THE

 MCKENZIE  METHOD  OF  

MECHANICAL  DIAGNOSIS  AND  
THERAPY  OF  THE  LUMBAR  SPINE  
   
IMAGES  FROM  :  WWW..MCKENZIEMDT.ORG;  HTTP://WWW.MCKENZIE.HR/ROBINMCKENZIE.HTML
 Who  is  Robin  McKenzie?  
•  Physical  Therapist  from  New  Zealand  
–  April  1931  –  May  13th  2013  
•  Influenced  by  Dr.  James  Cyriax  
–  Strong  influence  on  McKenzie’s  early  training  
–  Considered  the  framework  for  MDT  
•  Clinical  experience  
–  “Mr.  Smith”  1956  –>  3  weeks  of  radicular  sx  
unexpectedly  abolished  while  awaiVng  treatment.  
–  ExploraVon  of  end  range  moVon  
 Who  is  Robin  McKenzie?  
•  Developed  his  treatment  approach  over  the  
next  20  years  
•  Started  teaching  at  Rancho  Los  Amigos  in  1977  
•  Formed  McKenzie  InsVtute  in  1982  
•  Currently  28  branches  worldwide  
 Predisposing  Lifestyle  Factors  for  
Developing  LBP  
•  Bad  si^ng  posture:  
–  Slouched  si^ng  places  spine  in  the  same  amount  of  
flexion  as  a  fully  flexed  standing  posture.  
–  Intradiscal  pressure  increases  in  a  kyphoVc  posiVon  
and  decreases  the  more  the  spine  approaches  a  
lordoVc  posiVon.  
–  Can  overstretch  posterior  spinal  ligamentous  
structures  
•  Frequency  of  flexion:    
–  We  flex  a  lot,  we  do  not  extend  that  much  
 **These  appear  to  have  a  close  associaVon  with  the  development  of  
low  back  pain  but  lack  support  from  the  literature  to  date.**  
 Conceptual  Model-­‐Flexion    
•  Facet  joint  surfaces  distract  and  the  anterior  porVons  of  the  
vertebra  approximate  
•  The  vertebral  canal  lengthens,  placing  stretch  on  the  spinal  
cord,  dura  and  nerve  roots.    

hep://iecs.wordpress.com/2010/06/10/anatomy-­‐and-­‐physiology-­‐spinal-­‐stenosis/  
 Effects  of  Flexion  on  the  Disc  
•  Anterior  loading  of  the  intervertebral  disc  
–  Compresses  the  anterior  annular  wall  and  stretches  the  
posterior  annular  wall.  
–  Posterior  displacement  of  the  nucleus  pulposus.  
 Conceptual  Model-­‐Extension  
•  Facet  joints  approximate  and  anterior  porVon  of  the  vertebra  
gap.  
•  The  vertebral  canal  shortens  which  relaxes  the  spinal  cord,  
dura  and  nerve  roots.  Reduces  the  space  in  the  intervetebral  
foramen.  

hep://iecs.wordpress.com/2010/06/10/anatomy-­‐and-­‐physiology-­‐spinal-­‐stenosis/  
 Effects  of  Extension  on  the  Disc  
•  Loading  to  the  posterior  aspect  of  the  intervertebral  disc  
–   Compresses  the  posterior  annular  wall  and  stretches  the  
anterior  annular  wall.  
–  Anterior  displacement  of  the  nucleus  pulposus.    
Interview  with  Robin  McKenzie  

heps://www.youtube.com/watch?
v=8BXDe5fcp7I  
 ClassificaVon  of  McKenzie  Syndromes  

•  Three  Mechanical  Syndromes  

1.)  Postural  Syndrome  
2.)  DysfuncVon  Syndrome    
3.)  Derangement  Syndrome  
•  Other  
•  Spinal  stenosis,  hip,  SIJ,  mechanically  inconclusive,  
spondylolisthesis,  chronic  pain.  
POSTURAL  SYNDROME  
 The  Postural  Syndrome  
•  Pain  is  created  from  mechanical  deformaVon  
of  normal  som  Vssue  or  vascular  insufficiency  
as  a  result  of  prolonged  posiVonal  or  postural  
stresses.  
