0196-6011/84/0602-0130$02.

00/0
THEJOURNAL OF ORTHOPAEOIC AND SPORTS PHYSICAL THERAPY
Copyright 0 1984 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

A Preliminary Report on the Use of the

McKenzie Protocol versus Williams
Protocol in the Treatment of Low Back
Pain
DAVID JOSEPH PONTE, MA,* PT,* GAIL J. JENSEN, MA,t PT,t BARBARA E. KENT, MASPT*

The purpose of this study was to determine whether the Williams or McKenzie
protocol of treatment was more effective in both decreasing pain and hastening the
return of pain-free range of lumbar spine movement. Twenty-two subjects underwent
an initial evaluation which involved six measurements: subjective pain, comfortable
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sitting time, forward flexion, right and left lateral flexion, and straight leg raise.
Subjects required to perform Williams' protocol were assigned accordingly, while
those referred as "evaluate and treat" were placed in the McKenzie group. Following
the completion of treatment, a second evaluation was performed taking the same six
measurements. A comparison of the improvement scores of the two groups indicated
that those receiving the McKenzie protocol improved to a significantly (P < 0.001)
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

greater extent than did the subjects in the Williams group, and that these changes
came about in a significantly (P < 0.01) shorter period of time.

Approximately 80% of us will at some time in treatment for low back pain are so contradictory
our lives experience low back pain,22as reported in both theory and practice, as those described
by many epidemiological s t ~ d i e s . ' ~Kelsey13 ~ ~ ~ ~ ~ "by Paul C. Williams and Robin McKenzie.
Journal of Orthopaedic & Sports Physical Therapy®

