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Centralisation

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Textbooks, Chapters and Overviews of MDT

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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.

Holohan V, Deenadayalan Y, Grimmer K ; Evidence-based physiotherapy for acute low back pain: a composite clinical algorithm synthesized from seven recent clinical guidelines Physiotherapy Canada; Fall;58:280-292, 2006.

Evaluation and grading of 7 different guidelines, which graded interventions as having strong supportive evidence, moderate supportive evidence, or inconclusive evidence of effectiveness. McKenzie was said to have moderate supportive evidence from 3 of the guidelines.

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.

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

Abdulwahab SSA, Beati AM ; The effect of prone position and interferential therapy on lumbosacral radiculopathy Advances in Physio; 8:82-87, 2006.

In 28 males with lumbosacral radiculopathy and 28 controls the effect on H-reflex, pain intensity and pain distribution of prone lying for 3 minutes and 20 minutes, and after 10 and 20 minutes of interferential was monitored. There was no change in H-reflex latency throughout. In contrast there were significant reductions in pain intensity and pain distribution across all stages, thus demonstrating 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.

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.

Brotz D, Kuker W, Maschke E, Wick W, Dichgans J, Weller M; A prospective trial of mechanical physiotherapy for lumbar disk prolapse J Neurol Orthop Med Surg; 250:746-749, 2003.

Retrospective review of 50 / 150 patients with suspected disc herniation who responded to first 5 daily sessions with centralisation and were then treated with mechanical therapy. Exclusions: 64 disc herniation not confirmed on neuroimaging; 36 referred for surgery. There were immediate reductions in severe pain, and at 1-year high rates of recovery on all outcomes, with 5 patients who came to surgery.

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.

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, Grant W, Kamps C, Richman P.; Cervical and referred pain response to repeated end-range testing: a prospective, randomised trial. Nth Am Spine Soc; 1997

In patients with neck and referred symptoms 45% had pain reduced or centralised with sagital plane movements. Of this group 67% had a preference for extension and retraction and 33% had a preference for flexion and protrusion. In the remaining patients 14% showed a preference for extension, but not retraction, and 12% were worse with flexion, but not better with extension.

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.

Donelson RG, Grant WD et al; Low Back and Referred Pain Response to Mechanical Lumbar Movements in the Frontal Plane. May 12-16, 1991.

Centralisation can be achieved with end range frontal plane spinal movements in a majority of patients who failed to centralise with sagital plane movements.

Fritz JM, Brennan GP; Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther; 87:513-524, 2007.

Descriptive analysis of treatment based classification system and effect of different treatments in 274 neck pain patients. They were classified as follows: centralisation 35% (no operational definition given), exercise and conditioning 33%, mobility 17%, headache 9%, pain control 6%. Patients did significantly better if treatment was matched to classification, for instance in centralisation group Neck Disability Index reduced by 13 in matched group and 7 in unmatched group.

Fritz JM, Brennan GP, Clifford SN, Hunter SJ, Thackeray A.; An examination of the reliability of a classification algorithm for subgrouping patients with low back pain Spine; Jan 1;31(1):77-82, 2006.

Examination of treatment-based classification system, which includes detection of centralisation / peripheralisation by their protocol, in 60 patients. Reliability of detection of centralisation was ‘fair or poor’, kappa values 0.28-0.55.

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.

Grunnesjo M, Bogefeldt J, Blomberg S, Delaney H, Svardsudd K ; The course of pain drawing during a 10-week treatment period in patients with acute and sub-acute low back pain. BMC Musculoskeletal Disord; 7:65, 2006.

In a trial that compared stay active concept only to stay active plus manual therapy pain site, pain score and disability score were collected at baseline, and 5 and 10 weeks. Distal pain was abolished, and pain and disability scores improved over time and there was a significant correlation between these outcomes.

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.

Laslett M, Aprill CN, McDonald B, Oberg B.; Clinical predictors of lumbar provocation discography: a study of clinical predictors of lumbar provocation discography Eur Spine J; Oct;15(10):1473-84, 2006.

In over a hundred chronic patients with back pain the results of positive discography were compared to clinical findings. A combination of findings: centralisation, persistent pain, loss of extension and a subjective feeling of vulnerability when bending, were the most predictive. However this combination had a sensitivity of only 78%, but specificity of any 2 items was 100%.

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.

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.

Niemistö L, Sarna S, Lahtinen-Suopanki T, Lindgren KA, Hurri H.; Predictive factors for 1-year outcome of chronic low back pain following manipulation, stabilizing exercises, and physician consultation or physician consultation alone. J Rehabil Med; May;36(3):104-9, 2004.

Secondary analysis of previous randomised controlled trial to determine which factors were associated with poor recovery from the interventions. Variables significant in univariate analysis were entered in multiple regression analysis. Patients with centralisation and other factors benefited from manipulation and stabilisation exercises; non-centralisers failed to improve.

Pinto D, Cleland J, Palmer J, Eberhart SL ; Management of low back pain: A case series illustrating the pragmatic combination of treatment- and management –based classification systems. J Manual Manip Ther; 15:111-122, 2007.

Case series of 4 patients in which an unstable classification system is used, but one in which algorithm starts with directional preference before proceeding to clinical prediction rule criteria for manipulation or stabilisation responders.

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.

Scmidt I, Rechter L, Hansen VK, Andreasen, Overvad K; Prognosis of subacute low back pain patients according to pain response. Eur Spine J; 17.57-63, 2008.

Classification of nearly 800 patients with back pain who had failed to improve with earlier treatment into centralisation (18%), non-lasting centralisation (20%), peripheralisation (12%) and no effect groups (50%). No significant difference in outcome was seen between the groups at 1 year.

Skikic EM, Suad T; The effects of McKenzie exercises for patients with low back pain, our experience. Bosnian J Basic Med Sci; 3:70-75, 2003.

34 patients treated with McKenzie exercises for an average of 15 days. Centralisation was noted in 40% of acute, 57% sub-acute and 80% of chronic patients. There was significant improvement in pain and range of movement.

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 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.

Belanger AY, Depres MC, Goulet H, Trottier F; The McKenzie Approach: How Many Clinical Trials support Its Effectiveness? Proceedings of the World Confederat, 1991.

A review and analyses of the scientific literature that supports the effectiveness of the McKenzie approach. It concludes that despite worldwide popularity, scientific validation of the method is still not available.

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.

Faas, A.; Exercises: Which Ones Are Worth Trying, for Which Patients. and When? Spine; 21:2874-2879, 1996.

A review of 11 randomised exercise trials concerning exercise therapy. Two trials of McKenzie type exercises reported positive results but had low method scores.

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.

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.

Koes BW, Bouter LM, Beckerman H, van der Heijden GJ, Knipschild PG.; Physiotherapy exercises and back pain: a blinded review. BMJ; Jun 29;302(6792):1572-6, 1991.

Koes concludes that the quality of research on the effect of exercises in the treatment of LBP is disappointingly low and, therefore, no conclusion can be drawn on whether exercise is better than other treatments or whether a specific type of exercise is more effective.

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.

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.

Reddeck T; The Efficacy of the McKenzie Regimen - A Meta-analysis of Clinical Trials. Nov 156-161, 1997.

Finds some support for the efficacy of McKenzie regimen, but the limited number of trials and their poor methodology make it impossible to draw firm conclusions.

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.

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.

van Tulder M, Malmivaara A, Esmail R, Koes B; Exercise therapy for low back pain: A systematic review within the framework of the cochrane collaboration back review group. Spine; Nov 1;25(21):2784-96, 2000.

