McKenzie Method

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Description/Definition

The McKenzie method (or mechanical diagnosis and therapy, MDT) is a system of diagnosis and treatment for spinal and extremity musculoskeletal disorders.

MDT was introduced in 1981 by Robin McKenzie (1931–2013), a physical therapist from New Zealand .

A feature of the method is emphasizing patient empowerment and self-treatment. MDT categories patients complaints not on anatomical basis, but subgroups them by the clinical presentation of patients . The reliability of MDT classifications have been confirmed by several studies .

Watch him in action in the video below

In the treatment by MDT disorders in the spine, which have reverberated symptoms in the extremities, important place takes an Centralization - the symptoms movement from the distal segments of body to the proximal. Advent of centralization is a good signal and speaks of correctness actions being taken. And in contrast, Peripheralization - the movement of pain from the spine to the extremities, indicates a worsening .

MDT exists of 4 steps:

1. Assessment: The clinician takes a history of symptoms along with what activities either aggravate or relieve the symptoms. Next, a movement assessment is performed to determine if the patient has any movement loss, along with what the symptoms do with the movement. Then the clinician has the patient perform specific repeated or sustained movements to determine the effect on the symptoms.
2. Classification: Based on assessment the symptomatic response during the repeated or sustained movement testing, a classification is given. Most patient's symptoms are classified into: derangement syndrome, dysfunction syndrome, postural syndrome or other. The choice of exercises in MDT is based upon the direction that causes the symptoms to decrease, centralize, or abolish.
3. Treatment: Treatment consists of first finding a repeated or sustained movement that reduces and/or abolishes the symptoms. Next, the goal is to maintain this improvement for several days. Finally, the patient performs recovery of function, which is having the patient do once pain provoking movements to determine if they are now pain-free.
4. Prevention: The prevention step consists of educating and encouraging the patient to exercise regularly and self-care.

The exercise that is given typically will be in one direction based upon the symptomatic response. The exercise may be a repeated movement or a sustained position, it could also require reaching end range or sometimes mid-range, just depending on what happens with the symptoms. A single direction of repeated movements or sustained postures leads to sequential and lasting abolition of all distal referred symptoms and subsequent abolition of any remaining spinal pain.

Studies have shown that while this method may not be superior to other rehabilitation interventions for pain and disability reduction in patients with acute lower back pain, there is moderate to high-quality evidence supporting the superiority of MDT over other methods in reducing both in patients with chronic lower back pain. A recent study that evaluated the effectiveness of MDT compared to manual therapy in the management of patients with chronic low back pain concluded that MDT is a successful treatment to decrease pain in the short term and enhance function in the long term. One study showing significantly improved cervical posture of people with a forward head posture.

Classification

Patients are classified into four groups according to the mechanical and symptomatic response to repeated movements and/or sustained positions. Classifications are not always given at the initial evaluation, but in some cases, it may be 3-5 visits before a classification is confirmed.

The video below (4 minutes) gives some salient points to consider when using this approach.

Each syndrome demands a different management approach.

Below you will find the four categories of the McKenzie classification with their descriptions.

Derangement Syndrome

• This is the more common and known syndrome
• Inconsistency and change is the major characteristic of this syndrome
• Symptoms may be local, referred, radicular or a combination, the symptoms could also move from side to side or proximal to distal.
• Symptoms can be constant or intermittent and could vary through the day
• The onset can be sudden, with no known cause, or gradual over time
• The symptoms can be influenced by postures or normal daily activities
• Directional preference is a hallmark of derangement syndrome, which a specific repeated movement or sustained position causes a relevant improvement in symptoms.
• Treatments involve specific movements that cause the pain to decrease, centralize and/or abolish.

Dysfunction Syndrome

• Refers to pain which is a result of mechanical deformation of structurally impaired tissues like scar tissue or adhered or adaptively shortened tissue.
• The symptoms must be present for 8-12 weeks, this time allowed the tissues to deform
• The pain is always intermittent and arises at the end range of a restricted movement.
• The treatment includes: repeated movements in the direction of the dysfunction or in the direction that reproduces the pain. The aim is to remodel that tissue, which limits the movement, through exercises so that it becomes pain-free over time.

Postural Syndrome

• Refers to pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures.
• The pain arises during static positioning of the spine: for example sustained slouched sitting.
• The pain disappears when the patient is moved out of the static position.
• There is no pain with performing movement or activity.
• The treatment includes: patient education, correction of the posture by improving posture by restoring lumbar lordosis, avoiding provocative postures and avoid prolonged tensile stress on normal structure

Other or non-mechanical Syndrome

There are patients who do not fit within one of the three mechanical syndromes but who demonstrate symptoms and signs of other pathologies. Confirming a classification can take 3-5 visits to ensure all planes and forces are exhausted.

