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CORE LIST – Literature Relevant to the McKenzie Method
(Containing only articles published in peer review journals directly relevant to MDT)
Read Research Reviews
New! = Published in last 180 days!
The following articles are grouped together according to the type of study as follows:

Guidelines

<<< Rollover study type title to see section description below.

Lumbar: Systematic Reviews

Lumbar: Reviews

Lumbar: Trials

Centralisation

Lumbar: Observational studies

Lumbar: Surveys of Physical Therapy practice

Lumbar: Studies into assessment, diagnosis and procedures

Lumbar: Anatomical & physiological studies

Discussion Articles

Cervical: Reviews

Cervical: Trials

Cervical: Observational studies

Cervical: Studies into assessment, diagnosis and procedures

Cervical: Anatomical, physiological, and pain studies

Whiplash: Reviews

Whiplash: Trials

Extremities: Systematic reviews

Extremities: Reviews

Extremities: Trials

Extremities: Observational studies

Extremities: Studies into assessment, diagnosis and procedures

Extremities: Anatomical, physiological, and pain studies


Guidelines

American College of Occupation and Environmental Medicine ; Exercise and Manipulative Therapies for Treatment of Acute and Subacute Low Back Pain. , 2005.

McKenzie method is recommended as a classification based treatment system and some of the relevant evidence presented.

Bach SM, Holten KB; What's the best approach to acute low back pain? J Fam Pract; 58.E1-E3, 2009.

‘McKenzie exercises’ are recommended with ‘good-quality patient-oriented evidence’.

Danish Institute for Health Technology Assessment; Low-back pain. Frequency, management and prevention from an HTA persective. 1-106, 1999.

This wide ranging review and guideline includes a summary of the McKenzie approach, both as a treatment and as a diagnostic method. They concluded there was limited evidence to support its use as a treatment for both acute and chronic back pain, and moderate evidence indicating its value as a diagnostic tool and prognostic indicator.

Delitto A, George SZ, van Dillen L, Denninger TR, Sowa G, Shekelle P, Godges JJ; Low back pain. Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthpaedic Section of the American Physical Therapy Association JOSPT; 41:1-101, 2011.

Clinical guidelines that address numerous aspects of back pain, such as classification, red flags, risk factors, outcome measures, physical examination tests, screening tools, and interventions. Amongst other recommendation it was recommended that clinicians should use specific repeated movements to promote centralization in patients with acute low back pain; with recommendation based on strong evidence.

Delitto A, George SZ, van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ.; Low back pain. Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orth Sports Phys Ther; 42:A1-A57, 2012.

Guidelines which recommend classification of low back pain, and certain interventions, which included manual therapy, trunk coordination exercises, centralization and directional preference exercises, and progressive fitness activities – all based on strong evidence.

Philadelphia Panel; Evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain Phys Ther; 81; 1641-1674, 2001.

These guidelines have been developed using a structured and rigorous methodology. For sub-acute and chronic back pain they recommend that there is good evidence to include certain specific exercises, including the McKenzie method.

Poitras S, Rossignol M, Dionne C, Tousignant M, Truchon M, Arsenault B, Allard P, Cote M, Neveu A; An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project. BMC Musculoskeletal Dis; 9.54 http://www.biomedcentral.com/1471-2474/9/54, 2008.

Development of a clinical management model for back pain patients from previously published guidelines and systematic reviews. McKenzie approach was listed as a recommended therapeutic intervention for acute and for chronic back pain with ‘poor’ scientific evidence; and for sub-acute back pain with ‘moderate’ scientific evidence.

Rossignol M et al; Clinique des Lombalgies Interdisciplinaire en Premiee ligne. CLIP; , 2006.

McKenzie recommended for sub-acute back pain with moderate scientific evidence, and for chronic back pain with weak scientific evidence.http://www.santepub-mtl.qc.ca/Publication/pdftravail/CLIPenglish.pdf

Work Loss Data Institute. Encinitas, CA; Official Disability Guidelines - Treatment in Workers Comp (ODG) Online ODG, 2008.

McKenzie recommended for acute and chronic back pain. Guidelines noted the reliability of assessment with trained therapists; the value of sub-grouping using centralisation; and the ability of McKenzie method to improve pain and disability in the short-term. This was supported by best levels of evidence: systematic reviews and RCTs.http://worklossdata.com
Lumbar: Systematic Reviews

Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA; High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J; 9:147-168, 2009.

Only exercise was found effective in 7 / 8 trials (effect size 0.39 to > 0.69), which included extension exercises and an education session based on Treat Your Own Back. Stress management, shoe inserts, back supports, ergonomic advice and reduced lifting programmes were found to be not effective.

Choi BKL, Verbeek JH, Tam WWS, Jiang JY; Exercises for prevention of recurrences of low-back pain Cochrane Library; Cochrane Library 2010, Issue 3. www.thecochraneibrary.com, 2010.

13 articles were included in the review, 2 of which involved McKenzie exercises. Overall there was moderate quality evidence that exercises were effective at reducing recurrences at one year and the number of recurrences; but no evidence of difference between McKenzie and back pain education.

Chorti AG, Chortis AG, Strimpakos N, McCarthy CJ, Lamb SE; The prognostic value of symptom responses in the conservative management of spinal pain. A systematic review. Spine; 34:2686-2699, 2009.

22 articles were included; most symptom responses were not prognostic of clinical outcomes. Only changes in pain location and pain intensity with repeated movements or in response to treatment were associated with outcomes.

Clare HA, Adams R, Maher CG; A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother; 50(4):209-16, 2004.

Systematic review of 5 trials deemed to be truly evaluating McKenzie method with pooled data showing greater pain relief (8.6 on a 100 scale) and greater reduction in disability (5.4 on 100 scale) than comparison at short-term (less than 3 months). At 3 to 12 months results were unclear.

Cook C, Hegedus EJ, Ramey K ; Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature J Man & Manip Ther; 13:152-162, 2005.

This review uniquely only includes exercise trials for back pain in which patients were classified into exclusive, patient response groups based on physical examination findings. Given these inclusion criteria only 5 trials were included, 4 of these included elements of the McKenzie method, all included centralisation as part of the assessment process. All articles scored 6 or more by PEDro rating (suggesting high quality). 4 / 5 found that a PT directed exercise programme implemented according to patient response was significantly better than control or comparison groups. Authors note a positive trend, but that few studies have investigated this phenomenon.

Crawford C, Lee C, May T et al.; Physically oriented therapies for the self-management of chronic pain symptoms. Pain Med; 15:S54-S65, 2014.

This review looked at patient-centred complementary and integrative medicine that acknowledged the patients’ role in their own healing. The review included 10 studies investigating acupressure, ‘self-correcting’ exercises (including McKenzie exercises), and TENS. Results were promising, but more evidence is required.

Dunsford A, Kumar S, Clarke S ; Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain. J Multidisciplinary Healthcare; 4.393-402, 2011.

A systematic review that included 4 high quality studies that showed that directional preference exercises were an effective intervention in 3 / 4, showing significant differences compared to a range of controls, regardless of duration of symptoms. They also presented a case study of a patient with back and leg pain who demonstrated directional preference in response to repeated extension.

Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hersmeyer J, Andersson G.; The role of classification of chronic low back pain. Spine; 36:S19-S42, 2011.

A review of 28 classification systems: 16 diagnostic, 7 prognostic, and 5 treatment-based systems. They found the McKenzie system had strong evidence for reliability, and moderate evidence for effectiveness. Reliability increased with training and experience with a classification system.

Fersum KV, Dankaets W, O’Sullivan PB.; Integration of sub-classification strategies in RCTs evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review. Br J Sports Med; doi:10.1136/bjsm.2009.063289, 2009. (Ahead of Print)

Only 5 out of 68 studies sub-classified patients. Meta-analysis showed a statistically significant difference in favour of classification-based treatment over control for reduction in pain (p=0.004) and disability (p=0.0005).

Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N ; Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain Eur Spine J; 16:1539-1550, 2007.

28 studies investigated the disc, 8 the facet joint and 7 the SIJ. Various features on MRI were suggestive of disc pathology: high intensity zone likelihood ratio (LR) 1.5 to 5.9, disc degeneration 1.6 to 4.0, endplate changes 0.6 to 5.9. Centralisation and likelihood of disc pathology had LR of 2.8. Single tests of SIJ were uninformative; multiple pain provocation tests had LR of 3.2 and negative LR of 0.29. None of the facet tests were found to be informative.

Hettinga DM, Jackson A, Klaber Moffett J, May S, Mercer C, Woby SR ; A systematic review and synthesis of higher quality evidence of the effectiveness of exercise interventions for non-specific low back pain of at least 6 weeks duration. Phys Ther Rev; 12:221-232, 2007.

This systematic review found that higher quality evidence supported the use of strengthening exercises, organised aerobic exercise, general exercises, hydrotherapy and McKenzie exercises for back pain of at least 6 weeks duration.

Kent P, Mjosund HL, Petersen DHD (2010).; Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? BMC Med; 8:22, 2010.

A systematic review of targeted versus non-targeted exercise or manual therapy that included 4 studies; 1 McKenzie and 3 treatment-based classification system based. There was a statistically significant effect short-term for directional preference exercises. Overall there was only very cautious evidence supporting targeted treatment improves patient outcome.

Kolber MJ, Hanney WJ; The dynamic disc model: a systematic review of the literature. Phys ther Rev; 14:181-189, 2009.

Review of the dynamic disc model that suggests that the nucleus pulposus migrates in response to movement and positions. Twelve articles were located that demonstrated in vitro and in vivo that the nucleus migrated anteriorly during extension ad posteriorly during flexion. There was limited and contradictory data to support this model in the symptomatic and degenerated disc.

Machado LAC, de Souza MvS, Ferreira PH, Ferreira ML ; The McKenzie Method for low back pain. A systematic review of the literature with a meta-analysis approach Spine; 31:E254-E262, 2006.

Systematic review that included 11 trials and concluded that there is some evidence that the McKenzie method is more effective than passive therapies for acute back pain, but the size of treatment effect is unlikely to be clinically worthwhile. There is limited evidence for the McKenzie method in chronic back pain and overall effectiveness is not established. However the authors largely failed to perform the meta-analysis they intended, and many studies were included in which treatment was not classification based.

Oliveira VC, Ferreira PH, Maher CG, Pinto RZ, Refshauge KM, Ferreira ML; Effectiveness of self-management of low back pain: systematic review with meta-analysis Arthrit Care Res; 64:1739-1748, 2012.

A review of 13 trials with moderate evidence that showed that self-management is effective for improving pain and disability. The effect size short and long-term was respectively 3.2% and 4.8% for pain, and 2.3% and 2.1% for disability.

Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW.; Spinal manipulative therapy for acute low-back pain; an update of the Cochrane review. Spine; In Press, 2012.

Manipulative therapy was no more effective than inert interventions, sham manipulation or other active interventions. In the implication section the authors state that continuing research on the heterogeneous back pain population seems pointless, and instead subgroups should be researched, such as, based on clinical prediction rules or directional preference.

Slade SC, Keating J; Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with non-specific chronic low back pain: a systematic review. J Manipulative Physiol Ther; 30:301-311, 2007.

A review of unloaded exercises facilitating lumbar spine movement compared to a no-treatment control or other treatment; of the 6 studies located 4 used the McKenzie system. Strong evidence was found that such exercises improve pain and function compared to no exercise. The evidence slightly favoured McKenzie when compared to strengthening and stabilisation exercises.

Surkitt LD, Ford JJ, HahneAJ, Pizzari T, McMeeken JM.; Efficacy of directional preference management for low back pain: a systematic review. Phys Ther; doi: 10.2522/ptj.20100251, 2012. (Ahead of Print)

Six trials involving directional preference management were included in this systematic review; 5 deemed to be of high quality. Results were mixed, but there was moderate evidence that directional preference exercises were more effective than a range of comparison treatments short, medium and long-term. No trials found these were less effective.

Swinkels A, Cochrane K, Burt A, Johnson L, Lunn T, Rees AS; Exercise interventions for non-specific low back pain: an overview of systematic reviews. Phys Ther Rev; 14:247-259, 2009.

Only 4 systematic reviews were included, 27 were excluded. 3 / 4 were of high quality, and provided strong evidence that exercise programmes reduce sick-leave and improve pain and disability in people with non-acute non-specific back pain. The clinical value of this conclusion is reduced by the diversity of exercise interventions.
Lumbar: Reviews

Berthelot JM, Delecrin J, Maugars Y, Passuti N ; Contribution of centralization phenomenon to the diagnosis, prognosis, and treatment of discogenic low back pain. Joint Bone Spine; 74:319-323, 2007.

This review of centralisation concluded that it may indicate discogenic pain and is associated with better outcomes.

Donelson R; Evidence-based low back pain classification Eur Med Phys; 40:37-44, 2004.

Review of literature supporting Mechanical Diagnosis and Treatment – includes the value of a non-specific classification system, the value of establishing directional preference, its reliability as an assessment system, and the prevalence of centralisation in the back pain population.

Donelson R; Improving spine care using Mechanical Diagnosis and Therapy. SpineLine; October 19-26, 2012.

Summary of the system, with references, as relevant to the lumbar spine.

Ford JJ, Hahne AJ, Chan AYP, Surkitt LD.; A classification and treatment protocol for low back disorders part 3 – Functional restoration for intervertebral disc related disorders. Phys Ther Rev; 17:55-75, 2012.

This review proposed criteria for a non-reducible discogenic pain sub-group, and proposed a management programme for this group, as part of a wider project from the same research group.

Ford JJ, Surkitt LD, Hahne AJ.; A classification and treatment protocol for low back disorders Part 2 - Directional preference management for reducible discogenic pain. Phys Ther Rev; 16:423-437, 2011.

Presentation of directional preference management with other elements for reducible discogenic pain as the protocol to be followed in a trial protocol for patients classified with derangement and randomised to directional preference exercises or evidence-based practice.

Huijbregts PA; Fact and Fiction of Disc Reduction: A Literature Review J Man & Manip Ther; 6:3, 137-143, 1998.

This review examines the effect of manipulation, traction, and McKenzie exercises on the position of herniated nuclear material in lumbar intervertebral discs. From the evidence reviewed the author concludes that there is no proof that rotatory manipulation is effective and may lead to further displacement; that traction may temporarily influence displacement; and that extension exercises may influence displacement in non-degenerated discs, but does not allow conclusions about the effect in degenerated or herniated discs.

Kamper SJ, Maher CG, Hancock MJ, Koes BW, Croft PE, Hay E; Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best Pract Res Clin Rheum; 24.181-191., 2010.

Outline of key concepts related to sub-groups of back pain, and summary of current evidence. A 3-stage process is suggested as being necessary: 1) hypothesis generation to define sub-groups; 2) a randomised controlled trial to test that sub-group membership improves outcomes; 3) replication of stage 2. They concluded that all classification systems have not developed beyond first stage.

Karayannis NV, Jull GA, Hodges PW.; Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/ expert survey. BMC Muscul Dis; 13: 24, 2012.

A review of classification systems with confirmation from system experts. Five dominant movement based schemes were identified; including Mechanical Diagnosis and Therapy, Treatment-Based Classification, and Pathoanatomic classification systems. There was considerable diversity in how movement informs sub-grouping, but 2 dominant movement paradigms emerged: the 3 systems above all used loading strategies to elicit centralisation, the other 2 systems used modified movement strategies to document movement impairments.

Lederman E; The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. CPDO Online J; March 1-14, 2010.

Review article that challenges the links between postural-structural-biomechanical factors and the presence of back pain. With a review of literature relating to the absence of a link between asymmetries, degenerative changes, postural factors, and motor control variations and back pain. Furthermore the body has plenty of surplus capacity to cope with these minor variations without symptoms.

May S, Donelson R; Evidence-informed management of chronic low back pain with the McKenzie method. Spine J; 8.134-141, 2008.

Review that examines evidence for McKenzie method in an edition of Spine Journal that investigates the evidence for a wide range of different approaches in the treatment of chronic low back pain. Four guidelines, 5 systematic reviews, and 3 RCTs are quoted.

Stefanakis M, Key S, Adams M.; Healing of painful intervertebral discs: implications for physiotherapy. Part 1 – the basic science of intervertebral disc healing. Phys Ther Rev; 17:234-240, 2012.

Review of disc pathology and relationship with pain as the theoretical background to a proposed protocol to be discussed in part 2 of the review to improve nutrient supply and to stimulate biosynthetic processes to stimulate healing of the disc.

Wetzel FT, Donelson R; The role of repeated end-range / pain response assessment in the management of symptomatic lumbar discs. Spine J; 3:146-154, 2003.

Review of current literature regarding usefulness of dynamic mechanical assessment for diagnosis andd management of reversible discogenic pathology: and identification of irreversible pathology that may benefit from sugery.
Lumbar: Trials

Alexander AH, Jones AM, Rosenbaum Jr D H:; Nonoperative Management of Herniated Nucleus Pulposus: Patient Selection by the Extension Sign-Long term Follow-up. Orthopaedic Review; 21;181-188, 1992.

Follow-up study of 33/73 patients with acute disc herniation treated conservatively. Those unable to gain extension by 5 days were treated surgically. Ability to regain extension was a better predictor of outcome than a variety of other clinical and neurological signs and symptoms.

Apeldoorn AT, Bosmans JE, Ostelo RW, de Vet HCW, van Tulder MW.; Cost effectiveness of a classification-based system for sub-acute and chronic low back pain. Eur Spine J; DOI10.1007/s00586-011-2144-4, 2012. (Ahead of Print)

156 patients classified by the treatment-based classification system (directional preference exercises, manipulation, or stabilisation exercises) and then randomised to classification-based treatment or usual physiotherapy care. The classification-based group was only significantly better on global perceived effect, but no other outcome measure; but was not cost effective.

