Common steps and sub-activities

McKenzie method

Back pain may be caused by any number of things - from the referred pain from diseased organs, to pathogens in the spinal column, bad posture, injury, or draughts and cold causing muscle problems.  It is one symptom which must be investigated to find the cause before any treatment is begun, as if treatment is inappropriate, at best it will have no effect, but at worst it may make things worse.

The McKenzie method (also MDT = Mechanical Diagnosis and Therapy) is a method of physical therapy used for those cases of back pain where the cause is musculoskeletal and not referred pain or pathogenic for example.  It is principally used for low back pain and peripheral joint complaints.  Its objective is to treat both spinal back pain and related extremity pain, alleviating symptoms but also curing the underlying problem.

The approach is based on the use of specific repeated movements by the patients and their use of appropriate prevention measures.  Thus the entre treatment strategy is based on self treatment, and minimises manual therapy procedures.  It is thus ideal for those who do not like 'hands-on' treatment by the therapist, or treatment using, for example, acupuncture needles.

The McKenzie trained therapist supports the patient with passive procedures only if an individual self treatment program is not fully effective.  In other words, the emphasis is on teaching the patient how to heal themselves.

Background

New Zealand physical therapist Robin Anthony McKenzie, OBE (1931–2013) developed the method in the late 1950s.  The McKenzie method has its roots in a single event in 1956 that led to increased experimentation of certain movement in order to elicit what is now known as the ‘centralisation phenomenon’.

Robin McKenzie

‘‘Everything I know I learnt from my patients. I did not set out to develop a McKenzie method. It evolved spontaneously over time as a result of clinical observation’’

A patient who was experiencing pain on the right side of his lower back buttock, laid down on doctor McKenzie's treatment table. The patient ended up lying in significant lumbar extension for around five minutes, meaning his back was bending backwards because the head of the table had been raised for a previous patient. After ceasing this sustained position in lumbar extension the patient noted the pain on the right side of his body had experienced surprising and significant improvement.

This led McKenzie to continuously experiment with specific movement and movement patterns to treat chronic lower back pain. Over the years of experimentation, McKenzie noted patterns of symptom relief in response to prescribed spinal movements and positions and developed a classification system to categorise spinal pain problems.

In 1981 he launched Mechanical Diagnosis and Therapy (MDT) – a system encompassing assessment (evaluation), diagnosis and treatment for the spine and extremities.

The McKenzie Method

There are four major steps used in McKenzie method therapy: assessment, classification, treatment, and prevention.

  • The assessment - or evaluation procedure determines the type of movements that result in centralisation and reduction in pain [of which more in a moment].  This is a diagnostic step.
  • Classification - The classification process is a very important part of the method, because it determines if the McKenzie method is an appropriate approach for specific patients and also determines which movement and protocols should be used.  If we put this another way, the Method does acknowledge and specifically incorporate a means of recognising that back pain is not always musculoskeletal.  Thus if the doctor has not been thorough in his investigation, then at least this method incorporates safety measures.
  • Treatment - MDT primarily uses self treatment strategies, and minimises manual therapy procedures, with the McKenzie trained therapist supporting the patient with passive procedures only if an individual self treatment program is not fully effective.  McKenzie states that self treatment is the best way to achieve a lasting improvement of back pain and neck pain
  • Prevention - The last portion of treatment is designed to educate patients to ensure proper continuation of appropriate exercises and correct structural postures on a  day-to-day basis. Self-care and proper exercise are stressed and encouraged as prevention methods.

Assessment

The first step is understanding the patient’s symptoms - where he/she feels pain and when, how often in a day, to what degree, and in what specific movements or positions does pain intensify or express itself.

The patient is tested and asked to perform specific single direction movements, both sustained and repeated. A range of single direction movements are used in this phase of the McKenzie method.  Depending on how the pain expresses itself and changes, the clinician is able to then classify the type of problem.

Classification - Types of complaint tackled

There are three primary classifications that the McKenzie method uses to classify the symptoms.  - Postural syndrome, dysfunction syndrome, and derangements syndrome with a minority of patients falling into an 'other category. Each classification describes the underlying reason for experienced pain symptoms and symptom behaviour.

The following classes of musculoskeletal symptom can be addressed

  •  ‘Derangement Syndrome’ - This is defined by pain that is experienced due to a disturbance in the joint area resulting in diminished movement in certain directions.
  • Dysfunction Syndrome - This type of pain is categorised by mechanical impairments and deformities of impaired tissue within the body such as scar tissue or shortened tissues. To treat this treatment classification the goal is to remodel the impaired tissue by mobilisation exercise
  • Postural Syndrome - This type of pain is the result of postural deformation. Static holds of improper end-range positions, such as slouching are the cause of postural syndrome. Treatment is more geared towards education and proper posture training rather than repeated exercises as the other syndrome classifications prescribe.

