McKenzie Method Discussion

Pain & Rehab Forum [Moderated]
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This thread is for anyone who would like to discuss the McKenzie Method and its role in assessment and treatment in the rehabilitation setting. I have chosen to pursue MDT certification based on the system’s reliable and generalizable classification system with management that emphasizes patient empowerment and education.

I’m starting this thread per this post from Derek Miles in the Introduction thread.
“I would encourage you to start a thread related to your beliefs on the efficacy of the McKenzie Method and we can discuss your aforementioned nuance. The typical statement of “everyone thinks they know ‘x’ but they do not” is used by many camps as a way of arguing their understanding is far more profound than what the literature would state. I would not recommend the textbooks of Robin McKenzie as the overall bolus of literature does not state that it is superior to any other method and my understanding of the reading is it has a propensity for a structuralist approach to explanation. I am willing to have that understanding changed if you can support it with the literature.”

Here is a list of references investigating the method:

Here are some selected studies from the list: Werneke MW, Hart D, Oliver D, McGill T, Grigsby D, Ward J, Weinberg J, Oswald W, Cutrone G., Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation and stabilization clinical prediction rules., J Man Manip Ther, 18:197-210, 2010
Data collected on 628 patients from 8 different clinics by therapists with training in MDT found prevalence of derangement (67%), dysfunction (5%), and posture syndrome (0%); centralisation (43%), non-centralisation (39%), and not classified (18%); and positive to manipulation (13%) and stabilisation (7%) clinical prediction rules. Derangement classification and centralisation prevalence was high in patients who fulfilled both clinical prediction rules. Werneke M, Hart DL., Centralization phenomenon as a prognostic factor for chronic low back pain and disability., Spine, Apr 1;26(7):758-65, 2000
In 225 patients with acute back pain 24 psychosocial, somatic and demographic variables were recorded at initial assessment. Patient outcomes at one year were predicted by a range of independent variables. When all these variables were entered in a multivariate analysis only pain pattern classification (centralisation or partial centralisation v non-centralisation), and leg pain at intake were significant predictors of chronic pain and disability. Apeldoorn A, van Helvoirt H, Meihuizen H, Tempelman H, Vandepu D, Knol D, Kamper S, Ostelo R, The influence of centralization and directional preference on spinal control in patients with nonspecific low back pain , J Orth Sports Phys Ther, 46(4):258-69, 2016
This study explored whether clinical signs of impaired spinal control changed in relation to the outcome of an MDT assessment, it used a test-retest design. Of those patients that centralised 43% and 50% showed improvement in aberrant movements and ASLR respectively. Only < 10% improved in the non directional preference group. Clinical signs of poor motor control can be reduced spontaneously following an MDT assessment. Deutscher D, Werneke M, Gottlieb D, Fritz, J, Resnik L, Physical Therapists’ level of McKenzie education, functional outcomes, and utilization in patients with LBP, JOSPT, 44:12:925936, 2014
The study looked at the associations between Mckenzie training, functional status at discharge and number of visits for LBP patients. 20,882 patienst were treated and discharged in this observational cohort study. Patients treated by McKenzie therapists had better outcomes and fewer visits compared to those treated by other therapists. This suggests improved cost-effectiveness of advanced MDT training levels. Stynes S, Konstantinou K, Dunn K, Classification of patients with low back-related leg pain: a systematic review , BMC Musculoskeletal Dis, 17:226, 2016
This review looks at the relevant literature that classify / subgroup populations with low back-related leg pain, and how leg pain due to nerve root involvement is described and diagnosed in the various systems. The McKenzie System scored the highest of any system on criteria based upon validity, feasibility, reliability and generalisability. Looking forward to a discussion involving MDT and how it relates to athletic populations, barbell training, pain science, patient independence, and public health.

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Thanks for starting this thread. I’m more than happy to discuss the ins and outs of the McKenzie method and why I do not use it. I have perused the reference list of the McKenzie website before and actually do commend them for conducting research on their method which is more than can be said for most. I want to go through the references you have linked and why I would not weight those for influencing my decisions.

The Werneke 2010 paper assumes reliability and validity of the method. It also gets at why I have a problem with the system as a whole related to the vernacular associated with “derangement” and “dysfunction.” While there are so papers showing interrater and intrarater reliability

What is interesting is Wernke ( McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training - PubMed ) is also the lead author on a paper published in Spine in 2014 that concluded:

“Results indicate that level of inter-rater chance-corrected agreement of McKenzie classification system was not acceptable for therapists at any level of formal McKenzie postgraduate training. This finding raises concerns about the clinical utility of the McKenzie classification system at these training levels. Additional studies are needed to assess agreement levels for therapists who receive additional training or experience at the McKenzie credentialed or diploma levels.”

