The McKenzie Method – Part 1 – Clearing Misconceptions about MDT

imageThis week features a 2-part guest post discussing the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) by Christie Downing.  Christie is a frequent contributor to this site.  I think this is a great series to “clear the air” about some of the misconceptions regarding MDT, and more importantly, to share some of Christie’s experience and pearls of wisdom.  If you are unfamiliar with MDT, take this as an opportunity to get to learn more about the method.  While Christie discusses that MDT is not all about extension exercises, it does fit into my reverse posturing theory to an extent.

 

The McKenzie Method – Clearing the Air

What is your gut reaction when you hear “McKenzie Method?” I predict you are either excited or just rolled your eyes. If it is the later, I hope you will give this post due diligence. For it is my observation that those who despise it have not been fully informed about it. It’s one of the most researched physical therapy approaches, yet is fraught with misconceptions. For those interested in the research, the McKenzie Institute International maintains a database of the most relevant research. However, rather than discuss the literature, my objective will be to clear up misconceptions of what the McKenzie method entails and to give some brief “Pearls of Wisdom.” This first post will entail a brief overview of the McKenzie Method, otherwise known as Mechanical Diagnosis and Therapy (or MDT).

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Mechanical Diagnosis and Therapy – MDT

Due to long standing misconceptions, much has been inaccurately portrayed regarding MDT. When describing MDT to another practitioner, it is sometimes easier to first discuss what it is not. MDT is/does not:

  • A series of exercises
  • Only about derangement
  • Only extension
  • Only about the intervetebral disc
  • Only about repeated end range movements
  • Ignore biopsychosocial issues
  • Without the use of manual therapy
  • Only about spinal conditions

I will address each of these issues point by point to more accurately portray what MDT is:

MDT is not a series of exercises: Although some exercises are common, MDT is an assessment process and problem solving paradigm. One takes clues from the history about the effects of specific loading strategies on one’s symptoms. At the history, the therapist begins to formulate a differential diagnosis. First, is it a problem with a mechanical influence, a medical influence, a biopsychosocial influence or any combination of the above? Second, if mechanical, which of the syndromes are likely at play: derangement, dysfunction, posture or “other?” Then, the examination includes a series of loading strategies to confirm or refute the postulated diagnosis.

imageMDT is not only about derangement: Although found widely, derangement syndrome is not the holy grail of MDT. Muscular or articular restrictions (dysfunctions) and postural syndromes are part of the “main” three mechanical syndromes. However, stenosis, chronic pain state (i.e., centrally/periperhally sensitized pain), SIJ dysfunctions, s/p traumatic states, etc. are all recognized by MDT clinicians.

MDT is not just extension: Although a common treatment recommendation, all planes of movement can be considered in both the assessment and treatment recommendations.

MDT is not just about repeated end range movements: static positioning and mid range movements are all part of the spectrum of force progressions.

MDT is not just about the intervertebral disc: Although it serves as one model of joint derangement, other postulated mechanisms are frequently discussed including: joint inclusions, fat pads, loose bodies, capsular impingements, etc for both the spine and peripheral joints as applicable.

MDT does not ignore biopsychosocial influences: Although a positive mechanical response (such as centralization) can sometimes trump “yellow flag” indicators, fear avoidance behaviors and other biopsychosocial influences are always considered and dealt with by education and graded exposure to movement where necessary.

MDT does not exclude manual therapy: Although we take a “hands off” approach first, mobilization and manipulation are all part of the continuum of force progressions. We focus primarily on education and self directed treatments first in order to reduce dependency and empower the patient to control their symptoms; however, sometimes patients are not successful in reducing their own pain in the initial stages. It is at this time we consider the use of our hands. However, use our hands in order to foster greater success of the patient treating themselves. We put our hands on, only to take them off again.

MDT is not just about the spine: The concepts of assessment and classification can be applied to the peripheral joints as well.

As a brief summary, MDT is a classification system. It seeks to differentiate between mechanical and non-mechanical influences of pain and functional limitation by using mechanical loading strategies and assessing both the patient’s subjective response and any mechanical changes.

