McKenzie CONCEPT
McKenzie's concept is a classification-based treatment for a patient with low
back pain. An acronym for the McKenzie method is MDT (Mechanical,
Diagnosis, and Therapy). The concept was developed by 1981 by Robin
McKenzie a physical therapist from NEW ZEALAND. The concept has 3 steps:
Evaluation, Treatment, & prevention.
The method is based on self-movement i.e. to do the movement by own self
and he describes the pain has been broadly classified as:
1. Postural Syndrome
2. Dysfunction Syndrome
3. Derangement Syndrome
McKenzie TRAFFIC LIGHTS SIGNALS: it is a way to determine if you need to
progress the patient towards the movement or considered an alternative.
1. Green Light: The more a patient move in the particular direction
results in lessening of pain; centralization of peripheral symptoms and
rapid mechanical improvement. In this case continuation of the
current therapy if it is giving the desired response.
2. Yellow Light: It means to proceed with caution this happens when a
person experiences equivocal response i.e. could be somewhat how
better during movement but the nature of pain changes and doesn’t
so remain afterward.
3. Red Light: This is shown to stop a particular movement that wasn’t
present before or result in peripheralization of symptoms that remain
worse even after therapy. Red light requires a force alternative usually
a change in the direction of loading strategies.
MECHANISM OF PAIN PRODUCTION:
1. Chemical: Pain is produced by chemical irritation as soon as the
concentration of a chemical substance is sufficient to irritate free
nerve endings is involved soft tissue. It is maybe due to an
inflammatory or infective process.
2. Mechanical: Pain occurs by application of mechanical forces as soon
as mechanical deformation, containing the nociceptive receptor
system is sufficient to irritate free nerve endings. The pain will also be
produced by the application of forces sufficient to stress or deform the
ligamentous and capsular structure.
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McKenzie CONCEPT
3. Trauma: Pain due to trauma is produced by a combination of
mechanical deformation and chemical irritation. Initially, mechanical
deformation causes damage to soft tissue, and pain of mechanical
origin will be felt.
NOTE: In most instances, there is sharp pain shortly after injury; chemical
substances accumulate in the damaged tissue as soon as the concentration of
these chemical irritants is sufficient to enhance the activity of the nociceptive
receptor system in the surrounding tissue pain will be felt. The pain of chemical
origin will be experienced as a persistent discomfort or dull aching pain or
chemical are present in sufficient quantities.
TEST MOVEMENTS:
1. The test movements are first performed in standing and then lying
position. When performed in lying, they must be done in such a way
that the effect on the lumbar spine is a passive stretch and any form
of active movement produced by the muscle surrounding the lumbar
spine should be avoided.
2. If we have to relate movement to pain, the test movement must be
performed in such a way that they produce a change in the patient’s
symptoms. This change can be brought variously i.e. if before
movement pain is present, the test movement may increase or
decrease its intensity. It may alter the site of pain by centralization or
by abolishing one form of pain and introducing another form. If before
movement no pain is present, the test movement may produce pain
as complained due to some disorder.
3. If there is no change in the patient’s symptoms during or immediately
following test movements then the joint has not been stressed
adequately and the process should be repeated more vigorously. It
may also decrease the pain and it can be started by it. It is not by
mechanical origin because mechanical pain must be and always is
affected by movement or position.
REPEATED MOVEMENTS:
1. With a movement of the vertebral column, the nucleus can alter its
shape and with sustained position or repeated movement, it will alter
its position. The centralization of pain indicates that the movement
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McKenzie CONCEPT
should be chosen to reduce mechanical deformation.
Peripheralization of pain indicates the worsening of the condition and
avoidance of that particular movement.
2. In dysfunction syndrome, the performance of repeated movement in
the direction which stretches adaptively shorten structure will
produce pain at the end range of movement but repetition makes the
condition does not go progressively worse when the patient returns to
the neutral position the pain will disappear.
3. Patients with the postural syndrome will not experience pain with any
of the test movement or their repetition. These patients must position
in a particular posture to have their pain reproduce.
4. In derangement syndrome, the performance of repeated movement
in the direction which increases the accumulation of nuclear material
will result in spreading and increasing the derangement and hence
increase peripheralization of pain. The performance of repeated
movement in the opposite direction will result from the reduction of
derangement and centralization of pain.
