The McKenzie Method

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Who is Robin McKenzie?
 History MDT
Robin McKenzie
„ Physiotherapist from New Zealand
„ Dr. Cyriax
strong influence on McKenzie's initial training
considered the framework for MDT
„ Clinical experience
Mr. Smith 1956 – 2 weeks of radicular sx then
serendipitous surprise
Exploration of End Of Range - some improved,
while others worsened
 History - cont
Over next 20 years developed approach
Began teaching approach 1977 Rancho
Los Amigos
McKenzie Institute formed in 1982
26 branches around the world
 Epidemiology
50-80% population experience back pain
Peak prevalence 40-50 years of age and tapers after that
Csp -Women tend to be affected more men
Lsp – Men tend to more affected than women
First episodes of sx start in the 20’s w/ recurrency rates between 39-
71%
Majority (80-90%) of low back disorders occur at the L4/5 and/or
L5/S1
Most cervical disorders are found in the lower region with 41%
occurring at the C5/6 level and 33% at the C6/7 level
When the nerve root is affected, 36.1% involve the C6 root (C5-6
level), 34.6% C7 (C6-7 level) and 25.2% C8 (C7-T1 level)
Quebec Task Force Reports
Spine; 1987 – Comprehensive Scientific,
Multi-disciplinary Investigation
Most spinal disorders are non-specific
Classify by pain patterns
 Spitzer WO. Scientific approach to the assessment and
management of activity-related spinal disorders: A mono-graph
for clinicians. Report of the Quebec Task Force on Spinal
Disorders. Spine 1987;12(7 Suppl):1-59.
Class Symptoms
1 Pain w/o radiation
2 Pain + radiation-proximal extremity
3 Pain + radiation- distal extremity
4 Pain + radiation + neuro signs
5 Nerve root compression -fx, instab
6 Nerve root compression -image, EMG
7 Spinal stenosis
8 S/P surgery-6 months
9 S/P surgery->6 months
10 Chronic pain syndrome
11 Other dx
BIOMECHANICS
 Spinal Motion Segment
Basic functioning unit of
the spine
„ Vertebra
„ Intervertebral discs
Annulus fibrosus –
„ Functions to retain
nucleus
„ Weakest posterolaterally
Nucleus pulposa
„ connecting ligamentous
and soft tissue structures.
Analysis of segment to:
„ Load
„ Position
„ Movement
 Conceptual Framework:

DISC MODEL

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 Conceptual Model - Flexion
Zygapophyseal joint surfaces
distract
„ inferior articular processes of the
superior vertebra glide up and
forward upon the superior articular
surfaces of the vertebra below.
Anterior loading of the
intervertebral disc occurs with
compression of the anterior
portion, with relaxation and
bulging of the outer anterior
annular wall.
The posterior annular wall is
stretched and pulled taut.
The nucleus distorts posteriorly.
The vertebral canal lengthens,
stretching the cord, dura and root
filaments and opening the
intervertebral foramina.
Conceptual Model - Extension
Inferior articular processes of the
vertebra above glides down and
backward on the superior articular
surfaces of the vertebra below.
Posterior loading of the
intervertebral disc occurs with
distraction of the anterior portion
of the annulus, which is stretched
and pulled taut.
The posterior annular wall is
relaxed and there is posterior
bulging of the outer, posterior
annular wall.
The nucleus distorts anteriorly.
The vertebral canal shortens,
which relaxes the cord, dura and
root filaments, and reduces the
size of the intervertebral foramina.
 Literature
Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of
centralization of lumbar and referred pain. A predictor of
symptomatic discs and annular competence. Spine; 22(10):1115-22,
1997.
63 subjects sent for PRE SURGICAL
Discogram w/ Gadolinium for confirmation
of disc pre surgical diagnosis.
PT’s trained in MDT, did mechanical
evaluation. Therapist asked to predict:
„ Is the pain discogenic?
„ If discogenic then what level?

„ If discogenic then was nucleus contained?

„ Predict what the disc fissure pattern would

look like.
The patients then got the discogram in flexion
and extension.
 Comparisons were made between the
findings of the Discography and those
predicted by the therapist.

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Predicted vs Actual Discogram Results
„ Discogenic?
%Agreement – 83.3%
„ Level?
%Agreement 93%
„ Nucleus contained or non contained?
%Agreement – 85.5%
„ Fissure Pattern?
%Agreement rated good/excellent
 Conclusion
Dynamic disc injection outcomes are reliably
predictable w/ MDT exam and the dynamic
internal disc model
This strongly supports a mechanical cause –
effect relationship between IVD dynamics and
the symptom response patterns of centralization
MDT exam appears to be a dynamic, non-
invasive functional evaluation of symptomatic
disc pathology
TISSUE BASED
PAIN
MECHANISM
Nociception – stimulation of receptors which provide feedback for
pain
„ Mechanical – application of forces that contain the receptors is

sufficient to irritate the free nerve endings (pressure, distraction,

distension, abrasion, contusion, laceration)
„ Chemical/Thermal - chemical irritation when concentration of

chemical substances is sufficient to irritate free nerve endings.

