagnosis and Therapy Research Foundation" and mail to the Institute's Head Office. The McKenzie Institute International Attn. Mr. Lawrence Dott, CEO PO Box 2026 Raumati Beach 6450 New Zealand Any questions about the research foundation may be directed to the Foundation s Chairman, Ted Dreisinger at [email protected]. Volume 1, No. 1 March 2006 IJMDT 42

45 Clinical Viewpoint Clinical Reasoning Stuart Horton, Dip Phty, PG Dip Manip Phty., Dip. MDT International Journal of Mechanical Diagnosis and Therapy Clinical Reasoning History: 1. What are the potential diagnoses up to the better/worse section? 2. Does the better/worse section influence your decision further? 3. Identify baseline markers/functional disability. 4. Are there any red flags present? 5. Are there any yellow flags present? 6. What is your provisional diagnosis? 7. Are there any factors which may limit examination? 8. Which tests will you perform? Physical Examination: 1. Did the degree of functional limitation established in the history correlate with that seen in the physical examination? 2. Were you able to determine the direction of treatment with repeated movements as anticipated from the history? 3. What is your provisional classification following the complete examination today? 4. What is your management strategy today? 5. What do you think the prognosis is for this patient? 6. What change do you anticipate to occur in the patient s presentation at Day 2? 7. What will be your management plan for Day 2 if the patient presents: Better Same Worse See answers on page 45 Volume 1, No. 1 March 2006 IJMDT 43

46 Clinical Viewpoint Clinical Reasoning International Journal of Mechanical Diagnosis and Therapy THE MCKENZIE INSTITUTE LUMBAR SPINE ASSESSMENT Date Name GH Sex M / F Address Telephone Date of Birth Age 22 Referral: GP / Orth / Self / Other Work / Leisure student Plays netball, running, aerobic gym classes Postures / Stresses Functional Disability from present episode Can t run due to hips Functional Disability score VAS Score (0-10) Back 5/10, hips 3/10 HISTORY Present Symptoms LBP R>L and bilateral hip/buttock pain L>R Present since 5 months Improving / Unchanging / Worsening Commenced as a result of Bending and twisting while in gym class Or no apparent reason Symptoms at onset: back / thigh / leg back Constant symptoms: back / thigh / leg Intermittent symptoms: back / thigh / leg Hips Worse Bending(back) sitting(back) rising(back) Standing(back) Walking Prolonged(hips) lying am / as the day progresses / pm when still / on the move other Running (Hips) >5 mins Better bending sitting standing walking lying am / as the day progresses / pm other REIL/FIS helps back, Rest from running helps hips when still / on the move Disturbed Sleep Yes / No Sleeping postures: prone / sup / side R L Surface: firm / soft / sag Previous Episodes Year of first episode Previous LBP when doing gymnastics over 10 years up until age 14, Still gets occasional niggles mainly when Previous History sitting Never hip pain before Previous Treatments Previous physiotherapy 6 weeks ago?sij problem, no improvement. SPECIFIC QUESTIONS Cough / Sneeze / Strain / +ve(back) / -ve Bladder: normal / abnormal Gait: normal / abnormal Medications: Nil / NSAIDS / Analg / Steroids / Anticoag / Other General Health: Good / Fair / Poor Imaging: Yes / No Recent or major surgery: Yes / No Accidents: Yes / No Other: Night Pain: Yes / No Unexplained weight loss: Yes / No EXAMINATION POSTURE Sitting: Good / Fair / Poor Standing: Good / Fair / Poor Lordosis: Red / Acc / Normal Lateral Shift: Right / Left / Nil Correction of Posture: Better / Worse / No effect Back pain better Relevant: Yes / No Other Observations: Volume 1, No. 1 March 2006 IJMDT 44

47 Clinical Viewpoint Clinical Reasoning International Journal of Mechanical Diagnosis and Therapy NEUROLOGICAL Motor Deficit Sensory Deficit Reflexes Dural Signs MOVEMENT LOSS Maj Mod Min Nil Pain Flexion x Back R>L, deviates left Extension x back Side Gliding R x back Side Gliding L x back TEST MOVEMENTS Describe effect on present pain - During: produces, abolishes, increases, decreases, no effect, centralising, peripheralising. After: better, worse, no better, no worse, no effect, centralized, peripheralised. Mechanical Response Symptoms During Testing Symptoms After Testing Rom Rom No Effect Pretest symptoms standing: No pain FIS Rep FIS Prod LBP R>L, consistent deviation L NW EIS Rep EIS Prod LBP>L NW x Pretest symptoms lying: No pain FIL Rep FIL EIL Rep EIL Abolishes back, no PDM B Inc EIS If required pretest symptoms : SGIS R Rep SGIS R SGIS L Rep SGIS L STATIC TESTS Sitting slouched Increase pain Sitting erect Increase pain Standing slouched Standing erect Lying prone in extension Long sitting OTHER TESTS PROVISIONAL CLASSIFICATION Derangement Dysfunction Posture Other Subclassification PRINCIPLES OF MANAGEMENT Education Mechanical Therapy Equipment Provided Extension Principle Lateral Principle Flexion Principle Other Treatment Goals Volume 1, No. 1 March 2006 IJMDT 45

48 Clinical Viewpoint Clinical Reasoning History: 1. What are the potential diagnoses up to the better/worse section? Mechanism strongly suggests lumbar derangement. Bilateral referral to the hip is possible, although the difference in sidedness of back pain to hip pain could suggest these symptoms are not related. Lumbar dysfunction possible given time frame, although referral to hips and patient age makes it less likely. 2. Does the better/worse section influence your decision further? It does appear that the lumbar symptoms behave independently of the hip symptoms. Consider strong possibility of two separate problems. 3. Identify baseline markers/ functional disability. Sitting/Bending for the back, and running for the hips. Patient has stopped running primarily due to the hip pain. 4. Are there any red flags present? None 5. Are there any yellow flags present? None 6. What is your provisional diagnosis? Lumbar derangement and coexisting bilateral hip problem. 7. Are there any factors which may limit examination? Time factor involved in provoking hip symptoms. May not be able to reproduce unless get patient running several minutes. 8. Which tests will you perform? Posture correction, repeated lumbar movements. Depending on responses may consider testing hip. Physical Examination: 1. Did the degree of functional limitation established in the history correlate with that seen in the physical examination? Yes, pain present on sitting increased with slouch. Obstruction to extension present with erect sitting and EIS movement loss, correlates with pain worse standing. Hip pain not present as expected as patient hasn t run or walked far enough. 2. Were you able to determine the direction of treatment with repeated movements as anticipated from the history? Yes, patient had indicated that relief from back pain is obtained with EIL/FIS. Testing of REIL/RFIS demonstrates clear DP for extension. Response to posture correction supports this. 3. What is your provisional classification following the complete examination today? Lumbar derangement, assymetrical above knee. Separate bilateral hip problems not yet classified (Repeated lumbar testing has no effect on hip pains). 4. What is your management strategy today? Reduce lumbar derangement first with REIL x10/2 hrly and posture correction (extension principle). Explain findings regarding hip as separate to be assessed when lumbar spine sorted out. Continue to avoid running to prevent exacerbation of hip. 5. What do you think the prognosis is for this patient? Good. Lumbar derangement appears to be a simple extension responder. Should be able to reduce in 4-5 visits. Resolution of lumbar derangement may help the hips, but unable to comment on the hips confidently until after a few visits. 6. What change do you anticipate to occur in the patients presentation at Day 2? Improved presentation of lumbar symptoms due to day 1 responses. Expect better quality of ROM in flexion and extension. Improved tolerance to sitting. 7. What will be your management plan for Day 2 if the patient presents: Better - Continue with extension principle until fully reduced. Ensure recovery of flexion when indicated. Assess hips when lumbar derangement resolved Same - Review ROM, exercise and posture correction. Reinforce as necessary. Force progression if indicated Worse - Unexpected given good initial response. Review all movements and exercise/posture. Consider other possibilities for diagnosis. Authors Note: This case reminds us that we sometimes encounter dual/multiple pathologies. Accurate history taking, particularly focusing on the better/ worse section should heighten the clinician s awareness of separate entities. If spinal and extremity conditions co-exist, to keep things simple it may be worth exploring reduction of the central/spinal problem first and then re-evaluate the extremity problem. This patient s lumbar derangement was fully reduced and recovery of flexion restored after 5 visits. Interestingly running again at this point only provoked the left hip. Examination of the left hip did not show any movement loss either passively or actively. Resisted tests revealed concordant pain and weakness of hip extension and abduction, and this was exposed functionally with single leg standing and single leg squat. It was hypothesized that running with the back pain had initially been quite painful and perhaps the altered gait with this began to create altered hip/pelvic control leading to pain and subsequent weakness. Introduction of hip extension and abduction strengthening exercises resolved the pain on running within two weeks. Volume 1, No. 1 March 2006 IJMDT 46

49 Case Reports Aidan Sylvester, BSc Physio, PG Dip Phty. MDT International Journal of Mechanical Diagnosis and Therapy Lumbar derangement treated in three planes a case of acute low back pain managed with Mechanical Diagnosis and Therapy INTRODUCTION Mechanical Diagnosis and Therapy (MDT) is a system of assessment and treatment which utilises the application of mechanical loading strategies to categorise and treat patients with non-specific low back pain. It emphasises the empowerment of patients to self-manage their condition where possible, but not to the exclusion of therapistapplied procedures, as indicated by a clinical reasoning system of progressive force application to the involved lesion (McKenzie and May 2003). Symptomatic and mechanical (i.e. related to range and quality of motion) responses to repeated, end-range spinal movements and sustained positions, provide the essential clinical information required to guide patient management. A significant proportion of patients with non-specific spinal problems can be classified in the diagnostic subgroup of derangement (McKenzie 1981; Aina et al. 2004). The symptoms in derangement syndrome are dynamic and are sensitive to mechanical loading strategies (McKenzie and May 2003). The mechanical treatment of derangement syndrome aims to achieve reduction of the derangement, which is frequently accompanied by the phenomenon of centralisation. McKenzie s original conceptual model postulated that in derangement syndrome there is displacement of nuclear material within the intervertebral disc, which causes symptoms to appear in the spine and/or periphery due to mechanical deformation of spinal structures. Centralisation, i.e. the abolition of peripheral pain from a distal to proximal location in response to loading strategies, is purported to indicate that reduction of the derangement has occurred (McKenzie 1981). Loading strategies are used to establish a directional preference and guide specific exercise prescription. Significantly better outcomes have been demonstrated in low back pain patients performing specific exercises matching their directional preference than those exercising in the opposite direction (Long et al. 2004). This case report describes the mechanical assessment and treatment of a patient with lumbar derangement syndrome. It highlights the clinical application of some of the principles of MDT and also draws attention to the less well-known rotation mobilisation in flexion procedure. CASE REPORT History: A 27 year old male student presented with a two day history of central to right-sided low back pain (Figure 1) which had commenced suddenly after bowling a cricket ball. He denied any buttock, groin or lower extremity symptoms as well as any history of previous spinal problems. His usual hobbies were going to the gym and cycling, and he did not play cricket on a regular basis. Figure 1. Body chart depicting area of pain. At the initial assessment his symptoms were intermittent, being produced or worsened by bending, sitting for more than 15 minutes, rising from sitting, walking, lying on his right side and turning in bed. Reclined sitting and supine lying relieved his pain. His sleep was disturbed and initially coughing and sneezing had been painful. He reported general good health and no bladder or gait disturbances. Physical Examination: Observation revealed poor sitting posture, with normal lumbar lordosis and no lateral shift in standing. Routine assessment of the effect of kyphotic versus lordotic sitting postures was unremarkable. Due to the absence of lower extremity symptoms, no neurological testing was performed. Examination of active lumbar movements revealed a moderate loss of flexion, extension and left side gliding and a major loss of right side gliding. Side gliding has been suggested to cause greater localisation of movement to lower lumbar segments than side flexion (Mulvein and Jull 1995). All active movements reproduced his symptoms, which ceased immediately upon return to the neutral position. Mechanical Diagnosis and Therapy utilises so-called objective baseline measures to assess the effect of repeated test movements and in this case right side gliding was used for re-assessment. Test movement examination commenced with the patient lying prone, supported on his elbows. This initially produced his symptoms, which were abolished after two minutes in this position. Next, the effect of repeated, end-range extension in prone (McKenzie and May 2003, page 458) was explored. A recent review stated that the use of a repeated end-range/pain response assessment in patients with low back and leg pain is supported in the litera- Volume 1, No. 1 March 2006 IJMDT 47

