I recently read a great case report in the most recent JMMT. As mentioned before here, if you don’t read case reports and only stick with “higher level evidence”, you will only set yourself back as this level of evidence is significantly important in opening up your vision. I know case reports will not change our reimbursement rates and some of the more new issues along this realm that we need to address, but I feel that if our results continue to improve through cases like this, then it will elevate our status in the medical field and continue to push us to be the primary choice for musculoskeletal care.

I applaud the authors (Greg Lynch and Steven May) for writing this case up to be published as it certainly should get into the hands of all physical therapists. Here are some points that I will like to add to this report:
1. Cookie Cutter Approaches do NOT work. Ugh, I get on my soap box with my interns over this (enough that veins come out of my forehead!) but won’t spend too much time on it as I’m preaching to the choir. Nevertheless, the screenshot above of what was performed prior to this bout of physical therapy is true cookie cutter. In short, it pisses me off.

2. Simple management concept: Restore ROM first. Especially extension.
As mentioned in the article, the directional preference for this case was knee extension. I would definitely say this is the movement that is we need functionally and the best choice for success overall. Did the previous physiotherapist feel performing hamstring stretches and ultrasound was going to get this? Only in simple cases, and this is where Google Search for a client will get themselves better on their own.

3. Directional Preference is a high percentage shot.
Directional preference is classically thought of for the spine but as show in this article, it can be of significant benefit in the extremities. As I teach my interns, look into finding this first as it is similar to making a lay up instead of 3 pointer. It is a high percentage make and can get results, or points on the board. If not found, go on to other basic movements or manual therapy. And if found, great, go with it and then add other basic movements and manual therapy. Just don’t leave this simple concept out to dry.

4. Less is more.
I love that the authors only prescribed passive knee extension in several type of loaded positions! Wow, and the patient got better?! Once you restore ROM (reduce the derangement, improve arthrokinematics or however you want to look at it); the body can mend itself. Look at this past report on myself. The body just needs that simple mechanical stimulus. That stimulus doesn’t have to be 1 hour in the physical therapy clinic and 10 exercises for home. Less is more=greater compliance

5. You don’t have to be McKenzie trained to perform this strategy and execute in this manner.
I am not McKenzie trained, nor taken one single course. For those who are, you may frown upon me but I understand the concepts. I love the assessment process, and I use a mutt approach with it through my own assess / re-assess model. Would I benefit greatly from taking courses? Absolutely and will probably be on the calendar in the future but don’t limit yourself to great results if you don’t have a practitioner’s name behind your degree. McKenzie doesn’t own the term directional preference as chiropractors do not own the term manipulation. Use it and develop it further to add in your go to treatments based on your clinical experience and the patient’s circumstances right in front of you.

Oh, one last note: if your go to treatment is ultrasound and hamstring stretches, refer back to #1 and retire already. And this was done overseas, I thought physiotherapists didn’t do this stuff, only physical therapists?


    1. The profession of physical therapy overseas has a much longer history and historically more autonomy and respect.

      1. Really? That’s not what we are led to believe in Australia and NZ. It’s my experience that we have great autonomy and immense respect, largely due to our dedicated contribution to research. I have worked in the UK for two years in the NHS, have worked in NZ and many states within OZ. Would definitely rate our southern physios as higher quality than UK, can’t speak for USA. Just an interesting perspective you have.

        Keep up the great blog, I enjoy reading it.

  1. Thanks for the thoughts. I have only recently heard of the concept of using directional preference for the knee joint. Would you be able to direct me on any more information on the theory (i.e. articles or explanations for application)?

    1. Hey Peter,
      Thanks for commenting and reading the post. DP stems from specific exercise treatment based classification systems. McKenzie is most popular, but also Delitto’s work is highly regarded too.
      DP is studied significantly more (at least my knowledge) for spinal conditions. It is one of the treatment approaches of McKenzie and I believe the extremities are taught in Part E. Honestly, I haven’t taken any of their courses so can’t say for sure, but I recommend checking into Part E for more specifics.
      Here is an article from PT Journal: http://ptjournal.apta.org/content/92/9/1175.full


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