Reference List

Apeldoorn A, van Helvoirt H, Meihuizen H, Tempelman H, Vandepu D, Knol D, Kamper S, Ostelo R, The influence of centralization and directional preference on spinal control in patients with nonspecific low back pain , J Orth Sports Phys Ther, 46(4):258-69,2016

This study explored whether clinical signs of impaired spinal control changed in relation to the outcome of an MDT assessment, it used a test-retest design. Of those patients that centralised 43% and 50% showed improvement in aberrant movements and ASLR respectively. Only < 10% improved in the non directional preference group. Clinical signs of poor motor control can be reduced spontaneously following an MDT assessment.

Grasser P, Neto F, Veloso J, Costa R, Dorneles J, Mechanical diagnosis and therapy in musculoskeletal pain of individuals with spinal cord injury , J Spinal Cord Med, Apr 23 Online first,2023

This cohort study on 24 individuals with spinal cord injury and MSK pain (primarily lumbar and shoulder) showed the effect of MDT intervention on pain and function.

Lamb S, Gates S, Williams M et al, Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial, Lancet, 16;381(9866):546-5,2013

With this large RCT, the addition of 'active management consultations' in emergency department care did not provide benefit above usual care and a 4 month package of physiotherapy showed a modest benefit compared to a session of advice but was not cost effective.

Tagliaferri S, Owen P, Miller C, Mitchell U, Ehrenbrusthoff K, Belavey D, Classifying non-specific low back pain for better clinical outcomes: current challenges and paths forward, J Orthop Sports Phys Ther, Apr 23 Online first,2023

This review acknowledged that classifications systems, such as MDT had merit in providing a framework for clinical decisions, but currently have limited efficacy, and a number of factors need to be addressed.

Yoon-Ho K, Sung-In K, Seongjun P, Sung Hwan H, Sun G, Effects of Cervical Extension on Deformation of Intervertebral Disk and Migration of Nucleus Pulposus , PM&R, 9,4, 329-338,2017

This study on 10 healthy males used MRI to examine the effect of cervical extension on disc deformation and positional change of the nucleus. It found that extension produced anterior migration of the nucleus away from the posterior disc margin and "may have a clinical effect on discogenic neck pain resulting from internal disk disruption"

Abdollah V, Parent E, Battie M, MRI evaluation of the effects of extension exercises on the disc fluid content and location of the centroid of the fluid distribution, Musculoskeletal Science and Practice, 33, 67-70,2017

This study looked at the immediate effect of extension in lying on disc fluid content and movement. It concluded that the exercises likely do not change the fluid content of the disc, but 'possibly influence fluid distribution within the discs favouring a more anterior position'

Abdulwahab SS, Sabbahi M, Neck retractions, cervical root decompression, and radicular pain., J Orthop Sports Phys Ther, Jan;30(1):4-9,1999

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.

Agarwal V, Bansal A, Kolski M, Resolution of Noncardiac Chest Pain With Corrective Exercises for Neck and Upper Thoracic Spine , AIM Clinical Cases, 3:e230804. ,2024

This case series of 3 patients describes how cervical/thoracic Derangements can be responsible for persistent and in these cases, severe noncardiac chest pain, with ultimate resolution from DP exercises.

Agarwal V, Schenk R, Ross M, Primary care management of patients with pain complaints and the influence of physician training in mechanical diagnosis and therapy , J Public Health, 30:1265–1271,

This single-centre retrospective study, compared the health care utilisation and costs of patients seen by an MDT trained physician compared to the patients of a group of physicians not trained in MDT. Costs and health care utilisation were markedly less for patients managed by the MDT trained physician

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.

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

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

Al-Abaidi S, Asbeutah A, Alsiri N, Changes in Vertebral Artery Hemodynamics Associated With McKenzie Therapeutic Cervical Movements: An Exploration Using Duplex Ultrasound imaging, J Man Manip Ther., 2019;41;1:66-74,2019

This study examined the effects on McKenzie cervcial exercises on vertebral artery hemodynamics. It found that, for healthy individuals, these exercises were mostly associated with an increase in hemodynamics.

Al-Obaidi S, Al-Sayegh N,Ben Nakhi H, Al-Mandeel M, Evaluation of the McKenzie Intervention for Chronic Low Back Pain by Using Selected Physical and Bio-Behavioral Outcome Measures, Phys Med Rehab, Vol 3 (7): 637-646,2011

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

Al-Obaidi S, Anthony J, Dean E, Al-Shuwai N., Cardiovascular responses to repetitive McKenzie lumbar spine exercises, Phys Ther, Sep;81(9):1524-1533,2000

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

Al-Obaidi SM, Al-Sayegh NA, Nakhi HB, Skaria N., Effectiveness of McKenzie intervention in chronic low back pain: a comparison based on the centralization phenomenon utilizing selected bio-behavioral and physical measures, Int J Phys Med & Rehab, 1:4,2013

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

Al-Obaidi SM, Asbeutah A, Al-Sayegh N, Dean E., To establish whether McKenzie lumbar flexion and extension mobility exercises performed in lying affect central as well as systemic hemodynamics: a crossover experimental study., Physiotherapy, 99:3:258-265,2013

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

Albert HB, Hauge E, Manniche C., Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?, Eur Spine J, 21(4):630-6,2012

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

Albert HB, Manniche C., The efficacy of systematic active conservative treatment for patients with severe sciatica. A single-blinded randomized controlled trial., Spine, 37:7:531-542,2011

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

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.

Almeida MO, Narciso Garcia A, Menezes Costa LC, van Tulder MW, Lin CWC, Machado LAC , The Mckenzie Method for (sub)acute non-specific LBP, Cochrane Library, Issue 4,2023

This Cochrane review was based on low to very low certainty evidence and found that the McKenzie Method was ineffective for this population of LBP patients. Only 5 studies met the criteria, two of which were 25 years old, and none were from the last 10 years.

American College of Occupation and Environmental Medicine, Exercise and Manipulative Therapies for Treatment of Acute and Subacute Low Back Pain., Elk Grove Village, IL:ACOEM,2005

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

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

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

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

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

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.

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

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

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.

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.

Bardin L, King P, Maher C, Diagnostic triage for LBP: a practical approach to primary care, Med J Aust, 206,6:240-241,2017

The narrative review updates the diagnostic triage process. It details the diagnostic specifics of Radicular Syndrome and of Serious Pathology. It also outlines some of the options for management approaches.

Baumann A, Orellana K, Landis L, Crawford M, Oleson C, Rogers H, Curtis D , Baldwin K, The McKenzie Method Is an Effective Rehabilitation Paradigm for Treating Adults With Moderate-to-Severe Neck Pain: A Systematic Review With Meta-Analysis , Cureus, 15(5): e39218. DOI 10.7759/cureus.39218,2023

This SR and meta-analysis on moderate to severe neck pain concluded that MDT provided very small, but clinically and statistically significant pain improvement. There was no effect on disability.

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-S1 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.

Bernhardsson S, Oberg B, Johansson K, Nilsen P, Larsson M, Clinical practice in line with evidence? A survey among primary care physiotherapists in western Sweden., Journal of Evaluation in Clinical Practice, doi: 10.1111/jep.12380,2015

271 Swedish physios completed a survey on preferred treatment interventions on 3 msk disorders. Their responsers were compared to the current support of the evidence. Most interventions, including the use of MDT were supported by the evidence. However interventions with unclear or no evidence were also used to a high degree.

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.

Beyer R, Kongsgaard M, Kjær B, Øhlenschlæger T, Kjær M, Magnusson P, Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial, Am J Sports Med, 431,704,2014

This RCT with 58 patients with Achilles tendinopathy compared a 12 week intervention of eccentric exercises to a heavy slow resistance protocol. Outcomes on VISA-A and structural changes showed the same improvement with both groups both in short and long term (1 year)

Bid D, Soni N, Yadav A, Rahtod P, The effects of McKenzie exercises in chronic nonspecific low back pain patients with central sensitization: A pilot study, J Indian Assoc Physio, 12;1:37-42,2018

This pilot study investigates the use of MDT on central sensitization in patients with chronic LBP. Patients treated with McKenzie principles demonstrated greater improvements in pain-related disability, fear avoidance, and central sensitization scores compared to conventional physiotherapy exercises. It was determined that the patient generated forces may have an effect on the activation of descending antinociceptive pathways.

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.

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.

Bjornsson Hallgren H, Holmgren T, Oberg B, Johansson K, Adolfsson L, A specific exercise strategy reduced the need for surgery in subacromial pain patients, Br J Sports Med, 48:1431-1436,2014

97 patients on the waiting list for subacromial decompression were randomised into a loaded predominantly eccentric exercise group or a general exercise group. Those in the specific exercise group had significantly reduced need for surgery at 1 year

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

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

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.

Broetz D, Hahn U, Maschke E, Wick W, Kueker W and Weller M, Lumbar disc prolapse: Response to mechanical physiotherapy in the absence of changes in magnetic resonance imaging. Report of 11 cases., NeuroRehabilitation, 23(3): 289-294,2007

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.

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

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

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

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

Brosseau L, Taki J, Desjardins B et al, The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: Strengthening exercise programs, Clinical Rehabilitation, Online February,2017

This clinical practice guideline developed by a panel of international experts made recommendations on the management of knee OA in regards to strengthening exercises. MDT was 'strongly recommended' as an intervention for this population.

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.

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.

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).

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.

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.

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).

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, 15.54-60,2009

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.

Carlton L, Maccio JR, Maccio JG, Braga A, Tomanio E, Belikov E, The application of Mechanical Diagnosis and Therapy to the ankle-foot complex; a case series, J Man Manip Ther. , 26(3):181-188,2018

The case series follows 4 patients with ankle/foot pain,. All with Derangements at the ankle or at the lumbar spine. The patients responded rapidly and had a lastring change with MDT management

Carlton L, Maccio JR, Maccio JG, McGowan C , The application of mechanical diagnosis and therapy on hip osteoarthritis: A case report, Physio Theory and Pract., Online June,2018

The case report descibes the clasification and management of a 71 year old patient diagnosed with hip OA. The MDT assessment found a Directional Preference of extension and the patient had positive short and long-term oiutcomes. This resolution was despite the patient's presentation fitting with the CPR for Hip OA and being positive on initial orthopedic special testing

Chaiyawijit S, Kanlayanaphotporn R, McKenzie neck exercise versus cranio-cervical flexion exercise on strength and endurance of deep neck flexor muscles, pain, disability, and craniovertebral angle in individuals with chronic neck pain: a randomized clinical trial., J Man Manip Ther. , Online first,2024

This RCT compared retraction/extension exercises with cranial cervical flexion exercises with 40 patients with chronic neck pain. Both groups has similar effects at 6 weeks on strength, endurance, pain and disability. No DP was established for the retraction/extension group.

Chan AYP, Ford JJ, McMeeken JM, Wilde VE, Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique., Physiotherapy, 99:3:212-220,2013

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

Chan M, Dyck M, Thevasagayam G, Yap R, Ouellet J, Robbins SM, Inter-rater Reliability of the McKenzie Method of Mechanical Diagnosis and Therapy for the Provisional Classification of Low Back Pain in Adolescents and Young Adults , J Man Manip Ther., Online January,

The study investigated the inter-rater reliability of MDT classification in adolescents and young adults with LBP. Moderate reliability was found overall, with a good rate in older particiapants and poor in younger participants

Chang B, Schenk R, The influence of directional preference on lateral patellar dislocation: a case report , J Man Manip Ther., Aug 23 Online first,2023

This case report details the use of classifying with MDT and applying DP management to a patient with lateral patellar dislocation, restoring all baselines.

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

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

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.

Chiba H, Handa Y, Kikkawa K, Takasaki H., Research Priorities in the Mechanical Diagnosis and Therapy Among Diploma Therapists: An International Delphi Study., Cureus, 16(6):e62492.,2024

This modified Delphi study identified priorities for future research exploring the McKenzie Method.