stated that impairments of the low back were the W i l l i a m ~suggests

most frequent cause of activity limitation in per-
sons living in the United States under age 45, and
the third most frequent cause in the 45-65-year-
old age group. In addition, for every 100 subjects
(aged 25-44) an average of 28.6 work days are
lost per year due to low back pain. The techniques
employed to treat low back pain are many and
varied; however, they each share one factor in
common, a general lack of research evidence to
substantiate their use.12~'4~19s21~25~27 The purpose causing pressure on the spinal nerves. In addition
of this study was to measure whether the Wil-
liams' protocol was more effective in both de-
creasing pain as well as hastening the return of
pain-free lumbar spine range of movement in a
select group of individuals.
Perh'aps no two methods of physical therapy
'Division of Physical Therapy, Stanford University, school of Medicine, problem: "The fifth lumbar disc has ruptured in
Stanford, CA 94305. Mr. Ponte was a graduate student in the Division
of Physical Therapy, Stanford University, at the time the study was
conducted.
t Lecturer in Me Division of Physical Therapy at Stanford University.
*Adjunct Professor in the Division of Physical Therapy at Stanford
University.
130
~ ~ ~ ~ that
~ man, in forcing his
body to stand erect, severely deforms his verte-
bral column, redistributing body weight to the
posterior aspect of the intervertebral discs in the
lumbar spine. At the fourth and fifth lumbar levels,
great pressure is exerted on the posterior aspect
of each vertebra and transferred from the vertebra
to the disc. Williams specifies that in most cases
the fifth lumbar disc ruptures and the nuclear
material of the disc moves into the spinal canal
to the ruptured disc, irritation of the nerve at the
intervertebralforamen where the nerve exits from
the spinal canal may result. He states that this
rarely occurs except at the fifth lumbar level, and
the likelihood of the nerves being impinged is
greatly increased by extending the lumbar spine.
~ i l l i a m semphasizes
~~ the universality of this
the majority of all persons by the age of
twenty. . . ." He goes on to explain that although
most at this age have not experienced
severe low back pain, they will, in all likelihood,
 JOSPT SeptlOct 1984 COMPARISON OF TREATMENTS FOR LOW BACK PAIN
be subject to mild bouts of low back pain which
can be attributed to the ruptured disc. The solu-
tion, Williams explains, is to have the patient
perform exercises and adhere to postural princi-
ples which serve to decrease the lumbar lordosis
to a minimum, thereby reducing the pressure on
the posterior elements of the lumbar spine.28s29
Other investigators support Williams' theory
and have described asymmetric disc degeneration
with the posterior portion being destroyed
Fahrni7reports that although it cannot
15, l6
be said that all low back pain is caused by the
intervertebral disc, it can be claimed that ". . . pain
is produced largely by postural lordotic forces and
even in those who do not have pain yet, there is
an underlying deterioration process progressing
in the lumbar spine. There is ample confirmation
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for this in observations of tribal populations,where
the flexed posture is adhered to, and back pain
and disc degeneration are minimal both clinically
and radiologically." As treatment for low back
pain, Fahrni recommends the use of "Williams
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
lumbar flexion exercises" and instruction on pos-
ture and body mechanics which decrease the
lumbar lordo~is.~
McKenzie17suggests that all spinal pain can be
attributed to alteration of the position of the disc's
nucleus pulposus, in relationship to the surround-
ing annulus; mechanical deformation of the soft
tissue about the spine which has undergone adap-
tive shortening; or mechanical deformation of soft
Journal of Orthopaedic & Sports Physical Therapy®
tissue caused by postural stress. According to
McKenzie, these anomalies of the lumbar spine
are largely due to our lifestyle and "an almost
universal loss of exten~ion."'~As ,treatment,
McKenzie recommends exercises and postural
instructions which restore or maintain the lumbar
~ordosis.'~,'~ It should be noted that although
exercises involving lumbar spine extension are
emphasized in this protocol of treatment, partic-
ularly in the early stages, lumbar flexion exercises
are usually added at a later time in order that the
patient has full range of spinal flexion and exten-
sion.
Studies investigating the movement or shifting
of the nucleus pulposus of the disc in response
to vertebral movement were first described by
Arm~trong.~ Later Shah et a1.24demonstrated the
anterior to posterior movement of the nucleus
during lumbar flexion (decreasing the lumbar lor-
dosis) and the opposite movement of the nucleus
during extension (increasing the lumbar lordosis).
The posterior movement of the nucleus during
flexion could result in increased pressure on the
131
numerous pain-sensitive structures of the poste-
rior lumbar spine, while lumbar extension could
result in movement of the nucleus away from
these structures. McKenzie17 concluded that a
continually flexed lifestyle may cause the nucleus
to migrate more posteriorly, resulting in low back
pain.
Cyriax5 describes the protective role that lum-
bar lordosis plays by creating a slight pressure
which maintains the disc anteriorly and by acting
as a shock absorber to vertical stress. Cyriax5
goes on to suggest that "In patients with a flat
lumbar spinal column (decreased lordosis), the
intervertebral disc has no such protection, and it
is noticeable that patients with a lumbar spine
devoid of anterior convexity are more apt to suffer
from backache than those with a normal degree
of lordosis." In a study measuring intradiscal pres-
sures in the third lumbar disc during common
movements, NachemsonZ0concluded that when
sitting, "less disc pressure was found the more
the lumbar spine was moved toward the subjects