 The  Postural  Syndrome  
•  Pain  is  intermieent  and  only  brought  on  by  
prolonged  staVc  loading  of  normal  Vssues  
•  Time  is  a  causaVve  factor    
•  Pain  relieved  by  change  of  posture/funcVon  
•  No  deformity  present  
•  No  loss  of  movement              www.floota.com  

•  Rarely  presents  in  the  clinic  

 TreaVng  Postural  Syndrome  
•  Re-­‐educate  the  paVent  
•  Correct  si^ng  posture  
•  Teach  slouch/overcorrect  exercise    
•  Use  of  a  lumbar  roll  
•  Correct  standing  and  sleeping  posture  as  
appropriate  
DYSFUNCTION  SYNDROME  
 The  DysfuncVon  Syndrome  
•  Pain  is  caused  by  mechanical  
deformaVon  of  structurally  impaired  som  
Vssues.    
•  May  be  a  result  of  previous  trauma,  
inflammaVon,  repeVVve  microtrauma,    
degeneraVve  changes,  all  of  which  can  result  in  
imperfect  Vssue  repair.    
 The  DysfuncVon  Syndrome  
•  Pain  occurs  when  end  range  stress  is  
applied  to  adapVvely  shortened  
structures.  
•  May  be  discogenic,  facet  joint,  
ligamentous,  muscular,  tendinous    
•  Pain  is  never  referred,  except  for  in  the  
presence  of  an  ANR  (a  subgroup  of  
dysfuncVon  syndrome).    
 The  DysfuncVon  Syndrome  
•  History  of  trauma,  degeneraVve  changes  or  
years  of  poor  posture  
•  Symptoms  must  have  been  present  for  at  least  
6  to  8  weeks  
•  Pain  is  always  intermieent  
•  Pain  is  always  local  (except  with  an  ANR)  
•  A  limitaVon  of  ROM  is  present    
•  No  deformity  is  present  
 Treatment  for  DysfuncVon  Syndrome  
•  Goal:  Increase  ROM  by  remodeling  Vssue  
(takes  4-­‐6  weeks!)  
•  Teach  posture  correcVon  
•  Pain  should  stop  shortly  amer  exercises  are  
completed  
•  Pain  should  never  peripheralize  
•  Frequency:  10-­‐12  repeVVons  every  2  hours  of  
the  day;  5-­‐6  repeVVons  every  4  hours  for  older  
people.  
THE  DERANGEMENT  SYNDROME  
 The  Derangement  Syndrome  
•  Disturbance  in  the  normal  resVng  
posiVon  of  the  joint  surface  that  causes  
pain  and  obstructs  movement.  
•  The  most  common  mechanical  spinal  
disorder  
–  60-­‐78%  of  paVents  fall  into  this  category  (May  and  
Aina  2012).    
 Conceptual  Model    
•  Annulus  fibrosis  –  no  innervaVon  to  the  inner  
porVon.  
•  Fissures  develop  over  years  of  repeVVve  
microtrauma.  
–  First  circumferenVally,  then  radially  
–  Nucleus  becomes  compromised  
•  Internal  disc  disrupVon  and  displacement  
occur    
–  Pt  becomes  symptomaVc    
 The  Derangement  Syndrome  
•  Variable  symptoms,  omen  with  insidious  
onset  
•  Local  or  referred  pain,  possibly  paraesthesia  
•  Pain  can  be  constant  or  intermieent  
•  Aberrant  moVons  and  deformiVes  may  be  
present  
•  Always  loss  of  movement  and/or  funcVon  
•  High  rate  of  recurrence  
 The  Derangement  Syndrome  
•  Movement  found  to  decrease  the  pain  and  the  
deformity  are  used  in  treatment.  
•  Movements  or  posiVons  that  increase  the  pain  
or  deformity  are  avoided.  
 The  Derangement  Syndrome  
•  Larger  derangements  cause  greater  
mechanical  deformaVon  and  more  signs  and  
symptoms.    
•  Can  result  in  postural  deformiVes  
 CentralizaVon  
•  The  approximaVon  of  symptoms  TOWARDS  
the  spine.  
CentralizaVon  
 PeripheralizaVon  
•  Symptoms  peripheralize  from  the  spine  into  
the  lower  extremity.  
