SPINE Volume 31, Number 9, pp E254 E262

2006, Lippincott Williams & Wilkins, Inc.

The McKenzie Method for Low Back Pain

A Systematic Review of the Literature With a Meta-Analysis Approach
Luciana Andrade Carneiro Machado, BScPT (Honours),*
Marcelo von Sperling de Souza, BScPT (Honours),* Paulo Henrique Ferreira, PhD,*
and Manuela Loureiro Ferreira, PhD

Study Design and Objectives. Meta-analysis of randomized controlled trials to evaluate the effectiveness of
the McKenzie method for low back pain (LBP).
Summary of Background Data. The McKenzie method
is a popular classification-based treatment for LBP. The
faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials.
Methods. MEDLINE, EMBASE, PEDro, and LILACS were
searched up to August 2003. Two independent reviewers
extracted the data and assessed methodologic quality.
Pooled effects were calculated among homogeneous trials
using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie.
Results. Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, 4.16 points; 95%
confidence interval, 7.12 to 1.20) and disability (WMD
on a 0- to 100-point scale, 5.22 points; 95% confidence
interval, 8.28 to 2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction
in disability favored advice (WMD on a 0- to 100-point
scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at
12 weeks of follow-up. Heterogeneity prevented pooling
of studies on chronic LBP as well as pooling of studies
included in the sensitivity analysis.
Conclusions. There is some evidence that the McKenzie
method is more effective than passive therapy for acute
LBP; however, the magnitude of the difference suggests
the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic
LBP. The effectiveness of classification-based McKenzie is
yet to be established.
Key words: low back pain, effectiveness, exercise, systematic review, meta-analysis. Spine 2006;31:E254 E262

The diagnosis and treatment of low back pain (LBP) is

surrounded by substantial controversy.1 Although LBP
is frequently managed as a single condition (nonspecific
LBP),2 it has recently been hypothesized that negative
From the *Universidade Federal de Minas Gerais, Belo Horizonte,
Brazil; Back Pain Research Group, School of Physiotherapy, University of Sydney, Sydney, Australia; and Pontifcia Universidade
Catolica de Minas Gerais, Belo Horizonte, Brazil.
Acknowledgment date: May 13, 2005. First revision date: July 27,
2005. Second revision date: September 7, 2005. Acceptance date: September 12, 2005.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Luciana Andrade Carneiro Machado, BScPT, School of Physiotherapy, University of Sydney,
PO Box 170, Lidcombe NSW 1825, Australia; E-mail: lmac3689@mail.
usyd.edu.au

E254

results of conservative care in randomized controlled trials (RCTs) are a consequence of applying the same therapy to heterogeneous groups of patients.35 Nevertheless, a gold-standard subgrouping scheme for LBP is still
lacking, as most available classification systems have
weak evidence for their validity and reliability.6 8
In 1981, Robin McKenzie proposed a classification
system and a classification-based treatment for LBP labeled Mechanical Diagnosis and Therapy, or simply the
McKenzie method.9 Of the large number of classification
schemes developed in the last 20 years,10 16 the McKenzie method has the greatest empirical support (e.g., validity, reliability and generalizability) among the systems
based on clinical features.8 According to this method, the
classification of LBP patients is based on patterns of pain
response noted during the assessment.9 The centralization phenomenon is the most important pattern of pain
response observed in McKenzies assessment, as well as
the most studied feature of the McKenzie method.1723
Centralization is defined as the situation in which referred pain arising from the spine is reduced and transferred to a more central position when movements in
specific directions are performed (also called directional
preference).9
Although the main role of McKenzies classification
system is to guide treatment selection, many RCTs on the
effectiveness of the McKenzie method have overlooked
this principle by assigning patients of unknown classification to the same intervention.24 28 In this review, we
name this approach to the McKenzie method generic
McKenzie. In contrast, we call the McKenzie method
based on patient classification (as advocated in the McKenzie textbook9) classification-based McKenzie. It has
been suggested that the use of a generic approach is responsible for the underestimation of the effectiveness of
the McKenzie method in previous studies.29
Misconception of the McKenzie method is observed
in a systematic review evaluating the effectiveness of exercise therapy for LBP,30 in which this method was
equated to extension exercises. This is incorrect because
with the McKenzie method the direction of exercise is
not always extension but instead is dictated by the directional preference. In a prospective, multicenter study including 145 patients with nonspecific LBP, Donelson et
al31 reported a clear directional preference in nearly one
half of patients. Of these patients, 40% improved with
extension exercises, whereas 7% improved with flexion
exercises.31 The higher incidence of extension as the di-