50 Case Reports International Journal of Mechanical Diagnosis and Therapy ture (Wetzel and Donelson 2003). No pre-test symptoms were reported in prone lying. Initially, symptoms were reproduced during extension and maximum range was not obtained, but by the end of 20 repetitions full, pain free extension was achieved. On re-assessing active lumbar movements in standing, the patient reported similar pain with all movements, but a significant increase in his range of movement in all directions was observed. This favourable mechanical response prompted a provisional classification of lumbar derangement and his initial management followed the extension principle. He was advised to adopt a lordotic sitting posture, to minimise flexion activities and to perform repeated extension in lying 12 times, three hourly. Subsequent Visits: At a two day follow-up he reported a 75% overall improvement and demonstrated a painful, moderate loss of right side gliding. Flexion was painful but not limited. A similar mechanical effect to that of day one was obtained with extension in lying, thereby confirming the provisional mechanical classification. His exercise programme was left unaltered. Three days later he reported slight further improvement. His walking was now painfree (probably due to the increased extension range afforded by partial derangement reduction) and any pain now felt was more centrally located. Turning in bed and trunk rotation in standing were consistently painful. Range of motion was unchanged, but extension in lying no longer effected an improvement in right side gliding. Repeated extension in lying with clinician overpressure (McKenzie and May 2003 page 460) was performed ten times, resulting in full, pain free right side gliding. When seen two days later his sleep was undisturbed and improvement maintained. As he displayed no movement loss and reported only right lumbar discomfort at end range of flexion and right side gliding, it was decided to test the appropriateness of recommencement of flexion. Repeated flexion in lying (McKenzie and May 2003, page 487) had no symptomatic effect and did not result in a loss of extension. This exercise was added to his exercise programme, to be done ten times, twice daily and followed immediately by prophylactic extension in lying. He was also instructed to use a loss of extension range as a guide to stopping the flexion exercises. Worsening of extension range once commencing flexion procedures may indicate rederangement, thus it is important that the patient monitor this response. At his fifth visit two days later he was advised to increase the flexion exercises to three times daily as there had been no adverse reaction, and to gradually return to his gym and biking activities. Figure 2. Right rotation mobilisation in flexion. One week later he reported that improvement had plateaued and that trunk twisting remained a problem. Flexion and right side gliding remained full range but produced end range pain. It was decided to perform a right rotation mobilisation in flexion (McKenzie and May 2003, page 494), in which the pelvis is rotated to the right in relation to the trunk (Figure 2). This produced gradually less pain with each repetition and by 20 repetitions was painfree and end range was reached. As with extension in lying, obtaining end range is integral to the success of the procedure. On reassessment, flexion and right side gliding were completely painfree. His exercise programme was altered to include only right rotation in flexion (McKenzie and May 2003, page 493), performed 15 times, five times a day DISCUSSION Although this case is not particularly unusual, it does highlight many important principles of the clinical application of spinal mechanical therapy. A vital aspect, particularly in Volume 1, No. 1 March 2006 IJMDT 48

51 Case Reports International Journal of Mechanical Diagnosis and Therapy derangement syndrome, is the continuous analysis of the patient s symptomatic and mechanical responses to the application of force in different planes. The observed responses can be correlated with McKenzie s conceptual model of internal disc mechanics (McKenzie 1981), although a tissue-based interpretation of clinical findings is ultimately subservient to the observed symptomatic and mechanical responses and force progression principles in determining patient management. Discogenic pain has been described as an entity distinct from symptoms resulting from disc prolapse, and there is evidence to suggest that even in the presence of an intact outer annular wall, internal disc disruption can be a source of low back and referred pain (Kuslich et al. 1991; Schwarzer et al. 1995). In this case, a favourable initial response to patient generated extension was obtained. Force progression to clinician overpressure was implemented when no further mechanical improvement was evident. Although the patient did not demonstrate a typical centralisation response overall, he did state that upon regaining extension range by visit number three, his pain was generally felt more centrally. This may have represented part of the centralisation process, which was not complete until later in his management. In the presence of spinal pain alone, centralisation is said to occur when pain moves from a more lateral to a midline position and is finally abolished (McKenzie and May 2003). The occurrence of the centralisation phenomenon may well be less overt in patients without lower extremity symptoms. Patient improvement continued until visit four, when he reported only residual discomfort and not his original pain. Flexion was introduced and had not caused any worsening of symptoms by visit five. The re-introduction of flexion tests the stability of the posterior derangement, ensures that no endrange restriction to flexion develops and can be of value psychologically, restoring patient confidence in what is often the injuring movement. The distinct lack of further improvement a week later at visit six warranted a modified approach. The patient experienced pain at end range of flexion in standing, which was the principle baseline measure at this stage, and repeated sagittal plane movements did not alter this presentation. The presence of a relevant lateral component was considered and the rotation mobilisation in flexion performed. Despite the fact that full range of lateral movements had been regained at visit three, complete reduction of his derangement did not occur until this procedure was carried out. The indication for this technique could be retrospectively linked to the patient s continued report of pain on trunk rotation. Another key characteristic of the derangement syndrome is the rapid alteration of symptomatic and mechanical presentation in response to applied forces (McKenzie and May 2003). This was evident following the therapist overpressure to extension and the rotation mobilisation procedures. These observations significantly reduce the likelihood of these improvements having taken place as a result of the natural history of the condition. The indication for the application of rotation mobilisation in flexion in derangement syndrome is a failure to improve or a worsening with sagittal plane procedures (McKenzie and May 2003). At visit six this patient was made no worse with flexion and was therefore deemed unlikely to require extension or even combined extension and lateral forces to effect further improvement. The rotation mobilisation in flexion procedure is described as a lateral manoeuvre with considerable adjunct flexion (McKenzie and May 2003). Although it is used less frequently than extension procedures in the treatment of derangement syndrome, it can generate a powerfully reductive effect, and thus warrants further explanation. No literature to date has examined the biomechanics of this technique. Certain parallels, however, can be drawn with Maitland s lumbar rotation mobilisation (Maitland 1986), the kinematics of which have been analysed (Lee 2001). This technique, when applied as a grade IV mobilisation, was shown to place the lumbar spine in flexion, axial rotation and contralateral lateral flexion. The author concluded that this technique may be useful in regaining painfree lumbar movement in the sagittal, coronal and transverse planes. This may well explain the restoration of the patient s lumbar flexion after the application of rotation mobilisation in flexion. McKenzie s version of lumbar rotation places the patient s lumbar spine in considerably more flexion and uses both of their legs over the edge of the plinth as a lever for rotation. Although the indications for using lumbar rotation may differ within the two therapeutic concepts, Maitland (1986) stated that lumbar rotation is one of the most useful procedures for treating unilateral lumbar symptoms. It has been suggested that in increased flexion, more axial rotation is facilitated as the wedge-like ar- Volume 1, No. 1 March 2006 IJMDT 49

52 Case Reports International Journal of Mechanical Diagnosis and Therapy ticular facets become less apposed (Hindle and Pearcy 1989; Pearcy 1993). Another study concluded that when combined with flexion, axial torque can exert significant tensile stress on posterior and posterolateral parts of the annulus fibrosus (Shirazi-Adl et al. 1986). Thus, with the amount of adjunct flexion achieved at end range of the rotation mobilisation in flexion procedure, the disc is potentially subjected to significant torsional forces, akin perhaps to a wringing out effect. In contrast to most other MDT procedures, it is important to appreciate the multiplanar potential of this manoeuvre. In the context of the conceptual disc model, it is possible that this patient presented with an internal disc displacement consisting of two directional components - a smaller lateral and a larger posterior component. Although in retrospect an argument could be made for the earlier introduction of a lateral component to extension, namely extension in lying with hips off centre (McKenzie and May 2003, page 471), improving patient status justified perseverance in the sagittal plane. Unfortunately, at visit four, complete reduction of the derangement was assumed and the residual discomfort taken to represent soft tissue stiffness, when in fact it may well have indicated a minor lateral component in need of addressing. Continual re-assessment of symptomatic and mechanical responses resulted in this patient s mechanical subclassification changing from extension to lateral responder at the sixth visit. CONCLUSION Within the clinical reasoning framework of MDT, precise identification of the source of symptoms is not a prerequisite to successful and safe patient management. Indeed, in this case, the actual structures at fault are open to debate, but the symptomatic and mechanical behaviours have been analysed in the context of the conceptual disc model. This case report of a patient with acute low back pain has emphasised that the MDT system is a continuum of response assessment as opposed to an inflexible protocol or algorithm. It has also highlighted the potential value of the rotation mobilisation in flexion in the treatment of derangement syndrome. REFERENCES Aina A, May S, Clare H (2004). The centralization phenomenon of spinal symptoms-a systematic review. Manual Therapy Hindle RJ, Pearcy MJ (1989). Rotational mobility of the human back in forward flexion (Abstract). Journal of Biomedical Engineering. 11(3) Kuslich SD, Ulstrom CL, Michael CJ (1991). The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthopedic Clinics of North America. 22(2) Lee RYW (2001). Kinematics of rotational mobilisation of the lumbar spine. Clinical Biomechanics Long A, Donelson R, Fung T (2004). Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 29 (23) Maitland GD (1986). Vertebral Manipulation (5th Edition). Butterworths, London. McKenzie RA (1981). The Lumbar Spine. Mechanical Diagnosis and Therapy (1st Edition). Spinal Publications New Zealand Ltd, Waikanae. McKenzie RA, May S (2003). The Lumbar Spine. Mechanical Diagnosis and Therapy (2nd Edition). Spinal Publications New Zealand Ltd, Waikanae. Mulvein K, Jull G (1995). Kinematic analysis of the lumbar lateral flexion and lumbar lateral shift movement techniques. Journal of Manual and Manipulative Therapy. 3(3) Pearcy MJ (1993). Twisting mobility of the human back in flexed postures. Spine. 18(1) Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1995). The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine. 20(17) Shirazi-Adl A, Ahmed AM, Shrivastava SC (1986). Mechanical response of a lumbar motion segment in axial torque alone and combined with compression. Spine. 11(9) Wetzel FT, Donelson R (2003). The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. The Spine Journal Case Studies Online! The McKenzie Case Manager is a dynamic web-based experience that incorporates real-life clinical practice scenarios. Eight advanced patient case studies will help you focus on the power of using the information gathered on The McKenzie Institute Assessment forms to aid you in both diagnosis and treatment, and ultimately improve your overall competence through maintaining the mental acuity of the clinical reasoning process that is an integral component of the McKenzie Method. Take advantage of this valuable educational opportunity to sharpen your MDT knowledge and skills. Volume 1, No. 1 March 2006 IJMDT 50