Review of 39 trials to judge effectiveness of exercise for acute and chronic back pain; with particular judgements about flexion, extension and strengthening exercises. Their conclusions are as above: exercise therapy is ineffective in acute stage, there is conflicting evidence on the value of exercise in the chronic stage, there is no evidence for the effectiveness of any specific exercise. (see correspondence)

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.

Davies CL, Blackwood CM; The centralization phenomenon: Its role in the assessment and management of low back pain. BC Med J; 46:348-352, 2004.

Review of value of mechanical assessment and symptom responses in guiding management.

Dimaggio A, Mooney V; Conservative care for low back pain; what works? J Musculoskeletal Med; 4:9;27-34, 1987.

A review of conservative therapy and an introduction to the McKenzie individualised prescription of exercises aimed at influencing the mechanical source of pain.

Donelson R; Die McKenzie methods furdie behandlung von ruckenschmerzen. Teil 1: Mechanische untersuchung und klassifizierung. Teil 2: Reliabilitat, diagnostiche fahigkeit und behandlungsergebnisse. Manuelle Medizin; 39:337-343; 344-350, 2001.

In German

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.

Fast A; Low back disorders: conservative management. Arch Phys Med Rehabil; Oct;69(10):880-91, 1988.

Following relevant anatomical considerations, the many causes of LBP are outlined. The McKenzie approach is included as one of the many conservative treatment measures.

Frost H, Moffett JK; Physiotherapy management of chronic low back pain. Physiotherapy; 751-754, 1992.

A review of the psychological and physical benefits of an active, patient controlled treatment regime compared to passive modalities.

Haldeman S, Dagenais S; What have we learned about the evidence-informed management of chronic low back pain? Spine J; 8.266-277, 2008.

Editorial from edition of Spine Journal that explores the evidence behind a wide range of interventions for chronic low back pain. This article summarises similarities and differences between all approaches, and notes that the McKenzie method is one of the few approaches that links assessment and treatment.

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.

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.

McKenzie RA; REPEX in Acute and Subacute Low back Pain. Nov 27-28, 1992.

This article introduces the REPEX and includes a review of the use of end of range passive exercises and the literature pertaining to the method.

Mooney V, Eds G Onik, CA Helms; Herniated discs. In: Automated Percutaneous Lumbar Discectomy SanFran: Radiology Rsch & Ed Fnd; 53-70, 1988.

Mooney discusses herniated disc pathology and diagnosis, followed by conservative and surgical treatment options. The McKenzie method and studies that support it are included under conservative care.

Murphy DR, Hurwitz EL; A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskel Dis; 8.75, 2007.

Clinical decision rule hypothesis that starts by excluding patients with red flags and addressing centralisation first before considering other management strategies.

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.

Adams N.; Psychophysiological and Neurochemical Substrates of Chronic Low Back Pain and Modulation by Treatment Physiotherapy; 79:2;86 , 1996.

Chronic low back pain patients had decreased pain scale readings, increased lumbar range of motion, reduced EMG activity, and elevated levels of substance P following a 6 week treatment programme of McKenzie extension procedures.

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.

Borrows J, Herbison P; ACC chronic backs study. Report of the evaluation of four treatment programmes (ACC), New Zealand; , 1994.

Four rehabilitation programmes were compared. The McKenzie residential 9-day programme and one other non-residential one (104 days) produced significantly better outcomes in terms of those fit to work, and functional improvements at one month.

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.

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.

Buswell J; Low back pain: a comparison of two treatments NZ J Physiotherapy; Aug 13-17, 1982.

Patients were treated by extension or flexion protocols, both produced significant improvements in patient outcomes, with no difference between the 2 groups.

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.

Dettori JR, Bullock SH, Sutlive TG, Franklin RJ, Patience T; The effects of spinal flexion and extension exercises and their associated postures in patients with acute low back pain Spine; 20(21):2303-2312, 1995.

In the first week both exercise groups improved more than the control group. Subsequent to that there was no significant difference between the groups. Recovery of all groups was generally rapid, but recurrence was frequent.

Elnaggar IM, Nordin M, Sheikhzadeh A, Parnianpour M, Kahanovitz N.; Effects of spinal flexion and extension exercises on low-back pain and spinal mobility in chronic mechanical low-back pain patients. Spine; Aug;16(8):967-72, 1991.

Flexion and Extension exercises in a chronic low back pain population decreased pain levels and increased sagittal movement with no obvious preference to direction.

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.

Faas A, Chavannes AW, van Eijk JT, Gubbels JW.; A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine; Sep 1;18(11):1388-95, 1993.

No differences in outcomes were found between groups receiving flexion exercises and advice, placebo ultrasound, or usual GP care.

Fowler B, Oyekoya O; The therapeutic efficacy of McKenzie concept in the management of low back pain. June 25-30, 1995.

Retrospective case note review of 27 patients treated with McKenzie; 74% made rapid recovery.

Fredrickson BE, Murphy K, Donelson R, Yuan H; McKenzie Treatment of Low back Pain: a correlation of Significant Factors in Determining Prognosis 1986

In a large patient population, categorisation and treatment according to the McKenzie system is found to have definite prognostic value.

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.

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.

Gilbert JR, Taylor DW, Hildebrand A, Evans C.; Clinical trial of common treatments for low back pain in family practice. BMJ (Clin Res Ed); Sep 21;291(6498):791-4, 1985.

Bed rest, flexion exercise group with advice, and control group all had similar outcomes.

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.

Goldby L; A randomised controlled trial comparing the McKenzie method of mechanical diagnosis and therapy with a non-prescriptive exercise regime in the conservative treatment of chronic low back pain. Sept. 16-17, 1995.

36 patients randomised to McKenzie treatment or non-specific exercise – improvements both groups, significant differences in McKenzie group in pain, function, and health locus of control.

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.

Kay MA, Helewa A; The effects of Maitland and McKenzie techniques in the musculoskeletal management of low back pain: A pilot study Phys Ther; 74.5.S59, 1994.

12 acute back pain patients randomly assigned to one of 2 treatment groups. At 3 weeks there were significant differences between the groups in pain, but not in mobility or disability. The McKenzie group improved by 18 units on a pain visual analogue scale, the Maitland group deteriorated by 16 units.

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).

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.

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%.

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 J ; The McKenzie Method for the management of acute non-specific low back pain: design of a randomised controlled trial BMC Musculoskeletal Disord; 6: 50, 2005.

Describes design of a RCT to be conducted.

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.

Malmivaara A, Hakkinen U, Aro T, Heinrichs M-L, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, Hernerg S; The treatment of acute low back pain - bed rest, exercises, or ordinary activity? N Engl J Med; 332(6):351-355, 1995.

Ordinary activity group had significantly better outcomes than those prescribed bed rest, or extension and lateral bending exercises.

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.

Mayer JM, Ralph L, Look M, Erasala GN, Verna JL, Matheson LN, Mooney V.; Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial. Spine J; Jul-Aug;5(4):395-403, 2005.

100 patients with back pain for less than 3 months were randomised to heat only, directional preference (DP) exercises only, heat wrap with DP exercises, or control booklet. At 7 days from beginning of intervention the heat and DP exercises group had significantly better pain and function outcomes than the other groups.

McGuirk B, Bogduk N; Evidence-based care for low back pain in workers eligible for compensation. Occup Med; 57:36-42, 2007.

