herniated discs

[Luke Rickards]

What was her reaction at the end of the 25 minutes?

She was flabbergasted.

I also suspect that the musculo-skeletal aficionados would say that 'gapping' on the left 'relocated' the NP.

Why would they say this? Wouldn't right sidebending push the NP further toward the left side nerve roots?

[nari]

You're probably right. I find the whole principle behind McKenzie somewhat confused, which means I get confused too. maybe the gapping bit refers only to facet joints.....

Nari

[aléa]

Luke, your experience is very interesting, i've never heard of something like that before. How does it work ?

But opposing techniques is somewhat sterile. I can tell very spectacular stories of sciatics being succesfully treated with Mc K., but would it be interesting ? The point is that you've got to be able to switch from one technique to another if needed.

As a therapist, i can use some "touch" techniques, and manipulations too, working on visceras, light approach or deep massage, following what the tissues want. And repetitive movements too

Mc K is rather simple to employ, and who cares of the principles if our patients react accordingly to the theory ? Basically, it is a VERY PRAGMATIC approach, that's why i was seduced, then, of course, you get the results. Mc K is like : try a movement, see if it works, if not, try another. It's a great tool. But, like every method, it's just a tool, not a recipe.

[Luke Rickards]

The point is that you've got to be able to switch from one technique to another if needed.

I don't think everyone would agree with this.

[emad]

Luke:

You wrote :

side of the frontal bone with one hand and the occipital bone with

What are those the frontal and occiptal bones you meant ?

Emad

[nari]

Alea,

How do you know what the tissues want? Sorry if I misunderstood your English expression.

Sure, McKenzie's techniques can be effective; but it usually requires a commitment from the patient and good motivation. That is not always the case with LBP patients.
From my point of view, having many different techniques available can be a problem. Physiotherapy has a vast collection of methods and techniques and I am sure some physios can use them all to some effect. But for many, it makes life complicated; and rather daunting. I don't think that is necessary.

Nari

[Luke Rickards]

Emad,

These are bones that are part of the head.

[aléa]

Nari : When i say want, i refer to the sensation you have, not always, with your hands, and it's like the tissue does "ask" you to stay superficial or go deeper. I'm talking of very "thin" sensation, it is very difficult to describe.

To have different techniques is an asset, but too much techniques is a disadvantage, i agree with you. I don't have a lot of techniques, but my 2-3 different approaches do really help me.

[Barrett Dorko]

Luke's method seems to me to be a direct result of his reasoning, which is evolutionary or ultimate as opposed to proximal. See "Asking Why - Evolutionary Reasoning and Manual Care" on my site.

There I write about Gifford's brilliant take on the very problem we've been discussing: "Gifford goes on to describe the classic “lateral shift” often seen associated with lumbar and lower quarter pain. In such a case the shifting of the torso away from the symptomatic side and the loss of lumbar lordosis has been described as a response to intervertebral disc migration, specifically the “unloading” of the side containing the bulge. This is proximal reasoning. Evolutionary reasoning would consider whether the observed behavior was useful or not, and if useful, in what way toward which tissue. The proximal reasoning regarding lateral shifting ignores the fact that this posture does nothing to help the disc (See Does plate fixation prevent disc degeneration after a lateral annulus tear? Moore et al Spine 19(24) 2787-2790). Since immobility doesn’t help the disc, it doesn’t follow that a tear in the disc would lead to this behavior. If the immobility we see upon examination is instinctive and thus deemed defensive, efforts to extinguish it with manual coercion or instruction must be considered unreasonable."

I would agree as well that the the willingness to switch from one technique to another, especially when these techniques are derived from opposing premises of dysfunction, is not something that, to me, identifies a therapist as thoughtful, effective though it may be. My handling varies from moment to moment, but when examined carefully you'll see that I just come up with different ways to do the same thing. That is, nothing.

I wanted to add this: To say "What do the tissues want? might be more reasonably put: In what direction is the patient leading you?

[Diane]

Wow. Great thread. I think I recognize the style of handling.
alea, the only "technique" part of it, is just to rest fingers against the patient's head. That's the only physical contact.
The patient who was standing, got herself (or rather, her motor center got her) out of pain, through nonconscious movement. (I can just see those basal ganglia lighting up and fizzing.. those paraspinals and other deep rigging creaking and groaning back to life as she blew the wind back into her sails..)
Brilliant isn't it? The collection of "techniques" can get awfully neglected once this kind of handling/therapeutic contact starts to makes sense.

