The McKenzie Method
aka   Directional Preference Therapy
or   Mechanical Diagnosis and Therapy (MDT)

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

The McKenzie Method (aka Directional Preference Therapy or Mechanical Diagnosis and Therapy) is grounded in finding a cause and effect relationship between the positions a patient usually assumes while sitting, standing, or moving, and the generation of pain as a result of those positions or activities. The therapeutic approach requires a patient to move through a series of activities and test movements to gauge the patient's pain response. The approach then uses that information to develop an exercise protocol designed to centralize or alleviate the pain.

	Low Back Pain and Chiropractic Page A Chiro.Org article collection Millions of patients love their chiropractor and appreciate our unique and safe approach to recovery from pain. Significant research suggests that chiropractic is the safest approach available for relief from neck pain, back pain, headaches and other “musculo–skeletal” complaints. Lets review that research, and discuss how modern medicine has contributed to the Myth that chiropractic care is dangerous.
	Chronic Neck Pain and Chiropractic Page A Chiro.Org article collection Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.
	Centralization and Directional Preference: An Updated Systematic Review with Synthesis of Previous Evidence Musculoskelet Sci Pract. 2018 (Dec); 38: 53–62 ~ FULL TEXT This review has synthesised literature from 62 previous studies, but also evaluated 43 additional studies. The importance of centralization and directional preference as prognostic factors is probably overwhelming; whether they indicate a particular management pathway is not clear. Centralization and directional preference are still very important clinical indicators to monitor during the taking of patients' history and physical examination. Although about a third of patients may demonstrate neither clinical response, they are still common and important prognostic indicators.
	Directional Preference and Functional Outcomes Among Subjects Classified at High Psychosocial Risk Using STarT Physiother Res Int. 2018 (Jul); 23 (3): e1711 ~ FULL TEXT High STarT risk patients (n = 138) completed intake surveys, that is, the lumbar FS of Focus On Therapeutic Outcomes, Inc., and STarT, and were evaluated for DP by physiotherapists credentialed in McKenzie methods. The FS measure of Focus On Therapeutic Outcomes, Inc., was repeated at discharge. DP and No-DP prevalence rates were calculated. Associations between first-visit DP and No-DP and change in FS were assessed using univariate and multivariate regression models controlling for 11 risk-adjusted variables.
	Factors in Patient Responsiveness to Directional Preference-Matched Treatment of Neck Pain With or Without Upper Extremity Radiation J Patient Cent Res Rev. 2017 (Apr 25); 4 (2): 60–68 ~ FULL TEXT Patient compliance with directional preference exercise is associated with patient responsiveness to directional preference therapy in conservative care treatments of neck pain. Patients 55 years of age or older, those with acute/subacute chronicity and those who report symptom improvement following the first treatment session showed significant improvement. Implementation of these findings could improve care of patients with neck pain, with or without upper extremity radiation, at a local level.
	Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging Journal of Chiropractic Medicine 2016 (Dec); 15 (4): 281–293 ~ FULL TEXT Spinal and SIJ pathology commonly refers to the posterior hip. [22, 23] Despite the difficulty in differentiating these anatomical structures through history and physical examination findings, several significant clinical features have been identified. Centralization of symptoms from repeated lumbar movements (McKenzie assessment) has high sensitivity and specificity for nerve root pain associated with symptomatic discs. [24] In the absence of centralization of posterior hip symptoms, 3 or more positive SIJ provocation tests have been shown to detect the presence of SIJ pathology and have a combined sensitivity of 91%, specificity of 78%, positive likelihood ratio of 4.12, and negative likelihood ratio of 0.12. [25, 26] The suggested composite testing of the SIJ includes the thigh thrust, distraction, compression, sacral thrust, and Gaenslen tests. [26] When the McKenzie assessment is completed to rule out discogenic referral, the diagnostic accuracy of this composite testing improves, with higher reported specificity (87%) and positive likelihood ratio (6.97). [26]
	Deconstructing Chronic Low Back Pain in the Older Adult - Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VIII: Lateral Hip and Thigh Pain Pain Medicine 2016 (Jul); 7 (1): 1249–1260 ~ FULL TEXT Contrary to lumbar radiculopathy, lumbar radiculitis describes nerve root irritation without objective findings of nerve root damage (i.e., weakness or reflexes changes). Patients may complain of altered sensation (i.e., pain or pins and needles), but electrodiagnostic testing is normal and therefore not a recommended part of the work-up for lumbar radiculitis. For patients with lumbar radiculitis, we recommend a longer trial of conservative management prior to considering referral because, unlike in radiculopathy, these patients are not at immediate risk of progressive, permanent neurologic damage. For first-line treatment of radiculitis, we recommend McKenzie physical therapy, which is a standardized approach to the assessment and management of radicular pain. Also called Mechanical Diagnosis and Therapy (MDT), in this method McKenzie-certified therapists help patients identify a “directional preference” of lumbar spine motion (i.e., extension, flexion, and/or side-bending) which helps reduce radicular pain, centralize the pain to the back, and minimize pain altogether. McKenzie therapy teaches simple exercises which the patient should perform several times throughout the day, and it does not emphasize passive modalities such as manual massage or manipulation. [38] Patients who respond well to McKenzie therapy are likely to be able achieve adequate pain relief without operative intervention. [39]
	Identifying Patients With Chronic Low Back Pain Who Respond Best to Mechanical Diagnosis and Therapy: Secondary Analysis of a Randomized Controlled Trial Phys Ther. 2016 (May); 96 (5): 623–630 ~ FULL TEXT Being older met our criteria for being a potentially important effect modifier; however, the effect occurred in the opposite direction to our hypothesis. Older people had 1.27 points more benefit in pain reduction from MDT (compared with Back School) than younger participants after 1 month of treatment.
	Association Between Centralization and Directional Preference and Functional and Pain Outcomes in Patients With Neck Pain J Orthop Sports Phys Ther. 2014 (Feb); 44 (2): 68–75 ~ FULL TEXT Directional preference (DP) is a prevalent evaluation category that, when combined with treatments consisting of matched exercises and manual techniques, can be used to predict changes in function, but not pain, in patients with neck pain.
	Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients with Acute Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study   NCT00632060 Spine (Phila Pa 1976). 2013 (Apr 15); 38 (8): 627–634 ~ FULL TEXT Participants in the group receiving CMT in addition to SMC were scheduled for up to 2 visits weekly with a doctor of chiropractic (DC) for a period of 4 weeks. The initial visit with the DC included a focused history and physical examination and diagnostic imaging as indicated. Treatments consisted of HVLA manipulation as the primary approach in all cases, with ancillary treatments at the doctor's discretion, including brief massage, the use of ice or heat in the lumbar area, stretching exercises, McKenzie exercises, advice on activities of daily living, postural/ergonomic advice; and mobilization. HVLA manipulation involves a single load or impulse "thrust" to body tissues. Patients were placed in a lateral recumbent or side-lying position with the superior or free hip and knee flexed and adducted across the midline. The chiropractor Stabilized the patient's free leg with his own leg while holding the patient's superior shoulder. The manipulative load was applied by using a pisiform contact on the patient's lumbar spine or sacroiliac joint while preventing motion of the patient through stabilizing holds on the shoulder and hip. The single impulse load, or thrust, was delivered by a quick, short controlled movement of the shoulder, arm, and hand combined with a slight body drop.
	Patients with Low Back Pain Differ From Those Who Also Have Leg Pain or Signs of Nerve Root Involvement - A Cross-sectional Study BMC Musculoskelet Disord. 2012 (Nov 28); 13: 236 ~ FULL TEXT Directional preference was recorded from the clinical examination and defined as being present if either centralisation or peripheralisation of pain occurred with tests of end-range movements or postures as described in the Mechanical Diagnosis and Therapy system by McKenzie. [15] Centralization has been defined as “the abolition of distal pain in response to the deliberate application of movements or postures. If pain is only in the back this is centralized and then abolished”. [35] Peripheralisation is the opposite pain response to movements or postures.
