Spotlight on Robin McKenzie
Interview by UK members

Thank you to those of you who sent in questions, notably:

• Gillian Paterson-Brown
• Rachel Jackson
• Sandra McFaul

The winner of the competition and now the proud owner of the new Extremity textbook is Sandra McFaul. Sandra will hopefully be finding the book of great benefit as she is currently in Austin, Texas doing her Diploma course. Her winning entry follows:

There is a man called Robin McKenzie,
Who in the last century came across a discovery,
"Lying prone in extension is good for my back",
Out walked the patient with a smile on his face,
It was the best he'd been in over three weeks.

How did this happen?
He was not quite sure.
But Robin did not shun or shy away from this challenge,
Instead he came up with repeated movement testing,
With pain moving to the centre being a very good sign,
BUT, what happens in the extremity?
I am not quite sure,
I NEED ROBIN'S NEW BOOK TO FIND OUT MORE!

1. What was the most difficult aspect of developing the McKenzie method?

This question has been asked by many. Let me make it perfectly clear: I did not set out to develop "a McKenzie method". It evolved quite spontaneously

over time as a result of the observation and recording of patients' response to various loading strategies. In part, I suppose I subconsciously substituted over time the methods taught to me at the Physiotherapy School, with the more relevant and immediately effective mechanical procedures that evolved from my trial and error.

I was a comparatively recent graduate, having qualified in 1952, when I established a private practice in December 1953. In retrospect, physiotherapy was primitive at that time. We were trained in massage, movement and exercise, and were required to know the intricacies of delivery of an extraordinary array of electrotherapeutic junk.

So on commencing practice, it was not surprising that I acquired this "junk" in order to deliver to the patients the recommended therapy of the day. As was so often the case, if you gave the modality for a sufficiently long period of time, the patient was bound to recover. And so it was in my early experience.

The McKenzie system, as it is now known, grew out of chance observation and perhaps a certain disbelief in the credibility of some of the treatments we were obliged to provide on the blind prescription of either the GP or, even worse, the Orthopaedic Surgeon. It was not until the 1980s that I realised that neither of these colleagues are taught anything about the symptomatic response to mechanical loading in patients with low back pain.

The one thing that was difficult to prove was that, when applied to the appropriate patient, the methods were rapidly effective and lasting. Although now widely accepted by most medical and related clinical disciplines, proof of efficacy is still elusive when that proof is sought by non-clinical investigators.

2. Where do you see this method heading in the next 50 years?

It is only a matter of time before intelligently constructed studies demonstrate efficacy of the method. The day will come, but I shall not be here to see it, when mechanical evaluation of the symptomatic response to loading is a routine procedure that will be widely available, clinically and through all the various electronic sources that exist today.

The progressions of force will have been fine-tuned in the future as more attention is given to the finer points of assessment and selection. I believe that the "guess" will be taken out of the technique of manipulation as it is now widely practised. Mechanical therapists will select their patients prospectively with a great deal of certainty regarding the likely appropriateness of the procedure. The use of patient-generated force prior to the use of therapist-generated force will become the norm.

3. A recurrent episodic history is a common feature of the low back pain syndrome. Should we be advocating long term exercise when function has been restored and when should we educate people in prophylactic care?

Certainly the high incidence of recurrence of low back pain in individuals is common. Many successful practices have been built on the philosophy of early intervention. "At the first sign of recurrence, come and see me." or "The sooner we get on to it, the better." "If only you had come to me sooner."

I have always advocated that we must provide the Three R's:

• Re-educate posture
• Remodel dysfunction
• Reduce derangement.

Then the patient can be instructed to get on with all the things they ever did before. If they have not been exercising, they should start. If they have been exercising, the harmful exercises should be eliminated and replaced with those more appropriate. This programme should be instituted once the patient is pain-free and function-full.

Prophylaxis commences from the minute the patient describes the commencement of centralisation or the reduction of pain. "This exercise is first-aid for your back problem. At the first sign of trouble, this is what you should do. Don't come knocking on my door until you have first gone through the steps that will lead to recovery. In the event that you receive no benefit from your own self-treatment, then and only then should you contact us."

