OBJECTIVES 4/5/2018 CHRONIC BACK PAIN OR MECHANICAL DERANGEMENT? NURSE PRACTITIONER ASSOCIATION NEW YORK STATE REGION 4 TEACHING DAY APRIL 7, 2018

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1 CHRONIC BACK PAIN OR MECHANICAL DERANGEMENT? NURSE PRACTITIONER ASSOCIATION NEW YORK STATE REGION 4 TEACHING DAY APRIL 7, 2018 Mechanical Diagnosis and Therapy Of the Spine Joseph G. Maccio, MA, PT, Dip. MDT OBJECTIVES 1) Differentiate Mechanical VS. Chronic Pain 2) To be able to identify directional preference and the importance of centralization. 3) The when and why s of ordering a MRI. 4) Reducing the reoccurrence rate of back pain 5) Ruling out the spine as a source of extremity pain 1

2 Chronic Back Pain Defined Chronic back pain is defined as pain that persists for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. Chronic pain is any pain that lasts for more than three months. The pain can become progressively worse and reoccur intermittently, outlasting the usual healing process. Back-pain sufferers cost US more than $100 billion annually (according to an article published by News Medical) Neck-pain sufferers cost US more than $ 7 billion Annually (according to Evidenced- Based Education for allied professionals) 2

3 22 year old student Radiographic Findings: Degenerative Disc Disease Degenerative Joint Disease Schmorl s Nodes Spina bifida occulta WHY WE DO WHAT WE DO: REASON 1 Richard Deyo MD, MPH Study Results % increase in epidural injections ( ) 423% increase in opioids for back pain ( ) 307% increase in MRI studies ( ) 220% increase in spinal fusion surgeries ( ) WHY WE DO WHAT WE DO: REASON 2 WORSENING TRENDS IN THE MANAGEMENT AND TREATMENT OF BACK PAIN (Mafi et al., 2013) Prescribing narcotics doubled since MRI use for back pain almost doubled in the last 10 years. Higher MRI use resulted in more back surgeries. OPIOID OVERDOSE DEATHS SKYROCKET IN WOMEN (Mack et al., 2013) From 1999 to 2010 deaths from prescription opioid pain relievers (OPR) Increased by 415% in women Increased by 265% in men ER visits from misuse/abuse of OPR among women doubled from 2004 to

4 NEW YORK STATE S NURSE PRACTITIONER ASSOCIATION POSITION STATEMENT, OPIOID MISUSE AND ABUSE EPIDEMIC The Center for Disease Control and Prevention (CDCP) American Society for Pain Management Nurses (ASMN) Institute of Medicine of the Natural Academies (IOM) Top two recommendations: Physical Therapy Exercise 4

5 THE MCKENZIE METHOD OF MECHANICAL DIAGNOSIS AND THERAPY (MDT) -A Dynamic of Examination, Diagnosis, Intervention and Prevention -An evidence based assessment and diagnostic system with structured clinical reasoning framework whose principles integrate current research. -Management of the patient with both spine and extremity problems assessing mechanical responses as well as the influence of non mechanical factors. CERTIFIED MCKENZIE CLINIC Active physiotherapy utilizing the McKenzie Method of Mechanical Diagnosis and Therapy must be administered at the Certified McKenzie Clinic At least one of the therapists in the Certified McKenzie Clinic must hold the qualification of Diploma in Mechanical Diagnosis and Therapy Continuous staff training towards MDT Certification Assures the highest quality of care within the MDT system Dartmouth-Hitchcock, Cleveland Clinic, HSS, Temple, Bassett WHY WE DO WHAT WE DO: REASON 6 5

