McKenzie Method, Diagnosis No Better Than Treatment

McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training. Spine (Phila Pa 1976). 2014 Feb 1;39(3):E182-90.  Werneke MW, Deutscher D, Hart DL, Stratford P, Ladin J, Weinberg J, Herbowy S, Resnik L.

Abstract
STUDY DESIGN:
Inter-rater chance-corrected agreement study.
OBJECTIVE:
The aim was to examine the association between therapists’ level of formal precredential McKenzie postgraduate training and agreement on the following McKenzie classification variables for patients with low back pain: main McKenzie syndromes, presence of lateral shift, derangement reducibility, directional preference, and centralization.
SUMMARY OF BACKGROUND DATA:
Minimal level of McKenzie postgraduate training needed to achieve acceptable agreement of McKenzie classification system is unknown.
METHODS:
Raters (N = 47) completed multiple sets of 2 independent successive examinations at 3 different stages of McKenzie postgraduate training (levels parts A and B, part C, and part D). Agreement was assessed with κ coefficients and associated 95% confidence intervals. A minimum κ threshold of 0.60 was used as a predetermined criterion for level of agreement acceptable for clinical use.
RESULTS:
Raters examined 1662 patients (mean age = 51 ± 15; range, 18-91; females, 57%). Data distributions were not even and were highly skewed for all classification variables. No training level studied had acceptable agreement for any McKenzie classification variable. Agreements for all levels of McKenzie postgraduate training were higher than expected by chance for most of the classification variables except parts A and B training level for judging lateral shift and centralization and part D training level for judging reducibility. Agreement between training levels parts A and B, part C, and part D were similar with overlapping 95% confidence intervals.
CONCLUSION:
Results indicate that level of inter-rater chance-corrected agreement of McKenzie classification system was not acceptable for therapists at any level of formal McKenzie postgraduate training. This finding raises concerns about the clinical utility of the McKenzie classification system at these training levels. Additional studies are needed to assess agreement levels for therapists who receive additional training or experience at the McKenzie credentialed or diploma levels.

My comments:

This new study on McKenzie method of physical therapy shows regardless of how well physical therapists are trained in the method, they don’t agree very well on a diagnosis. Robin McKenzie’s primary idea in the 1980s was that bending forward too much caused posterior migration of the nucleus in spinal discs leading to bulges, herniations, and subsequent neck and low back pain. That much has been confirmed by subsequent research, but a 2006 meta-analysis (a study that combines and comparing a number of smaller studies) found his method of treatment had little to no benefit in treating low back pain.

This study found there was little agreement among physical therapists who took advanced training in McKenzie method as to which of McKenzie’s categories a patient fell into with regards to their particular type of low back pain. Regardless, I enjoyed McKenzie’s books and I think they should be read by all physical therapists specializing in low back or neck pain. However, as I commented in my earlier blog, I think he started off with a good idea that went too far. I often comment that his books are great if you only read the first half where he talks about avoiding spine flexion using lumbar support, and maybe doing some mild spine extension stretches. However, when he gets into end-range spine extension with overpressure and later advocates a return of lumbar flexion stretches I think he runs into problems. His treatment does not do anything to restore spine or extremity strength and endurance, which has been shown to reduce low back and neck pain.

I always thought his evaluations were a bit drawn out, and often left a patient with low back or neck pain feeling worse after the first day, so I’m a little happy to see I’m not missing anything by not adopting the majority of them. I’ll do a future blog on Stuart McGill’s study where they found spine extension did sometimes help to reverse disc bulges, and how milder extension stretches can be implemented into a comprehensive low back rehabilitation program with positive effects, so maybe McKenzie will find at least limited redemption.  This does illustrate a pretty good caution about avoiding particular “methods” because eventually it’s founder dies, science moves on, and followers are left carrying on an outdated legacy.  

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

8 thoughts on “McKenzie Method, Diagnosis No Better Than Treatment

  1. This article was very informative and helpful. I am not a PT. Just a LBP and Sciatica sufferer who absolutely did not respond favourably to McKenzie’s extension exercises. I’m very glad my PT opted for a much gentler approach to treatment. One that listens to my body and one that she has customized based on my own injury and needs for rehabilitation. I hadn’t found anything conflicting with McKenzie treatment and wondered how I could be the only one not responding well to that treatment. Thanks for the validation that I am on the right path.

