Monday 11 May 2020

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)
·         Stuart McGill
·         The biopsychosocial approach popularized by Lorimer Moseley, David Butler & Peter O’Sullivan
·         SFMA
·         Tim Gabbett
·         Good ol’ strength & conditioning (S&C)
·         And Robin McKenzie and the McKenzie Method (MDT)

During one of my clinical placements I worked with several strict McKenzie therapists – including Richard Rosedale who teaches many of the courses. Through the placement, and through all of my jobs, I’ve been quite happy with the results I’ve gotten from MDT – however I’d be lying if I said I didn’t need to adjust things along the way. 2 years ago I wrote an article critiquing MDT which would become my 2nd most viewed article. The focus of this article is to showcase how I’ve adapted the method, and my principles, to better suit the needs of my clientele.

Disclaimer: I am writing this assuming that you have a base knowledge of MDT. If you’re not reasonably familiar with the method I recommend you take the time to do a course and/or read the books in order to have a basic understanding of MDT. It’s more than just “chin tucks” or “sloppy pushups” and should be understood for what it is, not the bastardized version.

With that out of the way – here are the modifications I’ve used

1) Test non-painful directions first

The MDT therapists that I worked with in school taught me to test the most painful and/or most restricted movement directions first to see if a directional preference could be found that would improve symptomatic or functional baselines.

However – I found that about 50% of patients would benefit whereas the other 50% would be flared up … even more so for chronic cases.

I got more bang for the buck testing non-painful directions (where applicable) first. Then, if that didn’t produce any effect and didn’t flare up symptoms, I would then proceed to look at other directions of movement or positioning. I found by getting as much out of non-painful movement as possible that patients adhered to exercises better and got better results.

2) (For more irritable clients) Only test 1-3 “symptom modifiers” per session

 This is a tip that I learned on my own and was echoed by Greg Lehman when I took his course in December 2019. Two of the downsides of symptom modification methods (i.e. McGill, MDT, SSMP) is that you can easily flare irritable patients up with a lot of failed symptom modification tests plus a lack of success with them can make the patient less confident in themselves and the therapist – not what you’re looking for from a client retention perspective.

As such – I recommend testing no more than 2 or 3 symptom modifiers, whether that’s different positions and/or repeated movements in a direction, in a session. If it ain’t working it ain’t working. Don’t beat them up physically or psychologically.

3) (For more irritable clients with spinal pain) Test positions first – then work your way up

Even though MDT is predominantly associated with neck & low back pain (even though it can be applied to all joints) I never got what I wanted out of it with respect to spinal pain – particularly with neck pain.

Many people I see with spinal pain in my current job are more chronic & globally sensitized cases that have constant pain that’s aggravated by every position & movement. Many of the chronic, insidious onset neck pain cases tend to follow suit.

For these more irritable cases I usually just test static positions first (i.e. lying/sitting in a more flexed or extended position) to see if that provides some symptomatic relief or functional improvement – and then go from there. I’ve found many do find a position that finds relief but don’t necessarily tolerate repeated spinal movements in any direction.

4) Use it within a comprehensive approach

My second big knock against MDT, other than the ability to potentially flare patients up, is that it could be more comprehensive. What does this mean? Breaking it down by area I like to also look at

·         Psychosocial factors & beliefs: which MDT does and was way ahead of its time on
·         Endurance, strength & control of the affected area & other joints
·         Workload management: this is where Tim Gabbett’s stuff comes in
·         General lifestyle factors like sleep & bodyweight management

Repeated knee flexions may temporarily improve a person’s pain or their ability to do stairs – but if they’re running way more than they have in the past & flaring up their symptoms with it than you may not get far. Your client with discogenic back pain and a directional preference to lumbar extension may not make much progress if their hips & ankles are so stiff that they have to flex their spine excessively anytime they bend over.

If you have a directional preference that’s great – but if any of these other factors are heavily contributing to an individual’s sensitivity then they need to be addressed to allow for optimal recovery.

5) Know when to bail

Sometimes clients don’t have a directional preference to repeated movements or positions and/or it just flares them up everywhere. Sometimes those aren’t right for everyone and then patients have to be shifted to, and treated appropriately, within the “other” categories (refer to the books and courses for more detail on those).

