Traditional treatment for spinal (back and neck) pain tends to involve two extremes of intrusiveness: palliative approaches such as bed rest, heat, massage, generic exercises, etc., and/or the most invasive procedure available, some type of surgery. The McKenzie Method of evaluation and treatment, and the Alexander Technique, among other postural-movement approaches, fill in the large gap between these two extremes. As an Alexander Technique teacher and as a physical therapist trained in the McKenzie Method, I find their combination enormously enhances my effectiveness in working with people experiencing spinal problems. In this article I will focus on the McKenzie approach and briefly point out how the Alexander Technique articulates with it.
Robin McKenzie, a New Zealand physical therapist currently practicing there, started to develop his method when he observed that a supposed "mistake" he made in not following the conventional wisdom regarding appropriate exercise for back pain led to a dramatic improvement for the patient being treated. Because he had something else to take care of before seeing a back-pain patient, he instructed this patient, Mr. Smith, to lie down where a previous knee-pain patient had been. The head end of the treatment table had been elevated so that the previous patient's head and upper torso were raised while he lay on his back getting treatment to his knee. McKenzie assumed that Mr. Smith would also lie down that way. When McKenzie arrived in the room, he felt horrified to see Mr. Smith lying on the table on his stomach, with his back extended, at that time the exact opposite of what was considered the appropriate position for the patient's problem. However, the patient reported that he felt better than he had in days!
Thus challenged to reconsider his work, McKenzie developed an approach which involves a diagnosis based on individualized observation and emphasizes a treatment plan which uses a series of movements under the control of the patient to the greatest extent possible. This focus leans heavily on patient education and promotes self-care and a preventive orientation.
A number of studies have indicated that back and neck pain episodes tend to be self-limiting. A significant number of people will feel better with the passage of time no matter what treatment is used. Therefore, although the traditional passive approach to treatment, where medication, rest, heat or ice, massage or indiscriminate manipulation are "done to" the client, often seems to work, the usefulness of such often expensive treatments seems questionable. Other studies indicate that as many as 90% of people who have had significant episodes of back pain will have recurrences, even when they've had traditional treatment, and that 35% of these will eventually develop sciatica (pain radiating into one or more limbs). For the most extreme cases of pain, back surgery remains an option but the failure rate for this procedure remains appallingly high.
McKenzie and the physical therapists who follow his method believe that an active approach to treatment, where patients learn how to treat themselves, will not only shorten the present episode but reduce the probability and severity of recurrences as well as the recourse to surgery. Clinical observations and some studies indicate the promise of this approach and ongoing research is being done to further corroborate it.
See Back and Neck Pain Categories for an outline laying out the different types of spinal pain, citing the various diagnostic and treatment categories as understood and utilized in the McKenzie Method. I note in parentheses where I enhance this method with the Alexander Technique.
Based on my Alexander Technique work, I suggest a modification to this outline. While McKenzie acknowledges the dynamic nature of "posture" he still uses this generally-accepted term. I prefer to use a term that I coined, "postural-movement" habits and re-education, to get away from the static implications of "posture."
Evaluating Back Pain
What happens when a client consults me for back and/or neck pain? Depending on my initial assessment, sometimes on the phone even before the person comes in, I may recommend an evaluation by the person's physician. Assuming that illness has been ruled out as a cause and the injury is recent, much of the pain of an acute injury may be non-mechanical, caused by the chemical by-products of inflammation present within the first few days following an injury. At this point, positioning and movement will have no lasting effect on pain and too much movement may disrupt the healing process. I may recommend positions or movements that reduce stress on healing tissues, as well as rest, ice, etc., for a few days so healing can begin to take place. However, more than a few days of bed rest can create new problems. So, after a few days, I recommend another visit to reevaluate the client's condition. I start by taking a detailed history of the current and prior pain episodes. The history includes what happened prior to the pain, other antecedents, treatments to date for all episodes, results of treatments, a detailed description of the character and location of current pain, and relevant medical history and medications. I take detailed notes and chart the character and location of current pain.
Physical examination follows, based on the McKenzie Method. I first note structural aspects such as spinal curvatures, leg lengths, and shoulder and pelvic positions. Then I observe the range and quality of movement of the spine to determine how far and in what way the spine moves. Finally, since mechanical pain is caused by physical forces generated through positioning and movements, which stress the tissues of the spine, I have the client perform various movements, in various positions, noting in detail the effects of these movements on the pain experienced and on the range and quality of movement. Each movement gets repeated, from 5 to 10 times and maybe more, depending on the client's response. The client is encouraged to go through each movement to the furthest possible extent (called "end range"). This use of repeated movements originated with McKenzie and remains crucial for classifying the client into the appropriate syndrome.
