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McKenzie Back Exercises

Editor: Paramvir Singh Updated: 7/7/2025 1:20:34 AM

Introduction

The McKenzie back exercises form part of an exercise protocol developed by physiotherapist Robin Anthony McKenzie in the 1950s and popularized around 1985.[1] The McKenzie method, also known as Mechanical Diagnosis and Therapy (MDT), serves as a widely used classification system for diagnosing and treating various musculoskeletal conditions, including lower back, neck, and extremity pain.[2] Over time, McKenzie exercises have become closely associated with spinal extension movements. In contrast, Williams exercises, named after Dr. Paul C. Williams, have become associated with lumbar flexion exercises.

The McKenzie method has broad acceptance as an effective therapeutic approach for spinal pain. Central to this method is an emphasis on self-management through postural correction and repeated end-range movements performed frequently throughout the day. The hallmark of the McKenzie approach involves classifying nonspecific spinal pain into homogenous subgroups based on the symptomatic responses to applied mechanical forces.[3] These subgroups include postural syndrome, dysfunction syndrome, derangement syndrome, or a category labeled “other.” Treatment plans are tailored to each subgroup.

Assessment within the McKenzie framework prioritizes the centralization phenomenon, in which spinal pain referred distally is guided back toward the spine through targeted, repetitive movements. Clinical findings from this process inform the prescription of specific exercises and postural recommendations. Each patient follows an individualized program, often performing prescribed movements at home up to 10 times per day. This frequency contrasts with the typical schedule of 1 or 2 supervised physical therapy sessions per week.

Restoration of normal function is considered essential for tissue healing. Without functional recovery, symptoms are expected to persist according to the principles of the McKenzie method.

Effective treatment using the McKenzie method begins with classifying spinal pain into distinct syndromes based on mechanical responses. Each syndrome has characteristic features that shape exercise selection and expected outcomes.

The postural syndrome involves pain resulting from mechanical deformation of soft tissue or vasculature due to prolonged static loading. Affected structures may include joint surfaces, muscles, or tendons. Symptoms typically arise in sustained positions such as sitting, standing, or lying. Pain is usually reproducible during prolonged postures but absent with repeated movement. Symptom resolution occurs rapidly once abnormal posture is corrected.[4]

The dysfunction syndrome is marked by pain arising from mechanical deformation of structurally impaired soft tissue. Contributing factors may include trauma, inflammation, or degeneration, leading to tissue contraction, scarring, adhesion, or adaptive shortening. This syndrome is characterized by restricted movement and pain elicited at the end range of motion. Subsyndromes are defined by the direction that provokes symptoms: flexion, extension, side-glide, multidirectional, adherent nerve root, and nerve root entrapment. Management emphasizes patient education and targeted mobilization in the direction of dysfunction. Treatment aims to promote tissue remodeling, a process that typically requires extended time.

Derangement syndrome is the most commonly encountered classification within the McKenzie method, with a study reporting a prevalence as high as 78% among classified patients.[5] This syndrome results from internal displacement of articular tissue, which alters the normal position of joint surfaces and deforms the capsule and periarticular supportive ligaments. The resulting derangement produces both pain and obstruction of movement, typically in the direction of the displacement.

Seven distinct patterns are identified, based on pain location and the presence or absence of deformities. Pain is usually elicited during assessment movements such as spinal flexion or extension. Centralization and peripheralization of symptoms occur exclusively in derangement syndrome.

Treatment focuses on repeated movement in a single direction that progressively reduces symptoms. Studies indicate that centralization of lower back pain occurs in approximately 58% to 91% of affected individuals.[6] Among these patients, 67% to 85% exhibit a directional preference for spinal extension.[7] This directional trend may partly explain why the McKenzie method is closely associated with extension-based exercises.

Accurate identification of the direction of movement is critical. A randomized controlled trial demonstrated that prescribing exercises in the incorrect direction can lead to inferior clinical outcomes.[8]

The “Other” or nonmechanical syndrome includes cases that do not align with mechanical classifications but reflect symptoms of other identifiable pathologies. These conditions include spinal stenosis, sacroiliac and hip disorders, zygapophyseal (facet) dysfunction, postsurgical complications (such as postlaminectomy syndrome or epidural fibrosis), pregnancy-related back pain, spondylolysis, and spondylolisthesis.