own natural lordosis." Another investigator, An-
d e r ~ s o n ,has
~ . ~indicated his support for the thesis
that sitting with a flattened lordosis results in an
increased load on the lumbar spine and disc.
The Williams and McKenzietreatment protocols
differ markedly; however, both continue to be
widely prescribed despite the paucity of clinical
evidence measuring their efficacy. In a study done
by Zylbergold and Piper,30a clinical trial was con-
ducted to evaluate the efficacy of three common
physical therapy approaches in the treatment of
lumbar disc disease: lumbar flexion exercises,
manual therapy, and home care. A regression
analysis of improvement scores for subjects re-
ceiving these treatment methods indicated that
there were no statistically significant differences
between each of the three groups.
METHODOLOGY
Subjects
To be included in the study, subjects must have
satisfied the following criteria: a) aged 21-55
years; b) observable limitation of active movement
(forward flexion, lateral flexion or extension) of the
lumbar spine; c ) low back pain of duration no
longer than 3 weeks before the initial evaluation;
d ) no history of serious low back pain within 6
months prior to the present attack. Those patients
with deviation of the lumbar spine from the verti-
cal, paresthesias, decreased reflexes, and mus-
cular weakness without wasting were included.
 132 PONTE ET AL
The subjects were evaluated by the physician
and excluded according to the following criteria:
a) pregnancy; b) previous spinal surgery; c ) radi-
ological evidence of spondylolysis, spondylolis-
thesis, hemivertebra or other vertebral deformities
including those associated with systemic disease;
d ) bowel or bladder dysfunction; e) chronic low
back pain with long-standing pain or anesthesia
below the knee.
The subjects who took part in this study were
examined by a physician and referred to physical
therapy as outpatients for treatment of low back
pain. Those subjects requiredto perform Williams'
protocol were assigned accordingly, while those
referred as "evaluate and treat" were placed in
the McKenzie group. Upon arrival to the physical
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therapy department, the subject was assigned by
the receptionist to one of the two groups based
upon the physician's referral.
Twenty-two subjects entered the study, 12 re-
ceived the McKenzie protocol of treatment, and
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
10 received that of Williams. The two groups were
similar in mean age (McKenzie group, 41.3 8.2+
+
years; Williams group, 43.4 8.8 years) and sex
distribution (M:F, 7:5 and 6:4, respectively). Ad-
ditional demographic data including history and
physical was not obtained.
Measurements
Prior to initiating treatment, the subjects were
Journal of Orthopaedic & Sports Physical Therapy®
evaluated on six measurements by the investiga-
tor who was unaware as to which treatment pro-
tocol the patient was to receive. Following the
evaluation, the subject was treated first with moist
heat for 20 min followed by ultrasound at 1.0 w/
cm2for 5 min to the low back, and then either the
Williams or McKenzie protocol. After a maximum
of 11 treatments, the subject was re-evaluated by
the investigator who, still not knowing which treat-
ment protocol the subject had received, took the
same six measurements. During the initial and
final evaluations, the following measurements
were taken:
A. Subjective Measurements
I ) Pain measurement, presented in the form
of a graphic rating scale23 illustrated in
Figure 1, on which the subject was asked:
"Based on the pain you are feeling at this
moment, where would you estimate that
pain to be on this line? Please place an X
at that point." The scale (10 cm) was later
divided into ten equal sections and the
JOSPT Vol. 6,No. 2
patient's mark given a numerical value, 0
indicating no pain and 10 indicating pain
maximum.
2) The subject's estimate as to how long he/
she could sit comfortably at one time over
the course of one day.
B. Objective Measurements
1) Forward flexion was measured as the dis-
tance from the tip of the index finger to the
floor at maximal comfortable forward flex-
ion (Fig. 2). Lateral flexion was measured
as the distance from the tip of the index
finger to the floor at maximal comfortable
lateral flexion (Fig. 3). The subject was
instructed to move as far as possible into
lateral flexion and to stop at the first per-
ception of low back or leg pain. The dis-
tance was measured to the nearest half
centimeter for both right and left lateral
flexion, and each motion was performed
only once.
2) Passive straight leg raising was measured
using a mathematical model involving the
calculation of the sine of the right angle
developed by T a n i g a ~ a and
~ ~modified by
the investigator. With the patient supine on
a plinth, the greater trochanter and the
lateral malleolus of the. right lower limb
were palpated and marked with a felt tip
marker. Three measurements were taken:
first, the leg length taken by measuring the
distance from the greater trochanter to the
lateral malleolus; second, the distance from
the greater trochanter to the floor; and
third, the distance from the lateral malleo-
lus to the floor. The investigator instructed
the subject to relax the entire limb and then
allow him to passively elevate the limb. The
opposite limb was not stabilized. The sub-
ject was also instructed to verbally inform
the investigator the moment he perceived
any low back pain. The subject's limb was
passively elevated maintaining it in neutral
rotation. At the moment the subject ex-
pressed the perception of low back pain or
leg pain, the investigator noted the dis-
tance from the lateral malleolus to the floor.
If the subject's limb could be passively
raised to 90' without complaint of low back
or leg pain, this measurement was given
as the score. The formula to calculate the
angle of passive straight leg raising is
shown in Figure 4.
 JOSPTSeptlOct 1984 COMPARISON OF TREATMENTS FOR LOW BACK PAIN 133