The recent study by Brian Uderman assessing the usefulness of TREAT YOUR OWN BACK in patients with recurrent problems, demonstrated that 90-percent of over sixty patients with history of ten years recurring pain, either became symptom-free or significantly improved and attributed the improvement to the education provided by the booklet. That study was presented at the McKenzie Institute International Conference in Orlando, Florida, last year.

The key word in your question is "educating" the patient. In fact, the whole approach in this system of mechanical diagnosis and therapy is an approach based on education - education in causes, education in exercise and posture and, of course, finally, avoidance and prevention.

4. In patients who have returned with a recurrence of their symptoms, should we be questioning them more closely, eg:

• If and when they stopped exercising
• Why they stopped
• What they did at home when the symptoms returned

Whilst it is necessary to ask these questions, it is almost universal that a lack of compliance to exercise can be attributed to forgetfulness. When patients have been pain-free for several months, they tend to drop their guard. It is a natural consequence of feeling normal and too late, they recognise their mistake. In these cases, and there are many, it is important to draw to their attention the need to perform the exercises at the first sign of the onset of discomfort or pain. Although many patients have recurrences despite our education, many of those can abort the derangement process with early intervention, and thus reduce the severity and the time for recovery. This was demonstrated on more than one occasion when patients attending the rehabilitation programme at The Lodge near Wellington, suffered recurrence during their "play-hardening" but nevertheless quickly resolved the problems almost on the spot. Patients stop exercising either because they are symptom free and function full or because the exercise is of no benefit.

5. If you had your life over again, do you feel you would still choose physiotherapy as a career and would you do anything differently?

I have had tremendous satisfaction from treating patients using the methods that I was fortunate enough to have identified. It has also been a wonderful and rewarding experience to have been able to introduce my concepts and methods to physiotherapists, doctors and chiropractors in 27 countries worldwide. The demand for education in the "McKenzie Method" much of the time exceeds our ability to supply. This has always been the case and during the mid 1980s the demand was such that it was necessary for me to recruit assistance from those therapists whom I had personally educated in New Zealand and the United States. These were the core faculty of what was soon to become The McKenzie Institute International. They also experienced the rewards of teaching a new and exciting approach for the treatment of back problems. It must be realised that these methods were completely new in every country I visited.

Since that time, almost on a daily basis, I receive messages from physiotherapists and chiropractors worldwide telling me of the changes that this method has brought to their job satisfaction, and the way they practise, and how it has renewed their enthusiasm for their profession.

So, all in all, I have had a very rewarding career and as time passes and the research continues to substantiate much of the theoretical concepts and methods, things can only get better for me, personally, and I hope for the rest of the profession.

You ask would I do anything differently. Knowing what I now know, the answer is "yes". I would be more devious at a political level and would "go with the flow". By being outspoken on many issues, certainly within New Zealand, I have not always been viewed as a favourite son. My criticism of the continued use of electrotherapeutic devices is totally justified in the light of current knowledge.

Almost 20 years ago in New Zealand, I warned that the time would come when society would cease to tolerate the dispensation of, let alone pay for, the delivery of unproven therapies by physiotherapists. That time has come and we now have forced upon us guidelines for management of patients with musculoskeletal disorders in an endeavour to control expenditure. I believe the profession, had it taken a more enlightened political position, could have averted the restrictions now in place. As it is, there is much dissatisfaction within the profession in New Zealand and disillusionment with the prospects for physiotherapy in the future.

6. Do you think that manual therapy will become redundant?

The obsession of the manipulative professions to apply mobilisation or manipulation to determine retrospectively if the procedure was indicated, is an outdated concept and should stop. As I have said before, if it is at all possible to teach a patient to use his or her own resources to resolve a particular problem, every patient should receive that education and every therapist should be obliged to provide it. Why dispense manual therapy if the patient without aid is capable of achieving complete resolution of a particular problem?

