McKenzie Mechanical Diagnosis & Treatment of the Spine

Robin McKenzie, a New Zealand physiotherapist, developed a technique of assessing, classifying, and treating patients based on their response to repeated movements. It is a philosophy of treatment that emphasizes education in the causes and self management of pain, how to prevent recurrences, and the importance of posture and maintaining an active lifestyle.

Unique to the McKenzie Method, the process begins with a thorough history and testing of movements to identify distinct patterns of pain responses that are: reproducible, objective, reliable, and reflect the characteristics of the underlying pain generator.
The most common and meaningful pattern of pain response is "centralization" , which is well documented in the literature as both a diagnostic tool and a prognostic indicator. This is defined as a patient's referred or radiating pain (whether just slightly off the centre, into the buttock, or all the way to the toes) promptly reversing, returning to the centre of the back, and then usually also abolishing.
Whether the patient's pain is acute or chronic, if centralization occurs through this logical step-by-step assessment process, good outcomes are favourable. It provides a benefit to the patient and practitioner by eliminating the need for expensive and/or invasive procedures. Ultimately it provides a rational guide to the most optimal treatment strategy for a specific patient.
On your initial visit the examination includes a series of exercises and repeated movements designed to determine what structure is causing your pain and what movements aggravate your pain. Using this system of classification we can separate patients with apparently similar presentations into identifiable and reproducible subcategories to determine appropriate treatment. From this information you are prescribed a specific exercise regime working in only the direction necessary. Exercise choice is based on a well defined algorithm that depends on the relationship between pain behaviour and specific movements and positions.

The success of the McKenzie protocol is based on a correlation between spinal mechanics and symptoms during movement. How the symptoms change then can be used to determine the success of treatment. The use of over 40 different exercises can be customized to the patient's individual problem by affecting the internal dynamics of the disc.

The most basic faulty assumption made about the McKenzie Method is equating it with only extension exercises - it is so much more. When appropriate, the McKenzie treatment takes advantage of the patient's own movements and forces to abolish pain and restore function. A series of individualized exercises subsequent to the patient's responses during the assessment are prescribed and - most critically - are based on the directional preference that will centralize or abolish pain, i.e. extension or flexion, right or left lateral movement, etc. In essence, the treatment must match the assessment findings or the results will be inferior.
Furthermore, as Robin McKenzie states in his original 1981 text, "If no movement or position can be found to centralize or reduce the patient's presenting pain, the patient is not a suitable subject for mechanical therapy

In the case where a patient doesn't respond mechanically, alternative means of treatment or referral for further medical evaluation is warranted.

Most patients who do respond favourable to McKenzie methods of diagnosis and treatment can successfully treat themselves and minimize the number of visits to the clinic then provided the necessary knowledge and tools putting him or her in control of their treatment safely and effectively. Patients who stick to the prescribed treatment protocols are less likely to have persistent problems. Thus, by learning how to self-treat the current problem, patients gain hands-on knowledge on how to minimize the risk of recurrence and how to quickly manage themselves if symptoms to recur.

Achievable goals of McKenzie method of diagnosis and treatment of the spine are:
Reduce pain and deformity
Maintain the reduction with education and postural advice
Restore full function
Prevent recurrences

The Right Road to Restore Function

Assessment is the first step. Pain is a symptom, not a diagnosis. To successfully treat, one must first effectively evaluate.
While every patient can benefit from the McKenzie method of mechanical assessment, not all patiens will be suitable for mechanical therapy - and this is determined quickly so that alternative treatments can begin as soon as possible.
In fact, research has shown that the initial McKenzie assessment procedures performed by competent McKenzie trained practitioners are as reliable as costly diagnostic imaging ( i.e. x rays, MRI's) to determine the source of the problem and quickly identify those who will or will not respond to the treatment principles of McKenzie using the centralization phenomenon as a guide.
McKenzie protocol credits the patient's ability to learn the principles and be in control of their own symptom management, reducing their dependency on medical intervention and gaining lifelong pain management and preventive skills. It also promotes the body to heal itself without reliance on the practitioner.
Parts of this are exerpts from the Brochure "The Power to Control Pain" by The Robin McKenzie Institute Canada.

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The Derangement
disc

For instance, it is hypothesized that prior to a frank annular lesion and nuclear herniation there may be incomplete tears into which nuclear material may be displaced. This nuclear displacement (bulge) may alter joint mechanics causing a postural shift, disturbing the normal configuration of the spine, therefore changing the shape of the disc. Studies have shown the nucleus to move when various forces are applied to it and therefore choosing the correct exercise can decrease pressure on nerve roots when the nucleus is restored to its previous nonpathological state.

Donelson demonstrated it is possible to predict annular competence with the McKenzie mechanical assessment protocol. In his study patients were separated into centralizer's and non centralizer's (a phenomenon whereby sciatica type pain is perceived to move back up the leg). Discography was performed in both groups. Centralizer's tended to have an intact annulus or Grade 1-2 tears. Non centralizer's had a disrupted annulus , that is fissures to the outer third of the annular wall or Grade 3 tear. This is very exciting news for those who appreciate the centralization phenomenon because it allows us to clinically assess the competency of the annulus. Patients who do not centralize on initial examination are excellent candidates for traction/decompression therapy.

References

Donelson R, Aprille C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine 1997; 22(10):1115-1122.

Vanharanta H, Sachs B, Spivey M, et al. (1987) The relationship of pain provocation to lumbar disc deterioration as seen by CT/discogram. Spine 12:295-8.

Spilker RL, Daugirda DM, Schultz AB. (1984) Mechanical response of a simple finite element model of he intervertebral disc under complex loading. J Biomech 17:103-12.

Krag MH, Seroussi RE, Wilder DG, Pope MH. (1987) Internal displacement distribution from in vitro loading of human thoracic and lumbar spinal motion segments: Experimental results and theoretical predictions. Spine 12(10):1001-7.

Clare HA, Adams R, Maher CG; (2004) Reliability of the McKenzie spinal pain classification using patient assessment forms. Physiotherapy; 90:114-119.

Clare HA, Adams R, Maher CG; (2005) Reliability of McKenzie classification of patients with cervical and lumbar pain J Manipulative Physiol Ther; 28:122-127.

Fritz JM, Delitto A, Vignovic M, Busse RG; (2000)Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil; Jan;81(1):57-61.