It still does not make it a valid system. The truth is all systems have flaws and with the increasing evidential support of the BPS model (i.e. a movement away from the structuralist approach for which McKenzie tends to advocate) it is nearly impossible to distill pain to a particular method. InB4 anyone says McKenzie is not structuralist, straight from the website:

“MDT clinicians are trained to assess and diagnose all areas of the musculoskeletal system. That means that if a problem exists in or around the spine, joint or muscle, an MDT evaluation may be appropriate.”

Werneke (2001)- This is not a study of the efficacy of the McKenzie Method but rather a prognostic study of what predicts long term pain and disability, finding that patients who do not centralize were at increased risk. This is not unique to the McKenzie Method. From the study:

“Being classified in the noncentralization group was a predictor of those who did not return to work, continued to report pain symptoms, had extended activity interference or downtime at home, and continued to use health care resources”

Centralization as a subgroup was also a categorical part of the treatment based classification system developed my Delitto Treatment-Based Classification System for Low Back Pain: Revision and Update - PubMed

Even the TBC had to be expanded out, and is still called into question for its underappreciation of psychosocial factors. This is why continued research on the OSPRO (Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort - PubMed) and STarT back tool (Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting - PubMed) have come out in terms of determining prognostic factors for the development of prolonged low back pain.

Apeldoorn 2016- What is “poor spinal control”? Once again centralization phenomenon is not unique to MDT.

Deutscher 2014- Yeah, I’m not going to give that one to the McKenzie team. Being McKenzie trained reduced the number of visits “0.5 to 1 visit per episode of care out of an average of 7 visits would result in approximately 1.5% to 3% improvement in the overall physical therapy service efficiency.” Not exactly crushing the game there for the claims they made and if you look at Table 1. Those not trained in any McKenzie averaged 7.0+/-4.0 visits while those with the highest level (D) averaged 6.2 +/- 3.7 visits. That gives us an effect size of 0.2, or a “small” effect versus a cohort with no “advanced training.”

Stynes 2016- I’ll just go straight from the paper on this one “The treatment based approach classification systems included the McKenzie system which is a popular treatment based approach among clinicians, despite evidence that it is not superior to other treatments.”

Overall, time and again, the McKenzie system has shown to be just that, a system, not superior to any others. For references on that I would direct you to:

Lam 2018- Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis - PubMed

There is moderate- to high-quality evidence that MDT is not superior to other rehabilitation interventions for reducing pain and disability in patients with acute LBP. In patients with chronic LBP, there is moderate- to high-quality evidence that MDT is superior to other rehabilitation interventions for reducing pain and disability; however, this depends on the type of intervention being compared to MDT.

Machado 2006- The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach - PubMed

“There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.”

Pain is a complex topic in any population, having a system through which to think can be advantageous. I am disinclined to endorse any system that uses vernacular such as dysfunction and derangement that lacks any good evidence for its utilization. I do think there is a place for attempts at the centralization phenomenon, but that is not unique to McKenzie.

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I like to remind people this system started on a single PT’s clinical observation and gained popularity before science and research was able to touch it. At one point it was the Williams Flexion exercises, then the McKenzie extension exercises on and on and on and on…once the research got to these systems, things fall apart.

Having talked with Mark Werneke multiple times and listened to him discuss his clinical reasoning on patient cases, you wouldn’t know he was an MDT person. At no point in patient related discussions did he mention using any component of the MDT system. He knows the evidence inside and out…obviously he’s done quite a bit. He was open and clear to point out the MDT system lacking any superior outcomes for anything. If you listened to him, you’d think he was involved with Peter O’sullivan’s cognitive functional therapy group. I remember thinking, if I didn’t know any better, he was saying more to refute the system than support it.

The MDT system is just that. A clinical reasoning system. For that I give it credit. There is plenty of evidence on the system. Overall, to me, the evidence suggests save your money. There is some nice work on lumbar related presentations, but in saying that, the evidence is good quality, but the outcomes are no better than anything else. Outside of the lumbar spine, the outcomes don’t support the system.

If anything, in Spine 2004, Audrey Long’s paper is the best at supporting the concept of a directional preference.

