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Original article

MCKenzie classification of mechanical spinal pain:Profile 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 profile of the use of McKenzie classifications 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 classification of patients according to syndrome and directional preference have been mainly for the lumbar spine.

The 34 participants for this study each assessed and classified 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 classified as reducible

derangement syndrome, 11/187 were classified 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 flexion and 34/140 were given lateral movements of either side gliding or rotation. Classifications and treatment for the

cervical and thoracic spine groups followed similar patterns. These findings 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 classification; Directional preference

1. Introduction

In the absence of conclusive evidence for effectivetreatment of low back pain, researchers and clinicianshave been moving towards identifying subgroups ofpatients in order to improve the effectiveness of specifictreatments (McKenzie, 1981; Delitto et al., 1995; Wilsonet al., 1999; Fritz and George, 2000; Maluf et al., 2000;Fritz et al., 2003; Kent and Keating, 2004). Severalclassification systems have been described for back andneck pain (McKenzie, 1981, 1990; Spitzer et al., 1987;Delitto et al., 1995; Petersen et al., 1999; Fritz andGeorge, 2000; Maluf et al., 2000; McKenzie and May,2003; Petersen et al., 2003; Sterling, 2004). Because ofthe lack of agreement over a tissue-specific diagnosis for

see front matter r 2006 Elsevier Ltd. All rights reserved.

ath.2006.08.005

63 5257; fax: +64463 5257.

ress: cheryl.hefford@otago.ac.nz.

is article as: Hefford C MCKenzie classification of mechanical s

7), doi:10.1016/j.math.2006.08.005

low back pain, the Quebec Task Force in 1987recommended classifying patients according to symp-tom distribution and the existence or extent of radiatingsymptoms (Spitzer et al., 1987). While this was anacknowledgement of the difficulty of diagnosis of non-specific low back pain, it did not address possiblemanagement options. Kent and Keating (2004) foundthat primary care clinicians in Australia commonlyassign non-specific low back pain patients into somekind of subgroup which determines their management.However, there is no agreement among the clinicians onan acceptable classification system.

Mechanical classification in the McKenzie system ofmechanical diagnosis and therapys (MDT) was firstdescribed in 1981(McKenzie, 1981) and continues to bein 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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1MDT 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.

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

classification of patients into one of three mechanicalsyndromes (or as ‘other’), according to the symptomaticand mechanical response to repeated movements andsustained positions. Brief definitions of the threemechanical syndromes (posture, dysfunction or de-rangement (reducible or irreducible)), and ‘other’ aregiven below and described fully elsewhere (McKenzie,1981, 1990; McKenzie and May, 2003):

1. Posture syndrome pertains to pain arising as a resultof mechanical deformation of normal soft tissues fromprolonged end range loading of periarticular structures.The treatment principle for posture syndrome is posturecorrection.

2. Dysfunction syndrome pertains to pain occurring asa result of mechanical deformation of structurallyimpaired tissues (such as tissue which is scarred, adheredor adaptively shortened). The treatment principle fordysfunction syndrome is to exercise into the direction ofthe dysfunction with the aim of remodelling the tissue.

3. Derangement syndrome pertains to pain occurringas a result of a disturbance in the normal restingposition of the affected joint surfaces. Derangement maybe reducible or irreducible. The treatment principle forderangement syndrome depends on the clinically in-duced directional preference, identified by examining thepatient’s symptomatic and mechanical response torepeated movements or sustained positions. An irredu-cible derangement fits the history criteria for derange-ment but no loading strategy is able to produce alasting change on the symptoms. In the MDT system,this is conceptually thought to concern an incompe-tent or ruptured outer annular wall of the intervertebraldisc.

A reducible derangement typically demonstrates onedirection of repeated movement (directional preference)which decreases or centralizes (moves towards themidline) referred symptoms, or abolishes midlinesymptoms (Long et al., 2004), and the opposite repeatedmovement which produces or increases or peripheralizes(moves more distally) the symptoms. In the lumbarspine, movements typically include flexion in lying orstanding; extension in lying or standing; and lateralmovements of either side gliding or rotation. Similarprinciples of repeated movement testing and treatmentare applied in the cervical and thoracic spines. They arestandard movements in the MDT system and aredescribed fully in the text books (McKenzie, 1981,1990; McKenzie and May, 2003).

4. Other is used to describe those who do not fit withthe mechanical syndromes but who exhibit signs andsymptoms of other known pathology such as spinalstenosis, hip disorders, sacroiliac disorders, low backpain in pregnancy, zygapophyseal disorders, spondylo-lysis and spondylolisthesis, and post-surgical problems.

