The Bronze Lady

In speaking with therapists who utilize McKenize principles in their decision-making process, they are quick to remind you that the McKenize system is more than just extension exercise (ie, the fabled prone press up). Diplomates in this system in particular are quick to remind you. Fair enough. However, it seems odd then that their top research award each year is called ‘The McKenzie Institute International Extension Award‘. It’s even known within the Institute as "The Bronze Lady" and is presented to someone who has made an outstanding contribution to education or research in the field of Mechanical Diagnosis and Therapy.

We should applaud the Institute’s efforts in publishing clinical research to assist in the physical therapy decision-making process, espcially efforts to identify relevant sub-groups. However, it seems paradoxical and counterproductive to name your top award as an ‘extension’ award if in fact the Institute is trying to tone down perceptions that the McKenzie system is all about extension. See for yourself. Here is the logo:


Perhaps my understanding of their desire to reverse the common perceptions that McKenzie equates to extension exercise (namely the prone press up) is false. McKenzie Diplomates or others, feel free to chime in.



16 responses to “The Bronze Lady

  1. Mark Armstrong, PT, DPT, OSC says:

    One would speculate that the McKenzie Institute would move in the direction of marketing themselves as gurus in mechanical diagnosis or repetitive movement diagnosis. Perhaps the additional constructs such as pain location-driven Dx/treatment and pathoanatomic model-driven Dx/treatment added to the mix make it just easier to pursue the idol of Extension? I agree some thoughts from the Institute would add light. It would be good to see what this approach can add to the evidence or is the McKenzie model in need of a tune-up?

  2. Jim Cenova, PT, Cert. MDT says:

    I by no means represent the institute. Let me make that clear.
    I’m merely a Credentialed (or Certified some people prefer) McKenzie practitioner.
    McKenzie practitioners distance themselves from “gurus” as much as possible as much of what “gurus” do is very touchy feely and not grounded firmly in research. McKenzie is just that. Very research driven, research proven. By far, it is the dogma most criticized and analyzed. It’s also stood up to a lot of criticisms; certainly not all though.
    The EIM group and their research references many of the principles which guide McKenzie practitioners. Specifically, the Centralization phenomenon. There is disagreement as to the definition of centralization and the number of repetitions to get there, but the terms are being used by both EIM and McKenzie camps. The thought of McKenzie needing a tune-up is insulting and clearly shows what McKenzie needs is better marketing. Better penetration into the schools and the clinics to show that it is a system made up of principles. Principles of treatment based on responses to movement (repeated or single) or positioning (sustained). Much the same way the EIM group has principles of treatment based on responses to movement (CPR is a great example).
    The original question about why utilize a prone press-up? Probably out of respect and tradition. I mean, the “chance encounter” was an extension maneuver which was unheard of and heretical at the time to use as a treatment idea. But chance operates on the prepared mind, and the McKenzie method of treatment was borne.
    I agree with you, John, that the choice of a prone press up for the McKenzie Bronze Lady certainly reinforces the concept of “McKenzie is just extension exercises” to the people who don’t understand or want to understand McKenzie.

  3. Britt says:

    Just wanted to add a website for a systematic review of the McKenzie method from Australian J. of Physiotherapy.
    You can download the pdf.

  4. John Childs says:

    Good comment. By the way, just to be perfectly clear, I don’t criticize the McKenzie Institute for lack of effort in producing clinical research. Although the system has its limitations (as does any classification scheme), it’s one of the few organizations willing to subject its ideas to the rigors of clinical research. We can have some great debate on the pros and cons of the McKenzie system and how much evidence there is to support the various aspects of the system, but I certainly applaud the research efforts.
    My post is limited to questioning why the Institute would reinforce the extension bias through its award process if in fact it does not want to be viewed in this light. Just seems like a counterproductive and odd approach.

  5. Jim Cenova, PT says:

    John: I agree with that point. I hope someone from the Institute sees this post and answers the question.

