October 2002

The McKenzie Approach

By J. Mark Miller, PT, DipMDT, and Scott Herbowy, PT, DipMDT

Low back pain not only affects the individual sufferer but also society in general. In fact, 80% of the adult population in the United States will suffer from at least one episode of low back pain in their lifetime and 25% will seek medical help; 90% of these patients will have their pain resolved regardless of intervention within 2 months.¹ However, many people experience recurrences of their low back pain. The interventions available to these low back pain sufferers are as varied as the actual problems themselves, and society’s cost for the whole program is in the tens of billions of dollars annually.²

Interestingly, most patients arriving at a spinal clinic will receive the same treatment as the person before them, regardless of their problem. Symptom relief is the typical focus, rather than resolution of the condition. The McKenzie^3,4 assessment approach to spinal care offers a unique avenue for the back pain sufferer. The McKenzie approach allows the clinician and the patient to simultaneously recognize the mechanical reasons for the continued spinal complaint, which provides for an individualized treatment program that the patient can perform regularly throughout the day. The idea is that people treating themselves properly 10 times per day is better than clinicians treating patients once per day. The exercises can be performed in a standing position, and take no more than 60 seconds—less time than is needed to get a glass of water, take the pill out of the bottle, and swallow it.

Patient performs a lumbar spine extension with the therapist, J. Mark Miller, PT, DipMDT, applying over-pressure.

The majority of back pain is mechanical. Mechanical spinal pain is produced by the application of mechanical forces to spinal structures that contain nociceptors. If there is a sufficient amount of mechanical force or the tissue has been damaged or injured in any way, then pain is produced. Unless the irritating forces are stopped and normal tissue healing is allowed to occur uninterrupted, the spinal problem will persist, sometimes for years.⁴

The McKenzie assessment stresses the spine in different directions and with different degrees of force in order to monitor the responses to the different loads. Changes in symptom location, intensity, range of motion (ROM), and neurological signs are the monitored mechanical responses. The responses offer an understanding about the positive and negative relationships between movements and positions and the individual problem.^3,4 This, in turn, aids the McKenzie clinician in prescribing an individualized home treatment program, which consists of movements that aid in healing, and avoidance of those movements and positions that are impeding the healing process.

Miller performs an assessment of lumbar side-gliding movement quantity and quality, which is part of the premovement test baseline establishment.

POSTURE, DYSFUNCTION, AND DERANGEMENT

Robin McKenzie is a physiotherapist from Waikanae, New Zealand, who made a chance discovery with a patient in 1956 that led to the development of the McKenzie approach to assessment and treatment of spinal and musculoskeletal disorders. He has since published five books on the topic and has received numerous awards in the medical communities of New Zealand and the United States.

McKenzie^4,5 originally noticed specific patterns of response to the loading assessment, which he used to categorize patients’ conditions into different syndromes: posture, dysfunction, or derangement. Posture syndrome results from prolonged loading of normal tissue leading to pain. This pain is eradicated with change of position. Dysfunction syndrome occurs when abnormally shortened tissue restricts normal, pain-free movement. This is characterized by intermittent pain and partial loss of movement in a particular direction. Lastly, the derangement syndrome involves a change in the position of internal joint material. This alteration of position within the joint disrupts the mechanics of the motion segment. This disruption can result in constant or intermittent pain as well as varying degrees of disability, depending on the size and location of the displacement. These particular lesion presentations can often be reversed quite rapidly.⁴ On the basis of more than 45,000 patients evaluated, McKenzie states that at least 70% of low back pain patients fall into one of the three categories described.^4,5

Each syndrome demonstrates specific tissue responses to loading (repetitive movement or positioning). Once the response is understood, an individualized treatment program that patients can perform regularly throughout the day is put into place. The responsibility is then placed on patients to facilitate their own management and recovery. The rehab professional is responsible for accurately interpreting patients’ responses and making appropriate changes and progressions to their activities as needed. These may involve a change in direction, intensity, or frequency of the exercise loading of the tissue. The benefits to this approach are appropriate self-treatment throughout the day, constant self-assessment of condition, an early understanding of prophylaxis, decreased utilization of professional services, and, ultimately, patient independence and control over their spinal problem.