McKenzie Method for LBP Machado et al E255

rectional preference in LBP patients may explain why

many researchers make faulty assumptions by equating
the McKenzie method to extension exercises.
Although the McKenzie method is a promising classification scheme to be implemented in the management of
LBP, the evidence for its effectiveness is unclear. A systematic review of the literature was conducted to evaluate whether the McKenzie method is more effective than
other reference treatments for acute or chronic nonspecific LBP.
Methods
Studies and Participants. RCTs published in English, Portuguese, and Spanish were included. Trials reporting on treatment of nonspecific LBP of any duration were included. LBP
was defined as pain extending between the lower rib cage and
gluteal folds, with or without radiation.32 Trials on specific
pathologic entities (e.g., spondylolisthesis, infection, or inflammatory processes) were excluded.

Interventions. Trials were included when the term McKenzie

method or a synonym (McKenzie therapy, Mechanical Diagnosis and Therapy) was used to name one of the interventions.
Additionally, trials in which the term McKenzie method was
not mentioned were included if the intervention reflected
McKenzie principles, e.g., repeated passive spine movements or
sustained positions performed in specific directions. Trials in
which cointerventions had been given were included, since this
pragmatic approach matches closely the usual physiotherapy
practice. Trials were excluded when the experimental group
consisted of dynamic strengthening exercises as this intervention does not represent either the classification-based McKenzie
or the generic McKenzie approach.
Outcome Measures. Trials were included if one of the following outcome measures had been reported: pain, disability,
quality of life, return to work/sick leave, or recurrence.
Search Strategy for Identification of Studies. We searched
the MEDLINE, EMBASE, PEDro, and LILACS databases up to
August 2003. A combination of terms to search for RCTs and
low back pain (as described by the Cochrane Back Review
Group33), and the words McKenzie, extension exercises, flexion exercises, exercise therapy, active therapy, and centralization were used as search terms. A manual search of reference
lists of previous systematic reviews and relevant trials was conducted. The reference list from the McKenzie International Institute was also screened (www.mckenziemdt.org). Personal
communication with content experts completed the search
strategy.
Methods of the Review
Study Selection. Two reviewers (L.A.C.M. and M.vS.S.) independently conducted the search strategy and applied the selection criteria based on titles, abstracts, and key words. The
full text of studies considered eligible or potentially eligible was
retrieved. Consensus was used to solve disagreements, and a
third reviewer (P.H.F.) arbitrated if consensus could not be
reached.
Methodologic Quality Assessment. Two independent reviewers (P.H.F., M.L.F.) assessed methodologic quality using the

PEDro scale (www.pedro.fhs.usyd.edu.au/scale_item.html).

The PEDro scale is an 11-item checklist in which one point is
awarded for each satisfied item, except for the first that pertains
to external validity. In literature, consensus scores among raters for the total PEDro score has shown good reliability (ICC
0.68).34 When a trial had already been rated according to
PEDro scale and its score confirmed on the Physiotherapy Evidence Database (www.pedro.fhs.usyd.edu.au), this score was
used. Consensus was used to solve disagreements between reviewers, and a third reviewer (L.A.C.M.) arbitrated if consensus could not be reached.
Data Extraction and Analysis. Two reviewers (L.A.C.M.,
M.vS.S.) independently extracted data using a standardized
form. Mean scores and standard deviations were estimated
from tables and/or graphs when necessary. Consensus was used to
solve disagreements, and a third reviewer (P.H.F.) arbitrated if
consensus could not be reached.
Although the levels of evidence approach have been commonly used to summarize the evidence in previous systematic
reviews,30,3539 this approach lacks power and the different
criteria available can lead to different conclusions on treatment
efficacy based on the same group of studies.40 Therefore, we
used a meta-analysis approach based on the random effects
model to calculate weighted mean differences (WMDs) and
95% confidence intervals (CIs). The treatment effects of individual trials were calculated by the mean and 95% confidence
interval either for between-group differences in endpoints, or
for within-group change scores, according to available data.41
Continuous data were converted to a 0- to 100-point scale to
analyze the pooled effect of similar outcomes measured by different scales. Relative risks and 95% confidence intervals were
calculated for dichotomous data.42
Pooling was not attempted where there was statistical heterogeneity or clinical heterogeneity consisting of relevant differences with regards to population, reference treatments, outcome measures, and follow-up. The tree plots of trial outcomes
were inspected to make a decision on whether relevant heterogeneity was present when the number of studies was not sufficient to use the 2 test. Because patients under treatment with
the McKenzie method can experience rapid improvement in
symptoms,31 we decided to present outcomes at the precise time
point rather than collapsing time points to short-term (3/12);
intermediate (312/12), and long-term follow-up (12/12).33
To evaluate the effectiveness of the McKenzie method as a
classification-based treatment, a sensitivity analysis excluded
trials in which a generic McKenzie approach was used. The
RevMan software43 was used for the measurement of statistical
heterogeneity and pooled effects.