  6. Mark Armstrong says:

    No insult intended. I do appreciate the research the Institute has done and is doing. Also, I recognize the pragmatic approach of response to mvmt/position to guide treatment that this approach should be complimented for. I agree that more of the work done needs to get out there in the clinic(it is a nice convergence with treatment-based classification). I agree we can discuss this more and more. However, I am also interested in the original focus of the post as well. thanks
    Mark Armstrong, PT

  7. John Ware says:

    My clinical observations regarding the use of end ROM extension exercises, i.e. the prone press up:
    -If performed truly passively within pain free ROM, it’s an effective way to gain ROM in a generally stiff spine or in a spine that lacks general spinal extension.
    -I have absolutely no proof of this, but my experience tells me that if done correctly (passive, painfree), pt’s are improving thoracic extension mobility at least as much as lumbar mobility.
    -In a certain subgroup of pt’s, I suspect prone press ups are an effective, however inadvertant, stretch/lengthening exercise for the iliopsoas.
    -LOTS of young, middle-aged and old women have facet joint arthopathy (McKenzie: postural syndrome; Treatment-Based Classification: flexion preference; Movement Balance Theory: extension syndrome).
    N.B. Stuart McGill’s research has unequivocally shown that active participation of the erector spinae in prone press ups produces damaging levels of forces to the lumbar facet joints.
    Extend with care, my friends.
    John W.

  8. Morey says:

    The Bronze lady award is a research award. Simply, that is what it is. McKenzie institute is seeking to educate those who are not aware of the Mckenzie Method and commonly misrepresent it as an extension based model. I would imagine the position of the bronze lady is simply out of tradition as Jim had suggested.
    PS john W. -would you please provide some references to the readers. I am particularly interested in the research you mention; identifying the prevalence or incidence of Lumbar facet arthropathy in young women.

  9. Anthony Delitto says:

    Regarding Mr. Ware’s comments regarding Dr. McGill’s work: The majority of Dr. McGill’s work focusses on spinal stabilization exercises, of which the prone press-up does not apply. My recollection of the back extension exercise studied by Dr. McGill had more to do with active back extension versus the prone press-up. To my knowledge, he has never implicated the prone press-up as causing deleterious forces in the lumbar disc.
    Completely different exercises that should not be confused with one another.
    Authors Kavcic N. Grenier S. McGill SM.
    Institution University of Waterloo, Faculty of Applied Health Sciences, Waterloo, Ontario, Canada.
    Title Determining the stabilizing role of individual torso muscles during rehabilitation exercises.
    Source Spine. 29(11):1254-65, 2004 Jun 1.
    Abstract STUDY DESIGN: A systematic biomechanical analysis involving an artificial perturbation applied to individual lumbar muscles in order to assess their potential stabilizing role. OBJECTIVES: To identify which torso muscles stabilize the spine during different loading conditions and to identify possible mechanisms of function. SUMMARY OF BACKGROUND DATA.: Stabilization exercises are thought to train muscle patterns that ensure spine stability; however, little quantification and no consensus exists as to which muscles contribute to stability. METHODS: Spine kinematics, external forces, and 14 channels of torso electromyography were recorded for seven stabilization exercises in order to capture the individual motor control strategies adopted by different people. Data were input into a detailed model of the lumbar spine to quantify spine joint forces and stability. The EMG signal for a particular muscle was replaced either unilaterally or bilaterally by a sinusoid, and the resultant change in the stability index was quantified. RESULTS: A direction-dependent-stabilizing role was noticed in the larger, multisegmental muscles, whereas a specific subtle efficiency to generate stability was observed for the smaller, intersegmental spinal muscles. CONCLUSIONS: No single muscle dominated in the enhancement of spine stability, and their individual roles were continuously changing across tasks. Clinically, if the goal is to train for stability, enhancing motor patterns that incorporate many muscles rather than targeting just a few is justifiable.
    Publication Type Journal Article.

  10. David Poulter PT says:

    Sing to the theme tune of the beverly Hill billies.
    ” Come listen to the story of a man named McK.
    A poor physio who was working on the back.
    Then one day Mr Smith was on the bed, the theory of extension came into McK’s head.
    Centralisation that is, all the pain has gone.
    Now the next thing you know old McK’s a millionaire, kin folk said, “McK move away from here, said centralisation is the palce you wanna be.”
    Hence theory of extension had had just come to be.”
    History, William’s flexion versu McKenzie extension.
    It’s what he’s known for.
    E=MC squared. Einstein
    Extension doesn’t = MDT
    I guess the Bronze lady is like the Oscar, it is a symbol of a unique discovery, not a sole representation of a developing system.
    It’s a tribute to that discovery.
    I see my name on the list of recipients. The bronze lady makes a great book end.
    PS Great web blog carry on the great work JOHN et al

  11. John Childs says:

    Outstanding comment. Did you make this one up?
    The problem is that I’m not convinced that MDT does not equal extension. How could I have missed it in my original post!!! The cover of the new International Journal of Mechanical Diagnosis and Therapy also bears the bronze lady doing a prone press up ( If the McKenzie Institute indeed desires to rid itself of the perception that MDT = extension, they should fire their PR staff immediately. I am only becoming more and more convinced that MDT does in fact begin and end with extension, particularly in light of lacking evidence to support other aspects of the system besides the extension piece.