MAXIMUM P A l N I I NO P A I N

SEVERE MODERATE MILD

Fig. 1. Graphic pain rating scale used in the study.

were given the exercises shown in Figure 5 as

well as the postural instructions recommended by
Williams.29Those subjects in the McKenzie group
received selected exercises from the treatment
protocol demonstrated in Figure 6, and were given
postural instruction as described by McKenzie."
In all cases the physical therapist utilized the
forms to record which exercises the subject was
performing and how often during each treatment
session. The postural instructions were reviewed
and a copy given to each subject at the end of
the initial treatment. In addition to performing ex-
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ercises during the treatment session, the subjects

were instructed to do these same exercises at
home. The number of exercises and how often
they were performed was left to the discretion of
the physical therapist, each of whom had been
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

trained in the respective groups to which the

subjects had been assigned.
Journal of Orthopaedic & Sports Physical Therapy®

Fig. 2. Measurement of forward flexion.

TREATMENT
The subjects began treatment immediately fol-
lowing the initial evaluation. Preferably, treatment
was to continue daily for 1 week, then three times
a week for 2 weeks, bringing the total number of
treatments to 11. However, if this was not possi-
ble, the subject was allowed to come for treat-
ment three times a week for the first week and
three times a week thereafter until the subject
had completed 11 treatments. The exact sched-
uling pattern which most subjects followed is
unknown. Treatment could be stopped before the
completion of 11 treatments if the subject's symp-
toms had been completely relieved. This end point
was determined by the physical therapist respon-
sible for the subject's treatment.
Those subjects following the Williams' protocol
Fig. 3. Measurement of lateral flexion.
 Mal l e o l u s

a -ba = S i n Bit.

Greater
Trochanter

a = perpendicular distance from the l a t e r a l malleolus t o the level

o f the greater trochanter

b = the length o f the leg

*The a n g l e 8 can be d e t e r m i n e d f r o m a t a b l e o f n a t u r a l t r i g o n o m e t r i c
functions.
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Fig. 4. Formula for the calculation of the angle of passive straight leg raising.
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

Fig. 5. Williams group treatment form.

134
 JOSPTSeptlOct 1984 COMPARISON OF TREATMENTS FOR LOW BACK PAIN 135

DATE :

L y l n g Prone

L y l n g Prone I n
Extenslon

Extenslon I n L y l n g

Extenslon I n L y l n g
wlth Bell Flxatlon

Sustained Extenslon

Sustalned E x t r n s l o n

Extenslon M o b l t l -
Zet Ion

Exlenslon Manlpu-
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1st Ion

Rotatlon H o b l l l -
z a t l o n I n Extenslon

R o t a t l o n Manlpu-
l a t l o n I n Extenslon
Sustalned R o t a t l o n l
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

MobIl l z a i l o n I n
Flexlon

R o t a t l o n banlpu-
latlon In Flexlon

F I ~ x l o nI n L y l n g

f l e x l o n I n Stand

F l e x i o n I n Step
Standlng
Journal of Orthopaedic & Sports Physical Therapy®

Correct I o n of
L e t e r l e l Shlf t

S e l f - C o r r r c t l o n of
L a t e r a l Shlf t

Fig. 6. McKenzie group treatment form.

RESULTS TABLE 1
Mean and SD of initial evaluation scores for Williams and
Initial Evaluation McKenzie arouDs
Measurement Williams (N = 10) McKenzie (N = 12)
Twenty-two subjects, 10 in the Williams group
and 12 in the McKenzie group, took part in the Pain (1-1 0) 6.75 + 1.62 5.59 + 2.40
Sitting (min) 41.59 + 33.59 10.25 + 8.52
study. Table 1 lists the mean and standard devia- Forward flexion (crn) 50.60 + 14.54 +
50.25 16.52
tion of the initial evaluation of each of six meas- Lateral flexion (crn)
urements for both groups. Left 52.45 + 8.68 52.88 t 5.29
Right 52.50 t 8.58 +
50.50 7.01
Posttreatment Evaluation Straight leg raise (deg) 23.65 + 16.05 +
39.27 14.67

The mean and standard deviation of the six

measurements for each group on the posttreat- treatment groups are illustrated in Figure 7. As
ment evaluation are presented in Table 2. The can be seen, both groups improved to some
percent improvement scores between the initial extent in all of the test measurements. The mean
and posttreatment evaluation scores for the two improvement scores of the Williams and Mc-
 136 PONTE ET AL JOSPT Vol. 6, No. 2

Kenzie groups are listed in Table 3. To determine SITTING TIME

whether there were significant differences be-
tween the two groups, Student t-tests were com-
puted (Table 4).
SUBJECTIVE PAIN
The results indicate that the McKenzie protocol
was significantly (P < 0.001) better than that of
Williams in decreasing pain (Table 4). Sixty-seven
percent of the subjects receiving the McKenzie
protocol left treatment pain free, whereas 10% in
the Williams group reported complete absence of
pain at the posttreatment evaluation.
When comparing the two groups, the McKenzie
group exhibited a significantly (P < 0.001) greater
increase in comfortable sitting time as compared
to the Williams group (Table 4). Of the McKenzie
group, 67% reported the ability to sit as long as
they liked. When asked if they could sit for 2 hr
pain free, all answered that they could, although
for 75% of the subjects this was possible only if
they sat with a lumbar support. As for the Williams
group, 30% of the subjects could sit for 2 hr
comfortably; the remaining reported minimal or no
improvement.

