Robert Medcalf PT, Dip MDT and Mark Miller PT, Dip MDT
In episode 119 we continue with the question and answer format with Robert Medcalf and Mark Miller. They address additional patient situation questions, tissue pathology topics and more!
Mr. Robert Medcalf is a graduate of the Georgia State University Physical Therapy program. After advanced studies in New Zealand with The McKenzie Institute in 1991, he was granted the McKenzie Institute International Diploma in Mechanical Diagnosis and Therapy of the Spine. He was subsequently named to the teaching faculty of The McKenzie Institute and has taught numerous courses on the McKenzie approach to physicians and physical therapists throughout the United States and internationally. He has participated in published research studies on low back pain and cervical pain responses to mechanical interventions and the diagnostic accuracy of McKenzie’s mechanical assessment. Robert is Director of Spine Rehabilitation at Resurgens Spine Center in Atlanta, Georgia.
Mr. Mark Miller is an honors graduate from the University of Windsor in Human Kinetics, and went on to pursue his degree in Physical Therapy in 1987 at the University of Toronto. He received a Diploma in Mechanical Diagnosis and Therapy from the McKenzie Institute in New Zealand in 1991. He joined the Canadian branch faculty that year and the USA faculty in 1993. Mark was appointed to the International faculty in 1995. Mark has been actively involved from a scientific committee and a guest lecturer perspective in many McKenzie and non-McKenzie related scientific conferences. He currently works in his private practice in Tallahassee, Florida. He is also the Vice-President of Integrated Mechanical Care (IMC), a company designed to connect MDT trained clinicians to perspective payers, while maintaining MDT quality control.
Question 1: Spence Tomlinson asks about timeframe for classification as Mechanically Inconclusive, Mechanically unresponsive radiculopathy (MUR), or to move on to SI or other testing.
Robert reminds listeners that initial conclusions are ALWAYS provisional, and classification as MI or MUR can be provisionally made as soon as day one, with further mechanical testing in order to potentially “be wrong” and find another subclassification. He notes that SI testing can be done on a case-by-case basis based on mechanism of injury, and refers patients to Aprill and Laslett’s studies in order to avoid false positives i.e. only testing non-centralizers, as SIJ pain won’t centralize.
Mark emphasizes that a true MUR will have positive neural tension sign that does not alter with movement, and ties this into truly ruling out the lumbar spine before moving on to the SIJ.
Question 2: Bob Scanlon asks a clinical question regarding a challenging patient with a cervical derangement.
Mark and Robert share some excellent insights into fully reducing a derangement in the cervical spine, including utilizing clinician techniques or force alternatives, or exploring lateral movements and techniques.
Question 3: Gerry Gordon asks about the mechanical and inflammatory interface in the case of mechanical derangement with radiculopathy.
Robert and Mark share their thoughts regarding the pathoanatomy of reducible derangements with radiculopathy, and refer to stimuli reaching a threshold to create an action potential (pain response). They note that pulling part of the stimulus away from the threshold (chemical OR mechanical input) could decrease the stimulus enough to reduce pain. Robert makes the comparison to a decompression surgery, and Mark shares some theories regarding pH balance and pain.
Question 4: Faith Hagerty inquires about relevant research articles that can be shared with skeptics
Robert shares his 3 favorite studies and their role in defending MDT to skeptics:
1) Clare et al. Reliability of McKenzie classification of patients with cervical or lumbar pain. J Manipulative Physiol Ther. 2005 Feb;28(2):122-7.
2) Long et al. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004 Dec 1;29(23):2593-602.
3) van Helvoirt et al. Transforaminal epidural steroid injections influence Mechanical Diagnosis and Therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery. J Back Musculoskelet Rehabil. 2016 Jan 20
Mark shares how he uses the above studies to create a dialogue with skeptical patients and move forward into assessment with a strong therapeutic alliance between himself and his patients.
Question 5: David Ham asks about screening the spine when extremity symptoms are present without any ROM loss in the spine, and how we can sell this to our patients.
Robert and Mark agree that you should always screen the spine in the absence of extremity trauma, as referred pain can often be seen without the presence of local symptoms. Robert stresses the importance of screening the cervical and upper thoracic spine in presence of UE symptoms. Mark shares some insights into “selling” this concept to patients by getting their permission, easily done by sharing stories of unnecessary surgeries seen clinically. He notes the importance of setting and reassessing baselines in peripheral joints. Robert shares a story of a patient on a course who required a combination of lower cervical and upper thoracic extension to centralize and abolish upper extremity symptoms.
Bonus Question: Gary Jacob asks about the limitations of MDT and the greatest deficiencies amongst MDT clinicians.
Mark and Robert agree that the MDT assessment has no specific limitation. Mark goes on to say “We are not fixers… we are assessors.” Being able to recognize when we cannot help people is just as important as being able to help a patient abolish their symptoms. Robert notes that the understanding of the “Other” classification has been a limitation, but is currently growing in this understanding of treatment and education of these patients.
Mark and Robert also agree that the misapplication of the MDT assessment can be a deficiency of the clinician. Validity studies and comparisons between MDT and other treatment approaches continue to provide questions as to where MDT will go moving forward.