Of 253 consecutive workers with back pain 191 saw a staff specialist and 164 only saw the staff specialist. This person explained about the benign nature of back pain, identified patients' misconceptions, encouraged them to remain at work and instructed them in exercises from TYOB. Staying at work and recovery was significantly higher in this group compared to usual care with their GP.

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.

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.

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.

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).

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.

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%.

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.

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.

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.

Rasmussen C, Hansen VK, Larsen RJ, Olsen J ; Evaluering af de reumatologiske rygambulatorier i Nordjyllands Amt - med fokus pa behandlingen af diskusprolaps. Center for Evaluering og Medicinsk ; , 2004.

Report on surgery rate in local hospital for disc prolapse since introduction of McKenzie assessment method. When introduced in 1996-7 surgery rate was 85 per 100,000 population; by 2001-2 this had fallen to 40 per 100,000 compared to national average which remained at about 80 per 100,000.

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.

Roberts AP; The conservative treatment of low back pain. , 1990.

At 7 weeks post onset of LBP, Roberts showed that the group receiving McKenzie treatment produced significant disability reduction compared with those treated with a NSAID (Ketoprofen).

Saal JA, Saal JS.; Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine; Apr;14(4):431-7, 1989.

64 patients with herniated nucleus pulposus, including those with extrusions, were treated conservatively with a regime that included extension exercises, injections, lumbar stabilisation exercises, and a general exercise programme. The majority of patients had good or excellent outcomes, with failure to respond associated with stenosis.

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.

Skikic E, Trebinjac S, Sakota S, Avdic D ; The effects of McKenzie and Brunkow exercise program on spinal mobility comparative study. Bosnian J Basic Med Sci; 4:62-68, 2004.

64 patients with back pain performed McKenzie or Brunkow exercises and range of movement increased in both groups, with statistically greater improvements in the McKenzie patients.

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.

Udermann B, Spratt K, Donelson R, Tillotson J, Mayer J, Graves J; Can an educational booklet change behavior and pain in low back pain patients? ISSLS, Edinburgh; April, 2001.

Eighteen month follow-up to Udermann et al 2000, involving 54 patients. Over 90% still exercising and using posture. Showing long-term maintenance of symptom improvement.

Udermann B, Tillotson J, Donelson R, Mayer J, Graves J.; Can an educational booklet change behaviour and pain in chronic low back pain patients? ISSLS, Adelaide; April, 2000.

Nine months after reading Treat Your Own Back 81% of 62 recruits with chronic back pain of average 10 years duration were available. About 90% were still using posture and exercise advice from the book, 60% were free of pain, and another 22% had had less pain. Pain severity and number of episodes had significantly improved. Most attributed improvements to what they had learnt in the book.

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’.

Vanharanta H, Viedman T, Mooney V; Comparison of McKenzie Exercises, Back Trac and Back School in Lumbar Syndrome; Preliminary Results. , 1986.

138 patients allocated to McKenzie, traction, or back school; 97% of McKenzie group improved at one week, compared to less than 50%, with a significant difference at one month.

Weller M, Brotz D, Kuker W, Dichgans J, Gotz A; Mechanical physiotherapeutic diagnosis and therapy in patients with lumbar disc disease. Aktuelle Neurologie ; 28;74-81, 2001.

Uncontrolled study of 21 patients with confirmed disc prolapse treated with repeated active and passive movements selected according to symptom response; all patients were discharged improved, and most continued to improve.

Williams M, Grant R; Effects of a McKenzie spinal therapy and rehabilitation programme: preliminary findings , 1992.

Significant change in pain, function and psychological status in chronic low back pain patients was found following a 2 week residential programme based on the McKenzie method of treatment.

Williams MM, Grant RN; A comparison of low-back and referred pain responses to end-range lumbar movement and position. May 20-24, 1992.

The importance of monitoring changes in the distal symptoms is highlighted in a prospective trial comparing two forms of repeated end range 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.

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).

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.

Jam B, Varamini A; Physical therapy classification and management of mechanical low back pain: critical analysis and results of a survey. Orth Division Review; March/April 20-27, 2008.

Survey of 344 Canadian physical therapists about the classification and management of back pain, of who 62% had completed some McKenzie training. McKenzie was one of the most common classification systems used; 82% applied McKenzie concepts sometime, of which 23% used it the majority of time.

Laslett M, Michaelsen DJ, Williams MM; A survey of patients suffering mechanical low back pain syndrome OR sciatica treated with the "McKenzie Method". NZ J Physiotherapy; Aug 24-32, 1991.

A retrospective postal survey of patients' opinions about the success of treatment in dealing with their present pain, and enabling them to deal with recurrences showed high levels of satisfaction. Derangements 1 & 3 required fewer treatment sessions than Derangements 4,5,6.

May S; Classification by McKenzie mechanical syndromes: A survey of McKenzie-trained faculty. J Manipulative Physiol Ther; 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.

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.

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

Rath W, Rath JD; Outcome assessment in clinical practice. McKenzie Institute (USA) Journal; 4:3,9-16, 1996.

This retrospective study shows how neurological signs, chronicity of the problem, no centralisation, mechanically inconclusive findings on assessment, and postiive behvioural signs tend to be associated with a less good outcome. This survey also reports on number of visits related to QTF categories, and the results of a telephone follow-up of patients at least a year after discharge asking about recurrences and ability to self-treat.

Rath WW, Rath, JND, Duffy CG; A comparison of Pain Location and Duration with Treatment Outcome and Frequency. , 1989.

Rath's retrospective study shows that 87% of lumbar and cervical pain patients had good outcome using the McKenzie method of treatment.

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.

Sullivan MS, Kues JM, Mayhew TP.; Treatment categories for low back pain: a methodological approach. J Orthop Sports Phys Ther; Dec;24(6):359-64, 1996.

From this survey of PTs in USA 7 different treatment categories were proposed, which explained 62% of treatment variance. McKenzie treatment category was the most commonly used, explaining 21% of variance.

Axen I, Rosenbaum A, Robech R, Wren T, Leboeuf-Yde C.; Can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in persistent low back pain? J Manipulative Physiol Ther; Sep;25(7):450-4, 2002.

Prospective study of 615 patients receiving chiropractic manipulation relating initial response to final outcome - identifies symptom response as a prognostic factor. 84% of those who reported reduced pain after first session had ‘definitely improved by 4th visit, compared to 30% in those showing no initial reduction.

Bakker EWP, Koning HJCMF, Verhagen AP, Koes BW; Interobserver reliability of the 24-hour schedule in patients with low back pain: a questionnaire measuring the daily use and loading of the spine J Manipulative Physiol Ther ; 26:226-232, 2003.

Questionnaire to establish mechanical loading during normal activity in 40 subjects. Demonstrated high level of reliability. Flexed activities 8 times more common than extended ones.

Beurskens AJ, de Vet HC, Koke AJ et al.; A patient-specific approach for measuring functional status in low back pain. J Manipulative Physiol Ther; 22:144-148, 1999.

Patient-specific questionnaire for measuring functional disability. Commonest mentioned items: standing, lying, but over half of 400 items involved flexion.

Billis EV, McCarthy CJ, Oldham JA ; Subclassification of low back pain: a cross-country comparison. Eur Spine J; 16:865-879, 2007.

The McKenzie classification system was found to be ‘by far’ the most internationally used of back pain classification systems.

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.

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.

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).

Cooper K, Smith BH, Hancock E; Patients' perceptions of self-management of chronic low back pain: evidence for enhancing patient education and support. Physiotherapy; 95.43-50, 2009.