TABLE 2
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Mean and SD deviation of final evaluation scores for Williams FORWARD FLEXION
and McKenzie groups
Measurement Williams (N = 10) McKenzie (N = 12)
The McKenzie group showed a significantly (P
< 0.001) greater increase in the pain-free range
Pain (1-1 0) 3.55+ 1.98 0.65+ 1.60
Sitting (min) 56.59+ 46.25 100.83+ 36.70 of movement of forward flexion when compared
37.50+. 22.67 9.08 + 10.55 to the Williams group (Table 4). At the posttreat-
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Forward flexion (cm)

Lateral flexion (cm) ment evaluation, 42% of the subjects in the
Left 49.30+ 9.70 47.08+ 4.53 McKenzie group could touch the tips of their index
Right 49.50+ 9.85 46.04+ 5.35 fingers to the floor; in the Williams group, 10%
Straight leg raise (deg) 44.90 + 27.14 87.05 -+ 8.16
could do this.

0-
Journal of Orthopaedic & Sports Physical Therapy®

M c K e n z i e Group

Subjective Pain S i t t i n g Time Forward F l e x i o n Lateral Flexion Lateral Flexion S t r a i g h t Leg

Measurement Right Left Raise

Fig. 7.Percent improvement between pre- and posttreatment evaluation scores.

 JOSPTSept/Oct 1984 COMPARISON OF TREATMENTS FOR LOW BACK PAIN 137
TABLE 3
Mean and SD of improvement scores for both treatments protocols
Lateral flexion (cm) Straight leg
Subjects Pain (0-1 0) Sitting (min) Forward flexion (cm)
Left Right raise (deg)

Williams (N = 10) 2.85k1.73 15.00k28.96 13.20k11.50 2.30k4.07 3.00k4.84 20.80k16.66

McKenzie (N = 12) 4.90k2.79 90.60k36.48 48.10k19.37 5.83k5.06 4.50k3.38 47.70k16.02

TABLE 4 TABLE 5
Comparison of improvement scores of subject teated with the Comparison of mean and SD of number of treatments
McKenzie vs Williams protocols required by subjects in the two groups
Measurement t' P McKenzie IN = 10) Williams IN = 12)

Pain 4.4437t 0.001

Sitting 6.5270 0.001
Forward flexion 6.7342 0.001
Lateral flexion
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Left 0.8248 NS*

Right 1.8023 NS
Straight leg raise 3.8524 0.001
DISCUSSION
't-Test for a difference between two independent means.
t t-Test for related measures. The results of this preliminary study demonstra-
$ NS, not significant. ted that the McKenzie protocol of treatment for
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

low back pain was significantly better than that of

STRAIGHT LEG RAISE
The McKenzie group experienced a significantly
(P < 0.001) greater increase in the pain-free range
of movement of straight leg raise (Table 4). Eighty-
three percent of the subjects receiving the Mc-
Kenzie protocol could, at the posttreatment eval-
uation, have their right leg raised to 90' with no
Journal of Orthopaedic & Sports Physical Therapy®
Williams in decreasing pain, increasing the period
of comfortable sitting time, and increasing the
pain-free range of both forward flexion and pas-
sive straight leg raise (Table 4). Not only were
those improvements significantly greater in the
McKenzie group, but they also came about in
significantly fewer treatment sessions as com-
pared to the Williams group (Table 5).