The main 3 mechanical syndromes are derangement, dysfunction and postural syndromes.

Although the intervertebral disc serves as one model for mechanical influences of spinal pain, other influences are recognized. MDT focuses on patient education and empowerment in order to promote self directed treatment, reduce fear, and promote function.  In part 2 of this series, we will describe the syndromes in more detail and offer “Pearls of Wisdom.”

 

imageThanks Christie, great post!  One thing that I wanted to also mention was a book that you can read for more information, Rapidly Reversible Low Back Pain.  The book has been discussed here in the past, is a quick read, and I think is pretty cheap (~$10) on Amazon.  I thought it did a good job talking about MDT, including it’s origin.  My favorite story was the discovery of extension exercises for low back pain, check it out if haven’t already.

Have you heard these misconceptions? Did this post surprise you? What other questions do you have about what MDT is?

 

imageChristie Downing, PT, DPT, Dip. MDT, ICLM  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.

 

Photo credit toyourhealth

15 replies
  1. Phil
    Phil says:

    The main issue behind the method for me is that it does nothing to address a fifteen level fusion and someone who has titanium rods. Also I don’t pay people to watch me workout. I can look these exercises up on YouTube or any place. I’ve been to physical therapy ten times. The only method that was helpful was myofascial release. Which hardly anyone practices because it means you can’t have three people per therapist in your office. You actually have to focus on one person at a time which means less profit.

  2. anonymous2
    anonymous2 says:

    I have been to a pt clinic that uses the McKenzie method, for various issues after having been to a couple of traditional clinics that only made my problems worse. I can say hands down that this method is the only reasonable method and makes scientific sense. Each time, I felt batter after just one session and regained full function. I thank God for it, cus I wouldn’t be typing this right now if it hadn’t been for this method. Clinicians can talk back and forth and argue, whatever, it works.

  3. Rick Gustaitis, PT, Dip MDT
    Rick Gustaitis, PT, Dip MDT says:

    Interesting thread. While working in a clinic in WA we used hand held dynomometers to assess strength in our evaluations and assessments. I was surprised how many times I assessed a patient with joint pain in the hip, knee or shoulder and after performing repeated movements to rule out a derangement the strength was restored to full and equal to opposite limb. Also any poor movement patterns and substitution patterns dissappeared. This happened on a consistent basis.

    I use the MDT assessment of peripheral joints with nearly every patient and often including a post op patient with high success rate.

    What it might come down to is experience. If you use MDT on a consistent basis and trust the system it WILL work. If you simply use it as one of your "tools" and blend it with other techniques then the results will vary.

    MDT is a reliable assessment tool. It will assist with classification of a patient. If a patient is classified as a contractile dysfunction for example then strengthening is clearly indicated and that is spelled out in the McKnezie Extemities textbook and is being taught in the MDT courses.

    • Dan
      Dan says:

      The literature supporting MDT is not great. I see many clinicians hanging their hat on mainly anecdotal evidence and a few case studies. When it comes to LBP management the Delitto group from Pitt and newer studies from other groups at Pitt and Delaware should be the gold standard in LBP treatment. Also, the best data for the lumbopelvic manipulation and manuals is in the acute phase. Based on this data, why would it be a last resort? Also, a lot of these misconceptions exist because there are MDT trained PTs out there that think they can move the disc in a certain direction with repeated extensions. Show me one study that will support this claim. Moreover, there are PTs who rely solely on extension and will NOT assess flexion, R translocations or L translocations to determine a pattern of centralization. Please explain this to me.