POSTURAL SYNDROME:
Postural syndrome is defined as mechanical deformation of postural origin
causing pain of intermittent nature which appears when the soft tissue
surrounding the lumbar segment is placed under prolonged stress. Sitting is the
most frequent cause of postural pain. Alderson Etal stated that when sitting for
a few minutes the lumbar spine assumes a full flexed position and the muscle
supporting the low back becomes tired and relaxed. The starting postural
support is provided by the ligamentous structure and overstretching of these
structures leads to mechanical deformation and results in postural pain, thus
ligamentous fatigue falls muscular fatigue. There is no pathology present in
pure postural syndrome.
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McKenzie CONCEPT
✓ PATHOLOGY:
Maintenance of certain posture
or position produced
prolonged stress of soft tissue.
Produce pain of intermittent nature.
Relived by postural correction.
✓ C/F:
▪ Usually, age is under the 30s.
▪ Sedentary occupation and lack of physical fitness.
▪ Pain is produced by position and not by movement; which is
intermittent.
▪ No deformity and no loss of motion.
▪ Test movements are pain-free.
▪ No X-Ray abnormality.
▪ Standing and sitting posture must be poor.
✓ O/E:
▪ To reproduce the appropriate postural stress, the patient must
assume and maintain the position that causes pain; after the
passage of sufficient time the symptom appears in this position,
and up to half-hour may be required.
▪ Once the pain has produced by the adoption of a certain posture,
it will be abolished by the correction of that posture.
✓ T/t: In postural syndrome no pathology is present and the only treatment
is required is postural correction and reduction and prevention.
▪ Sitting: Correction and maintenance of corrected posture, use of
lumbar support for lordosis; conscious control of lumbar lordosis.
▪ Standing: To achieve postural correction in standing the patient
must be shown how to move the lower part of the spine backward
by tightening the abdominal muscles and tilting the pelvis
backward, while at the same time moving the upper spine forward
and raising chest.
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DYSFUNCTION SYNDROME: The word “dysfunction” chosen by Mennell to
describe the loss of movement commonly known as joint play or accessory
movement, which is caused by adaptive shortening. There are two types of
dysfunctions:
1. When dysfunction develops following trauma or derangement, the
patient will describe the symptoms from the date of trauma or
derangement and will be aware, but the pain will no longer be present
and the symptoms are loss of mobility and function.
2. When dysfunction is the result of poor posture or spondylolysis the
patient will be unaware of the onset, he will be unable to relate the
cause of the pain to a particular incident and usually describe a gradual
slow onset of pain.
✓ PATHOLOGY:
Mechanical deformation of soft tissue
caused by adaptive shortening
Loss of movement in certain direction and
cause pain before full range of movement
Intermittent pain when shortened
structure are stressed adequately
Relive is by lengthening of those
structure
✓ C/F:
▪ The patient is more than 30 years of age.
▪ Previous LBP or trauma, which results in loss of movement.
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McKenzie CONCEPT
▪ Pain is felt at the end range of certain movements or before the
end range is achieved.
▪ Pain is intermittent, recovery only when the peri-articular structure
is placed on full stretch.
▪ When dysfunction in the spine is the result of poor posture or
spondylosis, then there is symmetric movement loss in all
directions.
▪ When dysfunction is the result of trauma and derangement, then
there is asymmetrical movement loss.
✓ O/E:
▪ Test movement will be produced pain or symptom due to the
reduced end range of movement; pain is elicited readily as soon as
stretching of these movements is performed.
✓ T/t:
▪ Stretching must be performed in such a way that it allows
elongation of ligamentous structure and scar tissue without
causing micro-trauma.
▪ If no strain pain is produced during the performance of exercise for
the recovery of lost movement, the contracted soft tissue is not
being stretched enough to enhance the elongation of the
shortened structures.
✓ T/t of Extension Dysfunction:
▪ Modified Press-Ups (Procedure-3)
▪ Extension with Belt-Fixation (Procedure-4)
▪ Extension in Standing (Procedure-6)
▪ Mobilization (Procedure-7 & 9)
▪ Manipulation (Procedure- 8 & 10)
✓ T/t of Flexion Dysfunction:
▪ Flexion in Lying (Procedure-13)
▪ Flexion in Standing (Procedure-14)
▪ Rotational Mobilization & Manipulation (Procedure-11 & 12)
✓ T/t of Lateral Dysfunction:
▪ Self-correction of lateral shift (Procedure-17)
▪ Stand in Overcorrected position wherever possible
DERANGEMENT SYNDROME: Derangement syndrome is defined as the
situation in which the normal resting position of the articular surface of the
adjacent vertebrae is disturbed as a result of a change in the position of the fluid
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nucleus palposus between these surfaces. Derangement of the disc can cause
the deformities of kyphosis, lordosis, and scoliosis.