Results
Study Selection
The MEDLINE, EMBASE, PEDro, and LILACS
searches identified 364, 195, 90, and 56 studies, respectively. Of these, only 11 trials published in 12 papers
were included.24 28,44 50 Agreement between reviewers
for study eligibility was 84.25%, 82.57%, 85.06%, and
98.21% for MEDLINE, EMBASE, PEDro, and LILACS,
respectively. The main reasons for exclusions were the
use of interventions dissimilar from the McKenzie
method (e.g., dynamic strengthening exercises,5153

E256 Spine Volume 31 Number 9 2006

Table 1. Characteristics of Included Studies

Study
PEDro Score/10

Participants

Interventions

Outcomes

Cherkin44 (1998)*
8/10

321 patients with acute LBP, with

or without radiation, 168 men
and 155 women, ages 2064 yr; 2
subjects excluded after
randomization

Mean pain improvement (11-point

bothersomeness scale) after 4
and 12 wk: R1 significantly more
improved than R2 after 4 wk
Mean disability (RMQ) after 4 and
12 wk: no significant differences
after adjustment for non-normal
distribution
I1 and R1 rated care better than
R2 after 1 and 4 wk; recurrence
after 2 yr: no significant
differences

Delitto48 (1993)
4/10

24 patients with acute or subacute

LBP, with or without radiation,
classified into extensionmobilization category, 14 men
and 10 women, ages 1450 yr

(I1) McKenzie exercises aiming for

centralization, avoidance of
peripheralization, lumbar roll,
McKenzie book, max 9 visits over 1
mo at discretion of therapist
(n 133)
(R1) Chiropractic manipulation, shortlever, high velocity thrust, exercise
sheet emphasizing stretching and
strengthening, other treatments (ice
packs, massage, exercises in the
office or at home), max 9 visits over 1
mo, at discretion of chiropractor
(n 122)
(R2) Educational booklet (n 66)
(I1) Prone press-ups, lumbar roll,
postural instruction, sacroiliac joint
manipulation, physical therapist
supervision, 3 visits, self-treatment at
home (n 14)
(I2) Williams flexion exercises, physical
therapist supervision, 3 visits, selftreatment at home (n 10)

Dettori24 (1995)
6/10

149 patients with acute LBP, with or

without radiation, 120 men and 29
women, mean age 28.4 yr

Mean disability (RMQ) after 1 wk:

I1 I2 significantly more
improved than R; no significant
differences after 8 wk
Mean pain (6-point scale) after 1,
2, 4, and 8 wk: no significant
difference between groups
Return to work after 1 wk: I1
I2 significantly more improved
than R; no significant
difference after 8 wk

Elnaggar25 (1991)
4/10

56 patients with chronic LBP, 28

men, 28 women, ages 2050 yr

Erhard45 (1994)*
5/10

24 patients with acute or subacute

LBP, with or without radiation,
classified in an extensionmobilization category, 15 men
and 9 women, ages 1473 yr

Gillan46 (1998)
4/10

25 patients with acute or subacute

LBP, with or without radiation,
lateral, shift of lumbosacral
spine, 12 men and 13 women,
ages 2658 yr