[Nick]

It will be interesting to see how Luke's patient reacts when her CT scan shows a herniated disc ! Or shows nothing abnormal at all. Such possibilities, of course, point to the irrelevance of structure as the cause of pain. Luke's "question" was, by far, the most appropriate treatment choice. Asking the patient, rather than imposing the a particular movement. In one sense McKenzie (and why has this mode of treatment not moved beyond the name of its "founder"?), seeks a similar answer to the question of preferred movement. The difference is it dialogues with the client's conscious mind and Simple Contact with non-conscious (BTW Alea, this method of handling and the reasoning behind it, which most here would argue is the more important part, has been described at length here and other sites) responses. Since muscular responses to pain are involuntary, it makes more sense to address the person in this way and let the purpose of this muscle tension be expressed.


Alea,

Opposing techniques may indeed be sterile and boring, but opposing theories is certainly not. Patients reacting according to the prediction of a particular theory, does not confirm the correctness of such a theory. For all its pragmatism, McKenzie has been used widely for a long time and has had little impact on the problem of persistent pain. IMO, it has planted the disc meme firmly in the minds of far too many patients and therapists and that is very unfortunate.

To be fair, McKenzie did help make the connection between pain and movement more explicit. However, it is time to move beyond the eureka of someone's pain being relieved by lying prone or propping on their elbows. This is so terribly simplistic and ignorant of painful processes that it has become embarassing for our profession. Try a little neurobiology.

Nick

[aléa]

Diane:I had understood what the "technique" was, i just wanted to know what was the explanation.

Nari : Yes, McK requires commitment from the patient, and for LBP patients commitment is often a problem. But it teached them how tey can "heal" by themseleves, thus avoiding the fear of the pain : "i can handle it". In a way, it is a way for independence.

Barrett : the question of tissues and direction : you putted it the way i mean it.

One more time : why do you want to put an approach over another ? Every technique has its weaknesses, and it's strengths, and some patients will respond better to one technique than to the other. There's one solution for one person.

[Nick]

"There's one solution for one person."

True - and it emerges from the person, not the therapist.

[Diane]

Alea said:

One more time : why do you want to put an approach over another ? Every technique has its weaknesses, and it's strengths, and some patients will respond better to one technique than to the other. There's one solution for one person.

Nick said:

- and it emerges from the person, not the therapist.

The point is, there's no technique in the way Luke handled that patient. Nick's comment is about what makes the difference - we can sweat a lot less over our patients' pain problems by trusting their own nervous systems to make the necessary changes, through nonconscious movement, with just a little tiny bit of skin contact.

[emad]

Diane ;

Where was the contact ?! Just surprise ,was handling the patient,s head ,however the patient,s problem is at her lumbar region .Well,you will say the touch /contact was to the nervous system which is one entity regardless of the site of applying that ,for me applying that contact through head is not touch which we usually consider feedback !

Regards
Emad

[Diane]

No. But it (contact to head) is input. Given that the nervous system is fractal, with emergent properties, and is able to organize chaos, it was apparently enough to help it come out right side up in Luke's example. More than that or in a different place might have been overkill.

[emad]

Diane :

Thanks for that Vocublary fractal :

It was new word for me ,seems it is very experssive ,its meaning is ;

any of various extremely irregular curves or shapes for which any suitably chosen part is similar in shape to a given larger or smaller part when magnified or reduced to the same size

Emad

[BB]

Wow, what a great thread guys!

I am a young therapist, relatively green to the field. Most techniques and their teachers apply a bit of enthusiasm and pragmatism that tends to foster a "this is it! This is the one for me!" attitude, and I think that us young ones tend to be particularly susceptible to this type of thinking. What ends up happening though, is you go to the next class, where they claim again "This is it!" then "OK, well maybe THIS is the one for me!?" The trouble with pragmatism and techniques philosophies is that many often feel they have to throw out one if they want to use another, or collect of bag of tricks to run through until you find the "right one for that particular patient."

As I said I am young, but through past experiences I was lucky to also be carrying a distrust of pragmatism. As a result I have spent a considerable amount of time attempting to assimilate and integrate the various things I have learned, and it has been great fun. It is fun because when placed into contexts of "frameworks" versus technique collecting, things start making sense when compared against eachother. For example, you could look at Shacklocks categories and methodically place other "techniques" within that framework. Instead of fun, I think that the technique collector can quickly become frustrated, disillusioned, and exhausted with the collecting business.

My experience has been, in such a framework you begin to see similarities between certain techniques, and then begin to see that some working on certain premises make more sense than others. This makes some less useful. But, their role in figuring this out still made them a valuable, although now maybe useless, part in the process.

