Nov 30, 2012

Top 5 Fridays! 5 Ways McKenzie Predicted the Future of PT


I thought Adriaan Louw wrote a great piece on how Maitland was ahead of his time. That had me thinking, I believe Robin McKenzie was as well!
1) Specificity is not needed

Coming from the University of St. Augustine's mechanistic approach, you are really thrown for a loop when I learned MDT's approach of looking at movement without palpation or structure, and mobilization without specificity. It creates hypermobility! - was a detraction I heard 14 years ago. We don't hear too much of that now! With studies showing cavitation occurring 3 levels away, and the CPR for Lumbar Thrust Manipulation showing that a specific technique was not needed in a certain population, we can throw out much of the "magic hands" are needed old school paradigms.

2) Patient education/interaction is paramount

Interaction with the patient and leaving the treatment and outcomes up to them makes them not only understand their condition, but responsible for it as well. It was even an early model of pain science education to focus not on the medical (negative) side of things like arthritis, degeneration, and MRI results, but to focus on motion, loading, and restoration of function.

Empowering the patient also makes them less reliant on you as a practitioner, but in my experience, does not mean that they won't be back. In fact, the faster you get someone better, the more business you get.

Learning a MDT evaluation makes you listen to the patient, instead of thinking you have all the answers, McKenzie said the patient holds the key. Listening develops a rapport, which is also better for outcomes.

3) End range

Some now call it "resets" and Mulligan used to call them "miracles." The the focus is now on the neurophysiologics of the rapid change. McKenzie (and Mulligan) knew that getting to end range was important to make the rapid change in even chronic complaints. Hypermobility was not promoted, nor is it a negative thing as some people are just born with laxity anyway. One of the biggest reason why people cannot get MDT to work (patients or clinicians) is not pushing to end range.

4) Classification

Classification leads to improved outcomes as it enhances clinical decision making and facilitates treatment. The MDT system is simple and often knocked for looking at how movements and positions change the patient's presentation. Simplicity is what makes it reliable. With no emphasis on special tests or passive accessory motions, the evaluation is simplified, and trust me, that is not a bad thing.

5) Stabilization/strengthening is not always needed

MDT simplified HEPs making patients more likely to perform them. "That's all I have to do to get better and stay better?" patients often ask. Again, once knocked for its simplicity, how can you expect a patient to remain compliant with their HEP if you're giving them 10-20 exercises? How many do you do for your own workout? After resetting the movement system, retesting strength and function often shows that there was no "strength" deficit in the first place.

Maybe this will be part 1, as I could go on, but it's getting late, and I have an early patient tomorrow morning! I hope you all have a great weekend!

6 comments:

Harrison Vaughan said...

Great post E! I like all your pts but especially #5. This topic could go on forever but I find most of exercises performed in the clinic are 'fillers', meaning we don't really need to give them to the pt but have to as our pay us affected by time! Maybe another reason to go cash based. I like to keep HEP below 5 obviously depending on the situation but beyond that is bizarre.

Terry Rose said...

Therapists who classify their patients have much better outcomes according to literature, regardless of the system. Movement based classification also demonstrates excellent reliability.Systems that do not demonstrate good reliability involve palpation for joint position to movie joint segments. In so doing, nebulous symptoms are elicited, of which the patient was previously unaware off. Working with clinicians using these approaches is like watching a monkey try to throw a football. These patients are stuck in a cycle of dependent care. The McKenzie approach has optimally effective manual mobilization and manipulation procedures applied through a force progression at the level of best symptomatic response. The progression enhances patient safety, and the response utilizes the proven effective prognostic factors of centralization and peripheralization. Another outstanding movement based system is the Selective Functional Movement Assessment.

Jennifer Michelle said...

I always learn so much about the way PTs think about the body when I read your posts! I am a big proponent of #2 - not only does it put the patient center stage, which is only appropriate, but having control goes a long way towards reducing pain.

Dr. Erson Religioso III, DPT said...

Thanks Jennifer!

Dr. Erson Religioso III, DPT said...

I just have them demonstrate the HEP a few times and then possibly progress/regress as needed, make sure they do that correctly and don't even have them exercise in the clinic if it's MDT based. Patients appreciate the 30 minute visit.

Allan Besselink said...

Terry, I would have to disagree with your opening statement. Case in point: many palpation-based systems. Just because you have a means of classifying patients does not mean that you will have better outcomes - especially if the classification algorithm does not have any reliability or, worse yet, validity. The system does in fact matter because the clinical reasoning process varies significantly - oftentimes pitting "hypothetical concepts" against "cause and effect relationships".

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