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Matt,

I tend to reference the Lutz paper from 2003 on the history of LBP as the problem with systems in general. Looking back on back pain: trial and error of diagnoses in the 20th century - PubMed I am a big fan of the conclusion of clinicians “1) a tendency to prefer organic, visible abnormalities as etiologies; and 2) an inclination to trust technical diagnostic results more than clinical judgment.”

I came up in Delitto’s TBC with Steve George at Florida, and tried to implement it early in my practice. Thankfully, there was already an acknowledgement that the classification was flawed early and it was presented as only a heuristic through which to think. We all end up in the taxonomy from which we are trained, which is why I tend to advocate for looking at different systems versus going for every level of certification within one. Trying to be more fox than hedgehog on a daily basis.

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I would like to point out that I am not making the point that the system is complete on its own. If it were I would not be here searching for more thoughts and ideas. In this original post and my post on the introduction thread I have said the following, “Looking forward to a discussion involving MDT and how it relates to athletic populations, barbell training, pain science, patient independence, and public health.” My responses to Derek’s quotes are in bold.

As for some of your replies here are my responses.

The Werneke 2010 paper assumes reliability and validity of the method. It also gets at why I have a problem with the system as a whole related to the vernacular associated with “derangement” and “dysfunction.” While there are so papers showing interrater and intrarater reliability - I have never told the patient they have a derangement of dysfunction. Patient friendly language is used to describe these clinical phenomenon when speaking with patients. I posted this article because it shows that every patient can be classified by the system as apposed to other classification such as manipulation and stabilization which are subgroups of the TBC system.

https://www.ncbi.nlm.nih.gov/pubmed/29932871
This study shows acceptable reliability in credentialed clinicians, which is the minimal level of training required by the McKenzie Institute before you can “market use of the Method in practice.”

What is interesting is Wernke ( McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training - PubMed ) is also the lead author on a paper published in Spine in 2014
- All of these levels were before anyone has achieved the minimal accepted standard, certification, by the McKenzie Institute so essentially they were all the same level …not trained “Raters (N = 47) completed multiple sets of 2 independent successive examinations at 3 different stages of McKenzie postgraduate training (levels parts A and B, part C, and part D).” Certification can only be achieved after Courses A-D have been completed and a written and practical exam have been passed.

It still does not make it a valid system. The truth is all systems have flaws and with the increasing evidential support of the BPS model (i.e. a movement away from the structuralist approach for which McKenzie tends to advocate) it is nearly impossible to distill pain to a particular method. InB4 anyone says McKenzie is not structuralist, straight from the website:
“MDT clinicians are trained to assess and diagnose all areas of the musculoskeletal system. That means that if a problem exists in or around the spine, joint or muscle, an MDT evaluation may be appropriate.”
I would say that almost every patient visits a PT with a “problem” around a body part. Pain is a problem and most people identify were the pain is by body part i.e. “my knee hurts.” Most people find pain to be problematic when they are searching for a PT online. Not to mention all the people searching for a PT after they have seen a physician who has told them the have a “problem” somewhere causing their pain. The problem doesn’t have to be structural as I would say poor pain management skills are a “problem.”

Werneke (2001)- This is not a study of the efficacy of the McKenzie Method but rather a prognostic study of what predicts long term pain and disability, finding that patients who do not centralize were at increased risk. This is not unique to the McKenzie Method. From the study:
“Being classified in the noncentralization group was a predictor of those who did not return to work, continued to report pain symptoms, had extended activity interference or downtime at home, and continued to use health care resources”
Centralization as a subgroup was also a categorical part of the treatment based classification system developed my Delitto Treatment-Based Classification System for Low Back Pain: Revision and Update - PubMed
Even the TBC had to be expanded out, and is still called into question for its underappreciation of psychosocial factors. This is why continued research on the OSPRO (Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort - PubMed) and STarT back tool (Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting - PubMed) have come out in terms of determining prognostic factors for the development of prolonged low back pain. - I know centralization is not unique to the McKenzie Method but it is a central feature and the method absolutely encompasses it. The method is likely responsible for most of the research into centralization. The TBC repeated movement classification is a scaled back McKenzie evaluation. I have not looked at the OSPRO or the STarT back tool much so I will look at those links and would love to learn more about them.

