McKenzie Method vs. SFMA

Some time ago, I got a message from a clinician about Dr. Craig Liebenson’s video below.  More recently Craig and I chatted, not only specifically about this video’s intervention, but The McKenzie Method as a whole.  Keep in mind Craig is the first chiropractor to ever be a part of McKenzie’s US Board of Directors, and Robin McKenzie’s influence on his work is premiere and wide.
I’m also fairly confident in the McKenzie Method as I have studied with Wayne Rath for 4 of his 5 courses as well as working with/observing 5 MDT (1 Diplomat) @ CentraState in NJ, which is a “certified” McKenzie facility.

http://www.youtube.com/watch?v=b5ogPd9wino

[From the clinician]…………My question for you gents is, using the SFMA approach that lady would have touched her toes for one rep and been non-painful however MSE would have been painful. So that would have changed the treatment approach from the SFMA standpoint, no (because Craig had her doing exercises/activities into extension, the painful ROM)? I know there are multiple ways to treat the same issues and multiple ways to get the same information, but would you guys have done something different just by seeing her do the toe touch and the extension pattern?

Excellent question, but this is an excellent example of folks trying to make a method (McKenzie) into a system rather than use a systematic approach, and then allow the methods to present themselves as needed.
Starting off, rarely is the subjective of enormous value to me in working with a painful patient.  I am still quite consistent with what I wrote back in this article, Subjective Subjective.  Some folks got quite upset with that article suggesting I don’t care about my patients, they know they’re body better than anybody, blah, blah, blah, but when it comes to back pain, the subjective is actually very useful in terms of what provokes or relieves the symptoms.   Also, where the symptoms are located can be very telling.  If you ask the person do they prefer lying on back vs. stomach, lying vs. sitting, sitting vs. standing, standing vs. walking, walking fast vs. walking slow, walking or exercising, how they exercise, you can pretty much determine at some level if there is a flexion or extension bias.
Of course I’m always amused when folks have been told they have sciatica, and the pain goes down the front of their leg.  Wouldn’t that be Femoraltica?I’ve also mentioned before and notably on an interview with Phil Snell, there are few folks that have a flexion bias beyond immediate relief of spasm, at least according my over 15 years as a clinician.
The whole spinal stenosis = Williams Flexion exercises is really a myth as I’ve seen it.
Stretching out some spasm may be very useful in the short-term, but the symptoms always come back, and nothing is solved in the big picture.
Hey, if you need to do it to get out of bed, go ahead, but please don’t work with a PT or Chiro that has you doing this on a regular basis.  In that interview above with Phil, we talked about another of his interviews with Dr. Stuart McGill where that intimated there can be individuals that do require flexion intervention.  Yet, of course, he refused to mention any of these specific cases for what appeared to be the sake of staying neutral and non-committal towards some idiots that published some things about flexion, etc.

 

The McKenzie Method, according to my training from Wayne Rath, Dr. Marc Campolo and Dr. Bill Mahalchick , begins with repeated motions after the initial range and pattern inspection.  The goal of repeated motions is confirm or deny the pain site as discogenic, range of motion dysfunction, or postural.  The assumption to be played against the repeated motions profile is that any pain anywhere in a dermatome could be tracked back to a disc derangement at the level of that dermatome.

These repeated motions are Repeated Flexion in Standing (RFIS-repeated toe touch), Repeated Extension In Standing (REIS-repeated backward bend), RFIL (repeated double knee to chest), REIL (pressups). The verbage to bucket the result of the repetitions are such no change, no better, no worse, worsened, improved, abolished, centralized, or peripheralized. You can at times do as many repeated toe touches as you want to confirm or deny flexion tolerance.  I’ve seen many McKenzie clinicians do more or less when they “just know” based on experience.

There is also a very big difference between pain during movement (PDM) or ERP (end range pain).
Going back to Craig’s video, this is significant here because the extension was only ERP. ERP suggests end range dysfunction, not a disc, so the other symptoms someone identifies the use of an extension bias without full confirming worsened sx with repeated flexion.
The red herring that he mentioned is that this individual’s subjective is actually inconsistent with her McKenzie Method repeated motions profile.  The person’s subjective wreaks of posterior derangement of varying levels, but she had no pain in flexion and did have ERP in extension.  This is the opposite of the typical flexion bias profile.