(I1) Prone press-ups, lumbar roll, ice

pack, booklet, trunk shift correction,
home exercises, ibuprofen tablets,
physical therapist supervision
(n 60, after 2 wk, n 30)
(I2) Flexion exercises, pelvic tilt, partial
sit-ups, double knee to chest, ice
pack, booklet, home exercises,
ibuprofen tablets, physical therapist
supervision (n 60; after 2 wk,
n 30)
(I3) Same as I1, flexion exercises added
after 2 wk (n 30)
(I4) Same as I2, extension exercises
added after 2 wk (n 30)
(R) Ice pack while laying prone, no
exercise or postural instruction
(n 30)
(I1) 6 types of extension exercises, 10
reps each, 30min everyday sessions,
2 wk, 6 sessions supervised by
physical therapist, and 8 home
sessions
(n 28)
(I2) 6 types of flexion exercises, 10 reps
each, 30min everyday sessions, 2
wk, 6 sessions supervised by physical
therapist, and 8 home sessions
(n 28)
(I1) Prone press-ups, lumbar roll,
postural instruction, supervised by
physical therapist, 3 visits, selftreatment at home (n 12)
(I2) Sacroiliac joint manipulation, handheel rocking exercises, supervised by
physical therapist, 3 visits, selftreatment at home (n 12)
(I) McKenzie Method, no treatment
details, 2 to 3 times during the 1st wk,
further sessions at discretion of
therapist (n 11)
(R) Nonspecific back massage and
standard back care advice (n 14)

Mean disability (OSW) after 3

and 5 days: I1 significantly
more improved than I2

Mean pain (McGill Pain

Questionnaire) after 2 wk: no
significant difference

Mean disability (OSW) after 3

and 5 days: I2 significantly
more improved than I1

Disability (OSW) after 28 and 90

days: significant lower scores
for both groups; no significant
difference between I and R
(Table continues)

McKenzie Method for LBP Machado et al E257

Table 1. Continued
Study
PEDro Score/10

Participants

Interventions

Outcomes

Malmivaara26 (1995)
7/10

186 patients with acute LBP, with

or without radiation (sciatica
excluded), 62 men and 124
women, 16 subjects withdrawn
after randomization

Mean sick-leave after 3 and 12

wk: R1 significantly more
improved than I1 and I2
Mean pain (11-point scale) after
3 and 12 wk: no significant
differences
Mean disability (OSW) after 3
and 12 wk: R1 significantly
more improved than I1 after 3
wk, and R1 significantly more
improved than I2 after 12 wk

Petersen47 (2002)*
6/10

260 patients with subacute or

chronic LBP, with or without
radiation, 142 men and 118
women, ages 1860 yr

(I1) Repeated extension and lateral

bending exercises plus advice to
stay active, individual instruction
by physical therapist in 1st
session, written
recommendations for home
exercises every hour until the
pain subsided (n 42)
(I2) Bed rest, only essential walking
allowed, advice on resting
position (semi-Fowler), resume
activities as tolerated after 2
days of complete rest (n 62)
(R1) Advice to stay active (n 61)
(I1) McKenzie treatment planned
individually after assessment,
self-mobilizing repeated
movement or sustained positions,
manual overpressure,
mobilization by the therapist, max
15 sessions for 8 wk (n 132)
(I2) Strengthening training, 510 min
stationary bike, 10-min warm-up
exercises (10 reps of lowresistance lumbopelvic
exercises), intensive dynamic
back strengthening program,
groups of 6, guidance of physical
therapist, max 15 sessions for 8
wk (n 228)

Schenk50 (2003)*
5/10

25 patients with subacute LBP,

with radiculopathy,
derangement syndrome,
10 men and 15 women, ages 2176 yr

Mean change on pain (VAS) at

3rd visit: I1 significantly more
improved than I2
Mean change on disability (OSW)
at 3rd visit: I1 significantly
more improved than I2

Stankovic27 (1990)
6/10
Stankovic28 (1995)
3/10

100 patients with acute LBP, with

or without radiation, 77 men
and 23 women, mean age 34.4
yr (9.7 yr)

Underwood49 (1998)*
6/10

75 patients with acute LBP,

without radiation, no
peripheralization after 10 spine
extensions, 45 men and 30
women, ages 1670 yr