    • Thanks for the feedback Danielle. I’m glad your physical therapist figured things out for you too. Some feedback on my other McKenzie Method blog indicated a lot of therapists keep pushing in spite of what your body says about it. I think it fell under the “it has to hurt now to feel better later” clause.

  2. As with any technique, it is at the mercy of the clinician using its methods. If used correctly, “no pain, no gain” or therapists pushing through in spite of symptoms, is only used in limited capacity such as stretching shortened tissue. But even in this case, the clinician is to ensure that the pain is produced during the stretch, but no worse afterwards. Thus, clinician judgement is a big part of the method and if you have not been to a course, it is not responsible to comment on the method. The more appropriate comment, and this would be obvious if you had working knowledge of the method, is that the clinician is using the system incorrectly.

    Lastly, there is not great evidence for specific core stabilization vs. general exercise, so why McGill’s techniques or “Big 3” are thought of as the definitive way to treat lumbar pain is beyond me.

    Additionally, there are many MDT clinicians who use strength and stability exercises within their treatment depending on the needs of the patient.

    It is a great evaluative tool to guide treatment, however, it is difficult and takes time to master. The clinicians who struggle with it, typically give up once extension does not work, which is not the point of the system at all. It might be beneficial to talk to a Diplomat (highest level of training) to get a better idea of what the system is about.

    • Hi Sam,

      I’m sorry but I disagree with a lot of what you say. The study in question specifically found that the level of training of McKenzie method practitioners does not help with diagnosis. Plus I largely disagree with his diagnosis categories and his method of treatment. And even if I new more about the method, I wouldn’t want to use it because (on the whole) McKenzie method does not make sense given what we now know about spine degeneration and pain. AND meta-analysis show’s McKenzie method is no more effective than “advice to stay active.” In the comments on that linked blog, I did a fair amount of discussion with MDT therapists, so I would encourage you to read through those comments to see if I missed anything. And I’ve read the bulk of McKenzie’s books (including the big one’s on low back pain) so unless McKenzie himself was incapable of adequately describing his method in print, then I think I understand his method quite well.

      I’m not a big fan of “core stabilization” either and have written about that too in comparison to general exercise. Thus according to some definitions I’m more of a “general exercise” kind of therapist. I would encourage you to read McGill’s books yourself. Low Back Disorders really is fabulous and if you read it you would see that McGill himself does not think his Big 3 are the definitive way to treat low back pain, and personally I only sometimes use them. It’s my recollection that he would say removing the source of injury is the most important factor, second being to grove spine healthy movement patterns, bending through the hips, keeping the spine neutral, yadda, yadda, yadda. The big three are just one way of increasing one’s fitness to help you do so.

      I’m glad that many MDT clinicians use strength and stability exercises, though as I think not having them was a shortcoming in McKenzie’s method. I do think McKenzie was super smart though, and his responses (that I have read) to researchers later finding problems with his theory make me think he was open minded until the end. I think about half of his method was correct, but where it was he took it too far, and it wasn’t complete. Plus where he was wrong I think it negates some of his good ideas. I think the biggest problem is his method was codified decades ago, while understanding of spine degeneration and rehabilitation has continued to advance. If you think I’ve missed anything big let me know, but first I would encourage you to read through some of my other linked threads, and maybe read Low Back Disorders too. Cheers.

  3. I very much agree with Sam’s comments. People confuse the McKenzie or MDT system with a “treatment protocol” versus a diagnosis and classification method. When mastered and used properly, the system is better than anything else I’ve found to truly get to the actual mechanical cause of something. It ALSO tells you when something is not mechanical in nature – which then indicates a referral elsewhere or a different approach to treatment. The MDT system is designed to detect and then provide a protocol for decision-making around treating mechanical problems – which tend to comprise about 80% of all MSK problems.

