Greathouse Chiropractic & Physical Therapy

McKenzie Mechanical Diagnosis & Treatment

 The McKenzie Method is likely the the most valid and reliable method of assessing, diagnosing and effectively treating neck & back pain to date. The information below is a short synopsis of some of the data that supports this remarkably effective method.

Excerpts from Rapidly Reversible Low Back Pain (2007)

By: Ronald Donelson, MD, MS (Orthopedic Surgeon)

 An overlooked substantial piece of the low back pain puzzle.

An evidence based paradigm that starts with validated subgroups.

Alternative Research Strategies for Identifying Low Back Pain Subgroups

Ideally, researchers emphasize the need to identify and validate low back pain subgroups by means of anatomical tissue responsible for the pain: intervertebral disc, facet joint, sacroiliac joint, muscle or ligament, etc.  This is a real problem, and currently an insurmountable one, because there is no "gold standard" test at this time.  Consequently, with no means of identifying anatomically based low back pain subgroups, this means of identifying subgroups is for now, of little help.  Consequently, it's suggested that we look for subgroups by patient characteristics rather than their anatomical diagnosis.

"Mechanical diagnosis and therapy" (MDT) is the title increasingly used to describe a paradigm of care that has been best known for most of the past 25 years as the "McKenzie approach" to managing low back, thoracic and cervical pain. These two titles for this paradigm are absolutely interchangeable.

Name aside, this approach has become one of the most popular means of low back care utilized by some physical therapists as well as some chiropractors around the world for addressing low back pain.  (9, 60)

It also happens to be the most misunderstood, most misapplied and therefore unappreciated form of care.

In research circles, it's very often construed as a one-size-fits-all treatment, specifically, "lumbar extension exercises".  But such a focus completely misses the fundamental and essential element of this approach: patient assessment and classification.

MDT is also very useful in addressing cervical and thoracic pain, but the scientific documentation for its validity still lags behind that published for low back pain.

The most important and most often overlooked feature of the MDT is its clinical assessment value. It has  been acknowledged in some guidelines as a useful treatment (97, 112) but its assessment value has been largely overlooked by guideline reviews.

The single exception is the Danish Acute Low back Pain guidelines published in 1999.  (97) These guidelines uniquely concluded: "The McKenzie method has value as both a diagnostic tool and a prognostic indicator."  "This technique can be recommended as a diagnostic method for both acute and chronic pain syndromes."  In fact, they assigned their second-highest grade for scientific evidence in support of the diagnostic value of the McKenzie/MDT assessment procedures.

The assessment -- diagnosis link

Worth reiterating: the 1987 Quebec Task Force statement indicated that there was so much variability in making a diagnosis that this initial step routinely introduced inaccuracies which were further confounded with succeeding steps in care. (132) Also, Spratt, in 2002 stated "variability in diagnosis falls at the feet of invalid assessment."  (133)

* Nikolai Bogduk, MD, Ph.D., BSc., is a well-published researcher and professor of pain medicine at the University of Newcastle in Newcastle, Australia. He is known for being brutally honest in his critique of the quality of evidence pertaining to diagnostic or treatment intervention.  He accepted the invitation to write the foreword for the 2003 addition of McKenzie's lumbar textbook (103) in which he stated this about MDT, "reliability is now beyond doubt". 

 Continued next column... 

No other form of low back pain clinical assessment has been investigated for its reliability as extensively as the MDT assessment protocols and classification.

The initial centralization study published in 1990 (56) reported that the radiating pain of acute low back pain centralized during an MDT assessment 87% of the time.  The prevalence was nearly as high in patients with pain for over three months.

Since 1990, at least 10 other studies have reported on the high prevalence of centralization and directional preference in their study populations.  (37, 50-52, 56, 72, 82, 90, 129, 136, 158) Overall, reported prevalence has been 70-87% across acute low back pain studies and in 32-52% of patients with chronic low back pain.

To date, at least nine such studies have been published that were unanimous in reporting good to excellent reliability (Kappa values ranging from .79 to 1.0 when using trained examiners.  (30, 31, 64, 75, 76, 116, 134, 158, 161)

Two other studies reporting only poor to fair reliability utilized examiners who had little, if any, formal training in MDT as taught by the McKenzie Institute.  (62, 117)

Since the first centralization study, at least seven other cohort studies have unanimously reported that treatment strategies on individual patient's MDT exam findings produced good or excellent outcomes for both acute and chronic patients.  (56, 65, 72, 90, 1.9, 136, 157, 158)

Additionally, centralizers had a stronger chance of experiencing prolonged recoveries.  (157, 158)

Multiple studies and systematic reviews document that centralization and directional preference are highly prevalent.  (37, 50-52, 72, 82, 80, 90, 129, 136, 158) Multiple studies also document that centralization and directional preference are reliably identified when clinicians are adequately trained.  Finally, the same clinical findings have been shown in multiple studies to predict a highly successful outcome to patients that are treated accordingly.  (56, 65, 72, 88, 90, 129, 136, 157, 158,)

In Closing

It’s encouraging to see some change in direction of research and improved clinical indicators for nonspecific spine pain. More studies are on the horizon, from which I believe more subcategories will emerge, resulting in even better outcomes with less time and money wasted.

I’ve been studying and using the McKenzie/MDT method since 1995 with remarkable results. These protocols are not only effective but are empowering to the patient, as it provides them with effective independent management skills. This is by no means a panacea for all spinal pain sufferers, but it does offer, as earlier indicated, a valid and reliable assessment approach, identifying patients that better fit a mechanical approach to care.

Additionally, some patients do require additional stabilizing physical therapy, from simple uncomplicated reactivation advice to more comprehensive rehabilitation. Recent studies have shown that manual/mechanical therapy as well as rehabilitation is beneficial for onspecific spine pain. The MDT protocols give algorithmic guidance for manual therapy and rehabilitative exercise intervention.  As a rehab specialist, I have found this very instructive in case management.   Ultimately, the goal is to restore function and independence.

 If you decide you would like to receive care or refer patients for care, please be assured we will provide straight forward, no nonsense case management.  The results are many times notable.

If you have questions or for references you may contact me at 725-6314 or email me at makg1@netzero.com.

Thanks for your consideration.

James E. Greathouse Jr. BS, DC