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.

1 comment:

  1. Thank you for sharing your knowledge and experience with me.We appreciate your innovative thinking.You're so great

    Physiotherapy in London


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