53 Case Reports Chris Littlewood, BHSc(Hons), MSc, Dip. MDT International Journal of Mechanical Diagnosis and Therapy Introduction Over recent years physiotherapists have increasingly become the first line of contact for patients as well as extending the traditional scope of practice to become more involved in diagnostic triage and the pathway of care outside of physiotherapy. No longer do we rely on our medical colleagues to determine who should walk through our door, and no longer are we protected from unsuitable pathologies. Thus, our diagnostic/ classification and triage skills come under ever increasing scrutiny. In 1994 the Clinical Standards Advisory Group 1. (CSAG) described a diagnostic triage for clinicians involved with the assessment of back pain. The triage categories are now familiar to most and are as follows: Simple backache Nerve root pain Possible serious spinal pathology The CSAG report detailed signs potentially indicative of serious spinal pathology, termed red flags. 2 These red flags were divided into two categories: Signs/ symptoms requiring emergency referral to a spinal surgeon Signs/symptoms suggestive of possible serious spinal pathology 2. The signs/ symptoms indicating the need for emergency referral to a spinal surgeon are 1 : Difficulty with micturition Loss of anal sphincter tone/faecal incontinence Saddle anaesthesia Widespread (>1 nerve root) or progressive motor weakness in the legs Gait disturbance These guidelines continue to govern diagnostic triage. It has been suggested that the prevalence of serious spinal pathology is extremely low 3. The following case report details the history, examination and pathway of a patient recently encountered who met 3 out of 5 of the CSAG criteria. Outcome Based upon the preceding history and examination, the consultant orthopaedic surgeon on-call was contacted immediately and arrangements made to admit him via the accident and emergency department and undertake further investigation. A subsequent MRI scan detailed a narrow spinal canal throughout with a very large disc prolapse at the L4/5 level. Two weeks following the initial examination he underwent micro-discectomy at the L4/5 level. The potential for recovery with natural history is unclear. However, now two months post-operatively, I understand he is progressing well. Comment This case has detailed the history and examination findings including the treatment pathway of a patient who met 3/5 of the CSAG criteria indicating the need for emergency referral to a spinal surgeon. Following thorough neurological examination, the patient was referred to the spinal surgeon for opinion and further management. Despite clearly meeting these criteria it is interesting to note that in the absence of sphincter disturbance indicative of S2 S4 nerve root compromise 4, the spinal surgeon did not offer emergency spinal surgery. However, for this particular patient a mechanical assessment is not indicated and mechanical therapy is absolutely contra-indicated 3. Although red flag signs indicating the need for emergency referral to a spinal surgeon are rare, since encountering this gentleman in September 2005, I have identified a further case requiring similar action. A 65 year old gentleman presented with a 3 to 4 month history of increasingly frequent episodes of faecal incontinence and numbness over the sacral area. There was no precipitating factor. Pain was not an issue and the only disabling factor was fear of incontinence limiting usual activity. Neurological examination revealed brisk ankle and knee jerks bilaterally with an area of numbness overlying the sacrum posteriorly. Tone was normal but there was possible evidence of minor reduction in gluteal power bilaterally but no further myotomal deficit and anal sphincter tone was maintained. Lumbar range of movement was deemed to be within normal limits and did not provoke symptoms. An MRI of this gentleman revealed multi-level degenerative change with multi-level disc prolapse most significant at L1/2 with evidence of cord compression. At the time of writing, I am unaware of the outcomes of surgical opinion/ intervention. Although red flag signs/ symptoms are encountered infrequently these case reports should serve to remind physiotherapists of their presence and the need to act accordingly in line with current guidance. Reference List 1. Clinical Standards Advisory Group, Report of a CSAG committee on back pain. HMSO, London. 2. Roberts S, Flagging the danger signs of low back pain. P In: Gifford L (ed). Topical Issues in Pain 2. CNS Press, Falmouth, UK. 3. McKenzie R & May S, The Lumbar Spine: Mechanical Diagnosis & Therapy. Spinal Publications New Zealand Ltd, Waikanae, New Zealand. 4. Refshauge K & Gass E, The neurological examination. P In: Refshauge K & Gass E (ed). Musculoskeletal Physiotherapy. Butterworth-Heinemann, Oxford, UK. Volume 1, No. 1 March 2006 IJMDT 51

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56 Literature Reviews Stephen May, PT, Dip. MDT Miller ER, Schenk RJ, Karnes JL, Rousselle JG (2005). A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain. J Manual Manip Ther Objective To compare the effectiveness of two approaches (McKenzie / spinal stabilisation exercises) for the management of chronic low back pain. Design Randomised pragmatic controlled trial. Setting Out-patient physical therapy clinic in New York state, USA. Patients Patients with chronic low back pain referred to setting above. Patients under 18, pregnant, receiving Workman s Compensation, having had more than one lumbar surgery, with litigation pending, diagnosed with psychological or systematic illness, or unable to understand English were excluded. 30 patients were recruited with very chronic symptoms there were marked, but not significant differences between the groups at baseline, in terms of age (44 years v 54), symptom duration (20 months v 32) and some of the outcome measures. Intervention McKenzie group were classified and treated according to their classification; level of training of treating PTs and MDT classification is unclear. Spinal stabilisation group were taught how to perform multifidus and trans-abdominal contractions with a pressure gauge; initially in a neutral position, then progressing to functional positions. Treatment was over six weeks, but number of treatment sessions was not given. Patients were asked to perform minutes of home exercises, but compliance and regularity does not appear to have been measured. Main outcome measures Functional Status Questionnaire for self-reported disability; McGill Pain Questionnaire for average pain in last two weeks; SLR physical examination test. Examiners were not blinded during data collection. Outcomes were gathered at baseline and at the end of the six week treatment period. Main results Both groups showed improvement in all outcomes, with significant differences from baseline for pain visual analogue score, present pain index, pain descriptors, and SLR in stabilisation group; and present Figure 1. Visual analogue scores (a: baseline and 6 weeks) and present pain index scores (b: baseline and 6 weeks) in McKenzie and spinal stabilisation (ss) groups 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 a 6w b 6w Mck ss pain index only in McKenzie group. There were no significant differences between the groups. Conclusions The study did not support the initial hypothesis that a specific stabilising exercise programme would more positively affect pain and disability in patients with chronic low back pain than the McKenzie approach. Comments This was a randomised trial that compared McKenzie Method to spinal stabilisation exercises in a group of patients with very chronic symptoms. As such, it suffered from several weaknesses for instance lack of blinding in outcome measurement, lack of follow-up, lack of sample size calculation and small sample size. The latter means that a true difference between the groups may have been missed because the trial was under powered (type 2 error). As the authors state that their prior assumption was that spinal stabilization exercises would more positively affect pain and disability than the McKenzie programme, failure to impose strict blinding to the randomisation process and measurement of outcomes further weakens the validity of any results. It is not known how much treatment was given, nor the level of training of the therapists who gave the treatment; they were said to be certified in MDT, but what this means is unclear. Both groups showed some improvement between baseline and six weeks, with several significant differences in the spinal stabilisation group. There were no significant differences between the groups either at baseline or six weeks, but the spinal stabilisation appeared to improve more; however, higher pain scores initially meant this group was more likely to show improvements. As there was no non-intervention control group, it Volume 1, No. 1 March 2006 IJMDT 54

57 Literature Reviews cannot be discounted that changes were due to a non-specific treatment effect, regression to the mean or chance. Furthermore, although there were some significant differences over time the clinical significance of these is unclear. However, it appears from the mean and standard deviations that some patients in the McKenzie group were pain free at discharge. George SZ, Bialosky JE, Donald DA (2005). The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise. JOSPT Background and Objective Centralisation and fear-avoidance beliefs have both previously been shown to predict pain and function in patients with low back pain. The aim of this study was to compare both features in terms of their prognostic value, as both have not been routinely included in previous prognostic studies. Design Secondary analysis of a prospective cohort of patients with acute low back pain to investigate prognostic value of baseline variables to predict pain and disability at six months. Setting Four physical therapy clinics in Pittsburgh, USA from August 2000 to April Patients A previous RCT had been conducted that compared exercises according to a treatment-based classification (TBC) system with a fear-avoidance based education and graded exercise programme. Inclusion criteria were years of age, duration of back pain less than 60 days and English speaking. Exclusion criteria were less than six months post lumbar surgical status, signs and symptoms consistent with nerve root compression, pregnancy or any red flags suggesting serious spinal pathology. 202 consecutive patients were screened for eligibility; 120 were deemed ineligible, and of the remaining 82, 66 provided informed consent and entered the original trial. The TBC group were classified as specific exercises (28, 42%), immobilisation (17, 26%), mobilisation (15, 23%), and traction (6, 9%). Only the 28 classified for specific directional exercises (extension or flexion with appropriate postural advice) were included in this secondary analysis, as the authors surmised that in the other classifications a predefined zero prevalence minimises its predictive ability. For the 28; mean age was 39, 17 were women, mean duration of back pain was 21 days, mean pain intensity was 5.5, mean Oswestry score was 37%, mean FABQ physical activity 14/24, mean FABQ work 12/42, and 21 had accompanying back pain. 17 had received the fear-avoidance treatment, 19 specific extension exercises (makes 36 in total?), and 14 had demonstrated centralisation. Centralisers were significantly more likely to have had leg pain, but were no different from non-centralisers regarding symptom duration, FABQ, or history of back pain. Intervention During the initial assessment, a range of prognostic factors previously shown to be important were gathered: duration of back pain, previous history of back pain, and leg pain. Pain intensity (0 to 10 scale), function (Oswestry disability questionnaire, ODQ), fear avoidance (Fear Avoidance Beliefs questionnaire, FABQ), and centralisation (patient s pain being abolished, or being located more proximal or more medial to mid-line in response to single or repeated movements) were gathered at initial assessment. At six months, patients were mailed the same self-report measures. Main outcome measures Hierarchical multiple regression models involving baseline variable were analysed for their ability to predict pain and disability at six months. Main results Initial disability, treatment group (both explained 13% of variance), history of back pain, duration of back pain, and presence of leg pain (these factors increased explaining of variance to 23%) were not significant predictors of disability at six months. Centralisation (P = 0.004) and fear-avoidance (P = 0.27) were both significant predictors of disability at 6 months. When centralisation was added to the model 49% of variance was explained, and when fear-avoidance was added 61%. Centralisation, fear-avoidance beliefs about work, and initial disability were included in final parsimonious model explaining 49% of variance. Initial pain, treatment group (both explained 15% of variance), history of back pain, duration of back pain, and presence of leg pain (these factors increased explaining of variance to 26%) were not significant predictors of pain at six months. Centralisation (P = 0.044) was a significant predictor of pain at six months. When centralisation was added to the model 40% of variance was explained. Only centralisation and initial pain intensity were included in final parsimonious model explaining 29% of variance. Conclusions In patients classified into specific exercise groups, baseline elevation in fear avoidance beliefs about work and non-centralisation predicted higher disability at six months; and baseline non-centralisation pre- Volume 1, No. 1 March 2006 IJMDT 55

