The McKenzie Method and Spine Pain

Background:

The story goes that in 1956, a therapist named Robin McKenzie had a patient named Mr. Smith who had been experiencing an episode of acute low back and leg pain lasting for three weeks despite standard treatment interventions.  On arrival for a return visit for treatment, Mr. Smith was directed to an exam room and instructed to lie face down on the examination table to wait for Mr. McKenzie.

It just so happened that the room he was to use had had just been vacated by a patient with a knee problem and the head of the table had been elevated for the reclining patient to receive her knee treatment. Mr. Smith complied with his instructions, entered the room, and lay face-down on the table to await his treatment.

McKenzie extension position

Now this may not seem that unusual to most of us, but at the time lying in this prone position with the lumbar spine in extension was thought to be one to avoid for patients with low back pain.

Needless to say, when McKenzie entered the room he was reportedly alarmed at Mr. Smith being left in such an unorthodox position.  He was surprised, though, by Mr. Smith’s report that “his leg pain was completely gone and he was only feeling some mild low back pain. ‘This is the best I've felt in three weeks!’ he was reported to have said.”[i]

Intrigued McKenzie reportedly then suggested that the patient come back tomorrow for another treatment.  On the next day the patient again reported that his low back pain was abolished when McKenzie returned him to the same face-down, extreme back bending position.

This experience prompted Robin McKenzie to further experiment with a movement assessment of patients with back pain and eventually grew into a standardized method for approaching spine pain.

What is the McKenzie Method:

The McKenzie Method seeks to explore the cause and effect relationship between the positions a patient usually assumes while sitting, standing or moving, and the generation of pain as a result of those positions or activities.

The therapeutic approach algorithmically moves a patient through a series of activities and test movements to gauge the pain response. The approach then uses that information to develop an exercise protocol designed to centralize (to move pain from a limb to the central area of the back over the spine) or alleviate the pain.

The primary goal of patient assessment, then, is to determine sort through how a patient’s pain symptoms can be made better or worse by adopting various, differentiated active positions.  With that information, a trained therapist can determine the patient’s “directional preference of movement for treatment.”[ii]  

Scope of the McKenzie Method:

The McKenzie method for evaluation and treatment is generally most useful for treating acute, subacute or even chronic disc-related pain.  The method aims for a mechanical diagnosis and does not necessarily attempt to arrive at a pathoanatomical diagnosis (see “Pathoanatomical Perspective on Pain” section above).  Rather, the method focuses on a “Mechanical Diagnosis and Therapy” (or MDT). 

However, studies have generally shown the McKenzie approach to back pain to be most useful in situations of degenerative disc – related pain with associated pain referred to the limbs.  Research has found the following types of patients to not respond well to this mechanical approach[iii]:

• Extruded disc fragments
• Lumbar stenosis
• Internal disc disruption (which is a controversial group)
• Facet joint-related pain

McKenzie System for Classification:

The McKenzie Method divides pain syndromes into three broad categories[iv]:

1. Postural Syndrome:
   1. Viewed as being the result of prolonged postures or positions
   2. Pain is generally be local and reproducible when end range positions, such as slouching
   3. Response or pain relief is usually immediate to posture/position changes
   4. Dysfunction Syndrome:
      1. Characterized by:

                                                               i.      Adaptive shortening, scarring or adherence of connective tissue with associated movement loss and pain at the end range of movement.

                                                             ii.      Pain is decreased as the the patient moves away from end range

1. Successful treatment takes time because of requisite tissue remodeling
2.  Derangement Syndrome:
   1. Most common clinical presentation
   2. Characterized by sensitivity to certain movements and its preference for particular movement patterns.

                                                               i.      i.e. Extension of the lumbar spine causes pain to become either more central (e.g. just in the low back) or less intense.