[youtube_sc url=”http://www.youtube.com/watch?v=2DopGxUAoAY”]

It’s also significant that Craig points out the lunacy of hamstring stretching because 1) hamstrings rarely if ever require passive stretching or better put passive cranking, and 2) most people assume the position with lumbar flexion in the first place.  Hamstrings seem to gain length as a fake out when the pelvis posteriorly rotates and the spine rounds.  And of course this leads to more posterior disc.

SFMA

This is Standard Operating Procedure.
What you do afterwards is your business.

In this case with the lady on the video, the more complete and appropriate SFMA model would have not ignored, but temporarily bypassed the discogenic assumption and progressed through restoring flexion, as long as it continued to be pain-free. It is a much cleaner and quicker process than the McKenzie Method, and it allows for more logical inputs to solve the flexion intolerance from the subjective.
Breaking out the lumbar spine also would have revealed that the issue was either in the hips or t-spine since REIL was not painful.  Motor control is the target, not the disc, as REIS was painful, and REIL was not.  This is still lumbar extension of the same spine in the same pattern.  This inconsistency typical yields to a motor control fix, which may or may not include repeated motions directed at the disc.
Potentially, the same anterior hip mobility limitation is what dumped the lady forward into relative flexion all the time, which just the same is fostered by the stupidity of long slow and plodding running as we see in endurance running like marathons.
The running is nothing more than falling that pushes the mechanical limitations just described but also puts threat into the ANS and sets off the facilitation and inhibition of the upper- and lower-crossed.
The McKenzie Method simply adjudicates the discogenic pain. It does little else, and to be fair, nor do I believe it professes to do little else.

The excellent principles in the video are excellent and correct.  But most ideally, they are used underneath the standard procedures of the SFMA.  I will repeated motions to treat the painful spine, but honestly, but  training the non-painful patterns would also be very useful and yield a very fast outcome.

The problem with the McKenzie Method is if a bias is established and quickly improves symptoms, there is not a full body mechanism to determine if regional interdependence from a pattern level was really the root-cause.
That does not undermine the value of repeated motions as a treatment. It simply exposes it as something incomplete.
So the 2-4 visit outcome studies that make the McKenzie practitioner look like a stud don’t always include the fact that the patient goes to a different PT office in a month when their back pain returns.  And it returns not because McKenzie didn’t work for their back.  It fails them at diagnosing and treating what led their back to become unstable.

Even if you are going to measure Ankle DF with a bubble goniometer, can you please make sure they don’t pronate in the foot.
4″ = ~30 degrees DF = what you need to get out of the blocks as a sprinter

So back to the reader’s question, I do hope this lady in the video doesn’t have an ankle dorsiflexion limitation and goes back to running  What would she do then?
I mean every McKenzie Method Cert MDT knows you can’t perform Repeated Extension In Standing without adequate dorsiflexion, right?

How’s her ankle mobility while she does these McKenzie mobilizations?

  • August 30, 2012

Leave a Reply 64 comments

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Charlie,

I am more familiar with Craig’s work than Wayne’s. I’m sure they have both been challenged time and time again. An educator should be able to accept constructive criticism and questioning, and either defend or modify the point they are trying to make based on the evidence they have and the evidence shown to them. As Allan said, there needs to be evidence, not anecdotes and reference to superior levels of education.

As for my treatment approach, yes, I choose to use MDT first as this has the best evidence I have seen to support it. Most of my pts (>95%) complain of pain primarily. As a collegue of mine states, “When pain is the primary compaint, pain reduction should be the primary goal.” I don’t think I have ever had a pt c/o of their regional interdependence. Again, not to say that SFMA is not appropriate, just that I don’t know how the SFMA leads me to know when to use MDT or some other “method.”

As you said earlier, I am emotionally attached, but I understand there are different approaches to treatment. You appear to have emotional attachment to the SFMA. Don’t let this blind you to the discussion at hand, and I challenge you to maintain the “open-mindedness” that you have requested of other posters. Again, these are not personal attacks at you, but emotional attachment can lead you to think this.

