Gary Jacob, DC, LAc, MPH, DipMDT - PowerPoint PPT Presentation

Title: Gary Jacob, DC, LAc, MPH, DipMDT


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The McKenzie Method as a Public Health Campaign

• Gary Jacob, DC, LAc, MPH, DipMDT
• Chiropractic Consultant to the McKenzie Institute
  International
• garyjacob.com

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The McKenzie Method as a Public Health Campaign
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The McKenzie Method as a Public Health Campaign
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The McKenzie Method as a PHC

• McK is a Private Practice Intervention (PPI)
• However, McK principles are
• more consistent with Public Health Campaign (PHC)
  principles than the principles upon which most
  other PPIs are based

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McK as a PHC

• Biopsychosocial vs. Biomedical basis
• undervalued if viewed as biomedical/biomechanical
• Primary, Secondary and Tertiary Prevention
• vs. Secondary Prevention only
• Health education to promote self-efficacy
• vs. intervention without goal of health behavior
  change
• Educates populations to change behaviors
• vs. non-educational intervention targeting
  individual

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1. Biopsychosocial vs. Biomedical

• A PHC has a Biopsychosocial (BPS) basis
• Most PPIs are Biomedical (BM)
• biomedical SIPP
• biomechanical disc, Spasm
• biochemical Inflammation
• Proprietary Pathologies PT CAM
• SIPP precludes the ability to realize the
  potential of movement and positioning strategies

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Common PPI Interventions

• Multiple professions
• a vast array of approaches within each profession
• conflicting convictions re relevant findings,
  diagnoses, treatments

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Common PPI BM Themes

• Sufferers experience not the critical finding
• No intentional health education
• to change cognitions health behavior change
• Physical Target SIPP

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SIPP

• Spasm /or Inflammation
• assumed to be cause of nociception
• regardless of structure thought to be culpable
• basis for
• multiple passive interventions
• rest, meds, needles, modalities, bracing, manual
• restricted, delayed, discontinued ADLs, work, etc.

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SIPP Models

• Proprietary Pathologies
• PT CAM findings, diagnoses treatments
• unique to particular profession or subculture
• skills cannot be acquired by patient
• provider divines when it is that patient is well

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Common PPI Exercise

• One ceremony fits all tangential to needs
• SIPP assumptions
• delay exercise
• passive therapy meds routinely precede exercise
• limit cognitions and behaviors re exercise
• passive therapy/meds often proceed with exercise
• Proprietary Pathologies
• disability/athletic performance models
• Not informed by sufferers experience

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Origin of Biopsychosocial

• G.L. Engel, M.D. Writings 1960s and 70s
• Biomedical model deficient
• Insensitive, callous, neglectful, arrogant,
  MECHANICAL
• Biopsychosocial model to be replacement
• Meld physiology, psychology and sociology

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Dueling Models

• Biomedical
• Diseased Patient
• Physician detached
• in vitro
• Dualistic
• Reductionist

• Biopsychosocial
• Person suffering
• Physician engaged
• in vivo
• Systematist
• Holistic

Science deals with things, not people- Marie
Curie
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Engels Systems

• Biosphere
• ??
• Society-Nation
• ??
• Culture
• ??
• Subculture
• ??
• Community
• ??
• Family
• ??
• PERSON CONDUCT AND EXPERIENCE
• ??
• Systems
• ??
• Organs

• McK BPS emanates out (i.e. up ? down ?)
• FROM the person TO affect
• Psychosocial systems above
• Biomedical systems below
• vs.
• Psychosocial Above person down
• Biomedical Below person up

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Biomedical
Person Conduct And Experience ?? SYSTEMS ?? ORG
ANS ?? TISSUES

• Targets beneath the level of the person
• psychosocial dimensions are distractions
• Important for trauma infections
• psychosocial factors take a back seat
• Fails conditions with a propensity for chronicity
• conditions best avoided, resolved or managed with
  health education and behavior changes
• BM approach alone increases likelihood of
  chronicity

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Lets Blame Descartes!1596 - 1650
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Lets Blame Descartes!1596 - 1650
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Lets Blame Renee!

• Dualism mind and body separate things
• Understood independent of each other
• Can understand body without mind
• Reductionism reduce to simple components
• If not reducible, not amenable to scientific
  inquiry
• Math and physics are the real, hard sciences

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Lets Blame Renee!