Qualitative study of 25 people who had recently received physiotherapy in the UK. Strongly perceived need for self-management strategies, with the most common strategy being the use of exercises. However it was felt that physiotherapy was not very helpful at enhancing self-management strategies.

De Bruijn N, Doumen BM, de Mulder K ; Intra- en interbeoordelaarsbetrouwbaarheid van de movement loss tests van McKenzie voor de lumbale wervelkolom Ned Tijdschr Fysiother; 113:94-99, 2004.

10 therapists examined 39 volunteers to determine reliability of movement loss (major, moderate, minimal) of flexion, extension and side gliding. Intra-tester reliability was reasonable, but inter-tester was poor; group kappa < 0.32 (article in Dutch).

Delaney PM, Fernandez CE; Toward an evidence-based model for chiropractic education and practice. J Manipulative Physiol Ther; 22;114-118, 1999.

This commentary outlines the steps of evidence-based healthcare - formulating a question; searching the literature; critically appraising the literature; managing the patient accordingly; evaluating one's own practice. As an example of critical appraisal they examine Donelson (1997) and conclude that the McKenzie protocol is a useful, highly sensitive, and moderately specific diagnostic tool for discogenic pain and annular incompetency.

Delaney PM, Hubka MJ; The diagnositc utility of McKenzie clinical assessment for lower back pain. J Manipulative Physiol Ther; 22;628-630, 1999.

Re-analysis of Donelson (1997) calculating accuracy of McKenzie assessment in diagnosis. Sensitivity and specificity for discogenic pain 94% and 82%; for incompetent annulus 100% and 86%. Compares favourably with most other established tests.

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.

Fedorak C, Ashworth N, Marshall J, Paull H.; Reliability of the visual assessment of cervical and lumbar lordosis: how good are we Spine; Aug 15; 28(16): 1857-9, 2003.

28 mixed group of clinicians evaluated photos of 36 individuals to rate cervical and lumbar lordosis as normal, increased, or decreased. Intrarater reliability moderate (kappa 0.5), interrater reliability poor (kappa 0.16).

Fiebert I, Keller CD; Are "Passive" Extension Exercises Really Passive? J Orthop Sports Phys Ther; 19(2):111-116, 1994.

During EIL there is more EMG activity in the Erector Spinae muscles than during standing, EIS, or prone lying.

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.

George; Characteristics of patients with lower extremity symptoms treated with slump stretching: a case series J Orthop Sports Phys Ther; 32.391-398, 2002.

Out of 88 consecutive back pain patients 6 were identified who were considered appropriate for treatment by slump stretching – 4/6 would appear to fit category of ANR.

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.

Gutke A, Ostgaard HC, Oberg B; Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning. Spine; 31;E149-E155, 2006.

Descriptive study of types of back pain in pregnancy with use of MDT evaluation to identify mechanical lumbar responders. Results are presented as back pain per region regarding lumbar and / or pelvic and consequent disability.

Hahne AJ, Keating JL, Wilson SC; Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Aust J Physiother; 50:17-23, 2004.

Record of pain intensity and range of movement was taken before and after treatment session and at the beginning of next session in 53 back pain patients. Those who improved in first session significantly more likely to return with further improvements compared to those showing no within-session changes. 67% to 88% (depending on measure) could be correctly classified as improvers / non-improvers at second session by their within-session response to treatment.

Hazard RG, Williams MW, McKenzie RA ; Reliability of three methods for measuring prone lumbar extension NZ J Physiotherapy; April: 11-13, 1994.

Comparison of reliability of skin attraction, inclinometry and flexible ruler to measure extension ROM in 15 patients – ICC were 0.9, 0.83, and 0.62 respectively.

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.

Horton SJ, Haxby Abbott J ; A novel approach to managing graduated return to spinal loading in patients with low back pain using the Spineangel® device: a case series report NZ J Physio; 36:22-28, 2008.

Description of a sensor to be worn by patients to provide biomechanical feedback indicating spinal loading such as bending or sitting. Three case studies used to illustrate how it might be used as an educational tool to provide feedback about postural behaviour and home exercise adherence.

Kent P, Keating J; Do primary-care clinicians think that non-specific low back pain is one condition? Spine; 29:1022-1031, 2004.

Survey of > 600 physiotherapists, chiropractors, osteopaths and medical practitioners in Australia (60% response rate) regarding beliefs about existence of sub-groups in non-specific back pain population. 93% do not think non-specific back pain is one group and 93% treat patients differently depending on signs and symptoms.

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.

Kulig K, Landel R, Powers CM.; Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization. J Orthop Sports Phys Ther; Feb;34(2):57-64, 2004.

Effect of PA mobilisation on 20 volunteers as recorded by MRI – motion at target segment was always into extension. PA at L3-L5 caused extension at all segments; PA at L1-L2 caused extension upper lumbar, but flexion at lower lumbar.

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, 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.

McCarthy CJ, Arnall FA, Strimpakos N, Freemont A, Oldham JA ; The biopsychosocial classification of non-specific low back pain: a systematic review. Phys Ther Rev; 9:17-30, 2004.

Review of 32 classification systems of 4 types: patho-anatomical, clinical, psychological, health / work status. Out of total of 7 quality criteria only 7 systems scored 5 or more, including McKenzie system.

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.

McLean IP, Gillan MG, Ross JC, Aspden RM, Porter RW.; A comparison of methods for measuring trunk list. A simple plumbline is the best. Spine; Jul 15;21(14):1667-70, 1996.

Of 3 methods evaluated plumbline was the best, being reliable, simple to use, and accurate to within 4mm.

Mulvein K, Jull G; Kinematic analysis of the lumbar lateral flexion and lumbar lateral shift movement techniques. J Man & Manip Ther; 3:3;104-109, 1995.

Lateral shift technique (side gliding in standing) is found to produce movement with greater specificity to lower lumbar levels compared to lateral flexion. Above L4 either test movements can be used to examine movement abnormalities.

Pengel LHM, Refshauge KM, Maher CG; Responsiveness of pain, disability, and physical impairment outcomes in patients with low back pain. Spine; 29:879-883, 2004.

A comparison of the responsiveness to change of different outcome measures in 155 back pain patients: Roland Morris, pain scale, physical impairment measures, and patient specific functional scale, in which patients nominate problem activities. Most responsive measures as judged by global perceived effect were patient specific scale and pain scale, then Roland Morris, then changes in extension. Other measures of physical impairment were less responsive to change. Of 325 activities nominated by patients > 275 involved sitting / bending / lifting.

Petersen T, Laslett M, Thorsen H, Manniche C, Ekdahl C, Jacobsen S ; Diagnostic classification of non-specific low back pain. A new system integrating patho-anatomic and clinical categories Phys Ther Prac; 19:213-237, 2004.

This classification system for LBP takes the mechanical syndromes of Mechanical Diagnosis and Therapy and adds in a few other categories, such as spinal stenosis, zygapophyseal or sacro-iliac joint pain. A lot of the literature used to demonstrate the validity and reliability of the system relates to studies of the McKenzie approach.

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.

Pinnington MA, Miller JS, Rose MJ, Stanely IM, Rose GM; New episodes of back pain: how many patients can be classified into McKenzie syndromes? JBJS; 82B.Supp III 211-212, 2000.

Of 522 new patients referred, 307 (58%) were classified into McKenzie syndromes, while 215 (42%) were not. Significant differences were found between the groups in duration of episode, pain and disability scores, movement loss, and other variables.

