Questions & Answers features staff members of Rockhill Orthopaedics, the Kansas City Spine Center, and the Health and Rehabilitation Pavilion. Here, we interview Robert Takacs, M.D., medical director of the Spine Center, and Elizabeth Hesse, physical therapist at the Pavilion.

Within the back rehabilitation field, controversy exists over the comparative merits of the exercise treatment known as Williams Flexion and McKenzie Extension. What are each of these?
Hesse: There is some confusion about this. Both are patients self-treatment programs using exercise. Williams Flexion concentrates on exercises involving bending forward from the waist. The Mckenzie method, which is also used for neck discomfort, combines extensive and flexion, but it's better known for extension. This involves backward bending exercises.

Why do many physicians resist the McKenzie method?
Takacs: Williams Flexion has been around for a long time and is the time-tested and proven-effective method of relief. While many doctors think extension is good for strengthening the muscles and ligaments of the back, they have trouble accepting McKenzie's theory that you can actually alter the anatomy of the back. For example, with McKenzie, your goal may to alter a herniated disc and thereby take pressure off the nerves. This is the exact opposite of the Williams theory.
Hesse: McKenzie introduced his method in 1959 after discovering that a patient accidentally put into hyperextension was relieved of all his symptoms. Before that, it was universally believed that patients with back problems should not lie on their stomachs. Because the McKenzie method has been introduced recently enough that many physicians didn't hear about it in medical school, it will take some time before it becomes accepted.

Are there psychological differences between the two?
Takacs: Yes. The McKenzie method, which is named for Robin McKenzie, a physiotherapist in New Zealand, wants patients to take an active role in their treatment. He wants patients to take an active role in their treatment. He wants patients to be involved with their pain and to take responsibility for getting better.
Hesse: Because McKenzie is the exact opposite of what most people know about treating back pain, we usually must ease them into and through the exercise in order to prove to them that they won't hurt themselves and may very well find relief from their pain.

Have you encountered referring physicians who insist that one or the other not be used when you're treating their patients?
Hesse: Yes, and it's very frustrating. Physical therapists are taught to be very open minded, so we're ready to try things.
Takacs: As a physician, I have found that if I recommend that at first we try one and then the other, referring physicians don't resist.

Both treatments are used here. How do you decide on one or the other?
Takacs: I will often prescribe that our physical therapists try both, knowing that if one doesn't help, the other one very well might. For example, while one patient might complain about pushups, the next will find they relieve pain. In my experience, finding the right exercises can often prevent a patient form having to work back surgery.
Hesse: About 80 percent of the time we start with extension exercises. People are usually more flexible in their forward movements, so we begin with the backward movements. In that way, we're actually using the McKenzie method as a starting point for evaluation in order to find out what movements help. Our physicians here trust our judgement in determining what's most beneficial for the patient.