58 Literature Reviews dicted higher pain scores at six months. Comments This study reported a planned secondary analysis of data gathered from a clinical trial that included only those patients classified with specific exercise intervention. Some of these were treated with extension exercises and some received education based on the fearavoidance model and graded nonspecific exercises. Half of the group demonstrated centralisation at baseline, and half did not. It was then seen which baseline variables predicted pain and disability at 6 months. Centralisation and elevation in fear avoidance beliefs about work predicted disability; centralisation predicted pain. Centralisation was a stronger prognostic factor than fear-avoidance, and both are independently important. In various hypothetical cases using regression equation the authors show that a patient with centralisation with high baseline FABQ-work scores would at 6 months have an ODQ score of 17; a patient with centralisation and low baseline FABQ-work scores would at 6 months have an ODQ score of 9; a patient with non-centralisation and high baseline FABQ-work scores would at 6 months have an ODQ score of 27; a patient with noncentralisation and low baseline FABQ-work scores would at 6 months have an ODQ score of 19. These differences exceed minimally clinically important differences proposed for the ODQ. The predicted pain VAS will differ by 1.6 on the 0 to 10 scale based on whether the patient is in centralisation or noncentralisation group; again differences that are clinically meaningful. Centralisation occurred in 14 / 66 (21%) who completed the trial, which is a substantial lower prevalence of centralisation compared to other studies (Aina et al. 2004). This may relate to their definition of centralisation, which included single movements and only used sagittal plane movements; and that they defined centralisation at the initial assessment only. However 60% of initial non-centralizers have subsequently demonstrated centralisation (Werneke and Hart 2003). This study provides further evidence about the prognostic value of centralisation and fear avoidance. However because of a small sample size the regression analysis has wide confidence intervals indicating poor precision of any estimation based on it. Despite this overall the evidence appears very strong that centralisation is a clinical examination sign that should always be included in spinal examination and any future prognostic models concerning chronic back pain and disability. References Aina A, May S, Clare H (2004). Centralization of spinal symptoms a systematic review of a clinical phenomenon. Manual Therapy Werneke M, Hart DL: Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomic pain patterns. Spine 28 (2), 2003: Cook C, Hegedus EJ, Ramey K (2005). Physical therapy exercise intervention based on classification using the patent response method: a systematic review of the literature. J Manual Manip Thera Objective To determine the effectiveness of physical therapy-directed exercises in patient samples that were classified into mutually exclusive groups based on patient responses to examination; and to determine if classification leads to a positive outcome. Design Systematic review of the literature. Methods Medline, Cinahl and Spine were searched up to May 2005; only randomised controlled trials (RCT) or randomised pragmatic controlled trials (RPCT) were included; trials had to include classification of patients based on patient report during provocation, reproduction, and reduction of pain. Treatment had to be directed by a physical therapist (PT) and make use of specific back exercises. All abstracts from search were appraised for suitability; the full article was reviewed in those that appeared to be appropriate; and checked that inclusion criteria were met. The PEDro scale was used to quality score the included articles. Main outcome measures Outcome measures were required to be one of the following: pain scale, overall recovery status, a standard functional disability questionnaire, or a standard general health questionnaire Main results 82 potentially relevant abstracts were obtained from the literature search; 76 were excluded for failure to use patient-response based classification; of the 6 retrieved full articles 5 met all inclusion criteria. All 5 scored 6 or more out of 10 on the PEDro scale, indicating higher quality studies. 4 out of 5 found that a PT directed specific exercise programme based on classification by patient response was significantly more effective than the control group. 4 out of 5 studies used the McKenzie method, or an adapted version of it, and one used the treatment-based classification system of Delitto et al. Both classification processes used centralisation as part of the classification process. Volume 1, No. 1 March 2006 IJMDT 56

59 Literature Reviews Conclusions 4 out of 5 included studies demonstrated a positive improvement with a specific exercise programme based on symptom response compared to a control group. Centralisation and McKenzie method were common features, and the trials included patients with a range of acute to chronic problems. The patient response method of classification demonstrates a positive trend toward improving the likelihood of targeting the correct supervised exercises for patient intervention. Comments Previous reviews of specific exercises for back pain have reached negative conclusions about their value; stating for instance that they are ineffective for patients with acute back pain and only marginally effective for patients with chronic pain (van Tulder et al. 2000). This review came to very different conclusions the authors prestated inclusion criteria meant that a much smaller number of articles would be included; van Tulder et al. (2000) for instance included 45 in their systematic review. This review captures the clinical reality more realistically patients in the clinic are not randomly given a set of exercises without prior assessment for suitability, as is the case in the majority of trials evaluated by van Tulder et al. (2000). Patients usually, or should be, assessed by symptom response to repeated movements and according to their response, given a specific exercise regime. In all the trials included in this review, classification according to symptom response preceded randomisation. It was found in four out of five trials that the classification group had significantly better outcomes than the control group. Four out of five trials used the McKenzie system or an adaptation of it (Delitto et al. 1993, Erhard et al. 1994, Long et al. 2004, Schenk et al. 2003). The other trial (Fritz et al. 2003) involved assessment of directional preference, and centralisation was common to all. The trials included patients with a range of back pain duration and would suggest that classifying patients by back pain duration may be less relevant than previously considered. Although the conclusions of this review are reasonably positive for specific exercise programmes based on symptom response and a classification process, certain weaknesses must be recognised. Although rated high quality by the PEDro scoring system, only three trials scored 7 out of 10, and all trials had major weaknesses that were not necessarily identified by the PEDro score. These included most commonly small treatment groups, lack of sample size calculation, high attrition rates, and lack of long-term follow-up. Regarding the review process, two limitations were identified: the reviewers were not blinded to the authors of the articles, and a large number of articles that used the Quebec Task Force classifications system were not included. The reason for exclusion of this well recognised classification system was that it is time-based, not mutually exclusive and does not drive treatment. Furthermore, the database search was not comprehensive and relevant trials may have been missed. ONLINE REFERENCES (Click Research Link) MII Reference List: The Institute's official list of references is aptly and efficiently compiled and kept current online by Stephen May, PT, Dip. MDT of the UK branch. (Accessible to all.) Clinical Abstract Database: Searchable database containing over 2500 references with complete abstracts of the most significant MDT or related research. (The database is currently a benefit of the US branch membership, and we are working toward making this available to interested branches and branch members worldwide.) Volume 1, No. 1 March 2006 IJMDT 57

60 Diploma Dialogue Stuart Horton, Dip Phty, DMPhty., Dip. MDT International Journal of Mechanical Diagnosis and Therapy Hello! My name is Stuart Horton and I am a Clinical Educator at the School of Physiotherapy, University of Otago. The School is a clinical training site for the Postgraduate Diploma in Physiotherapy, endorsed in Mechanical Diagnosis and Therapy. My role is the Clinical Educator for the students on this programme. The purpose of this column in the IJMDT will be to communicate to you some of the things that occur during the Diploma programme here at Otago. Such things as student s experiences and reflections on the programme and interesting clinical viewpoints will be presented. Students attend one university semester (13 weeks) at Otago where they undertake supervised clinical practice and complete a university paper called Biomedical Science. March 2006 sees the arrival of three international students to complete this programme coming from New Zealand, Greece and United States. One unique aspect of the Diploma programme is the opportunity that therapists from different countries of the world have in coming together for a short period of time to practice, discuss, problem solve, reflect, debate and challenge their thinking on the McKenzie Method. Never again in their professional career is it likely they will have this unique opportunity to work in such an environment. This is not just the case at Otago, but also at the other Diploma clinical training sites in Europe and the US. Many previous therapists who over the years have completed their Dip.MDT state how it has really changed their approach to managing their patients! Til the next issue cheers! The Diploma in Mechanical Diagnosis and Therapy Full details on the Diploma Program are available at: Diploma Curriculum The language of the diploma program is English and the curriculum consists of two components: Theoretical and Clinical. Theoretical Component: Comprises a Distance Learning course titled Foundations in Mechanical Diagnosis and Therapy conducted by the University of Otago, School of Physiotherapy, Dunedin, New Zealand in collaboration with MII. All participants are enrolled at the University of Otago to enable access to the University s extensive resources, which have been developed specifically to support distance teaching. Clinical Component: Consists of two pathways to achieve a minimum of 360 hours of supervised clinical practice based on a variety of musculoskeletal disorders. It emphasises the central importance of the evidence of the patient. The maximum ratio of participants to Mentor is limited to four. Clinical Training sites are currently located in the USA, The Netherlands and New Zealand. 1) Two training sites (Otago-New Zealand and Austin-Texas, USA) are full time in one 9-week block: Clinical Training - University of Otago This pathway enables students to further their studies on completion of the Postgraduate Diploma by enrolling in a Masters of Physiotherapy endorsed in Mechanical Diagnosis and Therapy (PHTY590) conducted by the University of Otago. For more details visit: and click on Mechanical Diagnosis and Therapy. Clinical Training - Austin, Texas USA: It is most appropriate for the student who is primarily focused on being a clinician as it does not provide the opportunity for the student to attain a University based Postgraduate Diploma. 2) Two training sites (The Hague & Roermond in The Netherlands and Montclair, New Jersey in the USA) conduct the clinical training in 3 week blocks (3 separate blocks of 3 weeks onsite are required to complete the total number of clinical hours). Clinical Training - The Hague and Roermond, The Netherlands, & Montclair, New Jersey, USA: This option enables the training to be spread over a 12 month period. It is the most appropriate pathway for students who are primarily focused on being a clinician but who find it difficult to undertake their training in one 9 week block. Final External Examination Upon successfully passing both the Theoretical and Clinical Components of the Diploma Curriculum, the Final Examination is conducted by a Panel of Examiners appointed by MII and is supervised by the MII Director of Education consisting of a three hour written paper and a one hour oral/practical examination. Successful attainment of Diploma in MDT is the minimum pre-requisite to teach for the Institute. Persons wishing to apply for a Probationary Faculty position with the Institute must complete a minimum period of one year s clinical experience from attainment of the Diploma MDT and date of application for Probationary Faculty. Applying for the Program The level of interest for attendance is very high, and accordingly registrations are processed in the order they are received. The Institute is currently in contractual negotiations for the commissioning of further Diploma Clinical Component venues both within the United States and Europe. Application forms for Diploma Program may be obtained by contacting: Jan Harris International Diploma Administrator The McKenzie Institute International PO Box 2026, Raumati Beach 6450 New Zealand [email protected] If you have any further queries, please do not hesitate to contact Jan Harris at the above address. Volume 1, No. 1 March 2006 IJMDT 58