MDT can be a useful part of a comprehensive therapy program – but it does need to be adapted to the individual. I hope this article provides some insight into how I adapt the method. As always – thanks for reading.

Wednesday 29 January 2020

My Experience With A Learning Disability, Anxiety And Depression Part 2: Understanding Mental Health For The Rehab & Fitness Professional

                Two years ago, in honour of Bell Let’s Talk Day, I wrote about the battles I’ve had with a learning disability, anxiety and depression. It was one of my most viewed articles and got shared by many big names and organizations in the rehab & fitness industry. A lot of people messaged me and opened up about their own battles.
                After all that, I misguidedly thought I was in the clear. But two phases in my life, over the past year and a half, had flared up some old issues (although nowhere near to the same extent as they were a few years ago). The first was being too busy and having too much on my plate – which went away when I decided to cut back on a bunch of projects & prioritize my physical health and time with others. It got to a point where I realized that more success didn’t mean more happiness. The second, which I’ll describe in more detail here, in honour of Bell Let’s Talk Day, is learning how to manage the stresses of working with a primarily “persistent-pain” population.

In my current job at least 90% of the people I deal with are people with persistent pain and/or post-concussive symptoms secondary to workplace injuries. The vast majority of these people have been to therapy elsewhere and made no (or very little) symptomatic or functional progress. It’s well established in the literature that work-related injuries, all things being equal, have worse outcomes than non-work related injuries. The reasons and hypotheses why are another story for another time – but needless to say I don’t work with the traditional “private practice” population.

The staff I work with, and the management I work under, are wonderful. That said – working with a complex population can wear on you from time to time. Admittedly I hesitated about posting this piece, but after hearing other stories of practitioners struggling with their own confidence & mental health – it needed to be shared.

At the end of the day – we are able to help the vast majority of my clients function and feel better than they did when therapy started … and I’ve had many people tell me that I’ve been able to do more for them and help them get much further along than previous providers did.

Side note: I don’t want to sound arrogant or get on a high horse – but the rehab education system needs to really educate providers more on proper care for people with persistent pain. This is something that, in my experience, gets neglected in a lot of schools which leads to problems. While I see a lot of people who have been mis-managed by previous community providers, heck I wouldn’t have known what to do with this demographic had I not done a ton of independent reading/coursework + gotten a lot of advice from coworkers.

Back on track – while I think I did “ok” there were times where I felt like I couldn’t get any patients better or accomplish anything if my life depended on it. And to be honest – I came damn near quitting on more than one occasion. The sad thing is I know I’m not the only who felt this way.

Towards that end I realized I needed to get some more help. Here are some of the strategies I’ve used to help with managing people with persistent pain…..

1) Understand that you’re not probably gonna be Superman.

If you’ve read any of my old articles (and if you have, thank you) you’re probably someone who values your work very highly and wants to go beyond the traditional “physio” status. You take a lot of provide in your work and you want to be great. That’s the mindset I had and still have. We want spectacular outcomes that are well above that and our colleagues … and our self pressure, combined with that of social media, makes us feel bad (and sometimes demoralized) when we don’t get there.

In the process of dealing with my own stuff I had to think “why did I think this way.” Part of it was the pressure of being surrounded by amazing people both in my job and in my network, and the bigger part was the desire to “pay it back” and make my successes worth the time others put into me. I know other professionals who feel a great deal of pressure to perform.

The problem with a strictly “outcome based” measure of success is that there are so many factors that go into a patient’s recovery, or lack thereof. Below is a table which barely just scratches the surface…

Injury-related factors
Patient factors
·         Type of injury
·         Severity of tissue trauma
·         Context of injury (i.e. traumatic vs non-traumatic, work vs sport related)
·         Management of injuries in acute, sub-acute and chronic phases
·         Prior fitness levels
·         Medical comorbidities (i.e. diabetes, smoking)
·         Previous injuries
·         Personality & motivation levels
·         Beliefs
·         Preferences
·         Lifestyle (i.e. diet, sleep, relationships)
Workplace factors
Psychosocial factors
·         Whether or not
o   Work is enjoyable
o   Work is considered safe
·         Demands of work
·         Positivity or negativity of interactions with coworkers (both prior to and subsequent to the injury)

