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13 Articles in Volume 11, Issue #7
Fibromyalgia: Practical Approaches To Diagnosis and Treatment
Juvenile Fibromyalgia: Diagnostic Challenges and Treatment Options
Aqua Therapy Helpful in Treatment Of Systemic Lupus Erythematosus
Axial Neck Pain, Radiculopathy, and Myelopathy: Recognition and Treatment
Early Treatment of TMD May Prevent Chronic Pain and Disability
Identifying Psychological Factors That Influence Surgical Outcomes
Managing Morton’s Entrapment
Premedicated Mask May Hold Promise for Migraine Patients
Mother With Low Back Pain
The Hip Replacement Patient
Evidence-based Medicine: Losing the Patient’s Voice?
What Is Going Wrong With Research?
Risk for Sedation and Car Accidents

Mother With Low Back Pain

History

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.

 

Figure 2. Right-side glide movement.

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.

Case Diagnosis
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.

Treatment Program
The patient’s initial treatment program consisted of 10 repetitions of lying back extension exercises performed every hour (Figure 1). She was taught a better sitting posture with a more accentuated lordosis to maintain her extension position. The patient also was instructed on the mechanics of her condition and demonstrated an understanding of the disc mechanics model.

The next day she returned to the clinic, and reported no change in symptoms since her initial visit. She rated her pain intensity as 4 out of 10, and noted that the pain was focused in the low back and right buttock, with no complaints of thigh or leg pain. The patient said that she had religiously performed her exercises and posture as instructed, yet had not seen any further improvement. Assessment of her ROM showed marked improvement in flexion and extension but still showed a loss in both directions. She still had limited right-side glide.

After demonstrating that she was performing her exercises correctly, an additional component was added to the extension, exercise. Right-side glide movement was incorporated with extension, and the patient performed several sets (Figure 2). She reported further centralization—with her pain now localized to her low back and focused around the lumbosacral joint—but her pain score remained a 4 out of 10.

Her new home exercise program reflected this change in directional preference, but remained at a high volume of at least 10 repetitions per hour. Because sagittal movements had ceased to centralize her pain, and there was still a loss of movement in right lateral movements, an exercise program combining sagittal and lateral movements was initiated (Figure 2).

Figure 3. Standing side-glide exercise.

 

Figure 4. Therapist-assisted lateral movement.

The patient was examined 2 days later and reported further reduction in pain overall (2-3 out of 10). Symptoms remained in the low back centrally and, at times, off to the right side of the low back only. No complaints of buttock or thigh/leg pain were reported. Her treatment consisted of continued extension movements with side glide, combined with pure lateral movements only (Figure 3) and therapist manual techniques into lateral movements (Figure 4). She also began some gentle reactivation exercises with walking activities and paraspinal and gluteal strengthening, while maintaining an extension bias throughout.

Follow-up Outcome
The patient’s follow-up treatments over the next 1 to 2 weeks showed her once again tolerating pure sagittal extension movements with further reduction in the intensity of her low back pain (0-1 out of 10). She continued with a strengthening program in order to reduce any fear-avoidance issues, and flexion movements were gently reintroduced without any return of pain. On her sixth visit, she completed a second Oswestry Back Disability Index, which was 8 out of 100 (minimal to nil perceived disability). She was discharged to her home program consisting of extension movements with and without right-side glide movements, some simple paraspinal and gluteal strengthening exercises, and postural exercises.

Validating the Method
Shortly after McKenzie published his first paper in 1981,2 researchers began investigating the method. Ponte et al studied the effects of extension vs. flexion movements.9 The investigators found that those patients receiving lumbar extension reported greater pain relief, better tolerance for sitting, and greater ROM than those assigned to the flexion group (P<0.001)—all in less treatment sessions (P<0.01).

In 1985, Nwuga and Nwuga compared lumbar extension vs. lumbar flexion and found similar results in terms of improved pain scores, ROM, and longer sitting tolerance in the extension/McKenzie group.10 Although these two studies had flaws, including lack of randomization, small sample size, co-interventions, contamination, and so forth, they paved the way for awareness and discussion of the McKenzie Method as a viable approach to conservative treatment of spine conditions.

