Mr. Dana Greene has been an instructor for 22 years and co-owns Summit Physical Therapy in the Syracuse NY area. He received his diploma in MDT in 1990 and has been teaching and practicing full time since.
Dr. Steve Heffner has been practicing for 31 years. He practiced as a chiropractor in a more traditional manner for about 15 years until he learned about MDT. He was credentialed in 1995 and achieved the diploma in MDT in 1997. He has been teaching MDT for about 10 years and recently has been promoted to senior faculty.
Question #1 from Jason
If a patient has presented with central, symmetrical spinal symptoms and they have not responded to sagittal plane movements how likely do you find a directional preference with a lateral movement? Especially if the patient does not present with a unilateral motion loss or a symptomatic response to a lateral movement.
Dana mentions a few key points including: exhausting the sagittal plane but when they don’t respond he encourages to look in other directions.
Steve makes sure to check movement loss laterally and if they don’t show any loss he goes back to the history and studies any hints that this might be a lateral component. He often times goes back and tests a lot of flexion to ensure a posterior derangement. Both Dana and Steve mention that they have had times where they've had to go both lateral directions either through rotation mobilization in extension or flexion.
Key things to remember:
- this doesn’t happen often
- flex, flex, flex to ensure posterior derangement
- ensure you've exhausted the sagittal plane in flexion and extension including static or sustained and through the full progression of forces
Question #2 from Faith
What have you found as the most effective way to educate doctors, other healthcare practitioners and the public about MDT and it’s effectiveness as an assessment and treatment method. In particular when starting a practice in an area where there are other physical therapist doing traditional PT, not MDT, how do you best change physician mindset and gain a referral stream?
Dana says that he doesn’t market much to doctors due to his experience that those efforts haven’t returned much. He has gained some referrals from those healthcare practitioners whom he has treated. He asks for the doctor to send patients who have received therapy and failed and asked for those patients.
Dana finds more results in asking current, improved patients to refer their family and friends.
Steve agrees, saying to the doctor that he’d like to take those patients that are still complaining and the worst patient that he or she just doesn’t know what to do with them. Steve also tries to capitalize on those patients who are waiting on an MRI or other image or procedure and explains to their doctor that he can use that time to identify something that the patient could be working on in the interim.
Dana reminds everyone to not pass up an opportunity to speak to the public and joining and speaking to community or civic service groups also can be an avenue to gain patients.
Question #3 from Gerry
Regarding treating oppositeDo you experiment with lateral forces outside the norm and is this something you do earlier on in treatment or more as a last resort if other forces are not reductive?
Robert Medcalf was kind enough to reply to Gerry’s question with the following response:
Yes, I explore hips toward the side of pain after exploring hips away. This is prior to assessing any other lateral force direction. It is simple since the patient is already prone and the response will become clear quickly. As with hips away from the side of pain, once the lateral component has been adequately addressed, attempts are made to move the hips back to midline and proceed with sagittal extension forces to complete the reduction. Hope that helps, Robert
Steve agrees that he does similar to Robert. He also mentions that he’ll go to rotation at times checking each side.
Dana says that more often than not he finds closing the symptomatic side down is more productive but he mentions that he sees many people fail to explore the lateral movements closing down the anterior portion of the segment. And he mentions also to not forget sustained positions.
Question #4 from Joel
What confirmatory information does the mechanical evaluation offer the surgeon considering surgery for a patient. Is it more than just that the patient has failed conservative measures? Do we know that the irreducible derangement or a mechanically inconclusive patient fairs better than other back pain sufferers from decompression or fusion surgery? In other words can the mechanical evaluation help the surgeon with patient selection or procedure selection?
Dana says that by all means, the mechanical evaluation helps with patient selection. He reminds us that there are only two absolute indications for surgery, cauda equina syndrome and progressive neurological deficits.
Dana mentions that he’s heard from doctors telling him what he should do to a patient and he gets bent out of shape and similarly we shouldn’t propose to advise what type of surgery a patient should receive - that is out of our scope of practice. Simplistically Dana had it explained that the fusion is typically done for back dominant pain and the laminectomy is done for leg dominant pain.
Steve thinks of the Donelson, Aprill et. al. 1997 study on predicting annulus status. He believes we offer data that the disc is or isn't the source of pain.
I also presented Hans van Helvoirt with this question and he mentions:
Regarding the question of Joel, I’m not aware of any RCT comparing MDT patients to others and then follow them through after surgery, so not sure if patients are better of for that reason.
If you follow most international guidelines: patients with herniated disc problems should sent back to the GP to send to neurosurgery etc. Of course there we do play an important role. We can see if this radicular syndrome can be centralized or not and therefore offer MDT or not, or offer epidurals in MUR followed by MDT as in my study, before sending to surgery. ( my study one third centralized with MDT only. Only 15 % of all egible patients needed surgery although they were on waiting list for surgery ( CEN + NON CEN)
Important here is the connection you have with the surgeon, anesthesiologist etc.
I don’t think we will decide what sort of operation is best! The surgeon does that himself with technique he’s familiar with. Not related to whatever sort of HNP is present.
Trials about different disc surgery techniques haven’t shown any difference in outcome, patients are not subgrouped according more lateral or central disc hernias though
If you think about decompression for canal stenosis we can sort out those patients as well, do we better than other I don’t know. Evidence is conflicting what is best, the last review I read was in favor of surgery a few weeks ago.
For back pain, we shouldn’t do any surgery. The surgeon who still thinks that’s a cure is incorrect according to every RCT you can read about it