Chiu C, Chuang T, Chang K, Wu C, Lin P, Hsu W, The probability of spontaneous regression of lumbar herniated disc: a systematic review, Clinical Rehabilitation, 29,2,2014

This systematic review looked at the probability of spontaneous disc regression in the lumbar spine. Percentages were given for various types if disc herniations. Extrusions and sequestrations had the highest rates of regression

Choi BKL, Verbeek JH, Tam WWS, Jiang JY, Exercises for prevention of recurrences of low-back pain, Cochrane Library, 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.

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

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

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

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

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 _x0018_other_x0019_ 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, 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, Construct validity of lumbar extension measures in McKenzie 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, 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.

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).

Coeytaux R, Lallinger K, McBroom Brooks A, Sanders Schmidler G, Future Research Identification: Comparative Effectiveness of Nonsurgical Treatment for Cervical Disc and Neck pain, Patient-centred Outcomes Research Institute, October,2015

This review, undertaken at the request of the Patient-Centered Research Institute, aimed at identifying future research gaps in the conservative treatment for cervical disc and neck pain. It concluded that one of the priorities for future study should explore the comparitive effectiveness of centralisation vs non-centralisation and directional preference vs no directional preference as predictors of response to therapy.

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.

Cook J, Rio E, Purdam C, Docking S, Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?, Br J Sports Med, 50, 1187-1191,2016

This discussion paper reviews and updates the continuum model of tendon pathology. The implicatiosn of new research is discussed, especially the relationship between structure, tendon pain and function. Clinical implications are also hignlighted.

Cook JL and Purdam CR, Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy., Br J Sports Med, 43;409-416,2009

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

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

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

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

Cutkan NB, Lipson AC, Lisi A, Reinsel TE, Rich R, NASS; Evidence-based clinical guidelines for multidisciplinary spine care, NASS, Burr Ridge IL,2020

This guideline for diagnosis and treatment of low back pain found insufficient evidence that a self-directed McKenzie program for acute low back pain results in different outcomes than usual care. It found poor quality evidence that MDT is an option for the treatment of chronic low back pain, but insufficient evidence that MDT results in different outcomes in chronic low back pain when compared to dynamic strengthening or back school.

Danish Institute for Health Technology Assessment, Low-back pain. Frequency, management and prevention from an HTA persective., , 1-106,1998

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.

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.

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

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

de Campos T, Pocovi N, Maher C, Clare C, da Silva T, Hancock M, An individualised self-management exercise and education program did not prevent recurrence of low back pain but may reduce care seeking: a randomised trial , J Physiother, 66;3:166-173,2020

Patients recently recovered from an episode of LBP were randomised to a 'Mckenzie-based' self-management program or a single phone advice session. Time to recurrances was tracked. There was no differences in outcomes between the 2 groups.

de Campos TF, Elkins MR, Prevention of spinal pain, Physiotherapy, 67:158-159,2021

This editorial discusses the evidence for prevention in spinal pain, with exercise and education being noted as effective. The prevention study on MDT (de Campos et al) was referred to, as this concluded that MDT may produce a substantial reduction in health care seeking with LBP recurrence, though it does not reduce the risk of recurrences.

Decary S; Ouellet P, Vendittoli PA, Roy JS, Diagnostic validity of physical examination tests for common knee disorders: An overview of systematic reviews and meta-analysis , Physical Therapy in Sport, 23, 143-155,2017

This systematic review and meta-analysis looks at the diagnostic validity of knee examination testing. It concludes that most commonly used tests have questionable validity to diagnose or exclude knee pathologies. There are however, a couple of noted exceptions.

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

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

Delitto A, Piva S, Moore C, Fritz J, Wisniewski S, Josbeno D, Fye M, Welch W, Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis, Annals of Internal Medicine, 162,7,2014

This RCT compared surgical decompression to physical therapy for patients with spinal stenosis. 169 patients participated with a 2 year follow up. The PT group were given flexion based exercises, general conditioning and education. Both groups improved and there were no differences in outcome between the two groups for function or pain. However, there were a significant number of crossovers between the PT and surgical group

Deutscher D, Werneke M, Gottlieb D, Fritz, J, Resnik L, Physical Therapists' level of McKenzie education, functional outcomes, and utilization in patients with LBP, JOSPT, 44:12:925936,2014

The study looked at the associations between Mckenzie training, functional status at discharge and number of visits for LBP patients. 20,882 patienst were treated and discharged in this observational cohort study. Patients treated by McKenzie therapists had better outcomes and fewer visits compared to those treated by other therapists. This suggests improved cost-effectiveness of advanced MDT training levels.

Dionne C, Bybee RF, Tomaka J, Correspondence of diagnosis to initial treatment for neck pain., Physiotherapy, 93:62-68,2006

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.

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

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

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

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

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

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

Donelson R, 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):1115-22,1996

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, Long A, Spratt K, Fung T., Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica., Phys Med Rehabil, 23:4(9):667-81,2012

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

Donelson R, Silva G, Murphy K., Centralization phenomenon. Its usefulness in evaluating and treating referred pain., Spine, Mar;15(3):211-3,1989

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 R, Spratt K, McClelland S, Gray R, Miller JM, Gatmaitan E, The cost impact of a quality-assured mechanical assessment in primary low back pain care , J Man Manip Ther., (5):277-286.,2019

This claims based data analysis of over 5,000 patients compared the costs of those treated with MDT based care to those treated with usual community care. The utilization of MRIs, injections and surgeries were much reduced in the MDT group leading to a 50% reduction in costs.

Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG, Red flags to screen for malignancy and fracture in patients with low back pain: systematic review., BMJ, 347,2012

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

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

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

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

Edmond S, Werneke M, Grigsby D, Young M, Harris G, The association between self-efficacy on function and pain outcomes among patients with chronic low back pain managed using the McKenzie approach: a prospective cohort study , J Man Manip Ther. , 31:1, 38-45,2023

This cohort study with 282 patients with chronic LBP were treated by MDT credentialed clinicians till discharge. They exhibited an improvement in self-efficacy associated with improvements in pain and function.

Edmond S, Werneke M, Young M, Grigsby D, McClenahan B, Harris G, McGill T, Cognitive behavioural interventions, and function and pain outcomes among patients with chronic neck pain managed with the McKenzie approach , Musculoskeletal care, 1-7,2020

This prospective cohort study included 366 patients with chronic neck pain who were treated by Credentialed or Dipolomaed MDT clinicians. All patients received MDT intervention and those patients with ongoing cognitive drivers also had additional graded activity and / or graded exposure. There was no clinically relevant benefit from the addition of graded activity/exposure.

Edmond S, Werneke M, Young M, Grigsby D, McGill T, McClenahan B, Directional preference, cognitive behavioural interventions, and outcomes among patients with chronic low back pain, Physiother Res Int., 24(3): e1773,2019

This cohort study with 801 patients looked at the associations between graded activity and/or graded exposure, and DP or no DP combined with or without graded activity/exposure. For those who demonstrated DP, adding graded activity/exposure to MDT resulted in only a small improvement in function, yet for those with no DP, the addition of graded activity gave greater improvements in function.

Edmond SL, Cutrone G, Werneke M, Ward J, Grigsby D, Weinberg J, Oswald W, Oliver D, McGill T, Hart DL., Association between centralization and directional preference; and functional and pain outcomes in patients with neck pain, J Orth Sports Phys Ther, 44(2):68-75,2014

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

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

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

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):158-64,1999

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.

Elden H , Gutke A, Kjellby-Wendt G, Fagevik-Olsen M, Ostgaard H, Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study, BMC Musculoskeletal Dis, 17:276,2016

The longitudinal study looked at the predictors of those women who would have long term pelvic girdle pain following pregnancy. MDT was used in combination with SIJ tests for classification.

Elenburg JL, Foley BS, Roberts K, Bayliss AJ., Utilization of mechanical diagnosis and therapy (MDT) for the treatment of lumbar pain in the presence of known lumbar transverse process fractures: a case study., J Man Manip Ther, DOI 10.11729/2042618614Y,2015

Case report of a 24-year old woman with multiple transverse process fractures sustained 10-weeks earlier as a pedestrian in a motor vehicle accident who was classified as a derangement. She demonstrated considerable improvement with a change in Oswestry function score from 22% to 6% from initial presentation to discharge.

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

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

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.

Fatoye F, Gebrye T, Fatoye C, Mbada C, Olaoye M, Odole A, Dada O, Clinical and Cost-effectiveness analysis of telerehabilitation intervention for people with nonspecific chronic low back pain, JMIR Mhealth Uhealth, 8(6);e15375,2020

This cost-effectiveness analysis of an RCT, compared a clinical based MDT approach for low back poain with an MDT telehealth intervention. Patient with a DP of extension were included and both regimnes were extension based. The telehealth based MDT was associated with greater health benefits and 50% lower costs.

Fatoye F, GebryeT, Mbada C, Fatoye C, Makinde M, Ayomide S, Ige B, Cost effectiveness of virtual reality game compared to clinic based McKenzie extension therapy for chronic non-specific low back pain , British Journal of Pain, online first,2023

This randomised trial looked at a chronic LBP population with a DP of extension. The groups were a virtual reality based intervention where extension was a part of the game vs a repeated extension in standing group. The virtual reality group was more cost effective and there was an increase in QALYs for these patients

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, 19(7):1115-20,2010

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.

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, 44:14:1054-64,2010

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).

Flavell C, Gordon S, Marshman L, Classification characteristics of a chronic low back pain population using a combined McKenzie and patho-anatomical assessment, Manual Therapy, 26, 201-207,2016

This prospective study attempted to combine MDT assessment and classification with a pathoanatomical based assessment. The prevalence rates for Mckenzie syndromes reported contrasted significantly with previously reported data.

Ford J, Hahne A, Surkitt L, Chan A, Richards M, Slater S, Hinman R, Pizzari T, Davidson M, Taylor N, Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial , Br J Sports Med, 50, 237-245,2016

This RCT recruited patients with low back and /or leg symptoms who met the criteria for one of five pathoanatomical based subgroups. Patients were randomised into individualised therapy for the particluar subgroup for 10 sessions or guideline based advice for 2 sessions. Outcomes were significantly better for function and for back and leg pain, but the differences were less than the MCID. One component of the intervention were directional preference exercises and postural education.

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

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

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

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

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):1332-42,1998

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.

Franz A, Lacasse A, Donelson R, Tousignant-Laflamme Y, Effectiveness of Directional Preference to Guide Management of Low Back Pain in Canadian Armed Forces Members: A Pragmatic Study, Mil Med, 182, e1957-e1966,2017

This pragmatic trial with 44 consecutive military personnel with low back pain looked at the effectiveness of MDT versus 'usual care'. At 1 and 3 months 'DP-guided management' was found to be more effective for both pain and function

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.

Fritz JM, Cleland JA, and Childs JD, Sub grouping patients with LBP: Evolution of a classification, JOSPT, 6(6):290-302,2007

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, 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):57-61,1999

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.

Fritz JM, Lane E, McFadden M, Brennan G, Magel JS, Thackeray A, Minick K, Meier W, Greene T., Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica. A Randomised Controlled trial , Ann Intern Med., 174(1):8-17,2021

This RCT explored the response of patients with acute sciatica between usual care and early referral to MDT based physical therapy guided by centralization over 1 year. Early PT showed improved disability and other outcomes compared to usual care.

Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, Swalberg A, Rodriquez B, 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.

Fryer G and Adams JH, Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: a prospective case series, Spine J, Mar;11(3):171-176,2011

Garcia A, Costa L, Hancock M, Souza F, Gomes G, Oliveira de Almeida M, Costa L, McKenzie Method of MDT was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific LBP: a randomised placebo controlled trial with short and long-term follow-up, Br J Sports Med, 52(9):594-600,2018

This RCT studied 148 patients with chronic low back pain. It compared The McKenzie Method with ‘placebo’. Both groups also received ‘The Back Book’ for educational purposes. The single treating therapist for the McKenzie group had only completed McKenzie Part A, 3 years prior to the trial. Only a short term difference in pain was found between the groups in favour of the McKenzie Method.

