McKenzie Course Review: Part I
Last year I attended my first course in The McKenzie Method® of Mechanical Diagnosis® and Therapy which dealt with the evaluation and treatment of the lumbar spine (Part A). I very much enjoyed the experience and felt like I learned a lot from the course, so I signed up to take Part B (for cervical and thoracic spine) which took place this past weekend. I didn’t write a course review for Part A last year but thought I’d share my thoughts now after taking both courses.
If you’re unfamiliar with the McKenzie method and would like to read more about their approach, Christie Downing wrote a couple of blog entries detailing their philosophy on Mike Reinold’s website which you can read here and here. Physiopedia also has a summary of the McKenzie concepts here.
(The following consists of my opinions and interpretation of the course material; for more information on McKenzie from the horse’s mouth please refer to their website, YouTube channel, and their active LinkedIn page.)
Contrary to popular belief, using the McKenzie approach isn’t just a matter of having someone do prone press ups or standing back extensions when they have low back pain. The evaluation and treatment process involves providing direction-specific graded exposure in particular sequences, and the prescribed repeated motions can be in flexion, rotation, etc. based on patient presentation.
Some of the main strengths of McKenzie are 1) it’s simplicity and 2) that it encourages it’s patients to be self-autonomous.
The home exercise prescription consists of essentially one easy exercise at a time with high frequency, which can increase the likelihood of compliance when compared with giving a patient numerous, difficult exercises.
There’s not a huge emphasis on manual therapy and it’s used only when needed, as opposed to just defaulting to it automatically. I really like how this places the locus of control within the individual through movement and exercise, as opposed the patient just being a passive recipient of care and needing a physical therapist to “fix” their problems.
The business model and patient population of your work setting can be a big determinant of how effective the McKenzie method can be for you. If you work in a high patient volume setting with on average 30 minute windows of treatment for each patient, I think this can be a great approach to have. If you work in a low patient volume setting and have 60 minute treatment sessions, sometimes treatment as guided by McKenzie will take only 20 minutes long. You’d still have 40 minutes to provide treatment that is meaningful and purposeful, and for some patients giving a single exercise may not cut it. This isn’t really a criticism, just an observation that you’re going to have to maybe consider non-McKenzie-esque treatment approaches in those kinds of situations.
On that note, one of the reasons why I also like McKenzie is that it’s a system that still allows room for you to apply other preferred interventions as you please, as long as you’re being consistent with the McKenzie diagnosis classification and adhering to the appropriate treatment heuristics. If compatibility with other treatment philosophies that you subscribe to is important (as it is for me), McKenzie checks that box.
As far as the spinal pathology goes, McKenzie has moved away from a pathoanatomical model of pain when it comes to describing interverterbral disc-related pathology. They made it very clear during both courses I attended that resolving the derangement classification of low back pain doesn’t mean we’re trying to push a herniation back into place. The purpose of repeated extensions isn’t to reduce pain by changing things structurally at the disc level, and positive findings on an x-ray or MRI don’t correlate with pain and are probably normal, age-related changes that naturally occur in the spine. They acknowledge this and back this up by citing important research articles such as Brinkiji 2014, Kolber 2009, Albert 2012 and more.
Their official stance on this topic is that their treatment rationale and chosen interventions are based on patients’ mechanical response (i.e. observing directional preference and prescribing movements based on what positions they like or dislike) as opposed to being based on biomechanical theory. As far as what is precisely happening at the disc level to cause or alleviate pain, they say they can only speculate and aren’t concerned about the precise mechanism.
I’m good with all this but I think something that would strengthen McKenzie’s position when they are describing all this is to talk about how the central nervous system processes pain and the role of nociception. At one point a course attendee asked about what could be happening at the disc level and what’s the best way to educate a patient about this. I felt like the instructors’ response was still a little too pathoanatomically rooted—they kept referring back to the picture of a vertebral disc herniating and saying that it was just a theoretical model of a disc derangement. To me, that’s kinda confusing to use a model of a literal herniated disc and trying to abstractly conceptualize the derangement theory from it.
I think McKenzie could make a stronger response by bringing the following plausible explanations into the conversation:When seldom-performed movements are gradually re-introduced into a a region where pain is perceived, the novel afferent input to the nervous system decreases the perception of threat and thus mitigates the pain response.
In the clinic, we can’t verify which tissue or anatomical structure is the main source of nociception. Besides, what if there’s more than one? Either way, it doesn’t matter because our goal isn’t to direct an intervention at a structure.
So, when we resolve a derangement we’re affecting the way the central nervous system perceives a threatening, pain-eliciting movement. We do this by performing graded exposure in the form of repeated movements at end range, and determining the specific direction and dosage based on patient response.
I think a reason why McKenzie practitioners place emphasis on getting to end range is because you can potentially get more communication with mechanoreceptors in the joint capsule which in turn can provide more afferent information to the CNS and thus reduce pain in the manner described above.
I have some more thoughts about whether or not I’ll continue to take McKenzie courses in the future, along with an interesting case study that was highlighted during the course. If you have any questions or comments please feel free to share below!