  4. Anonymous
    Anonymous says:

    Dr. Seth- thank you for your response.
    As you have put it: "Optimal function is the end goal of all of our treatments" and there is no doubt about it. You're absolutly right.
    There are many different ways to help the patient to get it. And I strongly believe that repetitive motion is the key. If the patient is flexion, extension, or other plane biased I will encourage him/her to perform that at home to make the treatment extended far from the clinic, if he/she requires just posture correction is going be the same. I will not be concerned with hyper or hypo mobility on L L5 or on R L4 and stiffness of thorax perceived by my fingertips as long as these are not relevant with Pt's symptoms. First of all I would like to repeat after McKenzie and May that:" pain response is a more reliable indicator that perceptions of stiffness( Matayas and Bach 1985; Maher and Adams 1992, 1994). Going even further:" Increased stiffness may in fact be a normal variant and bear no relationship to the patient's presenting symptoms"( Maher and Adams 1992,p.259)"
    Talking about Mulligan, you are also right about this hip flexion with straight knee, but you have noticed too that it is repetitive motion with distraction or compression if you like, and the same, this is based on directional preference because there is guide: NO PAIN. Furthermore, Pts are encouraged to do at home as well as a simple repetitive motion. What Mulligan says about the efficacy (if it works) of the technique for tight hamstring is:" This leads me to believe that the tightness is in other structures causing the hamstring's to be ureasonably and prematurely stretched".(Self Treatment for back, neck and limbs, Brian Mulligan).
    Again, Mulligan as McKenzie cocentrate on symptomes and mechanical response with their therapeutic approach which is much safer than statement that, one address certain muscle or joint, relying on his/her palpatory skill.
    Going further, how do you want Dr.Seth to teach Pts to selectively activate the local stabilizers for example, if they have problems with proper execution of transfer to sit to stand while keeping their back straight, even if this give them relieve with LBP?
    Dr Seth with all due respect, going to deep to find more might be as fruitless as pursuing an answer for question: how many angels can dance on the head of a pin? There is no practical value of such an endevour. As a therapist I try to assist with natural healing process, to facilitate the function with as simple as possible instruction for the Pts, and using my hands only if they are needed to change the symptoms or improve the impaired function, to encurage the Pts further to move. Keeping simple with the therapy i.e. one or two exercises repeated as intended makes life easier for the Pt and the PT. If it is worse as a consequence of doing them just to stop it. If it is better it is clear what motion has done it. The same will follow mobilizations based not on the subjective assessment of texture, hypomobility, or hypermobility but just concentrating on symptoms or comparable signs like from Maitland approach. Tangible, practical and logic. Moreover, much more reproducible by other trained therapists who can continue outlined treatment unless it is time for modification to finally lead the Pt to regain: Optimal function as you Dr.Seth beautifully said.

  5. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    Seth:

    Regarding "pure inhibition will agreeably reverse itself…but it's not guaranteed", I say you are correct. This is a purpose of recovery of function. To put it simpler, think of patients who have PF weakness after an L-5/S-1 protrusion. Many times, once the pain and motion of the L-spine have been resolved (ie, the derangement is resolved), some residual weakness may persist. This is based on a number of factors. In cases such as these, we need to address that. I'm really over simplifying here, but my point is that recovery of function is not just about repeated end range motions. Recovery of function can be accomplished in a variety of ways. It depends on what the patient requires….which supports your statement that "nobody does a perfect job of describing spinal stability exercises." However, here, I'm talking about much more than that…neurodynamics, addressing fear avoidance, etc. These are ALL things that could possibly be addressed in recovery of function stage. Yet, if you are not looking for and addressing derangement, you are missing a big piece of the puzzle…and sometimes the simplest solution. If derangement doesn't exist, fine, move on.

    Your comment about "I fail to see how a series of directional movements can/will improve a motor program" makes me realize that it's still common for therapists to fall into the trap of thinking that repeated end range motions is MDT. Don't fall into that trap! Remember, MDT is an ASSESSMENT process. Repeated end range motions are generally only appropriate for derangement syndrome and articular dysfunction syndrome (each for different reasons). For those with other classifications: posture syndrome or "other" (which can include centrally mediated pain state, neuromuscular instability, etc), repeated end range motions are certainly of little value. However, it's the repeated motion TESTING that allows you to first exclude the derangement or dysfunction. You can then further classify to determine the most appropriate treatment…whatever that is. This is the beauty of the system.

