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A physical therapist performs the McKenzie Method on a patient.

For anyone suffering from spinal disorders, that unmistakable lightning bolt zap of back pain is easily recognized when it reappears. Often striking without warning, back pain can occur when performing the most innocuous of everyday motions, ranging from bending over to tie your shoe to getting out of bed.

Just as debilitating, balance problems are some of the most frequent complaints that annually send sufferers to the emergency room. The technical term for the false sensation that you and the world are spinning is "vertigo." There are many causes of vertigo, but when it occurs, the condition can cause episodes of that uncontrolled spinning sensation, nausea, inability to stand, double vision and trouble focusing the eyes.

For many plagued by these two serious medical conditions, the only solution used to be numerous visits to the physician's office, and in more severe cases surgery, followed by months of costly and often painful rehabilitation. If all of this time and trouble could be avoided by following a targeted exercise regimen, undoubtedly most people would sign up.

Preventive and rehabilitative programs are exactly what not only the doctor, but also the physical therapist, are now ordering for both back pain and vertigo, more commonly diagnosed as benign paroxysmal positional vertigo (BPPV).

"Simple" is the key word Tupelo physical therapist Craig Bertelsen uses to describe the McKenzie Method®, which is successfully providing relief from pain associated with back problems for many of his patients at North Mississippi Medical Center (NMMC).

Known internationally as The McKenzie Method of Mechanical Diagnosis and Therapy®, the treatment is a comprehensive approach to the spine based on a series of exercises that when understood and followed accordingly are successfully easing back problems that previously only responded to surgery or years of therapy.

Bertelsen said the first step in determining if a patient is a viable candidate for the McKenzie Method is a detailed assessment program that leads to the simple classification of spinal-related disorders.

"Just about every person experiences back pain at some point in their life," said Bertelsen. "Many episodes resolve themselves over time; usually within a two-month period. The patients that come to us are generally those with pain that hasn't gone away after two months. After many trips to the physician's office for medication and other treatment options that may or may not provide relief, the McKenzie Method is then the next step that we recommend."

The McKenzie Method is based on a consistent "cause and effect" relationship between historical pain behavior as well as the pain response to repeated test movements, positions and activities during the assessment process. The method consists of a systematic progression of applied mechanical forces (the cause) that utilizes pain response (the effect) to monitor changes in motion/function.

The underlying disorder can then be quickly identified through objective findings for each individual patient. Based on the findings of Robin McKenzie more than 40 years ago, the method focuses on three mechanical syndromes: postural, which focuses on the end-range stress of normal structures; dysfunction, the end-range stress of shortened structures such as scarring and fibrosis; and derangement, which deals with the anatomical disruption or displacement within the motion segment.

All of the syndromes share the commonality of occurring in the cervical as well as thoracic and lumbar regions of the spine.

According to Bertelsen, the method stresses the theory that if an individual adopts certain positions or performs certain movements that cause the person's back to 'go out,' then if therapists understand the problem fully, they can identify other movements and other positions that, if practiced and adopted, can reverse that process.

Bertelsen completed an extensive course of study and training to become certified in the McKenzie Method. This training enables him to identify those more difficult cases where advanced McKenzie techniques might benefit the patient versus patients whose diagnosis is nonmechanical in nature. Those patients are then quickly referred for alternate care, thus avoiding unnecessary periods of inappropriate or expensive management.

Those whose conditions are deemed appropriate for the McKenzie Method undergo a series of treatments that include exercises tailored to their particular back problem. Bertelsen said that most patients show remarkable results within a few sessions.

Since the McKenzie treatment emphasizes education and active patient involvement in the management of their treatment, patients are taught to perform the exercises at home, restoring function and independence, and minimizing the number of follow-up visits to the clinic, Bertelsen said.

If a back problem is more complex, self-treatment may not be possible right away.

However, Bertelsen said proper patient assessment and evaluation allow him to recognize situations when additional advanced hands-on techniques are needed until patients can successfully manage the prescribed skills on their own.

