A manual therapy school. Extension and Flexion based exercises.

1. MCKENZIE APPROACH
Radhika Chintamani

2. CONTENTS
• Introduction
• History
• Phenomenon of centralization
• Progression of forces
• Mechanical diagnosis
- Spine
- Extremities
• Predisposing and precipitating factors
• Precautions
• Physical examination
• Procedures and techniques
• Management of syndromes
• Summary
• Evidence

3. INTRODUCTION
• A progression of mechanical forces applied by or to the patient in such a
way that a minimal amount is utilized to effect a therapeutic change in the
presenting mechanical syndrome.
( Robin Mckenzie, 1981)

4. HISTORY
• Accidental discovery by Robin Mckenzie

5. PHENOMENON OF CENTRALIZATION
• As a result of certain repeated movements/ adoption of certain postures,
radiating symptoms originating from the spine and referred distally are
caused to move proximally towards the midline.
• Occurs in derangement syndrome
• Increase in localized central pain
• Reliable predictor

6. Evidence
• A study was conducted on 289 patients to determine the centralization
phenomenon with acute neck and back pain.
• During repeated movement testing 31% subjects had their pain centralized or
abolition of symptoms in 4 sessions.
• 46% subjects showed centralization on 8 sessions
• 23% showed no change in symptoms site or intensity in 8 sessions.

7. PROGRESSION OF FORCES
• Static patient-generated force
positioning in mid-range
positioning at end-range
• Dynamic patient-generated force
patient motion in mid range
patient motion to end range
patient motion to end range with overpressure
• Therapist generated forces
patient motion to end range with therapist overpressure
therapist overpressure- mobilization
therapist overpressure- manipulation
traction- manual, intermittent or sustained

8. THE THREE LIGHTS
• Red light
- Pain in derangement & dysfunction is produced/ increased & remains
worsened (not centralized)
• Green
- Pain in derangement is reduced/ abolished and remains better.
- Pain in dysfunction produced at the end range disappears when stretch is
released.
• Amber
- pain is not worsened nor better.

9. MECHANICAL DIAGNOSIS
1. Postural syndrome
2. Dysfunctional syndrome
3. Derangement syndrome
Syndrome ?
A characteristic group of symptoms & pattern of happenings typical of a
particular problem.
( Chamber’s dictionary)

10. POSTURAL SYNDROME
• Definition: mechanically deformed soft tissues due to sustaining end range
postures and positions.
• Mechanism of pain:
- Prolonged static loading of soft tissues within/adjacent to spine
- Causes overstretching & mechanical deformation
- Ligamentous followed by muscle fatigue
- Bent finger syndrome
• Clinical picture
- age< 30 yrs
- Sedentary occupation
- Insidious onset, gradually worsens
- Local, intermittent & symmetrical pain
- Associated with headaches for Cx spine
- Active pain free movements
- Worsens at the end of day
- No radiating pain

11. DYSFUNCTION SYNDROME
• Definition: shortened tissues are mechanically deformed by overstretching at
end range
• Mechanism of pain:
- Adaptive shortening, scarring, contracture, adherence/ fibrosis
- Reduced extensibility of soft tissues
- Static/ dynamic loading in end range ->mechanical stress on abnormal soft
tissues-> mechanical deformation-> pain
- Causes: trauma, degeneration, posture/ derangement
• Clinical picture:
- age: >30 yrs
- Past h/o trauma or derangement
- Poor posture
- Intermittent pain at end range
- No radiating pain
- Reduced spinal mobility
- Early morning stiffness & pain
- Structural deformities
- Asymmetrical movement loss

12. DERANGEMENT SYNDROME
• Definition: disruption or displacement of structures within the intervertebral
segment
• Mechanism of pain
- Unequal loading of IV disc-> nucleus purposes in eccentric position
->asymmetric compression->disruption in normal resting position of vertebrae->
discomfort-> pain
• Types -> anterior
- > posterior
• Clinical picture
- age: 20-55 yrs
12-55 yrs
- Sudden onset
- Asymmetrical
- Radiating symptoms
- Pain alters & differs
- Constant in nature
- Painful ROM
- Structural deformities

14. For extremities:
POSTURAL SYNDROME
• Pain caused by mechanical deformation/ vascular deprivation of soft tissues
due to prolonged postures
• Affects articular structures / contractile tissues, tendons / periosteul
insertions
• Joint capsule/ ligament pain-> prolonged end range position
• Contractile tissue pain-> prolonged static mid range loading
• Leads to CTDs

15. DYSFUNCTION SYNDROME
• Definition
• Cause of pain: d/t mechanical deformation of structurally impaired tissues
seen in previous h/o trauma/ inflammation/ degenerative processes.
• These events cause scarring, contraction, adherence/ adaptive shortening.
• capsule/ligaments affected-> painful restriction at end-range
• Contractile tissues affected-> pain during resisted movements/ loading
at any point of range
• Articular structures-> restricted end range & intermittent pain
• Pain in contraction & stretching