PeripheralizaVon  
Treatment  of  Derangement  Syndrome  
•  Reduce  the  derangement    
•  Maintain  the  reducVon  
•  Recovery  of  funcVon    
–  Treat  underlying  dysfuncVon  if  present  
–  Reintroduce  opposite  moVon  
•  PrevenVon  of  recurrence  
–  EducaVon  on  posture  with  si^ng/standing  acVviVes  
–  Recurrent  nature  of  LBP  
 EvaluaVon  
•  Pa=ent  history:  Primary  purpose  is  to  establish  a  
preliminary  classifica=on!  
•  Observe  si^ng/standing  posture  and  its  effect  on  
pain  
•  Note  any  deformiVes  
 Gather  Baselines  
•  Assess  AROM  in  this  order:  flexion,  extension,  
side-­‐gliding  R,  side-­‐gliding  L.  
•  Record  movement  loss  –  nil/min/mod/maj  
•  Note  pain  or  sVffness  that  is  reported  during  
ROM    
•  Note  any  aberrant  movements  
 Gather  Baselines  
•  Assess  the  effect  of  repeated  movements  on  
symptoms:  
–  Ask  about  pain  response.  Is  it  pain  during  the  
movement  (PDM)  or  is  it  pain  at  the  end  range  
(ERP)?    
•  Pain  during  moVon  rules  out  postural  syndrome  and  
dysfuncVon.  
•  Sustained  tests  
–  Can  be  performed  it  the  repeated  movements  do  
not  provide  adequate  informaVon.  
 Provisional  ClassificaVon  
•  Classify  the  syndrome  
•  Choose  a  direcVon  to  reduce  the  derangement  
•  Determine  the  appropriate  force  to  apply  
–  Sustained  posiVons    
–  Repeated  movements      
–  With  our  without  overpressure  
 Force  Progression  
•  Only  progress  force  when  symptoms  remain  
unchanged.    
•  Clinician-­‐generated  forces  should  never  be  
used  before  paVent-­‐generated  forces  have  
been  aeempted.  
•  Remove  clinician  forces  and  return  the  paVent  
to  the  sagieal  plane  as  quickly  as  possible.    
 Order  of  Force  Progression  
•  StaVc,  paVent  generated  
–  Mid  range  -­‐>  End  range  
•  Dynamic,  paVent  generated  
–  Mid  range  -­‐>  End  range  -­‐>  Self  OP  
•  Clinician  generated  
–  PaVent  takes  the  moVon  to  end  range  and  then  therapist  
applies  overpressure  
–  Therapist  mobilizaVon    
–  Therapist  manipulaVon    
 Exercise  PrescripVon  
•  Perform  10  repeVVons  of  the  moVon  every  2  
hours  of  the  day.    
•  Take  the  moVon  to  end  range    
•  Use  of  lumbar  roll  
•  Postural  awareness  
•  Follow  up  within  the  next  24  to  48  hours  to  
assess  progress.  
 Recovery  of  FuncVon  
•  Taper  off  exercise  frequency    
•  Create  a  prophylacVc  program  of  
reintroducing  flexion  moVon;  this  is  done  
gradually  and  based  on  symptomaVc  
response.  
–  Flexion  in  lying  followed  by  extension  in  lying,  10  
repeVVons  of  each  3x/day.  Avoid  flexion  during  
the  first  3  hours  of  the  morning.  
•  Over  2-­‐3  weeks,  progress  flexion  forces  
CLASSIFICATION  OF  THE  
DERANGEMENT  
 ClassificaVon  of  Derangements  
•  Central  symmetrical  symptoms  
•  Unilateral  asymmetrical  symptoms  to  knee  
–  Can  have  a  relevant  or  non-­‐relevant  lateral  
component  
–  Presence  of  a  lateral  shim  deformity  
•  Unilateral  asymmetrical  symptoms  below  knee  
–  Reducible  or  irreducible  derangement  
CENTRAL  SYMMETRICAL  
SYMPTOMS  
 Central  Symmetrical  Symptoms  
•  Symptoms  will  be  central  or  symmetrical  
across  the  back  and  may  include  radiaVng  
symptoms  bilaterally  into  both  bueocks.  