It is essential to identify the type of pain (chemical or mechanical)
because this will establish the tissue state and the subsequent
treatment selection
 Clinical Management
Goal:
„ Relieve Pain
„ Restore Function
„ Prevent reoccurrence
 Classification
Pain of spinal origin can be classified into
3 syndromes.
„ Posture Syndrome
„ Dysfunction Syndrome
„ Derangement Syndrome
Posture Syndrome
 Posture Syndrome
End range stress on normal structures
Mechanical deformation due to prolonged
stress eventually produces pain
Dysfunction Syndrome
 Dysfunction Syndrome
End range stress of adaptively shortened
structures
Mechanical deformation immediately
produces pain at end of range
May be discogenic, zygapophyseal,
ligamentous, muscular, apeneurosis, etc
Derangement Syndrome
 Derangement Syndrome
Anatomical disruption and/or displacement
of structures
The structures’ increased mechanical
deformation immediately or eventually
produce pain
 Definition of Terms
Centralization
„ Describes the phenomenon in which limb pain emanating from

the spine is progressively abolished in a distal to proximal

direction in response to therapeutic loading strategies , with each
progressive symptom change being retained over time. If back
pain only is present this is reduced and then abolished.
Peripheralization
„ Describes the phenomenon by which pain emanating from the
spine spreads distally into or further into the limb as a result
loading strategies. If pain is produced in the limb, spreads
distally or increases distally and remains worse the loading
strategy should be avoided.
Centralization/Periperalization - cont
 Def’n - cont
Lateral shift (right)
„ A lateral shift exists when the vertebra above has

laterally flexed to one side in relation to the vertebra

below, carrying the trunk with it. (The upper trunk and
shoulders are displaced to the right.)
Contralateral and ipsilateral shift
„ A contralateral shift exists when the patient's symptoms are on
one side and the shift is in the opposite direction. For instance,
left back pain, with / without thigh / leg pain, and upper trunk and
shoulders displaced to the right.

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Lateral Shift
 Def’n - cont
Criteria for Relevant lateral shift (structural vs
habitual)
„ Upper body is visibly and unmistakably shifted to one side
„ Onset of shift occurred with back pain
„ Patient is unable to correct shift voluntarily
„ If patient is able to correct shift they cannot maintain correction
„ Correction affects intensity of symptoms
„ Correction causes centralization or worsening of peripheral
symptoms
 Def’n - cont
Symptomatic responses
„ The changes in the patient symptoms that are elicited
and recorded with the application of assessment
procedures, treatment procedures or in response to
functional activities and positions.
Mechanical responses
„ The measurable changes that occur in movement
loss, dural tension, neurological function, tolerance to
functional activities and positions, or change in tested
physical abilities.
 Examination terms
Terms used to determine the response to
repeated movements, sustained positions,
treatment procedures and/or functional
activities and positions on pain patterns in
musculoskeletal disorders.
These are used BEFORE, DURING and
AFTER the procedure to accurately
evaluate the response.
 During Mechanical Loading
Increase Symptoms already present are increased in
intensity.
Decrease Symptoms already present are decreased in
intensity.
Produce Movement or loading creates symptoms that were
not present prior to the test.
Abolish Movement or loading abolishes symptoms that were
present prior the test.
Centralizing Movement or loading moves the most distal pain in
a proximal direction.
Peripheralizing Movement or loading moves the pain more distally.

No Effect Movement or loading has no effect on the

symptoms.
 After Mechanical Loading
Worse Symptoms produced or increased with movement or
loading remain aggravated following the test.
Not Worse Symptoms produced or increased with movement or
loading return to baseline after testing.
Better Symptoms decreased or abolished with movement or
loading remain improved after testing.
Not Better Symptoms decreased or abolished with movement or
loading return to baseline after testing.
Centralized Distal symptoms abolished by movement or loading
remain abolished after testing.
Peripheralized Distal pain produced during movement or loading
remain after testing.
No Effect Movement or loading has no effect on symptoms
after testing.
 EVALUATION PROCESS
PATIENT HISTORY– 1* role is to
establish a hypothetical diagnosis
„ Location of pain
„ Duration of current episode of pain
„ Intermittent or Constant pain
„ MOI
„ Symptomatic and Mechanical responses to:
bending, sitting, rising from sitting, turning, lying, rising form
lying; upon waking, as the day progresses, in the evening,
when still and when on the move
„ How many previous episodes and similarities?
„ RED FLAGS and possible contraindications to MDT?
„ Occupation:
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 PHYSICAL EXAMINATION
Primary role is to confirm hypothetical
diagnosis from patient history along w/
determining appropriate loading strategy
Posture:
„ Habits
„ Acute spinal deformity – lateral shift, torticollis,
etc
„ Other abnormalities: leg length difference,
scoliosis, atrophy, etc
 Physical Exam - cont
Neuro exam as appropriate
Movement Loss
„ Willingness to move/quality/quantity
„ Baseline for determination of the mechanical response of the
test movements/positions
Repeated Movement
„ Observations are made as to symptom and mechanical
response after several repetitions
Sustained test
„ can be performed if the repeated test movements don’t provide
adequate information to come to a conclusion
Other – ie VBI, Hip, SIJ, Shoulder etc clearing tests
 Test Movements – Cervical
aka Active Physiological
Movements