CASE STUDIES

A 33-year-old man presented with complaints of 2 weeks of left low back pain with associated left thigh pain and numbness radiating to the level of the knee. Symptoms had developed during heavy lifting and were described as intermittent. His history included a similar episode experienced 3 years previous that reduced with time and rest.

On examination, this patient presented with major losses of lumbar spine ROM on all planes. His lordosis was reduced and he presented with an acute lumbar shift to the right. Lumbar spine extension had no effect on his symptoms; however, lateral movements performed to the right were associated with a rapid increase in his ROM on all planes. He was sent home with lateral exercises to be performed hourly for 3 days.

Day 2: He returned describing a 90% decrease in leg pain; however, he continued to display major losses of lumbar movement. Lateral movements were no longer as effective in changing ROM, but now lumbar extension had a significant decrease in low back pain and improvement in extension and side-gliding. The patient was sent home with continued lateral movements to be performed every hour, adding sustained lumbar spine extension to be performed five times daily.

Day 5: Patient has continued with the self-treatment exercises. His ROM is within normal limits in all planes and he has returned to all activities of work and leisure. His prophylactic program of lateral movements and extension is in place, and the patient understands the concepts of self-diagnosis and treatment in order to reduce the risk of future problems.

A 63-year-old man presented with complaints of right low back, buttock, and lower extremity pain to the ankle. He described intermittent symptoms that worsened with prolonged sitting and improved when walking. He had undergone total hip replacements in 2000 and 2001. A cortisone injection into his right hip had been ineffectual. The patient’s main concern was his low back pain as he and his clinicians had attributed his hip and leg pain to a problem with his right total hip replacement. He was currently receiving an aquatic physical therapy program for this perceived right hip condition.

On examination, he displayed moderate losses of lumbar spine extension and right lateral movements with lumbar flexion and left lateral movements within normal limits. Right hip pain was eliminated with repeated lumbar extension exercises performed standing, and the remaining low back pain was alleviated with lumbar spine extension lying down. He was sent home with an exercise program of lumbar spine extension to be performed every 1 to 2 hours, along with postural correction and instructions to avoid lumbar flexion.

Day 2: The patient returned 3 days later rating his improvement at 75%. Lumbar extension had removed low back pain. The home program remained the same.

Day 3: The patient returned stating that, episodically, he was experiencing pain in his right leg. He also stated that even though his other clinicians had determined that his leg symptoms were hip-related, the low back exercises prescribed had alleviated his symptoms, which indicates that they originated in the spine.

He now displayed only a minor loss of lumbar extension. Right hip and leg pain were alleviated with repeated lumbar spine extension assuring that they were lumbar-related rather than hip-related. The home program remained the same, with an emphasis on compliance.

Day 4: Patient stated that his hip and leg symptoms were near fully eliminated and that he felt near normal overall. Minor low back pain was helped with lumbar spine extension in lying down.

EVIDENCE

The McKenzie approach has received a great deal of interest from the scientific community. Numerous studies have been published in the past decade assessing reliability, validity, treatment outcome, and prophylactic ability of the approach. Riddle and Rothstein6 determined that intertester reliability of the McKenzie diagnoses was poor. However, the authors utilized untrained therapists. In contrast, both Razjmou et a^l7 and Kilpikoski et al8 found good interexaminer agreement in determining McKenzie diagnostic syndromes. Both studies utilized highly trained McKenzie therapists. Studies of spinal clinicians in the state of Washington9 and in Ireland¹⁰ have shown that the McKenzie approach is the most frequently utilized for spinal assessment and treatment by physical therapists. Interestingly, however, these same clinicians listed McKenzie approach education as the third most important in continuing education pursuits. The clinical difficulties with this prevailing attitude have been well demonstrated by the intertester reliability study’s findings.

