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Original article

MCKenzie classication of mechanical spinal pain: Prole of syndromes and directions of preference
Cheryl Hefford
New Zealand Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand Received 14 October 2005; received in revised form 16 August 2006; accepted 30 August 2006

Abstract The purpose of this study was to develop a prole of the use of McKenzie classications of diagnosis and treatment, by physiotherapists credentialed in the McKenzie method in New Zealand. This system has been in common use for more than 20 years and the inter-rater reliability of the assessment has been previously established for therapists at this level of training. Prior studies identifying the classication of patients according to syndrome and directional preference have been mainly for the lumbar spine. The 34 participants for this study each assessed and classied 10 consecutive spinal patients during a 10-week period. Of the 340 patients assessed, 19 were excluded. Of those with pain arising from the lumbar spine; 140/187 were classied as reducible derangement syndrome, 11/187 were classied as irreducible derangement, 11/187 as dysfunction syndrome, 1/187 as posture syndrome and 24/187 as other. For treatment in the reducible derangement syndrome; 98/140 were given extension, 8/140 were given exion and 34/140 were given lateral movements of either side gliding or rotation. Classications and treatment for the cervical and thoracic spine groups followed similar patterns. These ndings add to the external validity of the McKenzie method, and support mechanical evaluation of spinal patients according to directional preference. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Back pain; Mechanical classication; Directional preference

1. Introduction In the absence of conclusive evidence for effective treatment of low back pain, researchers and clinicians have been moving towards identifying subgroups of patients in order to improve the effectiveness of specic treatments (McKenzie, 1981; Delitto et al., 1995; Wilson et al., 1999; Fritz and George, 2000; Maluf et al., 2000; Fritz et al., 2003; Kent and Keating, 2004). Several classication systems have been described for back and neck pain (McKenzie, 1981, 1990; Spitzer et al., 1987; Delitto et al., 1995; Petersen et al., 1999; Fritz and George, 2000; Maluf et al., 2000; McKenzie and May, 2003; Petersen et al., 2003; Sterling, 2004). Because of the lack of agreement over a tissue-specic diagnosis for
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E-mail address: cheryl.hefford@otago.ac.nz. 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.08.005

low back pain, the Quebec Task Force in 1987 recommended classifying patients according to symptom distribution and the existence or extent of radiating symptoms (Spitzer et al., 1987). While this was an acknowledgement of the difculty of diagnosis of nonspecic low back pain, it did not address possible management options. Kent and Keating (2004) found that primary care clinicians in Australia commonly assign non-specic low back pain patients into some kind of subgroup which determines their management. However, there is no agreement among the clinicians on an acceptable classication system. Mechanical classication in the McKenzie system of mechanical diagnosis and therapys (MDT) was rst described in 1981(McKenzie, 1981) and continues to be in common usage in the USA, UK and New Zealand (Sullivan et al., 1996; Jackson, 2001; Gracey et al., 2002; Reid et al., 2002). It involves the assessment and

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2 C. Hefford / Manual Therapy ] (]]]]) ]]]]]]

classication of patients into one of three mechanical syndromes (or as other), according to the symptomatic and mechanical response to repeated movements and sustained positions. Brief denitions of the three mechanical syndromes (posture, dysfunction or derangement (reducible or irreducible)), and other are given below and described fully elsewhere (McKenzie, 1981, 1990; McKenzie and May, 2003): 1. Posture syndrome pertains to pain arising as a result of mechanical deformation of normal soft tissues from prolonged end range loading of periarticular structures. The treatment principle for posture syndrome is posture correction. 2. Dysfunction syndrome pertains to pain occurring as a result of mechanical deformation of structurally impaired tissues (such as tissue which is scarred, adhered or adaptively shortened). The treatment principle for dysfunction syndrome is to exercise into the direction of the dysfunction with the aim of remodelling the tissue. 3. Derangement syndrome pertains to pain occurring as a result of a disturbance in the normal resting position of the affected joint surfaces. Derangement may be reducible or irreducible. The treatment principle for derangement syndrome depends on the clinically induced directional preference, identied by examining the patients symptomatic and mechanical response to repeated movements or sustained positions. An irreducible derangement ts the history criteria for derangement but no loading strategy is able to produce a lasting change on the symptoms. In the MDT system, this is conceptually thought to concern an incompetent or ruptured outer annular wall of the intervertebral disc. A reducible derangement typically demonstrates one direction of repeated movement (directional preference) which decreases or centralizes (moves towards the midline) referred symptoms, or abolishes midline symptoms (Long et al., 2004), and the opposite repeated movement which produces or increases or peripheralizes (moves more distally) the symptoms. In the lumbar spine, movements typically include exion in lying or standing; extension in lying or standing; and lateral movements of either side gliding or rotation. Similar principles of repeated movement testing and treatment are applied in the cervical and thoracic spines. They are standard movements in the MDT system and are described fully in the text books (McKenzie, 1981, 1990; McKenzie and May, 2003). 4. Other is used to describe those who do not t with the mechanical syndromes but who exhibit signs and symptoms of other known pathology such as spinal stenosis, hip disorders, sacroiliac disorders, low back pain in pregnancy, zygapophyseal disorders, spondylolysis and spondylolisthesis, and post-surgical problems. The system has demonstrated strong inter-rater reliability amongst physiotherapists trained in the