1. Can respond rapidly to treatment

Studies on the McKenzie Method:

The McKenzie Method has been studied extensively in the spine literature.  There remains some controversy this method and how far its influence can be extended (with some studies on both sides of the fence regarding its utility).[v]  However, there is generally good evidence for (1) the potential for McKenzie screening to classify back pain symptoms and (2) offer the potential for good outcomes with treatment McKenzie recommended treatment interventions.

First, as a classifying tool, Studies have shown that “The McKenzie assessment process reliably differentiated discogenic from nondiscogenic pain as well as competent from an incompetent anulus in symptomatic discs and was superior to magnetic resonance imaging in distinguishing painful from nonpainful discs.”[vi]  A related study showed that “Pain centralization during the first 5 treatment sessions of mechanical physiotherapy is a useful diagnostic tool to predict a good longterm outcome.” [vii]

 

There is some evidence that the McKenzie screening is most useful in the context of disc-related pain and when the fibers of the disc annulus (or outer fibers of the disc material) are intact.[viii] [ix]  So, it may not be applicable for all situations with low back pain.

There is positive evidence, though, for good outcomes with treatment according to McKenzie protocols.  For the management of acute low back pain, studies have shown good short-term benefits in terms of pain and reduce health care utilization.[x] [xi] 

Even from a more theoretical perspective, studies have shown that McKenzie-type extension can have positive mechanical effects on degenerative disc changes.  A study by McGill on this topic showed that “With repeated flexion, in porcine cervical spines, disc prolapse was initiated and that the displaced portion of nucleus can be directed back towards the center of the disc in response to particular active and passive movements/positions.”[xii]

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[i] http://www.spineuniverse.com/conditions/back-pain/origin-mckenzie-method

[ii] http://www.mckenziemdt.org/method.cfm

[iii] Pain Physician Vol. 3, No. 2, 2000

[iv] http://www.mckenziemdt.org/method.cfm

[v] BMC Med. 2010 Jan 26;8:10.

[vi] Spine (Phila Pa 1976). 1997 May 15;22(10):1115-22.

[vii] NeuroRehabilitation. 2010 Jan 1;26(2):155-8.

[viii] Ortop Traumatol Rehabil. 2006 Oct 31;8(5):531-6.

[ix] Spine (Phila Pa 1976). 1997 May 15;22(10):1115-22.

[x] BMC Musculoskelet Disord. 2005 Oct 13;6:50.

[xi] BMC Med. 2010 Jan 26;8:10

[xii] Spine (Phila Pa 1976). 2009 Feb 15;34(4):344-50.

Comments

[Janelle]

I am a physical therapist and use the McKenzie with great success for acute disc patients. One of the keys with McKenzie exercises is to correct any lateral shift before doing the extension exercises.

[Nate]

I think that all too often when the McKenzie method is mentioned it is automatically associated with extension-based exercise or "press-ups". This erroneous assumption often leads to premature judgements about who is going to be helped or harmed using this method. The press-up is only one of the several movements that McKenzie discovered were helpful for individuals with certain symtpom presentations. The important thing that McKenzie found was that the proper MOVEMENT applied to the proper patient was most helpful. I think we can all agree that movement is vital in every back patient. I don't think that any educated health professional would prescribe to his/her patient that it is detrimental to move their spine if no fracture or other sinister diagnosis is present. So the automatic assumption that the patient with "facet joint pain" or the "stenotic" patient is not going to be helped by this method is a premature and, quite often, an incorrect assumption. Most often the patient that is tagged with "stenosis" or "facet arthralgia" has been so due to radiographic analysis. We have seen several studies come out in the past 10 years that show that radiographic analysis whether it be MRI or otherwise is often responsible for misdiagnosis of the pain generator in the spine. My point is I believe that every patient, from the disc extrusion to lumbar stenosis, deserves a mechanical evaluation by a certified McKenzie provider.

[The Back Exercise Doctor]

Nate, thanks for the clarification. I can appreciate the fact that criticism of this method often comes from people that are less informed about the dimensions to the McKenzie teaching that extend beyond press-ups. Maybe we should all do the courses.