For the lower back examination, movements include: while standing, forward bending or flexion, backward bending or extension and side gliding which combines side-bending and rotation movements; while lying on back, knees to chest (a form of "flexion", the "conventional" type of exercise for back pain); while lying on stomach, pressing up with hands so back is arched (a form of "extension" and the position in which the "mistaken" McKenzie found that fortunate patient whose response triggered revisions in McKenzie's work). When necessary I may perform other tests such as ' neurological examination of reflexes, sensation and muscle strength. I use a similar examination scheme with different movements for the mid-back, neck and limbs.
Based on the history and examination, I make a tentative diagnosis regarding what is involved in the client's pain. I say "tentative" because I maintain an awareness that conditions and responses can change, requiring ongoing evaluation and revisions in diagnosis and treatment. I remain alert to the possibility of nonmechanical pain and need for referral to a physician for further medical evaluation. Thus, the history is brought up-to-date and an abbreviated version of the evaluation process is repeated at each visit.
Assuming that at any given time nonmechanical pain has been ruled out, I determine the mechanical syndrome. Details about each follow. This classification scheme, although based on the available medical literature, remains another origination of McKenzie's.
The client with a postural syndrome feels no pain when active and moving. Clients tend to be under thirty and have sedentary occupations. The pain can appear in the lower back, upper back, neck or all three areas and comes on with prolonged sitting or standing. On examination, the client appears asymptomatic with no loss of movement. With repeated movements, there is no pain. The only observable finding is poor sitting and standing posture.
The symptoms may be elicited at the time of examination by getting the client to maintain a static slouched position until the pain is brought on. What is the mechanism of pain? No pathology in the muscles or joints is present. Instead, the client is putting normal tissue under abnormal mechanical stress by hanging their spinal joints at end range in certain positions. Some tissues are getting unduly stretched while others are unduly shortened. This is what happens when you take your finger and bend it backwards until you feel pain. No damage has necessarily been done although some might occur if you persist in bending your finger like that over and over again and for prolonged periods. Repeated undue stretching probably leads to many of the dysfunctions and derangements people over thirty experience.
For this syndrome, postural-movement education becomes the main treatment. People with postural pain must come to realize that their symptoms are directly related to their posture. Sitting and standing postures are corrected through verbal and manual guidance. Individual problem areas such as sleeping and lying positions and working postures are dealt with as needed.
McKenzie has written two self-help books, Treat Your Own Back and Treat Your Own Neck which describe his educational approach to "posture" in more detail. Clients are shown how to recognize and maintain what I call 'neutral' spinal positions which involve a moderate amount, neither increased nor reduced, of the so-called normal curves of the spine. Clients are taught to practice exaggerating the two extremes of overcorrection and slouching in order to become more aware of how to find 'neutral' in sitting and standing.
Poor sitting postures and a life-style that involves frequent flexion of the spine and loss of normal lordosis or hollow of the lower back, along with loss of extension mobility constitute major predisposing factors in the production of back pain. Clients are taught how to maintain the lordosis in sitting either using their own effort or with the use of a lumbar roll. They are also taught to interrupt prolonged flexed positions by bending backwards and accentuating the lordosis, and to maintain the normal lordosis while bending and lifting. These instructions, which emphasize the importance of extension, directly contradict traditional approaches which encouraged people to flex while sitting, bending and lifting. They represent another innovation that McKenzie had a major part in promoting, and are accepted as valid by more and more therapists today. I combine these instructions with the more detailed and dynamic Alexander Technique work and find them thoroughly compatible.
The dysfunction syndrome is characterized by loss of mobility in one or more of the movements of the spine. Pain is localized near the spine and felt only at the end range of movement. Repeated movements do not worsen it. Because of this loss of motion, curves of the spine may appear distorted and posture often appears poor. Adaptive shortening of muscles, joints, ligaments and other soft tissues may be at fault here, secondary to habitual poor posture. Tissue shortening may also result from scarring following injury. Treatment involves postural re-education to reduce stress on the abnormally shortened tissues, and movements and exercises to stretch them. On occasion I may also use manipulative therapy, as described below, but less frequently than with the derangement syndrome.
In the derangement syndrome, posture again often appears poor. The client may appear fixed in a position of deformity. Loss of motion in one or more directions may be observed. The client may feel intermittent or constant pain locally on or near the spinal column or radiating into one or more limbs. The response to repeated movements differs from that observed in dysfunction. The client's symptoms may change site, increase, decrease, be produced or abolished rapidly in the course of relatively few movements. McKenzie conjectures that changes within the intervertebral disc are probably responsible for this syndrome. He also proposes that the less severe derangements, commonly referred to as "slipped discs", or "disc bulges", occur often and explain the majority of episodes when people's backs or necks "go out".