61 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT Indledning Hvordan kan det være positivt at patienten ikke er blevet bedre ved den opfølgende konsultation? Hvad nu hvis det er umuligt for patienten at blive bedre? Hvilke behandlingsmetoder skal vi forsøge os med og hvilke bør vi undlade? De to første artikler om Mekanisk Inkonklusiv (MDT nyhedsbrev Maj 2005 og September 2005), har fokuseret på diagnostisk afklaring gennem en struktureret anamnese og en klar objektiv teststrategi. Formålet med at lytte til hvad patienten fortæller os, at iagttage responset på mekaniske testbevægelser og statiske stillinger, er at afklare den mekaniske diagnose. Diagnostisk afklaring er en grundlæggende forudsætning for at vælge typen af behandling og håndtering. I denne tredje og sidste artikel om mekanisk inkonklusive patienter vil vi diskutere finesser i forhold til tests, baselines og monitorering af symptomrespons. Vi vil diskutere det videnskabelige fundament for vores behandling, i overordnede træk, ligesom vi vil kigge nærmere på hvilke perspektiver der kan inddrages i evidensbaseret praksis. Som appetitvækker - lad os starte med dette citat fra MTV-rapporten Ondt i Ryggen 20 : En af de største fejltagelser på rygområdet i dette århundrede har uden tvivl været den kritikløse anvendelse af passive behandlingsmetoder, ofte iværksat hvor den spontane bedring allerede var godt i gang. Ved passiv behandling risikerer man at fastholde patienten i en passiviserende patientrolle hvilket kan resultere i et langvarigt kronisk smerteforløb. At mange patienter selv har været medvirkende til, at behandlingen blev passiv, fordi de simpelt hen har forlangt de ofte behagelige passive behandlingselementer iværksat, undskylder ikke den professionelle behandlers valg af behandling. Evidensbaseret praksis Hvilke af de behandlingstiltag en fysioterapeut har kendskab til, kan anbefales til behandling af mekaniske rygproblemer og hvilke behøver man ikke spilde tiden med? For at kunne diskutere det emne, tager vi udgangspunkt i en foreslået definition af evidensbaseret praksis, som fokuserer på at integrere patientens ønsker med fysioterapeutens ekspertise og den eksisterende videnskabelige litteratur (Figur 1) Figur 1 - Evidensbaseret Praksis Patientens værdier og præferencer Integration Meningen med evidensbaseret praksis er at give patienterne mulighed for at foretage et informeret valg sammen med fysioterapeuten. De kliniske retningslinier som danner grundlaget for den evidensbaserede praksis, skal være dynamiske dokumenter, hvor ny information og erfaring opdateres jævnligt. Evidensen er et redskab til at optimere klinisk praksis og den generelle forvaltning af sundhedsydelser, og vil til stadighed udfordre klinikerens åbenhed til at justere på dét han gør hver dag! Grundig undersøgelse, præcis diagnose som forklarer årsagen til smerter, mindsket besvær med dagligdags aktiviteter, sygemelding m.h.p. social accept samt legitimering af inaktivitet, at klinikeren er god til at lytte og kommunikere, at der er god tid, at være med i beslutningsprocesser, at klinikeren tror på, at smerterne er ægte, et patient-behandler-forhold som er baseret på tryghed, information og vejledning om at håndtere smerter samt smertelindring. Generelt er forventning om smertelindring mindre hos kroniske patienter. Best research evidence Forsikre om god prognose, bearbejd patientens opfattelse og holdning til rygproblemet, minimér risiko for invaliditet, øg funktionsniveauet og få patienten tilbage til normal aktivitet, simpel symptomkontrol, undlad passiv behand- Referencer: 1,5-7,11,13,14,17,18,21,23-26 Klinisk ekspertise Viden, træning og erfaring, personlige egenskaber, klinisk ræsonnering, teknologi etc. Volume 1, No. 1 March 2006 IJMDT 59

62 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT Aktiv eller passiv behandling? Der er mange gode grunde til at vælge en aktiv behandlingsstrategi, når man arbejder med såvel akutte som kroniske rygpatienter: Passiv mestrings-adfærd betyder at patienten ikke selv tager ansvaret for at håndtere smerterne, eller det tillades at andre områder i livet bliver påvirket på en negativ måde. Passive mestringsstrategier er en stærk og uafhængig prædiktor for invaliderende nakke- og rygsmerter. Denne udtalte sammenhæng identificerer passiv mestring som en markør for invaliditetsrisiko, ligesom den understreger vigtigheden af at identificere individer, der med fordel kan justere deres mestringsstrategier mod en mere aktiv adfærd 7,17,21,26. Litteraturen støtter ikke anvendelsen af passive behandlingsmodaliteter (Laserbehandling, ryg-bælter, kortbølge-behandling, ultralydsbehandling, varmebehandling, lumbal traktion, TENS og massage) 11,24. Øvelsesterapi ser ud til at være fuldstændigt harmløs i forhold til patienter med akutte, subakutte eller kroniske lænderygsmerter. Det tyder Figur 2 Behandlingsfokus Patientens paradigme oven i købet på at bevægelse har en beskyttende effekt 23. Aktiv øvelsesbehandling resulterer i positivt udbytte hos patienter med kronisk LBP, uanset hvilken type af øvelser der er undersøgt i 16 RCT er af medium eller høj metodologisk kvalitet 13. De fleste patienter har den opfattelse at deres funktionsniveau nok skal blive normaliseret, når deres smerter reduceres eller forsvinder (figur 2). Som fysioterapeuter ved vi godt, at det kun er den halve sandhed. Hvis problemet udelukkende var et spørgsmål om at slukke smerterne, skulle patienterne jo være gået på apoteket efter smertestillende medicin, i stedet for til fysioterapeut. Det tilbud vi har til de fleste patienter med mekaniske problemer, er at få led og muskler til at fungere så normalt som muligt. Dernæst vil smerterne, i de fleste tilfælde svinde som resultat. Det kan derimod blive et problem hvis behandlingen hovedsageligt fokuseres på, at finde en måde hvorpå patientens smerter kan reduceres. Dels er en del af de modaliteter, som traditionelt anses for smertelindrende, ikke særligt velfunderede i den videnskabelige litteratur. Dertil kommer at de fleste smertelindrende modaliteter gør patienten passiv, og giver en falsk opfattelse af at fysioterapeuten kan fjerne problemet. Smerter er sommetider resistente overfor fysioterapi-behandling, men nedsat funktionsniveau er ikke en upåvirkelig konsekvens af rygsmerter. Funktionsniveauet kan normaliseres gennem træning. En sjælden gang hænder det, at man møder en patient, som målsat ønsker passive tiltag som varme og massage, og nogle patienter vil have en oplevelse af at passiv behandling over en udvidet tidsramme har hjulpet dem tidligere. Tilbage i 1960 erne var massage og varmebehandling standardbehandling for rygproblemer. Idag ved vi bedre, evidensen er et dynamisk dokument. Vores indgangsvinkel er som hovedregel, at alle patienter skal have et tilbud om vores bedst mulige behandling. Patienter med passive mestringsstrategier dem der plæderer for massage skal ikke bekræftes i, at det er den rigtige måde at håndtere problemet på. De skal tilbydes en aktiv behandlings- og rehabiliteringsplan. Skulle patienten ønske noget andet end dét vi kan tilbyde, på baggrund af vores ekspertise og den eksisterende evidens, sender vi dem altid et andet sted hen. Færre smerter Bedre funktionsniveau Som urutineret kliniker kan det dog være svært at afvise patienternes ønsker om en passiv behandling. Særligt hvis man ikke selv har et bedre alternativ, eller man mangler viden og argumenter. Fysioterapeutens paradigme Tabel 1 opsummerer behandlingsanbefalinger fra European Commission, Research Directorate General. Volume 1, No. 1 March 2006 IJMDT 60

63 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT Behandlingsredskaber i værktøjskassen Som fysioterapeut har man typisk en værktøjskasse fuld af behandlingstilbud, så man kan afprøve forskellige ting, og finde den behandling, som passer til den enkelte patient. Der eksisterer efterhånden en del litteratur som forholder sig til det klassiske indhold i værktøjskassen (tabel 1 Hildebrandt og Van Tulder). Tabel 1 Europæiske Guidelines Anbefales Anbefales ikke Behandling af patienter med kroniske uspecifikke lænderygsmerter (varighed >12 uger) 11 Superviseret øvelsesterapi anbefales som det første behandlingsvalg i forhold til at håndtere kronisk LBP. Man kan overveje en kort periode med mobilisering eller manipulation. Desuden anbefales ryg-skole, korte undervisningsseancer som bearbejder patientens opfattelse og holdning til rygproblemet, kognitiv adfærdsterapi. I de tilfælde hvor alt andet fejler kan man overveje multidisciplinær biopsykosocial rehabilitering m.h.p. at patienten kan vende tilbage til normalt funktionsniveau. Massage Kortbølge-behandling Ultralyds-behandling Varmebehandling Laserbehandling Ryg-korset Lumbal traktion TENS Best research evidence er rammerne for relevante behandlingsmuligheder. Patientens ønsker og klinikerens ekspertise afgør hvilke behandlingsmuligheder der implementeres i rehabiliteringsplanen. Vi skal lytte til patientens præferencer og ønsker, og agere på et evidensbaseret grundlag. Behandling af patienter med akutte uspecifikke lænderygsmerter (varighed <6 uger) 24 Giv patienten information og forsikring. Råd patienten til at holde sig aktiv og fortsætte med daglige aktiviteter inklusive deres job, såfremt det er muligt. Udskriv smertestillende medicin om nødvendigt (primært paracetamol, dernæst NSAID). Overvej henvisning til manipulationsbehandling, for patienten som det ikke er lykkedes at vende tilbage til normal aktivitet. Overvej multidisciplinær behandling for patienter som er sygemeldt i mere end 4-8 uger. Massage Specifikke øvelser (f.eks. styrketræning, udstrækning, extension). Der er dog konsensus om at aktivitet bør promoveres samt at øget fysisk form vil forbedre det generelle helbred. Den eksisterende videnskabelige litteratur støtter dog ikke specifikke styrke- eller fleksibilitetsøvelser, som behandling for akut uspecifik LBP. TENS, Sengeleje, Epiduralblokader Ryg-skole, Kognitiv adfærds-terapi Lumbal traktion DOWNLOAD European Commission Research Directorate General COST ACTION B13 Low Back Pain: Guidelines for its management Der er ofte fysioterapeuter, som spørger hvad man siger til en patient med kroniske problemer, som ønsker massagebehandling. Til sådan en patient kan man sige, at man tidligere har troet at massage var effektivt, men i dag ved vi, at den bedste behandling er baseret på aktivitet, øvelser o.s.v, og at man decideret fraråder passiv behandling. Det er vores pligt at informere patienten om de bedste muligheder. Hvis den enkelte patient ønsker at få massage i stedet for at lave øvelser, skal vi så være enige med dem i stedet for at give dem det rigtige sundhedsbudskab? Nej selvfølgelig ikke det gælder om at komme op af sofaen og bevæge sig! Der er aldrig nogen der er kommet til at fungere bedre af at ligge på en briks og blive gnedet med olie! Det ser ud til, at der er en gruppe af patienter, som har gavn af terapeutteknikker, mobilisering eller manipulation. I litteraturen anbefales det, at man overvejer en kort periode med mobilisering eller manipulationsbehandling 11,24. Følger man kraftprogressionen, respekterer kontraindikationer og gennemfører præmanipulative tests er denne type behandling sikker og sommetider effektiv for patienter med kroniske problemer. Et nyligt offentliggjort studie af 141 patienter, konkluderede dog, at de patienter som responderede på lumbal manipulation havde 2 karakteristika: symptomvarighed under 16 dage og ingen symptomer distalt for knæet 9. I forhold til de fleste kroniske patienter er det bedste værktøj aktivitet, bevægelse og træning som sigter mod at give patienten kontrol over smerterne og sætter dem i stand til at vende tilbage til de aktiviteter, de har måttet undlade, eller i det mindste har haft besvær med 7,26! Volume 1, No. 1 March 2006 IJMDT 61