Treatment

Depending on the classification and the nature of the underlying cause of disablement, the treatment protocol is chosen.  Patients perform specific exercises guided by the therapist.  “There will be limited mobility initially and the position will likely cause discomfort, but the patient repeats the exercises one after the other until centralisation occurs, pain symptoms subside, and mobility to end-range increases”.

As can be seen, the concept of ‘centralisation’ is an important part of the method.

In spinal patients centralisation refers to “a pattern of pain level response which is characterised by decreased or abolished pain symptoms, experienced sequentially, first to the left and right of the spine (distal symptoms), and ultimately abolished pain symptoms in the spine altogether.”

During the assessment step, the therapist attempts to discover the “directional preference”, which identifies the pattern of lumbosacral movement in a single direction that effectively results in centralisation and subsequent removal of pain symptoms in the spine and the return of proper range of motion.   Thus the assessment step provides the information needed to do the actual treatment.

In other words, depending on the patient’s specific directional preference as discovered in the assessment stage of the McKenzie method, patients are treated by repeating the movements in a single direction that caused the gradual reduction in pain and centralisation of pain symptoms. That is, symptoms of pain from the left and right of the middle-lower back become centralised to the centre of the lower back and over time result in lasting reduction of pain symptom intensity.

“According to the McKenzie method, movements and exercises that produce centralisation are very beneficial whereas movements that create pain that wander from the spinal mid-line are extremely detrimental to a patients’ specific condition. A 2012 systematic review found that lumbar centralisation was associated with a better recovery prognosis in terms of pain, short- and long-term disability, and reduced the likelihood of undergoing surgery”

References

Books

McKenzie wrote and published a number of ‘self help’ books whose aim was to teach people how to manage and then treat their own back pain, such as “Treat Your Own Back” first published in 1980, with the latest edition being published in 2011.

  •  McKenzie, Robin; May, Stephen (2006). Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Orthopedic Physical Therapy Products.
  •  McKenzie, Robin A.; May, Stephen (2003). The lumbar spine mechanical diagnosis & therapy.
  • McKenzie, Robin (2011). Treat Your Own Back.
  • McKenzie RA. The lumbar spine: mechanical diagnosis and therapy. 1981.
  • McKenzie, Robin (2000). Human Extremities: Mechanical Diagnosis and Therapy.

Available from the McKenzie Institute

"The McKenzie Method" And "What does it involve?"

Web sites


www.mckenzieinstituteusa.org.

http://www.mckenzieinstitute.org/

http://www.mckenzieinstitute.org/united-kingdom/en/

Other

May, Stephen; Donelson, Ronald (2008). "Evidence-informed management of chronic low back pain with the McKenzie method". The Spine Journal. 8:. PMID 18164461

May, S; Aina, A (2012). "Centralization and directional preference: A systematic review". Manual Therapy. 17 (6): 497–506. doi:10.1016/j.math.2012.05.003. PMID 22695365.

NOTE:  It is very difficult to find fair reviews or trials of the McKenzie method on PubMed, and this is because its aim is to help people to heal themselves. 
If its efficacy is admitted to be  superior to many of the treatments requiring, for example, weekly clinic visits where the therapist massages or manipulates the person [called 'passive therapy' in the literature], the Method threatens the livelihood of a whole host of therapists, whose skill is in the hands-on treatment of the person. 

One study, rather begrudgingly noted that "There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP"; and that there was " evidence for the use of McKenzie method in chronic LBP." [PMID: 16641766]


The McKenzie therapist provides a session for assessment, a session for teaching the steps, perhaps one more session of follow-up and then occasional sessions to teach preventative methods.  The therapist becomes a teacher.

From the patient's point of view the approach could not be more ideal from both a time and cost point of view.  It is also very appealing to those who do not like a stranger manipulating their bodies.  Help for the elderly in residential homes suddenly becomes affordable and accessible, as does help for very busy office-workers, teachers, tradesmen, and all those people whose jobs often produce backache, but who can ill afford effective treatment.  Given the meteoric rise in backache, no health service - free or not - is able to cope with this demand and a conventional physiotherapist can see only a very limited number of patients.

As such the demand is undoubtedly there and relative lack of PubMed papers should not be considered a sign of lack of efficacy. The patients themselves seem very happy with the results.

Observations

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