McKenzie Approach and Back Injury Nomenclature

Question 1

What are 10 “Back Facts” that are important to know?

Answer 1

(1) persistent back pain can be scary, but it’s rarely dangerous
(2) getting older is not a cause of back pain
(3) persistent back pain is rarely associated with serious tissue damage
(4) scans rarely show the cause of back pain
(5) pain with exercise and movement doesn’t mean you are doing harm
(6) back pain is not caused by poor posture
(7) back pain is not caused by a “weak core”
(8) backs do not wear out with everyday loading and bending
(9) pain flare-ups don’t mean you are damaging yourself
(10) injections, surgery, and strong drugs usually aren’t a cure

Question 2

Who and when was the “McKenzie Approach” discovered?

Answer 2

Robin McKenzie in 1956

Question 3

What was the “Williams philosophy” prior to the McKenzie Approach? And what was it based off of?

Answer 3

The Williams philosophy were flexion exercises proposed to minimize the lordotic curve with daily activities in an attempt to evenly distribute superincumbent weight evenly across the disc surface

Question 4

What were the exercises with Williams philosophy and what were the 3 goals associated with them?

Answer 4

The 7 exercises were aimed at improving lumbar flexion and avoiding extension.

The goals were: (1) open intervertebral foramina (2) strengthen abdominal and gluteal musculature (3) stretch back extensors, HS, and HF

Question 5

What are some examples of Williams’ Flexion Exercises? (8)

Answer 5

pelvic tilt, partial sit-up, single knee to chest, bilateral knee to chest, hamstring stretch, standing lunge, seated trunk flexion, and full squats

Question 6

Why was the McKenzie system developed?

Answer 6

To assist the clinician in recognizing mechanical reasons for patient’s spinal complaint

Question 7

What is the underlying rationale behind the McKenzie approach?

Answer 7

Lumbar movement can alter a patient’s symptoms and centralize and ultimately abolish a patient’s pain

Question 8

What are 3 predisposing factors to LBP?

Answer 8

(1) poor sitting posture: relaxed and unsupported with lumbar spine in a stretched position may produce, enhance, or perpetuate LBP
(2) loss of extension range: results in poor postural habits
(3) frequency of flexion: influences the disc

Question 9

What 3 movements/postures does the McKenzie approach use to determine responses before, during, and after?

Answer 9

(1) singular movements
(2) repetitive movements
(3) sustained postures

Question 10

For what patients is the McKenzie approach effective and not effective?

Answer 10

It is effective for both chronic and acute LBP, excluding those where no position or movement produces centralization of symptoms or does produce peripheralization of symptoms

Question 11

What percent of patients with LBP will their LBP resolve in 2 months no matter the treatment they receive?

Answer 11

92%

Question 12

Centralization

Answer 12

As a result of positioning or movement, peripheral symptoms will move proximally and stay changed

Question 13

What 4 facts are there to remember about centralization?

Answer 13

(1) pain may increase as it centralizes
(2) occurs only in the derangement syndrome
(3) most important guide in determining if you have the correct exercises for the patient’s condition
(4) strong indicator of a successful outcome

Question 14

Peripheralization

Answer 14

As a result of positioning or movement, symptoms move from a proximal to distal and remain changed

Question 15

What does peripheralization indicate?

Answer 15

That the exercise/movement should be avoided.

Question 16

What are the 3 syndromes that spinal pain of mechanical origin can be classified into?

Answer 16

(1) Postural
(2) Dysfunction
(3) Derangement

OR (4) Other: those that don’t fit into these groups

Question 17

Describe Postural Syndrome.

Answer 17

Pain associated with poor posture as a result of sustained position and mechanical deformation of soft/normal tissue at end-range.

Characterized by intermittent pain brought on by particular positions or postures after time has passed, and ceases with change in position.

Question 18

Describe Dysfunction Syndrome.

Answer 18

Strain on abnormal tissue/adaptively shortened tissue that results in pain before full normal ROM is achieved. Pain is intermittent and results in partial loss of motion, ceasing when the stress is removed.

Question 19

Describe Derangement Syndrome.

Answer 19

Internal derangement (intervertebral disc or motion segment) causes mechanical deformation of soft tissue in various forms and degrees (each with different symptoms). Pain is usually constant, but may be intermittent or radicular with partial loss of motion (some motions full with others restricted). Kyphosis and scoliosis are typical in the acute stage.

Question 20

Which of the 3 syndromes have pathology present?

Answer 20

Dysfunction and Derangement Syndrome

Question 21

Do the intervertebral discs move with movement?

Answer 21

Yes!

Question 22

What should the patient describe for their relevant symptoms?

Answer 22

They should describe their current episode of pain as a typical 24 hour course with the location of pain/symptoms.