•  Treat  with  sagieal  plane  forces  
 Management  of  Central  Symmetrical  
Symptoms  
•  The  Extension  principle  is  used  for  the  
majority  of  paVents  
–  Lying  prone,  lying  prone  in  extension,  extension  in  
lying,  extension  in  standing  
•  Perform  exercises  regularly  (every  2-­‐3hrs)  
•  Maintain  the  lordosis  
•  Correct  posture  
•  Avoid  flexion  
 Posterior  Derangement  
•  KyphoVc  deformity  
 Management  of  Central  Symmetrical  
Symptoms  
•  The  flexion  principle  is  used  for  a  small  
number  of  paVents  (anterior  derangement)  
–  Flexion  in  lying,  flexion  in  si^ng  
•  Perform  exercises  regularly  
•  Correct  posture  by  reducing  the  lordosis  
•  Avoid  lordoVc  postures  such  as  prone  lying  
and  prolonged  standing  
 Anterior  Derangement  
•  LordoVc  deformity  
UNILATERAL  ASYMMETRICAL  
SYMPTOMS  TO  KNEE    
 Unilateral  Asymmetrical  to  Knee    
•  Unilateral  or  asymmetrical  back  pain    
•  Distal  or  referred  symptoms  may  also  be  
present,  as  far  as  the  knee.    
•  Start  with  extension  procedures  
•  Do  they  have  a  relevant  or  a  non-­‐relevant  
lateral  component?  
 Lateral  Component  
•  Derangements  can  be  classified  as  having  
relevant  or  non-­‐relevant  lateral  component  
–  A  non-­‐relevant  lateral  component    
•   Improvement  with  pure  sagieal  plane  moVons.    
–  A  relevant  lateral  component    
•  Go  into  the  frontal  plane  to  resolve  symptoms.    
•  Can  present  with  or  without  a  lateral  shim  
deformity.  
 Posterior-­‐lateral  Derangement  
•  Lateral  shim  deformity  
 The  Derangement  Syndrome    

•  Lateral  Shim  deformity    

–  PaVent’s  trunk  is  offset  over  the  pelvis  in  the  
frontal  plane.    
•  Two  types  of  lateral  shim  deformiVes  
–  A  non-­‐relevant  or  “som”  shim  
–  A  relevant  lateral  shim  or  “hard”  shim  
 Relevant  Lateral  Shim      
•   Present  if:  
–  The  upper  body  is  visibly  and  unmistakably  shimed  to  
one  side  
–  Shim  occurred  with  low  back  pain  
–  They  are  unable  to  self  correct  the  shim  
–  If  they  can  correct  the  shim,  they  are  unable  to  
maintain  the  correcVon.  
–  CorrecVon  of  the  shim  affects  the  intensity  of  the  
symptoms  
–  CorrecVon  affects  the  site  of  the  symptoms  
 Relevant  Lateral  Shim        
•  A  contralateral  shim:  
–  Shimed  away  from  the  painful  side  
•  An  ipsilateral  shim:  
•  Shimed  towards  the  painful  side  
•  McKenzie  (1972)  found  96%  of  paVents  to  
have  contralateral  shims.  
 Relevant  Lateral  Shim  
•  Lateral  forces  will  be  needed  in  the  management  of  
their  symptoms  (even  if  there  is  no  shim  deformity)  
•  IndicaVons  that  lateral  forces  may  be  needed:  
–  Unilateral  or  asymmetrical  symptoms  
–  Both  flexion  and  extension  aggravate  symptoms  
–  Side-­‐gliding  moVon  is  asymmetrical    
–  Sx  do  not  change  over  several  days  of  using  
extension  moVon  
 Management  of  Relevant  Lateral    
•  Progressions  listed  in  the  order  that  most  frequently  
generates  a  favorable  response.  
–  Extension  in  lying  with  hips  off  center  
–  EIL  with  overpressure  
–  EIL  with  hips  off  center,  with  lateral  overpressure  
–  Side-­‐gliding  in  standing,  shim  hips  away  from  pain  
–  RotaVon  mobilizaVon  in  extension  
•  If  extension/lateral  procedures  or  pure  lateral  procedures  do  
not  improve  the  paVent,  flexion/lateral  procedures  are  
considered.  
