Current and Potential Practices in Athletic Training

A Review of the McKenzie Method of Spinal Rehabilitation and Evaluation

Kathryn Ramsdell
Undergraduate Athletic Training Education Program
California University of Pennsylvania

Abstract

Neck and lumbar dysfunctions are a common aliment worldwide. Through research, the McKenzie method of rehabilitation and spinal stabilization is a widely considered and practiced form of therapy for non-specific spinal dysfunctions. With the use of evaluation and determination of preference of movement, therapy is able to provide a functional manner for alleviation of symptoms. Although commonly practiced amongst physical therapists, certified athletic trainers could develop the use of the McKenzie method in order to ensure the wellbeing and safety of athletes. With further examination to determine the reliability and validity of the McKenzie method, the profession of athletic training could consider this new form of evaluation and rehabilitation.

History and Theory of McKenzie Method

The McKenzie method focuses on the idea of centralization as trained professionals find that the movement of symptoms from a location distal to the spine to a location more proximal to be an ideal effect of the therapy. The approach predominately relies on the theory of the movement of the nucleus pulposus of the spinal disc, antagonistically to the spines direction of preference.1 McKenzie theorized that through the directional preference movement, the end range of motion would allow for the nucleus pulposes to move in the opposite direction away from the area in the annulus fibrosis that was damaged. This movement would reduce the effect of the pulposus on the spine thus decreasing pain and symptoms.2-3 With the use of repeated motion in the direction of preference, whether mid-range or end-range, the McKenzie method has a goal of reduction of pain, and it is evident that centralization of symptoms is a useful and objective measure for evaluating patients1-3 with both cervical and lumbar back pain. From the determination of direction of preference, as well as an increase in centralization, both appear to be positively related; McKenzie-trained clinicians are able to determine and provide the proper treatment program with an idea of the direction of preference in mind. Standard directional movement for McKenzie results in repeated movements or static positions that reduce symptoms or pain, while continuing to avoid the direction that provokes further increase in pain or distal symptoms.4

Classification and Evaluation using the McKenzie Method

While still relatively recent in the medical field, the McKenzie method, also referred to as Mechanical Diagnosis and Therapy, is frequently used by clinicians5-7 for the treatment of their patients with both cervical and lumbar back pain. Patients are classified into four group based on the McKenzie classifications: derangement, dysfunction, postural, and other. The initial evaluation conducted by a McKenzie-trained clinician will determine the classification of the patient and then the treatment necessary for optimal outcomes. Derangement syndrome has appeared to be the most prevalent5-7 of all categories; this syndrome is defined by the centralization and peripheralization of symptoms, i.e., the increase in pain and/or symptoms away from the lumbar or cervical spine into extremities with repetitive motions or prolonged postural positions. Dysfunction syndrome, a second category of patients is characterized by intermittent spinal pain5-7 that becomes more prevalent upon the approach of the end range of the restricted motion. Unlike the first category of treatment options that emphasize opposite directional preference, the dysfunction syndrome focuses on mobilization of the motion that is restricted as well as on alleviating pain. Postural syndrome is the final classification,5-7 and unlike the first two syndromes it is associated with a static position of the spine, which may result in intermittent pain. Treatment will typically consist of more education-based repositioning and avoidance of postures that may provoke symptoms. A final category is given to patients who find that treatment is not able to reduce or alter symptoms.5-7 In some cases, the “other” group5-7 is determined based on the time frame in which their symptoms are not improving or lessening, and therefore it is suspected that possible complications, such as a fracture, requires patients to be referred to the physician for further testing.

A comprehensive evaluation form and assessment allows a McKenzie-trained specialist to determine the patient’s response to various mechanical stressors being place onto the spine, in neutral, flexion, and extension positions, as well as more advanced positions, such as lateral flexion and rotation.8 Basic evaluation techniques are used when determining the severity and direction of preference the patient exhibits to either centralization or reduction of pain. The McKenzie method began to focus on research pertaining to the extremities and use assessment forms to provide treatment plans for patients.

