McKenzie for lumbar region

Presented by:

Heba Mohamed Attia

Nehal Mahmoud Said
 Predisposing Lifestyle Factors for
Developing LBP
• Bad sitting posture:
– Slouched sitting places spine in the same amount of
flexion as a fully flexed standing posture.
– Intradiscal pressure increases in a kyphotic position
and decreases the more the spine approaches a
lordotic position.
– 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 association 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 portions of the
vertebra approximate
• The vertebral canal lengthens, placing stretch on the spinal
cord, dura and nerve roots.

http://ittcs.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 portion of the vertebra
gap.
• The vertebral canal shortens which relaxes the spinal cord,
dura and nerve roots. Reduces the space in the intervetebral
foramen.

http://ittcs.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.
Classification of McKenzie Syndromes

• Three Mechanical Syndromes

1.) Postural Syndrome
2.) Dysfunction Syndrome
3.) Derangement Syndrome
• Other
• Spinal stenosis, hip, SIJ, mechanically inconclusive,
spondylolisthesis, chronic pain.
POSTURAL SYNDROME
 The Postural Syndrome
• Pain is created from mechanical deformation
of normal soft tissue or vascular insufficiency
as a result of prolonged positional or postural
stresses.
 The Postural Syndrome
• Pain is intermittent and only brought on by
prolonged static loading of normal tissues
• Time is a causative factor
• Pain relieved by change of posture/function
• No deformity present
• No loss of movement www.floota.com