–  RotaVon  in  flexion;  usually  rotate  legs  to  painful  side  
–  RotaVon  mobilizaVon  in  flexion  
UNILATERAL  ASYMMETRICAL  TO  
BELOW  KNEE    
Unilateral  Asymmetrical  to  Below  Knee    
•  Low  back  pain  with  distal  leg  or  calf  pain  with  or  
without  neurological  signs  and  symptoms.    
•  Progress  is  slow.    
•  Our  ability  to  produce  change  in  the  volume  and  
locaVon  of  displaced  intradiscal  Vssue  is  dependent  
on  the  integrity  of  the  annulus  fibrosis.  
 Management  of  Unilateral  
Asymmetrical  to  Below  Knee    
•  The  sagieal  plane  is  explored  first  with  force  
progression  as  needed.  
•  If  there  is  an  unfavorable  or  lack  of  response  
to  extension  procedures,  the  lateral  
component  is  introduced.  
 The  Irreducible  Derangement  
•  When  all  movements  worsen  pain  and  no  
posiVon  can  be  found  to  provide  lasVng  relief.  
•  The  conclusion  that  a  derangement  is  
irreducible  will  be  made  over  up  to  5  sessions  
during  which  signs  and  symptoms  have  
remained  unchanged  or  have  worsened.  
McKenzie  Exercises  
25  PROCEDURES  TO  TREAT  LOW  
BACK  PAIN  
 Procedure  1-­‐  Prone  Lying  
•  PaVent  lies  prone  with  their  head  turned  to  
one  side,  arms  by  their  sides,  feet  of  the  edge  
of  the  plinth  or  in  IR.    
•  With  an  acute  lumbar  kyphosis,  add  pillows  to  
accommodate  the  deformity  as  needed  for  
pain.  
 Procedure  2-­‐  Prone  Lying  in  Extension  
•  PaVent  lies  prone  on  elbows,  allowing  the  low  
back  to  be  posiVoned  in  more  extension.  
•  This  posiVon  is  sustained  for  5  to  10  minutes.    
 Procedure  3-­‐  Sustained  Extension  
•  PaVent  lies  prone  with  the  table  posiVoned  in  
extension,  creaVng  a  gradual  and  sustained  
extension  stress  to  the  lumbar  spine.  
•  Gradually  lim  the  table  up  into  more  extension  
•  Use  this  for  paVents  
–  kyphoVc  deformity    -­‐  Major  derangements  
–  To  expose  an  anterior  derangement  
 Procedure  4-­‐  Posture  CorrecVon  
•  Educate  the  paVent  on  good  si^ng  posture.  
•  Guide  them  from  a  kyphoVc  posiVon  to  an  
upright  posiVon  by  anteriorly  rotaVng  the  
pelvis  and  increasing  the  lumbar  lordosis.  
•  Show  paVent  how  to  maintain  this  posiVon  
through  the  use  of  a  lumbar  roll.  
 Procedure  5  –  Extension  in  Lying  
•  Progression  of  procedures  1  and  2  
•  PaVent  starts  lying  prone,  hands  palm  down  
under  their  shoulders.  Raise  the  top  half  of  
the  body  by  straightening  arms,  return  to  lying  
prone.  Repeat  10-­‐15  Vmes.  
•  Keep  lower  body  relaxed  
•  PaVent  OP  -­‐  Sag  
 Procedure  6a  –  EIL  with  Clinician  OP  
•  Progression  of  procedure  5  with  the  addiVon  
of  clinician  overpressure  
•  OP  is  applied  using  body  weight  through  the  
arms,  symmetrical  pressure  is  applied  and  
maintained  while  the  paVent  performs  EIL.  
 Procedure  6B-­‐  EIL  with  Belt  FixaVon  
•  Same  as  procedure  6A  but  with  belt  fixaVon  
instead  of  clinician  overpressure  
•  Easier  way  to  add  overpressure  to  EIL  for  HEP  
 Procedure  7  –  Extension  MobilizaVon      
•  MobilizaVon  pressure  applied  to  lumbar  spine  
in  neutral  or  with  the  lumbar  spine  in  
extension  (prone  on  elbows)  
•  Apply  10-­‐15  repeVVons,  gradually  increasing  
force.    
