Spinal Preference™
Spinal Preference Maneuver™ and Directional Preference is a paradigm shift in Physical Therapy services offered in MIPT Network going from therapeutic exercise involving spinal muscles to spinal maneuvers resolving intervertebral disc injuries because as everyone knows, the injury is in the intervertebral disc rather than the spinal muscles. Therefore, it is only logical that Physical Therapy services need to focus on resolving disc injuries using MDT spinal maneuvers rather than stretching and strengthening muscles that are simply guarding against further disc degeneration.
Spinal Preference is based off Directional Preference just as Directional Preference is based off the Centralization Phenomenon. Spinal Preference is different from Directional Preference because Directional Preference only looks to establish the direction of an exercise that will centralize a patient’s symptoms but where Spinal Preference not only takes this into consideration but also looks to correlate a patient’s Directional Preference to the different stages of degenerative disc disease within the spine. Spinal Preference ask the question, why is it that a patient’s Directional Preference can change over a lifetime? More importantly, the Spinal Compass Guy was looking for the best way to provide quality control in a MDT Network where clinicians often have a bias for a particular MDT procedure.
Why Spinal Preference™
When tasked to provide quality control in a National MDT Network by a company rated by Inc. Magazine as one of the fastest growing companies in the USA, the Spinal Compass Guy proposed Spinal Compass as a tool to find each patient’s Spinal Preference ™ Maneuver and Clinician’s Compass to track the Treatment Process Data. The company had only recently heard of MDT but was interested in a paradigm shift from a National Spinal Surgery Network to a National MDT Network because they realized that patients who had surgery in their network were still having surgery after surgery and that surgery was not a long term solution for chronic low back pain even though they were contracting with the best surgeons available. This company reviewed the research and understood that MDT is not generalized exercise for low back pain but rather MDT offers a very specific Spinal Preference Maneuver based on whether or not the patient has an annular fissure, annular delamination or nuclear desiccation in the degenerative process which is far more relevant than if the patient is upstream, midstream or downstream on the degenerative timeline; far more relevant than if the patient is having their first episode of back pain, recurrent episodic back pain, or chronic back pain.
Performing Spinal Preference
A patient’s Spinal Preference ™ Maneuver is the perfect maneuver that when performed with just the right amount of force it will abolish all of the patient’s symptoms and where the symptoms remain better afterwards regardless of the stage of degenerative disc disease. Each patient’s Spinal Preference ™ Maneuver is a singular maneuver that when performed the patient may remark, “I cannot believe that this one maneuver turned off all of my pain!” Patients with chronic low back pain are not looking for a Mechanical Diagnosis or to be labeled with a particular syndrome, they simply want to be shown how to turn off their pain in order to avoid surgery. As Tim Flynn recently stated, "The future of Healthcare is helping patients help themselves."
Stages of Disc Disease
Stage One
The Spinal Preference ™ Maneuver for a posterior annular fissure correlates to McKenzie’s extension principle where the patient states that they are better standing and walking and worse sitting and bending. Standing involves static lumbar extension and walking involves dynamic lumbar extension. Sitting involves static lumbar flexion and bending involves dynamic lumbar flexion. The intervertebral disc is loaded against gravity with all of these activities where Audrey Long described the first as the...
The Spinal Preference ™ Maneuver for a posterior annular fissure correlates to McKenzie’s extension principle where the patient states that they are better standing and walking and worse sitting and bending. Standing involves static lumbar extension and walking involves dynamic lumbar extension. Sitting involves static lumbar flexion and bending involves dynamic lumbar flexion. The intervertebral disc is loaded against gravity with all of these activities where Audrey Long described the first as the Directional Preference and the latter as the Directional Vulnerability. Robin McKenzie always recommended unloading the patient in treating the lumbar spine and utilized clues on his Lumbar Assessment form to guide him to each patient’s Spinal Preference ™ Maneuver most often performed in lying. If a patient stated that they were better after walking for 10 minutes then that was a clue for him to explore the spinal lesion using the MDT procedure that matched the spine’s preference for extension as demonstrated in long distance walking. This is Stage One Degenerative Disc Disease where the patient feels best while walking and they may be encountered upstream, midstream or downstream on the degenerative timeline.