Garcia AN, Costa LCM, da Silva TM, Gondo LFB, Cyrillo FN, Costa RA, Costa LOP, Effectiveness of back school versus McKenzie exercises in low back pain, Phys Ther, 93(6):729-47,2013

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

Garcia AN, Menezes C, Souza FS De, Reliability of Mechanical Diagnosis and Therapy system in patients with spinal pain : A systematic review , J Orthop Sports Phys Ther, 48;12:923-933,2018

This systematic review looked at the reliability of MDT in patients with spinal pain. !2 studies were included. Trained clinicians had an acceptable level of reliability for classifying patients with lumbar pain, but there was conflicting evidence for patients with cervical pain.

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; 107-115,1999

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

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.

Georg S, Fritz J, Silfies S, Schneider M, Vining R, Beneciuk J, Lentz T, Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021 , J Orthop Sports Phys Ther , 51(11):CPG1-CPG60,2021

This was an update and change in focus from the 2012 LBP guideline. DP and CEN were not addressed in themselves, but classifications were examined. For acute pain, MDT was designated as 'can use'. For chronic LBP, MDT was designated as 'may use'.

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.

Goode, A, Hegedus, EJ, Sizer Jr, P, Brismee, J-M, Linberg, A, Cook, CE, Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility, JMMT, 16(1) 25-38,2007

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):406-11,2001

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.

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.

Greenhalgh S and Selfe J, A Qualitative Investigation of Red Flags for Serious Spinal Pathology., Physiotherapy, 95:3, Pgs 149-236,2009

Greer B, Tranquillo J, Maccio J, Flexion Directional Preference in a Patient with Low Back Pain, Utilizing Mechanical Diagnosis and Therapy: A Case Report , JOSPT Cases, 2(1):44–49,2022

The case report describes the use of flexion DP and numerous force alternative with a patient with acute LBP, leading to a quick resolution.

Gregg C, Dean S, Schneiders A, Variables associated with Active Spondylolysis., Phys Ther in Sports, 10, 121-124.,2009

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

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

Gutke A, Kjellby-Wendt G, Oberg B., The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain., Man Ther, 15.13-18,2009

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.

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

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

Habets B, van Cingel REH, Eccentric exercise training in chronic mid-portion Achilles tendinopathy: A systemic review on different protocols., Scandinavian Journal of Medicine and Science in Sports, 25(1):3-15,2015

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

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

Hahn T, Kelly C, Murphy E, Whissell P, Brown M, Schenk R., Clinical decision-making in the management of cervical spine derangement: a case study survey using a patient vignette., J Man Manip Ther, 22:213-219,2014

Survey via Survey Monkey was sent to 714 therapists with credentialed or diploma (MDT) or Fellowship in Orthopaedic Manual Physical Therapy (FAAOMPT), of whom 77 and 6 provided adequate data. All therapists chose posture analysis and active range of movement as their initial examination procedures, but the MDT clinicians then chose end-range active cervical repeated movements as their next examination procedure and then discontinued the examination. The FAAOMPT group used a much more varied examination process.

Haldeman S, Is it time to discard the term "diagnosis" when examining a person with uncomplicated axial neck pain?, Spine J, Mar;11(3):177-179,2011

Halliday M, Garcia A, Amorim A et al. , Treatment effect sizes for pain and disability are moderated by the delivery approach for Mechanical Diagnosis and Therapy in a population with low back pain: A systematic review with a meta-regression approach, J Orthop Sports Phys Ther, 49(4):219-229,2018

This systematic review investigated the difference between pain and disability in patients with LBP managed with the core principles of MDT versus treatment using only some or none of the MDT principles. Trials that followed the core principles of MDT had a greater treatment effect than trials that were non-adherent to MDT principles in both pain and disability (1.5 point difference on an 11 point numeric scale). Based on the findings, clinicians can optimize outcomes for pain and disability by following the core principles of MDT.

Halliday M, Pappas E, Hancock M, Clare H, Pinto R, Robertson G, Ferreira P, A randomized clinical trial comparing the McKenzie method and motor control exercises in people with chronic low back pain and a directional preference: 1-year follow-up , Physiotherapy, 1095;4:442-445,

This study reported the 1 year outcomes from a previously published RCT that compared the effects of MDT with motor control exercises on trunk muscle recruitment, function, perceived recovery and pain in people with chronic LBP. The effect on trunk muscle thickness was similar for both groups and there was no difference in any secondary outcomes.

Halliday M, Pappas E, Hancock M, Clare H, PT, Pint R, Robertson G PT, Ferreira P, A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People With Chronic Low Back Pain and a Directional Preference , J Orth Sports Phys Ther, 46, 7, 514-522,2016

In a LBP population with the classification of Derangement, this RCT primarily compared MDT to motor control exercises for the restoration of muscle recruitment. Muscle thickness recovered equally in both groups. The only significant difference in any secondary outcome was with Global Perceived Improvement, which favoured the McKenzie group

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%).

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.

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.

Harrison J, Brismee JM, Sizer P, Denny B, Sobczak S , Sustained versus repetitive standing trunk extension results in greater spinal growth and pain improvement in back pain: A randomized clinical trial , J Back Musculoskelet Rehabil, Online first,2023

This trial randomised 30 patients with LBP and an extension DP to a group who performed REIS or a group who performed sustained EIS to see which had a greater effect on spinal growth and pain. Those performing sustained EIS produced signifiantly greater reducations in pain and greater spinal growth than those people performing REIS.

Hashimoto S, Hirokado M, Takasaki H, The most common classification in the mechanical diagnosis and therapy for patients with a primary complaint of non-acute knee pain was Spinal Derangement: a retrospective chart review., J Man Manip Ther., 27;1:33-42,2018

This retrospective chart review documented 101 patients with non-acute knee pain. 44% had spinal Derangements, this was found more in those with LBP and without knee osteoarthritic changes. It demonstrates the importance of thoroughly screening the spine with extremity presentations

Hathcock JA, Boyer CW, Morris JB, Shoulder Pain of Spinal Source in the Military A Case Series, Mil Med, online,2021

This case series follows 3 patients with shoulder pain who are assessed and managed using MDT and respond to spinal intervention. They all experience a successful return to function

Hayden JA, Ellis J, Ogilvie R, Stewart SA, Bagg MK, Stanojevic S, Yamato TP, Saragiotto BT, Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis, J Physiother, 67(4):252-262,2021

This network meta-analysis compared different types of exercises for chronic low back pain in regards to efficacy. The findings were that Pilates, MDT and functional restoration were more effective than other types of exercise in regards to both pain and function. Other types of exercises included core strengthening, general strengthening, aerobic, stretching and yoga.

Hebert J, Fritz J, Koppenhaver S, Thackeray A, Kjaer P , Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables , Eur Spine J, 25, 310-7,2015

This study looked at the pre-op predictors of a successful outcome post lumbar surgery. Pre-operative peripheralisation was associated with greater improvements in pain and disability after multivariate analysis 10 weeks post-op. Per-op multifidus function was not associated with clinical outcome.

Hedberh K, Alexander LA, Cooper K, Ross J, Smith FW., Low back pain: an assessment using positional MRI and MDT., Man Ther, 2013:18(2):169-71,2012

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

Hefford C, McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference., Manual Therapy, 13.75-81,2007

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.

Hegedus E, Cook, C Lewis J, Wright A, Park J, Combining orthopedic special tests to improve diagnosis of shoulder pathology , Physical Therapy in Sport, 87-92,2015

This review looked at the 'best' combinations of shoulder orthopedic tests to help rule in or out different pathologies. It found there were significant issues and limitations with the studies looking at clusters of tests, but outlined a case study to illustrate how the clinical reasoning process can be guided by current findings.

Hegmann K (Editor), American College of Occupational and Environmental Medicine; Low Back Disorders Treatment Guideline, OCOEM, 1-844,2016

This treatment guideline recommends an early mechanical evaluation using repeated movements to check for directional preference and centralisation and states that these are indicators of improved outcomes. It also states that 'specific' exercises, like directional preference exercises, appear helpful in the treatment of low back pain

Heidar Abady A, Rosedale R, Chesworth B, Rotondi M, Overend T, Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy, Musculoskeletal Science and Practice, 38, 11-17,2017

This study, with a cohort of shoulder patients, looked at the consistency of three orthopedic special tests (OSTs) between sessions and in relation to the MDT classification. Both Cervical Derangements and Shoulder Derangements had an adverse impact on the consistency of all 3 tests. The authors hypothesized that these presentations may be in some way responsible for the historic poor performance of OSTs

Heidar Abady A, Rosedale R, Chesworth BM, Rotondi MA, Overend TJ, Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study , J Man Manip Ther, 25, 5, 235-243,2017

The was the first study to investigate the clinical application of MDT on a cohort of shoulder patients. Pain and functional outcomes were taken at 2 and 4 weeks. 29% of the patients had a cervical Derangement as a cause of their shoulder pain and 38% had a shoulder Derangement. So 2/3s of patients had a rapid response to treatment and an early discharge. The patients with shoulder Dysfunction had a slower response as would be predicted. MDT classification aligned with the outcomes and demonstrated some preliminary validity for MDT use in the shoulder.

HeidarAbady A, Rosedale R, Overend T, Chesworth B, Rotondi M, Inter-examiner reliability of diplomats in the Mechanical Diagnosis and therapy system in assessing patients with shoulder pain, J Man & Manip Ther, 22:4:199-205,2014

54 clinical vignettes were created by Diploma holders. Another 6 Diploma holders classified each vignette accoring to the MDT system. Very good reliability was demonstrtaed in classifying patients with shoulder pain (Kappa 0.90)

Hennemann V, Ziegelmann PK, Marcolino MAZ, Duncan BB., The McKenzie method delivered by credentialed therapists for chronic low back pain with directional preference: systematic review with meta-analysis, J Man Manip Ther., online first,2024

This review, including only studies that utilised credentialed clinicians, found low-to-moderate certainty evidence that MDT was superior to all other interventions up to 6 months for pain and 12 months for disability. Short term clinically important differences were found versus exercise, and in the intermediate term, versus minimal interventions.

Henschke N, Maher CG et al, Prevalence of and Screening for Serious Spinal Pathology in Patients Presenting to Primary Care Settings With Acute Low Back Pain, Arthritis and Rheumatism, Vol. 60, No.10, pp. 3072-3080,2009

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.

Hides J, Donelson R, Lee D, Prather H, Sahrmann S, Hodges P, Convergence and Divergence Between Exercise Based Approaches for Management of Low Back Pain that Consider Motor Control , J Orthop Sports Phys Ther, 49(6):437-452,2019

This clinical commentary on motor control interventions for patients with LBP desribes some of the commonalities and differences in commonly used approaches. MDT is one of the approaches considered, despite it not being usually characherised as a motor control approach

Holmes B, Brazauskas R, Cassidy L, Weigand R, Factors in Patient Responsiveness to Directional, J Patient Cent Res Rev., 4, 2, 60-8,2017

This was a retrospective chart review of 104 patients with cervical pain exhibiting direction preference (Cervical Derangements). The patients were treated by a chiropractor utilizing MDT. The study reported on the patient–related factors that predicted the responsiveness to treatment. Patient compliance, age>55, acute/subacute presentations and the experience of immediate symptom improvement were associated with a more successful patient outcomes.

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

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

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

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

Horton S, Johnson G, and Skinner M, Changes in Head and Neck Posture Using Office Chair With and Without Lumbar Roll Support, Spine, Vol. 35(12): 542-548,2010

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.

Hughes C, May S, A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series , J Man Manip Ther. , 28;3:170-180,2020

This case series followed 7 patient with long histories of chronic pelvic pain and who were assessed and classified with MDT. The outcomes showed very positive changes with directional preference exercises and loading. There was an average follow-up of 3.3 years.

Huijbregts PA, Fact and Fiction of Disc Reduction: A Literature Review, J Man & Manip Ther, 6:3, 137-143,1997

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.

Jabłońska M, Mączyński1 J,Fryzowicz A, Ogurkowska M, Electromyographic assessment of muscle fatigue after the Biering-Sorensen test in subjects with low back pain who underwent the McKenzie treatment , Acta Bioeng. Biomech, Online first,2021

The study looked at the effect on spinal muscle endurance of 19 males classified as having a lumbar Derangement. The Biering-Sorensen test was performed before and after the performance of DP exercises. An increased endurance of erector spinae, the gluteus maximus and biceps femoris was demonstrated which accompanied a decrease in pain.