•  Most  commonly  used  therapist  technique.  
Procedure  8  –  Extension  ManipulaVon  
•  Set  up  the  same  as  procedure  7  with  an  extension  
force  applied  and  sustained  for  5  to  10  seconds.  
•  The  symptom  response  to  this  pre-­‐manipulaVve  
tesVng  must  be  centralizaVon,  reducVon  or  
aboliVon  of  sx  during  the  procedure  but  that  
return  once  pressure  is  released.    
•  A  high  velocity,  short  amplitude  thrust  is  applied.  
•  Only  perform  once  or  at  the  most,  twice.  
•  Not  taught  unVl  diploma  level  
 Procedure  9  –  Extension  in  Standing  
•  PaVent  stands  with  feet  shoulder  width  apart,  
hands  placed  over  low  back  with  fingers  
poinVng  down.    
•  PaVent  leans  back  as  far  as  possible,  repeat  10  
Vmes.  
•  Not  as  effecVve  as  EIL  but  a  good  
       alternaVve.  
Procedure  10  –  Slouch  Overcorrect  
•  Use  for  postural  educaVon  
•  Instruct  paVent  to  slouch,  then  move  to  an  
upright  si^ng  posiVon  with  maximal  lordosis,  
repeat  this  sequence  10  Vmes.  
•  Back  off  10%  from  maximal  lordosis  on  the  last  
repeVVon.  This  is  considered  opVmal  si^ng  
posture.    
Procedure  11-­‐  EIL  with  Hips  Off  Center  
•  StarVng  posiVon  is  the  same  as  procedure  5  
but  is  asymmetrical  with  the  hips  off  center  in  
the  prone  lying  posiVon.    
•  Start  with  hips  shimed  AWAY  from  the  painful  
side.  Repeat  pressups  10-­‐15  Vmes.  
•  Used  in  derangements  with  unilateral  or  
asymmetrical  symptoms  that  
   have  not  responded  to  extension.  
Procedure  12-­‐  EIL  with  Hips  Off  Center  
with  Clinician  Overpressure  
•  12A  Sagieal  Overpressure    
–  PosiVon  hypothenar  eminences  on  TPs  of  painful  
segment.  Pt  performs  REIL.  
•  12B  Lateral  Overpressure  (more  commonly  
used  technique)    
–  Pressure  is  applied  at  the  ribs  and  iliac  crest.  Pt  
perform  REIL.  
 Procedure  13-­‐  Extension  MobilizaVon  
with  Hips  Off  Center  
•  Performed  the  same  as  procedure  7  except  
the  hips  are  posiVoned  off  center,  away  from  
the  painful  side.  
•  Once  in  this  posiVon,  the  extension  
mobilizaVon  is  performed.  
•  This  is  a  force  progression  for  a  derangement  
with  a  lateral  component.    
•  Do  not  perform  before  aeempVng  procedures  
11  and  12.  
Procedure  14-­‐  RotaVon  MobilizaVon  in  
Extension  
•  The  posiVon  is  the  same  as  in  procedure  7  but  
the  technique  is  modified  by  applying  pressure  
first  to  the  TP  on  one  side,  then  the  other  side  to  
produce  a  rocking  effect.    
•  Force  is  directed  anterior  and  slightly  medially.  
Repeat  10  Vmes.  
•  Generally  used  to  reduce  derangements  with  
unilateral  or  asymmetrical  symptoms  that  have  
remained  unchanged  with  previous  procedures.    
 Procedure  15-­‐  RotaVon  ManipulaVon  
in  Extension  
•  Same  as  procedure  14  but  with  a  high  velocity,  
low  amplitude  thrust.  
•  Only  one  manipulaVve  thrust  should  be  
performed  during  a  treatment  session  
•  Pre-­‐manipulaVve  tesVng  must  show  favorable  
results  before  performing  
       manipulaVon.    
 Procedure  16  –  Self  CorrecVon  of  
Lateral  Shim  Or  Side  Gliding  
•  The  direcVon  of  side-­‐gliding  is  named  by  the  
direcVon  that  the  shoulder  moved,  rather  
than  the  hips.    