• Rarely presents in the clinic

 Treating Postural Syndrome
• Re-‐educate
­ the patient
• Correct sitting posture
• Teach slouch/overcorrect exercise
• Use of a lumbar roll
• Correct standing and sleeping posture as
appropriate
DYSFUNCTION SYNDROME
 The Dysfunction Syndrome
• Pain is caused by mechanical
deformation of structurally impaired soft
tissues.
• May be a result of previous trauma,
inflammation, repetitive microtrauma,
degenerative changes, all of which can result in
imperfect tissue repair.
 The Dysfunction Syndrome
• Pain occurs when end range stress is
applied to adaptively 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
dysfunction syndrome).
 The Dysfunction Syndrome
• History of trauma, degenerative changes or
years of poor posture
• Symptoms must have been present for at least
6 to 8 weeks
• Pain is always intermittent
• Pain is always local (except with an ANR)
• A limitation of ROM is present
• No deformity is present
 Treatment for Dysfunction Syndrome
• Goal: Increase ROM by remodeling tissue
(takes 4-‐6
­ weeks!)
• Teach posture correction
• Pain should stop shortly after exercises are
completed
• Pain should never peripheralize
• Frequency: 10-­‐12 repetitions every 2 hours of
the day; 5-‐6­ repetitions every 4 hours for older
people.
THE DERANGEMENT SYNDROME
 The Derangement Syndrome
• Disturbance in the normal resting
position of the joint surface that causes
pain and obstructs movement.
• The most common mechanical spinal
disorder
– 60-­‐78% of patients fall into this category (May and
Aina 2012).
 Conceptual Model
• Annulus fibrosis – no innervation to the inner
portion.
• Fissures develop over years of repetitive
microtrauma.
– First circumferentially, then radially
– Nucleus becomes compromised
• Internal disc disruption and displacement
occur
– Pt becomes symptomatic
 The Derangement Syndrome
• Variable symptoms, often with insidious
onset
• Local or referred pain, possibly
paraesthesia
• Pain can be constant or intermittent
• Aberrant motions and deformities may be
present
• Always loss of movement and/or function
• High rate of recurrence
 The Derangement Syndrome
• Movement found to decrease the pain and the
deformity are used in treatment.
• Movements or positions that increase the pain
or deformity are avoided.
 The Derangement Syndrome
• Larger derangements cause greater
mechanical deformation and more signs and
symptoms.
• Can result in postural deformities
 Centralization
• The approximation of symptoms TOWARDS
the spine.
 Peripheralization
• Symptoms peripheralize from the spine into
the lower extremity.
Treatment of Derangement Syndrome
• Reduce the derangement
• Maintain the reduction
• Recovery of function
– Treat underlying dysfunction if present
– Reintroduce opposite motion
• Prevention of recurrence
– Education on posture with sitting/standing activities
– Recurrent nature of LBP
 Evaluatio
• n
Patient history: Primary purpose is to establish a
preliminary classification!
• Observe sitting/standing posture and its effect on
pain
• Note any deformities
 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 stiffness 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 motion rules out postural syndrome and
dysfunction.
• Sustained tests
– Can be performed it the repeated movements do
not provide adequate information.
 Provisional Classification
• Classify the syndrome
• Choose a direction to reduce the derangement
• Determine the appropriate force to apply
– Sustained positions
– Repeated movements
– With our without overpressure
 Force Progression
• Only progress force when symptoms remain
unchanged.
• Clinician-­‐generated forces should never be
used before patient-­‐generated forces have
been attempted.
• Remove clinician forces and return the patient
to the sagittal plane as quickly as possible.
 Order of Force Progression
• Static, patient generated
– Mid range ‐>
-­ End range
• Dynamic, patient generated
– Mid range ‐>
-­ End range ‐>
-­ Self OP
• Clinician generated
– Patient takes the motion to end range and then therapist
applies overpressure
– Therapist mobilization
– Therapist manipulation
 Exercise Prescription
• Perform 10 repetitions of the motion every 2
hours of the day.
• Take the motion to end range
• Use of lumbar roll
• Postural awareness
• Follow up within the next 24 to 48 hours to
assess progress.
 Recovery of Function
• Taper off exercise frequency
• Create a prophylactic program of
reintroducing flexion motion; this is done
gradually and based on symptomatic
response.
– Flexion in lying followed by extension in lying, 10
repetitions of each 3x/day. Avoid flexion during
the first 3 hours of the morning.
• Over 2-­‐3 weeks, progress flexion forces
McKenzie Exercises
25 PROCEDURES TO TREAT LOW
BACK PAIN
 Procedure 1-­‐ Prone
Lying
• Patient 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
• Patient lies prone on elbows, allowing the low
back to be positioned in more extension.
• This position is sustained for 5 to 10 minutes.
 Procedure 3-‐­ Sustained Extension
• Patient lies prone with the table positioned in
extension, creating a gradual and sustained
extension stress to the lumbar spine.
• Gradually lift the table up into more extension
• Use this for patients
– kyphotic deformity ‐-­ Major
derangements
– To expose an anterior derangement
 Procedure 4-‐­ Posture Correction
• Educate the patient on good sitting posture.
• Guide them from a kyphotic position to an
upright position by anteriorly rotating the
pelvis and increasing the lumbar lordosis.
• Show patient how to maintain this position
through the use of a lumbar roll.
 Procedure 5 – Extension in Lying
• Progression of procedures 1 and 2
• Patient 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
­ times.
• Keep lower body relaxed
• Patient OP ‐-­ Sag
 Procedure 6a – EIL with Clinician OP
• Progression of procedure 5 with the addition
of clinician overpressure
• OP is applied using body weight through the
arms, symmetrical pressure is applied and
maintained while the patient performs EIL.
 Procedure 6B-‐­ EIL with Belt Fixation
• Same as procedure 6A but with belt fixation
instead of clinician overpressure
• Easier way to add overpressure to EIL for
HEP
 Procedure 7 – Extension Mobilization
• Mobilization pressure applied to lumbar spine
in neutral or with the lumbar spine in
extension (prone on elbows)
• Apply 10-­‐15 repetitions, gradually increasing
force.
• Most commonly used therapist technique.
Procedure 8 – Extension Manipulation
• 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-­‐manipulative
testing must be centralization, reduction or
abolition 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 until diploma level
 Procedure 9 – Extension in Standing
• Patient stands with feet shoulder width apart,
hands placed over low back with fingers
pointing down.
• Patient leans back as far as possible, repeat 10
times.
• Not as effective as EIL but a good
alternative.
Procedure 10 – Slouch Overcorrect
• Use for postural education
• Instruct patient to slouch, then move to an
upright sitting position with maximal lordosis,
repeat this sequence 10 times.
• Back off 10% from maximal lordosis on the last
repetition. This is considered optimal sitting
posture.
Procedure 11-‐­ EIL with Hips Off Center
• Starting position is the same as procedure 5
but is asymmetrical with the hips off center in
the prone lying position.
• Start with hips shifted AWAY from the painful
side. Repeat pressups 10-‐15
­ times.
• 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 Sagittal Overpressure
– Position 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 Mobilization
with Hips Off Center
• Performed the same as procedure 7 except
the hips are positioned off center, away from
the painful side.
• Once in this position, the extension
mobilization is performed.
• This is a force progression for a derangement
with a lateral component.
• Do not perform before attempting procedures
11 and 12.
 Procedure 16 – Self Correction of
Lateral Shift Or Side Gliding
• The direction of side-­‐gliding is named by the
direction that the shoulder moved, rather
than the hips.
• Used for self-­‐correction of lateral shift
• Is taught after manual correction of
lateral shift for HEP.
 Procedure 17-‐­ Manual Correction of
Lateral Shift
• This procedure is used for patients with a
relevant lateral shift deformity.
• Has two parts: correct the lateral shift
deformity, THEN restore full extension.
• Go slowly and listen to patient
symptoms
• After manual correction, teach the
patient procedure 16 for HEP.
 Procedure 18 – Flexion in Lying (FIL)
• Patient 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 times.
• Always perform following stabilization of a
reduced posterior derangement so that no flexion
loss remains.
• Treatment of choice for lordotic
deformity.