Jiang Y, Xu Y, Kong X, Zhao E, Ma C, Lv Y, Xu H, Sun H, Gao X, How to tackle non-specific LBP among adult patients? A systematic review with a meta-analysis to compare four interventions, Orthop Surg Res, 3;19(1):1.,2023

This systematic review included 25 RCTs and found MDT no different in relieving LBP or improving function than motor control training or Pilates. All three were superior to passive Physical Therapy.

Kajbafvala M, Rahmani N,Bandpei M, Salavati M, Eligibility of the movement-based classification systems in the diagnosis of patients with low back pain: A systematic review, J Bodyw Mov Ther, 24:76-83,2020

This systematic review examined the reliability and validity of 'movement-based' classification systems in the diagnosis of patients with LBP. It concluded that these systems may be considered 'eligible' to diagnose patients with LBP and MDT was considered more reliable than other systems.

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.

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_x0019_s who demonstrates a directional preference and classified as derangement responds to repeated movements.

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, 77:354-360,1996

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.

Karayannis N, Jull G, Hodges P, Movement-based subgrouping in low back pain: synergy and divergence in approaches, Physiotherapy, 102(2):159-69,2016

This cross-sectional cohort study of low back pain patients aimed to explore the overlap between different classification systems (including MDT) in 102 participants. They concluded that there was 'overlap' and 'discordance' between the different approaches and proposed some means of future integration

Karayannis N, Jull G, Nicholas M, Hodges P, Psychological Features and Their Relationship to Movement-Based Subgroups in People Living With LBP, Archives PMR, 99, 121-8,2017

This observational study subgrouped patients into MDT, TBC and O'Sullivan classifications and then looked at scores on various psychosocial measures. There was an unusually high number of 'irreducible' Derangements and Dysfunctions reported. However, high catastrophising was more associated with the 'irreducble' Derangement classification and the TBC 'stabilisation' subgroup.

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

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

Karlsson M, Bergenheim A, Larsson M, Nordeman L, van Tulder M, Bernhardsson S, Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews, Syst Rev, 9:182,2020

This systematic review of included systematic reviews investigating exercise therapy in acute low back pain. 24 systematic reviews were included and exercise therapy was subcategorized as general exercise therapy, stabilization exercise, and McKenzie therapy. No specific form of exercise therapy showed important differences in pain or disability when compared with other interventions or other forms of exercise therapy.

Kent P, Mjøsund HL, Petersen D, Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review., BMC Medicine, 8:22,2010

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

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

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

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.

Kidd J, Treatment of shoulder pain utilizing mechanical diagnosis and therapy principles, JMMT, 21(3):168-173,2013

Kilpikoski S, The Mckenzie Method versus guideline-based advice in the treatment of sciatica: 24 month outcomes of a RCT, Clin Rehab, Aug 23 Online first,2023

This RCT compares the MDT management of patients with sciatica with guideline based care. There were no differences in outcome. There were some significant limitations of the study, including the majority of the guideline group receiving therapy including MDT, and a smaller sample size than planned.

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):E207-14,2001

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.

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, 11:210-217,2009

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

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

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

Kilpikoski S, Suominen EN, Repo JP, et al. , Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers , J Man Manip Ther. , online first,2023

This study examined the relationship between MRI findings and CEN vs NON-CEN. CEN had significantly more degenerative change, end plate damage and spondylosis than NON-CEN, but no differences in other MRI findings.

Kjaer, P., Kongsted, A., Hartvigsen, J. et al., National clinical guidelines for non- surgical treatment of patients with recent onset neck pain or cervical radiculopathy, Eur Spine J, Online May,2017

This paper summarises the Danish national clinical guidelines for recent onset neck pain and radiculopathy. Evidence in general was weak and many recommendations were based on consensus. Directional preference exercises were considered as one of the options for exercises for neck pain with 'low confidence in the effect size'. For cervical radiculopathy it was stated that "It is good clinical practice to consider treatment with directional exercise in patients with recent onset cervical radiculopathy in addition to other treatment".

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, 34:183-190,2001

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.

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.

Kongsted A, Kent P, Hestbaek L, Vach W, Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery or constant pain. A latent class analysis of longitudinal data., The Spine Journal, 885-894,2014

This prospective cohort study on over 1000 LBP patients explored subgroups for clinical course patterns. It identified 12 patterns and found that the majority did not become pain free within a year, but with only a minority developing chronic severe pain

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.

Korakakis V, O'Sullivan K, Sideris V, Giakas G, No differences in spinal repositioning error in patients with low back pain presenting with a directional preference into extension, Eur J Physiother, 22;4:212-220,2020

This study compared 15 patients with a Directional Preference of extension with 15 asymptomatic individuals in their ability to reproduce a neutral and lordotic target position after slumped sitting. No differences were seen between the groups in error detection, magnitude, and variability.

Krog C, May S., Derangement of the temporomandibular joint; a case study using Mechanical Diagnosis and Therapy, Manual Therapy, 17:483-486,2012

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

Kuhnow A, Kuhnow J, Ham D, Rosedale R, The McKenzie Method and its association with psychosocial outcomes in low back pain: a systematic review , Physio Theory and Pract., Online first,2020

This systematic review looked at the association between MDT intervention and psychosocial outcomes. It found that there was an association with improving fear-avoidance beliefs, pain self-efficacy, depression and psychological distress.

Kuo YL, Tully E, Galea MP, Video analysis of sagittal spinal posture in healthy young and older adults., J Manipulative Physiol Ther, Vol 32(3):210-215,2009

Lam O, Dumas JP, Simon C, Tousignant-Laflamme Y, McKenzie mechanical syndromes coincide with biopsychosocial influences, including central sensitization: a descriptive study of individuals with chronic neck pain, J Man Manip Ther, 26;3:157-169,2018

This observational study looked at MDT classification of chronic neck patients at baseline and how they co-occured with some specific psychosocial measures. The majority of Derangements scored highly on these measures. Only baseline measures were taken, and thus the study was unable to determine if, as has been reported in the lumbar spine, psychosocial measures diminish with MDT management.

Lam O, Strenger D, Chan-Fee M, Thuong Pham P, Preuss R, Robbins S, Effectiveness of the McKenzie Method (MDT) for treating LBP: Literature review with meta-analysis, J Orthop Sports Phys Ther, 48;6:476-490,2018

This review with meta-analysis looked at the effectiveness of MDT for patients with acute or chronic low back pain. 12 randomised controlled trials were analysed. For acute back pain there was no significant difference between MDT and other interventions. For chronic back pain there was moderate to high evidence that MDT is superior to other interventions regarding both pain and disability.

Lange T, Freiberg A, Dro€ge P, Lützner J, Schmitt J, Kopkow C, The reliability of physical examination tests for the diagnosis of anterior cruciate ligament rupture: A systematic review, Manual Therapy, 20,402-411,2014

This systematic review looked at the reliability of ACL testing. 7 articles were identified which examined 4 tests. The studies were of poor quality when assessed using the QAREL tool. Due to this, meta-analysis was not possible. The routine use of these tests for ACL diagnosis was questioned

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):2747-52,2001

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%.

Larsson MEH, Kall I, Nilsson-Helander K., Treatment of patellar tendinopathy a systematic review of randomized controlled trials., Knee Surg Trauma Arthro, 2012:20(8):1632-46,2011

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

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, 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.

Laslett M, Williams M, The reliability of selected pain provocation tests for sacroiliac joint pathology, Spine, 19(11):1243-1249,1993

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%).

Laslett, Mark., A Clinical Review: Evidence Based Diagnosis and Treatment of the Painful Sacroiliac Joint., JMMT, 16(3):142-154,2008

Lisi AJ., The centralization phenomenon in chiropractic spinal manipulation of discogenic low back pain and sciatica, J Manipulative Physiol Ther, Nov-Dec;24(9):596-602,2000

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.

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

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

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

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

Littlewood C, Bateman M, Brown K, Bury J, Mawson S, May S, Walters S, A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A RCT (the SELF study), Clinical Rehabilitation, 30(7):686-96,2016

This RCT looked at patients with rotator cuff tendinopathy. 86 patients were randomised into a self-management group who performed a single resisted exercise in sets performed twice per day or into a group where 'usual physiotherapy was the intervention. There was no significant difference in pain and disability outcomes at 3, 6 or 12 months.

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

Six patients and two therapists were recruited from a pilot randomised controlled trial, which compared usual physiotherapy to a self-managed loaded exercise programme. Preference and expectations for a more hands-on treatment approach was common amongst patients and therapists. There were several barriers to the self-managed approach, including these prior beliefs and response to therapy. However despite these beliefs some were positive about the self-managed approach, with good explanation, positive response, and patient_x0019_s self efficacy appearing key.

Littlewood C, May S, A contractile dysfunction of the shoulder., Man Ther, 12:80-83,2006

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.

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, 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, 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.

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.

Louw A, Farrell K, Nielsen A, O’Malley M, Cox T, Puentedura E, Virtual McKenzie extension exercises for low back and leg pain: a prospective pilot exploratory case series , J Man Manip Ther. , online first,2022

This pilot case series, explored looked at the effect of the motor imagery use of DP exercises on various pain and a range of other outcomes. Only the SLR showed a significant change that exceeded the MCID following the imagery intervention.

Luetchford S, Declich M, Tavella R, Zaninelli D, May S, Diagnosis of cervical and thoracic musculoskeletal spinal pain receptive to mechanical movement strategies: a multicenter observational study., J Man Manip Ther, 26(5):292-300,2018

This cohort study of 138 patients assessed and treated by 16 MDT clinicians looked at the distribution of MDT classifications. 83% of patients with cervical problems and 100% with thoracic were classified as Derangement Syndrome. Disability scores reduced from a mean of 24 to 12 by discharge

Lynch G, May S, Directional preference at the knee: a case report using mechanical diagnosis and therapy, J Man Manip Ther, 21(1), 60-66,2013

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

Maccio J, Carlton L, Fink S, Ninan C, Van Vranken C, Biese G, McGowan C, Maccio JG, Tranquill J, Directional preference of the wrist: a preliminary investigation, J Man Manip Ther, 25, 5, 244-250,2017

This study followed 19 consecutive wrist patients that were examined and treated with MDT. 79% were classified as wrist Derangements and 10% as cervical Derangements. The presence of 'mechanical stress' in the history was associated the presence of Derangement.

Maccio J, Carlton L, Levesque K, Maccio JG, Egan L , Directional preference of the extremity: a preliminary investigation, J Man Manip Ther, 26(5):272-280,2018

37 consecutive patients with extremity pain were classified using MDT. Nearly 90% were found to be Derangements, 46% being spinal Derangements. Findings from the history and exam were related to the occurrence of DP or spinal referral

Maccio J, Fink S, Yarznbowicz R, May S, The application of mechanical diagnosis and therapy in lateral epicondylalgia , J Man Manip Ther, Article published online,2016

Case series of 3 patients with lateral elbow pain assessed, classified as Derangements and treated with MDT principles. All patients responded rapidly with excellent outcomes up to one year follow-up.

Macedo L, Bostick G, Maher, C, Exercise for Prevention of Recurrences of Non-Specific Low Back Pain, Phys Ther, 93(12):1587-1592,2012

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.

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.

Maher C, Underwood M, Buchbinder R, Non-specific low back pain, The Lancet, 389, 10070, 736-747,2017

This ‘Seminar’ gives an overview of the current literature on non-specific low back pain. Review topics include epidemiology, risk factors, costs, clinical presentations, differential diagnosis, diagnostic investigations, prevention, clinical course, management and controversies. The review concludes that a research priority is the identification of LBP ‘phenotypes’, so that treatment can be targeted rather than generalised.

Malliaras P, Barton CJ, Reeves ND and Langberg H, Achilles and patellar tendinopathy loading programmes: A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness., Sports Med, 43:267-286,2013

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.