Apeldoorn AT, Ostelo RW, van Helvoirt H, Fritz JM, Knol DL, van Tulder MW, de Vet HCW.; A randomized controlled trial on the effectiveness of a classification-based system for suabacute and chronic low back pain. Spine; 37:1347-1356, 2012.

This trial compared treatment according to the treatment-based classification system, which includes a directional preference exercise group, to usual physiotherapy in 156 patients with subacute or chronic low back pain. There were no significant differences in outcomes between the groups.

Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE ; Identifying subgroups of patients with acute/sub acute “non-specific” low back pain. Spine; 31:623-631, 2006.

A randomised clinical trial comparing manipulation, stabilisation and directional preference exercises, but also analysing results according to whether patients were treated by classification sub-group or not. Classification sub-groups were determined by clinical features gathered at baseline. There were no significant differences between randomised treatment groups, but there were significant differences between patients matched with their classification sub-group and those unmatched.

Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, Grimm RH, Owens EF, Garvey TA, Transfeldt EE.; Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine J; 11:585-598, 2011.

Comparison of stabilisation exercises, chiropractic spinal manipulation and advice and home exercises, which appeared to focus on extension in lying exercises, in 301 patients with chronic low back pain. The stabilisation exercise group had higher levels of satisfaction and greater gains in trunk muscle endurance, but there were no significant differences between groups in pain and disability both short and long-term.

Browder DA, Childs JD, Cleland JA, Fritz JM; Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther; 87.1608-1618, 2007.

About 300 patients evaluated for eligibility of who 63 met inclusion criteria: back pain with referral below the buttock, plus centralization with 10 repeated extension exercises in standing or lying. These 63 patients were randomised to an extension protocol (extension exercises and posterior-to-anterior mobilisation) or strengthening programme for flexors and extensors. There were significant differences at 1 and 4 weeks and at 6 months for Oswestry scores favouring the extension protocol group, but only in pain scores at 1 week. There were significant differences in centralization of symptoms favouring the extension protocol group.

Chen J, Philips Amy, Ramsey M, Schenk R. ; A case study examining the effectiveness of Mechanical Diagnosis and Therapy in a patient who met the clinical prediction rule for spinal manipulation. J Man Manip Thera; 17.216-220, 2010.

Case study of patient who met 4/5 of clinical prediction rule for manipulation criteria who failed to respond to 2 sessions of manipulation, but then responded to repeated movements.

Cherkin DC, Deyo RA, Battie M, Street J, Barlow W.; A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med; Oct 8;339(15):1021-9, 1998.

McKenzie therapy and chiropractic manipulation are equally effective and both are slightly superior to the booklet in terms of patient satisfaction and short-term symptom reduction. The long-term outcome measures were the same in all 3 groups, including recurrences and care-seeking. The cost of the booklet group was considerably less than the 2 other groups.

Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA; Evidence for use of an extension-mobilization category in acute low back syndrome: a prescriptive validation pilot study. Phys Ther; Apr;73(4):216-22, 1993.

Delitto suggests that treatment strategy based on signs and symptoms and response to movement may result in a more effective outcome compared with an unmatched non-specific treatment. Patients classified as extension-responders did better with an extension, than a flexion oriented programme.

Donelson R, Long A, Spratt K, Fung T. ; Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica. Phys Med Rehabil; In Press, 2012.

Secondary analysis of data from Long et al. (2004) of patients with a directional preference and treated with directional preference exercises to see if there was any difference in outcomes across duration of pain or between QTF categories (1 = low back pain only; 2 = plus thigh pain; 3 = plus calf pain; 4 = plus neurological signs and symptoms). For patients with acute, subacute and chronic there were no significant difference in 5 / 6 outcomes at 2 weeks, but patients with chronic pain had less reduction in back pain intensity. Across different QTF groups there were no significant differences in all 6 outcomes at 2 weeks.

Erhard RE, Delitto A, Cibulka MT; Relative effectiveness of an extension program and a combined program of manipulation and flexion and extension exercises in patients with acute low back syndrome Phys Ther; 74:(12)1093-1100, 1994.

Manipulation and general exercise group had greater improvements than pure extension group.

Fritz JM, Delitto A, Erhard RE; Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. A RCT. Spine; 28:1363-1372, 2003.

78 patients with acute back pain randomised to AHCPR guidelines or care based on classification by therapist. Patients in classification group had significantly better functional outcomes at 4 weeks, and less work loss in follow-up year.

Fritz JM, Lindsay W, Matheson JW et al; Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Spine; 32.E793-E800, 2007.

64 patients with leg pain and signs of nerve root compression were randomised to extension oriented treatment by itself or with mechanical traction. Percentages demonstrating centralisation and peripheralisation in response to different movements were presented. The traction group had some greater improvements at 2, but not at 6 weeks, but received twice amount of treatment. Subjects who peripheralised with extension were more likely to improve with traction; subjects who centralised with extension did better what ever treatment was given.

Gagne AR, Hasson SM; Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc. Physio Theory & Pract; 256-266, 2010.

Case study of patient showing some improvement with extension exercises and greater improvement when combined with traction over 14 sessions of treatment.

Gagne AR, Hasson SM; Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with lumbar herniated disc. Physio Theor Pract; 26:256-266, 2010.

Case report of a patient presenting with lumbar radiculopathy treated with extension exercises later supplemented with traction whose symptoms fully resolved over about 5 weeks.

Garcia AN, Costa LCM, da Silva TM, Gondo LFB, Cyrillo FN, Costa RA, Costa LOP; Effectiveness of back school versus McKenzie exercises in low back pain Phys Ther; doi:10.2522/ptj.20120414, 2013. (Ahead of Print)

A randomised controlled trial with 148 chronic back pain patients with follow-up at 1, 3 and 6 months who received either 4 group back school standardised intervention or individualised McKenzie exercises based on directional preference. There was a clinically important difference in terms of disability, but not pain, for the McKenzie method short-term, but not long-term. It documents that roughly the same percentage had a directional preference (approximately 66.5%), but it is not documented how this was assessed, nor how this shaped management in the back school group. It is documented that the therapists who gave the McKenzie management were fully certified, but in fact had only attained part A course.

Garcia AN, Gondo FLB, Costa RA, Cyrillo FN, Silva TM, Costa LCM, Costa LOP; Effectiveness of the Back School and McKenzie techniques in patients with chronic non-specific low back pain: a protocol of a randomised controlled trial. BMC Musculo Dis; 12.179, 2011.

A protocol for a planned randomised controlled trial comparing McKenzie method with back school for chronic back pain.

Gillan MG, Ross JC, McLean IP, Porter RW; The natural history of trunk list, its associated disability and the influence of McKenzie management. Eur Spine J; 7(6):480-3, 1998.

Patients with a trunk list were randomised to McKenzie protocol or non-specific back care. At 90 days there was a significantly greater reduction of list in the McKenzie group, but no clinical difference. List and functional disability were poorly correlated.

Hahne AJ, Ford JJ, Surkitt LD, Ricahrds MC, Chan AYP, Thompson SL, Hinman RS, Taylor NF.; Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders BMC Musculo Dis; 12:104, 2011.

The protocol for a planned trial in which patients with low back pain will be classified into one of 5 subgroups: disc herniation, reducible discogenic pain with directional preference, non-reducible discogenic pain, zygapophyseal joint dysfunction, and multi-factorial chronic pain. Patients will be randomised to either appropriate interventions for the classification sub-group or reassurance and general advice about remaining active.

New! Henry SM, van Dillen L, Oulette-Morton RH, Hitt JR, Lomond KV, DeSamo MJ, Bunn JY. ; Outcomes are not different for patient-matched versus non-matched treatment in subjects with chronic, recurrent low back pain: a randomized clinical trial. Spine J; doi:10.1016/j.spinee2014.03.024, 2014. (Ahead of Print)

124 back pain patients were assessed for eligibility for Treatment-Based classification system or Movement System Impairment and then randomized to matched or unmatched treatments. 76 received a matched treatment and 25 an unmatched treatment. Both groups improved significantly, but there was no significant difference between groups at 7 weeks and 12 months

Hosseinfar M, Akbari M, Behtash H, Amri M, Sarrafzadeh J.; The effects of stabilization and McKenzie exercises on transverse abdominus and multifidus muscle thickness, pain, and disability: a randomized controlled trial in non-specific chronic low back pain. J Phys Ther Sci; 25:1541-1545, 2013.

Despite the title there was no evaluation of classification based treatment, as the McKenzie group were given extension and flexion exercises with no attempt to determine any directional preference. Given which the results are rather meaningless, though they seemed to favour the stabilization group.

Larsen K, Weidick F, Leboeuf-Yde C.; Can passive prone extensions of the back prevent back problems?: a randomized, controlled intervention trial of 314 military conscripts. Spine; Dec 15;27(24):2747-52, 2002.

314 male conscripts randomised into 2 groups: one group received theory session based on TYOB, disc model, tape to back, and instructed to do 15 EIL X 2 a day for period of military duty. 214 (68%) completed follow-up at 12 months. 1-year prevalence LBP in experimental group 33%, compared to 51% in control. Numbers seeking medical help for LBP also significantly less (9% to 25%). In those who had reported LBP at baseline 1-year prevalence 45% to 80%.

lbert H, Manniche C; The efficacy of systematic conservative treatment for patients with severe sciatica. A single-blind randomised clinical controlled trial. Spine; DOI:10.1097/BRS.)b013e31821ace7f (Ahead of Print), 2011. (Ahead of Print)

181 patients with severe sciatica were randomised to directional preference exercises or sham non-back related exercises, with both groups being provided with information and advice to stay active. A mean of 4.8 treatment sessions was given. Both groups improved over time, and there were significant difference that favoured the directional preference exercises group in terms of global assessment of improvement, and improvement in neurological signs; and a trend to better outcomes in leg pain.

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.

Long A, Donelson R, Fung T, Spratt K ; Are acute, chronic, back pain-only, and sciatica-with neural deficit valid low back subgroups? Not for most patents. Spine J; 7;5:63S-64S, 2007.

Sub-group analysis from previous RCT (Long et al 2004) of 80 with directional preference who were treated with exercises matched to directional preference. There were no significant differences in outcomes between QTF groups 1-4, and in 5 of 7 outcomes between acute and chronic groups, but chronic patients reported significantly less reduction of pain. (abstract only)

Long A, May S, Fung T; Specific directional exercises for patients with low back pain: a case series. Physio Canada; 60.307-317, 2008.

Further analysis from previous trial (Long et al 2004), in which patients (N = 96) who were worse, unchanged or wanted additional treatment at the end of the 2-weeks original trial were offered alternate directional preference exercises for 2 weeks. Outcomes were analysed after the original 2-week period (unmatched treatment) and then between 2 and 4 weeks (matched directional preference treatment). A few minor clinically unimportant changes became statistically and clinically important across all outcomes when patients received treatment that matched their directional preference.

Machado LAC, Maher CG, Herbert RD, Clare H, McAuley JH; The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med; 8:10, 2010.

Comparison of trained GP care (advice, reassurance, and paracetamol) with trained GP care plus McKenzie care delivered by therapists with credentialed qualification over 3 weeks. There were significant differences favouring the McKenzie group in pain over the first few weeks, though these differences were clinically small, but there were no significant differences in perceived effect, function or persistent symptoms. Patients in the McKenzie group sought significantly less additional care.

Manca A, Dumville JC, Torgerson DJ, Klaber Moffett JA, Mooney MP, Jackson DA, Eaton S ; Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis. Rheumatology; 46:1495-15010, 2007.

This was an economic analysis of the Klaber-Moffett et al (2007) trial. Despite a mean of one additional visit in the McKenzie group and being more expensive the McKenzie group had additional benefit and was deemed to be cost-effective in regard to acquiring additional Quality Adjusted Life Years.

May S, Gardiner E, Young S, Klaber-Moffett J ; Predictor variables for a positive long-term functional outcome in patients with acute and chronic neck and back pain treated with a McKenzie approach: a secondary analysis. J Manual Manip Ther; 16.155-160, 2008.

Secondary analysis of previous trial to determine if there were any clinical characteristics that distinguished patients who responded well to McKenzie regime, which was defined as 50% reduction in functional disability scores. Pain duration less than 12 weeks, back pain rather than neck pain and centralisation were all significant predictors of a good outcome at 6 or 12 months in both univariate and multivariate analysis.

Mbada CE, Ayanniyi O, Ogunlade SO, Orimolade EA, Oladiran AB, Ogundele AO.; Rehabilitation of back extensor muscles’ inhibition in patients with long-term mechanical low-back pain. Rehabilitation; In Press, 2013.

84 patients randomised to 3 groups all receiving an MDT protocol; in addition 2 groups received static back endurance exercises or dynamic endurance exercises as well; same trial as above. The outcomes only related to muscle endurance and muscle fatigue, with no recording of pain or function. All groups showed significant improvements in endurance and fatigue, but the MDT plus dynamic endurance exercise group showed significantly better outcomes at 4 and 8 weeks.

Mbada CE, Ayanniyi O, Ogunlade SO. ; Effect of static and dynamic back extensor muscles endurance exercise on pain intensity, activity limitation and participation restriction in patients with long-term mechanical low-back pain. Med Rehab; 2011;15:11-20, 2011.

84 patients randomised to 3 groups all receiving an MDT protocol; in addition 2 groups received static back endurance exercises or dynamic endurance exercises as well; same trial as below. The outcomes related to pain, back-pain related disability using Roland-Morris and Oswestry questionnaires. There were significant differences in all groups at 4 and 8 weeks. There were no significant differences between groups in pain and Oswestry at any time point, but there was a significant difference favouring the McKenzie group plus dynamic back endurance exercises in Roland-Morris at 4 weeks only. However this difference was less than 1 /24 and of negligible clinical significance.

Miller ER, Schenk RJ, Karnes JL, Rousselle JG ; A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain J Man & Manip Ther; 13:103-112, 2005.

29/30 patients with very chronic low back pain completed 6 weeks of either intervention depending on randomisation. Both groups improved from baseline, but there were no significant differences between the groups.

Moffett JK, Jackson DA, Gardiner ED et al ; Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: 'McKenzie' vs brief physiotherapy pain management. Rheumatology; Dec;45:1514-1521, 2006.

315 patients (219 with back pain 96 with neck pain) were randomised to either: McKenzie approach or a cognitive behavioural approach and were followed for 12 months, with the main outcome being the Tampa Scale of Kinesiophobia (TSK). Both groups reported modest but clinically important functional improvements, but there were few differences between the groups. Except greater TSK Activity-Avoidance improvement at 6 months and greater satisfaction in the McKenzie group; and greater change in one aspect of Health Locus of Control measure in the cognitive behavioural approach plus The Back or Neck Book.

Nwuga G, Nwuga V; Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. Physiotherapy Practice; 1:99-105, 1985.

A treatment trial of McKenzie versus Williams protocol favours the McKenzie approach in patients with a diagnosis of disc prolapse.

Paatelma M, Kilpikoski S, Simonen R, Heinonen A, Alen M, Videman T; Orthopaedic manual therapy, McKenzie method or advice only for low back pain in working adults: a randomized controlled trial with 1 year follow-up. J Rehabil Med; 11/01/2008, 2009.

134 recruits were randomised to one of 3 treatment arms and outcomes were gathered at baseline and 3, 6 and 12 months. All groups improved significantly at 3 months, but there were no significant differences between groups. At 6 and 12 months there were significant differences favouring the McKenzie group over the advice only group. There were no significant differences between the McKenzie and orthopaedic manual therapy group at any point.

Perry J, Green A, Singh S, Watson P; A preliminary investigation into the magnitude of effect of lumbar extension exercises and a segmental rotatory manipulation on sympathetic nervous system activity. Man Ther; 16.190-195, 2011.

50 healthy volunteers randomised to manipulation or extension exercises with over-pressure with sympathetic nervous system activity monitored by skin conductance. Manipulation had a significantly greater effect.

Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S.; The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A randomized controlled trial. Spine; Aug 15;27(16):1702-9, 2002.

260 patients with chronic back pain followed up at 2 and 8 months after 8 week treatment period. With intention to treat analysis both groups improved modestly, McKenzie group favoured at 2 months. Outcomes were better and differences favouring McKenzie group were more significant in those who actually completed treatment.

Petersen T, Larsen K, Jacobsen S; One-year follow-up comparison of the effectiveness of McKenzie treatment and strength training for patients with chronic low back pain. Spine; 32.2948-2956, 2007.

Long-term follow up of previous trial showing no significant differences between groups and examined factors associated with good and bad outcomes.

Petersen T, Larsen K, Nordsteen J, Olsen S, Fournier G, Jacobsen S; The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralisation or peripheralisation. A randomised controlled tri Spine; 36.1999-2010, 2011.

574 patients were screened and 53% demonstrated centralisation, and 7% peripheralisation. These 350 patients with back pain for at least 6 weeks were randomised to MDT or chiropractic manipulation. Both groups improved, but there were significant differences that favoured the MDT group in terms of numbers reporting success after treatment, and disability at 2 and 12 months.

Ponte DJ, Jensen GJ, Kent BE; A Preliminary Report on the use of the McKenzie protocol versus Williams Protocol in the treatment of Low Back Pain. J Orthop Sports Phys Ther; Vol. 6:2; 130-139, 1984.

In LBP patients, the McKenzie protocol was superior to the Williams protocol in decreasing pain and hastening the return of pain free range of motion.

Santolin SM; McKenzie diagnosis and therapy in the evaluation and management of a lumbar disc derangement syndrome: a case study J Chiro Med; 2.60-65, 2003.

