Written by Thomas E. Dreisinger, PhD
Of the many frustrations back pain patients face, the lack of a standardized or uniform treatment approach is high on the list. Especially for those patients with longer-lasting symptoms of sub-acute pain (lasting between six and twelve weeks) or longer than twelve weeks (chronic back pain), treatment approaches are very inconsistent.
While the McKenzie Method is successful with treating acute low back pain, it is also very helpful for those patients with sub-acute and chronic back pain.
McKenzie Method Assessment and Treatment
One of the benefits of the McKenzie Method (or McKenzie Therapy) is that it is a standardized approach to both the assessment and treatment of low back pain and/or leg pain (sciatica). The McKenzie Method is not simply a set of exercises; it is a defined algorithm that serves to classify the spinal problem so that it can be adequately treated.
The McKenzie Method is grounded in finding a cause and effect relationship between the positions the patient usually assumes while sitting, standing or moving, and the generation of pain as a result of those positions or activities. The therapeutic approach requires a patient to move through a series of activities and test movements to gauge the patient’s pain response. The approach then uses that information to develop an exercise protocol designed to centralize or alleviate the pain.
While there are certainly other forms and schools of physical therapy, this article discusses the components of the McKenzie assessment and classification system, and summarizes the experience of a typical patient whose pain classification reflects that he or she would benefit from McKenzie exercises.
McKenzie Method Assessment
When a patient’s pain symptoms can be made better or worse by adopting various, differentiated active positions, it is said that a patient has a directional preference of movement for treatment. The identification of a directional preference through mechanical means is the hallmark of the McKenzie Method (which is often referred to Mechanical Diagnosis and Therapy or MDT).
The patient’s beneficial ‘directional preference’ also is the direction of movement that causes pain symptoms to move more centrally (toward the mid-back or neck), where they are generally better tolerated than if the pain were to remain in the legs, hips or low back.
Correct assessment or mechanical diagnosis is the key to prescribing effective back pain exercises. Without the aid of a good assessment, there are no McKenzie exercises; there are just exercises, the efficacy of which is questionable.
The McKenzie assessment consists of taking a patient history and performing a physical exam. Both are used to gauge the degree of impairment as well as identify any red flags that might be contrary to exercise-based treatment (e.g. fracture, tumor, infections, or systemic inflammatory disease).
During the McKenzie physical examination, patients are taken through provocative loading strategies (movements) that help classify the patient and determine the best treatment approach. The movements are intended to either increase or decrease symptoms. For example, patients may be asked to perform single and/or repeated flexion or extension movements forward and backward.
These movements are done to ‘end range’ —the point at which the patient’s range is limited for any reason—and are done in both standing and lying positions. Lateral flexion movements may also be performed. These loading strategies may abolish symptoms, identify symptoms that occur only in certain positions, or cause symptoms to become either more central or peripheral. Once a directional preference is identified, the patient is classified and various McKenzie exercises prescribed for therapy.
McKenzie Therapy Classifications
The Mechanical Diagnosis and Therapy system has three broad treatment classifications: postural, dysfunction and derangement syndromes. Each classification treats a distinct underlying cause of disablement. There are also sub-classifications in each group.
A postural syndrome is the result of prolonged postures or positions that can affect joint surfaces, muscles or tendons. Pain may be local and reproducible when end range positions, such as slouching, are maintained for sustained periods of time. Repeated movements do not change symptoms in postural syndrome patients, and response (i.e. pain relief) is usually immediate.
It is valuable to have the patient perform poor postural positions followed by the symptom-abolishing positions in order for them to ‘understand’ what is leading to their discomfort and train patients to avoid them.
The dysfunction classification is so named because it implies some sort of adaptive shortening, scarring or adherence of connective tissue causing discomfort. A dysfunction may be intermittent or chronic, but its hallmark is a consistent movement loss and pain at the end range of movement. When the patient moves away from end range their pain is decreased.
Successful treatment takes time because it focuses on tissue remodeling which requires constant attention. Patient education is critical for this syndrome, because the patient will need to understand that remodeling tissue can be slow and often uncomfortable because the exercises prescribed are intended to challenge any adhesions or tissue scarring that has occurred.
The derangement classification is the most common syndrome that presents clinically. Its hallmark is its sensitivity to certain movements and its preference for particular movement patterns. When certain movements are performed, such as a flexion and/or extension (bending or straightening) the symptoms (e.g. low back pain) become either more central (e.g. just in the low back) or less intense.
It is not uncommon for a patient to experience rapid reduction of their symptoms immediately during the assessment. That is to say, if their symptoms were pain in their right thigh, the pain may be moved more centrally to their buttock, or in some cases be completely abolished. Treatment for the patient with derangement syndrome, as with the postural and dysfunction syndromes, is directly guided by the patient’s response to these provocative assessment movements.
While not all patients are successfully treated by Mechanical Diagnosis and Therapy exercise, it could be strongly argued that all patients with neck pain or low back pain may be successfully assessed by the Mechanical Diagnosis and Therapy method. Failure to find a mechanical component to the patient’s pain is a significant finding, in that it is as important to know for whom McKenzie exercises will be successful and those for whom they will not.
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