McKenzie method (k values from 0.79 to 1.0) (Werneke et al., 1999; Fritz et al., 2000; Razmjou et al., 2000; Kilpikoski et al., 2002; Clare et al., 2004, 2005). For the identication of derangement syndrome, there is good to excellent inter-rater reliability (k values 0.7 and 0.96) (Razmjou et al., 2000; Kilpikoski et al., 2002). In one study, the inter-rater reliability for identifying directional preference was reported as excellent (90% agreement, k 0.9) (Kilpikoski et al., 2002). There has been a large amount of research into the clinical ndings of centralization and directional preference, which are major aspects of MDT (Donelson et al., 1990, 1991; Long, 1995; Werneke et al., 1999; Werneke and Hart, 2001, 2003; Aina et al., 2004; Long et al., 2004). According to Clare et al. (2005), ve studies have looked at the reliability of MDT classication and have included prevalence of the syndromes (Kilby et al., 1990; Riddle and Rothstein, 1993; Razmjou et al., 2000; Kilpikoski et al., 2002; Clare et al., 2005); most of these studies have concentrated on the lumbar spine. The primary aim of this study was to establish how many of the patients with mechanical cervical, lumbar and thoracic pain were classied into each of the syndromes by specically trained clinicians (MDT credentialed) in New Zealand clinical settings. The secondary aim was to determine, within the reducible derangement syndrome, the proportion of patients in each symptom distribution category and their given treatment direction (directional preference). It was hoped that comparing these ndings with previous studies would further validate the MDT classication system. 2. Method A survey was undertaken of all the MDT credentialed physiotherapists1 who were McKenzie Institute New Zealand Branch members in July 2004 (N 50). Packs containing instructions, information sheets, consent forms, and data sheets were distributed to all members. They were all physiotherapists thought to be working in musculoskeletal outpatient settings, either in private practice (N 47) or at a public hospital (N 3). Of these 50 potentially eligible for the study, two were unable to be contacted (no response to post, email or phone) and nine were unable to participate due to external factors such as not currently seeing patients, being overseas or working in an inappropriate environment. This meant the number conrmed eligible for the study was 39. Thirty-four of the 39 eligible physiotherapists (87%) returned completed data sheets with details of 10 consecutive patients with spinal pain presenting in
1 MDT credentialed physiotherapists have completed the McKenzie Institute International education programme of a minimum of 98 h and passed a standardized examination at the conclusion of this.

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C. Hefford / Manual Therapy ] (]]]]) ]]]]]] Table 1 Data collection form Start date: Case/consent Gender/age Eg. M/56 Area Syndrome classication (tick the box) Finish date: Derangement symptom location (tick one if appropriate) Primary principle of treatment Extension Flexion Lateral 3

1O

Lumbar Cervical Thoracic

Reducible derangement Irreducible derangement Dysfunction Posture Other

Central symmetrical Unilateral asymmetrical symptoms to knee/elbow Unilateral asymmetrical to below knee/elbow