Ultimately, most patients can successfully treat themselves when provided the necessary knowledge and tools. An individualized self-treatment program puts patients in control of their life and minimizes the risk of recurrence, Bertelsen said.

"We're seeing a tremendous amount of success with the majority of our patients who are using the McKenzie Method," said Bertelsen. "There's no doubt that the McKenzie Method will continue to grow as more physicians are realizing that it is a viable treatment option for many of their patients."

The diagnosis and treatment of vertigo, a condition that was once thought to signal a tumor or stroke, have markedly improved in the last two decades. Vertigo is now believed to be caused by calcium debris that has dislodged from a part of the inner ear and strayed into one of the fluid-filled semicircular canals of the sensitive vestibular system.

The presence of these microscopic flecks of calcium debris does not actually create problems, but sometimes in their wandering path, they brush against delicate, hair-like cells, sending misinformation to the brain. When those signals conflict with more accurate signals from other nerves, the brain responds with disorientation and vertigo.

BPPV is one of the most common causes of dizziness caused by a malfunction of the inner ear's balance mechanism. Those afflicted by BPPV previously had two options: make it (with assistance) to the emergency room or to their physician's office. Now there's another place to receive much-needed relief: a physical therapist's clinic.

According to Alison Farley, also a NMMC physical therapist, benign paroxysmal positional vertigo can be distinguished from some other disorders by the fact that hearing is not affected, that dizziness occurs in repeated brief episodes — usually a few seconds to a minute — and can be provoked by specific body movements, such as rolling over in bed or rising abruptly.

Patients who exhibit BPPV's symptoms are usually given the vestibular test. Called the Dix-Hallpike test, it is a noninvasive positional procedure used to accurately determine if a person has BPPV.

For a large percentage of patients diagnosed with BPPV, vestibular rehabilitation is a relatively quick and easy solution to a problem that can often go untreated and cause problems for a lifetime.

Vestibular rehabilitation is an exercise program designed to help compensate for a loss or imbalance within the vestibular system. The program, which can be administered by trained therapists such as Farley, may include balance activities and/or eye or head movement exercises.

The balance activities help patients maximize the use of their remaining vestibular function, their sight, and the sensation in their feet to keep their balance.

When there is an imbalance in the vestibular system, a person may also experience dizziness because the reflexes that help with eye movement have been changed. Eye exercises help the brain relearn these reflexes. Because each patient's symptoms and needs are different, it is very important to design a program to meet individual needs.

Farley said in most cases when it is found that a patient has BPPV, a noninvasive positioning procedure is used to clear the crystals out of the canal and deposit them back into the part of the inner ear where they belong.

To help relieve BPPV, therapists use a series of simple maneuvers called the canalith repositioning procedure. The maneuvers involve moving the head into four different positions sequentially, taking advantage of gravity to roll the calcium flecks out of the sensitive part of the canal to a place where they cause less trouble.

The procedures vary, but in most cases, the patient is moved from a sitting to a reclining position and the head is extended over the end of a table at a 45-degree angle. The patient's head is turned to the side to allow the particles to dislodge before they are rolled onto the other side. The head is then slightly angled so the patient is looking down at the floor. The patient is then carefully returned to a sitting position, with the chin pointed down.

Farley said the success rate of these basic exercises usually surprises patients who are skeptical at first that life as they knew it before BPPV would ever return.

"Most patients who undergo canalith repositioning — at least 90 percent — have their symptoms alleviated in one set of treatments," Farley said.

The remaining 10 percent, she added, may need repeated treatments, but the overall recurrence rate is low. The majority of BPPV episodes may not come back for months or years.

For all but the most severe cases, which occasionally require more extensive treatment, the simple and low-tech maneuvers rank among the most effective and certainly the least costly of treatments for such a common and disabling source of misery.

"BPPV is a horrible feeling," said Farley. "Physicians and therapists do need to have empathy for these patients, and most do, especially when they witness first-hand the patient's suffering. In recent times, we're seeing more awareness of the condition and the maneuvers, both in the hospital emergency room and the family medical clinic. That is great news for the entire medical community, but especially for the BPPV patient."


ie.
October 2006

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