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The McKenzie Method:The Scope and Application of

Mechanical Diagnosis and Therapy (MDT)

Developed by faculty at the McKenzie Institute International:

Richard Rosedale PT, Dip. MDTKathy Hoyt PT, Dip. MDT

and Robert Medcalf PT, Dip. MDT

Mechanical Diagnosis & Therapy®of the Spine & Extremities

Robin A. McKenzieCNZM, O.B.E., FCSP (Hon), FNZSP (Hon), NZCP (HLM), Dip. MT Di MDTMT, Dip. MDT

President of The McKenzie Institute International


Outline

• History and background

• Institute and educational program

• The natural history of musculoskeletal conditions

Section 1 Section 2

educational program

• Principles, evidence overview

conditions

• The need for classification

• An outline of MDT classification

Outline

• Assessment overview

• Principles of

• Case examples

Section 3 Section 4

• Principles of management

• Summary

Section 5

History of MDT

• Robin McKenzie

• Mr. Smith

• Key to effective therapy

– Education

– Self‐treatment


Disc Model

Flexion Extension

Nuclear Movement

The next slide shows nuclear movement occurring in the lumbar spine in a laboratory setting.

Nuclear Movement

Sheppard J, Rand C. “Internal disc dynamics: a study of 100 specimens.” Hastings, England.


McKenzie Institute

• Founded in 1982

• Located in i hRaumati Beach,

New Zealand

• 27 branches worldwide

DenmarkUnited States Netherlands

Argentina Finland New Zealand

Brazil France Nigeria

Canada Germany Poland

Australia Hellas/Cyprus Saudi Arabia

McKenzie Institute International

Czech Republic

Belgium Italy Sweden

Croatia Japan Switzerland

Luxembourg United Kingdom

Hungary SloveniaAustria

McKenzie Institute

• 80 teaching faculty

• Roles of d i heducation, research, promotion


Mechanical Diagnosis and Therapy®

A unique, dynamicand comprehensive

systemy

of assessment, classification, treatment and prevention

for musculoskeletal disorders.

Mechanical Diagnosis and Therapy®not simply extension exercises…

Mechanical Diagnosis and Therapy®exploring different loading strategies, postures and movements…


Mechanical Diagnosis and Therapy® to classify and treat musculoskeletal conditions.

What Is the McKenzie System of Mechanical Diagnosis & Therapy (MDT)?

Diagnostic – Reliability

Prognostic – Validity

Therapeutic – Dx/Rx link

Client‐centered – Patient empowerment

Prophylactic – Prevent recurrences

Mechanical Diagnosis & Therapy®(MDT)

Positions

MovementsMovements

Postures

Activities


Mechanical Diagnosis & Therapy® (MDT)

DD TT OO

Reliable assessment

Patient‐generated exercises

AA DD TT OOValid classifications Better outcomes when

treatment matched to classification

AA

Spratt 2002.

Reliability Studies on MDT15+ pain response studies = good reliability

• Clare 2004, 2005

• Dionne 2006

• Kilpikoski 2002

• Laslett 2003

• May 2009

• Petersen 2003, 2004

• Seymour 2003

• Razmjou 2000

• Werneke 1999

Assessment

Diagnosis

The McKenzie Institute® Education & Certification Program

• Part A: Lumbar spine

• Part B: Cervical & thoracic spine

• Part C: Advanced lumbar spine and extremities: lower limb

• Part D: Advanced cervical spine and extremities: upper limb

• Credentialing examination

• MII Diploma Program

• In the United States: Fellowship in MDT/OMPT


Centralizationreliability

• Agreement – 88% to 100%

• Kappa – 0.51 to 0.96

Five studies

• Kappa – 4 studies > 0.70

• Good to very good reliability

• Level of training influenced the results

Extremitiesreliability

• Classification

– Kappa: 0.84 (May and Ross 2009)

Clinical Subgroup Studiesobservational, case series, prognostic, diagnostic validation, surveys