The system has demonstrated strong inter-raterreliability amongst physiotherapists trained in the

Please cite this article as: Hefford C MCKenzie classification of mechanical s

Therapy (2007), doi:10.1016/j.math.2006.08.005

McKenzie method (k values from 0.79 to 1.0) (Wernekeet al., 1999; Fritz et al., 2000; Razmjou et al., 2000;Kilpikoski et al., 2002; Clare et al., 2004, 2005). For theidentification of derangement syndrome, there is good toexcellent inter-rater reliability (k values 0.7 and 0.96)(Razmjou et al., 2000; Kilpikoski et al., 2002). In onestudy, the inter-rater reliability for identifying direc-tional preference was reported as excellent (90%agreement, k 0.9) (Kilpikoski et al., 2002).

There has been a large amount of research into theclinical findings of centralization and directional pre-ference, which are major aspects of MDT (Donelsonet al., 1990, 1991; Long, 1995; Werneke et al., 1999;Werneke and Hart, 2001, 2003; Aina et al., 2004; Longet al., 2004). According to Clare et al. (2005), five studieshave looked at the reliability of MDT classification andhave 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 thesestudies have concentrated on the lumbar spine.

The primary aim of this study was to establish howmany of the patients with mechanical cervical, lumbarand thoracic pain were classified into each of thesyndromes by specifically trained clinicians (MDTcredentialed) in New Zealand clinical settings. Thesecondary aim was to determine, within the reduciblederangement syndrome, the proportion of patients ineach symptom distribution category and their giventreatment direction (directional preference). It washoped that comparing these findings with previousstudies would further validate the MDT classificationsystem.

2. Method

A survey was undertaken of all the MDT credentialedphysiotherapists1 who were McKenzie Institute NewZealand Branch members in July 2004 (N ¼ 50). Packscontaining instructions, information sheets, consentforms, and data sheets were distributed to all members.They were all physiotherapists thought to be working inmusculoskeletal outpatient settings, either in privatepractice (N ¼ 47) or at a public hospital (N ¼ 3). Ofthese 50 potentially eligible for the study, two wereunable to be contacted (no response to post, email orphone) and nine were unable to participate due toexternal factors such as not currently seeing patients,being overseas or working in an inappropriate environ-ment. This meant the number confirmed eligible for thestudy was 39. Thirty-four of the 39 eligible physiothera-pists (87%) returned completed data sheets with detailsof 10 consecutive patients with spinal pain presenting in

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Table 1

Data collection form

Start date: Finish date:

Case/consent Gender/age Eg.

M/56

Area Syndrome classification

(tick the box)

Derangement symptom location

(tick one if appropriate)

Primary

principle of

treatment

1O Lumbar Reducible

derangement

Central symmetrical Extension

Cervical Irreducible

derangement

Unilateral asymmetrical

symptoms to knee/elbow

Flexion

Thoracic Dysfunction Unilateral asymmetrical to below

knee/elbow

Lateral

Posture

Other

C. Hefford / Manual Therapy ] (]]]]) ]]]–]]] 3

their normal clinic situation (a total of 340 patients).Patients were excluded if they failed to give consent or ifthey were under age 18. Data were collected over a10-week time frame. The University of Otago HumanEthics Committee granted ethics approval for the study(Ref. 04/096).

Data were collected at the initial assessment, accord-ing to the form shown in Table 1. Once therapists hadcompleted their data sheets on 10 consecutive patients,details were posted to the author who collated theresults using the Epi InfoTM (http://www.cdc.gov/epiinfo/) epidemiological database. The participatingphysiotherapists were mainly older experienced phy-siotherapists (88% aged between 30 and 59 years),qualified for an average of 22 years (SD 9.2) and MDTcredentialed for an average of 6.2 years (SD 3.6). All buttwo practised in a musculoskeletal private practicesetting with an even mix of large city, small city andrural town practice. In their clinics, 24% of therapistsstated that they saw predominantly acute and sub acutepatients and 76% said they saw a mix of acute andchronic patients; no one stated they saw predominantlychronic patients. The mean data collection period was22.8 days (SD 17.8). Of the 340 consecutive patients, 19were excluded from the study: nine were under the agespecified (18 years), and 10 did not give consent. Nodata 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 34physiotherapists; data are presented descriptively.

3. Results

Demographic data and classification of the 321patients into the syndromes is shown for each of thelumbar, cervical and thoracic areas (Table 2). Reduciblederangement was found to be the largest group in allthree areas.

Please cite this article as: Hefford C MCKenzie classification of mechanical s

Therapy (2007), doi:10.1016/j.math.2006.08.005

Symptom location patterns of the reducible derange-ment group, for each spinal area, are shown in Fig. 1. Aclear pattern emerged across all areas with the biggestgroup being the asymmetrical group (above the elbow inthe cervical and above the knee in the lumbar areas).The second largest group was the central or symmetricaldistribution of symptoms. The smallest groups con-tained those with the most distal symptoms.