Understanding the distinctions between these syndromes allows clinicians to match therapeutic strategies to the underlying mechanical behavior. Proper classification ensures appropriate exercises are selected and suboptimal outcomes are avoided.

Anatomy and Physiology

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Anatomy and Physiology

Intervertebral discs contribute to spinal motion by permitting flexion, extension, lateral bending, and axial rotation.[9] Degeneration may occur in the annulus fibrosus (annular degeneration) or the vertebral endplate, described radiographically as Modic-type degeneration.[10] The McKenzie protocol does not distinguish between these degenerative patterns.

Disruption and displacement of the nucleus pulposus-annulus fibrosus complex can result in axial back pain, radicular pain, or both. The clinical presentation depends on the degree of displacement and the presence or absence of nerve root compression. Extension-based pain most commonly arises from mechanical stress on the facet joints and posterior elements, whereas posterior migration of the nucleus pulposus within the annulus fibrosus is typically associated with flexion movements. This displacement may lead to mechanical deformation of the surrounding soft tissue, often provoked by postural stress.

To address flexion-related symptoms, McKenzie advocated spinal extension exercises aimed at restoring or preserving normal lumbar lordosis. However, the protocol has received criticism in the era of advanced imaging techniques, such as computed tomography and magnetic resonance imaging. Critics note that lumbar extension may promote facet joint overriding and contribute to narrowing of the lateral recesses and central canal, even in individuals without preexisting pathology.

Indications

McKenzie exercises are prescribed to patients who demonstrate the centralization phenomenon of back pain. "Centralization" refers to the resolution of distal referred pain in a sequential manner, with the discomfort ultimately localizing at the midline of the body. Exercises are selected based on directional preference, and the indicated movement aligns with this preferred direction. For example, if a patient exhibits a directional preference for spinal extension (most common), the exercises performed will involve spinal extension.

Contraindications

Any form of therapy may initially exacerbate symptoms before clinical improvement occurs. Spinal instability beyond grade I, clinical radicular features, saddle anesthesia, or sciatic-type pain during McKenzie extension exercises should prompt immediate cessation of the program. In such cases, clinicians should consider a flexion-based regimen, such as the Williams flexion exercises.[11]

The presence of red flags, such as fever, chills, or night sweats, requires further diagnostic workup prior to initiating therapy. If such red flags develop during treatment, all therapeutic interventions should be paused until evaluation is complete. Unexplained myelopathy or upper motor neuron signs also warrant a comprehensive investigation. These findings may not constitute absolute contraindications but remain clinically significant and must be evaluated thoroughly.

Equipment

A basic, simple therapy table is usually sufficient. Seated exercise balls may be used for additional core strengthening.

Therabands and similar tools help address secondary musculoskeletal conditions. Clinical lower back pain rarely occurs in isolation. Trochanteric bursitis and spinal enthesitis are often present.

Equipment for iontophoresis and phonophoresis is not part of the McKenzie protocol but may support overall care. These modalities may sometimes enable patients to perform the McKenzie regimen. Ice or heat, such as hydrocollator packs, is often applied before and after therapy sessions.

Personnel

Therapy is typically initiated by a clinician, such as a physician, osteopathic doctor, nurse practitioner, or physician assistant, who determines its appropriateness based on the patient’s history and physical examination. The referral may be broad and incomplete or highly specific, such as postprocedure therapy orders.

Therapists may pursue certification in the McKenzie method. The MDT Program of Certification includes comprehensive postgraduate coursework to prepare clinicians for the credentialing examination, which serves as the primary level of MDT certification. Certified providers join a patient referral network and must meet continuing education requirements to maintain their status. Most therapists and physicians consider this certification redundant, viewing it more as a political distinction than a necessary therapeutic qualification.

An orthotist may assist in measuring and fitting a lumbosacral corset. However, many high-quality off-the-shelf corsets may also be provided directly by the physical therapist.

Technique or Treatment

Physical therapists trained in the McKenzie method prescribe exercises based on the centralization phenomenon described earlier. Since most individuals demonstrate a directional preference for spinal extension, this mechanical response is typically the focus of the prescribed regimen.