Studies:

Alexander 1992; Brotz 2010; Bybee 2005; Clare2007; Donelson 1990, 1991, 1997; Erhard 1994;Fritz 2007; George 2005; Hefford 2008; Karas1997; Kopp 1986; Laslett 2005; Long 1995, May2006, 2008 (Rasmussen 2005); Skytte 2005;Sufka 1998; Young 2003; Werneke 1999, 2001,2003 2004 2005 2008

Treatment2003, 2004, 2005, 2008

Reviews:

Aina & May 2004; Berthelot 2007; Hancook May2006, 2007, 2008; Udermann 2004; Wetzel2005, May & Donelson 2008; Machado 2006;Peterson 1999

Diagnosis

30+ centralization/DP publications


Resultsprognosis

• 6 studies reported on prognosis.

• Outcomes for centralization subgroup compared to non‐centralization subgroup.

• Treatments were based primarily on MDT principles.

Resultscentralization

• Good/excellent overall outcomes

• Greater reduction in pain intensity

Centralization was correlated with:

Greater reduction in pain intensity

• Higher return‐to‐work rate

• Greater functional improvement

Randomized Clinical Trials with SubgroupsMDT, centralization, directional preference

• Brennan 2006

• Browder 2007

• Brotz 2007

• Delitto 1993

Treatment

Out‐comes

• Delitto 1993

• Fritz 2003, 2007

• Long 2004

• (Spratt 1993)


Treatment

DD TT OOAA DD TT OOAA

Building Evidence

Treatment

Outcomes

Diagnosis

Assessment


Section 2

The natural history of musculoskeletal conditionsand the implicationsand the implications

The need for classification

An outline of MDT classification

Epidemiology & Natural History

• Common life experience

• Middle stages of life in ispine

• Progressively worse with age in extremitieshttp://farm3.static.flickr.com/2443/4056452089

_2b169b685d.jpg

Epidemiology & Natural History

Persistent, episodic and recurrent symptoms common

http://www.pro‐motionphysicaltherapy.com/images/top/low_back_pain_program.jpg


EpidemiologyLBP, etc.

Natural History of LBP

• “Not a self‐limiting condition … almost half still have pain at one year.” (Schiotz‐Christensen)

• “At 12‐month review, only 25% of patients with acute LBP hadpatients with acute LBP had completely recovered.” (Croft)

• “During the 12‐month observation period, 76% of patients had a recurrence of their LBP.” (Van den Hoogen)

http://www.globalwellnesscentre.com/images/lower‐back‐pain.jpg

Clinical Implications?

• Long‐term management required

• Who is in the best position to achieve this?position to achieve this?

the patient


Clinical Management

• Specific “mechanical” syndromes

Classification and diagnosis

• Related to mechanism of symptom generation and response

Derangement

Mechanical Syndromes

The Three Syndromes

g

Dysfunction

Posture

Why the Need for Non‐Pathoanatomical Diagnoses?


Clinical Management

• Fourth classification utilized for specific identifiable pathologies:

Classification and diagnosis

– “Other”

Derangement

Internal derangement causes a disturbance in the normal resting

position of the affected joint surfaces.

http://www.reviewmylife.co.uk/data/2009/0902/knee‐mri‐scan‐front1.jpg

Derangement

• Varied clinical presentation

• Obstruction to movement

• Centralization/peripheralization (in spine)p p p

• Possibility of acute deformities

• Ability to change rapidly

• Directional preference


Directional Preference (DP)

Mechanical loading

examination,including

Identification of specific directional

Symptoms centralize

or decrease

Confirms classification

ofincluding repeated

movements

directional exercise or range

increases

of derangement

Prevalence Rates of DP

40

50

60

70

80

90

• A. 130 patients in 3 reliability studies

• SR centralization – B = 731 ALBP; C = 325 CLBP

• D. Long – 312 A‐CLBP

0

10

20

30

A B C D E F G H J

MDT Training No MDT training

• E. May – N = 607

• F. Hefford – N = 341

• G. Fritz – N = 120

• H. Browder – N = 300

• J. George

Derangement

• Central/symmetrical

In the spine, location of pain indicates sub‐classification:

• Unilateral/asymmetrical to the knee/elbow

• Unilateral/asymmetrical below the knee/elbow


Centralization

Process by which referred pain is sequentially

abolished in response to therapeutic or diagnostic positions or movements.

