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

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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   

Physiotherapists use a range of techniques to assess and diagnose low back pain. The most commonly used in the UK 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 Physio-pedia pages. A short summary will be provided for each below).

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 such as acupuncture, massage (Gross et al, 2010) or electrotherapy (Gracey et al, 2002).

This page aims to clarify each of the systems, to display the evidence on their effectiveness when treating low back pain and compare them using a generic case study. This will hopefully enable the reader to begin to make up their own mind, based on the evidence and the experiences of practising professionals.

Summary of Techniques and the Evidence to Support Them

Maitland's Mobilisations

[1] 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 (REF). There is no specific patient group that this is suitable for, although contraindications are shown to the right of this page. The nature of these contraindications shows that the Maitland techniques are a relatively conservative treatment for patients without severe or acute joint pathology.

Contraindications to Maitland's Mobilisations malignancy pregnancy vertebral artery insufficiency active ankylosing spondylitis rheumatoid arthritis spondylolisthesis gross foraminal encroachment acute nerve root irritation or compression instability of the spine recent whiplash

Key Principles of Maitland's approach include:

• Mobilisations should be focused on the specific lumbar segment(s) that are painful or restricted in their movement during diagnosis
• Regular re-assessment (to check and re-check that the current diagnosis is correct and that the treatment is having a positive effect)

What are Maitland's Mobilisations? A Recap

A mobilisation is a controlled oscillatory repeated movement of the joint (REF). Mobilisations are described in five grades, varying in amplitude of movement and force against resistance. Grade I - Small amplitude movements at the beginning of range of movement, against no resistance (pain gating effect) Grade II - Large amplitude movements, through range up to a feeling of resistance (also pain-gating effect) Grade III - Large amplitude movements, shallowly into resistance but not to the full feeling of restricted movement Grade IV - Small amplitude movements, deep into resistance to begin to increase the range of motion of the joint Grade V - High velocity, low amplitude thrust to a joint, beginning at the end point of resistance of the joint with decreased range (commonly called a 'manipulation' as opposed to a 'mobilisation').

......

Although these grades appear quite specific, Maitland himself wrote, as recently as 2005, that adaptations to technique will always need to be made as every patient is different and presents with different symptoms.

Evidence for the Effectiveness of Maitland's Mobilisations

• 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.
  

• Moderate evidence exists for the benefits of Maitland's mobilisations in combination with other approaches. However, this is often focussed on other parts of the body rather than the spine, such as the shoulder. In a systematic review of the effectiveness of manual therapy to the shoulder, Caraminos and Marinko (2009) found that end-range / high-grade mobilisations had greater significant positive outcomes compared to mid-range mobilisations. However, the review also showed that mobilisations-with-movement had a similar, though not as significant, beneficial effect. This literature is of course not specific to the spine, but may be taken to inform use of the mobilisations while the literature remains heterogenous on the subject.
  

Evidence for Effectiveness Compared to Other Techniques

• 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

(I imagine this section to be less evidence based but more practical, so why do some clinicians love it and others not? Interview with Heather?)

So and so reported that patients responded better with this passive approach / disliked its poky-ness

Student physios find it useful to develop their clinical reasoning before their sense of touch has been fully developed

And such like....

The McKenzie Approach 

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".

In Clinical Guidelines and Systematic Reviews the McKenzie method has frequently been defined as an intervention (often in the form of extension exercises) without a preceding MDT assessment.

A MDT assessment enables the clinician to clinically reason the most appropriate management to pursue for the specific classification.

 

What is the McKenzie Approach? A Recap
  

A combination of active therapy and education for patients with acute, sub-acute and chronic non-specific low back pain

McKenzie Classification

Derangement 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

Dysfunction Syndrome

• Pain consistently at the end of range (EOR) with reduced or eliminated symptom on returning from EOR position to neutral- repeated treatment

Postural Syndrome

• Pain in relaxed sitting position for long periods of time- patient requires postural advice and/or correction 

Evidence for the Effectiveness of the McKenzie Approach  

• When a lumbar assessment is performed by a clinician with McKenzie training there is high reliability of classifications (K =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

Movement Impairment Syndromes

Lea Cobham to Complete

Case studies: Applying Approaches to Clinical examples

How would each approach diagnose and manage these patients?

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. Patient is an office worker and is currently off work. she denies any leg and buttock symptoms, and has no obvious red flags.
Patient 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

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