Patient with back and buttock pain who initially responded to lateral forces and then extension forces.

Schenk R, Dionne C, Simon C, Johnson R; Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation. J Man Manip Ther; (ahead of print), 2011.

31 patients who met at least 3 out of 5 of the clinical prediction rules for improvement with manipulation were randomised to receive either manipulation or MDT management. At 4 weeks there were significant improvements in both groups, but no significant differences between groups.

Schenk R, Jozefczyk, Kopf A ; A randomised trial comparing interventions in patients with lumbar posterior derangement. J Man & Manip Ther; 11:95-102, 2003.

25 patients with lumbar radiculopathy classified as derangement then randomised to McKenzie or mobilisation therapy. Significantly better outcomes pain and function for McKenzie group short-term.

Sheeran L,van Deursen R, Catterson B, Sparkes V. ; Classification-guided versus generalized postural intervention in subgroups of nonspecific chronic low back pain. Spine; 38:1613-1625, 2013.

29 patients with chronic low back pain with ‘flexion pattern’ (made worse with flexion and better with extension) and 20 with ‘extension pattern’ (made worse by extension and better with flexion) were randomised to a classification based treatment approach or a generalised postural intervention. The classification based treatment produced significantly better outcomes in pain and function at short-term.

Sheets C, Machado LAC, Hancock M, Maher C.; Can we predict response to the McKenzie method in patients with acute low back pain? A secondary analysis of a randomized controlled trial. Eur Spine J; DOI10.1007/s00586-011-2082-1, 2012. (Ahead of Print)

Secondary analysis of a previous RCT between first-line care only, or first-line care plus McKenzie to see if any of 6 variables explained better response to latter: baseline, mechanical, leg, or constant pain, worse with flexion, preference for McKenzie. None were predictors of a more favourable response.

Snook SH, Webster BS, McGorry RW; The reduction of chronic, non-specific low back pain through the control of early morning lumbar flexion: 3-year follow-up. J Occup Rehab; 12.13-19, 2002.

3-year follow-up of previous study with 62% of subjects still restricting bending activities in the early morning and claiming benefit.

Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB; The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. A randomized controlled trial. Spine; Dec 1;23(23):2601-7, 1998.

Education in the control of early morning flexion produced significant reductions in pain intensity, days in pain, disability and medication use. High drop-out rates show the difficulty of getting people to make such behavioural changes.

Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H; Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation Spine; 18(13):1839-1849, 1993.

Improvement in the extension group was significantly greater, regardless of type of radiographic abnormality, than flexion or control group.

Stankovic R, Johnell O; Conservative treatment of acute low back pain. A 5-year follow-up study of two methods of treatment Spine; 20(4):469-472, 1995.

Difference between 2 treatments at 5 years was much less, however McKenzie group had significantly less recurrences of pain and episodes of sick leave.

Stankovic R, Johnell O.; Conservative treatment of acute low-back pain. A prospective randomized trial: McKenzie method of treatment versus patient education in "mini back school". Spine; Feb;15(2):120-3, 1990.

100 acute back patients randomised to McKenzie or back school; significantly better outcomes in McKenzie group in pain, function, sick leave, recurrences, and further health care.

Svensson GL, Wendt GL, Thomee R.; A structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery: a prospective cohort study. J Rehab Med; doi:10.2340/16501977/16501977-1255, 2014. (Ahead of Print)

This was planned as a randomised controlled trial, but due to problems with recruitment ended up as a cohort study of 41 patients given a structured physiotherapy programme, consisting of an MDT intervention and then stabilisation exercises for patients who qualified for lumbar disc surgery. There was a significant improvement in pain and function at three months that was maintained at 24 months.

Udermann BE, Mayer JM, Donelson RG, Graves JE, Murray SR; Combining lumbar extension training with McKenzie therapy: effects on pain, disability, and psychosocial functioning in chronic low back pain patients. Gundersen Lutheran Med J; 3:7-12, 2004.

18 patients received McKenzie therapy or McKenzie plus resistance training. There were no significant difference between groups at 4 weeks, but strength, endurance, range of movement and quality of life measures on the SF36 had significantly improved in both groups.

Udermann BE, Spratt KF, Donelson RG, Mayer J, Graves JE, Tillotson J; Can a patient educational book change behavior and reduce pain in chronic back pain patients? Spine J; 4.425-435, 2004.

Long-term (18 month) uncontrolled cohort study of effect of TYOB on 48 of 62 chronic back pain volunteers. There were significant differences in reductions in pain and pain episodes and perceived benefit over time. Significant differences remained even with a worst-case model to account for those lost to follow-up. Compliance with exercise and posture advice was reported by about 80% long-term.

Underwood MR, Morgan J.; The use of a back class teaching extension exercises in the treatment of acute low back pain in primary care. Fam Pract; Feb;15(1):9-15, 1998.

In an acute group of patients randomised to usual GP care or a one off back class according to McKenzie principles there were no significant differences in outcome, except one difference at one year, when more of the back class group reported ‘back pain no problem in previous 6 months’.

Williams B, Vaughn D, Holwerda T; A mechanical diagnosis and treatment (MDT) approach for a patient with discogenic low back pain and a relevant lateral component: a case report. J Man Manip Ther; 19.113-118, 2011.

Case study of patient with back and referred pain with MRI showing large postero-lateral disc extrusion with no lateral shift who worsened in response to extension-based therapy, but improved rapidly in response to frontal plane exercises.

Worsfold C, Langridge J, Spalding A, Mullee MA.; Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: a randomized trial. Br J Gen Pract; Mar;46(404):165-8, 1996.

Spinal and non-spinal musculoskeletal problems managed in primary care with advice and exercise, which included exercises from Treat Your Own Back / Neck, were seen more efficiently than hospital physiotherapy (3 sessions compared to 5), and had better outcomes, though only a few were significant.
Centralisation

Aina A, May S, Clare H; The centralization phenomenon of spinal symptoms - a systematic review Man Ther; Aug;9(3):134-143, 2004.

Systematic review of 14 studies into centralisation. Prevalence 70% in 731 sub-acute back pain patients and 52% in 325 chronic back pain patients. Centralisation was reliably assessed (kappa values 0.51 to 1.0). Centralisation was consistently associated with good outcomes, and failure to centralise with poor outcomes. Association was confirmed by high quality studies.

Al-Obaidi SM, Al-Sayegh NA, Nakhi HB, Skaria N.; Effectiveness of McKenzie intervention in chronic low back pain: a comparison based on the centralization phenomenon utilizing selected bio-behavioral and physical measures Int J Phys Med & Rehab; 2013;1:128 doi:10.4172/jpmr.1000128, 2013.

Comparison of outcomes in 2 groups of patients with chronic low back pain who demonstrate complete (N =62) or partial centralization (N=43), and followed-up over 10 weeks with treatment with MDT. The groups were significantly different at baseline in terms of fear-avoidance and Roland-Morris Back Disability questionnaire. Over time both groups had highly significant changes in all outcomes relating to pain perception, fear beliefs, disability beliefs and physical performance tests, but were better in the full centralization group.

Al-Obaidi SM, Nowall AA, Nakhi HB, Al-Mandeel M; Evaluation of the McKenzie intervention for chronic low back pain by using selected physical and bio-behavioral outcome measures. Phys Med Rehab; 3.637-646, 2011.

133 of 237 patients with chronic LBP demonstrated centralization; 62, who all demonstrated centralisation, met inclusion criteria and consented to participate and were followed up 5 and 10 weeks after completion of treatment. There were improvements in fear-avoidance and disability beliefs, pain and physical performance measures at 5 weeks, that mostly remained stable at 10 weeks.

Albert HB, Hauge E, Manniche C.; Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J; DOI 10:1007/s00586-011-2018-9, 2012.

Secondary analysis of previous RCT; 176 patients with sciatica and pain below the knee given a mechanical assessment and classified: 85% reported centralization, 7% peripheralization, and 8% no effect in response to repeated movements. Leg pain was significantly better in the centralization and peripheralization groups at 3 and 12 months. Centralization occurred in all types of disc lesions reported on MRIs, from normal through to sequestrations.

Bonnet F, Monnet S, Otero J; Short-term effects of a treatment according to the directional preference of low back pain patients: a randomized clinical trial. Kinesither Rev; 112.51-59, 2011.

54 patients were randomly allocated to McKenzie method or guideline-based treatment, and final assessments were taken at the end of one week. There were significant differences in centralisation in the McKenzie group (62% versus 17%), but no difference in other outcomes (Oswestry and pain intensity) ( In French).

Broetz D, Hahn U, Maschke E, Wick W, Kueker W, Weller M; Lumbar disc prolapse: response to mechanical physiotherapy in the absence of changes in magnetic resonance imaging. Report of 11 cases. NeuroRehab; 23.289-294, 2008.

11 patients with MRI confirmed disc prolapse with over half having weakness and sensory loss were treated with repeated end-range movements and re-evaluated after 5 treatment sessions. Centralisation occurred in 8 of 11 and all patients showed improvements in signs and symptoms, but no changes in MRI features.

Broez D, Burkard S, Weller M ; A prospective study of mechanical physiotherapy for lumbar disk prolapse: five year follow-up and final report. NeuroRehab; 26.155-158, 2010.

Follow-up of previous study in which patients with lumbar herniations and demonstrating centralisation predicted good long-term outcome in the majority of patients.

Bybee F, Olsen D, Cantu-Boncser G, Condie Allen H, and Byars A; Centralization of symptoms and lumbar range of motion in patients with low back pain. Physio Theory Pract; 25:257-267, 2009.

42 patients with back pain were classified as centralised (30), centralising (3), non-centralised (9); there were significant differences between initial and final extension range in first 2 groups, but not in the latter. Patients who showed centralisation on initial visit also showed an increase of ROM during initial visit.

Bybee R, Hipple L, McConnell R, Crossland P ; The relationship between reported pain during movement and centralization of symptoms in low back pain patients. Manuelle Therapie; 9:122-127 (German), 2005.

Occurrence of centralisation was correlated with occurrence of pain during movement in 33 patients with back pain. 22 (67%) reported centralisation, 8 (24%) centralising symptoms, and 3 (9%) reported no site change in symptoms; and 29 reported pain during movement. 97% of those who reported pain during movement reported centralisation/centralising; and 93% of those who reported centralisation/centralising reported pain during movement (p=0.001 for both).

Christiansen D, Larsen K, Jensen OK, Nielsen CV; Pain Responses in Repeated End-Range Spinal Movements and Psychological Factors in Sick-Listed Patients with Low Back Pain: is there an Association? J Rehabil Med; 41.545-549, 2009.

Cross sectional study looking at centralisation status and psychological factors in 331 patients with back pain. Centralisation occurred in 30% of their sample. There were significant associations between non-centralisation and mental distress and depression.

Christiansen D, Larsen K, Jensen OK, Nielsen CV.; Pain response classification does not predict long-term outcome in sick listed low back pain patients. J Orthop Sports Phys Ther; 40:606-615, 2010.

A cohort study running alongside a RCT of over 300 patients who were sick-listed for back pain and assessed for the presence of centralisation; with primary outcome being return to work. Following mechanical evaluation 30% were classified as centralisers, 8% as peripheralisers, and 62% as no response. All groups improved over the year, with no significant differences between pain response groups.

Donelson R, Aprill C, Medcalf R, Grant W.; A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine; May 15;22(10):1115-22, 1997.

63 chronic patients received a mechanical evaluation and discography, with clinicians blind to the findings of the other assessment. Centralisation (74%) and peripheralisation (69%) were strongly associated with discogenic pain, compared to no change in symptoms (12%). Centralisation (91%) was strongly associated with a competent annulus compared to peripheralisation (54%).

Donelson R, Grant W, Kamps C, Medcalf R.; Pain response to sagittal end-range spinal motion. A prospective, randomized, multicentered trial. Spine; Jun;16(6 Suppl):S206-12, 1991.

Donelson found that 47% of low back pain patients with or without referred pain displayed a directional preference to end range sagital spinal movement – 40% preferred extension, 7% preferred flexion.

Donelson R, Silva G, Murphy K.; Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine; Mar;15(3):211-3, 1990.

The centralisation phenomenon is found to be a reliable predictor of good or excellent treatment outcome. In 87 patients centralisation occurred in 87% - with centralisation occurring in 100% of 59 patients with excellent outcomes.

Edmond SL, Cutrone G, Werneke M, Ward J, Grigsby D, Weinberg J, Oswald W, Oliver D, McGill T, Hart DL.; Association between centralization and directional preference; and functional and pain outcomes in patients with neck pain J Orth Sports Phys Ther; In press, 2014.

304 patients with neck pain were included, and prevalence rates of 40% for centralization and 70% for directional prevalence were recorded. Neither were associated with pain outcomes, but directional preference and to a lesser extent, centralization, were associated with improvements in function. Younger subjects were more likely to centralize, and those with acute symptoms more likely to demonstrate directional preference.

Edmond SL, Werneke MW, Hart DL.; Association between centralization, depression, somatization, and disability among patients with nonspecific low back pain. J Orthop Sports Phys Ther; 40:801-810, 2010.

Secondary analysis of cohort study of 231 patients with back pain in which data was gathered about depression, somatization, and centralization at baseline, and measures of disability and pain at baseline and follow-up. Associations between depression and somatizisation and chronic disability were reduced in the presence of centralization.

George SZ, Bialosky JE, Donald DA ; The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise. J Orthop Sports Phys Ther; 35:580-588, 2005.

Secondary analysis of 28 patients who were classified as specific exercise category and observed for the effects of prognostic variables at baseline on outcomes at 6 months. Centralisation and fear-avoidance at work both independently and significantly predicted disability at 6 months. Only centralisation significantly predicted pain at 6 months.

Gregg CD, McIntosh G, Hall H, Hoffman CW; Prognostic factors associated low back pain outcomes J Primary Healthcare; 6;23-30, 2014.

Retrospective analysis of 1076 patients treated over 3 years with multivariate analysis to determine prognostic factors that were associated with outcome. Shorter duration of pain, lower baseline pain, intermittent pain, and a directional preference for extension were all associated with better outcomes.

Guzy G, Franczuk B, Krakowska A; A clinical trial comparing the McKenzie method and a complex rehabilitation program in patients with cervical derangement syndrome J Orthop Trauma Surg Rel Res; 2.32-38, 2011.

61 patients classified as derangement 5 (cervical radiculopathy) with centralisation at baseline were allocated to treatment by McKenzie method or heat, massage and exercises for 3 weeks. After treatment In the McKenzie group 60% had complete centralization compared to no patients in the other group; all other outcomes were also significantly better in the McKenzie group.

New! Hagovska M, Takac P, Petrovicova J.; Changes in the muscle tension of erector spinae after the application of the McKenzie method in patients with chronic low back pain. Phys Med Rehab Kuror; 24:133-140, 2014.

Comparison of muscle activity in centralizers and healthy controls, with the latter showing significantly lower erector spinae activity. Following centralization pain, disability, and erector spinae were all reduced.

Heintz MM, Hegedus EJ; Multimodal management of mechanical neck pain using a treatment based classification system. J Manual Manip Thera; 16.217-224, 2009.

Case report of patient with neck pain classified under treatment-based classification system, whose pain centralised with retraction exercises, mobilisations and posture advice.

Karas, R.; McIntosh, G.; Hall, H.; Wilson, L.; Melles, T.; The Relationship Between Nonorganic Signs and Centralization of Symptoms in the Prediction of Return to Work for Patients With Low Back Pain Phys Ther; 77:354-360, 1997.

Inability to centralize indicated a decreased probability of returning to work, regardless of the Waddell score. A high Waddell score predicted a poor chance of returning to work regardless of the patients’ ability to centralize symptoms. Waddell scores appear to be a better predictor of poor outcomes.

Kilpikoski S, Alen M, Paatelma M, Simonen R, Heinonen A, Videman T ; Outcome comparison among working adults with centralizing low back pain: secondary analysis of a randomized controlled trial with 1-year follow-up. Advances in Physio; DOI: 10.1080/14038190902963087, 2009.

Secondary analysis looking at outcomes in a group of patient with centralisation randomised to McKenzie, orthopaedic manual therapy (OMT) or advice to stay active. The McKenzie group had some significantly better outcomes after treatment and at 3 and 6 months than the advice group, but at one year there were no significant differences between the groups. There were few significant differences between the 2 active treatments (McKenzie group less leg pain at 3 months) or between OMT and the advice only group (OMT group less back and leg pain at 6 months).

Kilpikoski S, Alen M, Simonen R, Heinonen A, Videman T.; Does centralizing pain on the initial visit predict outcomes among adults with low back pain? Manuelle therapie; 14:136-141, 2010.

Secondary analysis of previous RCT (Paatelma et al. 2008) in which baseline centralizers (N=119) were compared to baseline non-centralizers (N=15) during follow-up. Centralizers had a significantly greater reduction in pain and disability immediately after the treatment period; and at 6 months for pain only. (In German)

Laslett M, Oberg B, Aprill CN, McDonald B ; Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J; 5:370-380, 2005.

83 patients with chronic low back pain underwent a full or partial mechanical examination and discography and the results were compared. The prevalence of positive discography was 75%, and of centralisation 32%. Sensitivity of centralisation to predict discogenic pain was weak (about 40%), but specificity was high and 100% in patients without severe distress or disability.

Lisi AJ.; The centralization phenomenon in chiropractic spinal manipulation of discogenic low back pain and sciatica J Manipulative Physiol Ther ; Nov-Dec;24(9):596-602, 2001.

3 case studies demonstrating value of centralisation. 2 patients displayed centralisation and responded to mobilisation / manipulation treatment. One patient only able to peripheralise came to surgery.