Mansfield C, Bleacher J, Tadak P, Briggs M, Differential examination, diagnosis and management for tingling in toes: fellow’s case problem, J Man Manip Ther, 25, 5, 294-299,2016

This case study reported the lumbar involvement of symptoms post-fasciotomy. Symptoms resolved with use of MDT and the extension principle

Masud S, Sheehan B, Rousseau-Saine A et al., Arthroscopy Association of Canada Position Statement on Exercise for Knee Osteoarthritis - repaired, Orthop J Sports Med, online,2021

This systematic review of guidelines on exercise for knee OA concluded that there is evidence that exercise is effective. An MDT RCT on knee OA was included as one of the exercise programs evaluated and was recommended for relief of pain and improvement of function

Matsudaira K, Hiroe M, Kikkawa M, Sawada T, Suzuki M, Isomura T, Oka H, Hiroe K, Hiroe K., Can standing back extension exercise improve or prevent low back pain in Japanese care workers?, J Man Manip Ther, DOI 10.11729/2042618614Y,2015

64 care workers received an exercise manual and advice to do extension in standing exercise on a regular basis, especially after lifting or being flexed for long periods; workers in the control group (N = 72) were only given the manual; there were no baseline differences in the two groups. In the intervention group 43% reported subjective improvement in back pain, compared to 15% in the control group (p=0.003); in the intervention group 83% reported compliance with the exercise, compared to 9% in the control group.

Mauck MC, Aylward AF, Barton CE, Birckhead B, Carey T, Dalton DM, Fields AJ, Fritz J, Hassett AL, Hoffmeyer A, Jones SB, McLean SA, Mehling WE, O'Neill CW, Schneider MJ, Williams DA, Zheng P, Wasan AD, Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach , Pain Reports Online, 30;7(5):e1019,2022

This evidence update looking at interventions for CLBP included DP as one of the movement based therapies. DP was deemed to have a moderate strength of evidence and a moderate treatment effect.

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

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

May S, Aina A, Centralization and directional preference: a systematic review., Manual Therapy, 17:497-506,2012

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

May S, Aina A, Letter to the editor on CEN and DP, Musculoskeletal care, Online first,2021

This letter to the editor expressed concern about the lack of literature reference to, and the lack of inclusion in physiotherapy training, of centralisation and directional preference. It highlighted the high prevalence and the extensive research supporting these phenonena as important clinical findings.

May S, Donelson R, Evidence-informed management of chronic low back pain with the McKenzie method., Spine J, 8.134-141,2007

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.

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.

May S, Greasley A, Reeve S, Withers S, Expert therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder pain: a qualitative study., Aust J Physiotherapy, 54(4):261-6,2007

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 _x0013_ the study demonstrating lack of reliability used inexperienced therapists with limited / no training in MDT.

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

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

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.

May S, Rosedale R, An international survey of the comprehensiveness of the McKenzie classification system and the proportions of classifications and directional preferences in patients with spinal pain, Musculoskel Sci and Pract, 39:10-15,2018

This International prospective observational study of patients with spinal pain looked at the comprehensiveness of the MDT system and the distribution of MDT classifications. Comprehensiveness of spinal MDT classification was established for the 750 patients included across 15 countries. Derangement was by far the most common classification with a substantial proportion of OTHER subgroups.

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

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

May S, Runge N, Aina A, Centralization and directional preference: An updated systematic review with synthesis of previous evidence, Musculoskelet Sci Pract., 38:53-62,2018

This systematic review found 43 additional articles from the previous review. Prevalence of Centralisation was 40% and Directional Preference was 66%, and they were both confirmed as key prognostic factors in patients with low back pain with limited evidence for the cervical spine

May SJ, Rosedale R, A survey of the McKenzie classification system in the extremities: prevalence of the mechanical syndromes and preferred loading strategy., Phys Ther, 92:1175-1186,2012

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

Mbada C, Ayanniyi O, Ogunlade S, Comparative efficacy of three active treatment modules on psychosocial variables in patients with long-term mechanical low- back pain: a randomized-controlled trial, Archives of Physiotherapy, 5,10,2015

This randomised conrolled trial looked at 'McKenzie Protocol'(extension only) alone and in combination with strengthening on psychosocial outcomes. At 4 and 8 weeks all groups demonstrated significant improvements on all measures of beliefs and fear avoidance

Mbada C, Ayanniyi O, Ogunlade S,, Rehabilitation of Back Extensor Muscles’ Inhibition in Patients with Long-Term Mechanical Low-Back Pain, ISRN Rehabilitation, 928956,2013

This RCT with 84 patients with LBP compared 3 treatment groups; 'McKenzie Protocol' (extension exercises), McKenzie + static back endurance exercises and McKenzie + dynamic back extensor exercises at 4 and 8 weeks. Physical performance tests, including static and dynamic endurance, were used as the outcome. The 'McKenzie Protocol' alone or in cimbination with the other exercises were effective in improving muscular endurance

Mbada CE, Ayanniyi O, Ogunlade SO, Orimolade EA, Oladiran AB, Ogundele AO., Rehabilitation of back extensor muscles inhibition in patients with long-term mechanical low-back pain., Rehabilitation, 2013: 928956,2013

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

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

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

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

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

McKenzie RA, A perspective on Manipulative Therapy, Physiotherapy, 75:8. pp 440-444,1988

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.

McKenzie RA, A Prophylaxis in Recurrent Low Back Pain, New Zealand Med J, No. 627, 89:22-23,1978

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.

McKenzie RA, Manual Correction of Sciatic Scoliosis, New Zealand Med J, 484,76:194-199,1971

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

Melbye M, An adherent nerve root-Classification and exercise therapy in a patient diagnosed with lumbar disc prolapse., Man Ther, 15:126-129,2010

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.

Menon A, May S., Shoulder pain: Differential diagnosis with mechanical diagnosis and therapy extremity assessment - A case report, Manual Therapy, 18;354-7,2012

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

Mercer S, Bogduk N, The ligaments and anulus fibrosus of human adult cervical intervertebral discs., Spine, Apr 1;24(7):619-26;,1998

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, 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.

Mihaela O, Mihaela C, McKenzie training in patients with early stages of ankylosing spondylitis (AS): results of a 24-week controlled study., Euro J Phys Rehab Med, in press,2015

52 patients with early lumbar AS were randomly assigned to McKenzie training or classic kinetic exercises and a number of functional and movement outcomes were registered at baseline, 12, and 24 weeks. There were significant differences in both groups, more in the McKenzie group; but there were significant differences in all groups that favoured the McKenzie group (p=0.001).

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.

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

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

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

Munster M, Brisbee M, Sizer P et al. , Can 5 minutes of repetitive prone press-ups and sustained prone press-ups following a period of spinal loading reverse spinal shrinkage?, Physio Theory and Pract., 35;3:259-267,2019

This report studied the effects of repeated extension in lying and sustained extension in lying on spinal height changes after a period of spinal loading, in asymptomatic subjects. There was no significant difference between repeated extension (4.85 mm) versus sustained extension (4.46 mm) for change in spinal height, however both increased spinal height by greater than 4 mm. Extension exercises could be used to preserve a healthy spine by increasing spinal height after periods of loading.

Munster M, Brismee JM, Sizer P, Browne K, Dewan B, Litke A, Pape J, Sobczak S, Can 5 minutes of repetitive prone press-ups and sustained prone press-ups following a period of spinal loading reverse spinal shrinkage?, Physio Theory and Pract., 22:1-9,2018

This study demonstrated that both repeated and sustained extension increased lumbar spinal height and speculated that this strategy may have some preventative value

Murphy DR, Beres JL, Is treatment in extension contraindicated in the presence of cervical spinal cord compression without myelopathy? A case report, Man Ther, 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.

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

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

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

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

Murphy DR, Hurwitz EL, 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.

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

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

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

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

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

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

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

Murtezani A, Govori V, Meka V, Rrecaj S, Gashi S, A comparison of mckenzie therapy with electrophysical agents for the treatment of work related low back pain: A randomized controlled trial, J Back Musculoslelet Rehabil, 28(2):247-53.,2015

This RCT on chronic LBP patients randomised to a McKenzie and a electrophysical agents group. Results at 3 months showed greater improvements in the McKenzie group

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

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

Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F, Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects, Spine, 40,6,392-398 ,2015

In this asymptomatic population disc bulging was seen frequently, increasing between the ages of 20 and 50. Even those in their 20s had a high proportion of disc bulging. Cord compression increased after the age of 50

Namnaqani F, Mashabi A, Yaseen K, Alshehri M, The effectiveness of McKenzie method compared to manual therapy for treating chronic low back pain: a systematic review , J Musculoskelet Neuronal Interact , 19(4):492-499.,2019

This systematic review looked at the effectiveness of MDT in patients with chronic LBP, compared to manual therapy. 5 trials were included. In regard to pain in the short term and function in the long term, MDT demonstrated more successful outcomes.

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

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

O'Keefe M, Dankaerts W,O'Sullivan P, O'Sullivan L, O'Sullivan K, Specific flexion-related low back pain and sitting: comparison of seated discomfort on two different chairs., Ergonomics, 56:4:650-658,2013

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

O'Sullivan 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, 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):1238-44,2001

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

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.

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

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

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

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

Olusola A, Arinola S, Olusegun O, Effects of the McKenzie protocol on pregnancy-related back pain, Journal of Experimental and Integrative Medicine, 6,3,2016

This RCT recruited 466 pregnant women with back pain and randomised them into a McKenzie group plus usual care and a usual care group. The participants were treated over 6 weeks and there was a low drop out rate. The McKenzie group had significantly less back pain and disability. The McKenzie Method was recommended in the management of pregnancy related back pain.

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.

Otero J, Bonnet F, Low back pain: prevalence of McKenzie's syndromes and directional preference., Kinesither Rev, 14:36-44,2014

66 French certified McKenzie therapists each collected data on 10 consecutive patients, providing data on 349 patients with back pain. At baseline 92% were classified with Derangement, 2.3% with Dysfunction, 0.9% with Postural, and 4.9% with Other. Centralization was recorded in 70.5% at baseline, which increased to 73.5%, and Directional Preference remained at 73.5%. Between baseline and the fifth session the classification remained the same in 90.1%. Directional preference was as follows: extension 79.5%, lateral 12.6%, and flexion 4.3%.

Otero J, Bonnet, F, Neck pain: Prevalence of McKenzie's Syndrome and Directional Preference, Kinesither Rev, 16:2-10,2016

This study investigated the prevalence of McKenzie classifications in the cervical spine. 66 French Certified MDT clinicians collected data on 297 patients. 92% were classified as Derangement with extension found to be the directional preference in 84% of these. Other proportions were collected and presented.

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),1999

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, Nov;40(10):858-63,2008

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.

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

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

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.

Petersen T, Christensen R, Carsten J, Predicting a clinically important outcome in patients with low back pain following McKenzie therapy or spinal manipulation: a stratified analysis in a randomized controlled trial, BMC Musculoskeletal Dis, 2015:16:74,

An analysis of a previous RCT with 350 patients looked at any factors that predicted outcome. There were no prdictore, Mckenzie Method was superior to manipulation across all subgroups. The two strongest preditors of success with MDT were nerve root involvement and peripheralisation.

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):1702-9,2001

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

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

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

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

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

Petersen T, Laslett M, Juhl C, Clinical classification in low back pain: best- evidence diagnostic rules based on systematic reviews, BMC Musculoskeletal Dis, 18:188,2017

This systematic review examined the latest evidence for the patho-anatomic diagnosis in the lumbar spine. There was 'sufficient evidence' to suggest a clinical diagnostic rule in some cases, but not in others. The presence, or lack of, centralisation was a key assessment finding in the diagnostic process for the disc and for the SIJ.

Peterson S, Hodges C, Lumbar lateral shift in a patient with interspinous device implantation: a case report, J Man Manip Ther, 24(4):215-22,2016

This case report describes the successful MDT management of a patient with a history of lumbar surgery and a lumbar lateral shift deformity.

Peterson S, Laslett M, Alternating lumbar lateral shift: a case report , J Man Manip Ther., 29(1): 59–66,2021

This case report is the first to detail the conservative management of an alternating lumbar shift, with the MDT classification of Derangement

Pheasant S, Cervical Contribution to functional shoulder impingement: two case reports, Int J Sports Phy Ther, 11, 6, 980-991,2017

This case series of two patients details the presentation and subsequent management of two young athletes. Both present with shoulder symptoms, positive shoulder tests and apparent shoulder 'impingement'. Both resolve rapidly with cervical retraction extension exercises and the cervical spine is concluded to be the source of the symptoms.