Further, mobilisation and manipulation should not be dispensed to all patients with back pain in order to deliver it to the very few who require it. Those in the manual therapy field who do not attempt to ascertain the effects of self-applied procedures, will never know what can be achieved using patient-generated forces.

Certain manual procedures will always be necessary when the earlier progressions of force are inadequate. Manual therapy techniques, therefore, will never become redundant but the indications for the use of manual techniques, with the passage of time and better understanding, will be dispensed with greater precision and effectiveness. I believe mechanical therapists will eventually replace manipulative and manual therapists.

7. Have you done any collaborative work with Brian Mulligan or have you any plans to do so?

In the mid 1950s Brian Mulligan and myself played a leading role in the embryonic stages of the formation of the New Zealand Manipulative Therapists Association. I was the first Director of Education of the Association and was responsible for the introduction of Kaltenborn to the New Zealand Manipulative Therapists Association education programme. During that period of time, Cyriax, Stoddard, Paris, Maitland, were also invited to New Zealand in various roles. In the early days Brian and I had many discussions about manipulative therapy.

However, following the events of "Mr Smith", my thought processes diverted from the intricacies of manual manipulative techniques. By the late 1950s I had found "Mr Smith". If a large percentage of the patient population could respond rapidly to repeated end-range loading or prolonged positional loading, how could one justify applying mobilisation and manipulation?

As a result of this change in my evolving philosophy, I found myself in a position where my conscience would not allow me to continue to take a leading role in the teaching of manipulative therapy. I resigned from the position of Director of Education of the NZ Manipulative Therapists Association. Brian Mulligan, whose skills in mobilisation and manipulative procedures had already been well established, was appointed as my successor.

In 1986 I invited Brian to join the Institute faculty to assist us with the ever-increasing demand for courses. Although I am not certain of the timing, he was probably already developing the courses for which he is now well known and nothing further was heard of the invitation. I think it unlikely that our two different philosophies on patient management would ever change.

8. The McKenzie approach has been widely researched by various people with mixed conclusions as to its effectiveness. What advice would you like to give to people thinking of undertaking future research into the method?

You are quite correct in that clinical trials, as they have been designed to date, have failed to show a superiority of the McKenzie approach. However, the Cherkin study clearly demonstrated that patients receiving a modified McKenzie protocol did equally as well as those receiving manipulation.

Although the McKenzie protocol for assessment excludes patients in whom no movement or position can be found to abolish, reduce or centralise the symptoms, no studies undertaken to date (including the Cherkin study) have honoured let alone recognised this requirement by excluding such patients. The infamous "intention to treat" clause is a great escape for inadequate protocols. Who in their right mind would include in a study on back pain treatment efficacy, patients who are unsuitable for one of the treatments under investigation? Certainly, in the McKenzie view, such patients should be referred on for further investigation.

A few of the pointers to improving the outcomes are outlined below but there are probably many more.

EXCLUSIONS:

1. Patients who are on Workers' Compensation.
2. Patients with a first time attack of back pain.
3. Patients who are already improving.
4. Patients whose symptoms are of two weeks' duration or less.
*5. Patients in whom no position or movement can be found that abolishes, reduces, or centralises symptoms. Three to four days of assessment should identify such subjects.

INCLUSIONS:

1. Patients who are self-employed.
2. Patients with recurring history.
3. Patients who are not improving with other treatments.
4. Patients with symptoms of more than two weeks' duration.
*5. Patients who on assessment abolish, reduce or centralise symptoms.

*The above criteria requires patient randomisation to be made after the full mechanical evaluation. This would exclude from any study, patients who are unsuited for mechanical therapy. Unfortunately the "intention to treat" clause requires randomisation to occur before any mechanical or other assessment. The argument used in support of this requirement is that the clinician would select only those patients likely to respond to the treatment under investigation. This is of course as it should be. We should not be treating those patients we cannot help. The absence of logic in science is sometimes perplexing to we clinicians!