Long A; The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain (a pilot study Spine; 20(23):2513-2521, 1995.

A pilot study indicating that centralisation is useful as an outcome predictor in chronic patients. There was a superior outcome comparing centralisers to non-centralisers in an interdisciplinary work-hardening programme.

Long A, May S, Fung T ; The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? J Manual Manip Thera; 16.248-254, 2008.

Secondary analysis from a previous trial (Long et al 2004) of 312 patients who received a mechanical evaluation at baseline, 84 were deemed to have a good outcome (defined as at least 30% reduction in baseline Roland-Morris score). Factors that were predictive of a good outcome were analysed using multivariate analysis. Only leg bothersomeness rating and treatment assignment survived multivariate analysis. Subjects with directional preference who received matched directional treatment were 7.8 times more likely to have a good outcome, which was a stronger predictor than a range of other biopsychosocial factors.

May S, Aina A; Centralization and directional preference: a systematic review. Manual Therapy; doi:10.1016/j.math.2012.05.003, 2012. (Ahead of Print)

The review included 54 studies relating to centralization and 8 relating to directional preference exercises. The prevalence on centralization was 44% in back and neck pain, with higher prevalence in acute (74%) than sub-acute or chronic symptoms (42%). Twenty-one of 23 studies supported the prognostic validity of centralization, whereas 2 did not. Centralization and directional preference appear to be useful treatment effect modifiers in 7 of 8 studies. Levels of reliability were very varied (kappa 0.15-0.9).

Murphy DR, Hurwitz EL; Application of a diagnosis-based clinical decision guide in patients with low back pain. Chiro Man Ther; 19:26, 2011.

Assessment of 264 consecutive patients using previously described algorithm found that 2.7% had serious pathology and 41% showed centralization. According to definitions used 23% / 27% / 24% showed lumbar, sacroiliac segmental signs (pain provocation tests) and radicular signs respectively. In 63% and 40% dynamic instability and fear beliefs were respectively diagnosed.

Murphy DR, Hurwitz EL; Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiro & Man Ther; 19:19, 2012.

Data on 95 patients with neck pain on their classification according to the diagnosis-based clinical decision guideline previously published. Potential serious illness was found in 1%, centralization in 27%, segmental pain provocation signs in 69%, and radicular signs in 19%.

Murphy DR, Hurwitz EL, McGovern EE; Outcome of pregnancy-related lumbopelvic pain treated according to a diagnosis-based decision rule: a prospective observational cohort study. J Manip Physiol Ther ; 32:616-624, 2010.

Use of a classification system that included centralisation as initial part of algorithm, after exclusion of serious pathology, in a cohort with pregnancy related back pain, of which 58% was pelvic pain, 20% back pain and the rest a mixture. Proportion with each classification is not given.

Murphy DR, Hurwitz EL, McGovern EE.; A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: a prospective observational cohort study with follow-up. J Manip Physiol Thera; 32.723-733, 2009.

Report on consecutive cohort study of patients with lumbar radiculopathy of who 62% demonstrated centralisation with repeated movements, and 8% peripheralisation. Centralisation was associated with functional improvement, especially at long-term follow-up.

Murphy DR, Hurwitz EL.; Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiro & Manual Ther; 19:19, 2011.

Application of a diagnosis-based classification system (not MDT) in 95 patients with neck pain; centralization was found in 27%. Larger proportions had segmental pain provocation signs, myofascial sign sand dynamic instability according to the study criteria. Classifications were not mutually exclusive.

Rathore S; Use of McKenzie cervical protocol in the treatment of radicular neck pain in a machine operator. J Can Chiropr Assoc; 47:291-297, 2003.

Case study of patient with cervical radicular pain, demonstrating centralisation in response to retraction and extension, categorised as derangement and treated with retraction and extension exercises.

Schenk R, Bhaidani T, Boswell M, Kelley J, Kruchowsky T; Inclusion of mechanical diagnosis and therapy (MDT) in the management of cervical radiculopathy: a case report. J Manual Manip Ther; 16:E2-E8, 2008.

Case report of patients with cervical radiculopathy whose symptoms centralise with repeated retraction and rotation, and then are abolished with repeated retraction and extension. Numeric pain rating scale and Neck Disability Index are reduced to zero at discharge and 3 month follow-up.

Skikic EM, Suad T; The effects of McKenzie exercises for patient with low back pain, our experience. Bosnian J Basic Med Sci; III.70-75, 2003.

Cohort study of 34 acute to chronic patients treated with McKenzie approach, with significant improvements in pain and range of movement: 61.5% demonstrated centralisation.

Skytte L, May S, Petersen P; Centralization: Its prognostic value in patients with referred symptoms and sciatica Spine; 30:E293-E299, 2005.

60 patients with referred symptoms and sciatica following a mechanical evaluation were classified as centralisers (25) or non-centralisers (35). Patients then followed a standardised management pathway that involved surgery if there was a failure to improve. Both short and long-term the centralisation group had significantly better outcomes for pain and disability. Non-centralisers were 6 times more likely to have surgery.

Sufka A, Hauger B, Trenary M, Bishop B, Hagen A, Lozon R, Martens B.; Centralization of low back pain and perceived functional outcome. J Orthop Sports Phys Ther; Mar;27(3):205-12, 1998.

Of 36 patients 70% centralised within 14-day test period – centralisation was less amongst those with chronic symptoms and those with more referred pain. Centralisation was associated with significantly more improvement on one of the functional outcome measures used.

Tuttle N; Is it reasonable to use an individual patient’s progress after treatment as a guide to ongoing clinical reasoning? J Manip Physiol Ther; 32.396-403, 2009.

Review and commentary about using patient responses as a guide to clinical reasoning. Changes in range of movement and centralisation of symptoms are better indicators of treatment effectiveness than changes in pain intensity or changes in joint position. Limited evidence to support the use of changes in segmental stiffness to guide management.

Werneke M, Hart DL, Cook D; A descriptive study of the centralization phenomenon. A prospective analysis. Spine; Apr 1;24(7):676-83, 1999.

Of 289 patients with acute neck and back pain 31% centralised during repeated movement testing in the clinic and achieved abolition of symptoms on an average of 4 sessions; 46% showed some centralisation or reduction of symptoms on an average of 8 sessions (partial response); 23% showed no change in symptom site or intensity over an average of 8 sessions. The authors question whether in the partial response group changes were a product of the natural history or exercise programme. Both centralisers and partial responders showed significant improvement in pain intensity and function, whilst the non-response group did not. Assessment of initial pain location was reliably assessed.

Werneke M, Hart DL, Resnik L, Stratford PW, Reyes A; Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther; 38:116-125, 2008.

Report of over 350 spine patients; 76% lumbar, 53% chronic symptoms (> 3 months), mean age 58 years. Overall rate of centralization at intake as measured on a body chart template was 17%, with higher rates in more acute and younger patients. For instance rates were 29% and 24% for acute (< 3 weeks) lumbar and cervical patients, and 32% and 30% for lumbar and cervical patients aged between 18 and 44. Centralization was much less common in those with chronic symptoms and those over 64 for lumbar problems and over 44 for those with cervical problems. Outcomes were better amongst centralizers and outcomes were worse amongst non-centralizers.

Werneke M, Hart DL.; Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine; Apr 1;26(7):758-65 , 2001.

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.

Werneke M, Hart DL:; Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomical pain patterns Spine; 28(2), 161-166, 2003.

Re-analysis of data from earlier study comparing prognostic usefulness of classifying patients as centralisers on the first visit compared to during subsequent visits. At first visit 130 (45%) were classified as centralisers, only 4 became non-centralisers, but 43 became partial centralisers. At first visit 157 (55%) were classified as non-centralisers – of these 95 (60%) became partial or full centralisers at later sessions.

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 MW, Hart DL, George SZ, Deutscher D, Stratford PW.; Change in psychosocial distress associated with pain and functional status outcomes in patients with lumbar impairments referred to physical therapy services. J Orth Sports Phys Ther; 41:969-980, 2012.

Re-analysis of data from 586 patients with back pain; patients who demonstrated non-centralization (37%) had significantly worse pain, functional disability and psychosocial distress outcomes compared to those who centralized (45%). No pain pattern classification was recorded in 18%.

Werneke MW, Hart DL, George SZ, Stratford PW, Matheson JW, Reyes A ; Clinical outcomes for patients classified by fear-avoidance beliefs and centralization phenomenon Arch Phys Med Rehab; 90:768-777, 2009.

Secondary analysis looking at predictors of outcome in 238 patients with back pain: 18% centralisers, 52% non-centralisers, and 30% could not be classified; 56% had low fear avoidance, 44% had high fear avoidance. Treatments depended on classification according to these variables. Patients who demonstrated centralisation improved most whatever their levels of fear avoidance; those with high levels of fear avoidance improved least. Both centralisation and fear-avoidance levels impacted on outcomes.

Werneke MW, Hart DL.; Categorizing patients with occupational low back pain by use of the Quebec Task Force Classification system versus pain pattern classification procedures: discriminant and predictive validity Phys Ther; Mar;84(3):243-54, 2004.

Re-analysis of previously collected data comparing different methods of classifying back pain patients for their ability to predict outcome. QTF 3 or 4 predicted high levels of pain and disability at intake, but only centralisation / non-centralisation categories predicted pain and disability at discharge. Non-centralisation was stronger predictor of work status at 1 year than fear-avoidance. Predictive value of centralisation / non-centralisation stronger when followed through rehabilitation period, than just at intake.

Werneke MW, Hart DL.; Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain. J Rehabil Med; Sep;37(5):286-90, 2005.

Re-analysis of data from previous study to determine association between centralisation category and psychosocial variables. Non-centralisation patients were significantly more likely to have positive non-organic signs, overt pain behaviour, fear of work activities and somatisation, but no difference was found between centralisation category regarding depression, fear of physical activity, disability or pain intensity.

Williams MM, Hawley JA, McKenzie RA, van Wijmen PM.; A comparison of the effects of two sitting postures on back and referred pain. Spine; Oct;16(10):1185-91, 1991.

Over a 24-48 hour period 2 groups of patients with back and referred pain were encouraged to sit in lordosis or in a kyphotic posture. Lordotic sitting group had back and leg pain significantly reduced and pain centralised compared to kyphotic group.
Lumbar: Observational studies

Escolar-Reina P, Medina-Mirapeix F, Gascon-Canovas JJ, Montilla-Herrador J, Valera-Garrido JF, Collins SM; Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study. Arch Phys Ther Rehabil; 90.1734-1739, 2009.

Prospective study looking at association between certain variables and adherence to self-management strategies. Adherence to strategies of self-management were more likely when patients received information about the strategy and about their problem.

Gard G, Gille KA, Degerfeldt L; McKenzie method and functional training in back pain rehabilitation. A brief review including results from a four-week rehabilitation programme. Phys Ther; 5; 107-115, 2000.

Uncontrolled study of 40 patients treated with McKenzie and functional rehabilitation; 14 pain free afterwards. 36 /40 derangements; 18 / 36 demonstrated centralisation.

Hammer C, Degerfeldt L, Denison E; Mechanical diagnosis and therapy in back pain: compliance and social cognitive theory. Advances in Physio; 9.190-197, 2007.

Study of 58 patents being treated with MDT that examined self-efficacy and compliance. Self efficacy was rated high; compliance tended to decrease over time, but at 2 months was still 64%. Pain and disability decreased over 5 visits and remained minimal at 2-month follow-up.

Hefford C; McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference. Manual Therapy; 13.75-81, 2008.

Survey of over 300 consecutive patients with cervical, thoracic and lumbar pain from over 30 therapists, which describes mechanical classification, pain patterns and directional preference of reducible derangements. Over 90% were classified with a mechanical syndrome and more than 80% with derangement. Extension was the commonest directional preference by far, especially amongst patients with central or symmetrical symptoms, but also in over 50% of patients symptoms in the arm or leg.

Kopp JR, Alexander AH, Turocy RH, Levrini MG, Lichtman DM.; The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. A preliminary report. Clin Orthop; Jan;(202):211-8, 1986.

67 patients with disc herniations and nerve root signs were given extension exercises. Of those who improved, 34/35 (97%) achieved full extension. 32 came to surgery, of which only 2 (6%) were able to extend. The ability to achieve full passive extension correlated with good response to conservative treatment, and this was mostly achieved in a few days. Sequestrations were found in 56% of those who came to surgery.

May S; Classification by McKenzie mechanical syndromes: A survey of McKenzie-trained faculty. J Manipulative Physiol Ther; Oct;29:637-642, 2006.

Survey of 57 therapists in 18 countries and details of 607 consecutively discharged spinal patients and their mechanical syndrome classification. Individually each therapist recorded a mechanical classification in 82% of their patients, in total 83% of 607 patients had a mechanical classification - derangement 78%, dysfunction 3%, adherent nerve root (1%) and postural syndrome (1%). 'Other' was recorded in 17% of patients, most commonly mechanically inconclusive, chronic pain state and post surgery.

Mbada CE, Ayanniyi O, Ogunlade SO.; Patterns of McKenzie syndromes and directional preference in patients with long-term mechanical low-back pain. Romanian J Phys Ther; 2013;19:62-68, 2013.

89 patients with low back pain for at least 3 months were classified by credentialed therapists using a repeated movements McKenzie assessment and based on symptom response: 80%, 7%, and 13% were classified with derangement, dysfunction and postural syndrome respectively.

McKenzie RA; A Prophylaxis in Recurrent Low Back Pain New Zealand Med J; No. 627, 89:22-23, 1979.

Frequent restoration of the lumbar lordosis and avoidance of flexion were seen as critical factors in prophylactic education for prevention of recurrent LBP. McKenzie reports on 318 patients - onset, aggravating and relieving factors, deformity, and the success of treatment in reducing further attacks as reported by the patients.

Melbye M; An adherent nerve root - classification and exercise therapy in a patient diagnosed with lumbar disc prolapse. Manual Therapy; DOI:10.1016/j.math.2009.04.010, 2009. (Ahead of Print)

Case report of a patient diagnosed as lumbar disc prolapse who in fact responds to flexion repeated movements and for whom the real classification is adherent nerve root.

Monk C; Measurement of the functional improvement in patients receiving physiotherapy for musculoskeletal conditions. NZ J Physiotherapy; 34:50-55, 2006.

Consecutive case series over a one month period of patients with back pain (N=29) or lower limb problems (N=39) treated according to MDT philosophy with record of before/after functional disability outcomes; 11 additional patients were excluded. Patients received an average of 5.1 treatment sessions; back pain patients improved by 71%, lower limb patients by 69% (p<0.0001 both).

Ojha H, Egan W, Crane P.; The addition of manipulation to an extension-oriented intervention for a patient with chronic LBP J Man Manip Ther; 21:40-47, 2013.

Case study of a patient with chronic low back pain who demonstrated centralization and 4 / 5 of the clinical prediction rules for manipulation. These combined treatments saw an improvement in outcomes after 7 treatment sessions.

Owen JE, Orpen N, Ayris K, Birch NC; Very early McKenzie protocol intervention for back pain in hospital workers. JBJS ; 82B. Supp III. 212 (abstract), 2000.

Following introduction of a McKenzie trained therapist to manage hospital employees days lost due to back pain fell be 52%, number of staff off due to back pain fell by 27%, and number of episodes of absenteeism due to back pain fell by 30%.

Padmanabhan G, Sambasivan A, Desai MJ ; Three-step treadmill test and McKenzie mechanical diagnosis and therapy to establish directional preference in a patient with lumbar spinal stenosis: a case report. J Man Manip Ther; 19:35-41, 2011.

Case study of a patient with apparent neurogenic claudication and degenerative spinal stenosis and spondylolisthesis on imaging, but had failed to respond to flexion exercises or epidural injections. As initially there was an improvement in walking time with repeated extension movements, he was started on an extension exercise programme and after 2-3 weeks there were major improvements in function, walking distance, and leg symptoms.

Rasmussen C, Nielsen GL, Hansen VK, Jensen OK, Schioettz-Christensen B ; Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine; 30: 2469-2473., 2005.

In region in Denmark following introduction of spine clinics there was a significant decrease in spine surgery that was not found in the rest of Denmark during the same period. The clinics were based on Indahl and McKenzie principles and patients were treated by McKenzie trained physical therapists.

Van Helvoirt H, Appeldorm AT, Ostelo RW, Knot DL, Arts MP, Kamper SJ, van Tulder MW. ; Transforminal epidural steroid injections followed by Mechanical Diagnosis and Therapy to prevent surgery for lumbar disc herniation. Pain Medicine; in press, 2014.

Patients were referred for surgery for disc herniation, confirmed by MRI with two or more neurological signs, after failed conservative care and no signs of centralization; 71 of 132 patients met these criteria. Patients received transforaminal epidural steroid injections (1-4) and then were re-evaluated by MDT clinicians. There were 2 drop outs, and the other patients were classified as follows: 11 resolved; 43 improved and pain now either centralizing or non-centralizing; 15 no improvement and no centralization and underwent surgery.
Lumbar: Surveys of Physical Therapy practice

Battie MC, Cherkin DC, Dunn R, Clol MA, Wheller KJ.; Managing Low Back Pain : Attitudes and Treatment Preferences of Physical Therapists. Phys Ther; 74:3, 219-226, 1994.

A survey of therapists in USA when presented with hypothetical back pain patients. The McKenzie method was deemed the most useful method of managing patients, and was said to be a very common means of evaluating patients.

Byrne K, Doody C, Hurley DA.; Exercise therapy for low back pain: a small-scale exploratory survey of current physiotherapy practice in the Republic of Ireland acute hospital setting. Man Ther; Nov;11(4):272-8, 2006.