Philadelphia Panel, Evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain, Phys Ther, 81; 1641-1674,2000

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.

Pleva DJ, Hanson JC, Greer B., Management of concussion symptoms utilizing Mechanical Diagnosis and Therapy: a case series., J Man Manip Ther., online first,2024

This case series detailed the responses from 3 people who had experienced a concussion and who were assessed and managed using MDT.

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

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

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.

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; 130-139,1983

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.

Post M, Mechanical Diagnosis and Therapy and Morton’s Neuroma: A Case Report , Physiother Can, 71;2:130-133,2019

This case report describes a patient with a diagnosis of 'Morton's neuroma'. The 44 year old, female patient was classified by an MDT clinican as a Derangement with a directional preference of flexion. Rapid and lasting improvement was achieved.

Post M, Maccio J, Mechanical Diagnosis and Therapy and Morton’s neuroma: a case-series, J Man Manip Ther. , 28:1:60-67,2021

This is a case series of 3 patients with plantar foot pain and the diagnosis of Morton's Neuroma. All 3 were Derangements, one at the lumbar spine and two at their metatarsophalangeal joints. All experienced quick and lasting resolutions.

Post M, Schenk R, Fargnoli R, Utilization of the Cervical Flexion Rotation Test to Confirm Rotation Directional Preference in People With Neck Pain: A Case Series, Cureus, 15 (10): e47389. DOI 10.7759/cureus.47389,2023

This case series of three consecutive patients with cervical pain used the cervical flexion rotation test as a baseline and to confirm DP.

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.

Pu L, Miller E, Schenk R, Utilizing directional preference in the management of cervicogenic headache: a case series, J Man Manip Ther., 31;6:466–473,2023

This case series describes 15 patients with cervicogenic headaches who were assessed by MDT clinicians and found to have a DP. All outcomes were signifacntly improved at 3 month follow-up.

Pynt J, Higgs J, Mackey M, Seeking the optimal posture of the seated lumbar spine., Physio Theory & Pract, 17;5-21,2000

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.

Quek J, Pua YH, Clark RA, Bryant AL., Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults., Manual Therapy, 18:65-71,2012

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

Rabey M, Beales D, Slater H, O'Sullivan P, Multidimensional pain profiles in four cases of chronic non-specific axial LBP: An examination of the limitations of contemporary classification systems, Manual Therapy, 20,138-147,2015

This paper discussed four case studies in relation to 'contemporary' classification systems in the lumbar spine. One of the systems considered was MDT. No consideration or acknowledgement of MDT as a comprehensive biopsychosocial system was given. Conclusions included an assertion of the limitations of current classification systems and the need for a system that 'considers all relevent dimensions'

Rabin A, Shmushkevich Y, Kalichman L, Initial pain and disability characteristics can assist the prediction of the centralization phenomenon on initial assessment of patients with low back pain, J Man Manip Ther., 27;2:66-72.,2019

This cohort study followed ninety LBP patients who were classified by a clinician who had taken the McKenzie Part D course, as centralisers or non centralisers. This was perfomed in a single session. The study attempted to derive a clinical prediction rule from the patient's history to predict centralisation.

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.

Rastogi R, Rosedale R, Kidd J, Lynch G, Supp G, Robbins S, Exploring indicators of extremity pain of spinal source as identified by Mechanical Diagnosis and Therapy (MDT): a secondary analysis of a prospective cohort study , J Man Manip Ther. , Jan 2022 Online first,2022

Potential indicators of a spinal source of extremity pain were explored from a prospective cohort study. Five indicators were found to be predictive and can be used by clinicians to aid in spinal/extremity decision making.

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.

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):368-383,1999

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%).

Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ, Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study, Am J Sports Med, 40(12):2720-4,2012

Reiman M, Goode A, Cook C, Hölmich P, Thorborg K, "Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: A Systematic Review with Meta-analysis, Br J Sports Med, 49, 811,2015

This systematic review found that few tests were available for diagnosing hip femoralacetabular impingement/labral tear and further study is needed

Reiman M, Goode A, Hegedus E, Cook C, Wright A, Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis , BR J Sports, 47,893-902,2013

This systematic review found that there were few quality studies to assist in clionical decision making. Only one test is supported by the data for the hipe physical examination

Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J., The pain of tendinopathy: physiological or pathophysiological., Sports Med, 44:1:9-23,2014

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

Roberts E, Goodier S, Warthling A, Lorenzetti J, Schenk R, The Influence of Centralization and Directional Preference on Spinal Control in People with Nonspecific Neck Pain: A Single Arm Clinical Trial , J Ortho Pract, 34 (1): 292-296,2022

A cohort of 25 patients with neck pain were assessed and managed by MDT clinicians. Those with a DP had a significant improvement in pain and improved on deep neck flexor performance. Those with no DP had no significant improvement in performance.

Robinson M, Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report , Physiotherapy Theory and Practice, 32, 4, 315-323,2016

This case report describes the successful classification and management of a patient with a Derangement and a directional preference of extension. Extension was performed in standing

Rohlmann A, Consmu ̈ller T, Dreischarf M, Bashkue M, Disch A, Pries E, Duda G, Schmidt K, Measurement of the number of lumbar spinal movements in the sagittal plane in a 24-hour period, Eur Spine J, 23,2375-2384,2013

This study used sensor strips on 208 non-symptomatic volunteers during daily living to measure sagittal spinal movements over 24 hrs. Volunteers spent much more time in flexion than extension, reaching full flexion 50 times and zero times reaching full extension. This study substantiates the previous data suggestions a great predominance of flexion in everyday life

Rose T, Butler J, Salinas N, Stolfus R, Wheatley T, Schenk R, Measurement of outcomes for patients with centralising versus non-centralising neck pain, J Man Manip Ther, 24, 5, 264-268,2016

This study looked at 11 patients with neck pain to see if there was a difference in outcomes between centralisers and non-centralisers. The 6 patients whose pain centralised had significantly more favourable disability outcomes.

Rosedale R, Hoyt K, Clare H, Schenk R, Letter to the Editor: On “Treatment-Based Classification System for Low Back Pain: Revision and Update.” Alrwaily M, Timko M, Schneider M, et al. Phys Ther. 2016;96:1057–1066., Physical Therapy, 96, 10, 1669-1670,2016

This letter to the Editor questions some of the statements made in the TBC update article by Alrwaily regarding the extensiveness of the evidence supporting MDT and TBC and also regarding the evidence demonstrating the effect of MDT on psychosocial variables.

Rosedale R, Lynch G, Clare H, Letter to the Editor; Regarding ‘Classification characteristics of a chronic low back pain population using a combined McKenzie and patho-anatomical assessment’ authored by Flavell C et al., Manual Therapy 26 (2016), 201-207 , Musculoskeletal Science and Practice, 26, e5-e6,2017

This letter is in response to an article that combines MDT and pathoanatomy. It discusses the value of such a combination of diagnostic approaches and questions some of the prevalence data presented.

Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins S, A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS), J Man Manip Ther., 28;4:222-230,2020

369 consecutive patients with isolated extremity pain were assessed by MDT clinicians in 4 centres. Using an MDT based 'baseline-test-retest baseline' process the clinicians determined which patients had symptoms that were of 'spinal source' and which had 'extremity source' symptoms. Overall, 43.5% of the patients were designated as having a 'spinal source' and were treated with solely spinal intervention. Outcomes between the the two groups were compared.

Rosedale R, Rastogi R, May S, Chesworth BM, Filice F, Willis S, Howard J, Naudie D, Robbins SM., Efficacy of exercise intervention as determined by the McKenzie system of Mechanical Diagnosis and Therapy for knee osteoarthritis: a randomized controlled trial., J Orth Sports Phys Ther, 44:3:173-181,2014

180 patients with established chronic osteoarthritis who were referred for potential surgery were randomized to an intervention or a control group. The intervention group received a MDT assessment, and were then classified as Derangement responders or non-responders; the control group remained on the waiting list for surgery. The intervention group with Derangement had significantly better outcomes at two weeks and three months

Rosedale R, Supp G, Hoyt K, Lynch G, Clare H, Letter to the Editor-in-Chief; Regarding the complexity of Low Back Pain, J Orthop Sports Phys Ther, 47(2), 126-129,2017

This letter is in response to an article that discusses some of the current issues with low back pain diagnoses and management. The letter clarifies the meaning of the Derangement classification as a non-pathoanatomic diagnosis and puts forward the case for MDT being a biopsychosocial approach.

Rosenfeld M, Gunnarsson R, Borenstein P, Early intervention in whiplash-associated disorders: a comparison of two treatment protocols., Spine, Jul 15;25(14):1782-87,1999

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.

Rossignol M et al, Clinique des Lombalgies Interdisciplinaire en Premiee ligne., CLIP, http://www.santepub-mtl.qc.ca/Publication/pdftravail/ CLIPenglish.pdf,2005

McKenzie recommended for sub-acute back pain with moderate scientific evidence, and for chronic back pain with weak scientific evidence.

Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW., Spinal manipulative therapy for acute low-back pain; an update of the Cochrane review., Spine, 38:3:E158-177,2013

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

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).

Sanchis-Sánchez E, Lluch-Girbés E, Guillart-Castells P, Georgieva S, García-Molinad P, Blasco J, Effectiveness of mechanical diagnosis and therapy in patients with non-specific chronic low back pain: a literature review with meta-analysis, Braz J Phys Ther, 25;2:117-134,2020

This systematic review assessed RCTs comparing MDT to active and passive physiotherapy interventions in patients with chronic low back pain. 14 studies were included and it was found that MDT was no more effective in decreasing pain and disability than active or passive interventions.

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

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

Scannell JP and McGill SM, Disc Prolapse: Evidence of Reversal with Repeated Extension, Spine, Volume 14, Number 4, pp. 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.

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 Man & Manip Ther, 16(1) E2-E8,2007

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.

Schenk R, Dionne C, Simon C, Johnson R, Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation., J Man Manip Ther, 20:(1):43-9,2012

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

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

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

Schenk R, Lawrence H, Lorenzetti J, Marshall W, Whelan G, Zeiss R., The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy., J Man Manip Ther, DOI 10.11729/2042618614Y,2015

49 patients were treated with mechanical diagnosis and therapy and were assessed with FOTO function score at baseline, at two weeks and at discharge. Mean FOTO scores improved from 49 points to 68, indicating improvement, in a mean of eight treatment sessions. There was no correlation between QTFC and change in FOTO, except there was a significant difference based on acuity (p=0.003), with patients with chronic pain less likely to improve.

Schmidt I, Rechter L, Hansen VK, Andreasen J, Overvad K, Prognosis of subacute low back pain patients according to pain response., Eur Spine J, 17:57-63,2008

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):412-22,2001

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

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

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

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

Sheeran L, Coales P, Sparkes V, "Clinical challenges of classification based targeted therapies, Manual Therapy, 20,456-462,2015

This qualitative study guaged the views, experiences and perceptions of barriers and enablers for using classification systems of physiotherapists and managers. Although the usefulness of classification systems was acknowledged and advantages seen, barriers were identified that may inhibit adoption.

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

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

Sheets C, Machado LAC, Hancock M, Maher C., Can we predict response to the McKenzie method in patients with acute low back pain? A secondary analysis of a randomized controlled trial., Eur Spine J, 21(7):1250-6,2012

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

Shin G, Mirka G, An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues., Clinical Biomechanics, 22(9):965-971,2007

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

Cohort of 34 patients of who 80% were fully recovered with a programme of progressive loading exercises and 5-year follow-up.

Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J, Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy, Br J Sports Med, 41:276-280,2006

Silva D, Calvo A, Alves-Ferreira R, Fernandes W, Albertini R, The application of directional preference for chronic non-specific knee pain: A pragmatic, controlled, randomized clinical trial. , J Bodyw Mov Ther, Online first,2024

This RCT looked at 28 young Jui-Jitsu practitioners with chronic knee pain who had a knee or spinal DP for their knee pain. They were randomized into an DP group and a control group. At 6 and 10 weeks there was significantly more improvement in the MDT intervention group for the PSFS, pain intensity and fear avoidance.

