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McKenzie Instituttet Danmark intervention trial of 314 military conscripts. Spine 2002;27:2747-52. 5. Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004;29:2593-602. 6. McKenzie R. The Lumbar Spine: Mechanical Diagnosis and Therapyed: Spinal Publications New Zealand Ltd., 1981. Introduction: I would like to give a special thanks to Mark Miller for the time and energy he has put in this interview. The idea of the interview was to elucidate the potential of MDT specifically in starting and running , “The Spine Center”. It gives an insight in the concept, the results, patient management for both responders and nonresponders, how to deal with patient expectations and reflections on the future of Mechanical Diagnosis and Therapy. If anyone should have any questions or reflections, please send them to the email address below, and Mark will be happy to answer in the upcoming Journal. Camilla Nymand, dip.MDT nymand@mckenzie.dk Mekanisk Inkonklusiv—de svære patienter 7. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis & Therapy Volume Oneed. Waikanae: Spinal Publications New Zealand Ltd, 2003. 8. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis & Therapy Volume Twoed. Waikanae: Spinal Publications New Zealand Ltd, 2003. 9. Mercado AC, Carroll LJ, Cassidy JD, et al. Passive coping is The Spine Center Mark Miller, Dip. MDT How did you get involved with MDT? I was introduced to “McKenzie’s Approach” during a clinical placement in college. I was given the book to read over the weekend and asked to see patients the following Monday. I became very interested with the rapid results noted with derangements. After college I moved to a remote area in the province of Ontario, and utilized this approach as a “stop gap” while waiting to start my manipulation a risk factor for disabling neck or low back pain. Pain 2005;117:51-7. 10. van Tulder et al. European guidelines for the management of acute non-specific low back pain in primary care: COIST B13, 2004. 11. Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine 1980;5:117-25. training. While waiting, however, I read Cyriax’s, and Kaltenborn’s textbooks along with about 1,000 articles related to spinal assessment and treatment, and decided to go this route. It looks like I picked the right horse. What is the idea/ concept of the Spine Center? The Spine Center started as a partnership between Scott Herbowy, myself, and St. David’s Hospital. Basically, they supplied the money and physical space and we supplied the “know how”. It is really a simple concept, market and provide a clinic that examines and treats muskuloskeletal pathology with Mechanical Diagnosis and Therapy. It took some persuading to convince the hospital that economics and appropriate, efficient, quality care can coexist. Generally, both parties have agreed on all aspects of the clinic, and 9 ½ years later we are still here. Volume 17. nr. 3. December 2005 McKenzie Institut Danmark, Nyhedsbrev 40
McKenzie Instituttet Danmark What is the set-up? This is easy. Until a recent move, the clinic was 550 square feet of treatment area, plus two private administrative offices. The treatment area was divided into 4 separate booths, by curtains, with a treatment table and a white board in each. Our gym area was one square foot (the shelf that held our theraband). We have recently moved, however, the concept and set-up has not changed. Our place is bigger in order to accommodate growth, and we now have walls instead of curtains. Our gym area size remains the same. What type of patients do you see? In the beginning we saw only spinal pathologies, ranging from local low back pain, to post-operative fusions. Over time we started to market the peripheral joint population and now we see all muskuloskeletal patients, including postops. We shy away from general rehabilitation, total joint replacement and post-operative patients where specific post-operative protocols require adherence. Our patient population remains dominantly spinal, however, we are currently marketing to physicians the wonders of MDT for the peripheral joints, and based on past history, are expecting a sizeable growth in this area. How many average visits per patient? An analysis of 10,050 consecutive patients done 2 years ago revealed that we average 5.25 visits per patient assessed. This of course includes the assessment. Interestingly, our partner (who has since bought the clinics back from us) was curious a few years ago as to why we could not increase this number by a few visits. Our expla- Mekanisk Inkonklusiv—de svære patienter nation was simple; don’t deviate from what is right and best for the patient, empower the patient to care for their problem themselves, don’t create a false sense of dependency, and the clinic will thrive as a result of the shear volume of patients wanting to come, and doctors wanting to send them. So far the model has worked. The Spine Center remains busy and viable, and Scott and I have remained sane (by our definition).. How do you measure patient outcome? We have kept our outcome measures fairly simple. We have kept these statistics for demonstration and marketing purposes only. At intake we have the patient rate their pain level (0-10), and their functional level (0-100%). At discharge we have them rate both again, along with their degree of satisfaction with treatment given (0-100%). At discharge, therefore, we have the following data; pain level and percent change, function level and percent change, satisfaction level, visit number and days/weeks under care. How many responders/non-responders do we see? It is not typical that we see a “nonresponder”. In other words, it is uncommon that we see a patient that cannot be helped with McKenzie’s approach - Mechanical Diagnosis and Therapy. A “nonresponder” means; assessment reveals a lesion not amenable conservatively, or assessment is nonrevealing. Derangements requiring surgery are rare, and entrapments not positively affected by load (from a remodeling perspective) are roughly 50%, however, entrapments themselves represent a small population of the spinal world. Purely stenotic patients are worth a couple of weeks of assessment as there is a group of these patients that responds well to movement and load, especially in the cervical spine. Mechanically inconclusive patients are excellent candidates for rehabilitation under McKenzie’s selftreatment dysfunction model. Loading tissue frequently throughout the day, without worry about derangement disruption or nerve irritation, has proven very effective as long as behavioural issues do not dominate the clinical picture. So the answer to your question is, not many. However, the answer depends on how we define “nonresponder”. What do you do with non-responders? I refer them to the necessary people depending on what type of nonresponder they are. Non- responders due to chemical issues see a chemist, non-responders due to irreducible lesions see a surgeon, non-responders due to behavioural issues see as FCE, and nonresponders that are not understood see their physician as soon as possible. However, if you are asking about the non-centralizer, I believe that I have answered the question above though I would like elaborate a little. McKenzie was asked at a conference how McKenzie and Medex would fit together, and his answer, though quite profound was lost on most of the people there. He said, “in the United States you have Medex, and in New Zealand we have a brick”. He actually was not telling the truth. We had a Medex machine at the clinic at the lodge. It had been donated by the company for trial by McKenzie in his “Lodge Program”. We used it to hang our laundry on. What I took from this was; we need to make rehabilitation as uncomplicated and self-directed as possible. This group of patients responds wonderfully to a home Volume 17. nr. 3. December 2005 McKenzie Institut Danmark, Nyhedsbrev 41
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