Apeldoorn 2016- What is “poor spinal control”? Once again centralization phenomenon is not unique to MDT. - I don’t know what spinal control is, but a lot of our colleagues seem to worry about it so I threw that study in. The authors of the study defined it as , “Four spinal control tests were conducted: aberrant lumbar movements while bending forward, the active straight leg raise (ASLR) test, the Trendelenburg test, and the prone instability test.”

Stynes 2016- I’ll just go straight from the paper on this one “The treatment based approach classification systems included the McKenzie system which is a popular treatment based approach among clinicians, despite evidence that it is not superior to other treatments.” **- This study was included based on these measures, not effect of treatment. "**The McKenzie System scored the highest of any system on criteria based upon validity, feasibility, reliability and generalisability." Studies evaluating the effectiveness of treatment of the McKenzie method typically just include pressups or extension. That is not the McKenzie system and in no way does the system conclude that non-specific treatment of extension will solve all problems. I have not looked at the studies included in this systematic review for treatment, but I would guess they do not use the McKenzie system and rather only extension exercises.

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Matt,

I agree with many of your thoughts. I agree that the strength of the McKenzie Method is its base as a clinical reasoning system. There are no McKenzie exercises. The exercises used when a directional preference is found are simply specific exercise that either centralize or reduce symptoms or improve movement. Extension exercises are not the McKenzie Method.

As far as Mark Werneke’s thoughts, Audrey Long’s research, and centralization in relation to the McKenzie Method here is just a simple and basic video only a couple minutes long. YouTube

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Can you expand more on this?

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Derek,

The University of Florida has had quite a crew of researchers with Bialosky, Bishop and George. That would be a fun discussion to listen to. I have referenced and enjoyed many of the papers they put out.

Floydd,

Thanks for the link. It sounds like Chad Cook and I agree…not a bad thing…

Though it sounded like I see the MDT system (I prefer MDT and not McKenzie) as extension exercises, that is not the case, my apologies. As I said, the MDT system is a clinical reasoning framework/process. This is a misunderstanding for many. I use the concept of directional preference consistently and if warranted attempt to create centralization of symptoms. I think this is another misunderstanding in many rehab settings; the difference between directional preference and the centralization phenomenon.

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Matt - I also prefer the MDT versus McKenzie. I also agree about the misunderstanding between directional preference and centralization. I feel that the research supports that an evaluation for a directional preference or centralization is warranted.

Derek and all others. I looked at a little about the STarT back tool during my down time today. Looks like a great tool to help classify. I also found this citation on the MII research list. I don’t have access to read the full text but if anyone would like to look into it it sounds interesting. Here is a link to a review.

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Hi Floydd,

when the STarTBack came out there was enthusiasm around it. Additional research has been less favorable for those with chronic LBP

with acute LBP

and those in secondary care

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See this is why I struggle with really understanding the literature. It’s likely due to my inadequate understanding of research design, extremely poor understanding of statistics, and honestly a little laziness. But I struggle with weighing 1 study versus another, as there are often studies that have conflicting results. Why do these studies listed above have any more power than the study originally posted by Derek? Or do they not and does this study mean more than those? Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting - PubMed

I know I have inadequacies in my literature critique but I also feel that the physical therapy research has some issues as well. I think that physical therapy research has some of the same issues as the nutrition research that Jordan speaks of in his new nutrition series. Such as the use of a biomedical research model in a biopsychosocial problem and the fact that any physical therapy intervention is just at tiny aspect of a persons life and therefore pain experience.

With all that said are there some good resources that could be shared so I can improve my literature critique skills that work with biopsychosocial model?

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I want to work backwards through the last posts. Floydd, the easy answer as to why the studies Matt posted hold higher weight over the ones I posted is we should always assume the null. Almost always there is a trend where early and/or underpowered studies come out and support a paradigm but it is disproven once better research is conducted. To your original question of how MDT (I will make the preferred semantic change as well) influences or is implemented to barbell athletes I would answer it does not. And while I understand that sounds dismissive it is because the treatment of pain is way to multifactorial and dynamic to be relegated to any particular system working. As mentioned prior, I just have an especially bad taste in my mouth for systems that talk about derangement or dysfunctions (whether or not to the patient). I had a client give me a note from an NDT therapist a few weeks ago that was almost indiscernible what they were trying to say from the technobabble involved in the description. While the practitioner may have been writing the note for another practitioner, it ended up in the client’s hands.

Once again, this is not to be dismissive of all of the principles of MDT as the centralization phenomenon does have evidential backing, for prognosis. Having a heuristic through which to attempt centralization is likely beneficial, but it is not unique to MDT.

