By Mike Cleek, PT, DPT
Physical Therapist, Pennsylvania Southeast

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a mainstay in every physical therapist’s toolbox when treating low back pain. While some of the theories and methods behind the original MDT are outdated, I want to outline why I still use MDT as a framework for my low back pain (LBP) treatment and some considerations for successfully implementing MDT with other adults in a home-based or senior living community settings. 

Outdated Beliefs Regarding the McKenzie Method

Prior to using MDT as my framework for LBP treatment, I found myself hesitant to utilize the methods because of the outdated theories and language perpetuated in the McKenzie world. While these methods certainly help many patients, not adapting to the current literature will lead to erroneous cultural beliefs and poorer LBP outcomes. 

The crux of the problem lies in the name “Mechanical Diagnosis and Treatment.” The core McKenzie belief is that a large majority of LBP is mechanical in nature and can be fixed by mechanical treatment. While there certainly may be a mechanical component, the current literature suggests that many other biopsychosocial factors play an important role in back pain. We now know that for most individuals who experience acute LBP, the best treatment is simply education to stay active and reassure them that their symptoms will improve.

For a subset of those individuals, physical therapy is necessary to reduce pain and improve function through exercise interventions. Failing to address other biological and psychosocial factors, in addition to providing biomechanical interventions, could posture patients for the transition to chronic LBP.

As physical therapists, we already know that mechanical flaws are not necessarily correlated with pain. For example, we know that lumbar imaging findings have little role in determining whether an individual will have pain, even at a 10-year follow-up. We are learning that factors such as negative recovery expectation, maladaptive coping strategies, comorbid psychiatric conditions, psychological stress, sleep, fear-avoidance of movement, and self-efficacy play equally important roles in the resolution of non-specific LBP. 

Under the purely mechanical lens of MDT, these factors are often left out. In fact, much of the language used by MDT practitioners can potentially do more harm by perpetuating fear-avoidance, psychological stress, and maladaptive coping strategies.

The McKenzie classification “syndromes” are broken down into three categories: 

• Postural syndrome 
• Derangement syndrome 
• Dysfunction syndrome

These names carry negative connotations and can perpetuate the idea that the spine is “damaged,” which is the sole cause of pain. 

For a patient, hearing this can be scary and may lead to fear-avoidant behaviors to limit further damage to their spine. It may also lead to harmful beliefs that the patient caused the back pain by sitting or lifting with poor posture, not having enough “core stability,” etc. 

The original McKenzie treatment also includes education about proper sitting and lifting postures. However, if posture is the cause of LBP, why did the pain start now? Presumably, the patient has been sitting and lifting similarly for their entire life. What changed? Postural variability is natural and there is little evidence to suggest that there is one perfect posture. In addition, some evidence points to sustained posture, rather than poor posture as the culprit.

Even so, I continue to educate on “good” sitting posture, with the acknowledgment that it is natural to fall out of that posture frequently throughout the day… which leads to postural variability… which the back likes! In general, avoiding language that promotes fear-avoidance of any posture or movement should be the goal. Education that backs are strong and benefit from movement should be a top priority for anyone treating LBP. 

Why I Still Use MDT as a Framework

So, after all my gripes, why do I still use MDT as the framework for my treatment of LBP? First, I like that it is a movement-based treatment technique. When applied correctly, it can address patient fears about movement, improve self-management, and increase self-efficacy. The interventions are easy to implement, and the focus of the home exercise program is one frequent, movement-based exercise. 

When performed with a good test-retest, MDT can also increase patient buy-in because the patient sees how their home exercise can change their symptoms. Some evidence even suggests that older adults with LBP may benefit more from MDT methods when compared to younger individuals.

Finally, MDT provides a good framework to base LBP evaluations on, regardless of whether MDT will be the primary treatment used. For example, in individuals who have recurrent acute LBP due to poor load tolerance, I can still use test-retest to find an exercise that reduces symptoms temporarily, while ensuring that I educate the patient that the long-term solution will be progressive strengthening and load desensitization. 

5 Tips for Physical Therapists Implementing the McKenzie Method

To help with the implementation of these techniques with older adults in the home setting, I will provide some useful tips that I believe are imperative for successful LBP outcomes.