The treatment principles given to the reduciblederangement group, for each spinal area, are shown inTable 3. Extension was consistently the most commontreatment principle across all spinal areas and flexion theleast common. The treatment principle for eachsymptom location pattern within the reducible derange-ment group for each spinal area is also shown in Table 3.When symptoms were central or symmetrical, theextension treatment principle was most commonly used;when symptoms were unilateral or asymmetrical, lateraltreatment principles were used (although, even thenextension principle was the most commonly used).

4. Discussion

For this survey, it was found that of 321 patientsassessed by 34 credentialed therapists, 92% of patientswere classified into one of the three mechanicalsyndromes, with more than 80% classified as ‘derange-ment’. The classification of patients into the MDTsyndromes in this survey is consistent with previouslypublished 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 classified asderangement by these authors was 71.6%. In this study,77.9% were classified as reducible derangement syn-drome (Table 4).

The treatment principle given, according to direc-tional preference, for the majority of patients classified

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30%

20%

37%

70%

63%45%

25%18%

0

20

40

60

80

Lumbar Cervical Thoracic

patie

nt n

umbe

rs

Central Symmetrical

Unilateral or asymmetrical above the elbow / knee

Unilateral or asymmetrical below the elbow / knee

Fig. 1. Symptom location patterns in the reducible derangement

syndrome.

Table 2

Demographic data and Syndrome Classification for each spinal area

Cervical Lumbar Thoracic Combined areas

Mean age 43.9 46.7 40.5 45.27 (SD 16.3)

Gender % of total

Male 42 (38%) 102 (55%) 12 (52%) 156 (49%)

Female 69 (62%) 85 (45%) 11 (48%) 165 (51%)

Syndrome %of total

Posture 3 (2.7%) 1 (0.5%) 0 (0%) 4 (1.3%)

Dysfunction 9 (8.1%) 11 (5.9%) 2 (8.7%) 22 (6.9%)

Reducible derangement 90 (81.1%) 140 (74.9%) 20 (87.0%) 250 (77.9%)

Irreducible derangement 1 (0.9%) 11 (5.9%) 0 (0%) 12 (3.7%)

Other 8 (7.2%) 24 (12.8%) 1 (4.3%) 33 (10.3%)

Total 111 187 23 321 (100%)

C. Hefford / Manual Therapy ] (]]]]) ]]]–]]]4

as derangement syndrome, was extension. However, it isimportant to note the smaller, yet highly relevant,number of patients who responded to lateral and flexionmovements. For the lumbar spine, the number of flexionresponders in this audit is consistent with what has beenreported previously. A randomized controlled trial(RCT) that classified lumbar spine patients prior torandomization identified 74% with a directional pre-ference, of which 83% were extension responders, 7%were flexion responders and 10% were lateral respon-ders (Long et al., 2004). A previous study that lookedonly at sagittal movements in the lumbar spine (did notinclude lateral movements in the assessment) foundthat 47% demonstrated a directional preference foreither flexion (7%) or extension (40%) (Donelsonet al., 1991). In a study looking at both back and neckpain 77% demonstrated a directional preference (cen-tralized or partial reduction) after multiple visits (o7visits over a 2–3 week time frame) (Werneke andHart, 2003). A recent systematic review of 14 studieson centralization found that on assessment, 70% ofacute and sub-acute back pain patients, and 52% ofchronic back pain patients demonstrated centralization.This occurred most commonly with extension exercises

Please cite this article as: Hefford C MCKenzie classification of mechanical s

Therapy (2007), doi:10.1016/j.math.2006.08.005

or postures but also with other loading strategies (Ainaet al., 2004). Although outcomes as a result ofclassification and treatment direction were not ad-dressed in this study, a recent RCT study showed thatgiving the ‘wrong’ direction of exercises to low backpain patients can lead to poorer outcomes (Long et al.,2004).

Most of the research into MDT has been on thelumbar spine, even though the system has alwaysincluded the cervical and thoracic spines (McKenzie,1990). No studies have previously looked at MDT forthe thoracic spine. The incidence of patients presentingfor thoracic spine pain was small compared to thosepresenting with lumbar and cervical spine pain and itwould be interesting to see how this might compare withstudies done in other countries. In New Zealand,because of the size of the country and the widegeographical location of the participants in this study,there was a unique opportunity to get a broad crosssection of the patient community. The demographics ofthe participants and distribution of patients was over arange of city and rural practices, with a mix of acute andchronic patients.

In the MDT system, classification is used to guidetreatment. For the reducible derangement syndrome, thedirectional preference becomes the treatment principle.

The viability of the system depends on the consistentinterpretation of the classifications and treatmentdirections. The clinical relevance of this study is that itconfirms previous work on the numbers of spinalpatients classified into the MDT syndromes. It adds toprevious work by detailing commonly encounteredspecific treatment directions for spinal patients accord-ing to their differing referral patterns of pain. Theseconsistent findings add to the stability of the MDTsystem and may be useful for future research designsinto the prognostic and therapeutic outcomes of thespecific classification groups.