Matt,

I certainly do not think the STarT is a panacea for identifying those at risk for chronic low back pain but the Kendall study seems a bit redundant if it is using a tool to identify people at risk for chronic low back pain in a cohort of patients with chronic low back pain. The Magel study is interesting as it still did identify a cohort that seemed to benefit from early intervention. This gets a point relevant to the STarT, MDT, and the OSPRO. Now that we have a piece of information, what does it mean and what do we do with it? I still don’t think we have a clear path with which to identify what constitutes “best care” with any cohort of patients. If we go by the often-cited heuristic of 80% of low back pain patients get better on their own, we’re actually trying to move the needle on that last 20%. I would tend to argue being able to sort out who falls in that 20% is imperative for not giving us a false sense of success with our interventions.

As a side note, having Bish, Joel, and Steve as mentors during residency certainly had a large impact on shaping the way I think now. It was a great time to be a Florida Gator.

Floydd,

In reference to the Lutz paper, this almost comes full circle to the “assuming the null” comment above. The paper essentially says that with each new imaging tool, we thought we had discovered the root cause of low back pain (i.e. x-ray=facets, MRI=discs, fMRI=it’s all in your head). It is a great perspective piece on it being “more complicated than that.” It is often difficult to not come off sounding nihilistic when talking about how little most things matter, especially when the information given to patients often matters A LOT to them.

I tend to invoke Heisenberg’s uncertainty principle as a parallel for trying to figure out a musculoskeletal diagnosis and prognosis. The more I’m focused on the “what is wrong” side of the diagnosis, the harder it is to focus on the “this is what we need to do about it” side of the prognosis. Or said in simple Heisenberg terms, if you want to know exactly where you are, it is impossible to tell where you are going. It is why I tend to gravitate more towards prognostic factors instead of trying to develop a mechanical diagnosis. If we know certain factors seem to have a protective effect, I want to maximize those factors in my treatment (re: training) plan.

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Derek:

“As mentioned prior, I just have an especially bad taste in my mouth for systems that talk about derangement or dysfunctions (whether or not to the patient)”

100% agree with this. Jason Silvernail wrote a nice piece in 2012 discussing the idea of “process vs product.” I think its relevant to this discussion.

“I certainly do not think the STarT is a panacea for identifying those at risk for chronic low back pain but the Kendall study seems a bit redundant if it is using a tool to identify people at risk for chronic low back pain in a cohort of patients with chronic low back pain. The Magel study is interesting as it still did identify a cohort that seemed to benefit from early intervention. This gets a point relevant to the STarT, MDT, and the OSPRO. Now that we have a piece of information, what does it mean and what do we do with it? I still don’t think we have a clear path with which to identify what constitutes “best care” with any cohort of patients. If we go by the often-cited heuristic of 80% of low back pain patients get better on their own, we’re actually trying to move the needle on that last 20%. I would tend to argue being able to sort out who falls in that 20% is imperative for not giving us a false sense of success with our interventions.”

100% agree with this too. I find these tools interesting from a research perspective and see them as having potential for something in the future. How they play out now, in the clinic, I’m not so sure. if we can identify a low, moderate, high risk for disability or pain can we do anything about it? If we can do something, what is it? If we do do something is it cost-effective and meet some clinically relevant outcome? As I read more on these topics, they continue to create questions. I for one, like that. Most everyday clinicians despise it.

Floydd,

Few people know where to start or how to handle the concept of “evidence.” The world of statistics and research is very complex. There are numerous branches and study designs all created to answer different questions.

That said, I am competent in the handling of evidence within my scope of practice. It takes time and effort to do so. It demands constant questioning and an auto-didactic personality. Here are some nice references that can help in the physical therapy world.

https://www.jospt.org/doi/pdfplus/10…ospt.2008.2722

https://www.jospt.org/doi/pdfplus/10…ospt.2008.2725

https://academic.oup.com/ptj/article/81/9/1546/2857672

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If you are saying that a word (product) without an understanding of its definition (process) can appear to be different that it actually is, then yes that is a relevant paper. As an aside, I think Silvernail may have misunderstood McKenzie’s comments as manual techniques are included in the core procedures of MDT. McKenzie was simply making the case of patient independence being superior to dependency on clinicians and that manipulative procedures should only be preformed when indicated by reliable tests. You can read McKenzie’s letter to the editor from the link in the references.