Question 23

What could make the pain better or worse? (7)

Answer 23

• Bending- flexion with nerve root on tension
• Sitting - sustained full flexion with nerve root off tension
• Rising - movement from a flexed to extended position
• Standing - mid to full range extension
• Walking - extended position
• Lying - unloaded
• Time of day

Question 24

In which way will a patient deviate towards in flexion with a (1) derangement or (2) entrapped or adherent nerve root?

Answer 24

(1) derangement = deviation will occur away from the painful side
(2) entrapped or adherent nerve root = deviation will always occur towards the painful side

Question 25

When examining repeated movements what should you do and take note of?

Answer 25

You should repeat movements 5-10 times (may need to perform multiple sets) and note pretest pain.

Then note any change in ROM or pain pattern, specifically when the pain occurs during the movement or at end range.

Question 26

What are the 6 structures that should be considered during the exam?

Answer 26

(1) facet joints
(2) intervertebral foramen
(3) anterior longitudinal ligament
(4) posterior ligaments
(5) posterior and anterior annulus
(6) dura and nerve roots

Question 27

What movements should be tested and repeated in lying and standing for the lumbar spine? (3)

Answer 27

(1) flexion
(2) extension
(3) side gliding (if needed)

Question 28

What would pain with flexion in standing represent? And in sitting?

Answer 28

Standing = either a bulging disc or an adherent nerve root

Sitting = bulging disc

Question 29

Would standing or lying extension allow greater extension range? Why?

Answer 29

Lying because compressive gravitational forces are eliminated

Question 30

What are 4 points to consider with the motion exam?

Answer 30

(1) Should be performed only if tolerable - may need to treat symptomatically for 1-2 days
(2) Perform a single motion, assess, and then repeat up to ten times
(3) Last movements during a repeated test should obtain maximal stretch
(4) If extension produces pain consider presence of a relative lateral shift

Question 31

Relevant Lateral Shift

Answer 31

A shift where movement of side gliding alters site or intensity of pain

Question 32

What is needed to centralize pain with McKenzie movements?

Answer 32

An intact annular wall

Question 33

What will repeated movements do for pain from dysfunction syndrome?

Answer 33

The pain will continue to be present due to stretch placed on tightened tissues. It won’t centralize or peripheralize, and will constantly occur at end range without worsening.

Question 34

What will repeated movements do for pain from postural syndrome?

Answer 34

It will typically have no effect.

Question 35

What syndrome would the following symptoms point towards?

• Pain during movement
• End range pain
• If condition remains better or worse
• Centralization
• Peripheralization

Answer 35

• Pain during movement = derangement
• End range pain = derangement or dysfunction
• If condition remains better or worse = derangement
• Centralization = derangement
• Peripheralization = derangement

Question 36

What are 2 basic principles of a McKenzie assessment?

Answer 36

(1) always correct a relevant lateral shift
(2) exhaust sagittal plane before testing or treating in the frontal plane

Question 37

What are some static tests you could do? How long should they be done?

Answer 37

They should be done for 3-5 minutes.

• Sitting slouched
• Sitting erect
• Standing slouched
• Standing erect
• Lying prone in extension
• Long sitting

Question 38

What two syndromes may present together?

Answer 38

Dysfunction and Derangement

Question 39

What’s the best treatment for postural syndrome?

Answer 39

Postural correction/education…but more movement would be better if possible

Question 40

What’s the best treatment for Dysfunction Syndrome?

Answer 40

Remodel shortened tissue with stretching (may take 6-8 weeks)…may increase symptoms.

Question 41

Describe “Directional Preference”.

Answer 41

It is a clinical phenomenon where a specific direction of repeated movements and/or sustained position results in a clinically relevant improvement in either symptoms and/or mechanics. (Doesn’t necessarily result in centralization)

Question 42

What syndromes are treated with:

(1) extension in lying
(2) sustained extension
(3) flexion in lying
(4) flexion in standing
(5) side gliding in standing
(6) flexion in step standing

Answer 42

(1) extension in lying = extension dysfunction and posterior derangement
(2) sustained extension = extension dysfunction and posterior derangement
(3) flexion in lying = flexion dysfunction and anterior derangement
(4) flexion in standing = flexion dysfunction, anterior derangement, and nerve root adherence/entrapment
(5) side gliding in standing = side glide dysfunction and posterolateral derangement that needs lateral techniques
(6) flexion in step standing = anterior derangement, nerve root adherence/entrapment, and flexion dysfunction

Question 43

What is the McKenzie treatment progression? (4)

Answer 43

(1) patient generated forces
(2) patient overpressure
(3) therapist overpressure
(4) manipulation procedures (if they’re needed…use self-treatment techniques as soon as possible)

Question 44

What could be the prescribed treatment of the initial McKenzie approach? (3)

Answer 44

(1) avoid flexed postures
(2) repeated extension exercises every 2 hours
(3) lumbar role when sitting