1. Mechanical Diagnosis & Therapy of the Spine:
The McKenzie Method
An Overview
Mechanical Diagnosis & Therapy of the Spine:
A Dynamic System of Examination, Diagnosis, Intervention and Prevention
PART II

2. Objectives Evaluation of Clinical Exam Prognosis Interventions
Treatment Principles
Force progression
ReEval/Intervention Progression

3. Characteristics of Three Syndromes See handout

4. Derangement Syndromes
Clinical Presentation 1
Central or symmetrical pain across L4/5
Rarely buttock or thigh
NO DEFORMITY 2
W/ or W/O buttock or thigh pain
LUMBAR KYPHOSIS

5. Derangement Syndromes
Clinical Presentation 3
Unilat or Asymmetrical pain across L4/5
w/ or w/o pain to buttock &/or thigh
NO DEFORMITY 4
RELAVENT LATERAL SHIFT

6. Derangement Syndromes
Clinical Presentation 5
Unilat or Asymmetrical pain across L4/5
w/ or w/o pain to buttock &/or thigh
W/ Leg pain extending below knee
NO DEFORMITY 6
RELAVENT LATERAL SHIFT

7. Derangement Syndromes
Clinical Presentation 7
Unilat or Asymmetrical pain across L4/5
w/ or w/o pain to buttock &/or thigh
INCREASED LUMBAR LORDOSIS

8. Prognosis Posture – posture correction Dysfunction - time factor
Derangement - Centralizer?

9. 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): , 1995.
A pilot study indicating that centralization is useful as an outcome predictor in chronic patients. There was a superior outcome comparing centralizers to non-centralizers in an interdisciplinary work-hardening programme.

10. Force Progression Patient generated Patient generated w/ self OP
Patient generated w/ therapist OP
Mobilization
Manipulation

11. Intervention Principles Lumbar
Extension principle
Lateral principle
Flexion principle

12. Extension Principle - Static
Prone
Prone on elbows
Sustained extension
Other:
Posture Correction

13. Extension Principle - Dynamic
EIL
EIL w/ self OP
EIL w/ therapist OP
Mobilization
Manipulation
EIS
Other:
Slouch/Overcorrect

14. Lateral Principle
SGIS
Manual Correction of Lateral Shift

15. Flexion Principle
FlL
FISitting
FIS

16. Intervention Principles Cervical
Extension principle
Lateral principle
Flexion principle

17. Dynamic Ret Ret w/ self OP Ret w/ therapist OP Ret Mobilization
Ret-Ext
Ret-Ext w/ rotation
Ext mobilization prone

18. Lateral Principle Lat Flex Lat Flex w/ pt OP
Lat Flex Mobilization sitting/lying
Lat Flex Manipulation
Rot
Rot w/ pt OP
Rot Mobilization
Rot Manipulation

19. Flexion Principle Flex w/ pt OP Flex mobilization
Flex w/ rotation mobilization

20. Exercise Prescription
Once a provisional mechanical diagnosis has been established and directional preference, the patient will continue on an independent basis until follow up.
Typically bouts of 10 reps 4-5x /day is a minimum to produce change
Dependent upon patients mechanical diagnosis, severity of problem, capabilities of the patient.

21. Long A, Donelson R, Fung T. Does it matter which exercise
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): , 2004.
Following a mechanical evaluation all patients who demonstrated directional preference (DP) (230/312, 74%) were randomized to receive exercise matched to DP (1), exercise opposite to DP (2) or evidence-based management (3). Over 30% of groups 2 and 3 withdrew because of failure to improve or worsening, compared to none in group 1. Over 90% of group 1 rated themselves better or resolved at 2 weeks, compared to just over 20% (group 2) and just over 40% (group 3). There were further significant differences between the groups in back and leg pain, functional disability, depression and QTF category.

22. Reevaluation/Treatment Progression
Confirm, reject or modify the provisional mechanical diagnosis
Determine the need for progressions/regression of force
Determine when it is appropriate and how to initiate recovery of function/reactivation
Determine any worsening or progression of the disorder which prompts the need to contact the referring medical physician
Determine the need and timing for discharge planning
Develop the patient's self management and problem-solving skills essential for long-term, prophylactic benefit.

23. Discharge Planning and Prophylactic Concepts
Provision of education
Encouragement of patients to ‘problem solve' their own difficulties should be part of treatment.
Supervision of patients must, in the light of the epidemiology of back pain, involve the nurturing of self-management strategies.
This should be done from day one and those strategies will need to be individualized according to the patient.

24. 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): , 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): , 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): , 2004.
McKenzie Course notes A, B, C, D, E
McKenzie RA The lumbar spine: mechanical diagnosis and therapy. Spinal Publications, New Zealand.
McKenzie RA The cervical and thoracic spine: mechanical diagnosis and therapy. Spinal Publications, New Zealand
McKenzieMDT.org
Petty NJ 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.