6 CONTRAST FROM OTHER TREATMENTS Repeated movements for assessment and management Emphasis on patient independence* Avoidance of therapist dependency Use of minimal intervention Combination of exercise and therapist intervention as necessary Exercises used for pain relief WHY WE DO WHAT WE DO: REASON 3 I cannot thank you enough. I never imagined that I would be out of back pain. I had been suffering with it for so long, I believed that was the way is was going to be for the rest of my life. When I was referred to your office, I did have doubts. I had supposedly seen a McKenzie therapist beforeboy, was I wrong. The methods you used were definitely more involved. You and your staff were all very kind and caring. You have given my life back to my family and me. Thank you! I had lower back pain on and off for 10 years. The last 2 years, I have been in constant pain. I had seen a chiropractor, a neurosurgeon, and a physical therapist and have had steroid injections. With all that, I had little to no relief of pain and it was getting worse. In October 2011, I was told by my neurosurgeon that my only option was to do a spinal fusion. I was devastated. I m in my mid-thirties and had no choices except surgery. I was referred to Maccio Physical Therapy by my sister who works with Mr. Maccio s wife. With Some hesitation, I scheduled an appointment. After a few appointments, I started to get relief. I was amazed. I had a little set back and I started to get discouraged. Mr. Maccio never gave up; he was patient, kind, and caring. The methods that Mr. Maccio taught were very different from the prior treatment I had. He has given me the tools so I can control and manage my back pain, myself. This is the greatest feeling of accomplishment. I just want to let other people know that you al-ways have options and should always get more than one opinion before making a decision such as surgery. I am so glad that I did. Keri 1/2012 Referred by a former patient In August of 2010, I was in a car accident and experienced bad pain in my lower back. I was referred to a neurosurgeon by the emergency room. After X-Rays, MRIs, and CT scans I was sent to physical therapy. By December, I was no better. My primary doctor sent me to a chiropractor. I felt relief from that for a few hours after the appointment but by the evening, my normal back pain returned. I went back to the neurosurgeon in May of 2011 and said the pain was still there and now radiating down my leg, and something needs to be done. I was told that I should try steroid injections. I had a CT scan after the injections didn t help either and was told I needed a spinal fusion. I saw my primary doctor again and she referred me to a second neurosurgeon who said surgery wouldn t help. After a weekend of complete confusion, I asked my primary to send me to a third neurosurgeon for one last opinion. He said surgery wouldn t help me and said I needed physical therapy again. I was skeptical since I had already tried it for five months and it did nothing for me, but I went anyway. I called Maccio Physical Therapy and had an appointment the same week. After two days, the pain in my leg was gone and after three weeks of the McKenzie Method, I am close to having my normal life back with my two-year-old son! I m so grateful I went for a second and third opinion! Maccio has really helped me to get my quality of life back to what it was last spring! - Kristie 6

7 WHY WE DO WHAT WE DO: REASON 4 HERZOG MRIs were obtained over a 3 week period Pt was middle-aged female with low back pain and associated radicular symptoms All 12 images were different, no one report had agreement on conclusive findings One found no HNP, 2 found HNP at all five levels, remaining 7 reports found HNP at one or more levels 7

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11 WHY WE DO WHAT WE DO: REASON 7 5 Things that can be done for a patient with neck, or back pain 1. Drugs 2. Injections 3. Surgery 4. Testing 5. MDT with positive results WHY WE DO WHAT WE DO: REASON 8 Gina - Original Success Story - November 2009 When I first came for McKenzie physical therapy I was discouraged with my prognosis. After 17 years of back problems - 4 epidurals, 1 surgery, multiple courses of PT, I wasn t so sure anything would help. Dartmouth-Hitchcock Spine Center referred me to a McKenzie Certified clinic. After 5 visits with Joe, I m not quite so discouraged. I might say I m a bit optimistic about my future. I m still skeptical, but hopeful. Thanks to all the staff. Gina - Update 2013 I could not believe I could continue to keep my back pain away after all I d been through. Joe Maccio gave me my life back. After seeing Joe three years ago I have not had one problem with my back. If you have back problems I urge you to see him to try to avoid invasive procedures, I only wish I knew about him sooner! MDT CLINICAL MANAGEMENT Goals Relieve Pain Restore Function Prevent Reoccurrence 11

