The full ‘McKenzie’ debate

What follows (click on links below) is all the material from the original PPA News Mckenzie ‘debate’.  It starts with my December 2002 Phyiotherapy Pain Association News Editorial.

The material is with the premission of the PPA (www.ppa.csp.org.uk/)

The responses that followed from the Mckenzie Institute, my response to them (my best bit!!), the letters I received and the article by Mick Thacker were all published in the PPA News of June 2003.  Thanks to everyone who took the time and participated.

Louis Gifford June 2013

1. Gifford Therapist and patient fear of bending

2. Mckenzie Institute response 01

3. Mckenzie Institute response 02

4. Peter Ward response

5. Mckenzie Institute Newsletter editorial

6. Elaine Buchanan letter to ppa news

7. Louis Gifford reply editorial

8. Thacker article – centralisation under scrutiny

9. Letters in PPA news 15

5 thoughts on “The full ‘McKenzie’ debate

  1. Abbie
    Thanks for your note and your kindness. I’m interested to know where you’re working – not exactly, but maybe whether UK or elsewhere?
    Well, from reading your comments you would be wise to understand more about pain, it will give you a great deal of answers to your questions and hopefully give you a more comfortable understanding of clinical observations. It did me a long time ago and I have never lost my enthusiasm for it. It helps exlain a great deal, thankfully.
    For example as to why two people with apparently the same problem respond differently to your inputs. Think of your own experiences perhaps, some people like being clicked and cracked, others dread it, some prefer soft and gentle, others firm and deep. Any given nervous system has preferences and those preferences are in the context of the ‘individual’s thoughts, feelings and beliefs – about their problem and what they think might help it, about physiotherapy, about what they think of you and their confidence in you… your patient that was successful might have felt confident in you and liked what you were doing – their nervous system ‘allowed’ your treatment input (basically comes down to impulses!) to interact with their pain processing (more impulses!) to give a good result. A patient with exactly the same pain might not be processing you, physiotherapy, the treatment you’re doing in a positive way. Their nervous system responds the opposite way and… oops, it’s worse.
    You may find a good understanding of the biology of nocebo and placebo very helpful.

    You ask about ‘a treatment that causes physical harm may relieve pain’ – well, yes, in pain biology theres a phenomenon called ‘Diffuse noxious inhibitory control’ – DNIC – it’s basically pain relieves pain – you have a pain in your foot and someone smacks you in the face… result! No pain in the foot, it’s fixed! It’s the basis of many ‘hard’ or intensive treatments… the cns produces a massive amount of endorphins in response to threat or hurt, even harm. It’s all good hunter-gatherer stuff – if you’re runnng for your life from some buffalo or lion, and trip up and break your big toe, you don’t want pain right then, and there is none, you carry on running, feel nothing and survive. Evolution has endowed you with this wonderful pain killing system that kicks in when there’s extreme danger or threat about.. so, you can have a pain, do something nasty somewhere else in the body that may even damage, and the pain goes…. for a while.
    Just a taster, hope it helps, and thanks again for your appreciation. More soon on ‘centralisation’ in the blog… just got to find a little time!
    Louis.

    • Hey Louis
      Thank you for your quick and thorough Response. I’m from Israel and working in the public health services clinic. As you can imagine, there is a tendency to look for “efficient” and “fast” ways of treatment like what is perceived to be The McKenzie method.
      I have learned about the DNIC phenomenon, Just wasn’t sure what you meant. I guess I haven’t yet applied some of the knowledge on what goes on daily in the clinic.
      Another question(s) , if you will :A highly used term in the clinic is radiated/ referred pain ( not talking about visceral pain). As a student I’ve learned that I should search the underlying cause for the radiated pain and to treat the area that is believed to be causing the Radiating pain. In light of knowledge of pain processing- Do you think in these terms? If so how do you address situations when an area of pain complaint is believed to be originating from a more distant area, Say like radiculopathy? I mean, if there is pain in a certain area then that area in sensitizes whether it is the cause or the result?
      How do you prioritize treatment if there are several areas of pain and believed to be linked to one another…
      hope I made sense, since I have all these questions running through my head with no answer (yet, hopefully ) Maybe I should start writing them down…
      I will absorb your answers and will look forward for new and interesting observations.
      Thanks again!!!
      Abbie.