	Conservative Management of a 31 Year Old Male With Left Sided Low Back and Leg Pain: A Case Report J Can Chiropr Assoc. 2012 (Sep); 56 (3): 225-232 ~ FULL TEXT The plan of management included interferential current, soft tissue trigger point and myofascial therapy, lateral recumbent manual low velocity, low amplitude traction mobilizations and pelvic blocking as necessary. Home care included heat, icing, neural mobilizations, repeated extension exercises, stretching, core muscle strengthening, as well as the avoidance of prolonged sitting and using a low back support in his work chair. The patient responded well after the first visit and his leg and back pain were almost completely resolved by the third visit.
	The McKenzie Method Compared with Manipulation When Used Adjunctive to Information and Advice in Low Back Pain Patients Presenting with Centralization or Peripheralization: A Randomized Controlled Trial Spine (Phila Pa 1976) 2011 (Nov 15); 36 (24): 1999-2010 ~ FULL TEXT Given the promising preliminary results in the literature and the improvement rate achieved in both our treatment groups, a future research area would be to explore clinical findings that identify which patients respond better to the McKenzie method or manipulation in patients with acute, subacute, or chronic LBP. Furthermore it seems worthwhile to test the effects of a combination of the two treatments as suggested by the results of a series of case reports. [44]
	Application of a Diagnosis-Based Clinical Decision Guide in Patients with Neck Pain Chiropractic & Manual Therapies 2011 (Aug 27); 19 (1): 19 ~ FULL TEXT All examinations were carried out by one of two chiropractic physicians, one with over 20 years experience and the other with nine years experience, or by a physical therapist with over 10 years experience. All had a minimum of 50 hours of postgraduate training in the McKenzie method. The physical therapist also had 80 hours of postgraduate training in manual therapy. Several discussions between the examiners took place over the course of five years prior to commencing data gathering on the application of the DBCDG. This occurred in the form of monthly clinical meetings in which the application of the DBCDG in particular patients was discussed as well as recent developments in the literature related to the evaluation and management of patients with NP. History and examination were performed according to the usual course of patient care at the Rhode Island Spine Center. These data, along with patient demographic data, and data from standardized outcome measurement instruments were then entered on a spreadsheet by a chiropractic intern. The standardized outcome measurement instruments were those tools used in the normal course of patient care at the facility at which the study was conducted to measure improvement in pain and perceived disability. These instruments were the Bournemouth Disability Questionnaire (BDQ) [14, 15] and Numerical Rating Scale [16] for pain intensity.
	Nucleus Pulposus Deformation Following Application of Mechanical Diagnosis and Therapy: A Single Case Report with Magnetic Resonance Imaging J Man Manip Ther. 2010 (Sep); 18 (3): 153-158 ~ FULL TEXT The patient was managed with a 1-month course of the McKenzie management strategy treatment.   One month later, the displaced portion of the NP was no longer present and the left-shifted NP was centrally located.   These intervertebral disc changes coincided with centralization and abolition of symptoms. This case may support the conceptual model of MDT.
	The Comparative Prognostic Value of Directional Preference and Centralization: A Useful Tool for Front-line Clinicians? J Man Manip Ther. 2008; 16 (4): 248–254 ~ FULL TEXT Pain duration, leg pain intensity, work status, depression, and QTF anatomic pain location (back pain vs. Sciatica) were all weak predictors of outcome. Weak is used here in the sense that these variables did not hold up when weighed against the variables of baseline leg bothersomeness and subgroup matched treatment (DP/centralization with matched treatment). Subgroup matched treatment appears to be a useful tool for front-line clinicians and an important factor that dominates other variables, including depression. As the science of LBP subgroups evolves, it may be possible to shorten the list of prognostic variables to those most amenable to change and those most important in preventing long-term disability.