(I1) Postural correction, 20-min walk

on treadmill, extension exercises
or extension with hips offset, 5
sets of 10 reps, 3 visits (n 15)
(I2) Postural correction, 20-min walk
on treadmill, spinal joint
mobilization based on
assessment, 5 sets of 10
mobilizations, 3 visits (n 10)
(I) 5 min lying prone plus 5 min
sustained lying prone in
extension on the elbows, prone
press-ups, correction of lateral
shift; after 2 wk flexion in lying,
followed by flexion in sitting and
in standing, postural and
ergonomic instructions, home
exercises (n 50)
(R) Mini Back School, 45-min lesson
on back care including anatomy
and function of the back, rest
position, avoidance of inactivity,
and ergonomic instructions
(n 50)
(I) McKenzie Method plus general
advice, educational leaflet,
groups up to 5 subjects, 1-hr
session, return for a further
session if pain recurred, home
exercises, cointerventions
allowed (n 35)
(R) Advice, usual general practice
care (n 40)

Median disability (15-item scale)

post treatment, and after 2 and
8 mo: trend favoring I1 at 2 mo
follow-up
Median pain (060 scale) posttreatment, and after 2 and 8
mo: no significant difference

Pain (graphic scale) after 3 and

52 wk: I significantly more
improved than R
Mean days on sick leave: I
significantly more improved
than R
Subjects on sick leave in the
preceding 4 yr: I significantly
more improved than R
Recurrences after 1 yr and in the
preceding 4 yr significantly
lower in (I) than (R)
Mean days on sick leave during
recurrences: no significant
difference
Mean change on pain (100 mm
scale) at 1, 2, 4, 8, 12, and 52
wk: no significant difference
Mean change on disability (OSW)
at 1, 2, 4, 8, 12, and 52 wk: no
significant difference
Subjects recording LBP no
problem in previous 6 mo: I
significantly better than R after
1 yr

LBP low back pain; I intervention (e.g., McKenzie method); R reference treatment; RMQ Roland-Morris Questionnaire ; OSW Oswestry Disability
Questionnaire; VAS visual analogue scale.
*Classification-based McKenzie.

E258 Spine Volume 31 Number 9 2006

Figure 1. Comparison of McKenzie and passive therapy on pain

at 1 week.

movements performed in multiple, nonspecific directions,54,55 multiple muscle strengthening and/or stretching, 56 59 lumbar stabilization exercises 60 ); quasirandomized trials61,62; inclusion of patients with specific
pathology63; and insufficient report of data on main outcomes.64
Study Characteristics
The characteristics of the included studies are presented
in Table 1. Five trials reported on acute LBP (6 weeks
duration),24,26 28,44,49 one reported on subacute LBP
(from 6 weeks to 3 months duration),50 and one trial
reported on chronic LBP (3 months duration).25 Four
trials reported on a mixed population of patients.45 48
Eight trials included patients who had LBP with or
without radiating symptoms,24,26 28,44 48 one included
patients with pain restricted to the lower back,49 one
included patients presenting radiculopathy,50 and one
trial did not report the location of the symptoms.25
No placebo-controlled trials were located. Different
types of interventions were used as reference treatments:
educational booklet,44 ice packs,24 massage,46 bed
rest,26 advice to stay active,26,49 flexion exercises,24,25,48
spinal manipulative therapy,44,45,50 back school,27,28
and back-strengthening exercises.47 For analysis purposes, the following reference treatments were considered under the label passive therapy: educational
booklet, ice packs, massage, and bed rest. A similar approach was used in a previous review in which these
interventions were labeled as inactive.30
Two trials did not use the term McKenzie method or a
synonym to name the intervention.24,26 However, the
repeated, direction-specific, passive spine movements
used in the studies of Dettori et al24 and Malmivaara et
al26 reflect McKenzie principles9; therefore, both studies
were included in this review. Four trials delivered the
McKenzie method together with passive or active cointerventions such as manipulation,48 ice packs,24 educational booklets,24,49 and walk on treadmill.50
In six trials,44,45,4750 the intervention was based on a
classification of patients according to the directional
preference (classification-based McKenzie); 2 of them
were published in the last 3 years.47,50 Among the trials
reporting on a generic McKenzie approach,24 28,46 the
treatment consisted of extension exercises,25 or the use
of extension exercises together with lateral bending,26
and with flexion exercises.24,27,28 One trial did not report treatment details.46
Although the studies of Delitto et al,48 Erhard et al,45
Schenk et al,50 and Underwood and Morgan49 clearly