    Prior to being trained in this classification method, I missed so many things – quickly moved on to exercise and functional training – only to have the symptoms come back – and then lead to pre-mature referrals to ortho’s that would then lead to a multitude of test, procedures, injections or surgery. This doesn’t happen anymore. I’m now the last resort and second opinion for a lot of folks, and saving these clients from unnecessary procedures and surgeries. I can confidently say that I would not have arrived at this level of analytical thinking and diagnosing without my MDT training. And I’ve been at this a pretty long time (16 years as a PT – 6 years training with MDT – 3 years certified)

    There is a very good reason that you don’t get awarded a certification in MDT after just once course. It’s takes several years and the test is no-joke. The clinicians actually getting their cert and sticking with the method are using it properly and getting amazing, long-lasting results for their clients that actually empower them – and allow them to stick with exercising longer – bc they know how to manage their own bodies. While I agree that functional training and strengthening is vital – it is NOT going to be enough to help you when you “throw your back out again” and it won’t actually prevent you from doing so. It will certainly help make you less likely to have a future back injury – but it is not a guarantee. What is a guarantee – as proven by the research – is that when you can find a directional preference that you respond to you can almost always go back to that tool to quickly fix yourself and get back on track with your every day activities and exercising. That is the beauty and often over-looked gold to this system. It turns patients into their own best body detectives.

    I appreciate you writing your blog and investigating so many other methods. But I felt it important to comment on this because your characterization of the MDT method indicates that you do not have a full understanding of what it was designed for and it doesn’t sound like you’ve been through all the training – but please correct me if I’m wrong 🙂 . I hate for someone who is really struggling to come across this and give up on MDT after just one or two sessions. I have to really educate and coach patients along in their first 3-4 sessions with me. Many of the tests can be provocative – for good reason – and that is why quick results can be seen. But there is certainly much education to be had about how pain works in the body. If those conversations aren’t happening – and aren’t being heard by the patient – then it is very easy to think its a “bad treatment technique”. Trust me – I’ve learned this from experience and practice – as is with most any method/technique/philosophy one intends to master. Gosh…. if I only think back to when I first got out of PT school. Imagine if they did a study of PT’s all across the board for one particular “method” and included brand new clinicians versus those of 10 or more years experience. I think you’d see some discrepancies of inter-rater reliability there as well – and they might just throw out the whole professional as being inadequate or ineffective!

    I was at the last USA McKenzie conference and spoke with many of the faculty. I believe they recognize that more standardization needs to happen across the board. I am positive this study done in 2014 was just one step toward that realization and they have made, and continue to make, positive changes to improve the teaching and learning of the method. While I can’t speak for the authors themselves, I imagine this study was done with that very intention in mind – to see where improvements needed to be made in the education and testing of the method.

    Cheers!

    • Hi Carrie,

      I appreciate you taking the time to write and I don’t mean to sound dismissive, but honestly I’m dismissive. I appreciate that McKenzie method is both a diagnosis and treatment. But honestly, it’s a 1980s diagnosis and treatment. Would you want your heart surgeon to be using 1980s techniques? What about your knee surgeon?

      Medicine progresses, it moves on as we learn more. All you MDT therapist who don’t like that I criticise the method have nothing more to say than that it seems to work for you and that I just don’t understand your 1980s technique well enough. I would appreciate if you understood placebo effect better, and could appreciate the fact that if I were criticizing vertebral manipulation some chiropractor could chime in that I haven’t been to chiro school, and most of their patients “seem” to get better too. With the often intermittent nature of back pain, many patients seem to get better for a time, but are they getting much better than they would have had they received placebo acupuncture and advice to stay active?

      The research I cite above factors out such anecdotes and found the McKenzie diagnosis “not acceptable.” Another meta analysis found McKenzie method treatment no better than advice to stay active, and comments on that blog are largely divided between patients with back pain who were made worse by their McKenzie therapist, and McKenzie therapist who like you, just think I don’t understand the system well enough.

      Now in my opinion McKenzie was right about a lot of stuff, but he often took his good ideas too far, and later contradicted himself even when he was correct. So on the whole I don’t think it’s a good way to treat back or neck pain and I would not send my mother to a McKenzie therapist. I think it survives because most other treatments are even more old fashioned giving you as a physical therapist few good options.

      I’d be happy to talk specifics with you if interested. I might want you to do some reading first to get us on the same page though. If interested, hit me back.

  4. Chad,

    Thank you for your response. You stated that you don’t agree with much of what I said, however, the only thing you didn’t seem to agree with was the level of training the Mckenzie therapists had. I will have to disagree with you as well, as the study in question has one very important and major flaw: they compared those who had taken part A&B, A,B,&C, and A-D. Those who have not completed the credentialing exam are not permitted to market themselves as MDT trained and are not deemed to have even entry level MDT skills. A better study design would be to compare Credentialed clinicians to Diplomats, as one has entry level knowledge/skill and the other is considered a master. The Mckenzie Institute has many studies that demonstrate high inter-rater reliability between Diplomats, which may be worth looking up.

