The Lumbar Spine: Mechanical Diagnosis and Therapy, ed 2 (Vols 1 and 2).

The Lumbar Spine: Mechanical Diagnosis and Therapy, ed 2 (Vols 1 and 2) McKenzie R, May S. Waikanae, New Zealand, Spinal Publications New Zealand (dist. OPTP), 2003, paperback, 767 pp, illus, ISBN: 0-9583647-5-3, $129.95.

At long last, Robin McKenzie has put together the second edition of his lumbar spine text. The second edition has been significantly expanded and is now presented in a 2-volume set. The updates and revisions have moved the text from a description of a specific treatment approach to a comprehensive review of the current literature related to the intervertebral disk, spinal pathology, and rehabilitation. This new edition also includes a revised description of the mechanical diagnosis and treatment concepts and diagnostic classification system.

Volume 1 consists of 13 chapters that address spinal anatomy, pathology, and mechanics. The text opens with an overview of the multitude of problems that low back pain poses to society and medicine as well as the common risk factors and prognostic factors associated with low back pain. Several chapters address connective tissue and pain, clinical anatomy, function and pathology of the intervertebral disk, and spinal mechanics.

Chapter 7, "Diagnosis and Classification," is a comprehensive review of the various diagnostic methods that are commonly used in the treatment of spinal pain (including pathoanatomically based diagnosis) and several classification systems. The hallmark of the McKenzie system, the derangement syndrome, is presented through a conceptual model of the intervertebral disk as the basis for this diagnostic category. The text gives an operational definition of the centralization phenomenon and the clinical impact of symptom response to movement and postures and how an understanding of the centralization phenomenon can ultimately guide the treatment of spinal pain. An extensive review of the peer-reviewed literature related to the centralization phenomenon and mechanical diagnosis and therapy is also offered. The authors group their reviews of the literature utilizing Sackett's levels of evidence hierarchy with systematic reviews and guidelines as the highest level, followed by randomized controlled trials and then other efficacy trials. Volume 1 concludes with chapters titled "Serious Spinal Pathology" and "Other Diagnostic and Management Considerations," which cover topics such as related spinal pathologies, hip pathologies, postsurgical status, and chronic pain.

Volume 2 closely resembles the original edition of this text, with its chapters addressing history and physical examination, mechanical diagnosis, and intervention procedures. An important revision in this edition is the change in the derangement syndrome subclassification. Previously, a derangement was assigned a numerical subclassification; now, a derangement is subclassified according in the location of signs and symptoms. This change may improve the ability of the clinician to accurately assign derangement diagnoses with higher accuracy than he or she would by using the original system. The lion's share of this volume is dedicated to the clinical management of low back pain and, in my opinion, makes this an important addition to any clinical library.

The mechanical therapy procedures are presented in a very clear and concise manner with images that enhance the reader's ability to appropriately perform the techniques. Each procedure is presented with a description of the technique, how it is performed, the appropriate clinical indications for use, and the expected patient response. The content addressing the clinical management of patients with each of the specific diagnoses also has been substantially enhanced. These chapters now include clear guidelines for clinical management and treatment progression as well as algorithms that guide clinical decision making. The photographic images, tables, and charts should enhance the clinician's ability to solve many of the clinical challenges that arise with the treatment of the various mechanical diagnoses. The usefulness of these features make this text an invaluable tool not only for the clinician beginning professional practice but also the seasoned McKenzie therapist.

Chapter 18--"Patient Management"--addresses clinical concerns related to patient management such as patient education, patient participation, communication, and patient satisfaction--topics that can be applied to all areas of practice. Although only a general overview of many of the interpersonal skills required of the successful clinician, this chapter serves as an excellent resource for improving outcomes by enhancing the clinician's patient management skills.

The text conspicuously lacks content addressing facet-related or muscle-related spinal pathology and the diagnosis and rehabilitation of these pathologies. Although this is not disheartening to the therapist who subscribes to a McKenzie-based approach, it may serve to further the perception that a mechanical approach to spinal examination and rehabilitation is appropriate only for the patient with the herniated disk.

This 2-volume set provides a large amount of information substantiated by current research, with well over 1,000 references mainly from peer-reviewed publications. The text is successful in presenting the evidence that supports the concepts embodied in the mechanical approach. The text is comprehensive in its presentation of the material; if the reader can accept the idea that classification of spinal pain leads to better outcomes based on the preponderance of the evidence, this text becomes the gold standard in the classification and management of low back pain. At a minimum, the text provides an authoritative resource for the operational definitions of central concepts, description of treatment techniques, and general guidelines for the diagnosis and treatment of low back pain using a mechanical approach. Future research into the McKenzie system can now become better standardized as a result of this publication.

Michael Buck, PT, ATC, Cert MDT, CSCS 

Ithaca College 

Ithaca, NY

Mr Buck is Clinical Assistant Professor in the Department of Physical Therapy, where he specializes in orthopedics with an emphasis on the mechanical approach. He also teaches "Mechanical Diagnosis and Therapy of the Spine."