Management of Low Back Pain

Abstract

To the Editor: I was interested to read the recent article by Maluf et al titled “Use of a Classification System to Guide Nonsurgical Management of a Patient With Chronic Low Back Pain” (November 2000). The authors correctly stated that there are “potential benefits to using a classification approach to guide identification and treatment of symptom-provoking movements and postures.” However, given the widespread recognition of a very similar, but more comprehensive, classification system proposed by McKenzie 20 years ago,1 I would question how Maluf and colleagues' proposal contributes further to our current understanding. McKenzie's Mechanical Diagnosis and Therapy (MDT) model1 first demonstrated the value of utilizing symptom-provoking-and-relieving movement and posture testing in assessing and classifying painful spinal disorders. Additionally, the major elements of both the MDT assessment and classification system have already been shown to yield measurements with interexaminer reliability.2–7 Both philosophies recognize that daily repetition of direction-specific postures and movements contributes to the development and recurrence of mechanical low back pain. Maluf et al recommended limiting motion in those directions identified as aggravating, but they did not discuss the possibility that exploring repeated motion in the opposite direction or another direction may also be beneficial in decreasing or eliminating pain. There is abundant literature reporting that patients not only have a directional “vulnerability” (to flexion most commonly), they also have a directional “preference” that can be identified with the MDT examination, namely the use of repeated end-range loading of the symptomatic spine while monitoring the symptom response.8–15 The patients' pain typically centralizes and abolishes when they perform therapeutic movements and postures that honor and match their directional preference found during their assessment. While Maluf et al reported that their patient's pain “localized” to the spine during treatment, they avoided the term …