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; Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther; Jul;78(7):708-37, 1998.

Critical analysis of various classification systems used for LBP, including McKenzie’s. Highlights strengths and weaknesses of them according to an established set of criteria for appraising classification systems.

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%.

Roach KE, Brown M, Dumigan KM, Kusek CL, Walas M; Test-retest reliability of a low back pain questionnaire. Phys Ther; 74:5,S56, 1994.

Patient reports concerning leg pain were generally more reliable than back pain. Reports of back and leg pain, with one exception, had good reliability as examined using the Kappa coefficient.

Sallade J; Variation on Robin McKenzie’s technique for correction of lateral shift. J Orthop Sports Phys Ther ; 8:8,417-420, 1987.

Author presents his own version of correcting the lateral shift with patient hanging by arms from overhead bar.

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

Spratt KF, Lehmann TR, Weinstein JN, Sayre HA.; A new approach to the low-back physical examination. Behavioral assessment of mechanical signs. Spine; Feb;15(2):96-102, 1990.

The presence of various behavioural responses to pain during physical examination may help to determine outcome of treatment, endorse physical signs and confirm diagnosis. Used repeated movements for some tests. Intertester agreement for patient reported pain status was nearly perfect.

Stankovic R, Johnell O, Maly P, Willner S.; Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus. A prospective clinical study. Man Ther; Feb;4(1):25-32, 1999.

105 patients were diagnosed by CT and/or MRI as having disc hernia (N=52), bulging discs (41), or without positive findings (12). A range of clinical and physical examination findings was generally unable to distinguish between these diagnoses. The only 3 variables that were of diagnostic value were ROM on flexion, side bending, and pain distribution on EIS. Neurological tests, EIL (not reported if single or repeated), and SLR were amongst the numerous variables that failed to be associated with any particular diagnosis.

Tenhula JA, Rose SJ, Delitto A.; Association between direction of lateral lumbar shift, movement tests, and side of symptoms in patients with low back pain syndrome. Phys Ther; Aug;70(8):480-6, 1990.

There was no significant relationship between the side of symptoms and the direction of the shift. Contralateral side bending was significantly more likely to provoke symptoms than ipsilateral. There was perfect agreement on judging presence and direction of shift.

Turner PA, Harby-Owren H, Shackleford F, So A, Fosse T, Whitfield TWA ; Audits of physiotherapy practice Physio Theory & Pract; 15:261-274, 1999.

An audit of physiotherapy notes from NHS hospitals in the UK, including 345 back pain patients. The McKenzie assessment sheets provided better quality records in terms of detail and objectivity. Use of McKenzie: in isolation 11% of notes and in combination a further 39%.

Weitz EM.; The lateral bending sign. Spine; Jul-Aug;6(4):388-97, 1981.

Study using dynamic lateral bending radiographs to localise disc lesions associated with a shift or reduced lateral bending.

Williams M M, Wright D G R, Mugglestone A A, Lynch G B, Spekreijse S A; Psychological distress in chronically disabled workers attending a McKenzie spinal therapy and rehabilitation programme. , 1993.

The Distress and Risk Assessment Method (DRAM) appears to have predictive value for treatment outcome in a chronically disabled low back pain population.

Williams MM, McKenzie R A, Reed R, Laslett M; Responsiveness to Change of Three Disability Assessment Instruments for Back Pain Research. May 12-16, 1991.

With chronic back pain patients the Dallas pain questionnaire is most sensitive to small changes compared with the Roland/Morris and Oswestry questionnaires.

Young S, Aprill C; Characteristics of a mechanical assessment for chronic lumbar facet joint pain. J Man & Manip Ther; 8.78-84, 2000.

Results of diagnostic injections (SIJ, facet, and disc) compared to mechanical evaluation involving McKenzie assessment, SIJ and hip tests in 93 chronic patients. Characteristics from mechanical assessment were compared in the different diagnostic groups.

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.

Adams MA, Dolan P.; Recent advances in lumbar spinal mechanics and their clinical significance. Clin Biomech (Bristol, Avon); Jan;10(1):3-19, 1995.

Comprehensive review of how spinal structures fail (over 200 refs) with emphasis on importance of mechanical loading in back pain. Discs particularly prone to fatigue failure.

Adams MA, Hutton WC; The effect of fatigue on the lumbar intervertebral disc. J Bone Joint Surg [Br]; Mar;65(2):199-203, 1983.

Cadaveric experiment simulating a vigorous day’s activity in flexion led to fatigue failure of annulus, with distortion of the lamellae and fissures in 23 out of 41 motion segments tested.

Adams MA, Hutton WC. ; Prolapsed intervertebral disc. A hyperflexion injury. Spine; 10.184-191, 1982.

Cadaveric experiment simulating hyperflexion led to disc failure by posterior prolapse in 26 out of 61 motion segments tested.

Adams MA, Hutton WC.; Gradual disc prolapse Spine; Jul-Aug;10(6):524-31, 1985.

Cadaveric experiment loading motion segments in compression and bending caused 6 out of 52 to gradual prolapse, starting with distortion of the lamellae and progressing to nuclear herniation. The most common mechanism of failure was end-plate fracture.

Adams MA, May S, Freeman BJ, Morrison HP, Dolan P; Effects of backward bending on lumbar intervertebral discs. Relevance to physical therapy treatments for low back pain. Spine; Feb 15;25(4):431-7, 2000.

Cadeveric experiment in which the distribution of compressive stresses within ‘degenerated’ discs were measured by dragging a stress transducer through it. Extension caused an average increase in localised stress peaks in the posterior annulus, however in 7/19 discs extension caused a decrease in stress peaks by up to 40%. It was hypothesised that this reduction was due to stress shielding by the neural arch in more degenerated discs.

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.

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

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.

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.

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.

Dickey JP, McNorton S, Potvin JR ; Repeated spinal flexion modulates the flexion-relaxation phenomenon Clin Biomech; 18: 783-789., 2003.

In asymptomatic volunteers repeated flexion increased final flexion angle; with greater increases in unloaded rather than loaded positions.

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.

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.

Green JP, Grenier SG, McGill SM:; Low -back stiffness is altered with warm-up and bench rest: implications for athletes. Med Sci Sports Exerc; 34: 1076-1081, 2002.

9 varsity level volleyball players had their lumbar spine stiffness measured before, after 30 minutes warm-up, and after 30 minutes bench rest in slumped sitting. Though there was no decrease in stiffness following the warm-up, but in general sitting led to an increase in spinal stiffness.

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.

Hoops H, Zhou BH, Lu Y, Solomonow M, Patel V; Short rest between cyclic flexion periods is a risk factor for a lumbar disorder Clinical Biomechanics; 22:745-757, 2007.

Feline model used to test the effects of sustained periods of flexion interspersed by varying periods of rest. Neuromuscular disorders were displayed more significantly with 5 minutes of rest than 10 minutes of rest, and both significantly more than 20 minutes rest.

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.

Kuslich SD, Ulstrom CL, Michael CJ.; The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am; Apr;22(2):181-7, 1991.

When mechanically stimulated during an operation the outer annulus, posterior longitudinal ligament, vertebral end plate, anterior dura and previously traumatised nerve roots, were all pain sensitive.

Magnusson, M.L.; Aleksiev, A.S.; Spratt, K.F.; Lakes, R.S.; Pope, M.H.; Hyperextension and Spine Height Changes Spine; 21:2670-2675, 1996.

Hyperextension was demonstrated to be a beneficial movement to unload the spine after loading, aiding rehydration and concomitant improvement of disc nutrition.