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

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

Skillgate E, Cote P, Cassidy JD, Boyle E, Carroll L, Holm L., Effect of Early Intensive Care on Recovery From Whiplash-Associated Disorders: Results of a Population-Based Cohort Study, Archives PM & R, 97, 739-46,2016

This cohort study demonstrated that early intensive conservative care led to a slower recovery following a whiplash injury. This was independent of the expectation of recovery. The conclusions indicate that the best care post whiplash should focus on reassurance and education rather than potentially counterproductive intensive care.

Skrzypiec D, Pollinyine P, Przybyla A, Dolan P, Adams M, The internal mechanical properties of cervical intervertebral discs as revealed by stress profilometry., Eur Spine J, 16(10):1701-1709,2007

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

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.

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.

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

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

Smith B, Hendrick P, Logan P, Patellofemoral pain: Challenging current practice - A case report, Manual Therapy, 22, 216-219,2016

This case study challenges some of the traditional ways of evaluating and treating PFP. It describes a young patient with years of anterior knee pain and failed interventions. The management was guided by the symptomatic response to painful exercises, using self-management and the 'produce/increase but no worse' MDT principle to achieve a successful outcome.

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):2601-7,1997

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.

Spanos G, Zounis M, Natsika M, May S., The application of Mechanical Diagnosis and Therapy and changes on MRI findings in a patient with cervical radiculopathy, Manual Therapy, 18(6):606-610,2013

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

Spargoli G, Treament of rotator cuff tendinopathy as a contractile dysfunction. A clinical commentary, Int J Sports Phy Ther, 14;1:148-158,2019

This clinical commentary describes the common diagnosis  and management of rotator cuff tendinopathy under the MDT principles of contractile dysfunction. The article suggests that the clarity of a mechanical assessment and classification can lead to better outcomes compared to using anatomical diagnoses. MDT offers a self-treatment approach using various loading strategies to remodel the impaired contractile tissue over time.

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.

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):469-472,1994

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):120-3,1989

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.

Steffens D, Maher C, Pereira L, Stevens M, Oliveira V, Chapple M, Teixeira-Salmela L, Hancock M, Prevention of Low Back Pain A Systematic Review and Meta-analysis , JAMA Intern Med, 176(2):199-208,2016

This is a systematic review and meta-analysis of the RCTs that have evaluated low back pain prevention strategies. The main finding was that the current evidence suggests that exercise alone or in combination with education is effective for preventing LBP, other interventions showed no preventative value.

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

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

Stochkendahl M, Kjaer P, Hartvigsen J et al. , National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy, Eur Spine J, 26;9;:2242-2257,2017

These Danish guidelines were based on systematic reviews and meta-analyses and offered grades of recommendations on interventions. Directional Preference exercises were given a weak/conditional recommendation.

Stynes S, Konstantinou K, Dunn K, Classification of patients with low back-related leg pain: a systematic review , BMC Musculoskeletal Dis, 17:226,2016

This review looks at the relevant literature that classify / subgroup populations with low back-related leg pain, and how leg pain due to nerve root involvement is described and diagnosed in the various systems. The McKenzie System scored the highest of any system on criteria based upon validity, feasibility, reliability and generalisability.

Supp G, Rosedale R, Werneke M, Letter to the Editor; Unjustified extrapolation, Scand J Pain, Online Apr,2017

This letter was in response to an article by Rabey et al. and discusses the use of MDT repeated movement testing vs. 'data driven' repeated movement testing. It also questions the unjustified extrapolation of the study results in regards to comprehensiveness of MDT as a biopsychosocial system.

Supp G, Schoch W, Baumstark M, May S, Do patients with low back pain remember physiotherapists' advice? A mixed-methods study on patient-therapist communication, Physiother Res Int, 25;4:e1868,2020

This mixed-methods study assessed how well patients with low back pain retained 3 items of advice given by their physiotherapists. Patients remembered 100%, 92%, and 67% of the the first, second, and third items of advice, respectively. They were more likely to remember advice when shared decision making was used at initial assessment, exercises were simple and few, and diagnostic concerns and expectations were addressed.

Surkitt L, Ford J, Chan A, Richards M, Slater S, Pizzari T, Hahne A, Effects of individualised directional preference management versus advice for reducible discogenic pain A pre-planned secondary analysis of a randomised controlled trial, Manual Therapy, 25, 69-80,2016

This was a secondary analysis from a multicenter RCT looking at directional preference management versus advice for ‘reducible discogenic pain’. Directional preference management was significantly better at pain reduction and other outcomes up to 10 weeks, but improvements were not sustained. Satisfaction with care was significantly better in the directional preference group up to 52 weeks.

Surkitt LD, Ford JJ, HahneAJ, Pizzari T, McMeeken JM., Efficacy of directional preference management for low back pain: a systematic review., Phys Ther, 2012:92:652-665,2012

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

Surkitt, L, Ford J, Chan A, Richards M, Slater S, Pizzari T, Hahne A, Effects of Individualised Directional Preference Management Versus Advice For Reducible Discogenic Pain: A Pre-Planned Secondary Analysis of A Randomised Controlled Trial , Manual Therapy, 25, 69-80,2016

This was a secondary analysis of an RCT comparing directional preference management to guideline based advice for LBP. It looked at a 'reducible discogenic subgroup' and found significantly less back and leg pain in the directional preference group at 10 weeks, but not at 26 or 52 weeks. There was no difference in functional outcomes, but significantly more DP patients reached the threshold for clinical meaningful improvement at 52 weeks.

Suzuki K, Takasaki H, Ability of Therapists Trained in Mechanical Diagnosis and Therapy to Guess Pain Catastrophizing and Kinesiophobia Scores for Patients with Low Back Pain, Open J Ther Rehabil, 8:119-130,2020

This observational study investigated whether a Diploma-trained MDT clinician could guess psychological patient reported outcome measure scores in patients with low back pain by taking a history and completing an examination. Statistically significant positive correlations were seen in the Pain Catastrophizing Scale and Tampa Scale for Kinesiophobia before history taking and after examination.

Svensson GL, Wendt GL, Thomee R., A structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery: a prospective cohort study., J Rehab Med, 46(3)233-40,2014

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

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.

Szulc P, Wendt M, Waszak M, Tomczak M, Cieslik K, Trzaska T, Impact of McKenzie Method Therapy Enriched by Muscular Energy Techniques on Subjective and Objective Parameters Related to Spine Function in Patients with Chronic Low Back Pain , Medical Science Monitor, 21,2918-2932,2015

This randomised trial compared 'McKenzie' (extension exercises ONLY), to 'McKenzie' + Muscle Energy to conventional physiotherapy in 60 patients with chronic LBP over 3 months. The 'McKenzie' group regardless of the addition of MET or not had significantly better pain and functional outcomes than the conventional physiotherapy group. Multiple measures of ROM were also documented with varying degrees of change reported. No limitations were discussed and there is no description of the therapist's training, sample size calculation or drop out rate.

Sørensen O, Straszek C, Kerry R, O’Sullivan K, Perimyocarditis presenting as thoracic spinal pain in a physiotherapy outpatient clinic – a case report, Eur J Physiother, online first,2022

This is a case report of a patient who presented with acute thoracic pain, which was deemed to be non-MSK after an examinatiuon including the use of a repeated movement exam. Perimyocarditis was the ulimate daignosis after medical follow-up.

Tagliaferri SD, Mitchell U, Owen P, Saueressig T, Miller CT Belavy DL, Classification approaches for treating low back pain have small effects that are not clinically meaningful: a systematic review with meta-analysis. , J Orthop Sports Phys Ther, 52(2):67–84,2022

This systematic review with meta analysis looked at whether the use of classification systems improved outcomes for people with LBP. None of the classifications examined, including MDT, had a meaningful effect size. There was moderate certainly, than in the medium-term MDT was more effective than other approaches at reducing disability.

Takasaki H, Comparable effect of simulated side bending and side gliding positions on the direction and magnitude of lumbar disc hydration shift: in vivo MRI mechanistic study, J Man Manip Ther, 32:2:101-108,2015

The study compared the effect of side gliding to side bending in the lumbar spine on disc hydration. Side gliding produced comparable effects to side bending on lumbar disc hydration

Takasaki H, Agreement of Mechanical Diagnosis and Therapy Classification in Patients With Extremity Conditions, Physical Therapy, 96(10):1525-1532,2016

This study examined reliability of MDT in the extremities with examiners using two methodologies; concurrently seeing the patients and seeing the patients successively. Inter-examiner agreement was good with concurrent observation and poor with successive observation.

Takasaki H, Mechanical diagnosis and therapy enhances attitude toward self-management in people with musculoskeletal disorders: A preliminary evidence with a before–after design, Sage Open Medicine, 5, 1-9,2017

This study explored whether self-reported skills of self management for patients with musculoskeletal problems (mainly LBP) were affected by a 1 month course of MDT. Self-management and self-monitoring skills were enhanced.

Takasaki H, Aoki S, May S, No increase in 6-week treatment effect of Mechanical Diagnosis and Therapy with the use of the LUMOback in people with non-acute non-specific low back pain and a directional preference of extension: a pilot randomized controlled trial, Physiotherapy, 104;3:347-353.,2018

This was a pilot RCT to see if the effect of MDT is improved with the LUMOback device with a group of patients with a Derangement and DP of extension. 22 patients were included. There was no significant difference between groups within 6 weeks.

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

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

Takasaki H, Handa Y, Kikkawa K, Mechanical Diagnosis and Therapy has a clinically meaningful effect on neck derangement syndrome with a directional preference for cervical retraction or extension in comparison to a wait-and-see approach: An assessor-blinded randomized controlled trial.., JOSPT Open, 2;2:106-113,2024

This RCT explored the effect of DP exercises vs wait and see on 40 young patients with chronic neck pain that demonstrated a DP. MDT had a clinically meaningful short term effect on symptoms.

Takasaki H, Herbowy S, Immediate improvement in the cranio-cervical flexion test associated with MDT-based interventions: a case report, J Man Manip Ther, 24(5):285-292,2016

A case report of a neck pain patient who had an immediate improvement in the cranio-cervical flexion test following treatment of a cervical Derangement. This suggests a possible link between MDT interventions and motor control of the cervical spine

Takasaki H, Iwasada Y, May S, Attitude towards the use of MDT and Reliability of Classification Extremity problems by Credentialed Therapists, Journal of Chiropractic Medicine, 14,32-38,2016

The purpose of the study was two-fold. Firstly to explore the attitudes of MDT credentialed therapists towards the use of MDT in the extremities and secondly to test the inter-examiner reliability of credentialed therapists using MDT for extremity patients. The survey to gauge attitudes was completed by 60 therapists abd found that there was low confidence in using the system in the extremities. The vignette based reliability component found a good level of reliability in using MDT classification for extremity problems.

Takasaki H, May S, Mechanical Diagnosis and Therapy has similar effects on pain and disability as wait and see and other approaches in people with neck pain: a systematic review., J Physio, 60(2):78-84,2014

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

Takasaki H, May S, Concerns related to the accurate identification of anterior derangement syndrome in mechanical diagnosis and therapy for low back pain: A case report.   , Physiother Theory Pract., 36(4):533‐541.,2020

This case report describes a patient who's problem is initially classified as a Derangement with a directional preference of extension. However, sustained extension revealed a worsening and a subsequent clear response to flexion. The case reinforces an ongoing reassessment of patients to ensure the response is consistent with expectations.

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

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

Takasaki H, Okuyama K, Rosedale R, Inter-examiner classification reliability of Mechanical Diagnosis and Therapy for extremity problems - Systematic review, Musculoskeletal Science and Practice, 27, 78-84,2017

This systematic review explores MDT's reliability with classification in the extremities. Six high quality studies were included. They demonstrated; strong evidence for acceptable reliability for vignette study design, limited evidence concurrent design and unacceptable reliability from a successive design study.

Takasaki H, Saiki T, Iwasada Y, McKenzie Therapists Adhere More to Evidence-Based Guidelines and Have a More Biopsychosocial Perspective on the Management of Patients with Low Back Pain than General Physical Therapists in Japan, Open Journal of Therapy and Rehabilitation, 2:173-181,2014

Survey of 56 Cred MDT therapists and 53 general therapist in Japan. Looking at adherence to LBP guidelines and how biopsychosocial orientated they were. Regression analysis was performed. Cred MDT therapists were more guideline consistent and had a more biopsychosocial orientation than general therapists.