Centralizationtransitions

Centralizationprevalence

• Meta‐analysis of 1,056 patients

• Centralization occurred in 681 patients

Eleven studies

(64.5%)

• Mean prevalence = 58% (31% to 87%)

• 731 acute or sub‐acute patients – 70%

• 325 chronic patients – 52%


Peripheralization

• The opposite of centralization

h i• When exercises or positions cause the spread of pain distally

Dysfunction

• Mechanical deformation of structurally impaired soft tissues.

• Contraction, scarring, adherence, adaptive shortening, or imperfect repair. g p p

http://www.evpedia.org/IMG/jpg/F35.jpg

Dysfunction• Local pain (except nerve root adherence)

• Intermittent, chronic

• Movement loss with pain reproduced at

• end range

• Consistent end rangeresponse

• No rapid changespain reproduced at

http://www.evpedia.org/IMG/jpg/F35.jpg


Extremity Dysfunction

• Articular: same criteriaas spinal dysfunction.

• Contractile: Whenstructural changesaffect contractile tissueaffect contractile tissue.

– Pain will be felt duringresisted movements,

– Or loading at any point through the range, i.e., when thetissue contracts.

– Pain may also be provoked when the tissue is stretched.

http://farm3.static.flickr.com/2099/2450480466_97aa0ffcb6_o.jpg

Postural

Caused by mechanical deformation of soft tissues or vascular

insufficiency arising from prolonged postural stresses affecting the articular or contractile

structures.

Postural

• Local pain

• Intermittent

• Symptoms with sustained end range gpositioning

• No movement loss

• No effect with dynamic movement testing

http://www.structuralwisdom.com/images/forward_head.jpg


Spinal “Other” Conditions

• Red flags

• Trauma

• Hip/shoulder

• SIJ• SIJ

• Stenosis

• Spondylolisthesis

• Chronic pain state

• Mechanically inconclusivehttp://www.faqs.org/photo‐dict/photofiles/list/695/1106spine.jpg

“Other” Conditionsin the Extremities

• Red flags

• Trauma

• Inflammatory

• Chronic pain state

• Articular structurally compromised

http://www.choa.org/images/photography/little_league_elbow.jpg

Centralization

MDT


Section 3

Assessment overview

Principles of management

A Day With McKenziepart one

Before we move on, here’s Robin McKenzie, in his own words, during a live presentation at the

2007 McKenzie Institute Conference2007 McKenzie Institute Conference in Queenstown, New Zealand.


A Day With McKenziepart one

Assessment Process1. history taking

Assessment Process: History Taking


Assessment Process2. physical examination

• Posture

• Neurological

• Movement loss (active, passive, & resisted in extremities)

Assessment Process2. physical examination: repeated movements

Examples of Test Movements in Lumbar Spine

flexion in standing



extension in standing


flexion in lying


extension in lying



side gliding in standing

Examples of Cervical Test Movements

Retraction Extension

Examples of Knee Test Movements

Knee extension Knee flexion


Definition of Terms

• Symptomatic responses

• Mechanical responses

Symptomatic Response

VAS 4/10 VAS 1/10 VAS 2/10

Mechanical Response

Establishmechanical baseline

Repeated movementRe‐check

mechanical baseline


Assessment Process2. physical examination: static tests, other tests

Assessment Process

3. Provisional classification

4. Reassessment

5. Confirm classification

A Day With McKenziepart two

Here are a few more words from Robin during the McKenzie Institute

Conference proceedings.