Maigne JY, LapeyreE, Morvan G, Chatellier G; Pain immediately upon sitting down and relieved by standing up is often associated with radiologic lumbar instability or marked anterior loss of disc space. Spine; 28:1327-1334, 2003.

Comparison of 42 patients with pain immediately on sitting and relieved on standing compared to 32 LBP patients who did not show this pattern - 86% were female and there were higher rates of radiological signs of instability.

Mork PJ, Westgaard RH; Back posture and low muscle activity in female computer workers: a field study. Clin Biomech; 24.169-175, 2009.

Investigation of 21 female workers who all adopted a very flexed posture whilst seated, with very low muscle activity according to surface electromyography. About half reported back pain aggravated by persistent sitting. Subjects with and without back pain were not distinguishable by any differences in posture or activity.

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

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‘Neill CW, Kurgansky ME, Derby R, Ryan DP.; Disc stimulation and patterns of referred pain. Spine; Dec 15;27(24):2776-81, 2002.

25 patients who met inclusion criteria and who received intradiscal electrothermal annuloplasty (IDET) treatment for chronic discogenic back pain were studied for pain response to procedure. All pain provoked by procedure was familiar to patients – 16 had back pain only, 6 back and thigh, 3 radiated into calf. The distance pain was referred correlated to intensity of stimulus as measured by heat and duration, and always preceded in order back, thigh, then calf.

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.

Parkinson RJ, Beach TAC, Callaghan JP ; The time-varying response of the in vivo lumbar spine to dynamic repetitive flexion. Clin Biomech; 19: 330-336., 2004.

In asymptomatic volunteers repeated lifting causes initial decreased stiffness and increased range of movement due to creep.

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.

Pynt J, Higgs J, Mackey M.; Historical perspective milestones in the evolution of lumbar spinal postural health in seating. Spine; Oct 1;27(19):2180-9, 2002.

Historical review of seating postures in the past, with analysis of what is deemed good posture from a recent evidence-based approach – favouring lordosis and interruption of sustained static sitting.

Reddeck T; An evaluation of the McKenzie regimen - validity of the disc model. , 1997.

This paper reviews the disc as a source of pain, the role of annular fissuring and displacement as a mechanism of pain production, and the relationship between the degree of disc pathology and the extent of symptoms.

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.

Schnebel BE, Watkins RG, Dillin W.; The role of spinal flexion and extension in changing nerve root compression in disc herniations. Spine; Aug;14(8):835-7, 1989.

Using cadaver models of herniated discs, Schnebel demonstrated that flexion increases tension and that extension decreases tension on the L5 nerve root.

Shepherd J; In vitro study of segmental motion in the lumbar spine. JBJS; 77B: S2,161, 1995.

Intradiscal material generally moved anteriorly on extension and posteriorly in flexion, but amount varied amongst the specimens.

Snijders CJ, Hermans PFG, Niesing R, Spoor CW, Stoeckart R; The influence of slouching and lumbar support on iliolumbar ligaments, intervertebral discs and sacroiliac joints. Clin Biomech; 19:323-329, 2004.

Cadaveric study of mechanical effect of slouched posture identifying stress on intervertebral discs and ligaments that is almost eliminated with use of lumbar backrest.

Sowa G, Agarwal, S; Cyclic tensile stress exerts a protective effect on intervertebral disc cells Am J Phys Med Rehabil ; 87.537-544, 2008.

An in vitro model in rats was used to test the effects of inflammation and mechanical forces on annulus fibrosus cells. The model showed that under inflammatory conditions moderate tensile stress had a protective effect by decreasing the expression of catabolic mediators.

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.

Van Deursen LLJM, Snijders CJ, Patijn J:; Influence of daily life activities on pain in patients with low back pain J Orthop Med; 24(3) 74-76, 2002.

4 GPs questioned 100 patients about back pain during 9 different postures / activities, to which patients could answer ‘yes’ or ‘no’. Pain was reported as follows: sitting 85%, partly bent 78%, standing 73%, sit-to-stand 70%, sauntering 66%, fully bent 60%, lying 47%, walking 23%, cycling 15%.

Vanharanta H, Ohnmeiss D, Rashbaum R et al: ; Effect of Repeated Trunk Extension and Flexion Movements as seen by CT/Discography. Orthopaedic Transactions ; 12:3;650-651, 1988.

No change observed in position of nucleus pulposus after flexion or extension.

Wand BM, Hunter R, O'Connell NE, Marston L, McAuley J; The self-reported aggravating activities of people with chronic non-specific low back pain do not involve consistent directions of spinal movement: an observational study. Aus J Physio; 55.47-51, 2009.

148 of 240 patients completed the Patient Specific Functional Scale and identified 3 activities that aggravated their back pain on that day (92 did not identify 3 activities). The 104 activities that were identified were classified as flexion (58%), extension (26%), unilateral (1%), or unclassifiable (15%); 32% of patients displayed a directional pattern with all 3 activities, of which 98% displayed a flexion aggravation pattern. According to their calculation this was no more than would be expected by chance.

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.

Dimaggio A, Mooney V.; The McKenzie Program: Exercise effective against back pain. J Musculoskeletal Med; Dec, 63-74, 1987.

The authors provide a review of the McKenzie assessment and treatment protocol and its rationale.

Donelson R.; The McKenzie approach to evaluating and treating low back pain. Orthopaedic Review; Aug;19(8):681-6, 1990.

Donelson presents an overview of the McKenzie approach to low back pain treatment.

Donelson RG; Identifying appropriate exercises for your low back pain patient. J Musculoskeletal Med; pp 14-29, December , 1991.

Donelson provides an overview of the McKenzie approach and reports on its success rates.

Donelson RG, McKenzie RA; Mechanical Assessment and Treatment of Spinal pain. Vol Two, Chapter 76:1627-1639, 1991.

A review of the McKenzie assessment and treatment philosophy is provided along with a review of the relevant research pertaining to the method.

Grant R N, McKenzie RA; Mechanical Diagnosis and Therapy for the Cervical and Thoracic Spines.

An overview of the McKenzie approach with specific reference to the cervical and thoracic spine.

Hazard RG, McKenzie RA, Mooney V; Helping your back pain patients make the most of spinal motion. J Musculoskeletal Med ; pp24-35, January, 1994.

Overview of benefits of activation, not rest. Includes active extension exercises, and continuous passive motion, achieved in lying on a repex machine and in sitting by a BackCycler.

Holdom A; The use of the McKenzie approach to treat back pain Br J Ther Rehab; 3:1, 7-10, 1996.

Overview of mechanical diagnosis, centralisation, force progressions, and value of approach in offering self-management.

Hyman MH, Jacob G, Lin K, Mooney V. ; Primary care update: brief summaries for clinic. Mechanical diagnosis and therapy: the McKenzie approach to spinal complaints. Consultant; 39.7.2115-6, 1999.

Overview

Leibensen C; Spinal therapeutics based on responses to loading pp. 22-252, 1996.

Chapter

Leibensen C; McKenzie spinal rehabilitation methods pp 330-351, 2000.

Chapter

May S, McKenzie RA; Mechanical diagnosis and therapy for the cervical and thoracic spine Phys Ther of the Cer Thor Spine; 3rd Edition, 2002.

Book Excerpt

McKenzie RA; Mechanical Diagnosis and Therapy for Low Back Pain: Towards a better understanding. , 1987.

