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

Chris Leavy Reply

Excellent…

Brian Kotoka Reply

Great Post Charlie.

Jason Sweas Reply

Charlie – you mention that there are not a lot of patients with a flexion bias. Do you mean the position of a lumbar spine rounded into flexion or flexion motion toward neutral? I find that the majority of my low back pain patients do prefer flexion motion toward neutral (which is what Shirley Sahrmann states in her book). Extension intolerance seems to be way more common than flexion intolerance in my experience – general outpatient orthopedic, more sedentary people than athletes. I find that more people fall into Janda’s lower crossed syndrome with very few having true disc pain. I definitely don’t want these people flexing their spines, but trying to get them flexing closer to neutral is my goal. Are you seeing similar patterns?

Charlie Reply

Jason, I agree 100%.
Flexion bias in terms of an anterior disc is not often.
Flexion as a return to neutral from excessive extension is very viable.

Charlie Reply

Thank you, Brian.

dsomerset@worldhealth.ca Reply

I love seeing the thought process on display of how to work with movement impairments. The separation of standing versus lying extension and the differentiation of motor pattern dysfunction versus disc issue is fantastic. I completely agree that runners with pronation issues that get back treatments will almost always come back with pain again unless the ankle is worked. Fantastic post!!

Barb H Reply

Amen! However, best clinical approach=use BOTH….

Charlie Reply

Agreed on using both.
Use McKenzie when it’s the right thing to fix the SFMA.
McKenzie is an excellent and efficacious painful approach.
As I said, it is incomplete at honoring regional interdependence
That doesn’t make it wrong.
It makes it incomplete.
Dr. Lewit has always told us he who chases pain is lost.

Tim Reply

Thanks Charlie,
It’s always fun to read about how you analyze information.
great post

Christie Dowing, PT,DPT, OCS, Dip. MDT Reply

Dear Charlie,

I find it interesting that someone who promotes a movement based assessment of an individual is so critical of the McKenzie method. However, based on your post, I can see why…as you have many erroneous assumptions about MDT. I don’t take much offense, however, because they are common misconceptions which I will clarify later. Furthermore, some of your arrangements against MDT represent a false dichotomies and non-sequitor errors in reasoning.

First, I cannot comment on the video as it appears it has been removed.

Next, lets discuss some of your conflicting statements:

1. You state that the history is of relatively little value to you. However, you later state that persons who reveal a history of preferring lying or sitting gives clues as if a directional bias exists. So this is important to you, isn’t it?

2. I’m trying to understand why you comment on sciatica versus “femoraligica” and how this relates to MDT. I’d make the same argument. Perhaps you got off track about comparing SFMA and MDT, at least I hope this is the case as I do not see how it supports your argument.

3. I’m not sure why “2-4 visit outcome” studies to which you are referring, but it’s an obvious exaggeration. Even in cases of a “rapidly reducible” derangement, a repeated motion program is only one part of the recovery. Being able to restore movement in all planes is a normal part of recovery of function. Many are critical of MDT because there is not much in the curriculum regarding restoration of function. However, my personal belief that this is because there are so many ways this could be done, and MDT cannot claim any proprietary educational information in this stage. It’s out there being done by many individuals amongst various schools of thought, and just because it’s not part of the official MDT ASSESSMENT, doesn’t mean that it should be excluded as part of a recovery program….SFMA included. Symptomatic reduction is only one stage…but this is where most clinicians struggle in my opinion.

4. OK, so now let’s talk about some errors in your description of MDT.
A. Regarding your claim that one of the goals is to determine if the pain is “discogenic”, dysfunction or posture. It’s first to determine if a pain is under mechanical influence or not (meaning it is affected by movement). Furthermore, “discogenic” is not a classification of the MDT syndromes. Rather, I assume you are referring to “the derangement syndrome”, and while this MIGHT include pain that is discogenic in nature, it could include anything that could cause physical obstruction to, not just the spine, but any joint in the body that moves.
B. Your understanding of REIS versus REIL does not appear complete. In an individual where REIS is painful, but REIL is not may give us some clues as to whether load is an important factor. Is it a “discogenic issue” or a “motor control issue”?…I think an argument could be made for either, but the fact that anomalies like this exist are indicative of need to address that patient’s tolerance for a loaded versus an unloaded condition.
C. Your explanation of ERP versus PDM is also incomplete. ERP is not the differentiating factor of derangement versus dysfunction, as either syndrome can display ERP. While PDM is only present in derangement as compared to dysfunction or posture, this does not define derangement. It’s the rapid reversibility of symptoms and mechanics that defines derangement when compared to dysfunction.