    While I’m impressed you’ve read all of Mckenzie’s books, I find it somewhat humorous that you seem to think it makes you an expert on the method. That would be like me saying, I’ve read the generally accepted text books on brain surgery and I feel I have a great understanding of all the information, can describe/perform the procedure, and critique it appropriately. There is merit in seeing it performed well, not to just reading a description. Per most of your comments, you do not understand the method very well, so it does not seem worthwhile to discuss it in-depth.

    However, I would like to understand your philosophy better. You stated in that you are a “general exercise” type of therapist. Since most people are sedentary, I don’t find this to be a bad approach, as just getting people to move is often helpful (if you care to read my opinion). My question is, what do you do with a study like the one done by Peterson, Laslet, and Juhl (Clinical classification in low back pain: best evidence diagnostic rules based on systematic reviews), which discusses, with regards to intervertebral disc involvement and to rule in/out SI joint involvement, the use of centralization as an acceptable tool. You mentioned in one of your responses to another therapist that you do not see the point in a movement exam. My question would be, how do you determine if symptoms will centralize if you don’t move them? Additionally, how do you differentiate between low back and hip, neck and shoulder, neck and elbow etc.. if you do not check baselines and then move the patient to determine if symptoms are reproduced or changed with spinal movement? What if arm weakness is actually secondary to nerve root impingement at the neck? Do you just strengthen said arm and advise “neutral” posture? So you know, this is a sincere question. I am genuinely interested to know how you evaluate a patient. Or, are you of the belief that it doesn’t matter where the problem originates and that general exercise is the answer no matter what? Also, this same article reports that there is not great evidence to make a Clinical Diagnostic Rule regarding facet joint pain, other than it can be ruled out if centralization occurs. So if we can’t diagnose it properly, how can we be sure of its cause? And we both know that X-rays/MRIs are not greatly reliable, so even the presence of facet joint degeneration or even stenosis, spondylolisthesis etc… cannot assure us that these findings are the cause of pain, as when pain is abolished these things are often still present with follow up imaging.

    Additionally, you mentioned that with what we know about spinal degeneration and pain, MDT is out of date. Although this is a bold statement, I will ignore it and instead ask a question: how do you feel about the numerous studies we have discussing the patients who show severe degeneration on an MRI, but do not have pain and the ones who have “clean” MRIs, but have severe pain? If people have severe degeneration, but have no pain or history of back pain, doesn’t this mean we actually don’t understand spinal degeneration that much, as it is not a great indicator of pain? Again, these are genuine questions.

    You also state that you don’t like lumbar rolls as they promote too much extension and you prefer the ever popular “neutral spine” position. Do you consider neutral the natural lordosis or do you feel that it should be more of a straight lumbar spine? I would argue a lumbar roll encourages a neutral spine, as it assists in keeping the natural lordosis. Of course, one needs to adjust the roll as not every lordosis is the same.

    I have been reading some of McGill’s studies and will get the book you recommended. I think most therapists can get on board with advising patients to avoid repetitive postures and repetitive end range loading for long periods of time. While I am not a fan of the TA/multifidi training, I do see a lot of merit in the importance of exercise, especially as it relates to recovering function, preventing injury, and overall health (duh). I think you would find, if you pursued it, that the leading McKenzie practitioners (Diplomats) use these exercises quite often, depending on patient response. They do not recommend people walk around in end range extension/flexion all day, which seems to be your general thought. The treatments are actually very reasonable, and not near as cookie cutter as flexion vs extension, repeated vs sustained movements, or even keep your spine neutral and do these exercises, they’re good for everyone.

    • Sam, I don’t have a lot of time to devote to this discussion, but I’ll make more time when you have finished reading Low Back Disorders thus putting us more on the same page.

      But let me ask, are you a McKenzie “Diplomat?”

      Do you think McKenzie diagnosis is really so difficult that you have to take four courses, then on top of that spend another $15,000 for training to become a diplomat, just so you can to tell people which of three syndromes you think they have?

      And for what? Research seems pretty clear that McKenzie treatment hardly works.

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.