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Table 3

Treatment principles for the reducible derangement syndrome according to symptom distribution

Extension Flexion Lateral movements (side

bending and/or rotation)

Lumbar

Central or symmetrical 48 (92%) 3 (6%) 1 (2%)

Unilateral or asymmetrical above the knee 36 (57%) 4 (6%) 238 (37%)

Unilateral or asymmetrical below the knee 14 (56%) 1 (4%) 10 (40%)

Total treatment directions for lumbar 98 (70%) 8 (6%) 34 (24%)

Cervical

Central or symmetrical 17 (94%) 1 (6%) 0 (0%)

Unilateral or asymmetrical above the elbow 36 (63%) 7 (12%) 14 (25%)

Unilateral or asymmetrical below the elbow 12 (80%) 0 (0%) 3 (20%)

Total treatment directions for Cervical 65 (72%) 8 (9%) 17 (19%)

Thoracic

Central or symmetrical 5 (83%) 0 (0%) 1 (17%)

Unilateral or asymmetrical 12 (86%) 0 (0%) 2 (14%)

Total treatment directions for Thoracic 17 (85%) 0 (0%) 3 (15%)

Table 4

Adapted from Clare et al (2005), Prevalence of syndromes

Reference No. of patients % Derangement % Dysfunction % Postural % Other

Kilby et al. (1990) (lumbar) 41 42.7 22 2.4 32.9

Riddle and Rothstein (1993) (lumbar) 363 52.9 34.7 9.6 2.8

Razmjou et al. (2000) (lumbar) 45 86.7 4.4 2.2 6.7

Kilpikoski et al. (2002) (lumbar) 39 90 2 Nil 8

Clare et al. (2005) (lumbar and cervical) 50 86 2 Nil 12

This study

Hefford (lumbar, cervical and thoracic) 321 77.9 (reducible derangement) 6.8 1.3 10.3

3.7 (irreducible derangement)

C. Hefford / Manual Therapy ] (]]]]) ]]]–]]] 5

5. Limitations

This study has only accounted for classificationsaccording to the first assessment session for eachpatient. It has been shown that in some cases,classification may be better judged over several visits(Werneke and Hart, 2003).

This is a descriptive study of classification at initialassessment; outcomes from the treatment have not beenaddressed. However, many studies have reported theprognostic and therapeutic outcomes of treatmentutilising movements of directional preference (Koppet al., 1986; Donelson et al., 1990, 1997; Long, 1995;Sufka et al., 1998; Werneke et al., 1999; Udermannet al., 2004).

The data was not completely independent in that eachtherapist collected data on 10 consecutive spinal patients.It is possible that the previous patients they had assessedand treated could have influenced their judgement. Thestrengthening reporting of observational studies inepidemiology (STROBE) guidelines (www.strobe-state-ment.org/PDF/STROBE-Checklist-Version3.pdf) suggest

Please cite this article as: Hefford C MCKenzie classification of mechanical s

Therapy (2007), doi:10.1016/j.math.2006.08.005

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

6. Conclusion

In a survey of 50 New Zealand physiotherapiststrained in the MDT system; out of 39 potential andcontactable therapists 34 provided classification detailsregarding 10 consecutive spinal patients. The therapistsworked in an even mix of rural and urban physiotherapypractices across the length of New Zealand. Mechanicalsyndromes as described by McKenzie were used forclassification purposes, with the largest single categorybeing reducible derangement. Most commonly theextension treatment principle was used; but flexionand lateral forces were used also, with the latter moreoften in the presence of referred symptoms. This isone of very few studies which include the cervical spine,and the first to include classification and treatmentof the thoracic spine, even though it was describedby McKenzie in 1990. More research is required to

pinal pain: Profile of syndromes and directions of preference. Manual

ARTICLE IN PRESSC. Hefford / Manual Therapy ] (]]]]) ]]]–]]]6

validate these findings as thoracic spinal pain numbersare small.

The study adds to the growing body of evidencesupporting the external validity of McKenzie’s mechan-ical syndromes. It confirms baseline findings of otherstudies and provides new findings about the profile ofclassifications into syndromes for all areas and thedirectional preference findings for the cervical andthoracic spine. These baselines are useful for bothclinicians and researchers. It also supports the need formechanical evaluation and subdivision of spinal patientsaccording to directional preference.

Acknowledgements

The author would like to thank the following:The McKenzie Institute New Zealand Branch Cre-

dentialed therapists, for their participation and encour-agement in this project.

Mr Stephen May, Dr Ron Donelson, Professor DavidBaxter and Professor S. John Sullivan for criticalrevision of drafts of this manuscript.

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