1. Acute Lumbar Kyphosis: The stresses most likely to cause an acute
lumbar kyphosis are sustained flexion stresses such as those applied
during sitting. Prolonged maintenance of flexed position and frequent
repetition of movement in flexion may lead to excessive accumulation
of the fluid nucleus in the posterior compartment between vertebral
bodies. Once this accumulation is great enough it may become a
blockage and present the erect position from being obtained.
2. Acute Lumbar Scoliosis: The posterior longitudinal ligament may
prevent postero-central disturbance I the disc wall, asymmetrical
stresses will force the fluid nucleus laterally where the outer annulus
will distend at its weakest point, and therefore bulging of the annulus
is more likely to occur at this point. The symmetrical posterior
accumulation becomes asymmetrical and moves to a more postero-
lateral position with the intervertebral compartment, the patient is
likely to develop sciatica and will acquire the deformity of scoliosis.
✓ PATHOLOGY:
Alteration of the position of the nucleus
palposus.
Disturbance in normal resting position of the
two vertebrae
Constant pain with partial loss of some movement and
some movement are full range
Deformity of kyphosis and scoliosis
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McKenzie CONCEPT
✓ C/F:
▪ Generally, patient age is 20-55 years
▪ History of constant LBP
▪ Pain increases in the flexed position
▪ The relieving factor is while walking
▪ Pain is worst on rest
✓ O/E:
▪ Patient with derangement often exhibit a deformity
▪ The flattened lumbar spine, lumbar kyphosis, lateral shift or
lumbar scoliosis can be present
▪ Always loss of movement and function
▪ Test movement will produce centralization of symptoms
▪ SLR test will be positive with sciatica or lumbar scoliosis
TYPES OF DEREANGEMENT:
✓ TYPE 1:
▪ Central or symmetrical pain at L4/5
▪ Rarely buttock and/or thigh pain
▪ No deformity present
✓ TYPE 2:
▪ Central or symmetrical pain at L4/5
▪ With/without buttock and/or thigh pain
▪ Deformity of lumbar kyphosis
✓ TYPE 3:
▪ Unilateral/asymmetrical pain at L4/5
▪ With/without buttock or thigh pain
▪ No deformity present
✓ TYPE 4:
▪ Unilateral/asymmetrical pain at L4/5
▪ With/without buttock and/or thigh pain
▪ Deformity of lumbar scoliosis
✓ TYPE 5:
▪ Unilateral/asymmetrical pain at L4/5
▪ With/without buttock and/or thigh pain
▪ Sciatica present below knee
▪ No deformity
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✓ TYPE 6:
▪ Unilateral/asymmetrical pain at L4/5
▪ With/without buttock and/or thigh pain
▪ Sciatica present below knee
▪ Deformity of sciatic scoliosis
✓ TYPE 7:
▪ Symmetrical/asymmetrical pain at L4/5
▪ With/without buttock and/or thigh pain
▪ Deformity of accentuated lumbar lordosis
T/t: The principal aim of treatment is to centralize pain and reduce deformity to
reverse all derangement to derangement 1. Patients with D-1 can treat
themselves. The treatment of derangement syndrome has 4 stages: Reduction
of derangement → Maintenance of reduction → Recovery of function →
Prevention of recurrence.
ASSESSMENT/EVALUATION OF PATIENT WITH LBP:
1. HISTORY:
▪ Where is the pain felt
▪ How long pain is present
▪ How it has produced
▪ Weather constant/intermittent
▪ Aggravating factor and relieving factor
▪ Previous history of LBP
2. EXAMINATION:
▪ Posture: sitting and standing; check for reduced lordosis, lateral
shift, and LLD.
▪ Movements: flexion, extension, slide gliding.
▪ Test movements.
▪ Repeated movement.
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TREATMENT TECHNIQUES:
✓ PROCEDURE-1: LYING PRONE; the patient is to advise to lying in the
prone position with the arm alongside the trunk.
✓ PROCEDURE-2: LYING PRONE IN EXTENSION; the patient is prone
lying, place the elbow under the shoulder, and raise the top half of his
body while pelvis and thigh remain on the couch.
✓ PROCEDURE-3: EXTENSION IN LYING; patient in the prone position,
places hand near the shoulder as for press up, he no presses the top his
body up by straightening the arm while bottom half, from the pelvis
down, is allowed to sag with gravity. The top of the body is then lowered
and the exercise is repeated about 10 times, it is essential to obtain the
maximum elevation by the last excursion.
✓ PROCEDURE-4: EXTENSION IN LYING WITH BELT FIXATION; same as
procedure-3 but now a fixating belt is placed at just below the segment
to be extended, it is used to enhance maximum extension.