Finally, your crassness and critique of other practitioners is a little harsh, IMO. For an example, regarding the runner who has resolved back issues, you make an erroneous assumption that the MDT provider will automatically send her back to running and discharge her without any further follow up. I’m sure this does happen, but we’ve all seen patients who’ve been to other therapists who “missed” something. It’s always easy to pretend to be the know-it-all genius when some other therapist has already removed several obstacles for you. I’ve seen patients from a number of “motor control” therapists who missed some things I thought were rather obvious, and I’m sure there are some patients I’ve had where I’ve missed something. However, sometimes we don’t always have an accurate picture as to the patients entire clinical profile prior to and after arrival at our clinics. It would certainly be pertinent in the example that if, upon return to running, the patient experienced a recurrence of symptoms for her to have a thorough biomechanical evaluation of running technique and form.

…give us a little credit.

In the end however, I think that many movement based assessment tools can be used and trying to lump MDT into a false dichotomy against SFMA is a little premature. I think we (the collective varieties of movement based assessments) all bring something of value to the table.

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Charlie,

Would you please reference the 2-4 visit outcome studies you are referring to? Thanks!

Charlie Reply

Christie – Sorry you missed the point about systems vs. methods.
I’m sure you know more about McKenzie than me.

Charlie Reply

Nick – This is from Centrastate in NJ, an official McKenzie Certified clinic.
I don’t know that it has ever been published.

Christie Dowing, PT,DPT, OCS, Dip. MDT Reply

Dear Charlie,

If asserting that the McKenzie method is a “method” as opposed to a “system” (all names aside) and that SFMA is a “system.” Then yes, I missed this point.

However, although you mention this in the opening body of your post, the content you have provided does not support your statement (rather, it seems as though it’s a fleeting thought). Rather, the body of your post serves as a critique of the “method” itself (with several critical errors), it’s practitioners and even the techniques themselves. Even the Title of your blogpost fails to give an accurate representation of your alleged “point.” Rather, you’ve put it out there as a “them versus them” argument.

If your “point” was to truly discuss why MDT is a “method” versus a “system,” then yes, I did miss this point. Based on many of the responses noted here, I would venture to say I’m not the only one. Would you care to answer the following questions?

1. Please define for your readers what are the fundamental differences between a “method” and a “system.” (let’s also consider that the definition of method is often described as a system: “a procedure or process for attaining an object: as a (1) : a systematic procedure, technique, or mode of inquiry employed by or proper to a particular discipline or art”–Merriam-Webster)
2. Are you advocating the use of a one versus another (I would assume a system)
3. Can you provide accurate information that would described why MDT is a “method” versus a “system” and vice versa for SFMA?

Finally, I would suggest that if you are going to compare the two methods and critique what they are at their core, that prior to posting on a public forum such as this, that it would require you have a thorough understanding of both; or at the very least, run the information by someone who does and use them as a reference as necessary.

Charlie Reply

Yeah, you missed the point. You’re correct.

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Charlie,

Could you explain the point in a different way? According to thersaurus.com, system and method are synonyms. Sorry, my training and background might make me a little biased, but perhaps a little more explanation of what you’re trying to say would help my misunderstanding.

My limited understanding of the SFMA leads me to believe that it could actually complement MDT in recovery of function, which is the 3rd of 4 phases to the McKenzie Method. I think that putting an acute or sub-acute pt who has a directional preference and is rapidly reducable is unnecessary until you reach this recovery of function phase. The SFMA sounds like it would by useful for pts in the dysfunction subgroup and perhaps postural. Thanks in advance.

Charlie Reply

Nick – No, I can’t.
What you can do is read the article and some of my notes above that speaks highly of the McKenzie Method as something that is a choice after you do the SFMA 1st.

You guys are only upset because you are reading that I am beating up on what you are emotionally connected to.
Seems like other brilliant clinicians such as those that have commented as well understand my message perfectly.

I use the McKenzie Method as I have been instructed by the great Wayne Rath and others.
It is a method.
The SFMA is the systematic operating procedure that allows me to prioritize painful and non-painful dysfunction and which tools I have to best solve the case.
We all have different tools. When we have 1 tool and make a system out of it, we miss things.

Charlie Reply

But you guys can keep posting, as I have received many private messages regarding how amused they are at your angry posts.

This is almost as bad as beating up on Crossfit.

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Charlie,

I am not upset, and I don’t think you are trying to beat up on MDT. I am trying to figure out how I can better integrate SFMA into my practice based on how I already practice. Sorry if you take offense to this, it is not what is intended. As I said, I am probably biased due to my training and backgroud, and I admit that I am emotionally connected to MDT just as there are those emotionally connected to Maitland, Paris, yoga, Crossfit, and SFMA.

Why is it that MDT cannot be considered a system as well as SFMA? MDT uses a systematic approach to tell me when a pt might respond to functional exercise (which I would like to learn more about SFMA to make this more specific) rather than REIL/REIS due to a derangement. Would this not be the same as SFMA telling you when MDT would be more appropriate? Please accept these questions as engaging discussion on the blog post rather than a criticism of your treatment technique. Thanks.