Charlie Reply

1. Actually, my emotional connection is to winning and providing the very best I can to the individuals I train.

2. Individuals that are compelled to keep saying they are not attacking someone………….are attacking someone.

3. Why do you people read my site?

Charlie Reply

Guys – Thank you for all of your contributions to my site.
I will get to answering your concerns as I can.

It’s disappointing that unfortunately some of you do not respect my views, but if you would like to learn more of what I represent, I have courses all over the country, and you can check out my DVD.

Please follow Nick’s lead with productive dissenting comments.

Charlie Reply

Christie – I wrote an article on a free website. You didn’t have to read it, nor did I have to respond to anything you wrote.
If you would handle your blog differently, then that’s fine.

Just like in treating patients, we all have a different standard.
And it’s quite ironic that it’s only the MDT folks that have issue with my understanding of MDT. Others that are respectful enough to not post on here are quite confident that I know exactly what I’m talking about.

I will continue to delete responses that are not productive to the many readers.
This isn’t some open, free forum. It does say my name at the top of the site.

I tried to teach you about systems and methods. I have failed.
Now perhaps I can teach you how to take the high road.
But you can still always go back and reread this article and the many others I have authored.
When the student is ready, the teacher will appear. I guess that’s not today.

Kyle Balzer Reply

Wow, reading that was way more entertaining than the facebook feeds.

A few comments that are mostly unorganized and random so I’ll post in bullet fashion:

1. There should have been a pre-requisite to have read Gray’s movement book before responding to this article.
2. The SFMA is a checklist used to classify movements into 1 of 4 categories: functional and painfree, functional and painful, dysfunctional and painfree, dysfunctional and painful. I don’t know much about McKenzie but it sounds like it doesn’t utilize all 4 of those categories, so something is being left on a table.
3. I find it amusing that someone with the following “initials”…PT,DPT, OCS, Dip. MDT…doesn’t know what the SFMA is. You’re not a lifelong learner…
4. Did the idiot who took Peterson as one of the top two picks draft in the middle of last season?
5. Charlie, thanks.

Kyle

Charlie Reply

Okay, you win.
No one ever said this was a discussion.
And I don’t discuss issues with watermelons.

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Kyle, thanks for the input. I’ll start with the important stuff. I understimated the emotional connection of a Vikings fan in my league to Peterson. I was actually eyeing Rogers with the 3rd pick.

As this blog post was a comparison, it would have been useful to have read both the texts that were being compared: Gray Cook’s Movement as well as Robin McKenzie’s Mechanical Diagnosis and Therapy. We could all read these texts, then rediscuss. FYI, it took my just over 6 months of dedicated reading to complete the 5 volumes of McKenze’s MDT. AND, since we are comparing schwartz lengths, to apply for Cert MDT, it requires 120+ hrs of coursework followed by a rigorous 1 day written and practical examination. The Dip MDT is a didactic cirriculum including intense online/distance learning coursework followed by a 9 week residency, then a 2 day written, practical, and oral examination. Hardly something to schoff at. These are the acknowledged paths towards these distinctions by the McKenzie Institute USA (MIUSA), the US branch of McKenzie Institute International. While I understand that Wayne Rath was at one time MIUSA faculty, he is no longer listed on their website and appears to have his own current method of teaching. While I don’t doubt that he teaches MDT in some fasion, it is not recognized by MIUSA and cannot therefore be said to be the same. Not better or worse, but different.

Can you further explain how Christie’s credentials should have included knowledge of the SFMA? She has expressed a desire to learn more about SFMA, as has everyone affiliated with MDT who has posted here.

Charlie, if this is not supposed to be open for discussion, what is the point of making it available for people to comment?

Charlie Reply

Wayne Rath is not the same as MDT. He is better. He is more complete.

You are welcome to comment, but when individuals attack my integrity and my intentions with inaccurate and angry posts, this is not productive to my goals of why I have this Website.
I did not solicit any responses.
There is a difference between honest inquiries and agenda-laden challenges.

You and others have said or intimated that my understand or what I am saying is wrong.
However, I am not wrong. And I have given you my background as to what and why I am saying what I’m saying. You don’t know what I know, yet, I do know enough of what you know to answer a reader’s question that this post was based upon.