      • Abbie,
        I am currently writing a book that has my answers to just your sorts of questions, hopefully it will be out in the new year.
        Anyway, comments on your comments.
        Regarding fast ways of doing things. I think we need to divide our thinking into two – think pain relief is one, think the natural history and healing is the second. If the patient in front of you has pain and is healing, how long is the healing going to take? Your empathy and touch or therapy presence may enhance the healing efficiency, but for most things musculoskeletal there is little else we can do to acually ‘fix’ something – think of interventions that would speed up the healing of a skin wound for example – you can put on a plaster and give antibiotics to stop infection, and there’s good evidence that when in low stress skin heals more quickly than in high stress… But that’s it. Skin takes a few days to be strong enough to load, and about a year to come to the end of healing (remodelling). Musculoskeletal tissues are far slower generally, but the pain can settle to more useful levels during the time….

        So the old thing about treating the source of the referred pain is a bit of a laugh if you’re thinking a few sessions and it’ll be fixed/healed/back to normal
        Now, if you think pain going away, that might be different. Things can carry on healing with far less pain quite often… many pain’s that folk get are ‘out of all proportion to the damage done’ – they’re maladaptive/unhelpful. So relieving the pain can be helpful… followed by good and adequate ‘loading’ – meaning return to normal acitvities and function in a gradual way suitable for the patient.
        So from pain processing perspective, pain can be relieved from anywhere… it doesn’t matter if it’s referred or not, but if you do something that helps the pain that’s fine. Hence, we instinctively massage the referred calf pain of sciatica… some people treat foot pain by pressing on weird places on the skull… others treat headaches by fiddling with the feet. Once you see it as ‘playing with processing’ you’re on your way.
        A good example of treating where the pain is located and helping is from studies of angina – pain ‘from’ the heart referring into the arm. Do an anaesthetic block to the nerves to the arm, or inject trigger points in the muscles where it’s painful… you get pain relief in the arm – and – the ECG improves!! So take the pain away may just be helping the healing/recovery a bit too… but you don’t have to treat where it’s coming from – it’s good to treat the actual part that’s painful too.

        Knowing where a pain might be coming from and it’s nature is important though – it gives you natural history… and here you need to know normal recovery times and normal pain graphs or curves for a given injury… something that I’ve been harping on about for years that needs proper research doing.
        Regarding prioritising treatment of several pains… a quickie…. That sounds like you’re focused with treatment on pain relief/fix… complex pain is sometimes best managed by simply getting the patient going again and not being over concerned about making huge sense of the complexity in terms of tissues being ‘wrong’. Just think to yourself – are the tissues safe to start a bit of activity/being loaded, explain to patient… and start a graded programme of getting them going again… activity gradually up, confidence back up… pain less of a problem… Sounds easy, it can be but often patients aren’t easy.
        All this stuff is in the forthcoming book! you need to know your ‘Red flags’ for the presence of serious pathology… if none… start loading and moving…

        Louis

  2. Dear LG,
    What an eye opener!! For A while now I’ve been struggling with this simplifying notion that “when the pain goes down- it’s a bad sign, when the pain travels up- it’s a good sign
    I’ve been working as a physiotherapist for a year now and in the clinic I use to work at they expect you to treat with the McKenzie approach, even though I’m not certified ( I have just resigned. now after reading this I understand even more why I did so )..
    It was so outrageous to me, this strong belief, but I wasn’t ready to make a serious case and ask how did the McKenzie institute formulate the centralization /peripheralisation theory. I felt I didn’t have the knowledge to fight this belief so I just loved to hate this approach.
    Your article freed something in me. so much thanks! But! Is raises many questions (that’s a good thing right?). it made me realize how much I need to learn on pain science etc. in order to gain the confidence in the clinic.
    What you said about pain having an unpredictable way of behaving just enforces what I felt lately and that is that many times , especially with manual therapy, in cases of diffused pain that seems to be neurogenic, I have no clue ( sometimes) if I’m helping or not. Two different patients can show the same clinical picture (supposedly) and to one, the technique I’m applying will help and to the other, it will worsen the pain. Is it realy that random? How do I know which pain will benefit from my touch and which is better left untouched, maybe some modalities and easy movement..
    Then you said in your 3rd observation: “a treatment that causes physical harm may relive pain”… what did you mean by that?
    Thank you sooo much!! Your my physio of the year 
    Abbie.

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