used extension exercises for all participants, this approach was not considered generic McKenzie because all
participants were classified before randomization as exhibiting directional preference for extension.
Methodologic Quality
Nine papers had already had their methodologic quality
previously assessed using PEDro scale.24 28,44 46,48 Two
reviewers (P.H.F., M.L.F.) independently assessed the quality of the other three trials using the same instrument.47,49,50 Eight papers scored 5 points or more and were
considered of high quality24,26,27,44,45,47,49,50 (Table 1).
Treatment Effects
Clinical and statistical heterogeneity prevented the pooling of trials in which the McKenzie method was compared with flexion exercises24,25,48 and spinal manipulative therapy.44,45,50 Pooling was also not possible for
trials in which the contrast therapy consisted of back
school27,28 and back-strengthening exercises47 because
of the absence of multiple studies. For the comparisons
with passive therapy and advice to stay active, a metaanalysis based on the random effects model was performed.
McKenzie Versus Passive Therapy. Four trials24,26,44,46 of

mostly high-quality reporting on acute LBP compared

McKenzie with passive therapy (educational booklets,
bed rest, ice packs, and massage). Two trials were both
clinically and statistically homogeneous when assessing
pain and disability at 1 week,24,44 and three trials were
homogeneous when assessing disability at 4 weeks follow-up.24,44,46 The pooled results show a statistically
significant decrease in pain (WMD on a 0- to 100-point
scale, 4.16 points; 95% CI, 7.12 to 1.20) and disability (WMD on a 0 100 point scale, 5.22 points;
95% CI, 8.28 to 2.16) favoring McKenzie at 1-week
follow-up when compared with passive therapy (Figures
1, 2). No difference in disability was found between
groups at 4 weeks follow-up (Figure 3).
McKenzie Versus Advice to Stay Active. Two high-quality
studies reporting on acute LBP compared McKenzie with
advice to stay active. The trials were clinically and statistically homogeneous when assessing pain and disability at 12 weeks follow-up.26,49 Both interventions were
similar when assessing pain (Figure 4). The pooled results in Figure 5 indicate a statistically significant decrease in disability (WMD on a 0- to 100-point scale,
3.85 points; 95% CI, 0.30 to 7.39) favoring advice at 12
weeks follow-up.

McKenzie Method for LBP Machado et al E259

Figure 2. Comparison of McKenzie and passive therapy on disability at 1 week.

McKenzie Versus Flexion Exercises. One high-quality24

and two low-quality studies25,48 compared McKenzie

with flexion exercises. Because of clinical and statistical
heterogeneity, the pooled effect was not measured on this
comparison. When analyzing the results of individual
trials, McKenzie was as effective as flexion exercises at 2
weeks for chronic pain (mean difference on a 0- to 100point scale, 2 points; 95% CI, 4 to 8),25 and marginally
better than flexion exercises for acute pain at 8 weeks
follow-up (mean difference on a 0- to 100-point scale,
2 points; 95% CI, 3 to 1).24 Delitto et al48 reported
a large effect on acute disability (mean difference on a 0to 100-point scale, 22 points; 95% CI, 26 to 18)
favoring McKenzie when compared with flexion exercises after 5 days.
McKenzie Versus Spinal Manipulative Therapy. Three highquality trials reporting on acute LBP compared McKenzie to spinal manipulative therapy.44,45,50 Again, clinical
and statistical heterogeneity prevented the pooling of trials on this comparison. Individual trials showed contradictory results. Schenk et al50 reported a large reduction
in pain (mean difference on a 0- to 100-point scale, 21
points; 95% CI, 41 to 1) favoring McKenzie at the
third visit, whereas Erhard et al45 reported a large reduction in disability favoring spinal manipulative therapy
after 5 days (mean difference on a 0- to 100-point scale,
17 points; 95% CI, 8 to 27) and 4 weeks (mean difference
on a 0- to 100-point scale, 22 points; 95% CI, 10 to 33).
McKenzie Versus Back School. The evidence for the effectiveness of McKenzie when compared with back school
is based on a single trial. Stankovic and Johnel27,28 reported lower pain scores favoring McKenzie at shortterm follow-up (high-quality paper27) and long-term follow-up (low-quality paper28). However, no data were
provided to support these findings. In the same study,
McKenzie resulted in a higher return to work rate (relative risk, 2.05; 95% CI, 1.43 to 2.95).