their normal clinic situation (a total of 340 patients). Patients were excluded if they failed to give consent or if they were under age 18. Data were collected over a 10-week time frame. The University of Otago Human Ethics Committee granted ethics approval for the study (Ref. 04/096). Data were collected at the initial assessment, according to the form shown in Table 1. Once therapists had completed their data sheets on 10 consecutive patients, details were posted to the author who collated the results using the Epi InfoTM (http://www.cdc.gov/ epiinfo/) epidemiological database. The participating physiotherapists were mainly older experienced physiotherapists (88% aged between 30 and 59 years), qualied for an average of 22 years (SD 9.2) and MDT credentialed for an average of 6.2 years (SD 3.6). All but two practised in a musculoskeletal private practice setting with an even mix of large city, small city and rural town practice. In their clinics, 24% of therapists stated that they saw predominantly acute and sub acute patients and 76% said they saw a mix of acute and chronic patients; no one stated they saw predominantly chronic patients. The mean data collection period was 22.8 days (SD 17.8). Of the 340 consecutive patients, 19 were excluded from the study: nine were under the age specied (18 years), and 10 did not give consent. No data was collected from the ten who denied consent (a line was drawn through the data sheet). The survey was, therefore, based upon the details of 321 patients from 34 physiotherapists; data are presented descriptively.

Symptom location patterns of the reducible derangement group, for each spinal area, are shown in Fig. 1. A clear pattern emerged across all areas with the biggest group being the asymmetrical group (above the elbow in the cervical and above the knee in the lumbar areas). The second largest group was the central or symmetrical distribution of symptoms. The smallest groups contained those with the most distal symptoms. The treatment principles given to the reducible derangement group, for each spinal area, are shown in Table 3. Extension was consistently the most common treatment principle across all spinal areas and exion the least common. The treatment principle for each symptom location pattern within the reducible derangement group for each spinal area is also shown in Table 3. When symptoms were central or symmetrical, the extension treatment principle was most commonly used; when symptoms were unilateral or asymmetrical, lateral treatment principles were used (although, even then extension principle was the most commonly used).

4. Discussion For this survey, it was found that of 321 patients assessed by 34 credentialed therapists, 92% of patients were classied into one of the three mechanical syndromes, with more than 80% classied as derangement. The classication of patients into the MDT syndromes in this survey is consistent with previously published data from other countries (Kilby et al., 1990; Riddle and Rothstein, 1993; Razmjou et al., 2000; Kilpikoski et al., 2002; Long et al., 2004; Clare et al., 2005). The mean percentage of patients classied as derangement by these authors was 71.6%. In this study, 77.9% were classied as reducible derangement syndrome (Table 4). The treatment principle given, according to directional preference, for the majority of patients classied

3. Results Demographic data and classication of the 321 patients into the syndromes is shown for each of the lumbar, cervical and thoracic areas (Table 2). Reducible derangement was found to be the largest group in all three areas.

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4 C. Hefford / Manual Therapy ] (]]]]) ]]]]]] Table 2 Demographic data and Syndrome Classication for each spinal area Cervical Mean age Gender Male Female Syndrome Posture Dysfunction Reducible derangement Irreducible derangement Other Total 43.9 42 (38%) 69 (62%) 3 (2.7%) 9 (8.1%) 90 (81.1%) 1 (0.9%) 8 (7.2%) 111 Lumbar 46.7 102 (55%) 85 (45%) 1 (0.5%) 11 (5.9%) 140 (74.9%) 11 (5.9%) 24 (12.8%) 187 Thoracic 40.5 12 (52%) 11 (48%) 0 (0%) 2 (8.7%) 20 (87.0%) 0 (0%) 1 (4.3%) 23 Combined areas 45.27 (SD 16.3) % of total 156 (49%) 165 (51%) %of total 4 (1.3%) 22 (6.9%) 250 (77.9%) 12 (3.7%) 33 (10.3%) 321 (100%)

patient numbers

80 60 40 20 0
37%

45%

63%

18%

20%

25% 30%

70%

Lumbar Central Symmetrical

Cervical

Thoracic

Unilateral or asymmetrical above the elbow / knee Unilateral or asymmetrical below the elbow / knee
Fig. 1. Symptom location patterns in the reducible derangement syndrome.

as derangement syndrome, was extension. However, it is important to note the smaller, yet highly relevant, number of patients who responded to lateral and exion movements. For the lumbar spine, the number of exion responders in this audit is consistent with what has been reported previously. A randomized controlled trial (RCT) that classied lumbar spine patients prior to randomization identied 74% with a directional preference, of which 83% were extension responders, 7% were exion responders and 10% were lateral responders (Long et al., 2004). A previous study that looked only at sagittal movements in the lumbar spine (did not include lateral movements in the assessment) found that 47% demonstrated a directional preference for either exion (7%) or extension (40%) (Donelson et al., 1991). In a study looking at both back and neck pain 77% demonstrated a directional preference (centralized or partial reduction) after multiple visits (o7 visits over a 23 week time frame) (Werneke and Hart, 2003). A recent systematic review of 14 studies on centralization found that on assessment, 70% of acute and sub-acute back pain patients, and 52% of chronic back pain patients demonstrated centralization. This occurred most commonly with extension exercises