The disc consists of a fibrous outer wall called the annulus fibrosus and a gel-like inner portion called the nucleus pulposus The disc consists of a fibrous outer wall called the annulus fibrosus and a gel-like inner portion called the nucleus pulposus. The disc has shock-absorbing properties that protect the spinal column. With normal aging, so-called "degenerative" changes, such as cracks and fissures, can occur in the structure of the disc. These may or may not be associated with symptoms. As a result of abnormal stresses such as poor and prolonged sitting and frequent or prolonged flexion of the spine or as a result of trauma, internal derangement can occur within the disc.
According to McKenzie's model, some of the nuclear material may get deranged, i.e., lodged out of its normal position, causing pain and loss of movement as surrounding tissues are placed under abnormal stress. At the extreme stage of this disorder, nuclear material may extrude through a broken annular wall and protrude into the surrounding tissue, causing nerve irritation or injury. Positions or movements are unlikely to have much of an effect in reducing symptoms when this first occurs. Time will be needed for the surrounding tissues to accommodate to the extruded material. Surgery may or may not be indicated. Short of this extreme case it is possible to reduce an internal derangement, in other words, change the shape and location of the displaced material, and restore normal relations among the spinal structures through the judicious use of mechanical therapy. Clients can do this themselves, using the positions and movements that were found in the evaluation to centralize, reduce or abolish symptoms. Symptoms are centralized when pain moves toward the spinal column and away from the periphery, e.g., when pain that was radiating down the leg becomes focused in the mid-point of the lower back. The phenomenon of centralization was observed by other clinicians but previous to McKenzie was never seen as very noteworthy or desirable. At the present time, a growing number of practitioners consider centralization of symptoms a consistently reliable guide to the success of a given treatment for derangement.
As McKenzie discovered, extension positions and movements often centralize, reduce and abolish pain. Thus, for example, one common movement and position involves "press ups": starting from lying on the stomach, the person pushes up with the hands until the back gets extended as far as possible, allowing the lower back to sag, and then returns to lying. This is repeated about 10 times many times through the day, as well as during treatment sessions.
Manipulative Therapy
Self-administered treatment using forces generated by the client may prove inadequate, even when they help somewhat. The client is moving the joints of the spine in the right direction but they are not generating enough force to remain improved. At this point therapist-generated forces can be used. The results of repeated-movement testing and of the client's own efforts indicate in which direction to move the joints. Starting with the least amount of force, the therapist applies pressure at the indicated level and in the indicated direction. The therapist continually monitors the client's response. Using this approach, the therapist can safely increase the amount of force as needed. These therapist-generated forces, also known generically as manipulative therapy, have been used for centuries. Within the category of manipulative therapy, McKenzie practitioners, along with other physical therapists who use these techniques, distinguish between joint mobilization (involving more slowly applied pressures throughout the range of motion of a joint), and manipulative thrusts (involving quickly applied pressures at the end range of a joint).
Another of McKenzie's innovations involves the realization that exercises done by the client and manipulative therapy done by the therapist, previously thought of as separate categories, can be viewed on a continuum of force. Traditionally people have gone to chiropractors, osteopaths and physical therapists and received manipulative treatment as the first and main treatment. McKenzie has shown that exercises constitute a form of manipulative treatment. Therapist techniques are not the main form of treatment in his method. They are applied only after the client has exhausted the self-treatment procedures and they are used to make self-treatment more effective. This involves a radical change in philosophy from previous schools of manipulation. Once a derangement gets reduced with client and, if necessary, therapist techniques and the client has been able to maintain a pain-free state for several days, clients may carefully begin to flex the spine in order to prevent the development of a dysfunction and to restore normal flexibility and movement. Throughout this process, I also provide postural-movement re-education.
The McKenzie Method and The Alexander Technique
Postural-movement re-education plays a crucial role for everyone who has experienced back and neck pain. I have indicated in Back and Neck Pain Categories where Alexander Technique work fits in with the McKenzie Method. At some point its use is appropriate with all people who experience or have experienced spinal pain. For people with the postural syndrome I use it as my main intervention, along with McKenzie's postural re-education procedures. For people with dysfunctions and derangements, I provide "mini"-Alexander Technique lessons during the self-treatment and therapist-treatment phases, followed by more extensive lessons nearing the end of treatment. In my experience, the McKenzie approach and the Alexander Technique provide a powerful combination of self-care methods for dealing with the epidemic of back and neck problems. As Robin McKenzie has pointed out, "By insisting whenever possible that our patients become responsible for their own care, we can help to make them independent of therapy and provide for them what is potentially a long-term benefit."
Important
note:
This material is
meant for your information and not intended to substitute for evaluation
or
treatment by a physician
or other health-care professional.
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