Again, as I said I am young and obviously have a LOT to learn, but I must say that in my current framework, I place mind processes and their physiological consequenses at the top, most broad position. So, to finally get to my answer of a question posted.....When working with my patients, my thoughts are revolving around what is currently a threat to them and why? Maybe the movement of flexion is a threat and extension is not. Why is that? Then I'll zoom in a bit and see how this is manifest in thier various bits. Them I'll start in by trying to bring about broad physiologic change (parasympathetic response) and then go from there (still having trouble with ideomotion, but I'm getting closer)

Thanks
Cory

[Nick]

Great post, Cory. Experience is no replacement for understanding. Learning about pain mechanisms, rather than wiggling bones or unwinding fascia or putting everything in neat and predictable categories or whatever may be the flavor of the month, will hopefully save you (and your patients) lots of frustration and keep it all "great fun."

Nick

[nari]

A phrase keeps roaming through my mind:

Hunters and Gatherers...

Gatherers collect what is visibly there, available for use according to needs or wants. They learn where the best places are to go and gather; they might modify it somewhat and then use it. Down the track they might find something else which is better; until they have a bit of a recipe book in their heads. What they gather can be nutritious and useful, or stodgy and unsuitable for long term needs. All these gathering tricks are passed down for others to use.

Hunters go out and search for what is not visible until they come upon it and recognise it for what it is. But during the process, they find out a lot about the environment and its nuances. Not much is visible; they have to understand the process of hunting.

Most PTs are gatherers. We do need more persistent and aware hunters.

Nari

[Luke Rickards]

my thoughts are revolving around what is currently a threat to them and why? Maybe the movement of flexion is a threat and extension is not.

Having worked with SC for a while now I have developed some doubts over the idea that a particular movement is ever, in itself, a threat. To many times I have seen people move immediately in a direction that they feared 10 seconds before. Contrary to the McKenzies, etc, I don't think the threat is the direction of movement. It seems more likely that threat emerges from the way in which the movement proceeds.

Luke

[nari]

Luke

Why wouldn't the conscious thought of moving into flexion, for example, be a perceived threat because it hurt before many times? With ideomotion, there is no consciously-derived concept of harm in a movement.

I have seen patients who, after pain education, and only that, move comfortably into a previously strictly avoided movement. So you may be right in saying that the threat may not have much to do with the direction of movement. Perhaps McKenzie aficionados can see only the NP moving around when the patient performs passive extension, and so tie that notion up with restricting certain movements. After all, McKenzie developed the technique nearly 20 years ago, when little was understood about pain.....

Nari

[Luke Rickards]

Why wouldn't the conscious thought of moving into flexion, for example, be a perceived threat because it hurt before many times? With ideomotion, there is no consciously-derived concept of harm in a movement.

Nari, that is precisely what I was referring to.

[nari]

OK, that's cool. Sometimes we talk different dialects!

Nari

[Barrett Dorko]

I think both of you are on to something that often confuses my students. I point out while treating people in front of the class that heretofore fear-filled and painful movements are very suddenly rendered neither when the nonconsciously generated ideomotion is permitted to perform them. This is common and often accompanied by range the patient hasn't achieved in years - all without any externally applied force. I say, "This is the reason I stopped manipulating 25 years ago."

The faces of those watching reveal a lot, I think. There's incredulity, amazement, sometimes excitement. I've seen people suddenly overwhelmed and simply shut down. I assume that this threatens their previously held beliefs to such an extent that they dare not accept it. In them, the "meme battle" within their heads is rapidly won by the traditional thinking that drives their practice. In others the battle is just beginning and confusion reigns.

It's my job to give this new meme some weapons.

[nari]

Barrett

I suspect it may have something to do with a lack of awareness of what the nonconscious actually is. I don't think its existence gels with what traditional PTs know. Maybe to them it smacks of hypnosis, Bowen's therapy and unconsciousness.....not sure, but the concept could be construed as "alternative"..

Just a thought, from my own experience recently when I tried unsuccessfully to inform a group of 8 PTs about SC......


Nari

[Diane]

As Xena, warrior PT would say,
Battle on Barrett.

[Barrett Dorko]

Originally Posted by nari

I suspect it may have something to do with a lack of awareness of what the nonconscious actually is. I don't think its existence gels with what traditional PTs know.
Nari

Typically PTs have no clear sense of consciousness to speak of. Balckmore's Consciousness - An Introduction should be read by everybody. They should be aware however that in the first few pages she says that "...a great deal of this book is aimed at increasing your perplexity rather than reducing it" and "...Warning - studying consciousness will change your life."

[rolf-inge nodberg]

Originally Posted by Luke Rickards

This thread came to mind while I was treating a patient this morning.