	Evidence-informed Management of Chronic Low Back Pain with the McKenzie Method Spine J. 2008 (Jan); 8 (1): 134-141 ~ FULL TEXT The McKenzie method has an important role to play in all patients with CLBP in terms of reliably classifying them into distinct, validated subgroups with distinctly different treatment needs. The reliability and prognostic validity of the assessment findings are well documented across multiple studies, along with more recent subgroup-specific RCTs showing the efficacy of classifying patients in this way. Subgroup classification of back pain and subgroup-specific management strategies appear to be a highly successful and objective way to improve the care of patients with CLBP, compared with the nonspecific, one-size-fits-all recommendations of most international guidelines to date.
	A Theoretical Model for the Development of a Diagnosis-based Clinical Decision Rule for the Management of Patients with Spinal Pain BMC Musculoskelet Disord. 2007 (Aug 3); 8: 75 ~ FULL TEXT Centralization signs are detected through methods originally developed by McKenzie [9,10]. The examination procedure involves moving the spine to end range in various directions and monitoring the mechanical and symptomatic response to these movements. Traditionally, the findings of this examination have been thought to identify the intervertebral disc as the source of pain, and some experimental evidence supports this [11–13], though further work in this area is needed. Nonetheless, the centralization sign has been demonstrated to be useful in prognosis [14] and in helping the clinician to make decisions regarding the best form of treatment for this particular aspect of the clinical picture [15].
	Reliability of McKenzie Classification of Patients with Cervical or Lumbar Pain J Manipulative Physiol Ther 2005 (Feb); 28 (2): 122–127 ~ FULL TEXT The reliability for syndrome classification was kappa = 0.84 with 96% agreement for the total patient pool, kappa = 1.0 with 100% agreement for lumbar patients, and kappa = 0.63 with 92% agreement for cervical patients. The McKenzie assessment performed by persons trained in the McKenzie method may allow for reliable classification of patients with lumbar and cervical pain.
	McKenzie Self-treatments for Sciatica   (PDF) Journal of Bodywork and Movement Therapies 2005; 9: 40–42 ~ FULL TEXT If your problem is worse with bending forward, after sitting, or in the morning, a few exercises originally developed, by a physical therapist Robin McKenzie from New Zealand, may also be helpful. The sphinx, cobra, and standing back extension (see Figs. 2–4). The sphinx and cobra can be performed a few times a day. Carry out 10–12 repetitions slowly. If it hurts in your low back, but not in your leg that is fine. If however, leg pain increases then stop the exercise. The standing back extension maneuvere can be performed a few times every 20 min when you have been sitting.
	The Effectiveness of Physical Modalities Among Patients with Low Back Pain randomized to Chiropractic Care: Findings from the UCLA Low Back Pain Study J Manipulative Physiol Ther. 2002 (Jan); 25 (1): 10–20 ~ FULL TEXT We are unaware of other randomized clinical trials (RCTs) that have compared chiropractic with and without physical modalities, although 4 RCTs comparing chiropractic care with physical therapy for LBP have been published. Outcomes from chiropractic and hospital outpatient (physiotherapy) care were clinically similar in the Meade et al trial, [33, 34] yet chiropractic patients reported greater satisfaction. Postacchini et al35 and Skargren et al [36, 37] also found little difference between outcomes from chiropractic and physical therapy at 6 or 12 months, although chiropractic patients’ expectations were more likely to have been fulfilled in the latter trial. During 2 years’ follow-up of patients randomized to chiropractic or McKenzie physical therapy, [38] satisfaction and pain and disability outcomes were similar.
	The Centralization Phenomenon in Chiropractic Spinal Manipulation of Discogenic Low Back Pain and Sciatica J Manipulative Physiol Ther. 2001 (Nov); 24 (9): 596–602 ~ FULL TEXT Assessment of the centralization phenomenon provided valuable diagnostic and prognostic information regarding chiropractic side-posture manipulation in this case series.

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