REFLECTIVE PRACTICE ON CLINICAL INCIDENCE TITLE: EFFECTS OF REPETITIVE MCKENZIE EXERCISE 1.

1 WHAT HAPPENED During my fourth week in Malacca Hospital for outpatient cases, I came across an old case which the patient is a 35 years old woman came into department independently with the normal walking gait. This time was her second visit with prolapsed intervertebral disc problem. Thus, I proceed to do my subjective and objective assessment thoroughly. Based on patient complain, she claimed that the condition still same with no reduce in pain compared to first visit. From my physical examination, she was having tenderness noted at lower back around L2L5, grade III with pain noted when doing PAIVM at L3-L5 and muscle tightness (piriformis and hamstring muscle). Thus, for intervention part, I decided to teach her in McKenzie exercise since she has not been taught during her first visit. Besides McKenzie exercise, I also added other exercises for hamstring and piriformis stretching. For McKenzie exercise, I have taught patient to do extension in forearm support with 8-10 repetitions. For home exercise program, I have advised patient to do extension in forearm support, 8-10 repetitions, 3 sessions per day. After doing the McKenzie exercise, patient claimed that pain centralized at back and pain has reduce more. As I got ready to give her the next appointment, the physiotherapist took over and said to me that she want to look what exercise that I have taught to the patient. Then, I explained all the exercise that I taught to the patient and the patient shows how to do the exercise. For McKenzie exercise, the physiotherapist changes the repetitions that I prescribed to the patient. She told the patient to do only 3 repetitions for

extension in forearm support (McKenzie exercise) because she said this exercise cannot be done for many repetitions. 1.2 MY REACTION At first I was not really happy with the physiotherapists action without discussing it with me. Im not satisfied with the less repetition that she told the patient to do. Because of that, I went to ask and discuss with her about this thing. However, Im still not satisfied because she said she not know the exactly reason why need to do less repetitions, she only follow the previous batch that doing less repetitions. 1.3 VALUE EARNED As we know, McKenzie exercise is more effective than other therapies/exercise as Machado et al (2006) stated that the McKenzie method is more effective than passive therapies, including educational booklets, ice packs, and massage for acute LBP patients. From my reading and in class, I learned that the repetitions of McKenzie exercise are commonly 8-10 repetitions (Liebenson, 2005). According to AlObaidi et al (2001), the recommended repetition for a home program, based on McKenzie approach is 1015 repetitions but some patients believe that more is better, and they may perform more than the prescribed number of repetitions. However, the number of repetitions and the type of exercise can affect the overall physiologic demand of exercise (McArdle, Katch , Katch, 1994). Thus, based on study done by Al-Obaidi et al (2001), repetitive McKenzie exercises for the lumbar spine have cardiovascular effects in people with no cardiovascular or cardiopulmonary conditions and who are within an age range of people susceptible to low back pathology. This effect is accentuated with increasing repetitions. The magnitude of the risk associated with lumbar spinal loading exercises reflects the type and severity of underlying cardiovascular or cardiopulmonary pathology, the type of spinal loading exercise, breathing rhythm, the number of repetitions and their pacing, and the number of sets and their frequency throughout the day. Thus, its important to reduce the repetition (less than 10 repetitions) whenever the patient having high risk for cardiovascular and cardiopulmonary conditions.

1.4 MY NEW UNDERSTANDING From this situation, now I understand that before prescribing the repetitions for McKenzie exercise, I need to look at the patients medical history whether the patient having cardiovascular or cardiopulmonary problem. Its because repetitive McKenzie execises of the lumbar spine would produce marked changes in the work of the heart and that these effects increase with multiple repetitions. However, for the patient just now, she was having no cardiovascular or cardiopulmonary problem. So, for my opinion, there is no harm for the patient to do 8-10 repetition for McKenzie exercise. Its just that we need to monitor patients blood pressure, heart rate and respiratory rate while doing the exercise. 1.5 HOW IT WILL AFFECT MY BEHAVIOUR IN FUTURE CLINICAL PRACTICE As conclusion, in treating patient with low back pain, I know that I should not overlook patients medical history and patients other problems especially when prescribing exercise to the patient. 1.6 REFERENCES 1. Al-Obaidi, S., Anthony, J., Dean, E. & Al-Shuwai, N. (2001). Cardiovascular Responses to Repetitive McKenzie Lumbar Spine Exercises. Physical Therapy. 2. Liebenson, C. (2005). McKenzie self-treatments for sciatica. Journal of Bodywork and Movement Therapies. 3. Machado, Souza, Ferreira, and Ferreira. (2006). The McKenzie Method for Low Back Pain. A Systematic Review of the Literature with a Meta-Analysis Approach. Lippincott Williams & Wilkins, Inc. 4. McArdle WD, Katch FI, Katch VL. (1994). Essentials of Exercise Physiology. Philadelphia.