16. DERANGEMENT SYNDROME
• Internal derangement is a common of pain in extremities.
(Cyriax,1981)
• Commonly seen in knee with meniscoid cartilage tear/ displacement of
deranged menisci.
• Causes locking/ restricted ROM.
• Internal derangement
disturbs normal resting position of joint
Deforms capsule & periarticular ligaments
pain

17. PREDISPOSING AND PRECIPIATING
FACTORSPredisposing: Precipitating:
• Prolonged sitting - Movements
• Frequency of flexion - trauma
- lifting
- lateral flexion or rotation

18. PRECAUTIONS
• Increase in central pain, decrease in distal pain.
• The increased spinal pain may be disconcerting to clients.
• Hence, prior to treatment they must be explained & fully assured.
• Stop the exercises if distal pain/ centralization worsens which should occur
during and not after several hours.
• If symptoms occur after several hours, cause is posture.
• Unused to exs clients may have new pains in thoracic, extremities d/t new
positions movements.
• In dysfunction, be cautious with clients recovered from a recent
derangement. Exs should not provoke pain.
• Manipulation may cause minor trauma & perpetuate the cycle of repair &
failure to remodel.

19. RED FLAGS
• Cauda equina syndrome
• Possible cancer
• Inflammatory disorders
• Stenosis
• Serious spinal pathology
• Hip pathology
• Symptomatic SIJ
• Symptomatic spondylolisthesis
• Mechanically inconclusive
• Chronic pain state

20. PHYSICAL EXAMINATION
• History
• Physical examination
Aims of physical examination:-
1. Usual posture
2. Symptomatic response to posture correction
3. Deformities/ asymmetries related to episode
4. Neurological examination
5. Baseline measures of mechanical presentation
6. Symptomatic & mechanical response to repeated movements
Conclusion:-
1. Syndrome classification
2. Appropriate therapeutic loading strategy
3. Appropriate testing loading strategy

21. 1. POSTURE:
i) Sitting
ii) Standing
iii) Leg length discrepancy
2. NEUROLOGICAL TESTS
i) Sensations
ii) Muscle power
iii) Reflexes
iv) Nerve tension tests
3. Movement loss
i) Flexion
ii) Extension
iii) Rotation
iv) Side flexion
v) Side gliding

22. 4. MOVEMENTS IN RELATION TO PAIN
- Standing
- Lying
5. REPEATED MOVEMENTS
- Diagnostic in derangement and dysfunction syndromes
- In derangement:
movement towards painful side - derangement & peripheralising pain
movement away from painful side- derangement/ centralization
- In dysfunction:
pain is produced at end range of movement & does not worsen
- In postural:
pain not produced with movement
aggravates on sustained positioning

25. PHYSICAL EXAMINATION FOR EXTREMITIES:
• Active movements
• Passive movements
• Passive movement with overpressure
• Resisted tests
• Repeated movements
- Postural syndrome
- Dysfunction syndrome
- Derangement syndrome
• Neurological examination

26. PROCEDURES
CERVICAL SPINE
• Retraction
• Retraction with extension (sitting/ standing)
• Retraction with extension (lying/prone)
• Retraction with extension with traction or rotation
• Extension mobilization (lying prone/ supine)
• Retraction and lateral flexion
• Lateral flexion mobilization and manipulation
• Retraction and rotation
• Retraction mobilization and manipulation
• Flexion
• Flexion mobilization
• Traction

29. THORACIC
• Erect sitting flexion
• Extension in lying
• Extension mobilization/ manipulation
• Erect sitting rotation
• Rotation mobilization/ manipulation

31. LUMBAR
• Lying prone
• Lying prone in extension
• Extension in lying
• Extension in lying with belt fixation
• Sustained extension
• Extension in standing
• Extension mobilization
• Extension manipulation
• Rotation mobilization in extension
• Rotation manipulation in extension
• Sustained rotation/ mobilization in flexion
• Rotation manipulation in flexion
• Flexion in lying
• Flexion in step standing
• Correction of lateral shift
• Self-correction of lateral shift

34. MANAGEMENT OF SYNDROMES
• DERANGEMENT SYNDROME:
Stages –
1. Reduction
2. Maintenance of reduction
3. Recovery of function
4. Prophylaxis
Treatment principles –
1. Extension
2. Flexion
3. Lateral
4. Combination
5. Irreducible

35. • DYSFUNCTION SYNDROME
• Process is lengthy & measured in week/months
• Frustration d/t lack of apparent change
• Exercises performed repeatedly every 2-3 hours
• Each session of 10-15 stretches
• Do not strain and cause micro trauma
• If pain persist after treatment:
i) Overstretching
ii) Micro trauma
iii) wrong diagnosis
• Pain is mandatory but subsides after 10 mins
• Stop exs if pain spreads distally/ deteriorates

36. POSTURAL SYNDROME
• Explain the correlation between posture & symptoms
• Educate on posture correction
- Attain posture
- Maintain posture
• Educate on avoidance of aggravating postures
• Correct posture

37. • EXTREMITIES:
1. POSTURAL SYNDROME
- Education in self management
- Exs can be performed 10 times 3-4 times daily
- repeated end range active movements
progress with self applied overpressure
Resistance towards/ away from direction of limitation at end range
Resistance throughout the movement