73% response rate to survey of 24 physiotherapy departments: stabilisation exercises were most popular with acute (39%) and chronic (51%) back pain, followed by McKenzie approach (36% and 17% respectively).

New! Davies C, Nitz AJ, Mattacola CG, Kitzman P, Howell D, Viele K, Baxter D, Brockopp D.; Practice patterns when treating patients with low back pain: a survey of physical therapists. Physio Theory Pract; 30:399-408, 2014.

250 physical therapists in Kentucky, USA were mailed the survey about the use of classification systems and outcome measures when treating patients with low back pain, and 120 (48%) responded. 73% reported using a classification system and 85% using outcome measures. The commonest classification systems were: McKenzie (61%), treatment-based approach (58%), movement impairment approach (21%), and other approached (16%). 86% reported that they learned the classification system as a post-graduate. The most common outcome measures were Oswestry, Numeric Pain Rating Scale, and Roland-Morris disability questionnaire.

Foster NE, Thompson KA, Baxter GD, Allen JM; Management of nonspecific low back pain by physiotherapists in Britain and Ireland. A descriptive questionnaire of current clinical practice. Spine; Jul 1;24(13):1332-42, 1999.

The McKenzie method was said to be the second most common treatment approach used by therapists. The Maitland approach was used by 59%, McKenzie method by 47%,, multiple other approaches were used as well with less frequency – combined approaches were common.

Gracey JH, McDonough SM, Baxter GD.; Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine; Feb 15;27(4):406-11, 2002.

Details of management of over 1,000 patients by 157 therapists over 12-month period. McKenzie was used in over 70% of patients, usually in combination, and was one of the most commonly used approaches. McKenzie course attendees ranged from 76% for A to 16% for D.

Hamm L, Mikkelsen B, Kuhr J, Stovring H, Munck A, Kragstrup J ; Danish physiotherapists’ management of low back pain. Advances in Physio; 5:109-113, 2003.

An audit of 242 Danish PTs (14% of total) during a 4 week period to see if they used recommended treatments. McKenzie was used in 40% of consultations; there was a lot of combination of treatments; 22% of consultations involved non-recommended treatments, such as ultrasound and short-wave. McKenzie was most commonly used in acute back pain with radiation (64%), acute back pain (44%), chronic back pain with radiation (40%), and least in chronic back pain (27%).

Jackson DA; How is low back pain managed? Retrospective study of the first 200 patients with low back pain referred to a newly established community-based physiotherapy department. Physiotherapy; 87;11 573-581, 2001.

In 58% of patients McKenzie approach was used, usually in combination with other therapies. Electrotherapy was commonly used also.

New! Miller-Spoto M, Gombatta SP.; Diagnostic labels assigned to patients with orthopaedic conditions and the influences of the label on selection of interventions: a qualitative study of orthopaedic clinical specialists (OCS) Phys Ther; 94:776-791, 2014.

Case reports of 2 patients with back and shoulder pain were developed and sent to 877 board-certified OCS with 107 (12%) responding with sufficient data. The most common labels used were respectively: combination (49%) and pathology (33%); and pathology (57%) and combination (35%). The most common classification systems used for back pain case study were McKenzie (47%), pathoanatomic (18%), and treatment-based classification system (9%). The most common classification system used for shoulder case study was pathoanatomic (58%), with only 3% using the McKenzie classification. The classification systems used did not impact on the interventions used, which were most commonly some form of strengthening or stretching, or mobilisation of joints or soft tissues.

Poitras S, Blais R, Swaine B, Rossignol M ; Management of work-related low back pain: a population-based survey of physical therapists. Phys Ther; Nov;85:1168-1181, 2005.

Survey of 328 physical therapists treating workers’ compensation patients with back pain in Quebec to find their treatment objectives and chosen interventions. Wide range of exercise, mobilisation, modality and other interventions were used. McKenzie approach was used by 37% of physical therapists for patients with back pain only and 63% of therapists for patients with back and radiating pain.

Spoto MM, Collins J; Physiotherapy diagnosis in clinical practice: a survey of orthopaedic certified specialists. Physio Res Int; 13.31-41, 2008.

A survey of 850 physical therapists in USA of who 253 (30%) responded - 38% utilised a pathoanatomical classification system, 32% the McKenzie classification system, 9% the treatment-based classification system, and 7% movement impairment classification.

Stanton TR, Fritz JM, Hancock MJ, Latimer J, Maher CG, Wand BM, Parent EC; Evaluation of a treatment-based classification algorithm for low back pain: a cross-sectional study. Phys Ther; 91.496-509, 2011.

Cross-sectional study evaluating the proportion of 250 patients with back pain who fit the treatment-based classification system of manipulation, directional preference, stabilisation, or traction groups using either individual classification criteria or the more comprehensive algorithm according to their criteria. According to the former 45% were classified as directional preference group; according to the latter 31%. 25% could not be classified into any subgroup.

Stanton TR, Fritz JM, Hancock MJ, Latimer J, Maher CG, Wand BM, Parent EC. ; Evaluation of a treatment-based classification algorithm for low back pain: a cross-sectional study. Phys Ther; 91:496-509, 2012.

250 patients were recruited in USA and Australia and classified according to directional preference or stabilisation exercises, manipulation or traction subgroups. Patients were classified as follows: 31%, 17%, 42%, and 10% respectively, but there was a degree of overlap between sub-groups (25%), and 25% did not fully meet the criteria for any sub-group.
Lumbar: Studies into assessment, diagnosis and procedures

Bybee RF, Mamantov J, Meekins W, Witt J, Byars A, Greenwood M; Comparison of two stretching protocols on lumbar spine extension J Back Musculoskeletal Rehab; 21.153-159, 2008.

101 volunteers without back pain were randomised to one of 3 groups: repeated extension or static extension stretching or a control group. Participants were to perform stretches 8 times a day for 8 weeks. Both stretching groups increased range of movement at 4 and 8 weeks, the repeated more than the static stretch.

Chan AYP, Ford JJ, McMeeken JM, Wilde VE.; Preliminary evidence for the features of non-reducible discogenic low back pain: a survey of an international physiotherapy expert panel with the Delphi technique. Physiotherapy; In press, 2014.

After 3 rounds 21 international physiotherapists had listed, ranked and reached consensus on 9 features of non-reducible low back pain, a sub-group of discogenic back pain, which included: no centralization or lasting easing of symptoms, peripheralization, no effect of loading strategies, constant and easily provoked symptoms.

Clare HA, Adams R, Maher CG ; Construct validity of lumbar extension measures in McKenzie’s derangement syndrome. Manual Therapy; 12:328-334, 2007.

50 consecutive patients were classified as derangement (40) or non-derangement (10) and treated with extension procedures; extension range of movement was measured at baseline and at day 5. All patients gained extension but those classified as derangement had significantly more improvement in extension and significantly better globally perceived effect scores. The modified Schober test in standing was the most responsive was to measure extension range of the 4 methods tested.

Clare HA, Adams R, Maher CG.; Reliability of detection of lumbar lateral shift. J Manipulative Physiol Ther; Oct;26(8):476-80, 2003.

148 therapists (students, PTs, PTs with McKenzie training) viewed slides from 45 patients to determine presence, direction, and certainty of lateral shift or absence of shift. ICC values represented fair to good reliability for both intra and inter-tester reliability; kappa values were all < 0.4 (fair reliability).

Donahue MS, Riddle DL, Sullivan MS.; Intertester reliability of a modified version of McKenzie‘s lateral shift assessments obtained on patients with low back pain. Phys Ther; Jul;76(7):706-16, 1996.

Determination of a lateral shift by observation was found to be very unreliable. Determination of positive side-gliding test, based on alteration of patient’s pain, was found to be of high reliability.

Fritz JM, Delitto A, Vignovic M, Busse RG; Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil; Jan;81(1):57-61, 2000.

40 students and 40 physical therapists reviewed a composite videotape made during assessment of back pain patients and had to make judgements on changes in pain status with movement testing. Intertester reliability was excellent, kappa = 0.79.

Green AJ, Jackson DA, Klaber Moffett JA; An observational study of physiotherapists’ use of cognitive-behavioural principles in the management of patients with back pain and neck pain. Physiotherapy; 94.306-313, 2008.

This was an observational study of 10 therapists conducted within a trial comparing McKenzie method to a cognitive behavioural approach to assess how much therapists involved patients in the consultation and empowered them to develop self-management strategies; it used a tool specifically developed for the study. Patient involvement and empowerment was low in both approaches, but the cognitive behavioural group scored higher overall in both.

Gutke A, Kjellby-Wendt G, Oberg B.; The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain. Man Ther; 15.13-18, 2010.

31 pregnant women were evaluated by 2 therapists using MDT assessment and pelvic pain provocation tests and classified as lumbar, pelvic or mixed in origin. There was 87% agreement, kappa 0.79; at least 23/31 had pelvic girdle or combined pain.

Hedberh K, Alexander LA, Cooper K, Ross J, Smith FW.; Low back pain: an assessment using positional MRI and MDT. Man Ther; In Press, 2012.

Findings from the MDT assessment lead to the classification of ‘other’ in a low back pain patient, which finding was validated by a positional MRI. This revealed degenerative changes, and disc bulges at several levels and a dynamic spinal stenosis most evident at L3-4 caused by extension.

Hedberh K, Alexander LA, Cooper K, Ross J, Smith FW.; Low back pain: an assessment using positional MRI and MDT. Man Ther; IN Press, 2012.

Findings from the MDT assessment lead to the classification of ‘other’ in a low back pain patient, which finding was validated by a positional MRI. This revealed degenerative changes, and disc bulges at several levels and a dynamic spinal stenosis most evident at L3-4 caused by extension.

Horton SJ, Franz A ; Mechanical Diagnosis and Therapy approach to assessment and treatment of derangement of the sacro-iliac joint. Manual Therapy; 12:126-132, 2007.

Description of a case in which lumbar spine pain was ruled out and then direction preference exercises targeting the SIJ abolished a patients 2-year history of buttock and thigh pain.

Kilby J, Stigant M, Roberts A; The Reliability of Back Pain Assessment by Physiotherapists using a 'McKenzie Algorithm'. Physiotherapy; 76:9;579-583, 1990.

Kilby presents a McKenzie algorithm which was found to be intertester reliable, except with regard to identifying the presence of a lateral shift or a kyphotic lumbar spine.

Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M.; Interexaminer reliability of low back pain assessment using the McKenzie method. Spine; Apr 15;27(8):E207-14, 2002.

39 patients with back pain were assessed by 2 therapists in turn, clinical and classification decisions were compared using Kappa statistics. Agreement was poorer for presence of lateral shift than relevance of shift or lateral component. Agreement on centralisation, directional preference, and mechanical classification was good to excellent.

Laslett M; Manual correction of an acute lumbar lateral shift: maintenance of correction and rehabilitation: a case report with video. J Manual Manip Ther; 17:78-85, 2009.

Case report of a patient with a lateral shift who responds rapidly to manual correction and progresses on to gym based rehabilitation, with an accompanying video.

Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B ; Agreement between diagnosis reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disord; 6:28, 2005.

In 216 patients with chronic low back pain structural diagnosis, as defined by intra-articular injections or discography was compared to clinical diagnosis: discogenic pain defined as centralisation or directional preference. Discogenic pain was the commonest diagnosis by both radiographer and physiotherapist, followed by ‘illness behaviour’ and ‘indeterminate’. Diagnoses of SIJ or ‘facet’ joint were rarely made. Agreement between radiographer and clinical examination was weak.

Laslett M, Williams M; The reliability of selected pain provocation tests for sacroiliac joint pathology Spine; 19(11):1243-1249, 1994.

Five of the seven tests were shown to be reliable, and may be used to detect a sacroiliac cause of low back pain. They were the distraction (or gapping) test, compression test, posterior shear (or thigh thrust) test, left and right pelvic torsion (or Gaenslen’s) test.

Laslett M, Young SB, Aprill CN, McDonald B.; Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother; 49(2):89-97, 2003.

Using initial Mechanical evaluation to exclude mechanical responders and 3 or more positive pain provocation SIJ tests compared to a double intra-articular injection was more accurate in diagnosing SIJ problems (sensitivity 91%, specificity 87%) than SIJ pain provocation tests only (sensitivity 91%, specificity 78%).

May S, Littlewood C, Bishop A; Reliability of procedures used in the physical examination of non-specific low back pain: a systematic review. Aust J Physiother; 52(2):91-102, 2006.

48 studies met the inclusion and exclusion criteria, and were grouped under types as: palpation, symptom response, observation, classification system. Very few physical examination procedures were deemed to be consistently reliable at threshold of reliability coefficient of 0.85. At reliability coefficient 0.70 evidence about pain response to repeated movements changed from contradictory to moderate evidence for high reliability. The McKenzie classification system had contradictory reliability; of 3 high quality studies 2 demonstrated reliability one did not – the study demonstrating lack of reliability used inexperienced therapists with limited / no training in MDT.

May S, Rosedale R; A case of a potential manipulation responder whose back pain resolved with flexion exercises. J Manipulative Physiol Ther; 30:539-542, 2007.

Case study of a patient who met 4 / 5 of clinical prediction rule criteria for a manipulation responder but who also displayed a directional preference for flexion exercises, and resolved symptoms and functional disability rapidly with self-management exercises. This suggests that clinical prediction rule criteria for manipulation responders and directional preference may not be discrete groups.

McKenzie RA; Manual Correction of Sciatic Scoliosis New Zealand Med J; 484,76:194-199, 1972.

McKenzie outlines the treatment procedure for manual correction of sciatic scoliosis.

Petersen T, Olsen S, Laslett M et al. ; Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain. Aust J Physiother; 50:85-91, 2004.

Reliability study of their classification system, which borrows many aspects from McKenzie system. Kappa values for mechanical syndromes (derangement, dysfunction, postural syndrome) mostly > 0.60.

Petersen T, Thorsen H, Manniche C, Ekdahl C; Classification of non-specific low back pain: a review of the literature on classification systems relevant to physiotherapy Phys Ther Rev ; 4:265-281, 1999.

A critical appraisal, using a systematic approach, of 8 classification systems for non-specific back pain. Various types of validity are examined, and despite having weaknesses in reliability and content validity, the McKenzie system is rated as one of the most promising.

Razmjou H, Kramer JF, Yamada R; Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther; Jul;30(7):368-383, 2000.

Two physical therapists, one assessor, one observer, both experienced in McKenzie assessed 45 subjects and were analysed on agreements using Kappa statistics. Agreement on syndromes was good (93%), derangement sub-syndrome classification was excellent (97%), presence of lateral shift was moderate (78%), relevance of lateral shift and lateral component was very good/excellent (98%), deformity in sagittal plane was excellent (100%).

Riddle DL, Rothstein JM.; Intertester reliability of McKenzie‘s classifications of the syndrome types present in patients with low back pain. Spine; Aug;18(10):1333-44, 1993.

369 patients assessed by 49 therapists with no or minimal training in McKenzie. Intertester reliability using author’s version of the system was poor, agreement on classification was 39%.

Seymour R, Walsh T, Blankenberg C, Pickens A, Rush H; Reliability of detecting a relevant lateral shift in patients with lumbar derangement: a pilot study J Man & Manip Ther; 10(3):129-135, 2003.

15 patients were examined by 6 therapists to determine reliability of determining if a lateral shift was present and if it was relevant; observed agreement was 73%, kappa 0.56

Werneke MW, Deutscher D, Hart DL, Stratfoed P, Ladin J, Weinberg J, Hebowy S, Resnik L.; McKenzie lumbar classifications: inter-rate agreement by physical therapists with different levels of formal McKenzie post-graduate training. Spine; DOI:10.1097/BRS0000000000000117, 2014. (Ahead of Print)

47 raters examined 1,662 patients who had completed various levels of courses; A through to D, and paired therapists sequentially examined the same patients in a blinded fashion. Agreement on McKenzie syndrome, lateral shift, reducible versus irreducible derangement, directional preference and centralisation was poor, with all kappa values below 0.44. Sequential course completion did not necessarily improve reliability.

Young S, Aprill C, Laslett M; Correlation of clinical examination characteristics with three sources of chronic low back pain Spine; 3.460-465, 2003.

In 81 chronic back pain patients 51 had positive response to diagnostic injection into disc, zygapophyseal or sacro-iliac joints. Centralisation, midline pain, and pain on rising from sitting were significantly associated with a positive discogram. Sacro-iliac joint pain was strongly associated with 3 or more positive pain provocation tests, pain on rising from sitting, unilateral pain and absence of mid-line or lumbar pain. Zygapophyseal pain was associated with absence of pain on rising from sitting.
Lumbar: Anatomical & physiological studies

Al-Obaidi S, Anthony J, Dean E, Al-Shuwai N.; Cardiovascular responses to repetitive McKenzie lumbar spine exercises Phys Ther; Sep;81(9):1524-1533, 2001.

Blood pressure and heart rate goes up in normal individuals when they perform repeated exercises as described by McKenzie.

Al-Obaidi SM, Asbeutah A, Al-Sayegh N, Dean E.; To establish whether McKenzie lumbar flexion and extension mobility exercises performed in lying affect central as well as systemic hemodynamics: a crossover experimental study. Physiotherapy; In press, 2013.

In healthy male volunteers repeated flexion and extension movements tend to increase the work of the heart, especially with more repetitions.

Alexander LA, Hancock E, Agouris I, Smith FW, MacSween A ; The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions. Spine; 32:1508-1512, 2007.

First ever study using upright magnetic resonance imaging of effect of functional positions on movement of the nucleus pulposus (NP) in 11 volunteers. In sitting there was significantly less lordosis than prone lying and standing, and significantly more posterior migration of the NP than other positions.