McKenzie Versus Strengthening Exercises. Only one highquality trial compared McKenzie to strengthening exercises. Petersen et al47 found no statistically significant
differences on pain (mean difference on a 0- to 100-point
scale, 7 points; 95% CI, 22 to 9) or disability (mean
difference on a 0- to 100-point scale, 1 point; 95% CI,
14 to 12) when McKenzie was compared with
strengthening exercises at 8 weeks follow-up for patients
with subacute and chronic LBP. At 10 and 32 weeks
follow-up, the differences were also nonsignificant.

Sensitivity Analysis
A sensitivity analysis was attempted to determine if excluding trials reporting on a generic McKenzie approach
had any effect on the results. Six trials comparing the
classification-based McKenzie with the following reference treatments were included in this sensitivity analysis:
educational booklet,44 advice to stay active,49 flexion
exercises,48 strengthening exercises,47 and spinal manipulative therapy44,45,50 (Table 1).
A pooled analysis could not be performed due to insufficient number of trials on each comparison,44,47 49
and also due to clinical and statistical heterogeneity
when there were multiple trials on the same comparison.44,45,50 When evaluating treatment effects of individual trials, the classification-based McKenzie was as effective as an educational booklet,44 advice to stay active,49
and strengthening exercises47 at all time points. Comparisons with flexion exercises48 and spinal manipulative
therapy50 yield statistically significant differences favoring the classification-based McKenzie. Nevertheless, as
described in the main analysis, the evidence for the effectiveness of McKenzie when compared with spinal manipulative therapy is not consistent.
Discussion
Although research on primary care management of LBP
was scarce until the late 1980s, the increase in govern-

Figure 3. Comparison of McKenzie and passive therapy on disability at 4 weeks.

E260 Spine Volume 31 Number 9 2006

Figure 4. Comparison of McKenzie and advice to stay active on

pain at 12 weeks.

mental funding and the establishment of scientific meetings on this topic have promoted the proliferation of publications in the last decade.65 LBP has been a frequent focus
of systematic reviews and meta-analyses evaluating the effectiveness of different types of interventions.30,3539,66 70
Nevertheless, consistent evidence on treatment effectiveness for this condition is still lacking.
There is a rising interest in classification systems that
could identify homogeneous subgroups of LBP patients
more likely to respond to specific interventions.10 16 The
current practice is to perform a diagnostic triage, in
which patients are classified into one of the following
categories: 1) nonspecific LBP, 2) sciatica/radicular syndrome, and 3) suspected serious spinal pathology.71 Although consistently recommended by clinical practice
guidelines,2 this diagnostic triage contains little therapeutic information since the former category refers to a
large group of patients that may present different pathophysiologic conditions under the label nonspecific.72
The hypothesis that different therapies have their effectiveness underestimated over the years due to difficulties in identifying homogeneous groups of LBP patients
has found some support recently. Fritz et al73 found that
acute LBP patients assigned to a classification-based
therapy reported not only lower disability scores at
short- and long-term follow-up, but also faster return to
work and lower medical expenses when compared with
general exercise therapy.
The McKenzie method9 is widely used for the management of LBP patients.74,75 Additionally, the McKenzie
method has the strongest evidence for validity among the
classification systems based on clinical features.8 However, the evidence for the effectiveness of this classification-based treatment for LBP is unclear. We conducted a
systematic review with a meta-analysis approach to summarize the available evidence on the McKenzie method
for the treatment of LBP.
No placebo-controlled trial was located by this review; therefore, the efficacy of the McKenzie method is
unknown at this stage. In the main pooled analyses, trials