64 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT Det anbefales at fokusere behandlingen af mekaniske problemer på : Forsikring om en god prognose Undervisning som bearbejder patientens opfattelse af, og holdning til rygproblemet Minimere risiko for invaliditet ved at fjerne patientens frygt for at gøre skaden værre Øge funktionsniveau og hurtigst mulig tilbagevenden til normalt aktivitetsniveau Simpel symptomkontrol og - reduktion Denne strategi er designet til at drage fordel af det godartede spontane forløb, som oftest observeres i relation til muskuloskeletale problemer, samt at forebygge unødvendigt funktionstab. Det fysiske symptom smerter er sommetider resistent overfor behandling, men funktionstab kan forebygges og behandles. Akutte rygsmerter er ofte en tilbagevendende gene for befolkningen, men spontanforløbet er hyppigst ganske godartet bortset fra en lille gruppe af mennesker 10. Derfor er der ingen grund til at skræmme patienterne til at indskrænke deres aktivitetsniveau Du må ikke sidde ned i længere tid ad gangen!, Undgå at løfte!, Din ryg kan ikke længere holde til alle de vrid, når du spiller golf!. Behandling af mekanisk inkonklusive patienter Overordnet set drejer behandling af patienter med mekaniske rygproblemer sig om at give klare informationer og involvere patienten i at træffe beslutninger. Denne indgangsvinkel sigter på at facilitere patientens oplevelse af at have indflydelse på problemet. Målet er at fordre aktive mestringsstrategier. Disse kerneområder diskuteres i de efterfølgende afsnit. Grundprincipperne i behandlingen går ud på at fokusere på normalisering af funktionsniveauet, at give patienten større viden om problemet samt at bevæge patienten mest muligt, uden at skade ham. Forklaringsmodeller I dette afsnit vil vi foreslå nogle forklaringsmodeller man kan anvende i håndteringen af den mekanisk inkonklusive patient. I stedet for, i et optimistisk gæt, at give en patoanatomisk forklaringsmodel, foreslår vi denne indgangsvinkel: Hos en del patienter med ondt i lænden kan vi ikke lokalisere årsagen til problemet med en MR scanner. En MR scanner viser kun en forenklet udgave af virkeligheden. Dét betyder ikke, at du ikke har ondt. Det ved vi du har. Faktisk er det positivt at vi ikke kan finde den præcis årsag til dine smerter for når man kan finde en specifik årsag, er det ofte noget grimt! 11. Selvom vi ikke kender den præcise årsag, har vi en mulighed for at kigge problemet nøjere efter i forhold til hvordan det reagerer på aktivitet og bevægelse. Patienten uddannes på baggrund af dysfunktionsmodellen. Det vil sige at han lærer at det godt må gøre ondt, når blot smerterne falder til ro igen. Han lærer med andre ord forskellen på smerte og skade. Når patienten oplever og accepterer at smerterne ikke er skadelige, er der større sandsynlighed for at hans funktionsniveau vil normaliseres 15,16. Det er altid et spørgsmål om, hvor lang tid man skal acceptere, at der er smerter efter øvelser, træning eller aktivitet. Den instruktion man giver patienten vil variere efter hvor sart patienten virker. Til de fleste patienter vil vi sige, at det er acceptabelt med smerter i minutter efter de har lavet øvelser. Er patienten meget sart eller sensitiv kan vi måske give lidt mere elastik og sige op til 60 minutter. Hos nogen patienter er smerterne et rigtigt dårligt styringsredskab, fordi alting gør dem værre og de falder aldrig til ro igen. Her vil det være mere hensigtsmæssigt at lære patienten at bruge en mekanisk baseline, som vil fortælle os hvis der skulle opstå en akut skade eller overlast i leddet (inflammation eller derangement) som konsekvens af vores øvelser. I det tilfælde kan man forklare patienten, at vævet er ekstremt sensitivt efter lang tid med grus i maskineriet. Derfor vil alle forsøg på bevægelse initialt blive opfattet som farlige og systemet reagerer med nociception det vi i fagsprog kalder central sensitivisering. Hjernen vil endda opfatte almindelige bevægelsesimpulser (proprioception) som smerter. Derfor er smerterne upålidelige i forhold til at sikre os leddets sundhedstilstand. Hvis leddet begynder at blive overbelastet eller skadet vil patienten miste ledbevægelighed. Det betyder at progressionen har været for hurtig, eller at leddet endnu ikke kan tolerere den aktivitet det har været udsat for. Informationen til patienten skal være brugbar, og meningsfuld for patienten. Man kan derfor med fordel bruge ord som patienten forstår, og være opmærksom på at give en forklaring der er i overénsstemmelse med det patienten tidligere har hørt. Dette kan sommetider være en kæmpe udfordring. Særligt når patientens opfattelse ligger meget fjernt fra fysioterapeutens vurdering, eller når han har fået adskillige divergerende forklaringer i forløbet igennem behandlersystemet. En mulig måde at slippe ud af potentielle modsigelser fra kollegaer, eller tidligere behandlere, er at fortælle patienten at forklaringsmodeller ofte er en forenklet del af virkeligheden. Rygproblemer er dynamiske skader Volume 1, No. 1 March 2006 IJMDT 62

65 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT som kan ændre karakter. Det vigtige er hvilke spilleregler der gælder NU for det pågældende problem, og hvilken strategi der vil gavne problemet. En anden forklaringsmodel vi kan anvende er baseret på den sparsomme vaskularisering af intraartikulære strukturer. Til forskel fra en muskel, er blodcirkulationen i vores led meget ringe. Opheling og regenerering tager derfor meget længere tid 4,8. Til alt held er der bruskvæv inden i leddet og brusk opfører sig som en svamp. Det vil sige at bevægelse og aktivitet har en pumpe-effekt som skaber cirkulation i leddet 12. Bevægelse er altså fysioterapeutens bedste medicin, til et led som er i gang med at hele. Der findes talrige andre forklaringsmodeller, dette er blot et udpluk. En sidste vi vil nævne her, relaterer sig til de vævsforandringer der ses på billeddiagnostiske undersøgelser 2,3. Denne forklaring vil ofte kunne tilpasses til patienter der har et røntgenbillede inde i hovedet, med masser af slidgigt og discusprolapser m.m. Nogle smerter skyldes at leddet er slidt. Den tilstand kan vi ikke tage væk, men vi kan sætte alle skibe i søen for at stoppe udviklingen. Behandlingen vil derfor fokuseres på at nedsætte sliddet på leddet (holdningskorrektion) samt at styrke de muskler omkring leddet (træning af muskelkorsettet, en aktiv livsstil og specifik træning af de funktioner som patienten har måttet stoppe med). Det er naturligt, at man søger en forklaring, når man har smerter i ryggen. Vel vidende at vi ikke altid kan identificere en patoanatomisk årsag, foreslås non-high-tech forklaringsmodeller. Patienten forventninger Alle mennesker der har ondt, vil gerne af med smerten, og helst NU det er klart!. Nogle patienter har et stærkere drev mod at få hjælp til at tage smerten væk end andre, og det er ikke udsædvanligt at nogle har den overbevisning, at en behandler kan fjerne smerten, mens patienten selv ligger på maven og venter på det sker. I nogle tilfælde er terapeutteknikker, eksempelvis mobilisering og manipulation, et kraftfuldt værktøj til at kunne mindske patientens smerter. Det kan give patienten en oplevelse af, at klinikeren ved hvad problemet drejer sig om. Det vil gøre nogle patienter mere tilbøjelig til at lytte til den strategi klinikeren stiller op for at løse problemet. Det kan dog aldrig anbefales at gå på kompromis med hverken sikkerhed eller kraftprogression blot for at tilfredsstille en patients forventninger. Nøglen ind til optimal håndtering af disse situationer er at være realistisk i kommunikation med patienten. Fortæl patienten, at nogle typer af rygsmerter kan afhjælpes hurtigt. Andre typer vil ikke kunne reduceres hurtigt. Det hat stor værdi at undervise patienten i hvorfor helingen vil gå langsomt. Når man skal opstille en strategi for at bearbejde patientens problem, kan det være smart at give patienten valgmuligheder. Vi kan eventuelt give mulighed for at vælge mellem to forskellige øvelser. På den vis involverer man patienten i behandlingen, i et tidligt stadie. Han har, i dét øjeblik han går ud af døren, en mission og en opgave frem mod næste konsultation hvor forventningerne til responset er diskuteret igennem med ham. Princippet om patienten som selvdiagnostiker som diskuteret i afsnittet forklaringsmodeller er en let håndgribelig måde at udøve simpel symptomkontrol og bearbejde patientens opfattelser på. Princippet om symptomkontrol efter dysfunktionsprincippet bygger på gentagne positive bekræftelser, og er det basale værktøj i omprogrammering der hvor katastrofealarmen plejer at fortælle patienten at der er fare på færde, og at han skal stoppe sin aktivitet. Mange patienter vil, med denne type af håndtering, opleve at de gradvist kan mere og mere, ikke nødvendigvis fordi smerten er væk, men fordi frygten for den og fokus på den som den endegyldige bremse ikke længere eksisterer. En interessant sløjfe på patientens tilfredshed er den begrænsede rolle som smertereduktion og øget funktionsniveau spiller, når patienten vurderer behandlingseffekten. Pincus et al (2006) 22 peger på at den relativt store patienttilfredshed rapporteret i litteraturen, skyldes at patienter i langvarige ikke effektive forløb selv sætter deres mål for behandlingen. Patienternes mål kan være at prøve alle slags behandling, at fysioterapeuten gør sit bedste eller at fysioterapeuten ikke opgiver patienten. Det er naturligvis vanskeligt for ethvert menneske at stille sig utilfreds overfor en behandler når man har fået alt dét man har bedt om på trods af udeblevet effekt. Konkrete øvelsesforslag Overordnet er der to muligheder: bevæg dét led der har problemet, dvs. med specifikke rygøvelser som fleksion, extension eller sideglidning. Alternativt, hold det skadede led neutralt og bevæg ekstremiteterne omkring leddet. Eksempler herpå kan være tå-vip, knæbøjninger op ad en dør eller elastik-øvelser. Skræddersy øvelserne til de funktionelle krav led og muskler må honorere for at vende tilbage til et normalt funktionsniveau. Med meget sarte patienter kan man med fordel vælge at bevæge noget andet end det skadede led. En fordel ved dén strategi er at give patienten en oplevelse med central sensitivisering. Det er ikke usædvanligt at Volume 1, No. 1 March 2006 IJMDT 63