• Spinal stenosis
• Hip disorders
• Sacroiliac disorders
• Low back pain in pregnancy
• Chronic pain syndrome
• Mechanically inconclusive
• Mechanically unresponsive radiculopathy
• Structurally compromised
• Post-surgical problems
• Trauma/Recovering trauma

Just because a patient is classified into the "Other" category, does not mean they may not change over time. Time is often a factor in the determination of treatment.

This classification shows strong inter-rater reliability amongst physiotherapist trained in MDT.

Management

Unlike other exercises for treating low back pain meant for muscle strengthening, stability and restoring range of motion, MDT exercises are meant to directly diminish or even eliminate the patients symptoms.  This effect is accomplished by providing corrective mechanical directional movements in end range. MDT educates patients regarding movement and position strategies can reduce pain. A cautious progression of repeated forces and loads is used in this method. The exercises may be uncomfortable at first, but after some repetitions the symptoms will decrease.

Examples of Common McKenzie-Method Exercises

These are common exercises or movements used in the treatment for patients with lumbar pain symptoms. The selection of a movement is determined based upon the assessment and patient's symptomatic response.

Lying Prone

The patient takes place at the treatment table in prone position. The arms have to be parallel with the thorax, with the hands next to the pelvis. The head is turned to one side. This position creates automatically a lordosis of the lumbar spine. Patients with posterior derangement should be careful when arising from the position to standing. It is important that, while arising, the restored lordosis is maintained. In any kind of derangement it is important to perform the exercise long enough (5-10 minutes) for the fluid to alter its position anteriorly. In minor derangement, prone lying may reduce the derangement without any other procedures being required. Although this position may be painful, the pain does not indicate the procedure is undesirable if it is felt centrally. In major derangement, for example patients with lumbar kyphosis, it is possible that the patients cannot tolerate the prone position unless they are lying over a few pillows. In case of dysfunction the loss of extension may be enough to prevent lying prone because the soft tissue shortening has reduced the range of motion and extension stress produces pain .

Extension in Lying

The patient lies on his abdomen while the hands are placed near the shoulders. The hands are placed with the palms down. Now the patient makes a press-up movement with straight arms. The Pelvis stays near the table while the patient presses the thorax upwards. After this movement the patient returns to his starting position and repeats this exercise 10 times. The first couple of exercises have to be done easily, but after a few times the movement has to be made to the maximum extension range that is possible. The aim of this exercise is to make the lumbar spine relax after the maximum extension, in the relaxation phase. The maximum degree of extension is obtained with this exercise. It is possible that there occurs central low back pain described as a strain pain, but it will gradually wear off. An intermittent extension stress is influencing the contents and surrounding structures of the lumbar segments, having a pumping as well as a stretching effect. This procedure is the most important and effective in the treatment of derangement as well as extension dysfunction .

Extension in Standing

The patient stands up straight with his feet apart, to remain a stable position. The hands are placed on the lumbar region, in the area of the spina iliaca posterior superior. His hands fixate the pelvis while the patient leans backwards. The patient has to lean backwards as far as possible. This exercise has to be repeated ten times. It has similar effects on derangement and dysfunction as extension in lying. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint. The procedure is important in the prevention of the onset of low back pain during or after prolonged sitting and is very effective when performed before pain is actually felt .

Rotation Mobilization in Extension

The patient lies in a prone position on the treatment table with his arms parallel with the trunk and the head turned to one side. The therapist stands next to the patient and places the heels of the hands on the lumbar region. One will fixate the processes transverses of the vertebra on top of the vertebra you want to rotate. The other hand will make a rotation of the vertebra beneath in the opposite direction. This is more a technique than an exercise, but has to be repeated also ten times. In derangement rotation mobilization in extension has to be performed first to bring about centralization of nuclear material in the disc. Followed by symmetrical extension mobilization to restore the nucleus to its more anterior position. In derangement mechanical deformation is extremely undesirable. In dysfunction an increase of deformation with certain limits is desirable.

Evidence supporting McKenzie approach

Many systematic reviews have shown the value of the MDT to treating spinal pain. If you wish to delve further into these reviews they are listed here

Presentations

Watch these videos below (around 40 minutes each) to get a better appreciation of the approach,