Ronald Donelson, MD, is the president of SelfCare First in Hanover, N.H., a consulting, publishing and musculoskeletal disorder management company. He is a board-certified orthopedic surgeon who has specialized in non-operative spine care and research for 30 years. In 1991, he was granted the Diploma in Mechanical Diagnosis & Therapy, a method diagnosing, classifying and treating most back and neck pain without surgery.
In the October issue of the North American Spine Society's SpineLine, Dr. Donelson wrote an article titled, "Improving Spine Care Using Mechanical Diagnosis and Therapy," and he also led a symposium on the topic at the NASS October conference in Dallas.
Here is Dr. Donelson's take on mechanical spine diagnosis and how it can improve patient care.
Question: What is the current method of diagnosing spine problems? What is problematic about this method?
Dr. Ronald Donelson: In spine, we are accustomed to trying to identify an anatomic diagnosis to explain why someone is having pain. However, it's well-accepted that we can only make an anatomical diagnosis in 15 percent of patients. In the other 85 percent, we are just theorizing what the source of pain might be. The pain of that large group is most commonly referred as "non-specific."
The most reliable anatomic diagnosis we are able to make is of a herniated disc causing sciatica and neurologic deficits which can be confirmed by imaging. The problem is this applies to only a very small percentage of the spinal pain population and, just as important, it doesn't help at all in determining the best treatment. Treatment is determined by which office you walk into. Everybody agrees on the diagnosis but there is no standard, predictably effective treatment. Despite these important limitations regarding our most reliable anatomic diagnosis, seeking an anatomic diagnosis remains the conventional way of trying to classify patients with back and neck pain.
Q: What is a mechanical diagnosis?
RD: I liken making a mechanical diagnosis to how we go about trying to solve a problem with our car. Let's say it's making a new and worrisome noise. A mechanic first asks questions, i.e. takes a history, about that noise. He's looking for a pattern or association between the sound and function of the car. He then doesn't take pictures of the engine or brakes but wants to take the car for a test drive. He monitors that sound seeking to associate it with a specific mechanical aspect of the car, looking for a pattern to help him solve the problem.
That's really what mechanical diagnosis and therapy is all about, taking a mechanical history to see if there is an identifiable pattern between the symptom behavior and various spinal movements, positions and activities. The exam then takes the spine on a dynamic mechanical test drive by having the patient repeatedly bend the symptomatic region of the spine to its available end-range while monitoring for patterns of how the symptoms respond. Bend backward repeatedly. What happens? Bend forward, bend sideways, even rotate, if necessary.
The most important and very common pattern is that, in most patients, a single direction of testing will begin to centralize and then eliminate the pain. That single direction is referred to as the patient's "directional preference." When found, the patient has an excellent prognosis if treatment focuses on the patient frequently performing that same direction of end-range movements as an exercise.
This assessment and these patterns of pain response were first observed by New Zealand physical therapist, Robin McKenzie, who fine-tuned the assessment and treatment methods in his own clinic 50 years ago. His methods are now taught world-wide in a standardized sequence of courses.
Q: How does the mechanical diagnosis work?
RD: As I said, it is common for single direction of testing to bring pain out of the arm or leg. This is called "pain centralization," where pain is moved back toward the center of back or neck. When that pain moves, it is obvious that something beneficial has just happened to the underlying pain source. The good thing is that you don't have to identify the anatomic pain source to change it beneficially. Once you find a directional preference, you have found how the patient can take their own pain out of the leg, buttock and back, or out of their arm, shoulder or neck. This phenomenon of centralization has a well-documented prevalence of 70 to 89 percent in acute and 50 percent in those with chronic low back pain.
Again, when the pain can be centralized and eliminated, it's not necessary to identify its anatomic source. This eliminates the need for MRIs or diagnostic tests in these patients. A way has now been identified to predictably eliminate pain by addressing the cause of the problem and not just the symptoms.
The most likely explanation for why some pain centralizes, that is supported by numerous studies, is that disc material that is bulging or herniating out of the back of the disc and causing pain, can be returned toward the center of the disc and away from the pain-generating annulus or compressed nerve root. The still-unchallenged theoretical model is that repeatedly extending the painful spine loads the herniated area and progressively moves that disc material back where it came from, moving it away from the nerve root or painful anulus.
Q: How quickly can the centralization of pain work? Does this solution last?