Everyone,

Derangement may be a scary sounding word. However, the derangement classification typically indicates a very good prognosis as directional preference is an essential feature. This word is never/rarely used in patient conversations and conversations/notes with other healthcare professionals because it is not understood or it is misunderstood.

Here is a video of a shoulder derangement. (It’s quite shocking)

https://www.youtube.com/watch?v=sL8_…8_1Iid8BY&t=42

PTs have to have Continuing Education credits of some sort (many other professions do too), so I recommend courses A-D for anyone interested in learning more about MDT.

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Here is a weightlifter that was helped with MDT

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Hi floydd,

Its easy to debate those individuals that hold each word of the MDT system in a literal fashion. They think a derangement or dysfunction is a true structural anatomical lesion, versus a symptom response to movement and position. Those that understand these as you describe are much more sensible. Unfortunately, clinician DO use this terminology with patients. I know because I still hear it on a regular basis; along with anterior rotations, upslips, unstable, weak and “mis-firing” of random muscles.

From the Silvernail paper:

“McKenzie’s Mechanical Diagnosis and Therapy (MDT) system is a well-researched, well-described systematic examination and intervention process that, when used appropriately, leads to good clinical outcomes for large numbers of patients with common clinical problems.2 Mechanical Diagnosis and Therapy is not, as is sometimes believed, the treatment of spinal disk problems with backward bending exercises. In my view, the strength of MDT is not that it provides a list of exercises for the patient to perform or for the clinician to experiment with, but that it is a systematic clinical reasoning process. This systematic process matches patient presentation with the benefits of various repeated movements or sustained positions in specific loading conditions. It also provides a method for assessing their clinical benefit and adjusts the treatment prescription in response to symptoms.”

I think this is a very fair, well reasoned explanation of the MDT system.

One of the concerns I have with the MDT system are this:
“Over a quarter (27%) of the patients in the current study could not be categorized within the MDT system, and somewhat higher percentage than other studies.7–9 Of those patients classifiable within the MDT system in the current study, the vast majority (92%) were in the derangement category, similar to other reports in the literature.7–10. Considering the results from Werneke along with the preponderance of evidence in the literature, the primary concern with respect to the MDT classification paradigm may be one of discrimination. If a classification system places nearly all patients into a single category, the efficiency, i.e. the value added relative to the amount of time required, of the classification paradigm in clinical practice, may be questionable.”

Fritz, Julie. “Disentangling classification systems from their individual categories and the category-specific criteria: an essential consideration to evaluate clinical utility.” The Journal of Manual & Manipulative Therapy 18.4 (2010): 205.

Just a side note: Julie Fritz is on the FOTO research board with Mark Werneke.

https://www.fotoinc.com/about-foto/board

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Austin,

I posted that to show the readers of this forum (who mostly all lift) that this system can be applied to them and it isn’t just for their weak and frail elders. I also think his comment about him having a strong core is important as many PTs will tell athletes that they have pain due to transversus abdominis weakness or recruitment issues. And I believe we would all agree that is not the case. I think it helps show that not all PT/PTs are the same.

Matt,
I agree that Silvernail has a good understanding of MDT, just as McKenzie understands the benefit of the occasional need for manual therapy. It seems to me as though Silvernail was under the impression that McKenzie’s note was saying that manual therapy didn’t have a place. He was simply stating that he does not feel manual therapy should be the first choice or applied without reliable clinical rationale.

The Julie Fritz article was an interesting read. Added to my favorites. One issue with her comments are that she considered the classification of “Other” as being “not classified” which is not the case. The other classification has clinical reasoning for its existence and multiple sub groups are included under the Other classification. Each with a treatment recommendation. The subgroups include Trauma, Chronic Pain, Inflammatory Conditions, Post-Surgical, Structurally Compromised, Mechanically Inconclusive, and Mechanically Unresponsive Radiculopathy, SIJ/PGP, and Spinal Stenosis for the lumbar spine. So 100% of patients can be classified and the 27% in the Other category on not defined as unclassifiable.

Derangements are common (67% of the patients included in the Wernicke 2010 paper Fritz mentions). There are subgroups of derangements as well based on direction of preference. If all patients with a specific clinical presentation can be managed with the same principles then there is no need for further distinguishing.

It needs to be noted that Julie Fritz is part of the team that developed/amended the Treatment Based Classification System.

