Diagnostic Approaches to Low Back Pain - Comparing Maitland, McKenzie and Movement Impairment Syndromes

Original Editor - Kathryn Priest, Katherine Portas, Lea Cobham and Anj Leung as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - Kathryn Priest, Katherine Portas, Angela Hiu-Wai Leung, Kim Jackson, Lea Cobham, Lucinda hampton, Admin, Candace Goh, 127.0.0.1 and Evan Thomas  

Introduction   

Lower-back-pain

Physiotherapists use a range of techniques to assess and diagnose low back pain. Three of the commonly used are those of Geoffrey Maitland (mobilisations), Robin McKenzie (derangement, dysfunction) and Shirley Sahrmann (movement impairment). For extensive details on each approach, please see the links above for the relevant Physiopedia pages.

Determining which approach is best to use, in what circumstances and with which patients, can be confusing, especially for students and newly qualified clinicians. Furthermore, clinicians rarely use just one approach, and can often use these in combination with other modalities eg education, exercise, acupuncture, massage.

Maitland's Mobilisations

Central posteroanterior mobilisation

Geoffrey Maitland first described his concept of mobilisations and manipulations in 1965. It is a passive mechanical approach that aims to move synovial joints ("passive arthro-kinematic motion"; literally 'joint-moving') and their surrounding tissues.

This can be applied both to the spine and to the extremities, with the goal of reducing pain and stiffness and restoring correct alignment and function.

For more see Maitland's Mobilisations

Evidence

• Chiradejnant et al (2003) found that although lumbar spine Maitland mobilisations did have an immediate pain-relieving effect, the specific mobilisation performed was not important. Pain-relieving effects tended to be greater if the mobilisation was performed at lower lumbar levels rather than higher
  

• In a small trial comparing grade II and grade III mobilisations in 30 patients with sub-acute to chronic lumbar spine pain, Seema (2012) found that both techniques had a significant positive effect (p=0.001) on pain scores. Grade III mobilisations had a greater effect than grade II.

• Naik et al (2007) suggested that Maitland's mobilisations are more effective at improving range of movement than Mobilisations With Movement (MWMs - Mulligan approach), although MWMs are more effective if pain is the most prominent factor for the patient. They also noted that the group receiving Maitland mobilisations required more sessions before being discharged than the MWM group. However it is worth noting that this was a study on mobilisations after a Colles (distal radius) fracture.
  

• In a systematic review of randomised controlled trials in five languages, Bronfort et al (2004) found that one treatment of spinal manipulation therapy (SMT) was superior to one treatment of spinal mobilisations for acute low back pain. There was also moderate quality evidence that SMT:
  • Is superior to detuned diathermy 1 week after treatment
  • Resulted in faster recovery than patients receiving a combination of diathermy, exercise and ergonomic instruction. 
  • Resulted in a faster recovery time than heat therapy for patients with LBP accompanied by sciatica
    

• A comparison of Maitland mobilisations versus McKenzie -style press ups in 30 patients with non-specific low back pain found that both methods significantly reduced the patient-reported pain rating. However, neither treatment was found to be superior to the other .
  

Other Points to Consider: Clinical Expertise and Practical Application see Interview with Heather Reid, Physiotherapy Lecturer at The University of Nottingham

The McKenzie Approach 

McKenzie side glide

Using McKenzie Mechanical Diagnosis and Therapy (MDT) the patient can be classified into one of three mechanical syndromes; Derangement, Dysfunction or Postural Syndrome. If the patient has no symptom improvement after several sessions they will be classified into "Other" .

The McKenzie approach is a combination of active therapy and education for patients with acute, sub-acute and chronic non-specific low back pain .

McKenzie Classifications

Derangement Syndrome	Dysfunction Syndrome	Postural Syndrome
Directional preference needs to be identified in flexion, extension or a lateral shift* apparent through observation. Then a suitable exercise program can be prescribed e.g. 'Lateral Shift' is the combination of side flexion and rotation	Pain consistently at the end of range (EOR) with reduced or eliminated symptom on returning from EOR position to neutral- repeated treatment	Pain in prolonged static or EOR positions (commonly stooped or relaxed sitting position) for long periods of time- patient requires postural advice and/or correction

For an in-depth description of these syndromes please follow this link:

Evidence  

• Many pain measures showed that the McKenzie method is a successful treatment to decrease chronic low back pain in the short term, while the disability measures determined that the McKenzie method is better in enhancing function in the long term
• When a lumbar assessment is performed by a clinician with McKenzie training there is high reliability of classifications (Kappa =0.89).
• Evidence highlights short-term improvements in pain and disability using the McKenzie method however; more research is needed into the long-term benefits.
• Directional preference exercises encourage active management and elicit patient empowerment. In health care practice it is perceived as a cost effective intervention.
• MDT primarily treats the mechanical dysfunction, with the intention that the improvement of symptoms may positively affect the psychological presentation of the patient .

The tables below summarise the evidence since 2009. This summary is not exhaustive, but follows the principles of critical assessment for randomised controlled trials as defined at www.bestbets.org .