38 year old woman presenting with severe acute LBP, localised to the left LS region and referring to the lateral left foot. Onset 3 weeks ago for no apparent reason. Otherwise well. No response to exercise therapy or manipulation. Decreased sensation in the S1 distribution and decreased S1 reflex. She was antalgic and pain restricted mvt at 25' flexion, 5' ext, and 10' left lat flexion. I didn't do SLR or Slump (because I generally don't).

I asked her to stand comfortably with the feet abducted and externally rotated. With my thumb and first two fingers I then lightly touched each side of the frontal bone with one hand and the occipital bone with the other. In 5 seconds she started to move into right lumbar lateral flexion and circled into flexion, and avoiding left lateral flexion, back to neutral again. This continued, though somewhat painfully for the first few minutes, in increasing amplitudes until after 20 mins she was touching her hands on the floor and lateral flexion was full in both directions. When we finished (25 mins) she had full painless ROM and normal sensation in the foot. She is getting a CT this week, and I'll be very interested to see what it shows.

Since September last year I have found this to be a very typical experience when treating 'herniated discs'. I wonder what repetitive extension would have done for this woman.

Luke

[rolf-inge nodberg]

Hi Luke!
How do you explain this SC aproach and why did you touch these areas!

RIN

[nari]

Perhaps a lot of PTs are just scared by the concept of 'dealing with the brain' in everyday work, which is why so few of them seem attracted to neurorehab.

I recall one good PT saying: "I love orthopaedics, because the patients usually get better". Predictability rules again, but only on visible structures.


Nari

[Luke Rickards]

Rin,

There is hundreds of pages of explanation here - http://www.barrettdorko.com/desk.htm

Luke

[Randy Dixon]

I'm ordering a book from the library called "Seeing Red" by Nicholas Humphrey. It is about consciousness, how it developed and what is it good for.

http://www.lse.ac.uk/collections/pre.../SeeingRed.htm

[nari]

Randy

Nicholas Humphrey is always worth a read. I have read his precis of the book and it is very worthwhile. Are you familiar with The Edge? He writes there sometimes.

http://www.edge.org


Nari

[Jon Newman]

I typically enjoy Humprhey's work. Randy, pick out a few interesting points and post them here if you would. I'd enjoy that. Nari's link is excellent. I enjoyed the current essay that's up. For a site specific to Humphrey try this.

The Humphrey Papers

Randy, you'll note he as a "post script" to his book available to read at the above link.

Thanks to Ian for pointing me toward Humphrey's work.

[Luke Rickards]

Spine
Volume 31, Issue 9 , April 20, 2006, Pages E254-E262
ISSN: 1528-1159

The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach


Abstract

STUDY DESIGN AND OBJECTIVES: Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP). SUMMARY OF BACKGROUND DATA: The McKenzie method is a popular classification-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials. METHODS: MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie. RESULTS: Eleven trials of mostly high quality were included. McKenzie reduced pain(weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passivetherapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis. CONCLUSIONS: There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.

[emad]

Luk:

Thanks for bringing that abstract here.

Emad

[nari]

Good to know that McK's techniques really do not work for chronic LBP; and especially the classification uncertainty.

Then again, what 'technique' actually works for chronic LBP? I don't think any specific biomechanical technique that has been studied significantly changes the pain perception.
This reminds me of an exchange I had with the McK Institute, whom I contacted via email about 4 years ago re this exact topic - chronic LBP. The reply was catastrophic, full of !!!!! and quite abusive. Somehow they thought I was doubting their work.
I was not impressed by the attitude and haven't changed my mind since.

Nari

[Luke Rickards]

An update on my patient.

The CT came back and showed a large lateral disc protusion with effusion ascending the IVF and moderate compression of the L5 nerve root.

I have now treated her four times. Since the third treatment she has maintained near full, painless ROM in every direction except extension, which is currently at about 15'. She experiences no pain except in this movement or prolonged flexion. There is still some motor and sensory loss at the foot, though it is not constant and appears to be improving.

Luke

[Barrett Dorko]

Luke,

As you might know by now this isn't an especially uncommon response to ideomotion and some home exercise. As yet, I make no claims beyond saying that and I am willing to admit I might be entirely wrong.

But from this single case might we conclude that the very real concerns that many have about connective tissue disruption - obviously present here - are not as grim as we've been led to believe?

In retrospect, was there something in this patient's story or your findings that made you think that simply allowing ideomotion would be the best approach until proven otherwise?

Is it fair at this point to say that it was purely an abnormal neurodynamic that accounted for her pain and disability?

Would any sort of connective tissue coercion (traction, manipulation, heavy pressure etc) have made a difference here?