A Day With McKenziepart two

Principles of Management

• Posture correction

Spine

• Flexion

• Extension

• Lateral

Principles of Management

Extremities


Management of Derangement

• Achieve reduction

= Centralization and/or abolishing of symptoms

= Obstruction removed

= Condition remains better

• Maintain reduction

• Recover function

• Educate in prophylaxis

Management of Dysfunction • Remodelling of tissue

• To regain the lost function (range)

• Produce symptoms at end range

• “No pain, no gain”

• Education and postural correction

• Prophylactic training

Management of Postural Syndrome

• Education re: mechanism of pain production

• Train correction ofTrain correction of postural habits

• Prophylactic instructions


Principles of Management examples

Derangement

Flexion Principle

Principle treatment for:

gw/ directional preference for flexion

Flexion dysfunction

Nerve root adherence in spine


Derangement w/ directional

Extension Principle


erangement w/ directionalpreference for extension

Extension dysfunction



Knee Extension


erangement w/ directionalpreference for extension forces

Extension dysfunction




Shoulder Internal Rotation


Derangement w/ directional preference for internal rotation

Internal rotation dysfunction

Procedures of Mechanical Therapy

Static patient‐generated forces: Positioning mid‐end range

Dynamic patient‐generated forces:Patient motion mid‐end range,then with over‐pressure (O/P)

Procedures of Mechanical Therapy

• Patient motion with clinician O/P

• Clinician mobilization ‐manipulation

Clinician‐generated forces:


Patientoverpressure

Therapistoverpressure

Mobilization

ManipulationForce Progression

McKenzie A

Patient‐generated

overpressure

Independent Dependent

Reassessment/Treatment Progressions

1. Confirm,

Reject,

Modify provisional classification

Reassessment/Treatment

Progressions

2. Determine need for progressions of forceprogressions of force.


Reassessment/TreatmentProgressions

3. Determine when to initiate recovery of function.

Reassessment/Treatment Progressions

4. Determine when further treatment with MDT is not appropriate.

Reassessment/TreatmentProgressions

5. Develop patient’s self‐management skills and

h l iprophylactic program.

6. Determine the need and timing for discharge.


Section 4

Spinal case study

Extremity case study

Spinal Case Study

40‐year‐old female with acute

lumbar painlumbar pain

http://www.stylishandtrendy.com/wp‐content/uploads/2009/06/women‐back_pain‐300x299.jpg


Date Feb 06

Name Daphne Sex M / F

Address

Telephone

Date of Birth Age 40

THE MCKENZIE INSTITUTE LUMBAR SPINE ASSESSMENT

Spinal Case Study

Referral: GP / Orth / Self / Other

Work: Mechanical Stresses Administration

Sitting++

Leisure: Mechanical Stresses Stand/walk > sitting

Functional Disability from present episode Cannot sit >2-3 mins

Functional Disability score RM: 19/24, Fear Avoid:14/24 (act)

VAS Score (0-10) 9/10

Spinal Case Studyclinical reasoning

• Derangement

• Posture

D f ti

• Hip

• Spinal stenosis

R d fl

Possible hypotheses?

• Dysfunction

• SIJ

• Chronic Pain

• Trauma

• Red flag

• Spondylolisthesis

• Mechanically inconclusive

Present Symptoms

Present since Yesterday Improving / Unchanging / WorseningCommenced as a result of

Doing the “bow” in yoga Or no apparent reason

Symptoms at onset: back / thigh / leg

Constant symptoms: back / thigh / leg

Intermittent symptoms: back / thigh / leg

Worse bending Sitting / rising standing walking

lying

am / as the day progresses / pm when still / on the move

other

Spinal Case Studyhistory

Better bending sitting standing walking lying

am / as the day progresses / pm when still / on the move

other

Disturbed Sleep Yes / No Sleeping postures: prone / sup / side R / L Surface: firm / soft / sag