Takasaki H, Yamasaki C, Immediate neck hypoalgesic effects of craniocervical flexion exercises and cervical retraction exercises among individuals with non-acute neck pain and a directional preference for retraction or extension., J Man Manip Ther., Apr 23 Online first,2023

Full title: Immediate neck hypoalgesic effects of craniocervical flexion exercises and cervical retraction exercises among individuals with non- acute neck pain and a directional preference for retraction or extension: preliminary pretest- posttest randomized experimental design . Summary: This pre/post test experiment for those with a cervical DPO of retraction or extension, demonstrated the greater immediate analgesic effect of cervical retractions compared with craniocervical flexion exercises.

Thoomes E, Falla D, Cleland J, Fernandez-de-las-Penas C, Gallina A, de Graaf M, Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study , Disability and Rehab, online first,2022

This Delphi study prouced a list of interventions deemed to be effective for lumbar radiculopathy. DP exercises were recommended in the acute phase with a 78% agreement, along with other active interventions and education.

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.

Tsuge T, Takasaki H, Toda M, Does the Keele STarT Back Screening Tool Contribute to Effectiveness in Treatment and Cost and Loss of Follow-Up of the Mechanical Diagnosis and Therapy for Patients with Low Back Pain? , Diagnostics, 10:536,2020

This retrospective chart study of MDT practice investigated whether medium-high risk in the STarT Back Screening Tool contributes to time and sessions until discharge and to loss of follow-up before identifying a promising management strategy. It did not impact time or sessions until discharge for 89 participants, while those with medium-high risk in the Mechanically Inconclusive subgroup were 4.61 times more likely to be lost to follow-up by the 5th session compared to the low risk group.

Turner A, Case studies in Physical Therapy: transitioning a 'Hands-on' approach into a virtual platform , Int J Telerehabilitation, 10;1:37-50,2018

This case series described 3 patients with Derangements, one lumbar, one cervical and one elbow. All patients were treated effectively via telehealth, demonstrating how MDT can be used to assess and treat patients remotely

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.

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):43-8,2004

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.

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.

van der Plas A, de Jonge S, de Vos RJ, van der Heide HJ, Verhaar JA, Weir A,Tol JL, A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy, Br J Sports Med, 46(3):214-8,2012

van Helvoirt H, Apeldoorn A, Knol D, Arts M, Kamper S, van Tulder M, Ostelo R, TFESIs influence MDT pain response classification in candidates for lumbar herniated disc surgery, J Back and Musculo Rehab, 1, 1-9,2016

This was a second analysis of prospective cohort data previously published which included 8 patients with symptoms less than 12 weeks. Results are similar to the previously published variation of the cohort. The discussion focuses on comparisons in the literature on the reported prognostic value of peripheralisation and centralisation.

Van Helvoirt H, Apeldoorn AT, Ostelo RW, Knot DL, Arts MP, Kamper SJ, van Tulder MW., Transforaminal epidural steroid injections followed by Mechanical Diagnosis and Therapy to prevent surgery for lumbar disc herniation., Pain Medicine, 15(7):1100-8,2014

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

Werneke M, Edmond S, Deutscher D, Ward J, Grigsby D, Young M, McGill T, McClenahan B, Weinberg J, Davidow A, Effect of adding McKenzie Syndrome, Centralization, J Orth Sports Phys Ther, 46, 9, 726-741,2016

This retrospective cohort study analysed the data from 723 lumbar patients. It looked at the value of adding certain MDT classification and psychosocial variables to a risk-adjusted model to see if they helped predict functional outcomes. These variables did not add significantly to the model. However, Diploma therapists achieved significantly better functional scores than non-diplomaed therapists and additional prognostic differences were found between MDT subgroups highlighting the potential for MDT clinicians to predict outcome dependent upon the patient's classification.

Werneke M, Edmond S, Young M, Grigsby D, McClenahan B, McGill T, Directional preference and functional outcomes among subjects classified at high psychosocial risk using STarT, Physiother Res Int, 23(3):e1711,2018

This cohort study looked at 138 patients classified as High STarT (high psychosocial risk) who were evaluated and treated using MDT. Those with a Directional Preference (65% of cohort) demonstrated greater improvements in function than those with no Directional Preference. MDT management may be an alternative for STarT high risk patients.

Werneke M, Hart D, Cutrone G et al., Association Between Directional Preference and Centralization in Patients With Low Back Pain, J Orthop Sports Phys Ther, 41(1), 22-31,2011

The longitudinal cohort study looked at the prevalence of DP and centralisation and their effect on outcomes. Prevalence was 60% and 41% respectively. Outcomes in regard to pain and function were significantly better in the DP and centralisation groups

Werneke M, Hart DL, Cook D, A descriptive study of the centralization phenomenon. A prospective analysis., Spine, Apr 1;24(7):676-83,1998

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):758-65,2000

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), 161-166,2002

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 _x0013_ of these 95 (60%) became partial or full centralisers at later sessions.

Werneke MW, Deutscher D, Hart DL, Stratfoed P, Ladin J, Weinberg J, Hebowy S, Resnik L., McKenzie lumbar classifications: inter-rate agreement by physical therapists with different levels of formal McKenzie post-graduate training., Spine, 39(3):E182-90,2014

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

Werneke MW, Edmond S, Young M, Grigsby D, McClenahan B, McGill T, Association between changes in function among patients with lumbar impairments classified according to the STarT Back Screening Tool and managed by McKenzie credentialed physiotherapists, Physiother Theory Pract, Online July,2018

This retrospective study looked at 705 patients with LBP classified with the STarT Back Tool and managed with MDT. Functional outcomes did not differ significantly between baseline STarT risk levels. Half of all patients decreased STarT risk levels during treatment. MDT management may reduce some of the psychosocial influences identified by the STarT Back Tool.

Werneke MW, Hart D, Oliver D, McGill T, Grigsby D, Ward J, Weinberg J, Oswald W, Cutrone G., Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation and stabilization clinical prediction rules., J Man Manip Ther, 18:197-210,2010

Data collected on 628 patients from 8 different clinics by therapists with training in MDT found prevalence of derangement (67%), dysfunction (5%), and posture syndrome (0%); centralisation (43%), non-centralisation (39%), and not classified (18%); and positive to manipulation (13%) and stabilisation (7%) clinical prediction rules. Derangement classification and centralisation prevalence was high in patients who fulfilled both clinical prediction rules.

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

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

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

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

Werneke MW, Hart DL., 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.

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.

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.

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

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

Willis S, Rosedale R, Rastogi R, Robbins S, Inter-rater reliability of the McKenzie System of Mechanical Diagnosis and Therapy in the examination of the knee , J Man Manip Ther, 25, 2, 83-90,2017

This vignette based reliability study showed substantial agreement (k=0.72) among MDT therapists in the use of MDT classification for the knee

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.

Woodley S, Nicholson H, Livinstone V, Doyle TC, Meikle GR, Macintosh JE, Mercer SR, Lateral Hip Pain: Findings From Magnetic Resonance Imaging and Clinical Examination, JOSPT, 38(6):313-328,2008

Work Loss Data Institute. Encinitas, CA, Official Disability Guidelines - Treatment in Workers Comp (ODG), , Online ODG; http://worklossdata.com,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.

Wu D, Ham D, Rosedale R, Physiotherapy assessment and treatment of chronic subjective tinnitus using mechanical diagnosis and therapy: a case report , J Man Manip Ther., 28(2):119-126.,2020

This case study reported on a 67 year old female with a history of subjective tinnitus and neck pain. The presentation was classified as a Derangement and all outcomes improved significantly with cervical directional preference exercises.

Wu D, Rosedale R, The use of Mechanical Diagnosis and Therapy (MDT) in patients with lower urinary tract symptoms (LUTS): case series, Physio Theory and Pract., 26:1-9,2018

This was a case series of 3 male patients with lower urinary tract symptoms. It demonstrated that the screening for, and treatment of lumbar Derangements with this population may lead to simple and self-management solutions

Wu SK, Chen HY, You, JY. et al., Outcomes of active cervical therapeutic exercise on dynamic intervertebral foramen changes in neck pain patients with disc herniation, BMC MSK, 23:728,2023

This biomechanical study followed 30 patients with cervical disc herniations before and after 8 weeks of Directional Preference exercises. The exercises led to significant increases in the dimensions of the intervertebral foramen.

Yarznbowicz R, A prospective study of patients with shoulder pain and Mechanical Diagnosis and Therapy (MDT) , J Man Manip Ther., Online first,2018

This prospective cohort study looked at the prevalence of MDT classifications in the shoulder and examined these classifications in relation to the outcomes. It concluded that shoulder Derangements and Dysfunctions were common and their outcomes conformed to the classifcation's predicted prognosis

Yarznbowicz R, A prospective study of patients with knee pain and mechanical diagnosis and therapy (MDT) classification , Physio Theory and Pract., 29(4):255-261,2021

The prospective cohort study looked at the prevalence of MDT classifications and the relative outcomes in patients with knee pain. Knee Derangements were most prevalent and achieved clinically significant improvement in outcomes in the shortest time frame.

Yarznbowicz R, Tao M, Directional preference constructs for patients’ neck pain in the absence of centralization , J Man Manip Ther., 27(4):229-236,2019

This secondary analysis of a previous cohort study, analysed data from 718 patients with neck pain with the aim of investigating the presence of DP constructs in the absence of centralisation and determining the association between DP constructs and clinical outcome. The most common DP constructs were related to ROM and to pain intensity.

Yarznbowicz R, Tao M, Owens A, Wlodarski, Doultan J, Pain pattern classification and directional preference are associated with clinical outcomes for patients with low back pain, J Man Manip Ther, 26,1, 18-24,2017

This prospective cohort study with 639 patients who had complete data, looked at the association between pain pattern classification, directional preference and outcomes. Both centralisers and those with directional preference had better pain and functional outcomes

Yarznbowicz R, Tao M, Wlodarski M, Dolutan J, Pain pattern classification and directional preference for patients with neck pain, J Man Manip Ther, 26(4):230-236,2018

335 patients with cervical pain were assessed and treated with MDT in this prospective cohort study. Prevalence of DP was over 80% with 15% demonstrating centralisation. Patients who demonstrated DP or centralisation did not have clinically significant lower pain intensity or disability at follow-up than patients who demonstrated Non-DP

Yarznbowicz R, Tao M, Wlodarski M, Matos A, Provider reliability with interventions for knee impairments: a preliminary investigation to facilitate development of an MDT-based knee intervention taxonomy, J Man Manip Ther, 26(4):218-229,2018

This study aimed to aimed to establish an MDT taxonomy and to test the reliability of clinicians using MDT for patients with knee pain. Acceptable levels of reliability were achieved for identifying knee interventions via video and vignettes.

Yarznbowicz R, Wlodarski M, Dolutan J, Classification by pain pattern for patients with cervical spine radiculopathy, J Man Manip Ther., 28;3:160–169 ,2020

This prospective cohort reported the prevalence of MDT classifications, Centralisation vs Non-Centralisation, and the association of the latter with outcomes for 19 patients with cervical radiculopathy. 79% were classified as Derangement; 36.8% overall were Centralisers and 47.4% were non-Centralisers. All patients made clinically significant improvements in disability, but not pain intensity; changes in disability were not statistically significant between Centralisers and non-Centralisers.

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.

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.

Zadro J, O'Keeffe M, Maher C, Do physical therapists follow evidence- based guidelines when managing musculoskeletal conditions? Systematic review , BMJ Open, ;9:e032329,

This systematic review compared phyocal therapy treatment choices to those recommended in guidelines / systematic reviews. Many PT treaments do not follow recommendations. MDT was listed as not recommended for actute LBP, but recommended for subacute and chronic LBP

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.

Zou J, Yang H, Miyazaki M, Mosishita Y, Wei F, McGovern S, Wang J, Dynamic Bulging of Intervertebral Discs in the Degenerative Lumbar Spine, Spine, 34(23):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.