Stage Two
The existence of annular delamination is the reason why MIPT only contracts with Certified and MDT Diplomates where inexperienced clinicians often try and force a square peg into a round hole because they haven’t practiced long enough to have seen a patient’s Directional Preference change and so they aren’t looking for it. The existence of the Stage Two patient with annular delamination is the reason why it was important for MIPT to take Directional Preference to the...
The existence of annular delamination is the reason why MIPT Network only contracts with Certified and MDT Diplomates where inexperienced clinicians often try and force a square peg into a round hole because they haven’t practiced long enough to have seen a patient’s Directional Preference change and so they aren’t looking for it. The existence of the Stage Two patient with annular delamination is the reason why it was important for MIPT Network to take Directional Preference to the next logical step in describing a change in Direction of Degeneration at the tip of the lesion. In like manner, we use the term Spinal Preference Maneuver because more than one feature of McKenzie’s conceptual model required modification. McKenzie also imagined that the Spinal Preference Maneuver for posterior annular delamination was actually treating anterior lateral disc lesions. Therefore, MIPT Network recruited a new term to provide a link to nerve root compression associated with posterior annular delamination and McKenzie’s Mechanical Inception of Directional Preference. The Spinal Preference ™ Maneuver for the Stage Two patient with annular delamination is the maneuver that has long hidden behind the fear and trepidation of both the patient and the clinician where certain features of McKenzie's conceptual model inadvertently generated bias. The patient when they reach Stage Two will state that everything makes them worse and nothing makes them better but they couldn’t be further from the truth. The truth has been hidden from the inexperienced clinician because the patient reports that they are worse bending, sitting, standing and walking but where Robin McKenzie importantly listed these as the criteria for a relevant lateral component or annular delamination. McKenzie would say that all of these activities of daily living are in the front to back or sagittal plane and McKenzie would say to explore lateral force progressions first. When the patient states that they are worse walking then they are describing either Stage Two verses Stage Three disc disease but where Stage Two is worse sitting and Stage Three is better sitting. The Stage Two patient is squirming in their chair but Stage Three patient is happy as a clam while sitting completely still. Stage Two typically reports symptoms in only one leg where Spinal Stenosis commonly reports symptoms in both legs.
Stage Three
The Spinal Preference ™ Maneuver for nuclear desiccation moves the patient in the opposite direction as that for an annular fissure where the patient states that they are better bending and sitting but worse standing and walking. The disc when it reaches the final stage is no longer bulging but rather it is drying up and disappearing slowly over time. The Spinal Preference ™ Maneuver for nuclear desiccation is very similar to that for Spinal Stenosis but where in the early stages the symptoms...
The Spinal Preference ™ Maneuver for nuclear desiccation moves the patient in the opposite direction as that for an annular fissure where the patient states that they are better bending and sitting but worse standing and walking. The disc when it reaches the final stage is no longer bulging but rather it is drying up and disappearing slowly over time. The Spinal Preference ™ Maneuver for nuclear desiccation is very similar to that for Spinal Stenosis but where in the early stages the symptoms may remain better afterwards. In the latter stages of nuclear desiccation, spinal stenosis has set in because the disc has lost its ability to function as a shock absorber thus producing facet arthrosis, lateral recess stenosis and central canal stenosis. More importantly, nuclear desiccation occurs because when the Stage Two patient is unable to walk due to debilitating pain, the nucleus or heart of the disc doesn’t obtain the vital pumping action that occurs while walking. This pumping action is vital because it brings nutrition into the disc from vertebral body above and below as well as removing waste products related to disc metabolism. If the Stage Two patient fails to return to walking functional distances at discharge then Stage Three Degenerative Disc Disease or nuclear desiccation and Spinal Stenosis will occur over time.
If the disc which also functions as a flexible spacer between vertebral bodies disappears completely then the patient will describe the shopping cart sign; the patient with Spinal Stenosis can only walk long distances while bent over leaning on a shopping cart where lumbar flexion opens the lateral foramen accommodating the stenosis. In order to preserve the remaining healthy disc, Spinal Stenosis at a single level requires surgery to return the patient to normal upright walking. Therefore, it is paramount to treat the Stage Two disc disease as early as possible on the degenerative timeline and prior to the onset of nuclear desiccation or Stage Three disc disease when the patients are slipping over edge of the waterfall awaiting surgery.