38. • DYSFUNCTION SYNDROME
a) Articular dysfunction
- End range self mobilizations
- Client moves the joint actively towards restriction until pain is felt
- Repetitions:10-12
- Frequency: 3-4 times/day
- Review in 2 days & at the end of 1 week
- Progress with resisted exercises
b) Musculotendinous/ contractile dysfunction
- static/ dynamic loading
- Target zone identified
- Active movements, static resisted movements, concentric & eccentric
loading given in inner, outer or in the target zone
- Frequency: 3-4 times/day

40. • DERANGEMENT SYNDROME
- Repeated end range movement loading in pain free direction
- Active exercises at end range
overpressure ( progression)
Resistance towards/ away from direction of limitation at end range

42. SUMMARY
• Definition:
Mckenzie approach - a progression of mechanical forces from patient to therapist
generated.
Centralization- radiating symptoms originating from the spine and referred distally
are caused to move proximally towards the midline due to adaption to certain
postures.
• History:
Accidental discovery of Robin Mckenzie
• Forces:
1) Static
2) Dynamic
3) Therapist generated

43. Postural Dysfunction Derangement
Definition Deformation d/t sustained
postures
Deformation d/t
shortened structures
Disruption/displacemen
t of structures
Mechanism of
pain
Overstretching &
mechanical deformation
Scarring, adherence,
contracture, fibrosis
Unequal loading
Clinical
features
Age: < 30 Age: > 30 Age: 20-55(Cx)
12-55 (Lx)
Insidious onset insidious/ aware about
onset
Sudden onset
No referred pain No referred pain Referred to arm/ leg
Local & symmetrical Symmetrical/
asymmetrical
Asymmetrical
Intermittent Intermittent Constant
Worsens at the end of the
day
Worsens in morning Worsens in morning
Sedentary occupation Poor posture occupation Repetitive/strainousmo
vements

44. • Examination:
History
Physical examination
SPINE EXTREMITIES
- Posture - Active movements
- Neurological examination - neurological examination
- Movements - resisted movements
- Repeated movements - repeated movements
- Painful movements - passive movements
• Procedures:
- Cervical
- Thoracic
- Lumbar

45. • Management:
Derangement Dysfunction Postural
posture correction
Extension flexion principle lateral principle
principle
• Postural syndrome:
- Educate
- Correct
- Avoid

46. • Dysfunction syndrome
- Stretch
- Maintain
• Derangement syndrome
- Reduction
- Maintain
- Recovery
- Prophylaxis

47. EVIDENCES
• A RCT study was conducted by Rosedale et al on the efficacy of exercise
intervention in patients with knee OA based on Mckenzie’s mechanical
diagnosis.
• 180 patients were assigned to MDT and a control group.
• Pain & function were assessed after 3 months of intervention
• The study concluded that MDT group showed superior outcomes than the
control groups

48. • Stanish et al conducted a study on the effect of eccentric exercises on 200
chronic tendononitis subjects.
• Eccentric strength training program was given daily over a six week period.
• Among 200 patients, 44% had complete relief of symptoms & return to
normal function.
• 43% had a marked decrease in pain & function
• 9% had their problems unchanged
• 2% had worse outcomes at the end of treatment.
• Study concluded that eccentric loading in particular was extremely useful in
rehabilitation of chronic tendonitis.

49. • Kjellman & Oberg in 2002 conducted a RCT on 77 patients to find out the
effect of general exercises, Mckenzie group and control group.
• Pain intensity & NDI were calculated.
• Pain intensity and disability scale showed improvements in all groups with
no significant difference.
• But, there was significant difference in Mckenzie group than the control
group & general mobility exercise group.

50. REFERENCES
• Jeffrey Boyling, Nigel Palastanga; GRIEVE’S modern manual therapy, chap 28,
42, 55; 2nd edition, the vertebral column.; Churchil Livingstone.
• Robin Mckenzie, Stephan May; The lumbar spine: mechanical diagnosis &
therapy. Volume I, II. 2nd edition, Spinal publications.
• Robin Mckenzie, Stephan May; The cervical & thoracic spine: mechanical
diagnosis & therapy. Volume I, II. 2nd edition, Spinal publications.
• Robin Mckenzie, Stephan May; Human extremities: mechanical diagnosis &
therapy. Volume I, II. 2nd edition, Spinal publications.
• Stanish WD, Rubinovich RM. Eccentric exercises in chronic tendonitis. Clinical
Ortho & Rel Res 208. 65-68.
• Rosedale R et al. efficacy of exercise intervention as determined by Mckenzie
system of mechanical Diagnosis & therapy for knee osteoarthritis: aRCT.
Journal of orthopaedic and sports physiotherapy; 44(3).

51. • Werenke M, Hart DL, Cook D. Descriptive study of the phenomenon. A
prospective analysis. Spine 1999; 24(7): 676-83.
• Kjellman, Oberg B. a critical analysis of randomized clinical trials on neck
pain and treatment efficiency. A review of literature. Scand J rehab Med
31. 139-152.
• Stanish WD, Rubinovich RM, Curvin S. eccentric exercise in chronic
tendonitis. Clinical ortho & rel res 208.65-68.