• Pain proportional to extent of physical damage
• Pain model pulling on rope of church bell
• Absent physical damage ? mind culpable

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Biopsychosocial ModelMain CJ, Williams ABC of
psychological medicine Musculoskeletal pain, BMJ
v 235 9/7/02

• Psychological and social factors
• Can exacerbate biological substrate of pain
• Can influence
• pain perception
• the MEANING of pain
• the development of chronic disability

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Evidence Supports a Change Main CJ, Williams AC
ABC of psychological medicine Musculoskeletal
pain, BMJ v 235 9/7/02

• From treating as a mechanic
• To coaching self-management

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Simple BPS StrategiesMain CJ, Williams AC ABC of
psychological medicine Musculoskeletal pain, BMJ
v 235 9/7/02

• Enhance accurate beliefs
• Explain hurt vs. harm
• Reassure re future benign nature
• Challenge unhelpful thoughts biases
• About pain its implications
• Avoidance of activities due to fear
• Enhance self management skills
• Manage and gain control over symptoms

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BPS vs. BM Sense Data

• The BM model traditionally employs
• Sight postural analysis to advanced imaging
• Touch palpation
• Taste is out
• Smell does not play much of a role

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WFC Montreal 2009
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Hearing
The Song the Derangement Sings
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McK vs. Common PPI

• McK-BPS
• informed by and targets cog-b processes
• the sufferer is the active, essential
• participant-observer-informant
• agent, lead actor hero of the narrative
• Provider has only a walk-on part supporting role

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McK- Psychosocial

• Education to change health-related
• knowledge, attitudes, beliefs, skills
• passive to active coping
• external to internal locus of control
• Shift responsibility to sufferer
• vs. occupation, community, institutions
• Communication is the key

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McK- Psychosocial

• McK Listens!
• subjective experience informs strategies
• McK teaches!
• de-catastrophizes the disc
• encourages sufferer to explore pain patterns
• reframes pain to diminish fear
• relaxed, reflective, contemplative study of pain
• student vs. sufferer

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McK- Psychosocial

• Explores self-efficacy FIRST
• if a health behavior is the first relief
  realized, that health behavior is likely to
  persist

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Centralization as BPS Phenomena

• Predictor of Provocation Discography
• Specificity 94
• Sensitivity 40
• LR 6.9
• Laslett, et al. The Spine Journal 5 (2005)
  370-380

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Centralization as BPS Phenomena

• Centralization
• better prognosticator than psychosocial (FAB)
• is centralization biomedical?
• Centralization mgmt has Cog-B components
• respects sufferers phenomenological experience
• deprograms and reprograms
• FEAR of centralization is obstacle to overcome

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Centralization as BPS Phenomena

• Centralization Management
• meaning ascribed to subjective perceptions
• educated/motivated to pursue and maintain
• vs. previous FEAR of central pain
• one provider may have the ability to motivate the
  pursuit - another may not

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Evidence informed management of CLBP with the
McKenzie methodMay, S, Donelson, R The Spine
Journal 8 (2008) 134-141

• Centralization better predictor of long term
  pain, disability, other health outcomes than FEAR
  avoidance work factors

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Evidence informedMay, S, Donelson, R The Spine
Journal 8 (2008) 134-141

• Non-Centralization predicts
• poor behavioral response to spine pain
• 9x more likely to have nonorganic signs
• 13x more likely to have overt pain behaviors
• 3x more likely to have fear of work
• 2x more likely to have somatization

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Evidence informedMay, S, Donelson, R The Spine
Journal 8 (2008) 134-141

• Psychosocial may not have dominant role
• Many studies have failed to demonstrate
• superiority of Cog-B vs. exercise, manual
• McK is a Cog-B approach to exercise manual tx
• psychosocial treatment improves CLBP
• McK is Biopsychosocial approach
• Reducing pain resolves most psychosocial
• the McK road to get there is Biopsychosocial!

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If McK is not psychosocial

• It is not necessarily biomedical
• Biomedical lacks Psychosocial
• Psychosocial lacks Bio
• Is the Bio of BM and BPS the same?
• NO!
• BM bio is in vitro
• BPS bio is in vivo

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Psychosocial vs. Biopsychosocial

• Psychosocial
• non-biological co-morbidities
• factors not rooted in relation to current,
  novel biology events
• Biopsychosocial PSYCH and SOCIAL processes
• ascribing meaning to BIO experiences
• McK bio rooting is unique
• primacy of sufferers direct/intimate in vivo
  experience of negotiable BIO phenomena

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BPS relationship centered

• "It's the relationship that heals,
• the relationship that heals,
• the relationship that heals
• my professional rosary."
• Yalom, I. (1989),Love's Executioner, London
  Penguin Books, p.91