✓ PROCEDURE-5: SUSTAINED EXTENSION; to apply sustained extension
stress to the lumbar spine as an adjustable couch, one end of which may
be raised. The patient lies prone with his head at the adjustable end of
the couch which is gradually raised, about 1-2 inches at the time over 5-
10 minutes periods.
✓ PROCEDURE-6: EXTENSION IN STANDING; the patient stands with the
feet 30 cm apart and place the hand on the buttock, he leans back as far
as possible, using hands as a fulcrum and then return to neutral standing.
The exercise is repeated 10 times.
✓ PROCEDURE-7: EXTENSION MOBILIZATION; the patient lies prone, the
therapist stand to one side of the patient, crosses the arm, and places the
heels of the hand on the transverse process of the lumbar segment.
Gentle pressure is applied symmetrically and immediately released, but
the hands must not lose the contact. This is repeated rhythmically to the
same segment about 10 times.
✓ PROCEDURE-8: EXTENSION MANIPULATION; the patient lies prone,
the therapist stands to one side of the patient and places the hand on
either side of the spine, the therapist leans over the patient with the arm
at the right angle to the spine and force slowly downwards until the spine
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feels taut, a high-velocity thrust of very short amplitude is applied and
immediately released.
✓ PROCEDURE-9: ROTATION MOBILISATION IN EXTENSION; the position
of the patient and therapist is the same as procedure-7, the pressure is
applied first to the transverse process on the one side and then on the
other side, each time vertebra is rotated away from the side to which
pressure is applied. The technique is repeated for 10 times.
✓ PROCEDURE-10: ROTATIONAL MANIPULATION IN EXTENSION; the
patient lies prone, the therapist stands to one side of the patient place
the hand on either side of the spine as for procedure-9, the therapist
reinforces the one hand with the other on the appropriate transverse
process, the manipulation is then performed as in procedure-8.
✓ PROCEDURE-11: SUSTAINED ROTATION/MOBILISATION IN FLEXION;
the patient lies supine on the couch, the therapist stands on the side to
which leg is to be drawn. The patient's shoulder is held firmly on the
couch by the therapist's hand, providing fixation and stabilization. On the
other hand, the therapist flexes hip and knee to a right-angle and carries
them forward himself causing the lumbar spine to rotate.
✓ PROCEDURE-12: ROTATION MANIPULATION IN FLEXION; the position
of patient and therapist is the same as above if the manipulation is
indicated a sudden thrust of high velocity and small amplitude is
performed, moving the spine into extreme side bending and rotation.
✓ PROCEDURE-13: FLEXION IN LYING; the patient lies supine with the
knee and hips flexed 45⁰ and feet flat on the couch. He bends the knee up
towards the chest, firmly clasp the hand about them and applies
overpressure to achieve maximum stress. The knees are released and the
feet placed back on the couch. The sequence is repeated about 10 times.
✓ PROCEDURE-14: FLEXION IN STANDING; the patient is standing with
the feet about 30 cm apart, bens forward sliding the hand down the front
of the leg. On reaching the maximum flexion, the patient returns to the
upright position. The sequence is repeated 10 times.
✓ PROCEDURE-15: FLEXION IN STEP STANDING; the patient stands on
one leg while other leg rests with the foot on a stool so that hip and knee
are flexed 90⁰, keeping the weight-bearing leg straight the patient draws
himself into a flexed position, firmly approximating shoulder and knee
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which is flexed. The pressure is then released and the patient return to
the upright position, the sequence is repeated about 6-10 times.
✓ PROCEDURE-16: CORRECTION OF LATERAL SHIFT; the patient
standing with the feet 30 cm apart, the therapist stands on the side to
which the patient is deviating and places the patient near the elbow at
right-angle by his side. The elbow will be used to increase the lateral
pressure against the patient rib cage. The therapist's arm encircles the
patient's trunk clasping the hand about the rim of the pelvis. The
therapist presses his shoulder against the patient elbow, pushing the
patient rib cage, thoracic, and upper lumbar spine away while at the same
time drawing the patient’s pelvis towards himself. The procedure is
repeated 10 times.
✓ PROCEDURE-17: SELF CORRECTION OF LATERAL SHIFT; patient and
therapist stand facing each other. The therapist place one hand on the
patient's shoulder on the side to which he deviates and the other hand on
the patient's opposite iliac crest. The therapist applies pressure by
squeezing the patient between his hands, ensuring that the patient's
shoulder remains parallel to the pressure applied by the therapist. The
position is to hold for 2-3 minutes in corrected posture followed by 10
repetitions.
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