Monday 26 February 2018

4 Ways We Can Make The Rehab Education System Better

Image courtesy of Ambro at

When I was a kid the Star Wars prequel films were coming out. While I’m not as critical of them as many are – they certainly fell short when compared to the originals. I’m glad that the last few Star Wars movies (The Last Jedi, Rogue One, and The Force Awakens) have helped the franchise regain its former pride.
                One of the highlights of the prequels was Ian McDiarmid’s performance as Chancellor and later Emperor Palpatine. Palpatine’s brilliant, cunning and deceptive character stood out to me as the most interesting characters of movies I-VI.
                As someone who’s battled frustrations with the education system of rehab & fitness professionals I’ve asked myself – what would I do if I was made absolute ruler of the education system and could do what I wanted? I’m involved off & on with the University of Waterloo Kinesiology program and the Western University Physiotherapy program and have seen a lot of great change in the education systems (especially the former) but we still have ways to go in improving the education system as a whole.
After reading my colleague Nick Ferrara’s brilliant article earlier this year I’m eager to post some ways we can improve the education system. While it is directed towards PT school the principles can apply to all rehab professions (Kins, PTs, OTs, Chiros, ATCs) and even fitness professionals to some degree.

Side note: I’ve written about many of these topics in detail before (and have links where applicable) or will continue to write about them in more detail in future articles.

A large body of research in the last three decades has shown that pain is not solely linked to injury and can be influenced by various biological, psychological and sociological factors. This is important to understand as many patients can be very fearful of their body & activity as they may think that their pain is due to damage. Health professionals, often well meaning, who think the same can sometimes feed into this cycle with negative language (please read this linked article if you haven’t already) as well as overrestrictive activity modifications which can feed into this negative cycle & promote disability.

Understanding that pain does not always mean damage & can be influenced by various factors can and should help with health professionals making better decisions for people with pain.

2) Educate professionals about real biomechanics – not pseudobiomechanical nonsense

This is a bias for me being friends (either in person or online) with many great biomechanics researchers such as Stuart McGill, Jack Callaghan and Tim Hewett.

Some may disagree – but I still think biomechanical research has huge merit in terms of understanding the loads and muscle activation levels associated with various exercises & movements as well as mechanisms of specific tissue injuries. This can go a long way in preventing injury as well as making smart exercise & movement decisions when rehabilitating from an acute injury.

That said – so much of what’s biomechanically taught in school revolves around many pseudobiomechanical variables such as upper/lower crossed syndrome, upslips/downslips/rotated pelvic bones, and hypermobile/hypomobile spinal segments (to name a few) that either can’t be reliably assessed or don’t correlate well with pain. Towards that end its critical to know when biomechanics is and isn’t important.

3) Teach manual therapy in a way that is simplified & in line with the evidence

I’ve talked to many new therapists who feel their manual therapy skills aren’t up to par with their colleagues as they can’t “detect” certain positioning or mobility defects and they can’t seem to “feel the joint.” As I’ve written about before – many manual therapy variables such as motion and positional palpation aren’t reliable, you can’t isolate a technique to one segment, and different techniques have shown equivalent results in RCTs for the same condition in some studies.

As such – understanding the true neural mechanisms of manual therapy & teaching it in line with the evidence, while robbing a few of the illusion of magic hands, will in my opinion create many more confident therapists moving forward.

4) Push more exercise & less passive treatment

One of the biggest gripes in my PT school experience, as with many I’ve talked to, is the lack of time spent teaching therapists to push forward what is often the most effective intervention for many (not all) musculoskeletal pain conditions – exercise. We cover the same manual therapy technique six times and learn all the ins & outs of an ultrasound machine but we don’t know how to coach, correct, progress, regress, and modify basic movements such as squatting, hip hinging, lunging, pushing, pulling, as well as more “traditional” PT exercises.

Most of my exercise knowledge has came from S&C coaches. While I’m not as knowledgeable as some when it comes to exercise – I realized the level of knowledge most PTs have with exercise when I attended a course in October and ended up being asked to teach a lot of cues and modifications I use with my patients on a day to day basis. What I thought was rudimentary, first line knowledge was something that most therapists apparently don’t know. This needs to change. I’m not saying you need to be a Brian Carroll, Eric Cressey or Chris Duffin of exercise knowledge – but having better knowledge, skills and confidence to recommend more exercise & less passive treatments can’t hurt.

So there’s my list of four ways we can improve the PT (and rehab) education system. 

Tuesday 13 February 2018

An Evidence & Experience Based Critique Of The McKenzie Method (MDT)

Updated February 18, 2018           

            Before we get started I just want to say thank you who read my latest article in honour of #BellLetsTalk day and to those who opened up about their own personal stories. Mental health is a big issue worldwide and is an issue amongst us hard driving, Type A rehab & fitness professionals. It needs to be talked about more.

Back in the Spring of 2015 I did a physiotherapy placement at University Hospital in London, Ontario, Canada. There I met some fantastic therapists who taught me a lot about using the McKenzie Method aka Mechanical Diagnosis & Therapy (MDT) to treat both spinal & extremity problems. I’m very grateful for the experience as I’ve found repeated movement testing & exercising to be a useful tool to guide my exercise prescription in rehab. That said – every method of therapy has its limitations which I will address in this article.

