This article is an excerpt from Dr. Donelson's book entitled: Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings. You can learn more about the book and order your own copy at www.selfcarefirst.com.
Robin McKenzie said, "Everything I know I learned from my patients. I did not set out to develop a McKenzie method. It evolved spontaneously over time as a result of clinical observation" (1).
Many great discoveries in medicine have been as a result of some accidental or serendipitous event, and that is how the McKenzie Method was discovered. The McKenzie Method is a comprehensive approach to the management of back and neck pain.
McKenzie Method History
In 1956, Robin McKenzie had a patient named Mr. Smith who had been experiencing an episode of acute low back and leg pain lasting for three weeks despite seeking Robin McKenzie's care. On arrival for one of his return visits for treatment, he was directed to an exam room and instructed to lie face down on the examination table to wait for Mr. McKenzie.
The room had just been vacated by a patient with a knee problem so the head of the table had been elevated for the reclining patient to receive her knee treatment. Mr. Smith complied with his instructions, entered the room, and lay face-down on the table to await his treatment.
Mr. Smith lying in lumbar hyperextension for ten minutes.
Five to ten minutes passed before McKenzie arrived to find Mr. Smith in this most unorthodox position. McKenzie was immediately concerned about his patient's well-being as this position was thought to be one to avoid for patients with low back pain (LBP). Upon asking Mr. Smith how he was feeling, Mr. Smith reported that his leg pain was completely gone and he was only feeling some mild low back pain. "This is the best I've felt in three weeks!" he's reported to have said.
Perplexed but intrigued, McKenzie says he replied, "Well, that seems to be working pretty well. I guess that will be all for today. Why don't you come back tomorrow and we'll try that again."
Upon arising from the table, Mr. Smith experienced no further leg pain. The next day, he reported he had only some back pain overnight, with no return of his leg pain. His LBP then completely abolished when McKenzie returned him to the same face-down, extreme back bending position.
Mr. Smith's unique experience both challenged and motivated McKenzie to explore the effect of this hyperextended (extreme backbending) position with other LBP patients. To his surprise, he found many who reported that, while they were lying in this position, their buttock or leg pain actually retreated back toward the midline of their lower back, a pattern of pain response that McKenzie soon labeled "centralization."
The motivation to search for centralization became quite compelling since, whenever this response was elicited, patients usually experienced a rapid recovery, often sped up by returning to this position at home if they noted any return of their symptoms.
With only one of these tables whose head could be raised, it soon became apparent that many patients could accomplish this same pain centralization effect by raising their chest up supported by their arms while letting their mid-section sag into this same hyperextended lumbar position. When their arms would fatigue before their pain had fully centralized, they rested by briefly lowering themselves, then pushing upward once again into the hyperextended position.
For many, this repetitive means of extending their lumbar spine to its fullest extent, called "end-range" extension, proved easier, more convenient, and even more effective in some cases than trying to find a place or means of propping one's upper body as high as was needed to bring the same beneficial pain response.
Passive prone end-range lumbar extension: the "press-up." This is both a test and a pain-controlling exercise.
This now familiar movement is used to both test and treat LBP with extension (backbending) and is often referred to as a series of "press-ups."
Directional Preference: The Key to Centralizing and Abolishing Pain
Of course, not everyone responded in such a favorable way. Such hyperextended lumbar positions promptly aggravated some patients' pain. McKenzie began to test other types of lumbar bending and found that centralization was experienced in other directions of bending, i.e., sideward lumbar bending or lumbar flexion (rounding the back). But interestingly, whenever centralization occurred, it was always the result of just one direction of testing.
Because of the substantial benefits of rapid recoveries by identifying a means of centralizing pain, a sequential examination evolved that has become the routine first step in evaluating and treating any new LBP patient with the McKenzie Method. It made no difference whether patients' LBP was acute, subacute, or chronic, or whether it was only LBP or had radiated all the way to the foot. Centralization was found commonly in all of these types of patients. Patients with radiating pain would experience and report centralization and those with only midline pain could abolish that pain rapidly, once the proper direction of bending was identified.
This common finding, where a single direction of testing centralized or abolished the pain, much later gained the name "directional preference" (2). Frequent repetitive exercising to the very end of patients' available lumbar range of movement in, and only in, that single "preferred" direction then became the patients' primary treatment intervention.
Most patients' directional preference was extension. This was followed in frequency by lateral (left or right) testing, and was only found to be flexion in a small percentage of patients.
The McKenzie Method: More Than Just Extension Exercises
It was this predominance of extension exercises (press-ups and/or standing back bends) that unfortunately led many unfamiliar with this assessment to over-generalize and incorrectly conclude that McKenzie care meant treating everyone with extension exercises. To this day, despite the extensive writings and teaching about this paradigm since 1981, this misconception persists commonly worldwide.
I should add that a consistent finding of these patients was that their range of lumbar movement was decreased, sometimes substantially, when they presented in pain for their assessment. This limitation in movement persisted in those whose pain cannot not be centralized during the McKenzie assessment.
But for those whose pain could be centralized and even abolished, the lumbar range of motion was simultaneously restored to normal. In other words, there was a consistent correlation between the range of the mechanical movements of the spine and the degree and even distribution of patients' pain.
Part of any assessment is taking a relevant history from the patient. What became evident to Mr. McKenzie was how often a patient's directional preference could be ascertained from the patient's report of what positions and activities made their pain better or worse.
The most common and clearest example was those patients whose pain centralized with extension testing. In their history, they invariably reported that their pain worsened with lumbar flexion: bending, forward leaning, mopping, vacuuming, working at a bench or sink, lifting and slouched sitting. They also reported their pain as better or even absent with walking or if they sat very erectly, both positions of relative extension.
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