RD: Patients in whom a directional preference is found commonly leave their first evaluation session with no pain at all. But it will usually come back again. But they are taught to do at home what they did in the exam room and they can eliminate their own pain again. If they keep that up, then the pain typically stops returning. Patients quickly learn to take control of the whole thing with a very rapid recovery. Again, the evaluation identified a way to reverse the painful problem without needing to identify what anatomic structure is causing the pain. Once you find a directional preference, that direction of movement becomes an exercise tool for patients to use to first eliminate and then prevent the return of the pain.
Q: Other than removing pain, what are the benefits to the mechanical diagnosis?
RD: It has significant implications. It adds a whole new layer of dynamic mechanical information about the underlying pain source that is not otherwise available with an MRI or with a standard clinical exam. Importantly, this dynamic evaluation shows whether the problem is reversible or not. And it is commonly reversible. The great majority of patients don't have a "non-specific" back problem. They have a "reducible derangement," which means that something is out of place causing the pain and it is reducible. Nothing inflammatory responds so quickly from mechanical movements — nor does a torn muscle or ligament. A tumor will not have a direction of movement that takes the pain away and then remains better. Only when something is out of place will one direction of movement put it back in place and another movement will bring it back.
There is also no risk to this method. The assessment is very safe as long as symptoms are closely monitored throughout. The exam reveals who has an excellent prognosis and how to treat it, and who does not. For most, we can show them how to take their pain away and restore full spinal movement. Patients then need to be educated on the proper exercise technique plus how to temporarily avoid any bad direction found during the exam. These methods have a dramatic effect on the diagnostic side and an equally dramatic effect on the treatment side.
A group of us presented at a symposium at the NASS meeting in Dallas with spine surgeons addressing the value of this assessment in their practice. For them, it quickly identifies who does and doesn't need surgery. Only those with no directional preference are potential surgical candidates because their problem has great difficulty getting better on its own. Surgeons who utilize this method in a pre-surgical evaluation feel they can operate earlier on those with no directional preference, and that helps reduce recovery time and the chance of a long-term or permanent neurologic deficit. Those who are found to have a directional preference and recover rapidly without surgery are very happy, and happy patients talk, leading to more referrals.
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In the October issue of the North American Spine Society's SpineLine, Dr. Donelson wrote an article titled, "Improving Spine Care Using Mechanical Diagnosis and Therapy," and he also led a symposium on the topic at the NASS October conference in Dallas.
Here is Dr. Donelson's take on mechanical spine diagnosis and how it can improve patient care.
Question: What is the current method of diagnosing spine problems? What is problematic about this method?
Dr. Ronald Donelson: In spine, we are accustomed to trying to identify an anatomic diagnosis to explain why someone is having pain. However, it's well-accepted that we can only make an anatomical diagnosis in 15 percent of patients. In the other 85 percent, we are just theorizing what the source of pain might be. The pain of that large group is most commonly referred as "non-specific."
The most reliable anatomic diagnosis we are able to make is of a herniated disc causing sciatica and neurologic deficits which can be confirmed by imaging. The problem is this applies to only a very small percentage of the spinal pain population and, just as important, it doesn't help at all in determining the best treatment. Treatment is determined by which office you walk into. Everybody agrees on the diagnosis but there is no standard, predictably effective treatment. Despite these important limitations regarding our most reliable anatomic diagnosis, seeking an anatomic diagnosis remains the conventional way of trying to classify patients with back and neck pain.
Q: What is a mechanical diagnosis?
RD: I liken making a mechanical diagnosis to how we go about trying to solve a problem with our car. Let's say it's making a new and worrisome noise. A mechanic first asks questions, i.e. takes a history, about that noise. He's looking for a pattern or association between the sound and function of the car. He then doesn't take pictures of the engine or brakes but wants to take the car for a test drive. He monitors that sound seeking to associate it with a specific mechanical aspect of the car, looking for a pattern to help him solve the problem.
That's really what mechanical diagnosis and therapy is all about, taking a mechanical history to see if there is an identifiable pattern between the symptom behavior and various spinal movements, positions and activities. The exam then takes the spine on a dynamic mechanical test drive by having the patient repeatedly bend the symptomatic region of the spine to its available end-range while monitoring for patterns of how the symptoms respond. Bend backward repeatedly. What happens? Bend forward, bend sideways, even rotate, if necessary.