McKenzie challenges the physiotherapy profession to critically look at the history of manipulative therapy, to learn from it, and to adopt a more organised rational approach to mechanical therapy.

McKenzie RA; Mechanical Diagnosis and Therapy for Low Back Pain: Towards a better Understanding. Chapter 16, pp 792-805., 1990.

McKenzie reviews his classification system and emphasises the need for self-treatment.

McKenzie RA; A Physical Therapy Perspective on Acute Spinal Disorders. 211-220, 1991.

McKenzie compares his system of classification to the Quebec task Force findings.

McKenzie RA; Spinal Assessment and Therapy Based on the Behaviour of Pain and Mechanical Response to Dynamic and Static Loading. Nov 27-28, 1992.

A review of the Quebec Task Force findings and the McKenzie classification system, incorporating an introduction to the use of REPEX to facilitate the treatment process.

McKenzie RA; Mechanical Diagnosis and Therapy for Disorders of the Lower Back. , 1994.

Overview

McKenzie RA; Treat Your Own Neck. Spinal Publications, Waikanae, New Zealand; 3rd Edition, 1998.

A basic overview of the self-treatment and management of neck pain for lay people. (First published, 1983)

McKenzie RA; Treat Your Own Back. Spinal Publications, Waikanae, New Zealand; 8th Edition, 2006.

A basic overview of the self-treatment and management of LBP for lay people. (First published, 1980)

McKenzie RA, May S ; The Human Extremities: Mechanical Diagnosis and Therapy Spinal Publications, Waikanae, New Zealand; , 2000.

A description of the McKenzie philosophy outlining assessment, treatment and prophylaxis for the human extremities.

McKenzie RA, May S; The Lumbar Spine. Mechanical Diagnosis and Therapy. (Vol. 1 and 2) Spinal Publications, Waikanae, New Zealand; 2nd Edition, 2003.

A revision and update of the McKenzie philosophy outlining assessment, treatment and prophylaxis for low back pain and leg pain. (Foreword written by Nikolai Bogduk MD, PhD, DSc) 1st edition published in 1981.

McKenzie RA, May S; The Cervical and Thoracic Spine. Mechanical Diagnosis and Therapy. (Vol. 1 and 2) Spinal Publications, Waikanae, New Zealand ; 2nd Edition, 2006.

A revision and update of the McKenzie method of mechanical diagnosis and therapy with specific reference to the cervical and thoracic spine. (First published in 1990)

Mooney V.; Treating low back pain with exercise: the McKenzie approach. J Musculoskeletal Med; 12.12.24-6,28,33-36, 1995.

Overview

Morris C; McKenzie protocols for mechanical assessment of the low back; McKenzie protocols for mechanical treatment of low back pain pp 463-476; pp 611-622, 2006.

Chapters

Moss JR; Cervical and lumbar pain syndromes Grieve's Modern Manual Therapy; Churchill Livingstone, Edinburgh, 1994.

Chapter

Murphy D; The McKenzie protocol in the cervical spine pp 641-661, 2000.

Chapter

Poulter DC, McKenzie RA; The Management of Work Related Back Pain.

The authors suggest common causes of LBP in the work place. They provide a review of tissue healing and suggest that self-treatment exercises can be used in the work place to prevent recurrence.

Robinson MG; The McKenzie Method of spinal pain management Grieve's Modern Manual Therapy; Churchill Livingstone, Edinburgh, 1994.

Chapter

Ross J; Management of the lateral shift of the lumbar spine. Man Ther; 3;62-66, 1998.

Description of proposed mechanisims and correction of lateral shift

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).

Sagi G, Kaplanis E, Guiraud M, Bagole L, Vandeput D, Boudot P ; La Methods McKenzie Kinesitherapie; 43:13-36, 2005.

An overview of the McKenzie method as utilised in lumbar and cervical spine and extremities in French.

Stevens BJ, McKenzie RA; Mechanical Diagnosis and Self Treatment of the Cervical Spine. , 1988.

A review of the McKenzie mechanical syndromes, patient evaluation, treatment progression, and prophylaxis as it pertains to the cervical spine.

Stude D; Evaluating the patient using the McKenzie approach pp 147-178, 1999.

Chapter

Taylor MD.; The McKenzie method: a general practice interpretation: the lumbar spine. Aust Fam Physician; Feb;25(2):189-93, 1996.

Overview of mechanical diagnosis and therapy in which the author proposes alternative nomenclature for mechanical syndromes – namely incipient trauma (posture), unhealed trauma (derangement), and healed trauma (dysfunction).

Jacob G; Specific application of movement and positioning technique to the lumbar spine, considering theoretical formulation and therapeutic application. Today’s Chiropractic; Part 1 Vol 18, No 6; Part II, Vol 19, No 1, 1989.

The rationale for flexion procedures is outlined which has resulted in a failure to adequately explore the relationship of pain behaviour to movement and positions of the lumbar spine.

Jacob G; The Mckenzie Protocol and the Demands of Rehabiliation. Cal Chiro Journal; 16:10 Oct, 1991.

Jacob likens the McKenzie approach and chiropractic approach and states that movement is the key to pain relief, either using patient generated forces or therapist generate forces when required.

Jacob G; Spinal therapeutics based on responses to loading. , 1995.

Discussion of mechanical and symptomatic responses to different loading strategies.

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.

Mooney V; Reducing Subacute and Chronic Low back disability Orthopaedic Review; Vol XIX, No 8, 1990.

Mooney concludes that active patient participation, early care and evaluation of function but not pain results in good outcomes when treating low back pain.

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.

Aker PD, Gross AR, Goldsmith CH, Peloso P.; Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ; Nov 23;313(7068):1291-1296 , 1996.

Review of 24 RCTs: positive treatment effect for manual therapy from pooled results; for passive therapies, drug treatment and education results are contradictory and inadequate to reach conclusions.

Bronfort G, Assendelft WJJ, Evans R, Has M, Bouter L:; Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther; 24.457-466, 2001.

Review of 9 trials suggests manipulation may have short-term efficacy, but better research is needed.

Coulter I.; Manipulation and mobilization of the cervical spine: the results of a literature survey and consensus panel. J Musculoskeletal Pain ; 4.113-123, 1996.

Review of 14 RCTs: for acute and chronic neck pain manual therapy may have some positive treatment effect, where tested exercises are as effective.

Di Fabio RP; Manipulation of the cervical spine: risks and benefits. Phys Ther; Jan;79(1):50-65, 1999.

Review of 12 RCTs: manual therapy has a positive treatment effect, with no proven difference between mobilisation and manipulation.

Hoving JL, Gross AR, Gasner D et al:; A critical appraisal of review article on the effectiveness of conservative treatment for neck pain. Spine ; 26.196-205, 2001.

25 review articles were included, 12 systematic reviews. Opinions varied in different reviews, regarding manipulation and traction there was inconclusive evidence.

Hurwitz, E.L.; Aker, P.D.; Adams, A.H.; Meeker, W.C. ;Shekelle, P.G.; Manipulation and Mobilization of the Cervical SpineA Systematic Review of the Literature Spine; 21:1746-1760, 1996.

Review of 14 RCTs, plus other studies, favouring short-term treatment effect of manual therapy.

Kjellman GV, Skargren EI, Oberg BE; A critical analysis of randomised clinical trials on neck pain and treatment efficacy. A review of the literature. Scand J Rehabil Med; Sep;31(3):139-52, 1999.

Review of 27 RCTs: positive outcomes and good quality studies supporting ‘active’ physiotherapy, manipulation, electromagnetic therapy.