The patients in Brian Uderman's study had symptoms averaging ten years in duration. They averaged four episodes per year. It would appear from the exceptional results that the high incidence of recurrence is a factor in leading to a satisfactory level of patient compliance. After learning from TREAT YOUR OWN BACK the simple measures of self-care described within, patients obtained the realisation that at last they were able to influence the course of their disorder. These patients had experienced an average of four episodes a year and had experienced spontaneous recovery each time. It seems the more often the problem occurs, the easier it is to reduce by deliberate means.

It is probable that patients with a first time attack are not aware that future attacks are likely. They probably consider it unlikely that they will have more trouble. Consequently they do not take education very seriously at the beginning of their history.

9. There are many approaches to treating patients with musculoskeletal problems (Mulligan, Maitland, muscle balance, neural tension/mobilisation, Pilates, craniosacral etc). Where do you see the McKenzie approach in relation to all of these others? What makes it special?

The other approaches you describe are all based on different causes for musculoskeletal problems. Each has its own theoretical model. Some of them don't make sense. Some of them are perfectly logical and are provided for in the McKenzie approach. Just one example: if we recover full pain-free function, there will be no neural tension. If there is an obstruction to movement (derangement), the McKenzie approach for the reduction of derangement is appropriate. If there is a restriction of motion, the remodelling approach for dysfunction is also appropriate.

I have never had a real problem with "keeping it simple", providing it is effective. I think that is why it is the first treatment of choice in so many States of the United States and by so many therapists in the United Kingdom.

10. Who were the people who influenced you most in your early career and why?

In the 1950s and 1960s there were international figures in the field of manipulative therapy who were regarded as the leaders in this field. Like others of my generation, I regarded those figures as providing the gold standard for the practice of manipulative therapy: James Cyriax, Alan Stoddard, Robert Maigne, James Mennell, Freddy Kaltenborn, Karel Lewitt and Geoff Maitland, were all considered to be the top of the field in that period.

By 1968 I had already, from the isolation of New Zealand, developed the methods for which I am known, although much refinement took place in subsequent years. After re-mortgaging our home, I set forth to spend weeks with each of the above believing that to do so would enhance even more the methods that I had serendipitously developed.

In retrospect, after returning to New Zealand I realised that expert as all these specialists were in manipulative therapy, it was clear that no one else had witnessed the phenomena of centralisation of pain which has become the cornerstone in the identification of patients who will rapidly respond to mechanical therapy. Neither had anyone hitherto identified the importance that can be attached to the failure to obtain centralisation or identify the different syndromes that occur commonly in non-specific low back pain.

The realisation was somewhat daunting for it was hard for me to believe that I was the first person in the world to recognise the importance of these phenomena. Now, most of the current generation of writers who address the subject of mechanical therapy and exercise have accepted the importance of centralising a patient's referred and radiating symptoms, and the methods required to achieve that result.

11. Apart from the discogenic displacement model, do you have any other explanations as to what could cause what we know as the centralisation phenomenon?

I believe it was Kellgren who first reported in the literature that as applied mechanical deformation increases, the extent and intensity of radiation of pain likewise increases. He found this to be the case in extremities where pain usually spread distally with increasing deformation. The same causes of pain may arise from mechanical deformation of spinal structures. It is likely that pain radiating laterally from the centre of the spine is caused by such deformation. Theoretically, pain arising in this manner could be seen to centralise with a reduction of the deformation. It follows that the production of such pain would be time related at end-range and would centralise over time on the release of tension. The process of peripheralisation and centralisation of back pain under these circumstances is almost certainly caused by prolonged end-range loading and its reversal. However, mechanical deformation of localised structures is unlikely to be the cause of pain referred to the limb.

12. How did you feel when confronted with antagonistic Orthopaedic consultants challenging your concepts?

Devastated! On many occasions I left the United States almost suicidal and certainly on several occasions, badly bruised. Usually I was determined never to return. However, on landing in New Zealand, I had usually recovered sufficiently determined to return and "teach those bastards a lesson."!