complaint of low back or leg pain. This was true
for 20% of the subjects in the Williams group.
LATERAL FLEXION
There was no significant difference between
the two groups for lateral flexion to either the right
or to the left (Table 4).
It should be that 920/0 the subjects in
the McKenzie group had received lumbarspine
flexion exercises in addition to lumbar spine ex-
tension exercises as part their treatment pro-
grams.
Treatment Sessions
A comparison of the mean number of treatment
sessions the subjects in the two groups required
revealed that the Williams group needed a signif-
icantly (P < 0.01) greater number of treatments
than did those in the McKenzie group (Table 5).
McKenziel' emphasizes the maintenance of
both the lumbar lordosis and a full range of lumbar
spine extension to maintain the nucleus pulposus
anteriorly. Extension exercises designed to
achieve this were utilized early in the treatment
and home programs of all sibjects in the Mc-
McKenzie also recog-
Kenzie group.
nizes the importance of lumbar flexion, and as
soon as it was determined that performing se-
lected flexion exercises would not increase the
subject's symptoms, they were instituted as part
of his treatment and home programs in an attempt
to gain full, painless range of lumbar spine flexion,
and return to normal function.
The significant difference in comfortable sitting
time would appear to be associated with the
distinctly different theories on correct sitting pos-
ture of Williams28and McKenzie.17 Williams rec-
ommends sitting with flattened or flexed lumbar
spine, whereas McKenzie's suggestion of sitting
with a lumbar support preserves the lumbar lor-
dosis. The results support the thesis held by
 138 PONTE ET AL
NachemsonZ0and Andersson2s3who suggest that
one should maintain his natural lordosis in sitting
to avoid undue increases in disc pressure and
perhaps future low back pain.
McKenzie17 suggests that subjects who have
responded to the basic extension and flexion prin-
ciples of his treatment protocol have the means
to relieve pain and restore function themselves.
He goes on to explain that following successful
treatment, it should require little emphasis to con-
vince subjects that if they could, ". . .reduce and
abolish pain already present it should also be
possible to prevent the onset of any significant
future low back pain," thus making the subject
independent of the physical therapist and virtually
self-treating.
The results of the study reveal definite short-
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term benefits which would support the use of the
McKenzie protocol over that of Williams in the
treatment of low back pain. However, a long-term
follow-up study would be required to substantiate
any significant difference between the two groups
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in the rate of recurrence of low back pain.
The results of this study have additional clinical
implications for the physical therapist. The signif-
icantly longer period of time spent in treatment for
the subjects in the Williams group indicates that
perhaps patients receiving the McKenzie protocol
will spend less time in the physical therapy clinic,
will return to normal function earlier, and as a
result have decreased health care costs as com-
Journal of Orthopaedic & Sports Physical Therapy®
pared to patients receiving the Williams protocol.
Also, because the only difference between the
two groups' treatment plan was the type of ex-
ercise protocol, it would appear that the significant
differences between the groups cannot be attrib-
uted to the application of moist heat or ultrasound.
Additional data such as occupation, previous
history, neurological status, diagnostic category,
and a random assignment of subjects to treat-
ment groups would be helpful to future studies.
From such a small number of subjects it is difficult
to infer that the differences noted would persist
in a larger population which, on the basis of
sampling alone, would be more representative of
the low back pain population at large. However,
despite the small sample size, the results suggest
that significant differences do exist between these
two widely prescribed treatment protocols, and
that in a select group of individuals, the McKenzie
protocol is more effective in both decreasing low
back pain and hastening the return of pain-free
lumbar spine range of movement.
JOSPT Vol. 6,No. 2
CONCLUSION
This preliminary study compared the effective-
ness of the Williams and McKenzie protocols in
treating low back pain. The subjects were given
an initial evaluation which measured six parame-
ters. Following this they were assigned to one of
the two treatment groups. At the completion of
treatment, the subjects were re-evaluated and
their improvement scores compared. The results
of this comparison indicate that the McKenzie
protocol of treatment was superior to that of
Williams in decreasing low back pain and hasten-
ing the return of pain-free range of lumbar spine
movement in a select group of individuals.
The authors would like to thank Joseph Lockyer, RPT; JoAnn
Lockyer, RPT; David Dold. RPT; Dr. Fredrick Blackwell; Vesper Me-
morial Hospital, San Leandro, CA; and Mrs. Donna Ponte for their
assistance in the preparation of this paper.
REFERENCES
1. Andersson BJG: Epidemiologic aspects on low-back pain in indus-
try. Spine 653-60, 1981
2. Andersson BJG, Ortengren R, NachemsonA, Elfstrom G, Broman
H: The sitting posture: an electromyographic and discometric
study. Orthop Cllin North Am 6;105-120, 1975
3. Andersson BJG, Murphy R, Ortengren R, Nachemson A: The
influence of backrest inclination and lumbar support on lumbar
lordosis. Spine 452-58, 1979
4. Armstrong J: Lumbar Disc Lesions, Ed 1.London: EBR Livingstone
Ltd., 1958
5. Cyriax J: Textbook of Orthopaedic Medicine, Vol 1, Ed 7. London:
Bailliere Tindall-Cassell Ltd, 1979
6. Dehlin 0, Hedenrud B, Horal J: Back symptoms in nursing aides
in a geriatric hospital. Scand J Rehabil Med 8:47-53, 1976
7. Fahmi W: Conservative treatment of lumbar disc degeneration: our
primary responsibility. Orthop Clin North Am 6:93-103, 1975
8. Fahmi W: Posturalconcepts in back pain (as applied to a treatment
program). In: Kent BE (ed), Proceedings of the International Fed-
eration of Orthopaedic Manipulative Therapists, 1978
9. Friberg S, Hirsch C: Anatomical and clinical studies on lumbar disc
degeneration. Acta Orthop Scand 19:222-242, 1950
10. Hirsch C, Jonsson B. Lewin T: Low back symptoms in a Swedish
female population. Clin Orthop 63:171-176, 1969
11. Horal J: The clinical appearance of low back pain disorders in the
city of Gothenburg, Sweden: comparisons of incapacitated pro-
bands with matched controls. Acta Orthop Scand (suppl) 118:l-
109,1969
12. Jayson M, Sims-Williams H, Young S, Baddeley H, Collins E:
Mobilizationand manipulation for low-back pain. Spine 6:490-495,
1981
13. Kelsey J: The impact of musculoskeletal disorders on the popula-
tion of the United States. J Bone Joint Surg (Am) 61:959-964.
1979
14. Lidstrom A, Zachrisson M: Physical therapy on low back pain and
sciatica. Scand J Rehabil Med 2:37-42. 1970
15. Lindblom K: Backache and its relation to ruptures of the interver-
tebral discs. Radiology 57:710-718, 1951
16. Lindblom K: Diagnostic puncture of inte~ertebraldiscs and scia-
tica. Acta Orthop Scand 17:231-239,1948
17. McKenzie R: The Lumbar Spine, Ed 1. Upper Hutt, NZ: Wright and
Carmen Ltd, 1981
18. McKenzie R: Prophylaxis in recurrent low back pain. NZ Med J
89:22-23,1979
Downloaded from www.jospt.org at on January 9, 2021. For personal use only. No other uses without permission.

