McKenzie Approach for the Lumbar Spine

prone lying

extension bias

progress toward extension

particularly after prolonged flexion or first thing in the morning, the patient may need time in prone before attempting extension in lying (EIL)

-> prone -> prone on elbows /pillows under chest -> plinth raised --> this is recommended progression for Pt presenting with back dominant pain, presenting "stuck" bent forward in flexion

repeated extension in lying (REIL)

extension bias

press ups

self overpressure can be given with the “sag,” exhaling at end

self overpressure for lower regions: raising Pt legs or moving arms back

self overpressure for upper regions: moving arms forward

REIL with overpressure (manual fixation)

extension bias

the effect of overpressure is assessed by the therapist fixing the pelvis

or specific spinal segment using overlapping or crossed hand technique

REIL with overpressure (belt fixation)

extension bias

belt fixation used to prevent hips leaving plinth

also used to localize self-stretch to a specific region of spine

patient extension with lateral component

extension bias

unilateral or asymmetrical symptoms not reduced with simple

usually move hips away from the side of pain

Progression --> therapist maintains lateral shift while pt extends (press up) or patient can maintain lateral shift while progressing into extension

patient extension in standing (EIS)

extension bias

this is used as soon as possible, as it is easier for most patients to do during the day

wide BOS, look straight ahead, do NOT push hips forward

main preventative movement, to interrupt / reverse prolonged flexion activities before the pain reappears

EIS with belt

extension bias

Patient holds belt around target lumbo-sacral segment

Arms hold ends of belt in front with elbows bent

Arch backwards using the belt as a fulcrum to arch over

Often works better if patient pulls forward / upward with belt as they arch

This is a variation of a Mulligan SNAG

lateral shift in lying

extension bias

patient in sustained lateral shift, using pillows in side lying

patient lateral shift in standing

extension bias

against wall, doorframe, with pillow to increase hip excursion

further away the pt leans, the more pressure from gravity

free standing, with one hand on hip, other on rib cage

lateral shift with mobilization in standing

extension bias

wide BOS

stabilize pt’s trunk with therapist’s hands, using pt’s bent arm held into rib cage

wrap arms around pt’s pelvis, pull hips toward you

may be oscillatory (slow) or sustained

lateral shift with mobilization in standing (with belt)

extension bias

wide BOS

stabilize pt’s trunk with therapist’s hands, using pt’s bent arm held into rib cage

wrap belt around hips

should be side glide, not flex

patient rotation mobilization in flexion

flexion bias

flex first then rotate, (swing legs to side)

usually move legs towards painful side

may need to hold for several minutes

therapist rotation mobilization in flexion

flexion bias

flex first then rotate patient’s legs as above

usually move legs towards painful side

apply overpressure by holding down pt’s trunk / ribcage

flexion in lying

flexion bias

may start with one leg, then both

extra ROM by abducting & rotating hips out

head stays on plinth

should be passive, using patient’s arms, not abdominals

stretch to lumbar spine increased by using pillow under pelvis

flexion in sitting

flexion bias

avoid sustained flexion, unless intended

alter seat height, position in chair

used for dysfunction and occasionally for acute derangements

overpressure with therapist fixation -> belt isolates lumbar motion

flexion in step-standing

flexion bias

used for asymmetrical dysfunction or adhered nerve root

SNAG for extension in sitting/standing

SNAGS - lumbar/thoracic techniques:

Ulnar border of your hand is placed under the SP or TVP of target segment

Stand to the side of the patient (so as to not block extension)

Glide vertebra upward as patient extends

Use belt to fix the pelvis if necessary

NOTE: patients must NOT lean back into your hand = rather they should extend over your hand

SNAG for flexion in sitting/standing

SNAGS - lumbar/thoracic techniques:

Ulnar border of your hand is placed under the SP or TVP of target segment

Stand behind the patient

Glide vertebra upward as patient flexes forward

Use belt to fix the pelvis if necessary

SNAG for side flexion in sitting/standing

SNAGS - lumbar/thoracic techniques:

Ulnar border of your hand is placed under the SP or TVP of target segment

Stand to the side of the patient (Opposite direction of movement)

Glide vertebra upward as patient side flexes

SNAG for rotation (using SP)

SNAGS - cervical techniques:

use edge of thumb on TP of target vertebra

force is imparted with thumb of other hand

aim along facet planes

PT hands must follow movement

Pt provides own (pain free) overpressure

SNAG for rotation (unilateral)

SNAGS - cervical techniques:

top of thumb is lateral to SP of target vertebra

force is imparted with thumb of other hand

aim along facet planes

therapist hands must follow the patient's movement

Pt provides own (pain free) overpressure

SNAG for side flexion (unilateral)

SNAGS - cervical techniques:

top thumb is lateral to TP of target vertebra

force is imparted with thumb of other hand

aim along facet planes

therapist hands must follow the patient's movement

Pt provides own (pain free) overpressure

can also use edge of thumb directly on SP of target vertebra

SNAG for extension (using SP)

SNAGS - cervical techniques:

use edge of thumb on articular columns of target vertebra

force is imparted with thumb of other hand

aim along facet planes throughout the movement

SNAG for rotation (bilateral)

SNAGS - cervical techniques:

alternate technique (usually more comfortable)

need to push anteriorly first to take up slack in soft tissues or won't be able to glide upwards

self-SNAG for rotation

SNAGS - self-techniques:

cross hands, with lower arm around chair back if possible to provide better fixation

upper hand aims towel edge along facet plane

Pt mut follow movement with upper arm

self-SNAG for extension

SNAGS - self-techniques:

edge of towel around target (lower) vertebra

Pt must raise arms to follow changing facet planes as they extend into pain free range

this is home exercise for Pts with ext block