ABBREVIATIONS for Tables:

CNSLBP = Chronic Non-Specific Low Back Pain
RCT = Randomised Control Trial
Rx = Treatment
n= number of participants

Other points to Consider: Clinical Expertise and Practical Application see Interview with Jackie Hollowell, Physiotherapy Lecturer at The University of Nottingham:

Movement Impairment Syndromes

Lumbar spine flexion

For a more detailed description of this approach and treatment structure visit Classification Of Low Back Pain Using Shirley Sahrmann’s Movement System Impairments, An Overview Of The Concept

Like McKenzie, Sahrmann’s Movement Impairment Syndromes (MIS) approach to diagnosis of LBP is one of a number of movement based classification systems designed to help therapists categorise patients and inform treatment .

The theory behind the approach revolves around the human ‘Movement System’ and impairments within this system. Impairments are caused by decline in the quality and precision of joint movements in the spine, as a result of repeated habitual movements or prolonged postures. This may result in:

• Muscle length/strength imbalances
• Altered patterns of motor recruitment patterns and timing
• De-recruitment
• Stiffness
  

These adaptations can cause altered movements resulting in microtrama to tissue that can accumulate to form macro trauma over time. This is because the human movement system works on the principle of the ‘Path of least resistance’. Stiffness in a muscle or joint will result in a compensatory movement elsewhere resulting in a movement strategy that is not mechanically advantageous and can result in pain.

Evidence Regarding the Effectiveness of the Movement Diagnosis Approach

• Intertester reliability for diagnosis using the MIS approach had ‘substantial’ agreement (Kappa >60%). But this was dependant on the diagnostic subgroup and training level of testers. The Flexion and Rotation with Flexion diagnosis the most reliably diagnosed.
• No clear advantage has been found for having a specific patho-anatomical diagnosis for LBP over a movement based approach, or vice versa. Although Sahrmann acknowledges that a ‘modified approach’ if needed when a patient has a specific medical diagnosis such a stenosis, but how this is to be operationalized is less well defined.
• MIS has established itself as an effective diagnostic tool for sub classifying LBP, however there is a sparse amount of literature showing the effectiveness treatment within this approach . There have been a few case studies reporting reduction of symptoms  and many physiotherapists utilising this approach with their patients have seen positive results anecdotally.

Limitations

• There is little reference to bio-psycho-social factors within the MIS approach, although fear avoidance can be measured, but it is not clear how differently a patient with high fear avoidance would be managed. Sahrmann and Van Dillen acknowledge that the bio-psycho-social subtype have not featured strongly in their research.

• No acknowledgement of central sensitisation within LBP was found in the MIS approach and Sahrmann has eluded to the overuse of this term by therapists as a way of explaining why their patients are not getting better. However, there is a growing amount of strong evidence that LBP, particularly chronic LBP, is fuelled by a combination of bio-psychosocial factors that lead to maladaptive behaviours and physiological changes that cause central sensitisation of the nervous system.

• This approach has been criticised for its exclusion of patho-anatomical factors; factors such as tissue healing which are important for effective treatment

• One final limitation of the MIS approach to diagnosis of LBP is that it takes quite a long time to perform this thorough assessment. In a busy hospital outpatients setting, time constraints may limit the practicality of using this approach.
  

Other Points to Consider: Clinical Expertise and Practical Application see Interview with Catherine Moore, Physiotherapy Lecturer at The University of Nottingham

Considering a Combined Approach see Interview with Roger Kerry, Physiotherapy Lecturer at The University of Nottingham

Case studies: Applying Approaches to Clinical examples

Patient 1

A 36-year-old male, presents with a 2-week history of right sided low back pain. Patient works as a shop assistant and recently had to complete extra shifts for Christmas. Whilst bending down to lift a heavy box, he felt a sharp pain and immediately struggled to stand back up. He has been experiencing occasional numbness in his right leg when he has been walking for more than 15 minutes.

Aggs:Bending forwards, walking the dog, walking up hill

Eases: sleeping on front with pillows propped up, rest, hot water bottle over back

Patient 2

A 56-year-old female, presents with a 3-month history of central low back pain. She has been experiencing low back pain for the past 18 months but has been gradually getting worse over the last 3 months. She cannot recall any trauma or change in activity to flare up the pain. The patient is an office worker and is currently off work. she denies any leg and buttock symptoms, and has no obvious red flags.
She recalls having had 3 sessions of physiotherapy previously, which had some effect but he was too busy to carry on with the exercise regime. She cannot recall any of the exercises she was given previously.

Aggs: bending forward, rotating to L+R, bending to the side L+R

Eases: lying flat on back, hot baths, heat rub

Conclusions

As a whole, all three approaches have their strengths and limitations. Clinical opinions on all three show both positives and negatives. Choosing which approach to use tends to depend on the learning experience of a therapist during their time as a student, as well as clinical and personal experiences.

Approaches can be adapted and used in combination; allowing a thorough assessment and diagnosis of a patient’s problem, looking at both mechanical, structural and movement impairments.