Common spinal extension exercises include, but are not limited to, the following:

  • Prone lying: The patient lies flat on the stomach with the spine in a neutral position.

  • Prone on elbows: The patient lies prone and props the upper body on the elbows, promoting gentle spinal extension.

  • Prone press-up: From a prone position, the patient extends the elbows to lift the upper body while keeping the pelvis in contact with the surface, increasing lumbar extension.

  • Standing lumbar extension: The patient stands upright with feet shoulder-width apart, places the hands on the lower back for support, and gently extends the spine.

Similar exercises may also be prescribed to target flexion, rotation, or lateral bending, depending on the patient’s directional preference.

Complications

As with any therapeutic program, some patients may fail to improve, transiently worsen before improving, or deteriorate due to the intervention itself or the progression of the underlying condition despite treatment. Careful clinical monitoring is essential to distinguish between expected responses and signs of treatment failure or complications.

Clinical Significance

Multiple studies have identified the positive prognostic value of centralization, with pain that fails to centralize correlating with a poor behavioral response.[12][13] Thus, the McKenzie method for assessing and classifying lower back pain is more dependable than any alternative examination approach if appropriately implemented.[14] Although this method may not outperform other rehabilitation interventions in reducing pain and disability in patients with acute lower back pain, moderate- to high-quality evidence supports its superiority in alleviating both pain and disability in patients with chronic lower back pain.[15] McKenzie exercises have also been shown to benefit the cervical spine, with a study reporting significantly improved cervical posture in individuals with forward head posture.[16]

Among various treatment protocols for chronic low back pain, a study comparing the McKenzie method to other conservative interventions found low-to-moderate certainty evidence that the McKenzie method was more effective in reducing pain for up to 6 months and disability for up to 12 months in patients with a directional preference.[17] This observation, however, is not unique to the McKenzie method. In the absence of a universally accepted standard of care, this modality is one of several empiric approaches that clinicians may trial and replace based on patient response.[18]

In a review of 5 trials comparing the McKenzie method with manual therapy, all studies reported greater short-term improvement in pain and disability within the manual therapy group at 2 to 3 months. By 6 months, 2 trials reported significant improvements in disability scores in both groups, and at 2-month follow-up, no significant differences in pain measures were noted.

Enhancing Healthcare Team Outcomes

Primary care physicians and nurse practitioners may prescribe physical therapy or a home exercise program for back pain, but such prescriptions are often sparse and nonspecific, typically written as "evaluate and treat." Physical therapists frequently determine the actual treatment protocol. The McKenzie method is an option, allowing therapists to tailor exercises based on classification obtained through mechanical assessment.

Although McKenzie exercises are often associated with spinal extension, the method includes exercises in any plane, depending on the patient’s directional preference. Centralization, the desired outcome, depends on identifying and following this preference. While most patients respond best to extension, some improve with spinal flexion instead. In these individuals, repeated extension movements can provoke peripheralization, a pattern in which distal referred pain worsens. Unlike centralization, peripheralization suggests a poor prognosis and should be avoided.

Accurate assessment of directional preference is essential. Assuming that a patient will respond to extension and proceeding accordingly risks therapeutic failure. Optimal outcomes require collaboration among physicians, nurses, and physical therapists to educate patients and ensure the exercise program aligns with their individual response patterns.

All clinicians should screen for myelopathy by evaluating for upper motor neuron signs. Therapy should not proceed unless these findings are clearly explained, determined not to contraindicate therapy, or appropriately worked up and managed. Further evaluation may require consultation with neurology, physical medicine and rehabilitation, neurosurgery, or hematology-oncology, depending on the suspected etiology.

Physical and occupational therapy roles may overlap, particularly in smaller hospitals or underserved regions. Iontophoresis or phonophoresis may be included in a comprehensive treatment plan, and therapists may request a specific prescription from the referring physician to initiate these modalities.

Spinal surgeons often provide more detailed or restrictive physical therapy prescriptions. For example, these specialists may explicitly prohibit lumbar extension, particularly in patients who have undergone lumbar or lumbosacral fusion.

