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.https://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="https://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.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.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?