Charlie Reply

Nick, I apologize as I am grouping you with the other angry contributor who has provided more characters in her 2 posts than I have in my article.

McKenzie in its excellence but also its totality reduces pain.
It does not account for the entire contributions to pain, mechanically or neuromuscularly.
That is what differentiates it as a painful method vs. an orthopedic evaluation system.

The question from my reader that spurred this article would be that the SFMA honoring the literature of pain and motor control would take a completely different approach given the profile in the video that unfortunately has been taken down for some reason.
Both approaches would work out the same in terms of treating pain. Method.
The McKenzie approach would not catch all the contributions to that pain. System.

John Madden Reply

Who should I take with the number three pick in my draft?

Charlie Reply

If McCoy drops, that’s big money @ 3.
ADP for Ray Rice is going to flesh out to the 3rd pick,

Christie Dowing, PT,DPT, OCS, Dip. MDT Reply

Charlie,

I hope you realize that I am not being critical of SFMA. Quite the contrary, I’m actually quite intrigued. A colleague of mine attended an SFMA course, and as I reviewed his material, the first thought I had was how complimentary it was to MDT. So I hope you can understand my surprise when your blog post tried to put them on polar opposites.

While I am not “angry”, I am critical that you’ve passed yourself off somewhat as an exert in MDT saying “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) ” when it’s clear you still lack some understanding of the basics. It doesn’t matter with whom you studied, it matters more on how you process the material. You’ve presented a good deal of erroneous material regarding MDT. In short, until you have passed a crendentialing or diploma or fellowship program, it would be best to leave that to someone who has.

You’ve responded by saying I “missed the point”, yet I still see no clear presentation of “system” vs. “method” and how each fits which description. If the message is up there, I’m sorry…but it got lost on your comments such as “the lunacy of hamstring stretching”, “the red herring”, “…outcomes studies that make the Mckenzie practitioner look like a stud” and of course I love the picture of someone performing REIL with OP questioning the ankle DF. If that’s your idea of “speaking highly of MDT”, again I think it’s not clear to the reader.

John Madden Reply

Christie,

Are you suggesting that I take McCoy as well?

Charlie Reply

I don’t see how you can get McCoy and Rice.

Charlie Reply

Seems like you’re the only that missed the point.
I guess it’s just ironic.

John Madden Reply

Charlie,

I was asking Christie her thoughts on McCoy.

However, without a response, I declare you the winner in this most important debate.

Charlie Reply

She would have to investigate if he has a disc first.

Carl Reply

I would have thought that real therapists at this point don’t take sides. Rather they evaluate the case at hand and apply the appropriate tool. Wayne Rath for one left McKenzie to fill the voids the McKenzie system had…. I for one am truly honored to have studied Kaltenborn, McKenzie, Duffy-Rath, Mulligan, and SFMA. All for the spine! And now Im adding in more McGill….. It is now my job to make it work for me and my patients….. But to also share with Christine, the first time I strayed from McKenzie was a little scary…. Good luck and thanks for the post Charlie. It confirms some of my internal struggles incorporating both.

Christie Dowing, PT,DPT, OCS, Dip. MDT Reply

John,

I’m in no way an expert on the draft. I will bow out. Charlie is clearly the winner here.

Charlie Reply

I am also the winner on this article’s discussion.

Christie Dowing, PT,DPT, OCS, Dip. MDT Reply

Sorry you feel there has to be a winner here. I was hoping this would be an informative blogpost that would tell me more about SFMA. Too bad it’s been used to poke a proverbial stick at others.

Charlie Reply

Yeah, there’s always a winner in the end.

When the student is ready, the teacher will appear.
If you were willing to learn about SFMA, you would have asked instead of trying to defend your precious little method that was not under attack in the first place.

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Thanks for the reply, Charlie. This does make it clearer what you’re getting at. As a request for a future blog post, could you explain more about when and how the SFMA directs you to use MDT? Thanks.

BTW, somehow Foster fell to me at 3rd. Rice and Peterson first and second.

John Madden Reply

Christie would take Cam Newton with the #1 pick. Pass it on.

Charlie Reply

Foster @ 3? Wow.

Nick, I will write that article in due time.

Charles Barkley Reply

That’s a turable choice.

Charlie Reply

This was already ridiculous before John Madden and Charles Barkley began posting.

Charlie Reply

What does Dr. McGill have to do with this?

John D'Amico MSPT, ATC, Reply

Big picture.
Find the mechanism of injury, the whole mechanism and fix it.
If that means starting at the the big toe, so be it.

Thanks Charlie.

John

Charlie Reply

100% JD. A system.will.reveal best practice.in the methods you possess.