Protrusion (Pro) and Repeated (Rep Pro)

Retraction (Ret) and Repeated (Rep Ret)
Retraction Extension (Ret Ext) and Repeated (Rep Ret Ext)
Sidebend (SB) and Repeated (Rep SB)
Rotation (Rot) and Repeated (Rep Rot)
Flexion (Flex) and Repeated (Rep Flex)
Protrusion
Retraction
Retraction Extension
Flexion
Sidebend
Rotation
Derangement Syndromes
 Derangement Syndromes
Derangement Clinical Presentation

1 Central or symmetrical pain across C5-7

Rarely Scap or shoulder pain
NO DEFORMITY
Extension limited
Rapidly Reversible
2 Central or symmetrical pain across C5-7
W/ or W/O Scap/Sh or Upper arm pain
KYPHOTIC DEFOMITY
Rarely Rapidly reversible
 Derangement Syndromes
Derangement Clinical Presentation

3 Unilat or Asymmetrical pain across C5-7

w/ or w/o Scap/Sh or Upper arm pain
NO DEFORMITY
Ext, Rot and later flex or combo limited
Rapidly reversible
4 Unilat or Asymmetrical pain across C5-7
w/ or w/o Scap/Sh or Upper arm pain
Relavent LATERAL SHIFT or Torticollis
Ext, Rot and later flex limited
 Derangement Syndromes
Derangement Clinical Presentation

5 Unilat or Asymmetrical pain across C5-7

w/ or w/o Scap/Sh or Upper arm pain
AND w/ arm sx distal to elbow
W/ Leg pain extending below knee
NO DEFORMITY
Ext, ipsilateral lat flex limited
Rapidly Reversible
6 Unilat or Asymmetrical pain across L4/5
w/ or w/o Scap/Sh or Upper arm pain
AND w/ arm sx distal to elbow
Relavent LATERAL SHIFT- Csp Kyphosis
or Torticollis
Not rapidly reversible
 Derangement Syndromes
Derangement Clinical Presentation

7 Unilat or Asymmetrical pain across C5-7

w/ or w/o Ant/Ant-lat neck pain
No deformity
Flex limited
Rapidly reversible
 Posture Dysfunction Derangement
Age Younger 20-40
Pathology None Adaptively Yes
shortened tissue
Pain Location Local Local (except ANR) Local or remote

Pain Referred None None (except ANR) Possible

Deformity None None (exceptions) Possible

ROM Loss None Yes Yes

Rep Test Mvt: PDM None None (except ANR) Possible

Rep Test Mvt: ERP None Yes Yes

Rep Test Mvt: Effects NE P, ERP, NW P/A, B/W, Incr/Decr,

NB/NW, Cent/Peri
Definition Normal tissue/ Adaptively Rapid change w/ mvt
Abnormal stress shortened tissue/ Mechanical displacmnt
normal stress of motion segment

Treatment Posture Correction Remodel: Rep mvt Reduce

Posture Ed TOWARD direction Maintain
Prophalaxis of restriction Remodel
Prophalaxis Prophylaxis
 References
Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of
lumbar and referred pain. A predictor of symptomatic discs and anular competence.
Spine; 22(10):1115-22, 1997.
Long A; The centralization phenomenon: its usefulness as a predictor of outcome in
conservative treatment of chronic low back pain, a pilot study. Spine; 20(23):2513-
2521, 1995.
Long A, Donelson R, Fung T; Does it matter which exercise? A randomized control
trial of exercises for low back pain. Spine; Dec 1;29(23):2593-2602, 2004.
McKenzie Course notes A, B, C, D, E
McKenzie RA 1990. The lumbar spine: mechanical diagnosis and therapy. Spinal
Publications, New Zealand.
McKenzie RA 1990. The cervical and thoracic spine: mechanical diagnosis and
therapy. Spinal Publications, New Zealand
McKenzieMDT.org
Petty NJ 2006. Neuromusculoskeletal examination and assessment: a handbook for
therapist, 3rd ed. Elsevier Limited.
Spitzer WO. Scientific approach to the assessment and management of activity-
related spinal disorders: A mono-graph for clinicians. Report of the Quebec Task
Force on Spinal Disorders. Spine 1987;12(7 Suppl):1-59.

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