Because the McKenzie approach uses a unique assessment procedure, it became something that was possible to study. Research testing the validity of this assessment process has been quite vigorous with several different results.11-14 The kappa values for intertester reliability ranged from 0.15 (poor reliability) to 0.95 (excellent reliability). A summary of this literature showed that when a study used therapists well trained in the McKenzie approach, much better agreement was obtained.

When using well-trained therapists in the method, the reliability is good to excellent—but what about the validity of the evaluation? In the case of the McKenzie Method, the evaluation is trying to determine discogenic pain from nondiscogenic pain. Does it accomplish this?

In 1997, Donelson et al reviewed the ability of the McKenzie Method to predict symptomatic discs and the annular competence of the disc when compared with discography.15 They found that a single McKenzie evaluation was effective in distin-
guishing between discogenic and nondiscogenic pain (P<0.001), as well as between a competent and incompetent annulus (P<0.042). They also found that when centralization occurred, 74% of patients had a positive discogram, of which 91% had a competent annular wall. This study helped validate the use of the McKenzie assessment to distinguish discogenic from nondiscogenic pain sources. It has been suggested that the disc can be responsible for low back pain in more than 60% of cases and therefore an accurate conservative assessment of this is important.16

When comparing the McKenzie Method with other interventions, there has also been some supporting evidence. In one study, 100 patients were randomly assigned to two groups: Group 1 received treatment according to the McKenzie technique, whereas group 2 received patient education in a “mini back school.”17 When compared with an educational approach alone, patients in group 1 showed a higher return to work percentage, significantly less sick days, and significantly fewer reoccurrences of low back pain, as well as less need for further medical attention compared with group 2. Group 1 also demonstrated significantly less pain and better ROM in all directions. Five-year follow-up results were similar but less statistically significant.18

In 2002, Petersen et al compared the McKenzie Method with intensive dynamic strengthening in
260 patients. The authors found that both techniques were effective in reducing pain and restoring function.19 A supplementary analysis (because of a high drop-out rate) showed a tendency toward a difference in favor of the McKenzie Method in reduction of pain at the end of treatment (P=0.02). This difference reached statistical significance at the 2-month follow-up assessment (P=0.01), but no difference was found after 8 months. The supplementary analysis showed no differences between the groups with regard to reduction of disability.19

Type of Exercise Is Key
Clearly, the McKenzie technique has been shown to have reliability and validity, and has demonstrated benefits over other interventions. But would any type of exercise help back pain patients? Does it really matter which exercise is prescribed? Long et al clearly answered this question in their randomized trial comparing three groups of interventions.20 They evaluated 312 patients using the McKenzie Method, of which a directional preference was identified in 230 patients. These patients were then randomized into three exercise groups: 1) those prescribed the directional preference exercise, 2) those prescribed an opposing direction exercise, and 3) those prescribed a collection of nonspecific exercises. The directional preference exercise group reported statistically significant less back and leg pain, less drug use, less perceived disability, less depression associated with the pain, and less interference with normal activities compared with the other groups (P<0.001).

In 2002, Larsen et al looked at the ability of extension movements only to prevent low back pain episodes among 314 military conscripts. The authors found that in the group that performed extension exercises, significantly fewer patients reported back problems in the intervention group vs. those in the control group over the course of the yearlong study (33% vs. 51%).21 Moreover, significantly fewer patients in the intervention group consulted the regiment infirmary compared with those who did not perform extension exercises (9% vs. 25%, respectively).

Summary
This case demonstrated a typical resolution of back and leg pain using the McKenzie Method for evaluation and treatment. This method has proven reliability and validity and good prognostic indicators with the presence of centralization with directional preference exercises. In the absence of red flag symptomatology (cauda equina, multiple nerve root involvement, progressive neurologic weakness), a trial of therapy using the McKenzie Method principles seems prudent. Management of both the patient’s current episode and hopefully preventing any future episodes can be accomplished with the application of the principles of mechanical diagnosis and therapy as described by the McKenzie Method.

Last updated on: November 10, 2011
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