Side note: before reading this you should have a thorough understanding of MDT through either taking the courses, working with MDT credentialed therapists and/or reading the books & research papers. I see too many people bastardize the method and say things like “oh my patient did 10 back extensions and didn’t feel better therefore McKenzie didn’t work.”

Side note 2: as with my other articles this will not be a comprehensive lit review just in the interest of keeping it easy to read. If you want I have attached a link to a comprehensive list of all papers on MDT.

The advantages of MDT

1) Simplification of HEP

Through the McKenzie method patients are often only given a very small number of exercises (1-3 on average) to do at home. Given some of the research that claims that up to 70% of patients don’t adhere to an exercise program … it doesn’t seem like a bad idea to give patients a small number of exercises that can, for the most part, be done anywhere and done often.

2) Thorough analysis of what movements, postures and loads are and aren’t tolerated by the patients

Going in hand with the above point … pain worsening with exercise can also be a big barrier to performance of a home exercise program. A reason why I’m a big fan of MDT is that you know which movements & exercises a patient will & won’t tolerate and can build a program around that.

Now there are some cases where a patient may not be able to tolerate anything without some increase in pain which I will elaborate on below.

3) Focus on active care & self management

As my friend Erson Religioso III wrote about one of the great aspects of MDT is it focuses on patient self-management & empowering the patient to control symptoms – something that is well in line with pain science & the biopsychosocial model … and something very underrated in today’s overuse of passive treatments.  

4) People who do have a directional preference tend to respond quite well

Some research in spinal pain and in the knees has shown that people who have a directional preference and perform the corresponding exercises have much better outcomes than people with a directional preference given traditional care.

5) The emphasis on functional testing vs pathoanatomical models

As I’ve written about before so much recent research has shown the discordance between imaging & symptoms. One of the advantages of MDT is it bases classification & treatment based on response to movements, loads, postures & repeated movements as opposed to just saying “oh your MRI shows degenerative disc disease, that’s what’s causing your back pain.”

The limitations of MDT

1) Sometimes repeated movements in every direction make a patient worse

My biggest critique against the McKenzie method is that sometimes (especially with necks) repeated movements (and positioning) in every direction worsen a patients symptoms and the patient doesn’t fit in with a “contractile dysfunction” presentation. When you hang your hat on one treatment method and all it does is worsen a patient’s symptoms that’s problematic and you need to be able to change gears.

Side note: Regardless of whether you’re a strict Maitland/McKenzie/SFMA/whatever therapist … or you’re an eclectic therapist I do believe you have to have a method or philosophy to consolidate all the information you have and know.

In these situations in spinal pain I often fall back on a Stu McGill-esque approach of using more isometric style exercises to help with pain relief and building fitness and later on returning them to full proper spinal movement. For extremities I often just have patients work within a range of motion & rep ranges that they can tolerate & then build up from there.

2) Utility with people with persistent pain

Research on chronic back pain and chronic neck pain has shown that MDT has produced results basically equivalent to a placebo or other general exercises.

The MDT books state that people with persistent pain may be worse with repeated movements in each direction. As I wrote above – people (with both acute & persistent pain) who have a directional preference often have a much better outcome performing those exercises … but people who don’t have a directional preference would get equal results with repeated movements or with any form of exercise. The books state in those situations (classified as ‘chronic’) working into some increase in pain with exercise may be acceptable, something line with a paper that came out last year, but great caution and monitoring of the exercise programs need to take place in order to minimize the chances of increasing central sensitization.  

3) Lack of comprehensiveness

To quote my friend Lars Avemarie

“When we reduce the cause (or solution) of pain to one single event, factor or biomechanical error we are in my opinion doing a disservice to our patients, and we are ourselves committing the fallacy of the single cause (also known as causal oversimplification).”

As I’ve written about before pain is complex and to assume that repeated movements in one direction will cure everyone’s pain is a major disservice.

The MDT books and research papers talk a lot about psychosocial factors in pain which is pretty good considering those books came out in 2003 long before a lot of the pain science information made it into mainstream therapy. But there are components of a comprehensive program that get missed through MDT such as pain science education, managing maladaptive beliefs around pain and managing other factors associated with certain conditions such as poor sleep and being overweight.

A simple way to tweak this is through adding other components to the rehab such as working on the kinetic chain, psychosocial factors & maldaptive beliefs, general health, strength/neuromuscular training, and workload management. Obviously all of these may not be relevant to each individual you work with but I do believe they need to be assessed. A very good paper recently came out in 2018 which summarizes a comprehensive assessment & treatment approach to people with low back pain.

The bottom line, as Stone Cold would say, is that MDT is a useful assessment & treatment model to determine what movements & postures a patient will tolerate and it has a lot of upside to it – but it needs to be looked at within a more comprehensive approach that is the biopsychosocial model.

How I've Adapted The McKenzie Method Over The Years

If someone were to ask me “what are the biggest influences on your therapy philosophy” they would be (in no particular order) ·  ...