Aota Y, Iizuka H, Ishige Y, Mochida T, Yoshihisa T, Uesugi M, Saito T; Effectiveness of a lumbar support continuous passive motion device in the prevention of low back pain during prolonged sitting. Spine; 32(23):674-677, 2007.

Asymptomatic volunteers tested prolonged sitting with 1) no lumbar support, 2) static lumbar support, or 3) continuous passive motion lumbar support. There were significant differences between 1 and 2 / 3 in discomfort / pain, stiffness and fatigue, but no significant differences between 2 and 3

Astfalck RG, O’Sullivan PB, Straker LM, Smith AJ, Burnett A, Caneiro JP, Dankaerts W; Sitting postures and trunk muscle activity in adolescents with and without nonspecific chronic low back pain. An analysis based on subclassification. Spine; 35:1387-1395, 2010.

Cross-sectional comparison of adolescents with and without back pain regarding posture and muscle activity, with no differences identified between groups. However flexion responders sat in more lordosis, and extension responders sat in more kyphosis, but muscle activity displayed no clear cut differences.

Bakker EW, Verhagen AP, Lucas C, Koning HJ, de Haan RJ, Koes BW.; Daily spinal mechanical loading as a risk factor for acute non-specific low back pain: a case-control study using the 24-Hour Schedule Eur Spine J.; Jan;16(1):107-13, 2007.

100 cases with acute back pain were compared by a blinded assessor with 100 controls using the 24-Hour Schedule, which quantifies spinal mechanical loading taking into account duration of activity, sagittal movement and loading status. There were no significant differences between cases and controls in predominant work postures. There were significant differences between the groups in hours in flexion and extension, with cases spending significantly more hours in flexion and significantly less likely to be in extended postures.

Bakker EWP, Verhagen AP, Lucas C, Koning HJCMF, Koes BW ; Spinal mechanical load: a predictor of persistent low back pain? A prospective cohort study. Eur Spine J; 16:933-941, 2007.

A prospective cohort study of 100 back pain patients who were reviewed at 6 months (N = 88) when 60% reported persistent back pain. Baseline factors were analysed for their association with back pain. Multivariate analysis found smoking and older age (protective) to be associated, while univariate analysis found the 24-hour schedule to be, this is a measure of spine mechanical load.

Balkovec C, McGill S; Extent of nucleus pulposus migration in the annulus of porcine intervertebral discs exposed to cyclic flexion only versus cyclic flexion and extension Clin Biomech; 27:766-770, 2012.

Basic science experiment using porcine spines exposed to both repeated flexion and extension, or just repeated flexion. The specimens exposed to both directions of movement showed significantly more damage to the annulus and more axial creep.

Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L ; The immediate reduction in low back pain intensity following lumbar joint mobilization and prone press-ups is associated with increased diffusion of water in the L5-S! intervertebral disc. JOSPT; 40.256-264, 2010.

20 patients with back pain who received extension mobilizations and extension in lying were monitored with MRI before and after, and classified as responders if there was a reduction in pain score of 2 or more. Responders demonstrated a mean increase in diffusion coefficient in the middle portion of the disc compared to a mean decrease in the non-responders.

Beattie PF, Brooks WM, Rothstein JM, Sibbitt WL Jr, Robergs RA, MacLean T, Hart BL.; Effect of lordosis on the position of the nucleus pulposus in supine subjects. A study using magnetic resonance imaging (MRI). Spine; Sep 15;19(18):2096-2102, 1994.

In vivo some anterior displacement of the nucleus pulposus with extension movements was observed. Degenerated discs appear to behave differently from non-degenerated discs.

Boissonnault W, Fabio RP.; Pain profile of patients with low back pain referred to physical therapy. J Orthop Sports Phys Ther; Oct;24(4):180-91, 1996.

98 patients with chronic back pain surveyed about aggravating and relieving factors etc. Pain was worse in morning and evening, and commonest aggravating factors were sitting, driving, bending, and lifting. Commonest alleviating postures were recumbency, changing positions, and walking. Non-serious night pain was common.

Botwin KP, Skene G, Torres-Ramos FM, Gruber RD, Bouchlas CG, Shah CP; Role of weight-bearing flexion and extension myelography in evaluating the intervertebral disc. Am J Phys Med Rehab; 80.289-295, 2001.

Three patients with negative MRIs then investigated with weight-bearing flexion-extension myelography, which more clearly demonstrated a herniated nucleus pulposus and compression of the nerve root, which was more pronounced on flexion.

Chan AYP, Ford JJ, McMeeken JM, Wilde VE; Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique. Physiotherapy; http://dx.doiorg/10.1016/j.physio.2012.09.007, 2013.

This was a 3-round Delphi study involving 21 international physiotherapists to gain their opinions about the clinical signs for discogenic pain. After 3 rounds consensus was agreed on 10 items: directional preference, lateral shift, worse with sitting, positive discogram, pain changes sides, cough / squeeze positive, postural preference, worse with flexion, onset with trauma, mechanical pain behaviour. Consensus was also agreed on 9 items for non-reducible discogenic pain: no directional preference or centralisation, increase / peripherlisation with all loading strategies, and provocative and movement testing, no effect of loading strategies, constant pain, symptoms difficult to control, and positive discogram.

Dankaerts W, O'Sullivan P, Burnett A, Straker L.; Differences in sitting postures are associated with nonspecific chronic low back pain disorders when patients are subclassified Spine; Mar 15;31(6):698-704, 2006.

An examination of the sitting posture of back pain patients, analysed as non-specific or according to a novel classification system, and non-back pain controls. There was no difference in sitting posture between controls and un-differentiated back pain patients; however there were significant differences between sub-groups and controls. ‘Flexion pattern’ patients, with a directional preference for extension, had a more kyphotic sitting pattern than controls; and ‘active extension pattern’ patients, who had a directional preference for flexion had a more lordotic sitting posture than controls.

Dankaerts W, O’Sullivan P, Burnett A, Straker L, Davey P, Gupta R; Discriminating health controls and two clinical subgroups of non-specific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements. Spine; 34:1610-1618, 2009.

According to the authors’ classification system those who get pain relief from spinal extension sit in more flexion and those who get relief from spinal flexion sit with more extension compared with control groups.

Edmondston SJ, Song S, Bricknell RV, Davies PA, Fersum K, Humphries P, Wickenden D, Singer KP.; MRI evaluation of lumbar spine flexion and extension in asymptomatic individuals. Man Ther; Aug;5(3):158-64, 2000.

Between flexion and extension there was anterior displacement of the nucleus pulposus of 6.7%, this was significant at L1/2, L2/3 and L5/S1. Displacement did not occur in 30% of discs.

Fazey PJ, Song S, Monsas A et al; An MRI investigation of intervertebral disc deformation in response to torsion. Clin Biomech; 21;538-542, 2006.

MRI investigation of 3 asymptomatic women showing that in most instances extension caused anterior deformation of nucleus, flexion posterior deformation, and left rotation deformation to the right.

Fazey PJ, Takasaki H, Singer KP; Nucleus pulposus deformation in response to lumbar spine lateral flexion: an in vivo MRI investigation. Eur Spine J; DOI 10.1007/s00586-010-1339-4, 2010. (Ahead of Print)

A novel MRI method derived from pixels and the effect lateral flexion is described; in 95% of healthy subjects the nucleus pulposus was displaced away from the direction of lateral flexion.

Fennell A.J.; Jones, A.P.; Hukins, D.W.L.; Migration of the Nucleus Pulposus Within the Intervertebral Disc DuringFlexion and Extension of the Spine Spine; 21:2753-2757, 1996.

In vivo flexion tends to cause posterior displacement of the nucleus pulposus and extension anterior displacement using MRI.

Fredericson M, Lee SU, Welsh J, Butts K, Norbash A, Carragee EJ ; Changes in posterior disc bulging and intervertebral foraminal size associated with flexion-extension movement: a comparison between L4-5 and L5-S1 levels in normal subjects. Spine J; 1:10-17, 2001.

MRI of 3 volunteers with no history of back pain; clear trend for flexion to cause greater posterior bulging and extension to reduce posterior bulging. Intervertebral foramina increased in flexion and decreased with extension.

Geldhof E, De Clercq D, De Bourdeaudhuij I, Cardon G; Classroom postures of 8-12 year old children Ergonomics; 50(10):1571-1581, 2007.

Pupils (N = 105) were observed to spend 85% of classroom time sitting, 28% of which was flexed forward and 91% of time was static. Children who spent more time sitting flexed forward reported significantly more low back pain.

Harrison DD, Harrison SO, Croft AC, Harrison DE, Troyanovich SJ; Sitting biomechanics, part 1: Review of the literature / Sitting biomechanics, part 2: Optimal car driver’s seat and optimal driver’s spinal model. J Manipulative Physiol Ther ; 22:594-609; 23:37-47 2000, 1999.

Extensive literature review on the biomechanical effects and comfort of different sitting postures to identify optimal seating and driving posture. Concludes that maintenance of lumbar lordosis, seat-back inclination, freedom to move, and minimal anterior head translation have been shown to reduce sitting stress and be associated with higher comfort ratings.

Key S, Adams MA, Stefanakis M.; Healing of painful intervertebral discs: implications for physiotherapy. Part 2 – pressure change therapy: a proposed clinical model to stimulate disc healing. Phys Ther Rev; 2013;18:34-42, 2013.

Narrative review about the possible cause of discogenic pain, relating to inflammatory pain in the acute stage. Suggesting that physical therapy should aim to stimulate healing, as in other connective tissue problems, with loading, by stimulating cells, boosting metabolite transport, discouraging adhesion formation and preventing re-injury.

Kolber MJ, Hanney WJ; The dynamic disc model: a systematic review of the literature. Phys Ther Rev; 14.181-295, 2009.

Review of the dynamic disc model that suggests that the nucleus pulposus migrates in response to movement and positions. Twelve articles were located that demonstrated in vitro and in vivo that the nucleus migrated anteriorly during extension ad posteriorly during flexion. There was limited and contradictory data to support this model in the symptomatic and degenerated disc.

May S, Nanche G, Pingle S; High frequency of McKenzie's postural syndrome in young population of non-care seeking individuals. J Man Manip Ther; 19:48-54, 2011.

In a population under 30 years of age 138 were approached to participate in a questionnaire and 100 agreed to participate; of these 66 appeared to have postural syndromes, and they were asked to attend a physical examination, of which 37 consented. Of these 31 met the criteria for postural syndrome, with the syndrome being significantly associated with sustained loading and abolition of pain on posture correction. Symptoms were mostly, but not only, spinal, and mostly, but not only, provoked by sustained sitting.

Murphy S, Buckle P, Stubbs D ; Classroom posture and self-reported back and neck pain in school children. Applied Ergonomics; 35:113-120, 2004.

The sitting posture and self-reported pain was measured in 66 school children, mean age 13. Significant associations were found between self-reported spine pain and: lesson length, sustained trunk or neck flexion, and time working at the desk

Nairn BC, Chisholm SR, Drake JDM.; What is slumped sitting? A kinematic and electromyographical evaluation. Manual therapy; 18:498-505, 2013.

Twelve asymptomatic males were assessed. Slumped sitting was associated with posterior pelvis rotation, near-end range flexion of the mid and lower thoracic spine, and mid-range flexion of the upper thoracic and lower lumbar spine. Muscle activity decreased in the slump sitting posture.

Nazari J, Pope MH, Graveling RA. ; Reality about migration of the nucleus pulposus with in the intervertebral disc with changing postures. Clin Biomech; 27:213-217, 2012.

Magnetic resonance images of lumbar spines of 25 asymptomatic volunteers in different postures, which showed that the length of the nucleus pulposus (NP) changed in different postures rather than actual migration of the NP.

O'Sullivan K, O'Dea P, Dankaerts W, O'Sullivan P, Clifford A, O'Sullivan L; Neutral lumbar spine sitting posture in pain-free subjects. Man Ther; 15:557-561, 2010.

The habitual sitting posture of 17 pain-free individuals was significantly more flexed than individuals' subjectively perceived ideal posture, and the tester perceived neutral posture; with no significant difference between the last 2. Two testers could reliably position subjects in the tester perceived neutral posture (ICC = 0.91).

O'Sullivan P, Dankaerts W, Burnett A et al ; Evaluation of the flexion relaxation phenomenon of the trunk muscles in sitting. Spine; 31;2009-2016, 2006.

In 24 healthy volunteers neutral lordotic sitting posture facilitated multifidus and internal oblique muscles, whereas slumped sitting caused a significant decrease in their activity. Activity of erector spinae varied during slumped sitting in some it increased and in some it decreased.

O'Sullivan PB, Mitchell T, Bulich P, Waller R, Holte J ; The relationship between posture and back muscle endurance in industrial workers with flexion-related low back pain. Man Ther; 11:264-271, 2006.

24 workers with back pain provoked by flexion activities compared with 21 healthy workers had: significantly reduced muscle endurance, increased posterior pelvic tilt and sat closer to their end range of lumbar flexion.

O‘Sullivan PB, Grahamslaw KM, Kendell M, Lapenskie SC, Moller NE, Richards KV.; The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine; Jun 1;27(11):1238-44, 2002.

Compared to erect sitting and standing most trunk muscle activity is significantly less in slumped sitting or standing.

O’Keefe M, Dankaerts W, O’Sullivan P, O’Sullivan L, O’Sullivan K; Specific flexion-related low back pain and sitting: comparison of seated discomfort on two different chairs. Ergonomics; doi.org/10.1080/001401.39.2012.762462, 2013. (Ahead of Print)

In 21 participants, whose low-back pain was aggravated by sitting and better with standing, two sitting positions were trialled. Back pain was significantly more in those who sat on the normal office chair compared to those who sat on anterior-tilted seat (increased lordosis).

O’Sullivan K, McCarthy R, White A, O’Sullivan L, Dankaerts W.; Can we reduce the effort of maintaining a neutral sitting posture? A pilot study. Manual Therapy; 17:566-571, 2012.

In 12 symptom-free volunteers maintaining unsupported neutral, lordotic sitting abdominal muscles were activated. Activity only in lumbar multifidus was significantly less when maintaining same position in a forward sloping chair.

O’Sullivan K, O’Keefe M, O’Sullivan L, O’Sullivan P, Dankaerts W; Perceptions of sitting posture among members of the community, both with and without non-specific chronic low back pain. Manual Therapy; 18:551-556, 2013.

355 community participants considered posture to be important and rated 9 photographs. 54% rated a neutral lordotic posture as the best, and 78% rated a slumped sitting posture as the worst sitting postures.

O’Sullivan K, Verschueren S, van Hoof W, Ertanir F, Martens L, Dankaerts W.; Lumbar repositioning error in sitting: healthy controls versus people with sitting-related non-specific low back pain (flexion pattern). Manual Therapy; 18:526-532, 2013.

In patients made worse with flexion, compared to asymptomatic controls, there was a significant deficit in certain aspects of lumbar repositioning ability.

Powers CM, Beneck GJ, Kulig K, Landel RF, Fredericson M ; Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with non-specific low back pain. Phys Ther; 88:485-493, 2008.

Comparison of the effects, on short-term pain scores on extension in standing and extension range as measured by MRI, in 30 patients with back pain randomised to a single session of spinal mobilisation or extension in lying. There were significant improvements in both pain and range in both groups, but no significant differences between the groups.

Pynt J, Higgs J, Mackey M; Seeking the optimal posture of the seated lumbar spine. Physio Theory & Pract ; 17;5-21, 2001.

A review of the literature on the optimal sitting posture for spinal health, based mostly on cadaveric studies, but some clinical studies. They conclude that the arguments in favour of a kyphotic sitting position are not substantiated by research; and that a lordotic position, interspersed with regular movement, is the optimal sitting posture and assists in preventing back pain.

Scannell JP, McGill SM; Disc prolapse. Evidence of reversal with repeated extension. Spine; 34.344-350, 2009.

Porcine cadaver study of cervical spine - loading in flexion produced nucleus prolapse in 11 of the 18 specimens. In 5 of the 11 the prolapse was reduced with repeated loading into extension.

Schnebel BE, Simmons JW, Chowning J, Davidson R.; A digitizing technique for the study of movement of intradiscal dye in response to flexion and extension of the lumbar spine. Spine; Mar;13(3):309-12, 1988.

Nuclear material in normal discs moves anteriorly with extension and posteriorly with flexion, however movements in degenerated discs were less predictable.

Smart KM, Blake C, Staines A, Doody C.; The discriminative validity of “nociceptive,” “peripheral neuropathic”, and “central sensitization” as mechanism-based classifications of musculoskeletal pain. Clin J Pain; 2011;27:655-663, 2011.

464 patients with low-back pain were assessed using a standardised assessment protocol, assigned a mechanism-based classification according to their clinical experience, which was then checked against the protocol criteria: 55%, 22%, and 23% were classified as nociceptive, peripheral neuropathic and central sensitization respectively. Nociceptive, in other words mechanical pain, was very strongly associated with localized pain, clear aggravating and easing factors, and less strongly with intermittency of pain. Peripheral neuropathic pain was very strongly associated with dermatomal pain and positive nerve movement tests; whereas central sensitization was strongly associated with: disproportionate aggravating and easing factors, diffuse painful palpation, and psychosocial symptoms.

Takasaki H, May S, Fazey PJ, Hall T.; Nucleus pulposus deformation following application of mechanical diagnosis and therapy: a single case report with magnetic resonance imaging. J Man Manip Ther; 18:153-158, 2010.

Case study in which symptom resolution coincided with change in MRI findings from baseline to one month with use of MDT therapy.

Tsantizos A, Ito K, Aebi M, Steffen T; Internal strains in healthy and degenerated lumbar intervertebral discs. Spine; 30.2129-2137, 2009.