or postures but also with other loading strategies (Aina et al., 2004). Although outcomes as a result of classication and treatment direction were not addressed in this study, a recent RCT study showed that giving the wrong direction of exercises to low back pain patients can lead to poorer outcomes (Long et al., 2004). Most of the research into MDT has been on the lumbar spine, even though the system has always included the cervical and thoracic spines (McKenzie, 1990). No studies have previously looked at MDT for the thoracic spine. The incidence of patients presenting for thoracic spine pain was small compared to those presenting with lumbar and cervical spine pain and it would be interesting to see how this might compare with studies done in other countries. In New Zealand, because of the size of the country and the wide geographical location of the participants in this study, there was a unique opportunity to get a broad cross section of the patient community. The demographics of the participants and distribution of patients was over a range of city and rural practices, with a mix of acute and chronic patients. In the MDT system, classication is used to guide treatment. For the reducible derangement syndrome, the directional preference becomes the treatment principle. The viability of the system depends on the consistent interpretation of the classications and treatment directions. The clinical relevance of this study is that it conrms previous work on the numbers of spinal patients classied into the MDT syndromes. It adds to previous work by detailing commonly encountered specic treatment directions for spinal patients according to their differing referral patterns of pain. These consistent ndings add to the stability of the MDT system and may be useful for future research designs into the prognostic and therapeutic outcomes of the specic classication groups.

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C. Hefford / Manual Therapy ] (]]]]) ]]]]]] Table 3 Treatment principles for the reducible derangement syndrome according to symptom distribution Extension Flexion Lateral movements (side bending and/or rotation) 5

Lumbar Central or symmetrical Unilateral or asymmetrical above the knee Unilateral or asymmetrical below the knee Total treatment directions for lumbar Cervical Central or symmetrical Unilateral or asymmetrical above the elbow Unilateral or asymmetrical below the elbow Total treatment directions for Cervical Thoracic Central or symmetrical Unilateral or asymmetrical Total treatment directions for Thoracic

48 (92%) 36 (57%) 14 (56%) 98 (70%) 17 (94%) 36 (63%) 12 (80%) 65 (72%) 5 (83%) 12 (86%) 17 (85%)

3 (6%) 4 (6%) 1 (4%) 8 (6%) 1 (6%) 7 (12%) 0 (0%) 8 (9%) 0 (0%) 0 (0%) 0 (0%)

1 (2%) 238 (37%) 10 (40%) 34 (24%) 0 (0%) 14 (25%) 3 (20%) 17 (19%) 1 (17%) 2 (14%) 3 (15%)

Table 4 Adapted from Clare et al (2005), Prevalence of syndromes Reference Kilby et al. (1990) (lumbar) Riddle and Rothstein (1993) (lumbar) Razmjou et al. (2000) (lumbar) Kilpikoski et al. (2002) (lumbar) Clare et al. (2005) (lumbar and cervical) This study Hefford (lumbar, cervical and thoracic) No. of patients 41 363 45 39 50 321 % Derangement 42.7 52.9 86.7 90 86 77.9 (reducible derangement) 3.7 (irreducible derangement) % Dysfunction 22 34.7 4.4 2 2 6.8 % Postural 2.4 9.6 2.2 Nil Nil 1.3 % Other 32.9 2.8 6.7 8 12 10.3

5. Limitations This study has only accounted for classications according to the rst assessment session for each patient. It has been shown that in some cases, classication may be better judged over several visits (Werneke and Hart, 2003). This is a descriptive study of classication at initial assessment; outcomes from the treatment have not been addressed. However, many studies have reported the prognostic and therapeutic outcomes of treatment utilising movements of directional preference (Kopp et al., 1986; Donelson et al., 1990, 1997; Long, 1995; Sufka et al., 1998; Werneke et al., 1999; Udermann et al., 2004). The data was not completely independent in that each therapist collected data on 10 consecutive spinal patients. It is possible that the previous patients they had assessed and treated could have inuenced their judgement. The strengthening reporting of observational studies in epidemiology (STROBE) guidelines (www.strobe-statement.org/PDF/STROBE-Checklist-Version3.pdf) suggest

discussion of the direction and magnitude of such potential bias, but this is unknown.