  12. David Poulter says:

    All my own work, I’m affraid.
    I think it would be interesting, as most people are probably hoping, to here from representatives of the McKenzie Institute.
    I currently have no association with them so I do not want to be percieved as having any relationship with the Institute.
    In my former life I remember my common line when teaching the diploma course was ” You will learn more from the patient who you flex than the one you extend.”
    It was also a mystery to me why everyone went through an indepth examination of every repeated movement to end up giving the vast majority of people extension.(I think I’m agreeing with John.)
    I often proposed giving every patient extension to see who didn’t need it.
    I think we should remember that the stake holders will always try to defend their position, and may be emotionally invovled in doing so, if not financially.
    I would be extremely interestd to hear from the Instiute’s current teaching faculty on how they incoporate the research John and his group are doing on CPR for manipulation, exercise and stabalization.
    If the Institute isn’t incorporating the evidence in to their teaching why not?

  13. John Ware, PT, MS, FAAOMPT says:

    Dr. Delitto:
    I mis-stated in my note at the end of my comment regarding Dr. McGill’s research. Indeed, his research shows the potential deleterious effects of active lumbar extension on the facet joint (not the disc). The point I was trying to make was that the prone press up is often prescribed in the clinic without careful instruction for the pt to avoid active participation of the long spinal extensors. This can be a difficult exercise for women, in particular, to perform because of the upper body strength required to perform it correctly (which is one reason why I tend to agree with John C. about the use of the Bronze Lady to represent the McKenzie Institute). Thus my admonition to “Extend with care.”
    I was merely relating my clinical experience with regards to the prevalence of lumbar arthropathy among females throughout the lifespan, including relatively young women. I did not cite any literature. But since you asked, there is an excellent descriptive study by Einstein and Parry in the British version of the Journal of Bone and Joint Surgery. They make an interesting comparison b/w chondromalacia patellae and facet joint arthropathy.
    John W.

  14. David Browder says:

    I think a fundamental difference between the McKenzie ‘system’ and, for example, the treatment based Classification approach, is the level of complexity. The McKenzie system is complex to the point of being shrouded in mystery unless you are an initiate of the order- despite the large amount of research done on it. I cannot read the literature and then apply the McKenzie method. The treatment based classification approach, in contrast, is simple without being simplistic- no initiation required – and is inclusive vs. exclusive. So I’m going to assume there isn’t that much more than the prone press up – that way I don’t feel like the outsider looking in- and I don’t have to take all those classes.

  15. suresh says:

    hi the bronze lady is jus a recognition of an individual’s efforts in understanding and further reasearch on the mckenzie principles. thats it, lets do some productive work than critizing the award.

  16. Luis says:

    So many misrepresentations of MDT.
    It is not a complicated method, it is reliable, so long you are trained. It is not a form of treatment, it is a way to collect data and interpret it. Then you subclassify who would benefit of what is best for the patient based on the patient response. It is a patient centered model.
    The more you do it, the more you flex people, and you have more certainties of the central mechanisms that may be dominating in chronic pain states. It is not a cure all, but you can complement it with other subclassifications that are complementary like the pain mechanism classification system by Annie O’Connor and Melissa Kolski.
    Peripheral nervous system:
    Chemical inflammatory P.R.I.C.E.
    Mechanical inflammatory ( derangements ) centralization /
    Preferential direction
    Ischemic ( dysfunctions) gradual progressive of load of tendon
    Articular tissue, slow responders.
    Peripheral neurogenic( tight or trapped nerve) neurodynamics,
    NRA McK
    Central nervous system:
    Central sensitive: brain decides to protect
    Affective: brain decides to divert, distract,
    Motor autonomic: neglect and forget In order to protect.

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