18

The issue is I can likely find a video of an athlete “helped” with any system so an n=1 video does not do much for me.

I would like to ask for your definition of a “derangment” at this point? If 67% of patients fit into a particular category it would seem easy to make the inclusion criteria broad enough for most to fit in. This is not unlike the “stabilization” category of TBC. But to your point, most would consider there to be subsets within that category as well but it reduces down to “what exercise would I start with” and often there is still not a definitive right answer to that and it is highly patient specific based on priors of expectations and training history as much as actual presentation.

My impression, and correct me if I’m wrong, is that you have wholly bought into this system. This is a point I take issue with with ANY system as we do not have evidence of a particular system being better than another. The only criteria being what system the person touting it has been trained in. What advantage would you see in taking the A-D courses over just reading the peer reviewed literature on the system as it currently stands?

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Derek,

I agree that n=1 tells us very little. That video is just an example that is very well explained by the derangement syndrome described in MDT. I would say I have essentially bought into the system. At this time in my development have found no other way of evaluating, classifying, and treating patients that is more concise, generalizable, reliable, or effective. Derangement is defined by the McKenzie Institute as: a clinical presentation associated with mechanical obstruction of an affected joint. The key words being clinical presentation. It is not based on theory, it is based on what is observed by the patient and the clinician during the assessment process. Derangement syndrome requires obstruction and a directional preference (ideally centralization in the spine). As I have shown with the studies already posted and the McKenzie Institute has included on the reference list, this is a reliable system in properly trained MDT clinicians. Therefore 67% is about the right percentage of patients that fit this criteria whether everyone likes that or not. Derangement also has a good prognosis. I very much appreciate that MDT includes derangement as I know of no other system that includes any classification resembling derangement which in my opinion is therefore missing out on an important classification. I mean 67% of patients is a big number to miss out on (granted other systems have ways of classifying a percentage of these patients as well). Look at Audrey Long’s paper regarding matched exercise for directional preference. If a clinician can improve their results by 50-70% on 74% of there patients (all of these would be considered derangements) by using direction preference exercise I think that warrants an evaluation for a direction preference. (again directional preference is an essential feature of derangement). Seems like an important thing to miss out on. How do you recommend clinicians assess for directional preference?

Long A, Donelson R, Fung T, Does it matter which exercise? A randomized control trial of exercises for low back pain., Spine, Dec 1;29(23):2593-2602, 2004

“Following a mechanical evaluation all patients who demonstrated directional preference (DP) (230/312, 74%) were randomised to receive exercise matched to DP (1), exercise opposite to DP (2) or evidence-based management (3). Over 30% of groups 2 and 3 withdrew because of failure to improve or worsening, compared to none in group 1. Over 90% of group 1 rated themselves better or resolved at 2 weeks, compared to just over 20% (group 2) and just over 40% (group 3). There were further significant differences between the groups in back and leg pain, functional disability, depression and QTF category.”

Everyone must develop some sort of system for classification and treatment. I feel the McKenzie Institute has done a good job developing and supporting their system with their reference list (Reference List | The McKenzie Institute International®). Clinical development is likely expedited by guidance versus…go look at the tens to hundreds of thousands of research articles published each year that often contradict each other and find your own way. What I am explaining is essentially the reason we have systematic reviews/meta analysis, clinical practice guidelines, schools/professors, and organizations like the McKenzie Institute. They do some of the work for us to help make sense of the complexities of our field and never ending circulation of contradictory research that is often of poor quality with conclusions similar to “their is insufficient evidence to support/refute this diagnosis/treatment/etc.” Also I have not seen quality research that sufficiently refutes the utility of the method.

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“Derangement is defined by the McKenzie Institute as: a clinical presentation associated with mechanical obstruction of an affected joint.”

How are you determining this mechanical obstruction? Can you not see the issue with this line of thinking? You are associating a syndrome with a mechanical obstruction that has never been validated. How then can it be reliable?

What would constitute evidence worthy to “sufficiently refute” the utility of the method? Have you considered you may not have found another system because you haven’t looked into other systems as a result of pursuing the full gamut of McKenzie methodology?

If I may present an alternative hypothesis to the paper you referenced, are you familiar with the concept of clinical equipoise? Maybe it is your beliefs (or clinicians wholly bought into McKenzie) that have a large effect on the programs effectiveness. What if it wasn’t the exercise but the belief in the effectiveness of the exercise?

​​​​​​ The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental
study.The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental study - PubMed