·         Prior psychiatric history
·         Psychosocial factors arising from injury (i.e. PTSD)
·         Pain behaviours and beliefs,
·         Poor or excessive social support
·         Cultural beliefs about pain and activity and work
·         Family lifestyle

With all those factors going on – it makes you realize how complicated it is. When I look at many of the patients that I’ve struggled with – the main reasons are (starting with the most common) psychosocial, workplace related, medical comorbidities, and poor pacing strategies. And these all interrelate and don’t exist in a vacuum. For instance poor pacing may be related to psychosocial barriers.

These can also be tough things to change. To steal one of the quotes from Difficult Conversations “it’s not my responsibility to make things better; it’s my responsibility to do my best.” One of the best things I ever did in my career was let go of the desire to be “superman.”

2) Learn to manage the difficult conversations

The biggest thing I struggled with in this job, which was probably in part due to having Asperger’s which already makes communication difficult, is learning to have difficult conversations with clients pertaining to
·         Communicating realistic outcomes/prognoses
·         Setting realistic goals
·         And trying to motivate/navigate cases who
o   Don’t want to do therapy or aren’t buying in
o   Are using therapy as a means of secondary gain
o   Are fearful of going into any kind of pain or causing more damage
o   Don’t want to go to work … or are afraid of going to work
o   Get in “boom or bust” cycles where they overdo it, flare themselves up, rest, feel better, overdo it and repeat…

It’s tough as communication isn’t something we’re taught much in university – so you either have it or you don’t. I’ve found the following books to be helpful
·         Motivational Interviewing In Healthcare
·         Difficult Conversations
·         Crucial Conversations

Also having good psychologists/psychotherapists and occupational therapists is a must for this population.

3) Take time to remember what does go well

 When I was at Know Pain I asked Mike Stewart “how do you deal with this stuff.” He said that one of the strategies he uses is to look at 3 things that go well each day in the clinic. I’ve adopted that practice – and it has certainly helped put things perspective … especially when you have those moments where it seems like no one is getting better.

4) Understand that you will make mistakes and that professionals are also complex

With high performance demands and sometimes challenging clients it can be easy to beat yourself up over past mistakes/failures. Hell – I still struggle with this. With all the new information that comes out each year on exercise, patient communication, pain science, and the like I’ve found myself second-guessing cases all the time and thinking “damn I wish I knew this for the client I saw 2 years ago.”

At the end of the day – I remind myself that I did the best I could with the knowledge, experience, and confidence level that I could to manage the situation that I was in. And if I made a mistake (hell I don’t know if anyone is 100% perfect working in complex healthcare situations) I look back to see what caused it – and come up with a plan to handle the situation differently.

One of the things I learned from Difficult Conversations is that we are complex human beings and that our wishes, desires are all complex as we balance multiple things in our lives and our careers. It also takes acceptance that you will make mistakes. By learning and accepting this, it helped me greatly diminish that “all or nothing” thinking that can be bad for both people with Asperger’s and Type A personalities.

5) Learn to be present

Sometimes it can get easy to caught up in a lot of drama, worrying about the next patient or worrying about the next meeting. I’ve found simple things like mindfulness strategies (deep breathing, focusing on your feet and the environment around you) plus having a to-do-list to offload stuff that needs to be done later – help a lot with keeping me focused on the situation I’m in and not worrying about 20 things.

6) Don’t be afraid to ask for help

In the Fall of 2019 I reached out to my old psychotherapist and got set up with him. It was one of the best decisions I’ve ever made and has helped to give me useful strategies and keep me accountable through this process.

7) Remember to do the simple stuff like getting good sleep, nutrition, exercise, and time with friends/family.

This isn’t, and shouldn’t be, considered a “end-all be all” or fix for managing the stresses of working with a persistent pain population. It’s a tough clinical job … and is not for everyone. Heck – I’m by no means a master at all of these and find myself needing to reset. But – I hope you find these tricks helpful.

Have you found any strategies helpful? If so comment below or message me at As always – thanks for reading.

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) ·  ...