•  Used  for  self-­‐correcVon  of  lateral  shim  
•  Is  taught  amer  manual  correcVon  of    
       lateral  shim  for  HEP.  
 Procedure  17-­‐  Manual  CorrecVon  of  
Lateral  Shim  
•  This  procedure  is  used  for  paVents  with  a  
relevant  lateral  shim  deformity.    
•  Has  two  parts:  correct  the  lateral  shim  
deformity,  THEN  restore  full  extension.  
•  Go  slowly  and  listen  to  paVent  symptoms  
•  Amer  manual  correcVon,  teach  the    
       paVent  procedure  16  for  HEP.  
 Procedure  18  –  Flexion  in  Lying  (FIL)  
•  PaVent  supine  with  hips  and  knees  flexed  at  45  
degree  angle,  bring  knees  to  chest  and  apply  self  
over  pressure.  
•  Knees  released  and  placed  back  on  the  mat.  
Repeat  10  Vmes.  
•  Always  perform  following  stabilizaVon  of  a  
reduced  posterior  derangement  so  that  no  flexion  
loss  remains.  
•  Treatment  of  choice  for  lordoVc  
         deformity.  
 Procedure  19-­‐  Flexion  in  Si^ng  
•  A  progression  of  force  from  procedure  18  
•  Sit  with  hips  at  90deg,  reach  between  knees  
•  Is  a  useful  technique  in  remodeling  an  
adherent  nerve  root.  
Procedure  20-­‐  Flexion  in  Standing  (FIS)  
•  A  progression  of  procedure  19  
•  PaVent  stands  with  feet  shoulder  width  apart,  
instruct  them  to  run  their  hands  down  their  
thighs  and  reach  as  far  as  possible  towards  the  
ground.  Repeat  x  10.  
•  Necessary  in  remodeling  an  ANR  
Procedure  21-­‐  FIL  with  Clinician  OP  
•  Same  as  procedure  18  but  with  clinician  
overpressure  at  endrange  flexion.    
 Procedure  22  –  Flexion  in  Step  
Standing  (FISS)  
•  This  procedure  creates  an  asymmetrical  
flexion  stress  and  is  applied  when  there  is  a  
deviaVon  in  flexion    
•  Can  occur  in  derangement  (ant/lat)  or  dysfuncVon  
(ANR)  
•  Raise  the  leg  that  is  OPPOSITE  the  side  to  
which  the  deviaVon  in  flexion  occurs  
•  Restore  lordosis  between  each  rep  
 Procedure  23-­‐  RotaVon  in  Flexion  
•  This  procedure  is  used  in  the  management  of  
derangements  that  have  not  improved  or  have  
worsened  with  sagieal  plane  movements.  
•  PaVent  lims  their  pelvis  off  the  mat,  places  it  off  
center,  away  from  the  painful  side.    
•  The  knees  are  then  raised  unVl  they  are  over  the  
hips  and  lowered  to  the  mat  (towards  the  painful  
side).    
•  Hold  the  posiVon  2-­‐3  minutes.  
 Procedure  24  –  RotaVon  MobilizaVon  
in  Flexion    
•  Same  as  procedure  23  but  with  the  paVent’s  
knees  resVng  on  the  clinician’s  thighs  and    a  
mobilizaVon  pressure  applied  through  their  
knees,  while  simultaneously  anchoring  their  
contralateral  shoulder.  
 Procedure  25-­‐  RotaVon  ManipulaVon  
in  Flexion  
•  Same  set  up  as  procedure  24  but  with  a  high  
velocity,  low  amplitude  thrust  applied  through  
the  paVent’s  knees.    
•  Only  one  manipulaVve  procedure  should  be  
performed  during  a  session.  
QuesVons??  
 References  
•  McKenzie  R,  May,  S.  (2003).  The  Lumbar  Spine  
Mechanical  Diagnosis  &  Therapy,  Volume  One  
and  Two.  Spinal  PublicaVons,  New  Zealand.    
•  Kroon  P,  Kruchowsky  T.  (2014).  Advanced  
Lumbar  Spine.  Manual  Therapy  InsVtute  
PublicaVons.    
•  Images  on  ppt  slides:  
hep://drmiglis.com/mckenzie-­‐method-­‐
explained/  Accessed  on  May  29th,  2014.