Previous Episodes 0 1-5 6-10 11+ Year of first episode

Previous History 1 episode 7 years ago, resolved in 1 month…nothing since

Previous Treatments none


Cough / Sneeze / Strain / +ve / -ve Bladder: normal / abnormal Gait: normal / abnormal Medications: Nil / NSAIDS / Analg / Steroids / Anticoag / Other Robaxacet, Ibuprofen

General Health: Good / Fair / Poor Imaging: Yes / No

Spinal Case Studyspecific questions

Imaging: Yes / No Recent or major surgery: Yes / No Night Pain: Yes / No

Accidents: Yes / No Unexplained weight loss: Yes / No

Other:

McKenzie Institute International ©2005

Spinal Case Study

• Chronic pain

• Trauma

• Dysfunction

• Hip

What have we ruled out?

• Red flags

• Posture

• Spinal stenosis

Spinal Case Study

• Derangement

• SIJ

Extension

Flexion

Lateral

What’s left?

SIJ

• Spondylolythesis

• Mechanically inconclusive


POSTURE Sitting: Good / Fair / Poor

Standing: Good / Fair / Poor Lordosis: Red / Acc / Normal Lateral Shift: Right / Left / Nil

Correction of Posture: Better / Worse / No effect Relevant: Yes / No

Other Observations: NEUROLOGICAL Motor Deficit Reflexes

Sensory Deficit Dural Signs

Spinal Case Studyexamination

MOVEMENT LOSS

Maj Mod Min Nil Pain

Flexion * LBP (No loss of lordosis)

Extension * LBP

Side Gliding R * LBP

Side Gliding L * LBP

Spinal Case Studytest movements

Describe effect on present pain – During: produces, abolishes, increases, decreases, no effect, centralising, peripheralising. After: better, worse, no better, no worse, no effect, centralised, peripheralised.

Symptoms During Testing Symptoms After Testing Mechanical Response

Rom RomNo

Effect

Pretest symptoms standing: LBP

FIS

Rep FIS

EIS Increase LBP

Rep EIS Increase LBP W * Pretest symptoms lying: NIL y p y g

FIL Produce LBP

Rep FIL Produce LBP B in F

EIL Produce LBP

Rep EIL Produce LBP W In F

If required pretest symptoms:

SGIS – R

Rep SGIS - R

SGIS - L

Rep SGIS- L STATIC TESTS

Sitting slouched Sitting erect

Standing slouched Standing erect

Lying prone in extension Long sitting

OTHER TESTS

Spinal Case Studyprovisional classification

Derangement Flexion Principle


Spinal Case Studyprinciple of management

• Flexion: RFIL x 10 / 1‐2 hours

• Posture: Neutral (sit and stand)

• Avoid extension

Spinal Case Studyfollow-up (4 days later)

• Hx:

– “85% better,” much less pain, moving well

• Exam:Exam:

– Movement loss:

• Flexion: No loss (full reversal of lordosis)

• Extension: No loss

Spinal Case Studyfollow-up (4 days later)

• Pre: No symptoms

• RFIL: NE

• Rx:

– Decrease frequency RFIL to 3‐4x/day

– Review posture


Spinal Case Studyvisit 3 (2 days later)

• Hx: Only experiencing odd twinge; otherwise pain‐free, moving fully

• Exam:

– No movement lossNo movement loss

– No baseline pain

• Rx: Review prophylaxis

– Resume all previous activities

– Review posture…..D/C

Spinal Case Study1-month follow-up

• Pain‐free: 0/10

• Roland Morris score: 0/24

• Resumed all activities, including yoga

Extremity Case Study

34‐year‐old female with long history of

left knee painleft knee pain

http://images.teamsugar.com/files/upl1/1/12981/18_2008/runners‐knee.jpg


Extremity Case Studyhistory

• 4‐year Hx of intermittent left knee pain.

• Progressively worsened over years.

• Night pain.Night pain.

• Unable to squat at all, run and pain/unsteadiness with walking.

• Pain with ascending/descending stairs.

Extremity Case Studyhistory

• Injection 2 years ago: no help.