6. Conclusion In a survey of 50 New Zealand physiotherapists trained in the MDT system; out of 39 potential and contactable therapists 34 provided classication details regarding 10 consecutive spinal patients. The therapists worked in an even mix of rural and urban physiotherapy practices across the length of New Zealand. Mechanical syndromes as described by McKenzie were used for classication purposes, with the largest single category being reducible derangement. Most commonly the extension treatment principle was used; but exion and lateral forces were used also, with the latter more often in the presence of referred symptoms. This is one of very few studies which include the cervical spine, and the rst to include classication and treatment of the thoracic spine, even though it was described by McKenzie in 1990. More research is required to

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6 C. Hefford / Manual Therapy ] (]]]]) ]]]]]] reliability and short-term treatment outcomes. Spine 2000;25(1): 10614. Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in northern Ireland. Spine 2002;27(4):40611. Jackson DA. How is low back pain managed? Retrospective study of the rst 200 patients with low back pain referred to a newly established community-based physiotherapy department. Physiotherapy 2001;87(11):57381. Kent P, Keating J. Do primary-care clinicians think that nonspecic low back pain is one condition? Spine 2004;29(9):102231. Kilby J, Stigant M, Roberts A. The reliability of back pain assessment by physiotherapists, using a McKenzie algorithm. Physiotherapy 1990;76(9):57983. Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 2002;27(8):E20714. Kopp JR, Alexander AH, Turocy RH, Levrini MG, Lichtman DM. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. A preliminary report. Clinical Orthopaedics and Related Research 1986;202: 2118. Long A. The centralization phenomenon. Its usefulness as a predictor or outcome in conservative treatment of chronic law back pain (a pilot study). Spine 1995;20(23):251320 discussion 2521. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 2004;29(23):2593602. Maluf KS, Sahrmann SA, Van Dillen LR. Use of a classication system to guide nonsurgical management of a patient with chronic low back pain. Physical Therapy 2000;80(11):1097111. McKenzie R. Mechanical diagnosis and therapy of the lumbar spine, 1st ed. Waikanae, New Zealand: Spinal Publications Ltd.; 1981. McKenzie R. Mechanical diagnosis and therapy of the cervical and thoracic spine. Waikanae, New Zealand: Spinal Publications Ltd.; 1990. McKenzie R, May S. The lumbar spine mechanical diagnosis and therapy. 2nd ed. Waikanae, New Zealand: Spinal Publications Ltd.,; 2003. Petersen T, Laslett M, Thorsen H, Manniche C, Ekdahl C, Jacobsen S. Diagnostic classication of non-specic low back pain. A new system integrating patho-anatomic and clinical categories. PhysiotherapyTheory Research and Practice 2003;19(4):21337. Petersen T, Thorsen H, Manniche C, Ekdahl C. Classication of nonspecic low back pain: a review of the literature on classications systems relevant to physiotherapy. Physical Therapy Reviews 1999;4(4):26581. Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical lowback pain. Journal of Orthopedic and Sports Physical Therapy 2000;30(7):36883 discussion 384369. Reid D, Hing W, McNair P, Larmer P, Robb G. Managing an acute lumbar spine condition: the ndings of a vignette. In: Paper presented at the New Zealand Manipulative Physiotherapists Association biennial conference, Rotorua, New Zealand; 2002. Riddle DL, Rothstein JM. Intertester reliability of McKenzies classications of the syndrome types present in patients with low back pain. Spine 1993;18(10):133344. Spitzer W, LeBlanc F, Dupuis M. Scientic approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on spinal disorders. Spine 1987;12(7 Suppl):S1S59. Sterling M. A proposed new classication system for whiplash associated disordersimplications for assessment and management. Manual Therapy 2004;9(2):6070.

validate these ndings as thoracic spinal pain numbers are small. The study adds to the growing body of evidence supporting the external validity of McKenzies mechanical syndromes. It conrms baseline ndings of other studies and provides new ndings about the prole of classications into syndromes for all areas and the directional preference ndings for the cervical and thoracic spine. These baselines are useful for both clinicians and researchers. It also supports the need for mechanical evaluation and subdivision of spinal patients according to directional preference.

Acknowledgements The author would like to thank the following: The McKenzie Institute New Zealand Branch Credentialed therapists, for their participation and encouragement in this project. Mr Stephen May, Dr Ron Donelson, Professor David Baxter and Professor S. John Sullivan for critical revision of drafts of this manuscript.

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