From the study:
“Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up.”
“When analyzing the results of individual trials, McKenzie was as effective as flexion exercise at 2 weeks for chronic pain.. … and marginally better than flexion exercise for acute pain at 8 weeks…”
“Delitto et al reported a large effect on acute disability… …favoring McKenzie when compared with flexion exercises after 5 days.”
“Two high-quality studies reporting on acute LBP compared McKenzie with advice to stay active… The pooled results in Figure 5 indicate a significant decrease in disability… … favoring advice to stay active at 12 weeks follow up.”
“There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects.”
This is not exactly breaking news but McKenzie method of diagnosis and treatment of low back pain is still being taught to physical therapists and physical therapy patients still have to endure end range, and sometimes end range plus overpressure, spine extension, and to a lesser degree flexion stretches. Googling “Mckenzie method” will bring up a plethora of physical therapists touting Mckenzie method benefits and anecdotal reports of it being great. But what does the actual research say? Ehh, the reality seems a little less remarkable. The results of the above study (which was a meta-analysis that pooled the results of relevant research that went before it) are about what I would expect. Overall the researchers found the McKenzie method is perhaps slightly better than passive modalities (but not enough to matter), better than Williams’ lumbar flexion exercises, but slightly less effective than the simple advice to keep active. I’ve read McKenzie’s books so I have a pretty good grasp on his techniques and why I think they don’t work so well for the average low back pain sufferer.
I do agree with much of McKenzie’s observations that spine flexion happens too often and for too long for most people in activities of daily living, and I do agree that people should take steps to lessen spine flexion. I think this is why this study found McKenzie worked better than Williams flexion exercises but not much better than nothing at all. Williams flexion exercises were the standard McKenzie was reacting to when he came out with his method favoring spine extension in 1981. This is because once you remove any placebo and gate control effects of flexion stretches on pain, you are left with a motion that causes posterior displacement of nucleus material in the lumbar disc and stretch/creep to passive ligaments that are supposed to control spine motion. Thus flexion stretches over time decrease spine stability, increasing long term pain and disability. So I would say McKenzie is not as harmful as Williams spine flexion exercise.
In his books McKenzie likes to use the example of having a person hold their finger backwards at end range until it starts to hurt as analogous to what goes on in the discs during spine flexion, and that if you remove the stress on the finger and bend it the other way the pain goes away. The problem I think is that McKenzie goes too far the other way. The solution to pain injury in flexion is not hyperextension but just eliminating the flexion and returning the joint to a more neutral position. This works with both the finger and low back. I would not cure the finger joint pain from prolonged extension by bending it the other way as far as possible and holding it there, rather I would just remove the stress.
As this paper correctly asserts, McKenzie method should not be thought of as just extension exercise because McKenzie also teaches spine flexion stretches if the patient has an increase in symptoms with extension during his evaluation. I disagree with this as well, because posterior disc herniation caused by too much flexion during ADLs can be irritated with extension and still worsened in the long run with more flexion. Different spinal structures can also play a role in these symptoms’ presentation as well. For example, if one already has a collapsed disk at L5-S1 causing facet joint approximation and arthritis at that level, we would expect to see worsened symptoms with back extension. Flexion stretching in this case might unload the irritated facet joint and provide short term relief, but would be putting the discs above (T12 and L1-L4) at risk for flexion-related injury. A better method in this example (and in most cases of low back pain) would be teaching the patient to avoid both extremes in flexion and extension. This would serve two roles: lessening stress and pain on the posterior facet joints, while preventing further degeneration of the remaining vertebral discs.
Worth mentioning is that even with McKenzie’s more common extension-related treatment, he still teaches flexion exercises after pain is resolved, “to restore normal range of motion.” I disagree with this as well, since (as McKenzie rightfully surmises) daily activities still generally give people too much spine flexion. As such I think most don’t need any stretches in spine flexion but rather total body fitness, mobility around the peripheral joints, and motor control/postural awareness to maintain a neutral and pain free spine position during work, play and, rest.
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.
This is currently my second most popular blog, and while I think it’s good stuff, I think my best material is written below in answer to comments and questions. Also this blog is a bit negative, being mostly about what doesn’t work, or at least what the above meta-analysis suggest doesn’t work very well. However, in answering questions below I wrote a great deal below about what I think does work. Much of which has been summarized in my low back pain info page. Also, I made an example low back pain workout video of what I would say is my stereotypical low back pain workout. I don’t start people off on all these exercises, but generally start with the standing rows, standing presses, and maybe add the hip in/out machine on day one. All performed 3 sets or 15 reps (easy, medium and hard weights) stopping immediately if there is any pain. If the person does well with those exercises on day one, I’ll add 1-2 exercises per day, until I get to what I think is a complete program. Some patients can’t do all the exercises, some do alternatives and some do extra, but the video program is my basic. The exercises themselves only make up about ⅓ of what it often takes to recover from low back pain. The other parts are improving static postures and motor control during active motions, the latter of which the exercises help teach. To help it all, unless a patient has an abdominal hernia, or a pacemaker, I almost ALWAYS perform electric muscle stimulation (EMS) to the abdominal and low back region to both decrease pain and improve core strength. This works especially well when patients can’t perform regular exercises intense enough to increase strength, and the lucky side effect is the harder you do EMS, generally the less pain you have after.