12 LUMBAR CENTRALIZATION 54 scientific studies on centralization 12

13 Results: In chronic LBP, there was a significant difference in disability (SMD=-0.45) with results favoring MDT compared to exercise alone. BACKGROUND Presence of Centralization has been shown to be an excellent predictor of a good outcome. (Werneke (99, 01), Aina (04), Long (04, 08) Prevalence of Centralization diminishes with age (Werneke 2008) The Medical Management of Low Back Pain appears to be greatly influence by imaging. PREDISPOSING AND PRECIPITATING FACTORS PREDISPOSING FACTORS Sitting posture Frequency of flexion Loss of extension range PRECIPITATING FACTORS Movements Lifting 13

14 WORKING POSTURES THE REDUCTION OF CHRONIC NON-SPECIFIC LOW BACK PAIN THROUGH THE CONTROL OF EARLY MORNING FLEXION: A RANDOMIZED CONTROLLED TRIAL. 86 volunteers with chronic/reccurant low back pain 6 months no treatment Phase 1: 6 months - 1 group eliminate early morning flexion, 1 group sham treatment Phase 2: Sham group switched to flexion avoidance for last 6 months Results: Flexion Avoidance Group Significant pain reduction (p<0.01) Reduction of medication use (p<0.05) Reduction of impairments (p<0.01) 80% of participants elected to continue avoidance of AM flexion 14

15 POSTURE SYNDROME End range stress on normal structures Mechanical deformation due to prolonged stress eventually produces pain Can eventually lead to a derangement DYSFUNCTION SYNDROME End range stress of adaptively shortened structures Mechanical deformation immediately produces pain at end of range consistently May be discogenic, zygapophyseal, ligamentous, muscular, apeneurosis, etc ANR Trauma and time DERANGEMENT SYNDROME : THE MASTER OF DISGUISE Anatomical disruption and/or displacement of structures The structures increased mechanical deformation immediately or eventually produce pain Lower and upper cervical spine dynamics 15

16 DISC BULGE HERNIATION EXTRUSION NUCLEUS PULPOSUS DEFORMATION FOLLOWING APPLICATION OF MECHANICAL DIAGNOSIS AND THERAPY: A SINGLE CASE REPORT WITH MAGNETIC RESONANCE IMAGING. Before Physical Assessments Immediately After Centralization Pixel Intensity 16

17 EVALUATION PROCESS PATIENT HISTORY 1* role is to establish a hypothetical diagnosis Location of pain Duration of current episode of pain Intermittent or Constant pain Do you have the pain all the time? Or does it come and go? Mechanism of Injury Symptomatic and Mechanical responses to: Bending, sitting, rising from sitting, turning, lying, rising from lying when still and when on the move Time of day: upon waking, as the day progresses, in the evening Better, worse, no change What is guaranteed to make your symptoms worse? What is guaranteed to make your symptoms better? How many previous episodes and similarities? RED FLAGS and possible contraindications to MDT? Occupation: Terms used to determine the response to repeated movements, sustained positions, treatment procedures and/or functional activities and positions on pain patterns in musculoskeletal disorders. These are used BEFORE, DURING and AFTER the procedure to accurately evaluate the response. PRINCIPLE OF MANAGEMENT 1. Reduction of derangement (end-range is where the magic happens!) 2. Maintenance of reduction (5-7 days) 3. Recovery of function 4. Prevent recurrence 17

18 MECHANICAL (INTERMITTENT /CONSTANT) VS INFLAMMATORY (CONSTANT) Evaluate Location Classification Direction Load Re-evaluate AREAS OFTEN OVERLOOKED Education Recovery of function Over pressure End Range 18

19 WHY NON-SPECIFIC EXERCISE SOMETIMES FAILS CARDINAL FEATURES Symptomatic and mechanical responses Classification of subgroups (syndromes) Focus on centralization Self treatment Progression of forces Patient education Case Study Female with neck and arm pain for 1 year Failed general physical therapy and cervical fusion 4 months later she was worse Referred to us by a friend Visit 1: 50% better Visit 4: return to gym 1 year later still pain free 19

20 McKenzie Institute Part A: Lumbar Spine Course April 13-15, 2018 And Part D: Advanced Cervical/ Thoracic Spine & Upper Extremities June 7-10., 2018 at Russell Sage College YOU HAVE A CHOICE Only 18% of patients with lower back pain are referred to physical therapy by their doctor s Medicare reports a 629% increase in cost for epidural steroid injections and a 220% increase in spinal fusion surgery rates Physical therapy is safe, has no side effects and teaches you what to do to manage and prevent your pain from coming back 20