Yet, you and others do not respect my point of view. I will not allow this on my site.
I’ve attempted to be flip and childish to reflect difficult roads.

I never named any of you. I did not privately message this to you. It wouldn’t have made a difference to me if you had never read this. I’m disappointed you did read it actually because since you chose to challenge my correct and accurate message. we know have a negative relationship. I prefer to build relationships on common ground. If there is no common ground, discord is all that we can hope for. And guess what? We got it.

You don’t want to learn. You just want confirmation that what you already know is correct. I do know McKenzie, and a lot of people agree that I know it, and I have said nothing inaccurate.
Your thinly veiled suggestion that you want to learn SFMA could have been met by just a 1-line post asking “Where can I learn more about this SFMA?” Instead this is shrouded with 5 other attacks to my knowledge and integrity.

But instead you disrespect me and my site and my readers with your vitriolic cult-like views of an archaic and incomplete method.
I feel bad for you and your patients.

Nick, I will comp you a copy of my DVD or one of my courses so I can help you get away from your current dogmas.
Please private message me if you would like to take me up on this offer.

Guy Reply

Video removed….can it be viewed elsewhere?

Charlie Reply

Check with Craig.

Kory Zimney, PT, DPT Reply

Very interesting debate of ideas, which is always healthy to improve our thinking and challenge ideas to make sure they can withstand the rigor of sound questioning.

Dr. Weingroff, I am confused by your latest response.

“You are welcome to comment, but when individuals attack my integrity and my intentions with inaccurate and angry posts, this is not productive to my goals of why I have this Website.
I did not solicit any responses.”

I read some people questioning your ideas, but not you as an individual. Unfortunately we often hold our ideas very close to our personhood, but they are two distinct and sepereate things. Someone’s personhood should never be disrespected, but their ideas should be challenged. You state that people are welcome to comment, yet you then say you did not solicit any responses. If you don’t want responses, then why do you have a comment section?

I have no vested interest in either SFMA or MDT as I am not trained in either. But I do have a vested interest in PT and gaining a deeper understanding of all the techniques that PTs might use and to see what commalities are present and what differences there are, so we can use those to move the profession forward. It is unfortunate that the discussion was seen as personal attacks and not challenges to ideas and thus came to a halt. I would like to see our profession be able to discuss and challenge ideas openly and not have to always feel as if it is personal.

Anyway thanks for the information, your willingness to publicly display and share your ideas is great and very few in our profession are willing to do this. Just wish we could go one step further and have debates of these ideas and not been as personal attacks.

Charlie Reply

1. I deleted the posts from the folks that were being jerks.

2. I have comments for conversation that I deem as productive to the goals of my website.

3. I appreciate your comments, Kory. You can blame others for your disappointment. I apologize for them.

Tim Reply

Charlie

I just returned from a weekend of lecture from Annie O’Connor from The Rehab Insitute of Chicago. This was the main take away:

Use the McKenzie screening protocol to asses for directional preference (derangement) and use other ranges of motion/muscle strengths/neuro centralization as your indicator (agreeing with your pain/subjective as a lesser measurement)

Postural/Kinetic Chain/other is a different category of problem, BUT it does not discount the others. Will someone with a derangement have a functional/postural issue— yes, almost certainly. What they are trying to prove at RIC is that if you don’t address the directional preference 1st and WITH the movement flaws then you’ll never have your patient back to optimal.

(On a side note, good McKenzie therapists will eventually work into and encourage movement in ALL planes, as symmetrical motion in all planes is what a healthy joint should do. Directional preference issues aka derangement need to be ACTIVELY monitored and altered to improve function in all plantes).

My biggest take home was your functional/postural/movement/kinetic chain issue, no matter what it is, will not be back to functioning as best as possible unless the direction of preference is addressed 1st or at least concurrently. Since implementing these ideas in I’ve already noticed a difference in practice in 2 weeks. My patients are getting better faster.

Phil Reply

And for someone post surgery for scoliosis or scheuermann’s kyphosis how would this method be at all effective? The answer is it’s not. I am well aware of what is causing me pain and working out more is not a solution to the pain caused by severe deformity.

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