Six Highlights From The 12th International Conference In Mechanical Diagnosis And Therapy

The 12th International Conference in Mechanical Diagnosis and Therapy was held October 5 – 7, 2012 in Austin. This conference (along with the Conference Of The Americas) always provides a great opportunity to catch up with many friends, colleagues, and fellow MDT clinicians from around the world. This year was special though – it would be held in Austin. It was the first of many international conferences that I have attended at which I could go home at night and not have to sleep in a hotel bed. Ah yes, it is the simple things in life that we appreciate the most!

Once again, the McKenzie Institute International brought together a great panel of speakers and experts from around the world. One thing that has always impressed me most about this conference is the broad range of speakers, controversial or otherwise. The commonality is that they all attend with a willingness to collaborate and improve the quality of musculoskeletal care, regardless of their expertise or background.

Here are just six of many highlights from the conference.

1. Further confirmation of the failure of the patho-anatomic model. Jeremy Lewis noted in his presentation that 30 – 54% of people with partial full thickness tears of the rotator cuff have no loss of function, and that 50 – 96% of asymptomatic individuals have some degree of structural failure. He reported that there is little relationship between shoulder structural diagnosis and shoulder symptoms.

It has now been shown that knee, shoulder, and spine MRI all reveal structural failures but are not predictive of symptoms. Simply stated, an abnormal MRI is not predictive of pain (or problem). Traditional orthopedic tests may also have high sensitivity (for concordant symptom reproduction) yet low specificity.

But with the current over-utilization of MRI comes another more significant problem - “imaging has a negative psychological effect on the patient” and that the patient “bears that burden” (Lewis).

2. An anatomical “reality check” on core stabilization. Susan Mercer provided some anatomical research regarding the core musculature. She discussed all of the primary muscles of the core, including transversus abdominus and multifidus, with respect to vector analysis and force production. Throughout each and every example, she stated that research now indicates that the basis for the role of these muscles in stabilization is NOT confirmed. I am sure many practitioners advocating for reams of core stability work will be a little dismayed by these findings.

For those who like systematic reviews, Stephen May presented some research indicating that stabilization exercises are no more effective than other active interventions for the management of chronic low back pain. Perhaps more interesting is that they do not appear to prevent a future onset of back pain either.

As an anatomical sidebar, Mercer also noted that “stretches are not stretching connective tissue” as this would entail 5 weeks of non-stop repetition, with more load applied more frequently, in order to do so. How many clinicians, athletes, and coaches are doing that?

3. Obstacles to recovery and prognostic indicators. Nadine Foster gave a couple of great presentations on prognostic factors, classification, and obstacles to recovery. With regards to classification and sub-grouping, she noted that it was important to "spend more time getting science right", and to focus on prognostic factors that actually predict outcome. Her research indicates that there are two prognostic factors that are predictors of a poor outcome at both 6 months and 5 years: pain intensity, and a strong belief and negative perception about back pain.

4. MDT as cognitive behavioral therapy (CBT). Mark Werneke and Gary Jacob both presented their perspectives on a very valuable clinical benefit of MDT. It is, in effect, a cognitive behavioral approach as it incorporates behavioral change as its most basic level. Although this is something that MDT clinicians intrinsically understand, it was an interesting way to phrase the discussion.

As an aside, Jacob noted that 50% of premature deaths could be prevented by behavioral change. Now that is something that could have a huge impact on health care costs in this country.

5. Classification schemes are the latest trend in health care. There were a number of presentations regarding classification schemes and their defining elements. Nadine Foster, Tom Petersen, John Childs, Wim Dankaerts, Robert Medcalf, and Maurits van Tulder all contributed to the discussion. As would be expected, all presenters espoused the benefits (and some of the realities) of their respective classification scheme.

Unfortunately, the abundance of classification schemes creates a huge problem. New additions to the fray oftentimes try to “re-invent the wheel” and overlap many effective strategies already in place. Long-term, I expect this to be a global problem of further micro-management.

6. The clinical value of the MDT mechanical assessment. One thing that takes place at all McKenzie conferences is the evaluation and treatment of patients on stage. This is something that few (if any) other approaches to care are typically prepared to do. The live patient assessments always provide conference participants with a view of the inner workings of MDT, and can serve as great learning experiences.

Along with these live patient assessments, there were studies presented on the use of MDT with osteoarthritic knees (Richard Rosedale) and elderly patients with back pain (David Oliver). The spectrum of clinical value is increasing steadily, and now has even more research to support the use of Mechanical Diagnosis And Therapy.

But were there only six highlights? Absolutely not! Of course, this doesn’t do justice to the vast amount of research and experience shared at the conference. Add to that the interactions amongst clinicians, and it was a highly valuable learning and collaborative experience.

My “quote of the conference” goes to none other than Dr. Wetzel, a noted spine surgeon from Philadelphia:

“Nothing destroys confidence like follow-up”.

Embracing and implementing the research won’t come without some challenges and difficult conversations amongst clinicians. Fortunately, the 12th International Conference provided an environment for good, positive discussion. Patients are too important and deserve no less than that from all of us.

Onwards to the 2013 Conference of the Americas in Denver – and the 2015 International Conference in Copenhagen!

Photo credits: abesselink