21 McKenzie Online Course Overview of the McKenzie Method this free course is designed to provide a very broad overview to better understand the principles of the McKenzie Method before embarking on formal training Go to: 1 New Hampshire Ave Troy, NY (518) jmaccio@macciophysicaltherapy.com 21

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23 29% HEIDAR ABADY % Hashimoto submitted 2017 Worth exploring further 23

24 OUR PUBLISHED RESEARCH 24

25 OUR CONTRIBUTION TO OTHERS RESEARCH 25

26 References 1. Long A, Donelson R, Fung T. Does it Matter Which Exercise? A randomized control trial of exercise for low back pain. Spine. 2004; 29(2): Long A, May S, Fung T. Specific Directional Exercise for patients with low back pain: A case series. Physiother Can. 2008;60(4): Long A, May S, Fung T. The comparative prognostic value of directional preference and centralization: A useful tool for frontline clinicians? J Man Manip Ther. 2008;16(4): McKenzie R, May S. The cervical and thoracic spine: Mechanical diagnosis and therapy. Vol 1. Waikanae, New Zeland. Spinal Publications New Zealand Ltd McKenzie R, May S. The cervical and thoracic spine: Mechanical diagnosis and therapy. Vol 2. Waikanae, New Zeland. Spinal Publications New Zealand Ltd McKenzie R, May S. The cervical and thoracic spine: Mechanical diagnosis and therapy. Vol 1. Waikanae, New Zeland. Spinal Publications New Zealand Ltd McKenzie R, May S. The cervical and thoracic spine: Mechanical diagnosis and therapy. Vol 2. Waikanae, New Zeland. Spinal Publications New Zealand Ltd Boden SD et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990:7A: Jensen MC et al. MRI imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(1): Boos et al Volvo Award in clinical science: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying static disc herniations. Spine. 1995;20: Wood et al. Magnetic resonance imaging of the thoracis spine> Evaluation of asymptomatic individuals. J bone Joint Surg Am. 1995;77(11): Donelson, Ronald. Rapidly Reversible Low Back Pain. An Evidence Based Pathway to Widespread Recoveries and Savings. 2007; Hanover, New Hampshire. Self Care First, LLC. 13. Wetzel TF, Donelson R. The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. Spine J. 2003:3(1): References 13. Wetzel TF, Donelson R. The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. Spine J. 2003:3(1): Oliver D, May S. An observation study of centralization and directional preference in older patients with back pain. Int J Mech Diagnosis Ther. 2010;5(1): Deyo R, Miraz SK, Turner JA. Overtreating chronic back pain: Time to back off? J Am Board Fam Med. 2009;22(1): Maccio Physical Therapy. Available at: Accessed on April 10, The McKenzie Institute International. Available at: Accessed on April 10, Self Care First. Available at: Accessed on April 10, Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med Jul 29. [Epub ahead of print] 20. Mack KA, Jones CM, Paulozzi LJ. Vital signs: overdoses of prescription opioid pain relievers and other drugs among women. MMWR. 2013;62(26): Healing Arts Continuing Education. Available at: Accessed on August 19, Hogg-Johnson S, van der Velde G, Carroll LJ, et al. The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(Suppl):S39 S Luime JJ, Koes BW, Miedem HS et al. High incidence and recurrence of shoulder and neck pain in nursing home employees was demonstrated during a 2-year follow-up. Journal of Clinical Epidemiology 2005;58: Connor et al. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5 year follow-up study. Am J Sports Med. 2003; 31(5): Cram P, Lu X, Kates S, et al. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, JAMA. 2012;308(12): Adams, J. E., Sperling, J. W., Hoskin, T. L., Melton, L. J., & Cofield, R. H. (2006). Shoulder arthroplasty in Olmsted County, Minnesota, : a population-based study. Journal of shoulder and elbow surgery, 15(1), Mather, Richard C., et al. "Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty." Journal of shoulder and elbow surgery 19.3 (2010):