Lumbar: Studies into assessment, diagnosis and procedures

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 _x0018_by far_x0019_ the most internationally used of back pain classification systems.

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

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

Chan AYP, Ford JJ, McMeeken JM, Wilde VE, Preliminary evidence for the features of non-reducible discogenic low back pain: 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.

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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., 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).


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

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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.

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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.


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

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

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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.


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.


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

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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.

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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.

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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.


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

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

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


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

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


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


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, 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.

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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.


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'

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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%).


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

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


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


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.