66 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT kroniske lænderygproblemer føler en forværring uanset hvad man gør. Ofte føler de at de bliver værre uden at der reelt er fare på færde. Ved at adressere noget andet end problemet kan denne sammenhæng demonstreres, gennem en oplevelse af forskellen på smerte og skade. Ofte bruger vi Slouch Overcorrect som en test for egnethed til mekanisk rehabilitering. Argumentet er, at alt andet patienter gør i sin hverdag vil være mere belastende, end 10 gange slouch-overcorrect-bevægelser. Tolererer patienten ikke disse øvelser, er oddsene for at kunne hjælpe ham med mekanisk terapi ikke gode. Styringsredskaber Et velkendt mantra indenfor MDT er: Patienten har alle svarene!. Det er rigtigt at vi får de mest værdifulde oplysninger ved at lytte til patienten. Indimellem er det blot sådan, at det patienten fortæller med ord er i direkte modstrid med det der sker, når vi begynder at bevæge ham. Et af de karakteristiske træk ved mekanisk inkonklusive læsioner er, at de opfører sig uforudsigeligt. Derfor kræves det som regel at man holder tungen lige i munden i et velstruktureret og præcist styret rehabiliteringsforløb. Et af de gode styringsredskaber ved opfølgende konsultationer er et struktureret interview. Hvis vi skal træffe kliniske beslutninger, er der nogle oplysninger som er meget relevante. Indledningsvist: Fastslå compliance: Hvor ofte har du været i stand til at lave dine øvelser? eller Hvor mange gange har du haft mulighed for at lave dine øvelser?. Har patienten lavet øvelserne med den frekvens vi har anbefalet? Hvad med deres holdning sidder de og hænger ude i venteværelset medbringer de deres lumbar roll? Ligeså skal man kontrollere deres øvelsesteknik. Når de til end-range vel at mærke hvis det er meningen med øvelsen? Hvis de træner i mid-range, eller der er tale om stabilitetstræning skal man naturligvis kontrollere at kvaliteten af øvelsen i orden? Er patienten værre, bedre eller uændret som resultat af de øvelser han har lavet? Patienten er bedre: Hvis patienten siger at han er blevet bedre, skal vi vide hvad der er forbedret (smerter, smidighed, funktionsniveau osv.), hvordan er han bedre, hvor meget er han bedre? Siger han bare at han er bedre, fordi han ikke kan få sig til at sige andet? Er forbedringen sket fordi tiden er gået eller skyldes det øvelserne? Hvis patienten føler sig bedre skal man kontrollere om ledbevægelighed, neurologiske baselines, funktionelle baselines og så videre, også er bedre. Diskuter med patienten, hvad status er i.f.t. behandlingens mål, justér eventuelt øvelserne, behandl med terapeut-teknikker hvis der er behov for det, uddan patienten så han selv kan anvende simple baselines til at justere sine øvelser. Eksempelvis: Når du mister evnen til at bøje dig ned og nå anklerne, er det på tide at lave dine øvelser! gør ham til selv diagnostiker! Patienten er forværret: Udforsk årsagssammenhængen er det øvelserne der har gjort patienten værre eller er det noget andet. Bliver du værre når du laver øvelsen eller først bagefter? Bagefter - hvor lang tid bagefter 1 minut eller 1 time? Hvis patienten først bliver værre nogen tid efter øvelserne, er der ingen kraftige indikationer af nogen årsagssammenhæng mellem øvelser og forværring. Altså er der tungtvejende argumenter for at det ikke er øvelserne som har skabt forværringen. Så må man vurdere om man skal forsøge at forklare patienten det, eller om man bare vælger en anden øvelse. Hvis patienten ikke kan lide extensionsøvelser så lad ham lave fleksionsøvelser og se hvad der sker! Brug forværringen positivt: uddan patienten Så ved vi nemlig hvor grænsen går for, hvad leddet kan tolerere nu!, eller: Værre er super-godt! Så ved vi nemlig at vi ikke skal løse problemet, ved at bevæge leddet i den retning!. Værre så ved vi at vi rammer problemet, det er godt. Værre kan altid vendes til noget positivt, blot vi bibeholder patientens tillid. Re-evaluér og justér eventuelt øvelserne. Patienten er uændret: Udforsk årsagssammenhænge Hvad sker der når du laver øvelsen?. Re-evaluér hvis patienten siger at han er uændret, bør alle baselines også være uændrede. Måske er ledbevægeligheden markant ændret uden at patienten har bemærket det, måske har patienten ikke tillagt det værdi fordi vi har glemt at uddanne ham i relevansen heraf?! Måske kan han nu extendere ryggen uden smerter, i modsætningen til forrige konsultation hvor extension fremprovokerede bensmerter. Justér eventuelt øvelserne (endrange, flere gentagelser, overpres, mobilisering, holdningskorrektion). Patienten er forandret: Hvad er forandret? Nye smerter, centraliseret, periferaliseret, træningsømhed? Uddan patienten, re-evaluér eller fortsæt som hidtil. Volume 1, No. 1 March 2006 IJMDT 64

67 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT Ved opfølgende konsultationer anbefales det at dokumentere funktionsbegrænsninger eller -forbedringer som supplement til symptomatiske forandringer. Dette for at kunne tilrettelægge træningen så den retter sig imod patientens ønsker og mål. Et andet formål er at dokumentere om patienten blot føler sig bedre, eller om de reelt også fungerer bedre. Sommetider er der patienter som vedbliver at have de samme smerter, men som i betragteligt grad opnår et øget funktionsniveauet. Et eksempel er patienten som brokker sig over, at han ikke har fået færre smerter. Ved behandlingsstart kunne han ikke spille badminton, og nu spiller han 2 gange om ugen Det er ikke mystisk og faktisk heller ikke farligt, at du mærker smerterne endnu i betragtning af at du er gået i gang med noget du har holdt pause fra i lang tid!. Uanset hvad patienten vender tilbage og siger, kan det bruges til noget positivt. Naturligvis kan man komme i en situation, hvor alting gør patienten værre eller intet ser ud til at kunne forandre dem. Så må man bare lade patienten vælge om interventionen skal fortsætte. Vi er bevægelsesterapeuter vores medicin er bevægelse. Kære patient har du en oplevelse af at bevægelse kan reparere dit problem?. Patientens udsagn, baselines, symptomer, ledbevægelighed samt funktionsniveau er vores styringsredskab. Non-respondere Af alle de patienter vi møder med rygproblemer vil en begrænset gruppe ikke respondere på mekanisk behandling og rehabilitering. Det er vores erfaring, at det drejer sig om en relativt lille gruppe, som har en læsion, der ikke responderer på bevægelse. På baggrund af vores optegnelser fra klinikken over de sidste 12 måneder tyder det på at de patienter som vi ikke kan hjælpe findes blandt ikke reducérbare derangements, entrapments, mekanisk inkonklusive patienter og patienter med ikkemekaniske problemer. Halvdelen af de patienter vi ikke kan hjælpe ikkemekaniske problemer! MDT er vores system til at opsnappe den mindre gruppe af patienter, som er overvejende kemiske og har gavn af at blive set af en rheumatolog. Ligeså er der en gruppe med røde flag som skal udredes yderligere. Afrunding Udgangspunktet for håndtering af et mekanisk rygproblem, er at skabe et samspil mellem en præcis og struktureret undersøgelse samt patientens mål og opfattelse af problemet. Disse faktorer danner fundamentet for bearbejdningen af patientens problem, som helhed. I den tilgang til diagnosticering og behandling af mekanisk inkonklusive rygpatienter, vi har beskrevet i denne artikelserie, er fysioterapeutens paradigme et centralt emne. I det øjeblik terapeutens paradigme bliver en opfattelse af sig selv som Figur 3 Jamen det skader jo ikke Massa- Varme Referencer: 1,11,17,20,21,24 Kortbølge Myofascial release behandler, og måske som den eneste, der vil kunne hjælpe denne patient, er det ikke længere svært at forestille sig, at der bevidst eller ubevidst opstår en situation, hvor patienten bliver afhængig af behandling og bekræftelse. På trods af en til stadighed stigende mængde af evidens på lænderygområdet, tyder det på at vedblivende ineffektiv behandling udover en acceptabel tidsgrænse ikke er hverken et sjældent eller usædvanligt fænomen 22. Et nyligt publiceret kvalitativt studie peger på terapeutens rolle som en mulig forklaring 22. Sommetider fortsættes ineffektiv behandling fordi patienten ville havne i et behandlingsmæssigt tomrum, hvis fysioterapien blev afsluttet. Et andet argument for at fortsætte ineffektiv behandling er at terapeuter ikke kun betragter sig selv som behandlere, de betragter sig selv som ansvarlige for at vedligeholde patientens helbred, som ansvarlig for at beslutte hvilke faktorer der kunne forværre problemet. Her kan man virkelig tale om en situation hvor patienten får mulighed for at opbygge en tæt afhængighed at sin Laser Jo det gør det faktisk! TENS Ultralyd Volume 1, No. 1 March 2006 IJMDT 65

