I ALWAYS KEEP COMING BACK TO "ROBIN MAC"

A personal viewpoint by Lawrence Baker Credentialled Therapist

Sorry about the rather cliché title but I couldn't think up anything more original! A discussion a couple of years ago with Julie Shepherd at Cheltenham centred on a comparison of all the postgraduate courses and training including the Mckenzie courses that I had undertaken, and Julie asked me at some point in time to put pen to paper and share my thoughts with the rest of you Mckenzieites. Please note that the following is only a personal and hopefully amusing overview of the courses that I have encountered, and is not in anyway meant to be a direct criticism to past tutors or other course organisers. Like so many other physiotherapists, a new trend or fashion in treatment arises along with a new course to back it up and I have been there with my "boots blacked" and like a sponge soak it all up often not questioning the sense behind it all.

I have been qualified about 14 years and have covered a multitude of educational courses based on musculoskeletal healthcare - whoops sorry I've slipped up already I need to make the word a bit longer - neuromusculoskeletal healthcare, that's feels better already doesn't it? Why make life simple and have a 15 letter word to describe what we do, when a 20 letter word is so much more technical and clever sounding and unpronounceable! During my time as a physiotherapist, I have covered the Mckenzie educational courses up to and including the credentialing exam like many therapists, and hope to complete the Diploma next year. Oh and the other courses. So here goes.

Initially I did the Australian bit, that is the Maitland type courses. I trained at a time when everything that walked through the door needed to be "mobed". "That's it Mr. Smith you'll feel much better for that Grade I technique to your supraspinatus tendonitis!" "Supra what" says the patient. On such courses I never could understand how something so passive could correct a patient's problem, but we were told time and time again, that the joint accessory movement was what it was all about- no room for generalist approaches here! Certainly the precision with which I could apply a Grade I to C7 must obviously bear fruit and be the answer to my patients' problems? Sorry but no, they kept coming back with apparently no framework in which they could manage their ongoing spinal problems. The process involved a lengthy subjective and particularly objective examination and at the end, a few oscillatory mobilisations were applied. I can remember thinking there must be more to it than this, and of course, there was.

Then for me came the Cyriax range of courses which was similar to the Mckenzie approach insomuch as it provided a definitive diagnosis to a lot of soft tissue disorders. This seemed so much better than the Maitland approach to my simplistic mind, "something to hang your hat on" if you'll excuse the expression. But whilst hanging with all my bodyweight on to somebody's head and then twisting it off I thought how is the patient going to manage after this; yes you guessed it, as soon as the benefit of my treatments wore off they were back again for another bout of mediaeval contortionist manoeuvres. Oh and don't your thumbs hurt after all that frictioning of soft tissues!

Then the adverse neural tension courses as they were then called where patients were put into positions that stretched their nerves like elastic bands in order to relieve their peripheral pain. No doubt, that many a patient was helped by being put into positions that they never dreamed possible but then there were a lot made significantly worse. Maybe the pain was more central after all!

Then there was acupuncture, a little bit of yin and yang and chi and we could cure everything from low back pain, insomnia to in growing toenails! Mmmm perhaps. But isn't it wonderful how there is nothing better for creating a long chronic waiting list and patient dependence on a mystical treatment than acupuncture? that is unless it is part of an overall patient centred self-management strategy. I went through a period of sticking needles into everything that moved and did get some very good short-term results in pain management, but it doesn't last. I grew disillusioned with my treatments never really feeling that it was getting to the root of the problem.

Then there were the sacro-iliac courses and muscle energy techniques which made me wonder how big a role a forward sacral torsion had to play in somebody's low back pain, especially as it may have been there all of their adult lives. Pelvic downslips and innominate upslips - and that's nothing to do with ladies' underwear!

Then the answer to all of our dreams. Dynamic stability and correction of movement dysfunction. What followed was a rather lengthy and at times overly complicated series of courses that were a bit like the "Emperor's new clothes". Everybody pretending that they all understood the principles and agreeing how great it all was but secretly wondering whether they were the only ones who were a tad confused by all the techno speak. We were introduced to our "transsexual aborigines", sorry or was it transversus abdominis? I clearly remember after the 4th day on the first course of setting my trans. abs. feeling smug with myself, only to be told I was out flaring my internal obliques! Oh, my God if I can't get the hang of it how can your average "Joe Soap" patient! No chance! I really cannot believe that stone age man set his transversus abdominis before lifting a boulder, yet I am sure back pain or no back pain, he still managed a lot better than we do today! How guilty I felt after all of these years that I had neglected to use my trans. abs!
On one of the courses, we had a physiotherapist who clearly had a detectable asymmetry to his multifidus who was told that he was in trouble of severe problems with his back. Maybe so, but he had never had low back pain in his life, he was sporty and ultra fit, and yet there were many perfectly balanced physio specimens on the course who could set their trans. abs. to the delight of both themselves and the tutor, but funnily enough they had histories of being riddled with chronic back pain. Therefore, I began to question the rationale behind all of this. Certainly, correct any obvious imbalances in muscle length or weakness if you can, but does it have to be made to sound like "rocket science"? Surely, we cannot afford either the time or effort in making it so difficult for our patients.

Finally threaded throughout all of this like many physiotherapists, I have completed the Mckenzie courses. I have never come across a more clear thinking doctrine of treatment that is so easily taken back to the workplace to the benefit of the patient. The whole concept makes you very good at clinical reasoning at the "coalface".
Let's face it before we all get too self important that is what we are all here for - the benefit of the patient. We owe it to them to provide a straightforward, easily understood conceptual framework of self-treatment. Surely add force progression if needed, add any strengthening exercises if necessary once directional preference of movement has been ascertained, and marry it up with a complement of NAGS and SNAGS and any other similar techniques if needed, but let's keep it simple. How many people in everyday life have got the time to partake in lengthy, complicated exercises regimes, unless they are either already either overly obsessed with exercise or introspective or both. Or come to that keep re-attending for appointment after appointment to no real avail?

Also, with our ever burgeoning waiting lists we cannot continue to dispense passive treatments to our patients without giving patients some responsibility for their own care. "Here we go again Mr Bloggs, I'll just squirt these magic rays on to your back to make it better!"

Whilst the Mckenzie approach is not the "be all and end all", it does benefit about 70% of our patient caseload and provides a basis for prevention of recurrence of problems even if other techniques are deployed. Where I work in an attempt to reduce a growing waiting list I have been utilising the Mckenzie approach combined with "big picture" self management strategies and advice in a fast track assessment clinic. It is early days but so far, only about 24% of patients have needed any follow up and the rest report that they can manage their own problems well.

So there we go, that is a review of my experiences and why I keep coming back to "Robin Mac"!