Unlocking Your Pain
After taking the history a clinician may tell the patient that from all of the information that they have gathered thus far, the spine is pointing them to explore a particular Spinal Preference ™ Maneuver where the Compass Critique listed below allows both the patient and clinician to analyze each potential spinal maneuver or force progression. The clinician may say, “The spine is pointing to a specific maneuver that may hold the secret to unlocking all of your pain but first we need to take a compass reading before and after each potential maneuver by bending you frontwards, backwards, right and left…North, South, East, West. We need to see what it feels like when we carefully move your spine in each direction. Please try and remember what it feels like because we are going to take a compass reading before and after each spinal maneuver; this is your chance to critique each potential maneuver one at a time by looking at your pain during motion verses any obstruction to motion. We only need to find one spinal maneuver to unlock your pain but we also want to address the pain that occurs while moving your spine in each of these four directions. In taking a compass reading before and after each maneuver, we should be able to know if you are getting better, worse or if everything is just staying the same.” The Compass Critique is a tool employed by MDT Clinicians to know on day one if we are on the right track. In MIPT Network, we also link the Lumbar Stress Test with the Compass Critique during each visit so we can be assured that Spinal Compass is always taking us right where we need to go.
Spinal Poker Tells
Each patient has hidden within them the clues regarding what maneuver will unlock their pain. It’s fun to imagine that MDT Clinicians are experienced poker players just like Mel Gibson in the movie Maverick. It was priceless when Maverick explained to Jodie Foster’s character, Annabelle that he was able to tell if she was bluffing, had a good poker hand or a bad poker hand just by reading her explicit poker tells. Patients don’t know that they have poker tells but McKenzie gave us all the right questions to ask on his Lumbar Spine Assessment form. Each patient’s poker tells will either point to a Spinal Compass heading of North, South, East or West because it is all about listening to the spine and understanding that each patient has their own Directional Preference according each stage of disc disease. It is true that a patient’s poker tells may change over time just like Jodie Foster’s did in the movie Maverick but a great MDT Clinician doesn’t have a favorite MDT procedure, they just listen to what the spine is telling them and using the Compass Critique as a baseline investigation they are able to confirm their suspicions finding each patient’s stage specific Spinal Preference ™ Maneuver.
Right Direction
Each patient’s Spinal Preference ™ Maneuver is a singular maneuver that when performed the patient may remark, “I cannot believe that this one spinal maneuver turned off all of my pain!” The clinician can then reply, “You have been exercising in lots of different directions and therefore you have been going in circles! If you are tired of going in circles, then you need Spinal Compass? What just happened is not too good to be true. Spinal Compass points in the right direction based on what your spine is telling us makes you feel better and worse.” In MIPT Network we ask questions purposefully and without bias with the intent to determine each patient’s Directional Preference regardless of the stage of degenerative disc disease.
Unlocking Pain
We are finally to the point in the telling of the Spinal Compass guy’s journey where Audrey Long responded with a great big smile. Up to this point, none of this was new to Audrey because she was mentored by none other than Robin McKenzie himself; Audrey is an MDT Instructor and understands and therefore has taught in MDT courses for years McKenzie’s criteria for a relevant lateral component. Also up to this point, she understood where North on the Spinal Compass correlated to lumbar flexion, South correlated to lumbar extension, East correlated to a relative right lateral component and West to a relative left lateral component. However, in performing her research using MDT she had performed thousands of baseline investigations but had never described a baseline investigation using a compass. Prior to exploring a spinal lesion where the spine is telling the clinician to move the patient North, South, East or West, the clinician needs to establish the baseline of what it feels like to move in each of these four directions and the patient needs to be involved in the baseline investigation. Therefore, a Compass Critique is an easy way to describe Directional Preference to our patients in order that they may participate in the process of finding their specific Spinal Preference ™ Maneuver.