1. Spend the Time to find a Good Test-Retest

This should be the priority during the objective portion of the exam. A good test-retest can provide accurate information about which interventions are helping, and which are not. I typically start with lumbar AROM because it is frequently a good test-retest and I will want to evaluate it anyway during my initial evaluation; however, any functional movement from the subjective that elicits the symptoms reported in the chief complaint will work. Each time you run the patient through the test-retest, you will be asking them how their symptoms changed compared to the most recent time they performed the activity, looking for centralization, pain reduction, or increased ROM. It is important that you educate the patient on the reasoning behind your test-retest, as you will have them perform it often throughout the initial evaluation. 

2. Perform Test-Retest after EVERY Item in the Objective Portion of Your Evaluation

Once you have found a good test-retest, it is important that you test it after every section (ex. lumbar AROM, strength testing, lumbar spring testing, etc.) of your objective evaluation. Typically, I look for a home exercise directly following the identification of a good test-retest. After each MDT exercise, I ensure that I perform the test-retest and ask the patient to compare their symptoms to the most recent performance. 

If symptoms worsen, I usually educate the patient that if we can quickly change symptoms for the worse, we also can quickly change them for the better. If symptoms change for the better, you have found a possible direction preference for the home exercise and can explore progressions or regressions as necessary. Sticking to this method will also increase patient buy-in since they can immediately see the benefit of the home exercise.

Once you have found a home exercise, do not forget about the test-retest. I continue to use it throughout my session to determine which other interventions might benefit my patient. For example, increased symptoms after hip strength testing might indicate some load tolerance problems that need to be addressed.

3. Respect Irritability

I find myself differing from many McKenzie clinicians when it comes to irritability. Respecting irritability is one of the most important factors to consider when treating back pain. We are trying to reduce fear avoidance of movement by providing exercise as a reliever of pain. While we should not avoid pain altogether and should educate that pain does not indicate damage, pushing someone too far can create negative associations between movement (or exercise) and pain. 

In an ideal McKenzie exercise, the patient goes to end-range lumbar motion; however, I typically tell my patients to push up to the point of increased pain. In my experience, if I have found the correct exercise, the pain diminishes with increased reps and the patient can progress to the end range relatively quickly, potentially within the first session.

4. Utilize Caregivers

It can be difficult to get patients with dementia or other cognitive disorders to follow through with their home exercises. With MDT, home exercises are the core of the program; after all, I just mentioned one of the major benefits being self-efficacy. Involving caregivers from the evaluation can be a tremendous help when coming up with a HEP that is reasonable to perform for the patient and those that care for them. In some situations, the amount of caregiver support is not enough to accommodate the HEP. Be creative in choosing an easy exercise that can be visually represented. For example, I have taped a picture of double knees to the chest next to a patient’s bed with a caption in large letters: “WHEN YOUR BACK HURTS”. I have also collaborated with caregivers for individuals with mobility deficits to find a HEP that limited positional change and reduce the amount of time required of the caregiver. In some instances, you may have to sacrifice the perfect exercise for something that will actually be performed. When in doubt, I always choose an exercise that promotes frequent movement over one that can only be performed a few times per day due to logistical barriers.

5. Educate

Finally, without education, any LBP treatment is doomed to fail. I typically educate patients on the importance of frequent movement, which is the reasoning behind their one-home exercise performed hourly (I often tell patients eight times per day, or every hour in the standard workday). In addition, I am always sure to tell patients that soreness, which is different from pain, is to be expected after the initial examination, due to their back having performed many movements that it might not be used to. The patient should continue their home exercise through any soreness but should continue to respect the pain threshold and adjust ROM accordingly. 

Something that I believe is often overlooked is the value of asking the patient to stop other back-specific exercises for the short term. For example, many patients have already researched exercises to improve their pain and are performing them in addition to their HEP. Emphasis should be placed on back pain treatment being a trial-and-error process; without stopping other exercises, it will be difficult to pinpoint which exercises are beneficial or detrimental. With that said, I always educate patients to otherwise continue with normal activities as long as they do not provoke pain. 

When using these tips, I have found great success in using MDT as my treatment framework for LBP. By showing patients how quickly movement-based therapy can improve their symptoms we can promote self-efficacy, decrease fear avoidance, and improve LBP outcomes for older adults. Thanks for reading, I hope that you find some of these tips useful and can apply them to improve outcomes for your patients!