Mother With Low Back Pain
A 32-year-old mother of two presented to the clinic with a 6-week history of low back pain and right posterior thigh and calf pain. Although she said her symptoms began for no apparent reason, she reported that prior to the onset of pain she had been a passenger in a car for almost 8 hours. Her symptoms began when she got out of bed the following morning. The pain was confined to her low back. Throughout the day her symptoms became more intense, and by the end of the day, her symptoms had migrated into her thigh and calf.
Since then, her symptoms have waxed and waned in her calf; however, her low back and thigh pain has been mostly constant. She reports worse pain after sitting and on bending. In the morning, she experiences pain and stiffness, and she cannot remain in one position for long periods of time. She feels better with movement and when standing or walking. She said she gets most relief when she is in a fully reclined position; however, the relief is only temporary. She completed an Oswestry Back Disability Index showing 48 out of 100 (moderate–severe disability perception).
The rest of her medical history is unremarkable. Her primary care physician prescribed nonsteroidal anti-inflammatory drugs and muscle relaxers with minimal relief. She recently had a magnetic resonance imaging (MRI) scan, and although no images were available for review, the radiologist’s report showed generalized mild degeneration in the discs and mild arthritic changes throughout. The report also found a posterior-lateral disc protrusion at L5-S1 with mild compression of the exiting nerve root.
Back pain continues to be a major cause of disability in developed countries. In fact, it has been said that after more than 50 years of research, we have not learned much and can truly only agree on one thing—activity is better than extended rest. As healthcare providers trying to answer patients’ questions, we need better tools to assist in their understanding of this, at times, complex problem. This article aims to look at one conservative approach to the treatment of a typical back pain sufferer—the McKenzie Method.
Theory Behind the Method
Developed by Robin McKenzie, a physiotherapist in New Zealand, the McKenzie Method consists of three components: assessment, directional preference exercises, and prevention strategies against future episodes. Although the disc model of back pain is now widely accepted,1 it was McKenzie’s chance discovery that sustained and repeated extensions of the spine can alleviate back pain that led to the development of the McKenzie Method in the early 1960s. Since then, the McKenzie Institution has developed a full education program for physicians, physical therapists, and chiropractors, and has spawned a body of research testing the method’s ability to assess, classify, and treat spinal pain and dysfunction.2
What Is the McKenzie Method?
As noted, patient assessment is the first component of the McKenzie Method. The method uses repeated movement testing to help classify patients into different groups or subgroups (ie, discogenic or nondiscogenic), and then tailors their treatment goals and approaches accordingly. When evaluating a spine patient, the use of repeated movements is not widely performed in a typical physical therapy practice, but it is the core component of the McKenzie evaluation.
The idea is to elicit change in the patient’s symptoms with repeated flexion, extension, or lateral movements in the standing and prone positions in order to determine which movements exacerbate symptoms and which alleviate them. The helpful movement then becomes the patient’s “directional preference” movement. Frequently repeated exercises designed for the patient’s directional preference can bring about rapid change in both the intensity and location of symptoms (ie, centralization).
Figure 1. Back extension exercise.
By definition, this phenomenon of centralization, originally described by McKenzie, is when distal limb pain emanating from the spine is reduced and abolished as a result of a loading strategy (exercise, mobilization, or sustained position), and then remains better. The consensus is that centralization can occur anywhere from 30% to 80% of the time, depending on factors such as acuity of symptoms, training of therapists, and absence of nonorganic signs. A number of studies have examined centralization, with favorable outcomes associated when it is present.3-8 In fact, in one study, the presence of centralization was strongly associated with a good outcome and allowed the therapist to confidently inform the patient of the likelihood of a good prognosis within a short time frame (ie, seven visits or less).7
After assessing and treating the spine complaint, the final stage of the McKenzie Method is that of prevention. A home exercise program using the patient’s directional preference, combined with posture awareness, generalized reconditioning, and recovery of function in all movements, helps maintain those benefits gained.
With minimal response from the patient’s medications, a mechanical spine complaint was suspected. The patient’s MRI results concurred. The patient began to demonstrate a directional preference; she disliked flexion movements (sitting, bending, and standing from a sitting position) and tolerated extension movements (standing and walking). Sustained flexed positions during her prolonged car ride may have been the predisposing factor to the onset of her low back pain.
On examination, the patient was found to have poor sitting and standing posture, with a flattening of normal lumbar lordosis. Her range of movement (ROM) showed a moderate loss in both flexion and extension (>50% loss of ROM) and no loss of left-side glide but a minimal loss of right-side glide noted.
Her repeated movement testing showed an increase in low back pain and increased area of pain into her leg/calf with repeated flexion in standing (peripheralization). The patient rated her pain intensity as
7 out of 10 on the visual analog scale (VAS). Repeated extension in standing position had minimal effect on her symptoms—feeling no better or worse afterward. Repeated flexion in a lying position also increased her low back and leg pain, but after five to six sets of 10 repetitions of lying back extension exercises, she reported lessening leg pain and migration of leg pain into her right buttock and low back; she rated her pain intensity as 4 out of 10 on the VAS. After reassessing the patient in the standing position, her symptoms remained improved and centralized.