The last post (#2 in this series) explained how classification of spinal pain by position or anatomic abnormality has generally failed to yield tangible results when linked to conservative (non-surgical) treatment. Through classifications based on cyclical loading (as well as some other factors) better rates of success have been achieved (both anecdotally and through research trials) in treating spinal pain.
The McKenzie Method
The first widely used syndrome classification system was the McKenzie Method of Mechanical Diagnosis and Treatment which not only advocated the classification of patients based on a combination of pain provocation and gross motion restriction (mechanical testing), but outlined plans of treatment that could be altered based on changes in the patient’s status with treatment.
Treatment usually focused on restoration of motion first, before strengthening – by beginning movement (depending on the results of the examination) in unloaded positions, then progressing to higher level of force in standing (back) or sitting (neck) that increases motion while strengthening the surrounding musculature to stabilize the spine. The recovery plan and timeline were fairly predictable as long as the examination was carried out in a careful manner, observing rules that were laid out in several continuing education courses.
Therapists and chiropractors who attended all of the course offerings and passed a certification test were (are) given a certification in mechanical diagnosis and treatment. A select few go on to complete residency programs entailing months of concentrated study and focused work, and are then awarded a diploma in mechanical diagnosis and treatment. While this system worked well for therapists around the country, until the late 1990s it was not validated with peer-reviewed clinical research studies.
The entire method as such as not been validated, but various parts and aspects of the method have. Clicking on the McKenzie link above will lead you to a list of clinical research studies supporting this method of classification and treatment of spinal pain. Initially there was resistance in the research community to the idea of centralization, but once initial studies were published in peer-reviewed scientific journals, further studies were produced and accepted for publication.
Other Classification Systems
Another method of classification of spinal pain was proposed, and subsequently refined by Dr. Anthony Delitto. Although some aspects of the McKenzie classification system are present (directional preference) this method was developed somewhat independent of the McKenzie method. While the McKenzie method is proprietary (owned by The McKenzie Institute) Delitto’s research is published directly in medical journals and readily available for all clinicians to read and apply.
While the McKenzie method includes specific exercises and hands-on techniques, Delitto’s research is not a technique or method per se. Many clinicians have used both to evaluate patients with spinal pain, and find that most of the time these two methods lead the treating therapist to select similar treatments. Regardless of the specific methods utilized, evaluation and classification by mechanical means (and treatment addressing the findings of the examination) has proven to be beneficial to patients with spinal pain.
Several other methods exist between physical therapists and chiropractors that utilize a combination of patient history, pain provocation, mechanical testing, and positional palpation that can lead to similar treatment prescriptions, and usually emphasize hands-on adjustments or manual therapy, but none are as comprehensive or research validated as the two previously mentioned systems. New research is slowly revealing similar treatment approaches to other joints.
A recent example: Dr. Richard Steadman, of the Steadman-Hawkins Clinic in Vail, Colorado told a sports medicine conference in Dallas that the major pain generator in arthritic (degenerative) knees was not the damaged cartilage surfaces, but tight connective tissues that appeared to result in aberrant/limited motion. His treatment emphasis (surgical and non-surgical) involved similarly classifying loss of motion and aggressive techniques to restore it first, before strength training. He provided several examples with professional athletes that he had treated in the past, as well as anatomical and clinical research to validate his claims. Over the past several years the McKenzie Institute has also added a course of the Mechanical Diagnosis and Treatment of extremity joints as well.
So that’s that! I wish that I had a more concise, “sexier” explanation for you, but this is what we now at this time, and it is not likely to change too much in the near future.