68 Mekanisk Inkonklusiv Behandling og Rehabilitering, artikel 3 ud af 3 Camilla Nymand, dip. MDT & Martin Melbye, dip. MDT fysioterapeut! Selvom mange af de passive behandlingsmodaliteter ser ud til at være uskadelige set ud fra et fysiologisk perspektiv, er der flere undersøgelser som fraråder brugen heraf fordi de har en skadelig effekt på patientens prognose og funktionsniveau (figur 3). Udover overvejelser omkring identifikation af den mekanisk inkonklusive patient, har vi ønsket at diskutere mere overordnede emner såsom inddragelse af patienten, psykosociale faktorer og vurdering af patientens egnethed til mekanisk behandling og rehabilitering. Forhåbentligt vil der i nær fremtid blive udviklet flere klinisk anvendelige screeningsværktøjer for identifikation af psykosociale faktorer, ligesom vi vil drage nytte af større viden om hvordan de bør influere på kliniske beslutningsprocesser. Det har været essentielt at tegne et overordnet billede af den litteratur vi kan bruge som grundlag for samarbejdet med patienten, hvad angår valg af behandlingstrategier, patientens ønsker, kommunikation og håndtering af forskellige scenarier for responset på behandlingen. Rygsmerter er ikke blot et strukturelt bio-anatomisk fænomen, men snarere en kompleks funktionsforstyrrelse som involverer psykosociale aspekter. Målet for ethvert møde med et menneske, som har et mekanisk rygproblem, må være at normalisere funktionsniveauet, reducere smerterne, mindske frygten og gøre patienten uafhængig af behandling. Så det spørgsmål enhver fysioterapeut må stille sig selv er vil jeg være en del af problemet eller vil jeg være en del af løsningen? God arbejdslyst derude! Litteraturliste 1. Blyth FM, March LM, Nicholas MK, et al. Self-management of chronic pain: a population-based study. Pain 2005;113: Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72: Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72: Buckwalter JA. Do intervertebral discs deserve their bad reputation? Iowa Orthopaedic Journal 1998;18: Burton et al. European guidelines for prevention in low back pain: COST B13, Daykin AR, Richardson B. Physioterapists' Pain Beliefs and Their Influence on the Management of Patients With Chronic Low Back Pain. Spine 2004;29: de Jong JR, Vlaeyen JSW, Onghena P, et al. Fear of movement/(re)injury in Chronic Low Back Pain: Education or Exposure In Vivo Mediator to Fear Reduction? Clinical Journal of Pain 2005;21: Evans P. The healing process at cellular level: a review.physiotherapy 1980;66: Fritz JM, Childs JD, Flynn TW. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Fam Pract 2005;6: Grotle M, Brox JI, Veierød MB, et al. Clinical Course and Prognostic Factors in Acute Low Back Pain. Spine 2005;30: Hildebrandt et al. European Guidelines for management of chronic non-specific low back pain Holm S, Nachemson A. Variations in the Nutrition of the Canine Intervertebral Disc Induced by Motion. Spine 1983;8: Liddle SD, Baxter GD, Jacqueline JH. Exercise and chronic low back pain: What works? Pain 2004;107: Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004;29: McCracken LM, Eccleston C. A comparison of the relative utility of coping and acceptance-based measures in a sample of chronic pain sufferers. Eur J Pain 2006;10: McCracken LM, Eccleston C. A prospective study of acceptance of pain and patient functioning with chronic pain. Pain 2005;118: Mercado AC, Carroll LJ, Cassidy JD, et al. Passive coping is a risk factor for disabling neck or low back pain. Pain 2005;117: Moffett JA, Carr J, Howarth E. High Fear- Avoiders of Physical Activity benefit From an Exercise Program for Patients With Back Pain. Spine 2004;29: Mootz RD. When evidence and practise collide. JMPT 2005;28: MTV-rapporten. Ondt i ryggen: Forekomst, behandling og forebyggelse i et MTVperspektiv. Medicinsk Teknologivurdering Serie B 1999;1(1): Statens Intitut for Medicinsk Teknologivurdering, 1999: Picavet HSJ, Vlaeyen JWS, Schouten JSAG. Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain. Am J Epidemiol 2002;156: Pincus T, Vogel S, Breen A, et al. Persistent back pain - why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. Eur J Pain 2006;10: Rainville J, Hartigan C, Martinez E, et al. Exercise as a treatment for chronic low back pain. The Spine Journal 2004;4: van Tulder et al. European guidelines for the management of acute non-specific low back pain in primary care Verbeek J, Sengers MJ, Riemens L, et al. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine 2004;29: Von Korff M, Balderson BHK, Saunders K, et al. A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. Pain 2005;113: Volume 1, No. 1 March 2006 IJMDT 66

69 Klassifikation af skulderpatienter ad modum McKenzie -et intertester reliabilitetsstudie Camilla F. Lauridsen, Helene Olsen, Line Martley Jensen og Mette Brøndum Bachelorafhandling fra Sundheds CVU Aalborg, fysioterapeutuddannelsen. Projektet er blevet til i samarbejde med Klinik for Fysioterapi, Aalborg Baggrund McKenzie-metoden er velundersøgt i relation til undersøgelse og behandling af mekaniske rygproblemer. Litteraturen er dog meget sparsom, når det gælder metodens anvendelse, værdi og gyldighed i forhold til problemer i ekstremitetsleddene. Epidemiologiske studier har vist, at almenbefolkningen oftere generes af problemer i ekstremiteterne end i ryggen. Desuden har det vist sig, at skulderen er det andet hyppigst rapporterede ledproblem (20,9 %) efter lænderyggen (26,9 %) (Picavet 2003). Det har vist sig, at op til 80 % af alle ekstremitetspatienter kan klassificeres i McKenzies subgrupper (May 2004, Turner 2002), hvilket indikerer, at McKenzie-metoden er et godt redskab til at klassificere, ikke kun ryg-, men også ekstremitetspatienter. Formålet med dette projekt har været at undersøge intertesterreliabiliteten af McKenzies klassifikationssystem brugt til skulderpatienter efter 1. undersøgelse. Dette er blevet gjort ved at lade to diplomauddannede fysioterapeuter undersøge de samme patienter. Metode Patienterne er randomiseret i blokke á 4. I halvdelen af tilfældene er det henholdsvis den ene eller den anden fysioterapeut, der styrer anamnesen og starter med at undersøge. Anamnesen optages, hvor begge fysioterapeuter er til stede. Herefter udfører hver fysioterapeut en undersøgelse af patienten separat. Den fælles anamnese varer 20 minutter, og hver af de to efterfølgende undersøgelser varer ligeledes 20 minutter. Inklusionkriterierne er patienter med skulderproblemer i alle aldersgrupper. Eksklusionskriterierne er patienter med smerter refereret fra nakken, patienter der ikke kan læse, forstå eller tale dansk, neurologiske sygdomme, inflammatoriske tilstande, mistanke om fraktur, dislokationer samt maligne sygdomme. Fysioterapeuterne undersøger og klassificerer patienterne på baggrund af teorien bag Mekanisk Diagnostik og Terapi (McKenzie 2000). I dette projekt indgår subgrupperne derangement, kontraktil dysfunktion, artikulær dysfunktion samt andet. Graden af enighed udregnes i form af procentuel enighed samt kappa koefficienten. Resultater I forsøget indgår der 9 patienter med en gennemsnitsalder på 39,6 år (18-79). Kønsfordelingen var 4 kvinder og 5 mænd. Fysioterapeuterne var enige om syndromet ved 4 ud af 9 patienter. Disse 4 patienter blev alle klassificeret som kontraktil dysfunktion. Den procentuelle enighed blev udregnet til 44,4 % og kappa koefficienten -0,07. Konklusion Ud fra den procentuelle enighed og kappa koefficienten viser forsøget en dårlig intertesterreliabilitet med hensyn til klassifikation af skulderpatienter efter 1. undersøgelse. Diskussion Herunder diskuteres forskellige faktorer, der kan have indflydelse på de dårlige resultater. Størrelse af dette forsøg spiller i stor grad ind på de fundne resultater. Ud fra det lille patientgrundlag, som indgår i forsøget, er det svært at udlede brugbare resultater. Det kunne derfor være relevant at udføre dette forsøg i større målestok for at opnå statistisk signifikans. Man kunne have valgt andre studiedesign for at undgå de fejlkilder, der kan opstå, når fysioterapeuterne undersøger separat. Herunder at nogle syndromer er dynamiske og derfor kan ændre sig, samt at fysioterapeuterne eventuelt får forskellige tilbagemeldinger fra patienten. Vi fandt dog, at det valgte studiedesign var det mest objektive, som ville give udtryk for de mest reliable svar. I studiedesignet valgte vi at udelade posturalt syndrom, da det sjældent ses i praksis (May 2004, Turner 2002). Man kan stille sig kritisk i forhold til, om man kan tillade sig at udelade ét af de tre overordnede syndromer, når McKenzie-metoden ønskes undersøgt. Det er krævende for fysioterapeuterne at skulle være i stand til at klassificere patienterne efter kun én undersøgelse. Dette faktum sammenholdt med skulderens komplekse anatomi kan eventuelt betyde, at det er for svært at klassificere skulderpatienter efter 1. undersøgelse. Det er desuden muligt, at McKenzies klassifikationssystem ikke er udviklet nok endnu til at klassificere skulderpatienter efter 1. undersøgelse. De patienter hvor fysioterapeuterne var enige omkring syndromet, blev alle klassificeret som kontraktil dysfunktion. Dette medfører, at kappa koefficienten blev dårligere i forhold til, hvis fysioterapeuterne også var enige omkring andre syndromer. Der var en tendens til større enighed i slutningen af forsøget, hvilket kunne indikere, at et større forsøg ikke nødvendigvis ville vise samme dårlige resultater. Afsluttende At udføre et studie omhandlende dette kan være første skridt på vejen til at få en mere reliabel og valid klassificering af skulderpatienter, hvilket eventuelt kan føre til en mere optimal behandling. Med dette sagt, vil vi opfordre til yderligere forskning på området! Volume 1, No. 1 March 2006 IJMDT 67

70 Klassifikation af skulderpatienter ad modum McKenzie -et intertester reliabilitetsstudie International Journal of Mechanical Diagnosis and Therapy Litteratur: May, Stephen (2004). An Audit of Mechanical Diagnosis Classification at Multiple Sites. The McKenzie Institute USA Journal. Vol. 12 : 3, s McKenzie, Robin & May, Stephen (2000). The Human Extremities Mechanical diagnosis & Therapy. New Zealand: Spinal Publications New Zealand Limited. Picavet, H. S. J. & Schouten, J. S. A.G. (2003). Musculorskeletal pain in the Netherlands: prevelances, consequences and risk groups, the DMC3 study. Pain. Vol. 102 : s Turner, Kevin (2002). An Audit of Extremity Patients. Nyhedsbrev McKenzie Institute Danmark. Vol. 9 : Volume 1, No. 1 March 2006 IJMDT 68

71 Kursusoversigt 2006 / 10. Internationale McKenzie Konference New Zealand Mckenzie Kursus Program Part A Part B Part C Part D Part E JUNI 15-18, København MAJ 25-28, Esbjerg APRIL 26-28, København MAJ 17-20, Ringe SEPTEMBER 8-9, Esbjerg AUGUST AUGUST AUGUST AUGUST 23-26, Århus 16-19, Århus 20-22, Århus 16-19, Århus OKTOBER SEPTEMBER OKTOBER OKTOBER 19-22, København 14-17, København 7-9, København 10-13, København NOVEMBER NOVEMBER NOVEMBER 9-12, København 16-19, København 2-4, København REFRESHER KURSUS 29. April, Århus 26. August, København 28. Oktober, Århus CREDENTIAL EVALUERING 6. Maj, Århus 9. September, København 4. November, Århus CREDENTIAL UPDATE 7. Juni, København (for kursister med Part E) 8. Juni, København (for kursister uden part E) TILMELDING: Kursussekretær Eva Hauge, Ny Kongevej 40, 5000 Odense C Telefon: / [email protected] / Eller online The McKenzie Institute International and The Institute s Australian and New Zealand Branches Announce the 10 th International Conference in Mechanical Diagnosis and Therapy THE EVIDENCE MOUNTS Honorary Chairman: Robin McKenzie, CNZM, OBE, FCSP (HON), FNZSP (HON), DIP MDT Key Note Speakers: Nikolai Bogduk, Peter Croft, Richard Deyo, Paul Hodges, Susan Mercer, Barry Vernon-Roberts The programme will comprise a range of general sessions and break-out workshops. Optional Events will include: Golf Tournament Friday 23 March 2007 MV Earnslaw Cruise & Walter Peak Station Dinner - Saturday 24 March 2007 Partners Programme Saturday 24 March and Sunday 25 March 2007 Childrens Programme Saturday 24 March and Sunday 25 March 2007 Queenstown, New Zealand March 2007 Conference Venue: / Queenstown, New Zealand: Bookmark our Conference page for more info: Volume 1, No. 1 March 2006 IJMDT 69

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