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Biomedical?
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Biopsychosocial!
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BIOMEDICAL REDUCTIONIST
Renee Descartes
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SOCIALIST
Karl Marx
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PSYCHOSOCIALIST
Josef Stalin
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BIOPSYCHOSOCIALIST
Gordon Waddell
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2. Primary, Secondary, Tertiary Prevention
3-Lines of Prevention

• Primary Prevention PHC-BPS
• efforts to avoid acquiring the condition
• lay public conception of prevention
• Secondary Prevention PPI-BM
• attention to those who acquired condition
• lay public conception of treatment
• Tertiary Prevention PHC-BPS
• mitigation of chronic residual effects
• BPS model most important here and needed here if
  not applied at earlier stages

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McK 1 Prevention

• Efforts to avoid acquiring LBP
• McKenzie shown to be prophylactic
• vs. most PPI interventions for LBP

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McK 2 Prevention

• Attending those who have acquired LBP
• Typically the province of PPI vs. PHC
• Evidence for McK as 2 Prevention

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McK 3 Prevention

• Mitigation/management of chronic LBP
• requires education re appropriate cognitive and
  behavioral (self-management) measures
• Self mgmt essential for chronic health problems
• McK benefits acute, subacute or chronic

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3. Health education to promote self-efficacy
Cog-B Models!
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Stages of Change (?)

• Pre-contemplation unaware, not thinking of ?
• Contemplation thinking about future ?
• Decision/Determination making plan to ?
• Action implementation of specific action plans
• Maintenance continuation of desirable actions

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McK-Pre-Contemplation Stage 1

• UNAWARE of
• relation between perceived
• symptoms
• mechanics
• potential of movements positioning
• to eliminate complaints
• need to pursue centralization vs.
• fear avoidance of centralization

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McK-Contemplation Stage 2

• THINKING ABOUT FUTURE CHANGE
• Mindfulness of patterns of in vivo responses to
  movement and positioning permits
• pain/disc de-catastrophized
• entertainment of notion that self treatment is
  possible
• issues of choice and responsibility introduced

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McK-Decision/Determination Stage 3

• MAKING PLAN TO CHANGE
• based on realization that self-generated
  movements and positionings result in diminution
  of complaints

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McK-Action Stage 4

• IMPLEMENT SPECIFIC ACTION PLAN
• self treatment plan prescribed
• issues of choice and responsibility stressed
• early return for reinforcement of self-care

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McK- Maintenance Stage 5

• Likelihood of new health behavior being
  maintained is greater if the
• main focus of care is coaching
• first relief experienced is from self-care

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4. Educates populations to change behaviors

• Public Health Campaigns
• target populations
• to change individual behaviors
• top-down (population-to-individual) effect
• change Cog-B culture re health problem
• Knowledge, attitudes, beliefs, skills
• provider contact avoided/minimized
• intent to not treat
• intent to educate

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McKenzie as a Public Health Campaign

• TYOB
• first published 1980
• 17 languages
• 5-6 million sold
• MII
• 28 country branches
• 330 DipMDT
• 5,000 CredMDT

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McK-PHC Messages

• Logical Ethical to explore
• self-generated movement positions first
• Myths about LBP prevent relief, self-efficacy
• Most spinal dxs do not preclude self-efficacy
• most LBP not SIPP

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McK-PHC Messages

• General recommendations for the population
• Avoid
• repetitive or prolonged spinal flexion,
  especially early a.m.
• Perform
• spinal extension movements to counteract flexion
  life
• Maintain
• a hollow in the back when sitting
• Simple movement and positioning strategies can
• Prevent
• Rapidly resolve
• Offer coping skills for those that do not resolve

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McKenzie as a Public Health Campaign

• McK Global PHC activities
• changing cognitions behaviors
• providers
• educators
• research
• public

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Mindfulness
Schell, Clinical and Professional Reasoning in
Occupational Therapy, 2008 Lippincott Williams

• Strategically arranged experiences
• Yield articulated knowledge
• Which is meta-cognitively examined
• Through reflection, for meaning

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SUMMARY

• Most PPIs vs. McKenzie
• are biomedical secondary prevention interventions
  
• no health education to promote self-efficacy
• perpetuate cultural myths about back pain
• The McKenzie
• PPI more like a PHC than other PPIs
• BPS, Cognitive-Behavioral approach
• Primary, Secondary and Tertiary prevention
• Health education principles to promote self
  efficacy
• Impact on population spinal culture

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• Its not the size of your disc that matters
• Its how you use it!

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