After what I considered to be an excellent presentation to 2,000 orthopaedic surgeons at the American Orthopaedic Association Annual Meeting in 1983, I was confronted with a very aggressive surgeon at question time. He said "Mr McKenzie, we orthopaedic surgeons have been in there (the disc). The disc does not move, so why do you keep on saying that it does? You are misleading the therapists whenever you say that, and you must stop." Needless to say, I was lost for words and didn't grasp the opportunity to provide the obvious retort that, "If the disc doesn't move, why do you all use the phrase, 'herniated nucleus pulposus?'

The sequel to this story occurred in Adelaide in the year 2000. I was walking down a long corridor at the hotel hosting the International Society for the Lumbar Spine Conference of that year. In the distance coming towards me I saw the same figure that confronted me in 1983. He extended his hand as we approached, and said, "Robin McKenzie, I owe you a great apology. You were right and I was wrong." We had a long talk about the event and we parted very good friends, looking forward to the next meeting.

I am sure that all of you reading this will have had similar challenges from members of the orthopaedic profession. Get used to it, it will stop in time. The challenges that were made to me were common and frequent in the 1980s. I have outlived some of the critics and silenced others. However, it is a long time now since I have received any criticism from the various disciplines of medicine. On the contrary, I now receive only encouragement and congratulations.

13. Should we be teaching some of the principles of Mechanical Therapy in physiotherapy schools?

The basic principles of mechanical therapy should be part of the curriculum of all physiotherapy schools. In the United States there are already several physiotherapy schools where a rounded education is provided in mechanical diagnosis and therapy. I believe three or four of the most influential chiropractic colleges in the United States are already teaching mechanical diagnosis and therapy. There is no reason why the same should not be happening at physiotherapy schools worldwide. However, there is resistance from some quarters to the introduction of even the Part A course. I would have thought that in the final year of education, a four-day Part A course would not be beyond the scope of the students. Perhaps the whole system is viewed by some as being too simple. Certainly Part A does not require the "magic fingers" containing pain and restriction divining qualities that require years of practice to perfect. Perhaps this lack of manual content diminishes the attractiveness of the whole approach. I believe that manual dexterity is a less valuable tool in the management of musculoskeletal pain in comparison to a structured intellectual analysis based on the patient's response to repetitive static end-range loading.

The inclusion of mechanical diagnosis and therapy in undergraduate curriculum would provide the perfect environment for honing clinical reasoning. (previously known as logic!)

14. Do you have a favourite condition to treat?

I can't say that I do. What I enjoy most about this process is the ability to predict from the history that a certain condition will be exposed and then to have that prediction confirmed at the conclusion of the mechanical evaluation. If a prediction that a favourable outcome then follows, that is icing on the cake.

15. What do you see as the greatest hurdle to further development of Mechanical Therapy world-wide?

Ignorance of it.

16. How should we "spread the word" more effectively.

In 1976, try as I might, I realised that no one outside of New Zealand had any knowledge of, or experience of either the theoretical concepts or the practice of what has become known as the McKenzie Approach. I realised also that it was probably never going to be known in my lifetime. When the first invitations came from the United States, I was overjoyed. At last, I thought, someone wants to listen. From that time, I have seen the adoption of the McKenzie approach throughout the world. I have already described the satisfaction that this has given me. Although to get to this point has taken 25 years, it is but a fraction of the time it has taken for some more important developments in medicine to see the light of day. I believe I am lucky indeed to have seen the widespread adoption in my lifetime.

Each and every one of you involved in the teaching of our education programme is making as great, if not greater, contribution to the "spread of the word" than was possible when I commenced down this pathway. You should be very proud and content with the progress that you are all making. Without the support of the faculty and the generality of physiotherapists worldwide, I would not have received the recognition that has come my way and I thank you all for the support over the years. Certainly, we have seen some of our colleagues fall by the wayside, do their own thing, or lured by the opportunities that are presented elsewhere as a result of rising through our ranks. But they, in turn, continue to use and promote mechanical diagnosis and therapy, albeit with slight variations.

Thank you for this opportunity. It has been a pleasure to answer your intriguing questions.
Robin McKenzie