Carl Reply

McKenzie initially never spoke of core stability (dont know about now) and denied SIJ movement. Only after Laslett proved it and went on his own did they start to acknowledge it. Thereby making a point that McKenzie system although good, still has limitations and need to grow. McGill in my opinion is more the guru for stabilization of the spine and a ‘Missing Link’ or adjunct to McKenzie… You might say SFMA is a more direct approach to incorporating all these concepts…. Im just not that skilled with SFMA yey. Need to take another course and finish reading Grays book to have a more informed discussion comparing all the concepts.

Charlie Reply

TRUTH

Carl Reply

Yey = Yet

Christie Dowing, PT,DPT, OCS, Dip. MDT Reply

Carl,
You are correct about Laslett. His work heavily influenced the MDT approach assessing and treating the SIJ…and now the extremities. Regarding core stability, there is no formal MDT classification for core stabilization and no formal way recommended by MDT to assess for it…other than to rule out the other three main syndromes first. Someone in this case would be categorized as the “other” category which includes a variety of diagnoses including SIJ, stenosis, centrally mediated pain states, etc. People in the “other” categories have no formal treatment recommendations under MDT (other than SIJ) that I’ve noticed, only that in these cases, it would be appropriate seek strategies from a variety of schools of thought.

Failure to specifically sub-classify all patients is a limitation of MDT, as you mention as it doesn’t necessarily capture all patients. However, in most cases, a through MDT assessment can at least be a starting point by ruling out what the problem ISN’T. This is what perked my interest about SFMA is that it could be another tool to either:
A. capture patients who cannot be classified by derangement, posture or dysfunction -or-
B. people who are recovering from such but have further mechanical issues that need to be addressed before returning to their activity.
…at least, that’s my impression at first glance… I’m sure it could be argued the other way around as well…like you, I need to learn more about SFMA.

Jeff Cubos Reply

Christie.

I’m curious as to why the 3 syndromes must first be ruled out prior to assessing the presence of a stability/motor control dysfunction?

Charlie Reply

Because we’re not McKenzie Certified. We can’t possibly understand.
Even though my 60+ hours with Wayne Rath doesn’t count for anything when they realize he teaches it better than they do.

Everybody’s open-minded until they find out someone else has a better mouse trap.

Nick Nordtvedt, PT, DPT, Cert MDT Reply

Jeff,

Flip the question around. Why do you need to assess stability and motor control dysfunction before ruling out a quickly reducing derangement? I think this is a chicken or the egg question. As the original question stated, “I know there are multiple ways to treat the same issues…” If you treat from the SFMA standpoint and think this needs to be addressed first, so be it. If you treat from a MDT standpoint and think that this needs to be addressed first, so be it. I want to know how the MDT “method” fits into the SFMA “system.” Again, this is not to point out that anyone is “wrong,” but for better understanding of implementation of the two systems.

Charlie,

I think you infer too much from these posts. This is constructive criticism and, I believe, a genuine attempt at trying to better understand. I’ve remained open-minded, and am genuinely trying to learn. Does “the great” Wayne Rath integrate SFMA and MDT?

Charlie Reply

Nick, that may be your approach, but it is not the approach of others. If it was, the tact would be, “Hey, this is interesting. Tell me more about the SFMA.” Instead there is defense of your precious education that was never under attack in the first place. Are there not multiple phrases where I say McKenzie is correct, efficacious, and excellent?

In regards to Wayne Rath, no, he doesn’t use SFMA.
He, like others that use a similar model, leaving things on the table particularly after pain is resolved.
McKenzie is a painful approach. I quote the similarly great Craig Lienbenson, the first DC to be on the Board of Advisors for McKenzie Institute.

And I don’t challenge Wayne or Craig or anybody else that came before me. I may not have what I have without others paving the way, so I don’t challenge them or constructively criticize. I respect those that came before me, and honor them by teaching others what I have learned. I show them respect and just listen and take what I choose, dismiss what I reject.

There’s a difference between an inquiry and a challenge.

When someone objectively points out the inequities in another objective approach, there are 2 options: humbly follow or contemptuously challenge.

I choose to follow or ignore. It’s called respect for others.

Jeff Cubos Reply

Nick. I don’t think you need to assess for stability / motor control first.

I personally think the assessment, which in my (own) opinion should be directed by the history, should be wide enough of a filter to be able to recognize the presence of either yet be specific enough to determine the why.

As a disclaimer, I am only trained in McKenzie A. And I think both can be integrated together but from my experience since being trained, I have found that the approach that has been most successful is when either the history or the SFMA directs me to use the McKenzie approach. If the history does direct me to that approach, I will still utilize the SFMA to attack the mechanical why (ADLs notwithstanding).

I understand that I’m not following the McKenzie rules directly, but that’s just what has worked best for me in practice.

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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