Similar to theory of spinal evaluation, McKenzie identified classification systems for the extremities: derangement, articular dysfunction, contractile dysfunction, postural syndrome, and other.7-8 Derangement can be identified by the abolition or decrease of symptoms and increase in range of motion in the extremities associated with repeated movements.6-7 Articular dysfunction can be identified6-7 by intermittent pain that is continually produced by the restricted end range motion of the extremity. Contractile dysfunction is indentified6-7 by intermittent pain that can be caused by overloading of the musculotendinous unit, such as a prolonged isometric contraction. Postural syndrome6-7 is pain that can only be caused by sustained position loading. If the position of discomfort were avoided, the patient would have a normal evaluation. Similar to the classification strictly dealing with spinal dysfunctions, the category of “other” pertains6-7 to the result of being unable to classify the patient with any of the above syndromes and thus may require additional testing for non-mechanical dysfunction determination.6-8

Reliability of the McKenzie Method in Comparison to other Forms of Rehabilitation

 Multiple studies have been conducted to determine if McKenzie method and the therapists trained with the techniques are able to classify and treat patients with significant reliability. 6-8 Although the theory in general provides adequate explanations of the techniques being performed, it is still uncertain if this method is useful in the prevention and rehabilitation of non-specific spinal dysfunctions. Reliability, as mentioned previously, is determined through the use of interrater testing and the ability of multiple physical therapists to adequately classify and place patients into appropriate categories in respect to the McKenzie method. Research indicated reasonable interrater reliability6-8 with patients using the McKenzie system of classification and treatment.7-9 Studies have typically used interexaminer reliability testing, with multiple clinicians for multiple patients, one clinician observing while the other conducts the examination. From that point, therapists are responsible for making an adequate conclusion as to what category they believe their patients fit for purposes of rehabilitation and treatment—thus determining the interexaminer reliability of experienced mechanical diagnosis and therapy trained clinicians. It leads to questions, as mentioned above, regarding the varying degrees of education and certification available to those clinicians who wish to continue their rehabilitation training with the McKenzie Institute, assuming that the higher the educational training, the more reliable the clinicians are in determining how to approach a lumbar, cervical, or extremity patient.

Summary

The McKenzie method, while still a relatively new form of rehabilitation for patients with spinal and extremity dysfunctions, is now a more recognized approach for physical therapists to apply to their patients appearing with symptoms that may qualify them into one of the dysfunction categories. With further investigation and research, the idea of McKenzie method could provoke a new approach for the athletic training community for the prevention and treatment of athletes and the physically active that display signs and symptoms that are indicative of non- specific spinal dysfunction. Although studies have demonstrated significant reliability in the clinicians’ ability to classify patients based on McKenzie’s method, it is clear that, with varying forms of education, further testing may need to be conducted to increase the reliability of the McKenzie theory.

References

  1. Dale R. Managing low back pain with exercise interventions. Athletic Therapy Today [serial online]. September 2005;10(5):31-35.
  2. Bybee R, Olsen D, Cantu-Boncser G, Allen H, Byars A. Centralization of symptoms and lumbar range of motion in patients with low back pain. Physiotherapy Theory & Practice [serial online]. May 15, 2009;25(4):257-267.
  3. Werneke M, Hart D. Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain. Journal of Rehabilitation Medicine [serial online]. September 2005;37(5):286-290.
  4. Hammer C, Degerfeldt L, Denison E. Mechanical diagnosis and therapy in back pain: Compliance and social cognitive theory. Advances in Physiotherapy [serial online]. December 2007;9(4):190-197.
  5. May S, Ross J. The McKenzie classification system in the extremities: a reliability study using McKenzie [sic] assessment forms and experienced clinicians. Journal of Manipulative & Physiological Therapeutics [serial online]. September 2009;32(7):556-563.
  6. May S. Classification by McKenzie mechanical syndromes: a survey of McKenzie-trained faculty. Journal of Manipulative & Physiological Therapeutics [serial online]. October 2006;29(8):637-642.
  7. Clare H, Adams R, Maher C. Reliability of McKenzie classification of patients with cervical or lumbar pain. Journal of Manipulative & Physiological Therapeutics [serial online]. February 2005;28(2):122-127.
  8. Long A, May S, Fung T. Specific directional exercises for patients with low back pain: a case series. Physiotherapy Canada [serial online]. October 2008;60(4):307-317.
Bibilography

Broetz D, Hahn U, Maschke E, Wick W, Kueker W, Weller M. Lumbar disk prolapsed: response to mechanical physiotherapy in the absence of changes in magnetic resonance imaging. Report of 11 cases. NeuroRehabilitation [serial online]. June 2008;23(3):289-294.

 

 


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