As with any approach to spinal care, efficacy of treatment and treatment outcomes are two very important parameters to consider. In 1994, the United States government published its guidelines for spinal injury care.¹¹ Its recommendations were based on an exhaustive literature search, and recognized the use of manipulation and analgesic medications as the primary treatment options for acute and subacute low back pain. Cherkin et al¹² displayed similar outcomes when comparing the McKenzie method of treatment to chiropractic manipulation for low back pain. However, even though the McKenzie group had been practicing the approach for less than 1 year, they were able to achieve these results with 50% fewer visits than the well-trained chiropractic group. Good long-term outcome with the McKenzie approach was recognized by the 5-year study of Stankovic and Johne^ll,13 demonstrating the approach’s strong role in prophylaxis. McKenzie considers this the most important role of his approach, as 90% of spinal pain presentation is recurrent.

A paper published by Donelson et al,¹⁴ comparing the results of a McKenzie lumbar evaluation to those of CT/discography, displayed a strong correlation between the McKenzie clinician’s findings and those of the radiologist. In fact, the patients in the study had received one or more inconclusive MRIs, which led to Donelson’s supported conclusion that the McKenzie evaluation, performed by trained clinicians, is more specific and clinically useful than an MRI when evaluating and treating patients with radiating low back pain.

CONCLUSION

The primary concerns of patients with low back and radiating low back pain are: accurate assessment of the condition, swift relief of pain, and a plan to reduce the risk of future episodes. In the hands of trained McKenzie clinicians, the McKenzie approach to assessment and treatment of musculoskeletal disorders offers a solution to the problem of low back pain that is pleasing to both. Analysis of the patient’s condition leads to an individualized treatment program offering rapid and long-lasting relief. Patients can take comfort in the accuracy of the analysis, and payors can appreciate the low cost of assessment and treatment.

REFERENCES

1. Dixon A. Diagnosis of low back pain. In: Jayson M. The Lumbar Spine and Back Pain. London: Churchill Livingstone; 1987.
2. Nachemson AL. Newest knowledge of low back pain: a critical look. Clin Orthop. 1992;279:8-20.
3. Jacob G. The McKenzie protocol and demands of rehabilitation. California Chiropractic Journal. 1991;16:10.
4. McKenzie RA. The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications; 1990:xx-xxiii.
5. McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications; 1981:xvii-xix.
6. Riddle DL, Rothstein JM. Intertester reliability of McKenzie’s classifications of the syndrome types present in patients with low back pain. Spine. 1993;18:1333-1337.
7. Razjmou H, Kramer J, Yamada R. Inter-tester reliability of the McKenzie evaluation in assessing patients with mechanical low back pain. J Orthop Sports Phys Ther. 2000;30:368-383.
8. Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine. 2002;27:207-214.
9. Battie MC, Cherkin DC, Dunn R, Ciol MA, Wheeler KJ. Managing low back pain: attitudes and treatment preferences of physical therapists. Phys Ther. 1994;74:219-226.
10. Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine. 2002;27:406-411.
11. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No 14. Rockville, Md: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1994. AHCPR publication 95-0643.
12. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021-1029.
13. Stankovic R, Johnell O. Conservative treatment of acute low back pain, a five year follow-up study of two methods of treatment. Spine. 1995;20:469-472.
14. Donelson R, April C, Medcalf R, Grant W. A prospective study of centralization of lumbar referred pain: a predictor of symptomatic discs and annular competence. Spine. 1997;22:1115-1122.

J. Mark Miller, PT, DipMDT, and Scott Herbowy, PT, DipMDT, are codirectors of the Physical Therapy and Spine Center, St David’s Medical Center, Austin, Tex. Both graduated from the McKenzie Institute International, Wellington, New Zealand, with diplomas in mechanical diagnosis and therapy of the spine and are members of the American and International Teaching Facilities of the McKenzie Institute.

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