The most important and very common pattern is that, in most patients, a single direction of testing will begin to centralize and then eliminate the pain. That single direction is referred to as the patient's "directional preference." When found, the patient has an excellent prognosis if treatment focuses on the patient frequently performing that same direction of end-range movements as an exercise.
This assessment and these patterns of pain response were first observed by New Zealand physical therapist, Robin McKenzie, who fine-tuned the assessment and treatment methods in his own clinic 50 years ago. His methods are now taught world-wide in a standardized sequence of courses.
Q: How does the mechanical diagnosis work?
RD: As I said, it is common for single direction of testing to bring pain out of the arm or leg. This is called "pain centralization," where pain is moved back toward the center of back or neck. When that pain moves, it is obvious that something beneficial has just happened to the underlying pain source. The good thing is that you don't have to identify the anatomic pain source to change it beneficially. Once you find a directional preference, you have found how the patient can take their own pain out of the leg, buttock and back, or out of their arm, shoulder or neck. This phenomenon of centralization has a well-documented prevalence of 70 to 89 percent in acute and 50 percent in those with chronic low back pain.
Again, when the pain can be centralized and eliminated, it's not necessary to identify its anatomic source. This eliminates the need for MRIs or diagnostic tests in these patients. A way has now been identified to predictably eliminate pain by addressing the cause of the problem and not just the symptoms.
The most likely explanation for why some pain centralizes, that is supported by numerous studies, is that disc material that is bulging or herniating out of the back of the disc and causing pain, can be returned toward the center of the disc and away from the pain-generating annulus or compressed nerve root. The still-unchallenged theoretical model is that repeatedly extending the painful spine loads the herniated area and progressively moves that disc material back where it came from, moving it away from the nerve root or painful anulus.
Q: How quickly can the centralization of pain work? Does this solution last?
RD: Patients in whom a directional preference is found commonly leave their first evaluation session with no pain at all. But it will usually come back again. But they are taught to do at home what they did in the exam room and they can eliminate their own pain again. If they keep that up, then the pain typically stops returning. Patients quickly learn to take control of the whole thing with a very rapid recovery. Again, the evaluation identified a way to reverse the painful problem without needing to identify what anatomic structure is causing the pain. Once you find a directional preference, that direction of movement becomes an exercise tool for patients to use to first eliminate and then prevent the return of the pain.
Q: Other than removing pain, what are the benefits to the mechanical diagnosis?
RD: It has significant implications. It adds a whole new layer of dynamic mechanical information about the underlying pain source that is not otherwise available with an MRI or with a standard clinical exam. Importantly, this dynamic evaluation shows whether the problem is reversible or not. And it is commonly reversible. The great majority of patients don't have a "non-specific" back problem. They have a "reducible derangement," which means that something is out of place causing the pain and it is reducible. Nothing inflammatory responds so quickly from mechanical movements — nor does a torn muscle or ligament. A tumor will not have a direction of movement that takes the pain away and then remains better. Only when something is out of place will one direction of movement put it back in place and another movement will bring it back.
There is also no risk to this method. The assessment is very safe as long as symptoms are closely monitored throughout. The exam reveals who has an excellent prognosis and how to treat it, and who does not. For most, we can show them how to take their pain away and restore full spinal movement. Patients then need to be educated on the proper exercise technique plus how to temporarily avoid any bad direction found during the exam. These methods have a dramatic effect on the diagnostic side and an equally dramatic effect on the treatment side.
A group of us presented at a symposium at the NASS meeting in Dallas with spine surgeons addressing the value of this assessment in their practice. For them, it quickly identifies who does and doesn't need surgery. Only those with no directional preference are potential surgical candidates because their problem has great difficulty getting better on its own. Surgeons who utilize this method in a pre-surgical evaluation feel they can operate earlier on those with no directional preference, and that helps reduce recovery time and the chance of a long-term or permanent neurologic deficit. Those who are found to have a directional preference and recover rapidly without surgery are very happy, and happy patients talk, leading to more referrals.
More Articles on Spine:
Biggest Challenges for Spine Surgeons Heading Into 2013: Q&A With Dr. Jeffrey Goldstein
The Arduous Path Toward Healthcare Reform: Is Unification of Ideals and Realities Possible?
St. Joseph's Hospital Surgeons Perform Spinal Surgery on Texas A&M Linebacker