JOSPTSeptlOct 1984 COMPARISON OF TREATMENTS FOR LOW BACK PAIN 139

19. Nachemson A: Physiotherapy for low back pain patients: a critical 26. Tanigawa M: Comparison of the hold-relax procedure and passive
look. Scand J Rehabil Med 1:85-90.1969 mobilization on increasing muscle length. Phys Ther 5:725-734,
20. Nachemson A: Towards a better understanding of low-back pain: 1972
Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

a review of the mechanics of the lumbar disc. Rheumatol Rehabil
14:129-149,1975
21. Nachemson A: A critical look at conservative treatment for low
back pain. In: Jayson ML (ed), The Lumbar Spine and Back Pain,
Ed 2, Vol 1. pp 355-365. London: Sector Publishing Ltd, 1976
22. Nachemson A: The lumbar spine: an orthopaedic challenge. Spine
159-71, 1976
23. Scott J. Huskisson E: Graphic representationof pain. Pain 2:175-
184, 1976
24. Shah J. Hampson W, Jayson M: The distribution of surface strain
in the cadaveric lumbar spine. J Bone Joint Surg (Br) 60:246-251.
1978
Journal of Orthopaedic & Sports Physical Therapy®
27. Wiesel S. Cuckler J, Deluca F et al: Acute low-back pain: an
objective analysis of conservative therapy. Spine 5324-330, 1980
28. Williams P: Examination and conservativetreatment for disc lesions
of the lower spine. Clin Orthop 528-40, 1955
29. Williams P: Low Back and Neck Pain: Causes and Conservative
Treatment. Ed 3. Springfield: Charles C Thomas, 1974
30. Zylbergold R. Piper M: Lumbar disc disease: comparative analysis
of physical therapy treatments. Arch Phys Med Rehabil 62:176-
179.1981

25. Sims-Williams H. Jayson M, Young S, et al: Controlled trial of

mobilization and manipulations for patients with low back pain in
general practice. Br Med J 2:1338-1340, 1978