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A Clinician’s Guide to the Stoplight Rule

The McKenzie Method teaches the Stoplight Rule, a very useful means of testing and re-testing based on directional preference and repeated loading strategies. However, you can apply this to any treatment strategy you're using.


I often get asked about this and teach it in all of my Modern Manual Therapy Seminars, so I thought I'd make a handy guide for you to refer to.

Infographic: The Stoplight Rule

A Clinician's Guide to the Stoplight Rule

The "Stoplight Rule" is a key clinical reasoning tool to guide treatment decisions. It uses the patient's symptomatic response to repeated movements to determine if a loading strategy is appropriate.

First: Establish a Clear Baseline

Before testing, precisely document the patient's symptoms. This is the reference point for all change.

  • LOCATION: Map the precise distribution of symptoms.
  • INTENSITY: Rate pain at rest and with movement (e.g., NPRS 0-10).
  • QUALITY: Describe the nature of the symptom (dull, sharp, numb, etc.).
Example: Right-sided neck pain (3/10 NPRS) with sharp, radiating symptoms to below the right elbow.
R

RED LIGHT

STOP

Distal symptoms are produced and remain worse or peripheralize for > 5 minutes post-testing.

Ex: Baseline 3/10 neck pain becomes 3/10 neck pain with 4/10 hand numbness. Symptoms peripheralized.

ACTION: Choose a different direction or strategy.

Y

YELLOW LIGHT

CAUTION

Symptoms temporarily increase or peripheralize, but return to baseline in < 5 minutes post-testing.

Ex: 3/10 neck pain was 5/10 during loading but returned to 3/10 after 3 min of walking.

ACTION: Proceed cautiously. Ensure you are reaching end-range. Keep loading, as this could still be the directional preference. Monitor closely.

G

GREEN LIGHT

GO

Distal symptoms decrease, abolish, or centralize and remain better.

Ex: Baseline 3/10 hand pain is abolished, but neck pain is now 2/10. Symptoms have centralized.

ACTION: This is the directional preference. Prescribe as a home exercise.

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References

Clare, H. A., Adams, R., & Maher, C. G. (2004). A systematic review of efficacy of McKenzie therapy for spinal pain. Australian Journal of Physiotherapy, 50(4), 209-216.

Donelson, R., Silva, G., & Murphy, K. (1990). Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine, 15(3), 211-213.

Long, A., Donelson, R., & Fung, T. (2004). Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine, 29(23), 2593-2602.

McKenzie, R., & May, S. (2003). The lumbar spine: Mechanical diagnosis and therapy (Vol. 1). Spinal Publications New Zealand Ltd.

Werneke, M., Hart, D. L., & Cook, D. (1999). A descriptive study of the centralization phenomenon in patients with low back and referred pain. Spine, 24(7), 676-683.

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