Pharmacologic management may be necessary to facilitate participation in therapy. Muscle relaxants, benzodiazepines, or, in some cases, opioids may be prescribed. Prescriber attitudes and comfort levels vary, and many clinicians instruct patients to take medication approximately 30 minutes before therapy sessions. This practice generally applies only during the acute phase of care.

Nursing, Allied Health, and Interprofessional Team Interventions

Common physical therapy prescriptions from primary care clinicians are often brief, typically stating “evaluate and treat.” In some clinics, this instruction may appear as a prechecked box on standardized forms provided by the therapy office. Neurosurgeons and pain management specialists may provide more detailed instructions. Postsurgical and postprocedural referrals may follow modified or mixed McKenzie protocols, depending on the intervention (eg, facet joint injections, laminectomy, vertebral augmentation), upcoming procedures (eg, radiofrequency ablation), or patient factors such as sensory neuropathy or osteoporosis.

Therapy recommendations vary according to the procedure and the individual performing it. Therapists may identify secondary musculoskeletal conditions, such as bursitis or enthesitis, not addressed by McKenzie principles but interfere with progress. An extended prescription may be requested to address these issues.

Since effective therapy requires managing all contributing pain generators and functional impairments, therapists may also request modalities such as iontophoresis, ultrasound, or phonophoresis. These interventions often need a separate prescription for a corticosteroid, typically dexamethasone.

Nursing, Allied Health, and Interprofessional Team Monitoring

Clear communication is essential, and no aspect of care, including physical therapy, functions in isolation. Therapeutic interventions often overlap.

The physical therapist may need to contact the surgeon or prescribing clinician if the patient cannot tolerate certain components of therapy. Secondary musculoskeletal issues, such as trochanteric bursitis, spinal enthesitis, or Baastrup disease, may emerge and interfere with progress. Additional modalities such as therapeutic ultrasound, heat or cold application, or iontophoresis, though not part of the McKenzie method, may be necessary to support a comprehensive treatment plan and improve tolerance for McKenzie-based exercises.

A separate prescription is required for corticosteroid use, typically dexamethasone, in iontophoresis or phonophoresis, and must be requested by the physical therapist from the prescribing physician.

New-onset weakness and upper motor neuron findings should be evaluated by all clinicians, including physicians, osteopathic physicians, podiatrists, physical therapists, occupational therapists, nurse practitioners, and physician assistants. The prescribing clinician must be notified when these findings are observed, particularly following an interventional procedure. Ongoing therapy may need to be paused to allow for further evaluation. An increase in pain following a procedure, particularly after provocative studies such as diskography, should prompt immediate communication with the proceduralist.

Some individuals may present with spinal instability, critical stenosis, or large herniated nucleus pulposus and may be unsuitable for surgical intervention due to comorbidities, such as reduced cardiac ejection fraction, pacemaker dependence, dialysis dependence, or severe osteoporosis. Although these cases are not ideal for the McKenzie method, a modified or adapted version may need to be implemented when alternatives are limited.

Although physical therapy addresses the majority of spine-related rehabilitation, occupational therapy often overlaps in scope. In smaller or underserved hospitals, one discipline may cross-cover for the other due to staffing constraints.

Clinical vigilance for red flags is essential in any case of spinal pain, and particularly important when managing vertebral compression fractures with conservative care.[19][20] Prompt identification allows for timely referral, advanced imaging, or specialist evaluation when necessary.

References


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Level 1 (high-level) evidence

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Garcia AN, Costa Lda C, da Silva TM, Gondo FL, Cyrillo FN, Costa RA, Costa LO. Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical therapy. 2013 Jun:93(6):729-47. doi: 10.2522/ptj.20120414. Epub 2013 Feb 21     [PubMed PMID: 23431213]

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Kim J, Kim S, Shim J, Kim H, Moon S, Lee N, Lee M, Jin E, Choi E. Effects of McKenzie exercise, Kinesio taping, and myofascial release on the forward head posture. Journal of physical therapy science. 2018 Aug:30(8):1103-1107. doi: 10.1589/jpts.30.1103. Epub 2018 Aug 7     [PubMed PMID: 30154609]


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Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. The Cochrane database of systematic reviews. 2023 Aug 24:8(8):CD014461. doi: 10.1002/14651858.CD014461.pub2. Epub 2023 Aug 24     [PubMed PMID: 37615643]

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