  6. Dr. Seth Burke
    Dr. Seth Burke says:

    Christie- Just a few thoughts after looking at your response;

    Optimal function is the end goal of all of our treatments. I fail to see how a series of directional movements can/will improve a set motor program. The firing sequence, timing, and relative contributions from various muscles that induce a movement need to be examined and if necessary modified. Pure inhibition will agreeably reverse itself when the SIJ (glut max) or lumbar disc (TA, mult, PF) are corrected, but it's not guaranteed!!

    Anonymous- It really depends on the level of the spine that you're treating. Facilitation and inhibition are tricky subjects to approach, but HS tightness is not a universal indicator of how the CNS or the spine for that matter is behaving. Mulligan can distract the hip, cycle a few SLR's and blammo you have 20 more deg of SLR. No spinal movement needed.
    And what to do if you have a L L5 hypo mobility, a R L4 hypermobility with a stiff T-spine?!!

    I think the deeper you go, the more you find. Sahrmann's directional susceptibility to movement (DSM) reveals how people "tend" to move given their unique body type, postures, and stresses. It's not "cook book" treatment at all. BUT…she fails to analyze the joint glides, TpS, etc. NAIOMT examines the glides, but doesn't examine any soft tissue textures, etc. NOBODY does a perfect job of describing spinal stability exercises. I find that an eclectic grab bag of all these techniques works the best. I decide how much weight to give each segment (no pun intended) and proceed from there……but I digress…..

  7. Anonymous
    Anonymous says:

    Hi guys, just my 2 cents. Talking about issue of neuromuscular imbalance,flexibility which are not adequately address in McKenzie approach.It just happened to me recently, that treating a guy with central symmetrical back pain and bilateral hamstring tightness,after one or two sets of 10 reps extension in lying the SLR increased 15 degrees roughly. I often use this technique even if I deal with hamstring tightness alone to see if the extension might be helpful, and it is. I noticed that it is a regular pattern. So then, intentionaly or not MDT address this problem as well. Furthermore, increased strenght or normalized deept tendon reflexes after series of certain directional consistent motions, often shows that we influence the neuromuscular imbalances too, even without using intricate evaluations based on palpation and observation mostly, from other therapeutic approaches such as from: kinetic control and Mark Comerford, Stuart McGill, Shirley Sahrmann, Gwendolen Jull and other greats.

  8. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    Hi everyone! Thanks for the comments so far.

    The topic of neuromuscular re-education and flexibility always comes up in discussion…especially for those with limited exposure to MDT. I'll try to sum up my thoughts as swiftly as possible.

    A. Strength, neuromuscular function and flexibility ARE important and need to be addressed during "recovery of function" if, indeed, function remains limited after the derangement is stable. Anecdotally, many patients who have resolveable derangements return to function well once their pain subsides. In these cases, I would presume that inhibition was the result of the pain and not the cause. For others, it certainly needs to be addressed.
    B. These issues are not addressed at MDT courses specifically. The focus of the MDT courses is to learn how to implement the problem solving strategy and not specifically on how best to induce neuromuscular reeducation. There are plenty of people who research and promote this outside MDT. The beauty is, these techniques can be used with MDT where needed during the recovery of function phase.
    C. The issue of nueromuscular education is debated even amongst MDT trained therapists. Anyone who visits the MDT list serve will see this topic come up frequently…it's certainly not "ignored."

    Douglas, you've got the right idea…in derangement syndrome, indeed, where directional preference exists, the very deficits you discuss are often rapidly reversible.

  9. Douglas R. Krebs D. C. FACO
    Douglas R. Krebs D. C. FACO says:

    Seth,

    I agree with you that MDT classically does not mention muscle length, strength or movement re-education. But I have been continually surprised that once I have identified a directional preference how quickly perceived weakness, poor movement patterns and/or muscle lengths disappeared.

  10. Dr. Seth Burke
    Dr. Seth Burke says:

    I took level 1 in MDT, and have the big books by McKenzie, but rarely use it as a "stand alone." Muscle length and strength is largely ignored, movement re-education is not mentioned, and important factors such as breathing are again suppressed. Nothing against it because some techniques do work well though. As always, just a piece of the puzzle.

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