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.

Hanten WP, Barrett M, Gillespie-Plesko M, Jump KA, Olson SL; Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physio Theory & Pract ; 13.285-291, 1997.

One session of either intervention caused no significant changes in trigger point sensitivity.

Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C.; A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine; Sep 1;27(17):1835-43, 2002.

200 patients with cervical headaches randomised to manipulation, exercise, combined, or control group. ‘Exercise’ consisted of craniocervical flexion endurance exercises (ie retraction), postural correction exercises, and isometric rotation exercises. At 12 months all 3 active treatments significantly better than control, combined treatment better, but not significantly.

Kjellman G, Oberg B ; A comparative study of objective outcomes after three different treatments in patients with neck pain Intl Forum for Primary Care; 42, 2004.

Further analysis from 2002 study. Only the McKenzie group improved in all measures of range of movement, muscle endurance and strength.

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.

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.

Schmidt I, Rechter L, Hansen VK, Therkelsen K, Rasmussen C; The association of the involvement of financial compensation with the outcome of cervicobrachial pain that is treated conservatively. Rheumatology; 40: 552-554, 2001.

Of 60 patients with neck and arm pain treated with the McKenzie approach those involved in financial compensation showed no improvement, whilst those that were not showed a significant improvement.

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.

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.

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.

Donelson R; Cervical protrusion and retraction. McKenzie Institute (UK) Newsletter; 3:2;20-21, 1994.

A radiographic and range of movement study of the effects of protrusion/retraction, and an analysis of symptom response to sagittal end-range test movements. Of the 45% who experienced improvement “directional preference” was for extension in 67%, and for flexion in 33%.

Edmondston SJ, Chan HY, Ngai GCW, Warren LR, Williams JM, Glennon S, Netto; Postural neck pain: an investigation of habitual sitting posture, perception of ‘good’ posture and cervicothoracic kinaesthesia. Manual Therapy; 12.363-371, 2007.

Comparison of individuals with postural neck pain and matched asymptomatic controls. There was no difference between groups in habitual sitting posture, but there was a significant difference between groups in perceived ‘good posture’, with the postural neck pain group demonstrating a more protracted head position.

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.

Falla D, O’Leary S, Fagan A, Jull G ; Recruitment of the deep cervical flexor muscles during postural-correction exercise performed in sitting. Manual Therapy; 12:139-143, 2007.

Activation of deep cervical flexors and lumbar multifidus was significantly greater when therapists facilitated posture correction than independent sitting correction in 10 patients with chronic neck pain.

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.

Lentell G, Kruse M, Chock B, Wilson K, Iwamoto M, Martin R.; Dimensions of the cervical neural foramina in resting and retracted positions using magnetic resonance imaging. J Orthop Sports Phys Ther; Aug;32(8):380-90, 2002.

MRI study of neural foramina in 20 asymptomatic volunteers – retraction at most levels caused a slight but not significant enlargement of foraminal area.

McAviney J, Schulz D, Bock R, Harrison DE, Holland B.; Determining the relationship between cervical lordosis and neck complaints. J Manipulative Physiol Ther; Mar-Apr;28(3):187-93, 2005.

Retrospective analysis of 277 radiographs of neck pain patients and non-neck pain patients. Patients with neck pain were significantly associated with decreased cervical lordosis / extension, but not with forward head posture.

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.

Persson PR, Hirschfeld H, Nilsson-Wikmar L ; Associated sagittal spinal movements in performance of head pro- and retraction in healthy women: a kinematic analysis. Manual Therapy; 12:119-125, 2007.

Study of the relative contributions of different parts of the spine to produce retraction in 14 healthy women using a computerised video analysis: 60% of movement came from cervical spine, 30% from C7-T4 and 10% from the rest of thoracic spine.

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.

Tuttle N, Laakso L, Barrett R ; Change in impairments in the first two treatments predicts outcome in impairments, but not in activity limitations, in subacute neck pain: an observational study Aust J Physiother; 52:281-285, 2006.

Improvements in measures of range of movement, functional disability, pain intensity and pain location were noted during first 2 and final treatment sessions in 29 neck patients receiving manual therapy. All measures improved by the end of treatment, but improvement in each measure only predicted improvement in that measure and not in other impairments.

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.

Barnsley L, Lord S, Bogduk N; Clinical Review: Whiplash Injury Pain; 58;283-307, 1994.

Thorough review of epidemiology, pathology, symptoms and litigation issue. Studies show that about a quarter will continue to have persistent pain.

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.

Magee DJ, Oborn-Barrett E, Turner S, Fenning N:; A systematic overview of the effectiveness of physical therapy intervention on soft tissue neck injury following trauma. Physiotherapy Canada; 111-130, 2000.

Only 8 papers met validity criteria, these showed a weak to moderate positive effect for exercise, advice, manual therapy, and pulsed electromagnetic therapy. Quality of all papers very poor.

Peeters GG, Verhagen AP, de Bie RA, Oostendorp RA.; The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials. Spine; Feb 15;26(4):E64-73 , 2001.

11 studies met inclusion criteria all of poor methodology, only 3 were considered to have acceptable validity. Active treatment shows benefit long-term, whereas ‘rest makes rusty’.

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.

Spitzer WO, Skovron ML, Salmi LR et al; Scientific Monograph of the Quebec task Force on Whiplash-Associated Disorders: Redefining Whiplash and its Management. Spine; 20;1S-73S, 1995.

An extensive review of the problem condoning an active, exercise, early return to normal function approach; stressing the self-limiting, favourable prognosis of the condition.

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 et al ; Neck collar, “act as usual” or active mobilization for whiplash injury? A randomized parallel-group trial. Spine; 32:618-626, 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.

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.

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.

Cherkin D; Cherkin Study N Engl J Med; 340.5.388-391, 1999.

Commentary

Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA; Author response Phys Ther; 73:4;226, 1993.

The authors claim that they are testing the effect of treatment to a diagnostic classification, not the McKenzie method.

Donelson R, McKenzie R; Letter to the Editor Spine; 17:10;1267, 1992.

In reference to the study by Elnaggar I M, et al: Effects of Spinal Flexion and Extension Exercises on Low-Back Pain and Spinal Mobility in Chronic Mechanical Low-Back Pain patients.(Spine 16:8;967-972, 1991) The authors explain that extension exercises have been used, not the McKenzie approach in comparison with spinal flexion exercises.

Donelson R, McKenzie R, May S; Letter to the Editor Spine; 26:1827-1831, 2001.

Commentary on Van Tulder M, Malmivaara A, Esmail R, Koes B: Exercise therapy for low back pain. A systematic review within the framework of the Cochrane collaboration back review group. Spine 25;2784-2796, 2000.

Fernando CK., Donelson R; Letter to the Editor Spine; 16.1008-1009, 1991.

2 letters concerning Stankovic trial (Spine 15:120-123, 1990).

Long A; More on centralisation J Orthop Sports Phys Ther; 29.8.489-490, 1999.

Commentary

Silva GJ. Riddle DL & Rothstein JM. Donelson R; Letter to the Editor Spine; 19:12;1413-1415, 1994.

Correspondence concerning Riddle & Rothstein paper (Spine 18:1333-1344, 1993).

Williams MM, McKenzie RA, Farrell JP; Commentaries Phys Ther; 73:4;223, 1993.

McKenzie and Williams point out some inconsistencies and inadequacies with Delitto’s study, but commend the authors on the study and agree that further research needs to be done.

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.

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

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.