Cadaver study looking at the effects of degeneration and loading on nucleus pulposus deformation. The nucleus migrated to the opposite side of bending direction regardless of loading and significantly more in degenerated discs.

Van Deursen LL, Patijn J, Durinck JR, Brouwer R, van Erven-Sommers JR, Vortman BJ; Sitting and low back pain: the positive effect of rotatory dynamic stimuli during prolonged sitting Eur Spine J; 8: 187-193, 1999.

120 back pain patients sitting for 1 hour – pain increased in 104; 2 had to stop; a few got better. Pain increase was less in those with dynamic stimuli.

Womersley L, May S.; Sitting posture of subjects with postural backache J Manipulative Physiol Ther; Mar-Apr;29(3):213-8., 2006.

Nine students were classified as postural backache (history of mild backache but no functional disability) and 9 as control (no history of backache). Postural activity was recorded over 3 days and relaxed sustained sitting posture observed with computerised video analysis. The postural backache group had significantly longer periods of uninterrupted sitting and sat with greater flexion when relaxed.

Zou J, Yang H, Miyazaki M, Morishita Y, Wei F, McGovern S, Wang JC; Dynamic bulging of intervertebral discs in the degenerative lumbar spine. Spine; 34:2545-2550, 2009.

On a kinematic MRI non-degenerated discs moved posteriorly in flexion and anteriorly in extension. However more degenerated discs behaved much less predictably, and extension may lead to posterior disc bulging.
Discussion Articles

McKenzie RA; A perspective on Manipulative Therapy Physiotherapy; 75:8. pp 440-444, 1989.

McKenzie presents a review of spinal manipulative therapy and suggests that therapist generated forces should only be indicated when patient generated forces have been exhausted.

Sagi G; Process to clinically identify a directional preference in patients suffering from spinal mechanical pain with the McKenzie method. Kines Rev; 99.17-23, 2010.

Summary of how therapists can find clues for directional preference in the history and confirm these on physical examination (in French).

Watson G; Neuromusculoskeletal physiotherapy: Encouraging self-management. Physiotherapy; 82:6;352-357

Watson urges that physiotherapists should promote a therapeutic alliance with patients to encourage self-management, an approach that is efficient, increases patient compliance, and helps prevent recurrences.
Cervical: Reviews

Donelson R; Mechanical Diagnosis and Therapy for Radiculopathy. Phys Med Rehabil Clin Nth Am; 22.75-89, 2011.

Review of role of MDT in patients with sciatica or radiculopathy.

New! Takahashi H, May S; Mechanical Diagnosis and Therapy has similar effects on pain and disability as ‘wait and see’ and other approaches in people with neck pain: a systematic review. J Physio; http://dx.doi.org/10.1016/j.phys.201405.006, 2014.

This systematic review included 5 randomised controlled trials that scored between 5 and 8 on the PEDro scale regarding quality. Most demonstrated mean differences that favoured MDT in terms of pain and disability, although most were not statistically significant. Pooled data from some of the studies revealed marginal, but probably not clinically important differences favouring MDT.
Cervical: Trials

Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH.; Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain. Ann Int Med; 156:1-10, 2012.

272 patients randomised to manipulation, medication, or home exercise programme, which consisted predominantly of retraction, extension, plus some lateral exercises. Manipulation was no more effective than the home exercise programme at any time point, with one year follow-up.

Guzy G, Franczuk B, Krkowski A. ; A clinical trial comparing the McKenzie method and a complex rehabilitation program in patients with cervical derangement syndrome. J Orth Trauma Surg Rel Res; 2011;2:32-38, 2011.

Sixty-one patients with cervical radiculopathy randomised to McKenzie method or a multi-dimensional rehabilitation programme. The group receiving McKenzie method had significantly better results regarding centralization, upper extremity pain and pain-free days.

Kjellman G, Oberg B:; A randomised clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain. J Rehabil Med; 34:183-190, 2002.

77 patients with acute to chronic neck pain randomised to 1 of 3 treatment arms, 93% follow-up at 12 months. All groups significant improvements in pain and disability, no significant difference between groups. Trend towards greater improvements in McKenzie group compared to controls at certain times. Significant improvements in DRAM scores in McKenzie group only. Recurrence rates similar by 12 months, but additional healthcare usage much less in McKenzie group.

Menon A, May S; Shoulder pain: differential diagnosis and therapy extremity assessment – a case report Man Ther; In press, 2012.

A case report of a patient referred with shoulder pain, who had shoulder impairments, but whose shoulder signs and symptoms improved with repeated movements of the cervical spine; proving the shoulder pain was due to a cervical derangement.
Cervical: Observational studies

Abdulwahab SS, Sabbahi M; Neck retractions, cervical root decompression, and radicular pain. J Orthop Sports Phys Ther; Jan;30(1):4-9, 2000.

In a group of patients with neck and radicular pain a posture of sustained flexion caused a significant increase in peripheral pain and root compression as measured by H reflex amplitude. Repeated retractions caused a significant decrease in peripheral pain and decrease of nerve root compression.

Hahn T, Kelly C, Murphy E, Whissel P, Brown M, Schenk R.; Clinical decision-making in the management of cervical spine derangement: a case study survey using a patient vignette. J Man Manip Ther; 22:115-121, 2014.

Survey of 714 certified or diplomaed McKenzie therapists, including some with Fellowship of the American Academy of Orthopaedic Physical Therapy (FAAOMPT), who were asked questions about their sequence of examination in a case vignette of a patient with cervical spine derangement. 83 responded: 77 with MDT credentials only, 6 with both MDT and FAAOMPT credentials. The MDT group used predominantly repeated end-range movements, whereas the latter group tended to continue examining and use passive movements.

Murphy DR, Beres JL; Is treatment in extension contraindicated in the presence of cervical spinal cord compression without myelopathy? A case report Manual Therapy; 13.468-472, 2008.

Case report of patient with neck pain and peripheral numbness who lastingly abolished symptoms with cervical extension exercises despite MRI evidence of disc protrusions.

Spanos G, Zounis M, Natsika M, May S.; The application of Mechanical Diagnosis and Therapy and changes on MRI findings in a patient with cervical radiculopathy Manual Therapy; In Press, 2012.

Case report of woman with signs and symptoms of cervical radiculopathy and MRI showing a large disc herniation at the relevant level who was successfully treated with retraction extension exercises until she was symptom free. Shortly after this a repeat MRI showed a 56% reduction in the size of the herniation.
Cervical: Studies into assessment, diagnosis and procedures

Bybee RF, Dionne CP ; Interater agreement on assessment, diagnosis, and treatement for neck pain by trained physical therapist students. J Phys Ther Edu; 21;2:39-47, 2007.

17 students who had completed parts A and B viewed a video recording of assessment of 20 patients with neck pain and recorded classification and classification-treatment link. There reliability was compared to that of post-graduate physical therapists from a previous study. Reliability was kappa 0.5 for initial classification, 0.55 for initial treatment, and 0.58 for classification-treatment link; for clinicians the latter kappa was 0.46. The students were significantly more reliable.

Chaniotis SA; Clinical reasoning for a patient with neck and upper extremity symptoms: a case requiring referral. J Bodywork Movement Ther; 16:359-363, 2012.

A case report of a patient with neck and arm pain referred to an MDT clinician with cervical radiculopathy, but whose history suggested serious pathology and so the therapist referred the patient to an oncologist. A bone scan revealed multiple metastases in the spine.

Clare HA, Adams R, Maher CG; Reliability of the McKenzie spinal pain classification using patient assessment forms. Physiotherapy; 90:114-119, 2004.

50 completed neck and back assessment forms were sent to 50 credentialed McKenzie therapists to classify - kappa values of 0.56 were recorded for syndromes and 0.68 for sub-syndromes.

Clare HA, Adams R, Maher CG; Reliability of McKenzie classification of patients with cervical and lumbar pain J Manipulative Physiol Ther; Feb;28(2):122-7, 2005.

25 lumbar and 25 cervical patients were assessed simultaneously by pairs of credentialed therapists; 14 in total. Prevalence of derangement was 88%/84%, dysfunction 0%/4%, posture 0%/0%, and ‘other’ 12%/12% for the 2 therapists. Kappa values for lumbar syndromes and sub-syndromes was 1.0 and 0.89, and for cervical syndromes and sub-syndromes 0.63 and 0.84 respectively.

Dionne C, Bybee RF, Tomaka J ; Correspondence of diagnosis to initial treatment for neck pain. Physiotherapy; 93:62-68, 2007.

54 trained clinicians viewed videotapes of the assessment of 20 patients with neck pain to determine the reliability of MDT diagnosis to management link and derangement classification and directional preference (DP) link. For derangement-DP link kappa values were 0.46, and for extension, lateral flexion DP 0.4, 0.45, and 0.04 respectively.

Dionne CP, Bybee RF, Tomaka J ; Inter-rater-reliability of McKenzie assessment in patients with neck pain. Physiotherapy; 92:75-82, 2006.

54 physical therapists with a range of MDT training reviewed 20 video-taped examinations and offered a MDT classification, sub-classification and directional preference if relevant. The majority classification was derangement (16), then dysfunction (2) and postural syndrome (1). The majority decision on directional preference for derangement was extension (15) and lateral (1). Reliability statistics (kappa) were: classification, 0.55; sub-classification, 0.47; directional preference, 0.46.
Cervical: Anatomical, physiological, and pain studies

Auvinen J, Tammelin T, Taimela S, Zitting P, Karppinen J ; Neck and shoulder pain in relation to physical activity and sedentary activities in adolescence. Spine; 32:1038-1044, 2007.

Cross-sectional study amongst 6000 15-16 year olds to determine activities associated with neck and shoulder pain. About 50% of the girls and 30% of the boys reported some pain, and 5% and 2% respectively reported severe pain in the last 6 months. Pain was associated with high levels of physical activity and with prolonged sitting.

Caneiro JP, O’Sullivan P, Burnett A, Barach A, O’Neill D, Tveit O, Olafsdottir K.; The influence of different sitting postures on head/neck posture and muscle activity. Man Ther; 15.54-60, 2010.

20 subjects with no symptoms were placed in 3 different sitting postures to investigate influence on head/neck postures and muscle activity. Slump sitting was associated with greater flexion, head protrusion, and increased erector spinae activity compared to upright sitting.

Cloward RB; Cervical discography. A contribution to the aetiology and mechanism of neck, shoulder and arm pain. Ann Surg; 150:1052-1064, 1959.

At surgery stimulation of cervical discs produced intra-scapular pain, with stimulation mid-line producing central pain and off-centre producing lateral pain.

Dunleavy K, Goldberg A; Comparison of cervical range of motion in two seated postural conditions in adults 50 or older with cervical pain. J Man Manip Ther; 21:33-39, 2013.

In 36 adults of 50 years or older with neck pain range of movement was compared between their ‘normal’ and ‘erect’ sitting postures. Extension, rotation and lateral flexion range was significantly greater in the erect sitting posture, and flexion was significantly less.

Falla D, Jull G, Russell T, Vicenzino B, Hodges P ; Effect of neck exercise on sitting posture in patients with chronic neck pain Phys Ther; 87:408-417, 2007.

Comparison of sustained sitting posture for 10 minutes in 58 patients with chronic neck pain and 10 controls, with a distraction computer task. The neck pain group demonstrated a significantly reduced ability to maintain an upright sitting posture and adopted amore forward head posture over time.

Harms-Ringdahl K.; On assessment of shoulder exercise and load-elicited pain in the cervical spine. Biomechanical analysis of load--EMG--methodological studies of pain provoked by extreme position. Scand J Rehabil Med; 14:1-40, 1986.

Various motor and sustained loading tests carried out on asymptomatic volunteers. When sustaining extreme flexion pain was produced after 2-15 minutes and stopped test within hour, when the pain abated. Pain was mostly neck and shoulders.

Mercer S, Bogduk N; The ligaments and anulus fibrosus of human adult cervical intervertebral discs. Spine; Apr 1;24(7):619-26;, 1999.

Anatomical study of 12 adult specimens. Anulus is thick anteriorly, but posteriorly is minimal, reinforced by the posterior longitudinal ligament centrally and virtually absent poster-laterally.

Mercer SR, Jull GA.; Morphology of the cervical intervertebral disc: implications for McKenzie‘s model of the disc derangement syndrome. Man Ther; Mar;1(2):76-81, 1996.

As the morphology and degenerative process of the cervical spine is different from the lumbar spine the authors conclude that the model does not conform to known anatomy. (see also discussion McKenzie Institute (UK) Newsletter 5:1;10-14,1996)

Ordway NR, Seymour RJ, Donelson RG, Hojnowski LS, Edwards WT; Cervical flexion, extension, protrusion, and retraction. A radiographic segmental analysis. Spine; Feb 1;24(3):240-7, 1999.

Study into the paradoxical movement pattern of the cervical spine – retraction produces lower C extension and upper C flexion, protrusion produces lower C flexion and upper C extension. Full range extension is produced in lower C by extension, but in O-C2 by protrusion; full range flexion is produced in lower C by flexion, but in O-C2 by retraction.

Pearson ND, Walmsley RP; Trial into the effects of repeated neck retractions in normal subjects. Spine; 20(11):1245-1251, 1995.

Retraction range did not increase on repetition, and range was greater in the younger population.

Quek J, Pua YH, Clark RA, Bryant AL.; Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults. Manual Therapy; 18:65-71, 2013.

In 51 older adults (mean age 66) with neck pain, with or without referred pain, measurements were taken of neck disability, the thoracic kyphosis, forward head posture and cervical range of movement to determine if there was a relationship between these variables. Greater thoracic kyphosis was significantly associated with more forward head posture; and less forward head posture was significantly associated with greater cervical flexion and rotation. Results support correcting both forward head posture and thoracic kyphosis in those with neck pain.

Schellhas, K.P.; Smith, M.D.; Gundry, C.R.; Pollei, S.R.; Cervical Discogenic Pain. Prospective correlation of MRI and discography in asymptomatic subjects and pain sufferers. Spine; 21:3;300-312, 1996.

Most cervical discs are morphologically abnormal, with outer annular tears found in both volunteers and patients. Gives areas of referral for discogenic pain.

Skrzyplec DM, Pollitine P, Przybyia A, Dolan P, Adams MA.; The internal mechanical properties of cervical intervertebral discs as revealed by stress profilometry. Eur Spine J; 16:1701-1709, 2007.

In this cadaveric study of 46 cervical motion segments from the cervical spine some aspects were the same as the lumbar spine: a hydrostatic nucleus with regions of higher compressive stress concentrated anteriorly in flexion and posteriorly in extension. Some features were unique to cervical spines: a stress gradient across their central region, and stress gradients in the posterior were generally small.

Takahashi H, Hall T, Kaneko S, Ikemoto Y, Jull G; A radiographic analysis of the influence of initial neck posture on cervical segmental movement at end-range extension in asymptomatic subjects. Man Ther; 16:74-79, 2011.

Comparison of the effect of different starting positions on range of extension. There was a significant difference in the pattern of extension, but no difference in the total range. Starting from protraction produced significantly more extension at C1-2, and starting from retraction produced significantly more extension at C6-7.

Tuttle N.; Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain? Aust J Physiother; 51(1):43-8, 2005.

Response of 29 patients with neck pain to manual therapy in one session and between treatment sessions. Centralisation, decreased pain intensity and increased range of movement within one session all predicted lasting between session improvements.

Yip CHT, Chiu TTW, Poon ATK; The relationship between head posture and severity and disability of patients with neck pain Manual Ther; 13:148-154, 2008.

Comparison of forward head posture among 62 neck pain patients and 52 non-neck patients with a reliable measurement method to measure the craniovertebral angle (ICC 0.98). There was a significant difference between the 2 groups, with neck pain group displaying more forward head posture. The greater the forward head posture the higher pain and disability scores; also forward head posture was associated with older age.
Whiplash: Reviews

Cote P, Soklaridis S.; Does early management of whiplash-associated disorders assist or impede recovery? Spine; 36:S275-S279, 2012.

Randomised controlled trials suggest that education, exercise and mobilisation are effective modalities to treat whiplash, but epidemiological studies suggest that too much rehabilitation early on can be associated with delayed recovery and the development of chronic pain and disability.

Drescher K, Hardy S, MacLean J, Schindler M, Scott K, Harris SR; Efficacy of postural and neck-stabilisation exercises for persons with acute whiplash-associated disorders: a systematic review. Physio Canada; 60.215-223, 2008.

8 studies were included in this review, with only 2 being of high quality and mixed results being reported. There was moderate evidence for the value of postural exercises and advice for decreasing pain and time off work in acute whiplash from one high quality study. There was moderate evidence to suggest that active interventions are more effective than soft collar. There was conflicting evidence about the value of stabilising exercises for acute whiplash.

Scholten-Peeters GG, Bekkering GE, Verhagen AP, van Der Windt DA, Lanser K, Hendriks EJ, Oostendorp RA.; Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders. Spine; Feb 15;27(4):412-22, 2002.

Active interventions, such as exercise, educational advice and normal activity are recommended.

Seferiafis A, Rosenfled M, Gunnarsson R; A review of treatment interventions in whiplash-associated disorders Eur Spine J; 13.387-397, 2004.

Systematic review of treatments for whiplash. Recommends early activity in acute whiplash;, radiofrequency neurotomy, cognitive behavioural therapy with other physical therapy interventions, and coordination exercise in chronic whiplash.

New! Sterling M; Physiotherapy management of whiplash-associated disorders (WAD). J Physio; 60:5-12, 2014.