in which patients were classified according to the centralization phenomenon (directional preference) were analyzed together with trials in which patients of unknown
classifications received the same intervention (generic
McKenzie). The same procedure was used in the Cochrane review of exercise therapy for LBP.30 In a sensitivity analysis, we attempted to evaluate whether the exclusion of trials reporting on a generic McKenzie
approach altered the results of the main pooled analysis.
According to the main pooled analysis, there were
statistically significant differences in pain and disability
favoring the McKenzie method when compared with
passive therapy at 1-week follow-up for acute LBP.
However, advice to stay active showed larger effects on
disability at 12 weeks when compared with McKenzie
for the same population. It is difficult to explain the superior effect of advice to stay active over the McKenzie
method because both interventions are similar when it
comes to advising patients to avoid bed rest and return to
normal activities. The difference between these two approaches might lie on the importance of the structural
damage (e.g., disc disease) in McKenzies educational
program. According to McKenzies conceptual model,
the structural pathology is responsible for the symptomatic presentation, and patients are instructed that, by
adopting certain postures and performing specific exercises, the damage can be reversed. The biomedical model
of explaining LBP in the McKenzie method may contribute to iatrogenic disability71 that could explain the
poorer results of this therapy when compared with information emphasizing positive attitudes without focusing
on any damage to the spine. However, it is also hypothesized that the direct association of damage-healing and
movement strategies in the McKenzie method provides a
learning platform that enable patients to feel greater control over their back problems as well as contributes to
improve compliance with their exercises.9
The small magnitude of the differences observed in the
pooled analysis (6 points on a 0- to 100-point disability
scale and 5 points on a 0- to 100-point pain scale) may

Figure 5. Comparison of McKenzie and advice to stay active on

disability at 12 weeks.

McKenzie Method for LBP Machado et al E261

reflect the absence of clinical worthwhile effects. It is

important to note that our results cannot be generalized
to a classification-based McKenzie because trials reporting on generic McKenzie were included in the main analysis. In this review, it was not possible to evaluate the
effectiveness of a classification-based McKenzie for LBP
due to insufficient number of trials and heterogeneity.
Another limitation of the main analysis is the use of
cointerventions in two studies included in the pooling.24,49 Although this approach reflects the usual physiotherapy practice, it does not permit any conclusion on
the effectiveness of the McKenzie method over and above
the effects of the cointerventions.
The study of Delitto et al48 clearly differs from the
other included studies showing a large reduction in disability favoring McKenzie (mean difference on a 0- to
100-point scale, 22 points; 95% CI, 26 to 18). In
the Delitto et al study,48 McKenzie was compared with
flexion exercises and only patients with directional preference for extension were included.48 Therefore, it
would be expected that flexion exercises had shown
poorer outcomes since exercises performed toward the
directional preference promote centralization of symptoms, whereas exercises performed in the opposite direction promote worsening (peripheralization) of symptoms.9 The study of Dettori et al24 also compared
McKenzie with flexion exercises, although no attempt
was made to exclude patients that did not present a directional preference for extension, what may have contributed to the underestimation of outcomes in the group
assigned to this generic McKenzie approach. Apart from
the use of a classification-based McKenzie, the poor
methodologic quality from the study of Delitto et al48
prevents any conclusion on the effectiveness of the
McKenzie method when compared with flexion exercises.
As occurred in the study of Delitto et al,48 Schenk et
50
al also found a large effect favoring the McKenzie
method. McKenzie reduced pain by 21 points on a 0- to
100-point scale (95% CI, 41 to 1) when compared
with spinal manipulative therapy.50 the Schenk et al
study50 presents an important distinction from other included studies with regards to the population as it is the
only study that included patients presenting with radiculopathy. Because the conceptual model that explains
the derangement syndrome (the most common mechanical spinal disorder according to McKenzies classification system9) is primarily based on internal intervertebral disc displacements, one may consider that McKenzie
would be more effective for this particular population.
However, there is no consensus on what is the best conservative treatment for this population of LBP patients.76
According to our results, there are an insufficient
number of trials comparing the McKenzie method to
back school or strengthening exercises; therefore, the evidence regarding the effectiveness of the McKenzie
method on these comparisons is limited at this time. The
insufficient number of trials together with heterogeneity
among the available trials also prevented any conclu-

sions on the effectiveness of a classification-based

McKenzie for LBP. There is still a need for further research in order to clarify whether the McKenzie method
as a classification-based treatment differs from a generic
McKenzie approach.
Conclusion
The results of this meta-analysis suggest that the McKenzie method is more effective than passive therapies,
including educational booklets, ice packs, and massage
for acute LBP patients. However, the small magnitude of
the difference may not be considered clinically worthwhile. The effectiveness of classification-based McKenzie
is yet not possible to be estimated. Future studies on the
McKenzie method should be aware of classifying patients with LBP before assigning them to treatment.
Key Points
A meta-analysis of randomized controlled trials
was performed.
Many trials apply the McKenzie method in a generic fashion and fail to consider patient classification.
The McKenzie method does not produce clinically worthwhile changes in pain and disability
when compared with passive therapy and advice to
stay active for acute LBP.

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