• Scope left knee 5 months ago.

• Continued pain post‐scope, “worse than pre‐surgery.”

Extremity Case Studypost-scope diagnosis

• Scope:

– Removal lesion and debridement

– Partial lateral menisectomy

• “Osteochondral lesion from lat femoral condyle, unrepairable displaced chronic bucket handle tear of the lateral meniscus.”


Extremity Case Studypost-scope MRI findings

• Complete absence of normal lateral meniscus, “flipped” with multiple fragments in joint space.

• Thickening of patellar tendon, consistent with partial teartear.

• Suspected partial tear of quad tendon and ITB.

• Osteochondral injury and fragmentation of the subchondral region with fragment (1.1x1.7cm).

• Joint effusion and Baker’s cyst.


What’s the prognosis?

Extremity Case Studyexamination

• Knee flexion 135 degrees: painful lack of 5‐8 degrees.

• Full and pain‐free extension.

• Squat painful and less WB on left.

• Resisted strength strong, painless.


Extremity Case Studyrepeated movement exam

• Repeated flexion produced knee pain, but no worse symptomatically.

• Mechanically

– Increased range.

– “50% less pain” on squatting.


? D t

What’s the classification?

? Derangement

Extremity Case Studytreatment

• The classification of derangement determines the treatment of a specific directional exercise.

• In this case, it is end‐range repeated knee flexion, 10‐15 repetitions 5‐6x per day.


Extremity Case Studyprognosis

• The classification also determines the prognosis.

hi h l ifi i f• In this case, the classification of a derangement would predict a rapid and successful outcome.

Extremity Case Studyoutcomes

• 24 hours:

– “Walking is much better, best it’s been in the past few months.”

– Jogging on treadmill with

• 1‐week follow‐up:

– “80% better since initial visit.”

– Full range knee movement.

Pain free squat (still WB lessJogging on treadmill with no pain.

– Pain‐free squat.

– Pain‐free squat (still WB less on left).

• 3‐week follow up:

– Full squat.

– “Not experiencing pain.”

Extremity Case Studypost-scope MRI findings

• Complete absence of normal lateral meniscus, “flipped” with multiple fragments in joint space.

• Thickening of patellar tendon, consistent with partial teartear.

• Suspected partial tear of quad tendon and ITB.

• Osteochondral injury and fragmentation of the subchondral region with fragment (1.1x1.7cm).

• Joint effusion and Baker’s cyst.


Section 5

Summary

Summary

• Comprehensive system

• Spine and extremities

• Principles are based on sound scientificsound scientific rationale

• Identifies those that are appropriate for therapy

Summary

• Meticulous assessment/reassessment of patient

• Emphasis on

Patient ed cation &– Patient education &

– Training in self‐management

• Use and timing of treatment and progressions


Summary

• Reliability

Research is extensiveand growing:

• Validity

• Prognostic value

Summary

Effective andEffective and efficient use of MDT is dependent upon the level of clinical training of the practitioner.

A Day With McKenzie

The following video clips were taken during a live presentation at the

2007 McKenzie Institute Conference, with highlights of Robin McKenzie g g

assessing actual patients.

While time constraints do not allow the entire assessment process to be shown, these are two

great patient examples.


A Day With McKenziepart three

A Day With McKenziepart four

Peter Hitchman, outdoor education instructor18 months of intense pain and neurological deficit

A Day With McKenziepart five


A Day With McKenziepart six

Clare Field and Peter Hitchman, 4 months after attending the Spine Symposium.

Summary

Thank you for participating!

www.mckenziemdt.org

Special thanks to the MI International Education Committee under the direction of Helen Clare, Ph.D., FACP, MappSC, Dip. Physio, Dip. MDT

for material contributions for this course.


Documents

McKenzie Method APAapa.educata.com/APAMcKenzie/SlideHandout.pdf · Mechanical Diagnosis and Therapy® A unique, dynamic and comprehensive system of assessment, classification, treatment