General narrative review of WAD natural history, prognostic factors, and management, suggesting that after 2-3 months there is no further improvement, with initial high pain and disability, post-traumatic stress, negative expectations, and high catastrophizing associated with poor outcomes. The mainstay for acute WAD is exercise, including McKenzie, although the effect size is small and no particular approach is best, and the proportion that develops chronic symptoms is high. For chronic WAD exercise is also useful. Accompanying manual therapy may enhance outcomes, which should be measured using established pain and disability outcomes.
Whiplash: Trials

Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I; Acute treatment of whiplash neck sprain injuries. A randomized trial of treatment during the first 14 days after a car accident. Spine; Jan 1;23(1):25-31, 1998.

Continuing to engage in normal activities led to fewer symptoms than did sick leave and use of a collar.

Kongsted A, Qerama E, Kasch H, Bendix T, Bach FW, Korsholm L, Jensen TS.; Neck collar, "act-as-usual" or active mobilization for whiplash injury? A randomized parallel-group trial. Spine; Mar 15;32(6):618-26, 2007.

Comparison of 3 treatments for 458 acute whiplash patients, with active mobilisation group using MDT principles. All groups reported reduced pain with most of the improvement occurring during the first 3 months, but there were no significant differences between the groups in any outcomes. About half of all patients sought additional care, and about half of all patients reported considerable neck pain and disability at one year.

McKinney LA, Dornan JO, Ryan M.; The role of physiotherapy in the management of acute neck sprains following road-traffic accidents. Arch Emerg Med; Mar;6(1):27-33, 1989.

Outpatient treatment and advice to mobilise earlier were both more effective than analgesics and a collar in treating acute neck sprains.

McKinney LA.; Early mobilisation and outcome in acute sprains of the neck. BMJ; Oct 21;299(6706):1006-8, 1989.

A single advice session produced fewer patients with persistent symptoms at 2 years than a course of manipulative physiotherapy. Prolonged collar wearing is associated with persistence of symptoms.

Mealy K, Brennan H, Fenelon GC.; Early mobilization of acute whiplash injuries. BMJ (Clin Res Ed); Mar 8;292(6521):656-7, 1986.

Early active mobilisation and exercises produced significantly less pain and improved movement compared to rest and use of a collar.

Michaleff ZA, Maher CG, Lin CWC, Rebbeck T, Jull G, Latimer J, Connelly L, Sterling M. ; Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet; 6737:60457-8., 2014.

Trial in which 172 patients with neck pain following whiplash injury at least 3 months, but less than 12 months were randomised to a comprehensive exercise programme of 20 sessions or one advice session, with optional telephone support. 150 (87%) patients were followed up at 12 months. There was no clinically or significant difference between the groups.

Rosenfeld M, Gunnarsson R, Borenstein P; Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine; Jul 15;25(14):1782-87, 2000.

Nearly 100 acute patients randomised to one of 4 arms: active (1) or standard (2) treatment, within 96 hours (1a, 2a) or after 2 weeks (1b, 2b), with follow-up at 6 months. If symptoms persisted in active treatment group beyond 20 days a McKenzie assessment was conducted and specific, rather than non-specific exercises used. Active treatment was significantly better than standard (initial rest, collar, gentle movements), early treatment better than delayed. Minimal or no symptoms at follow-up: 1a: 48%, 1b: 70%, 2a: 64%, 2b: 91%.

Rosenfeld M, Seferiadis A, Carlsson J, Gunnarsson R.; Active intervention in patients with whiplash-associated disorders improves long-term prognosis: a randomized controlled clinical trial Spine; Nov 15;28(22):2491-8, 2003.

3-year follow-up of 73 patients (75%) from previous study. Still significant differences between active and standard treatment in pain intensity and sick leave. Only early active treatment group had similar range of movement to matched controls.

Rosenfeld M, Seferiadis A, Gunnarsson R.; Active involvement and intervention in patients exposed to whiplash trauma in automobile crashes reduces costs: a randomized, controlled clinical trial and health economic evaluation. Spine; Jul 15;31(16):1799-804, 2006.

An economic evaluation of previous study that showed that costs were significantly lower for the active intervention group at 6 and 36 months, as well as being more effective.
Extremities: Systematic reviews

Kuhn JE; Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shld Elb Surg; 18.138-160, 2009.

Included 11 trials that demonstrated that exercises had a significant effect on pain reduction and improved function, but not on range of movement or strength, which were augmented with the addition of manual therapy. Recommended exercise protocol included stretching and strengthening exercises.

Larsson MEH, Kall I, Nilsson-Helander K. ; Treatment of patellar tendinopathy – a systematic review of randomized controlled trials. Knee Surg Trauma Arthro; DOI 10.1007/s001167-011-1825-1, 2011. (Ahead of Print)

Review contained 13 articles and concluded that there was strong evidence for the use of eccentric training, moderate evidence for heavy resistance training, and moderate evidence that ultrasound was ineffective.

Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B.; Exercise for rotator cuff tendinopathy: a systematic review. Physiotherapy; 98:101-109, 2012.

Systematic review of five articles, with low risk of bias, that supported the use of loaded repeated exercises for patients with contractile dysfunction at the shoulder.

Pienmaki T, Karinen P, Kemila T, Koivukangas P, Vanharanata H; Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scand J Rehabil Med; 30:159-166, 1998.

RCT of loading exercises versus ultrasound for chronic ‘tennis elbow’ (contractile dysfunction) with long-term follow up. In a range of outcomes, such as return to work, pain, function, and healthcare usage, the actively treated group had significantly better outcomes both short and long-term.

Woodley BL, Newsham-West RJ, Baxter GD; Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med; 41.188-199, 2007.

Review of 11 studies that met inclusion criteria, which concluded there was some evidence for eccentric exercises over control treatments, but that the quality of the literature was generally poor.
Extremities: Reviews

Khan KM,Scott A; Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med; 43:247-251, 2009.

A summary of mechanotransduction, which describes the effect that mechanical loading exercise has on the biochemical responses of cells. Loading deforms cells, which causes chemical signals that stimulate growth and repair. The authors term this mechanotherapy.

Kjaer M, Langberg H, Miller BF et al; Metabolic activity and collagen turnover in human tendon in response to physical activity. J Musculoskeletal Neuronal Interaction; 5.41-52, 2005.

In response to mechanical loading tendons blood flow and collagen synthesis increase, thus providing the rationale for controlled loading as in contractile dysfunction.

Kraushaar BS, Nirschl RP ; Tendinosis of the elbow (Tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. JBJS; 81A.259-278, 1999.

Review of pathophysiology of tennis elbow, which is characterised by failed repair and disorganised collagen, rather than inflammation. Provides the rationale for controlled loading as used in contractile dysfunction.

Littlewood C; Contractile dysfunction of the shoulder (rotator cuff tendinopathy): an overview J Man Manip Ther; 20:209-213, 2012.

A narrative review of contractile dysfunction of the shoulder reporting what is known about pathology, diagnosis, treatment and prognosis. It is suggested that classification is based on excluding cervical spine, minimal resting pain, largely preserved range of movement, and consistent pain on resisted tests. And that management should be based on loaded exercises that are painful to perform.

Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J.; The pain of tendinopathy: physiological or pathophysiological. Sports Med; DOI10.1007/s40279-013-0096-z, 2014. (Ahead of Print)

A review of possible mechanisms for tendon pain, which includes local sources, but also central mechanisms.

Scott A, Huisman E, Khan K ; Conservative treatment of chronic Achilles tendinopathy. Can Med Assoc J; 183.1159-1165, 2011.

Review of treatments for chronic Achilles tendinopathy (contractile dysfunction in MDT terms); the only intervention with strong evidence for a treatment effect was loaded exercises, including eccentric exercises. Evidence was inconclusive or absent for all other interventions.
Extremities: Trials

Bennell KL, Egerton T, Martin J, Haxby-Abbott J, Metcalf B, McManus F et al.; Effect of physical therapy on pain and function in patients with hip osteoarthritis. A randomised clinical trial JAMA; 311:1987-1997, 2014.

Active treatment included education, advice, manual therapy and home exercise; the placebo treatment included inactive ultrasound and inert gel, both over 12 weeks. There was no significant difference between groups, but outcomes for the placebo group were sometimes better than the active intervention.

Brox JI, Gjengedal E, Uppheim G et al; Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomised, controlled study in 125 patients with a 2 ½ -y J Shoulder Elbow Surg; 8:102-111, 1999.

RCT of loading exercises versus surgery versus placebo for chronic rotator cuff problems (contractile dysfunction) with long-term follow up. Both short and long-term exercise and surgery groups had significantly better outcomes than control group, with no differences between them.

Brox JI, Staff PH, Ljunggren AE, Brevik JI; Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ; 307:899-903, 1993.

see below

New! Cakir S, Hepguler S, Ozturk C, Korkmaz M, Isleten B, Atamaz FC.; Efficacy of therapeutic ultrasound for the management of knee osteoarthritis. A randomized, controlled, and double-blind study. Am J Phys Med Rehab; 93:405-412, 2014.

60 patients with knee osteoarthritis were randomised to continuous, pulsed or sham ultrasound in addition to a home exercise strengthening programme. All groups showed significant improvements in pain and function, with no significant differences between groups, at 6 months.

Holmgren T, Hallgren HB, Oberg B, Adolfsson L, Johansson K.; Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study Br Med J; 344:e787, 2012.

102 patients with at least 6 months shoulder pain with several signs of ‘impingement’, who had failed previous conservative care and were referred for surgery, were randomised to either eccentric strengthening exercises for the rotator cuff, concentric scapula exercises and mobilisation or non-specific neck shoulder exercises. Patients who received the specific strengthening exercises had significantly better outcomes in terms of pain and function, and were significantly less likely to undergo surgery.

Holmich P, Nyvold P, Larsen K; Continued significant effect of physical training as treatment for overuse injury. 8-to-12-year outcome of a randomized clinical trial. Am J Sports Med; 39:2447-2451, 2011.

Long-term follow-up from previous randomised controlled trial in which loading, as in management of a contractile dysfunction, was compared to passive management with stretching. In the original trial there were significantly better results in the loaded management group with 79% returning to previous level of sport without groin pain. 80% were available for long-term follow; there were still significant differences favouring the loaded management group.

Holmich P, Uhrskou P, Ulnits L et al; Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet; 353:439-443, 1999.

RCT of loading exercises versus passive interventions and stretches for chronic adductor problems (contractile dysfunction). Of those completing treatment 79% in active group had no residual pain and had returned to same level of sports, compared to 14% in passive treatment group.

Littlewood C, Ashton J, Mawson S, May S, Walters S.; A mixed methods study to evaluate the clinical and cost-effectiveness of a self-managed exercise programme versus usual physiotherapy for chronic rotator cuff disorders: protocol for the SELF study BMC Musc Dis; 13:62, 2012.

The protocol for a planned study comparing usual physiotherapy with loaded exercise in patients with rotator cuff dysfunction at the shoulder.

Pienimaki TT, Tarvainen TK, Siira PT, Vanharanta H; Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy; 82:522-530, 1996.

see below

Rosedale R, Rastogi R, May S, Chesworth BM, Filice F, Willis S, Howard J, Naudie D, Robbins SM. ; Efficacy of exercise intervention as determined by the McKenzie system of Mechanical Diagnosis and Therapy for knee osteoarthritis: a randomized controlled trial. J Orth Sports Phys Ther; In press, 2014.

180 patients with established chronic osteoarthritis who were referred for surgery were randomized to an intervention or a control group. The intervention group received a MDT assessment, and were then classified as derangement responders or non-responders; the control group remained on the waiting list for surgery. The intervention group with derangement had significantly better outcomes at two weeks (p<0.01) and three months (p<0.02) regarding pain and function compared to both control group and evidence-based practice group.
Extremities: Observational studies

Aina A, May S; Case report - A shoulder derangement Man Ther; 10:159-163, 2005.

Case report of a patient with shoulder pain who responds typically as a derangement.

Alfredson H, Pietila T, Jonsson P, Lorentzon R; Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis Am J Sports Med; 26:360-366, 1998.

15 patients with chronic Achilles tendinosis (contractile dysfunction) treated with eccentric loading make quicker recovery than patients treated with surgery.

Aytona MC, Dudley K; Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series. J Man Manip Ther; 21:207-212, 2013.

Case series of 4 patients classified as derangement who responded well to repeated movements in slightly different directions, but mostly using medial rotation.

Kaneko S, Takasaki H, May S; Application of mechanical diagnosis and therapy to a patient diagnosed with de Quervain’s disease: a case study. J Hand Ther; 22:278-284, 2009.

Description of a patient with diagnosis of de Quervain’s who demonstrates a directional preference and classified as derangement responds to repeated movements.

Krog C, May S.; Derangement of the temporomandibular joint; a case study using Mechanical Diagnosis and Therapy Manual Therapy; doi:10.1016/j.math.2011.12.002, 2012. (Ahead of Print)

A case study in which a patient with lots of previously unsuccessful treatment responds rapidly and successfully to treatment using directional preference exercises establishing the patient as fitting operational definitions for a derangement.

Littlewood C, May S; A contractile dysfunction of the shoulder. Man Ther; 12:80-83, 2007.

Description of a single case study with chronic shoulder pain who is classified as a contractile dysfunction, treated with loading exercises, and recovers within 2 months. The characteristics of contractile dysfunction are presented.

Lynch G, May S. ; Directional preference at the knee: a case report using mechanical diagnosis and therapy. J Man Manip Ther; 21:60-66, 2013.

A case report of a patient presenting with lateral knee pain, and a positive McMurray’s test on several occasions, and referred with meniscus lesion, but who in fact responded to repeated movements of knee extension with overpressure in a few sessions, and returned to a demanding swimming schedule.

Menon A, May S. ; Shoulder pain: Differential diagnosis with mechanical diagnosis and therapy extremity assessment - A case report Manual Therapy ; 18;354-7, 2013.

A case report of a patient who presents with typically shoulder pain brought on apparently by a lifting job, but who actually responds to repeated movements of the cervical spine with full resolution of symptoms.

Silbernagel KG, Btorsson A, Lunberg M; The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone. A 5-year follow-up. Am J Sports Med; 39.607-613, 2011.

Cohort of 34 patients of who 80% were fully recovered with a programme of progressive loading exercises and 5-year follow-up.
Extremities: Studies into assessment, diagnosis and procedures

Littlewood C, Malliaris P, Mawson S, May S, Walters S.; Patients with rotator cuff tendinopathy can successfully self-manage, but with certain caveats, a qualitative study. Physiotherapy; 100:80-85, 2014.

Six patients and two therapists were recruited from a pilot randomised controlled trial, which compared usual physiotherapy to a self-managed loaded exercise programme. Preference and expectations for a more hands-on treatment approach was common amongst patients and therapists. There were several barriers to the self-managed approach, including these prior beliefs and response to therapy. However despite these beliefs some were positive about the self-managed approach, with good explanation, positive response, and patient’s self efficacy appearing key.

May S, Ross J; The McKenzie classification system in the extremities: a reliability study using McKenzie assessment forms and experienced clinicians. J Manip Physiol Ther; 32:556-563, 2009.

126 therapists with Diploma in MDT were sent 25 patients vignettes on extremity assessment forms with instructions to classify them in line of the mechanical syndromes, other or a spinal problem. 97 provided data, with 92% agreement and a kappa value of 0.83.

May SJ, Rosedale R; A survey of the McKenzie classification system in the extremities: prevalence of the mechanical syndromes and preferred loading strategy. Phys Ther; doi:10.2522/ptj.20110371, 2012. (Ahead of Print)

Data on 388 patients with extremity problems gathered by 30 therapists: 120 had shoulder problems, 103 had knee problems, and 72 had ankle / foot problems; 37% had derangements, 17% had contractile dysfunctions, 10% had articular dysfunctions, and 36% were 'other'. Classification remained consistent between initial and final treatment in 86%. For derangements at the shoulder extension and medial rotation were the most common directional preferences, at the knee extension was directional preference in 40-44 derangements.
Extremities: Anatomical, physiological, and pain studies

Duparc F, Putz R, Michot C, Muller JM, Freger P. ; The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surg Radiol Anat; 24:302-307, 2002.

Cadaveric study in which folds in the synovial capsule were commonly found, and suggested as a possible cause of intra-articular symptoms.

McNulty AL, Estes BT, Wilusz RE, Weinberg JB, Guilak F.; Dynamic loading enhances integrative meniscal repair in the presence of interleukin-1. Osteoarthritis & Cartilage; 18:830-838, 2010.

Cadaver porcine model that looked at effect of loading on meniscus, which suggested that joint loading through physical therapy may be beneficial in promoting healing of meniscal lesions under inflammatory conditions.

Mercer SR, Bogduk N ; Intra-articular inclusions of the elbow joint complex. Clin Anatomy; 20:668-676, 2007.

Cadaveric study of 28 elbow joints to investigate intra-articular inclusions. Ft pads and fibroadipose meniscoids were found in all joints, and capsular rimes in 50% of joints.

Slater H, Theriault E, Ronningen BO, Clark R, Nosaka K. ; Exercise-induced mechanical hypoalgesia in musculotendinous tissues of the lateral elbow. Man Ther; 15.66-73, 2010.

Volunteers performed repeated low-load concentric-eccentric or eccentric wrist extension exercises on different arms over 4 weeks, which lead to significant increase in pressure point threshold around the elbow.

Zalaffi A, Mariottini A, Carangelo B et al; Wrist median nerve motor conduction after end range repeated flexion and extension passive movements in carpal tunnel syndrome. Pilot study Acta Neurochir; S92:47-52, 2005.

38 patients with carpal tunnel syndrome performed repeated movements following which electrophysiological measurements were made. 32% of hands worsened with flexion and extension movements; 22% of hands improved with extension movements and some improved with flexion.


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