An individualised self-management exercise and education program did not prevent recurrence of low back pain but may reduce care seeking: a randomised trial.

QUESTION: What is the effect of a McKenzie-based self-management exercise and education program on the risk of recurrence of low back pain (LBP) and on the impact of LBP? DESIGN: Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: 262 adults recently recovered from an episode of LBP. INTERVENTION: The experimental group received a McKenzie-based self-management exercise and education program delivered over two individual sessions of 30 to 45 minutes with a physiotherapist, approximately 2 weeks apart. The control group received a single advice session over the phone. OUTCOME MEASURES: The primary outcome was time to first recurrence of an episode of activity-limiting LBP. Secondary outcomes included time to recurrence of any LBP, time to a recurrence causing care seeking and a composite measure of pain and function ('impact of LBP'). Participants were followed-up monthly for ≥ 12 months. RESULTS: The estimated effect of the experimental intervention on the risk of recurrence of an episode of: activity-limiting LBP was HR 1.11 (95% CI 0.80 to 1.54), any LBP was HR 0.95 (95% CI 0.72 to 1.26), and LBP for which care was sought was HR 0.69 (95% CI 0.46 to 1.04). The quarterly estimates of the experimental intervention's effect on impact of LBP and their 95% CIs were all within 4 points above or below 0 (no effect) on this scale from 8 to 50. CONCLUSION: This study's best estimate is that a McKenzie-based self-management exercise and education program does not produce a worthwhile reduction in the risk of an activity-limiting episode of LBP; however, modestly reduced or moderately increased risk cannot be ruled out. It may markedly reduce the risk of an episode of LBP resulting in care seeking, but does not have any worthwhile effect on the impact of LBP over 12 months. TRIAL REGISTRATION: ACTRN12616000926437.

A randomized clinical trial comparing the McKenzie method and motor control exercises in people with chronic low back pain and a directional preference: 1-year follow-up.

OBJECTIVE: The primary objective of this study was to compare the long-term (1-year follow-up) effects of the McKenzie method and motor control exercises on trunk muscle thickness in people with chronic low back pain (LBP) and a directional preference. DESIGN: Randomized controlled trial. SETTING: A secondary public health facility in Sydney, Australia. PARTICIPANTS: Seventy adults with greater than 3-month history of LBP and a directional preference. INTERVENTIONS: Participants were randomized to receive 12 treatments of either the McKenzie method or motor control exercises over 8-weeks. OUTCOME MEASURES: Muscle thickness of the transversus abdominis, obliquus internus, and obliquus externus measured from ultrasound images. Secondary outcomes included function, perceived recovery, and pain. Outcomes were collected at baseline, post intervention at 8-weeks, and at 1-year follow-up by blinded assessors. The current paper focuses on the 1-year follow-up. RESULTS: Fifty-eight participants completed data collection for the primary outcome at 1-year. There were no significant between group differences for changes in trunk muscle thickness for any of the three investigated muscles: transversus abdominis [3%, 95% confidence interval (CI): -5%, 11%], obliquus internus [-4%, 95% CI: -9%, 2%] and obliquus externus [3%, 95% CI: -4%, 11%]. Similarly, there were no significant differences between groups for the secondary outcomes of function, perceived recovery and pain. CONCLUSION: Trunk muscle thickness, function, perceive recovery and pain are similar between patients receiving McKenzie method or motor control exercises at a 1-year follow-up in a population of people with chronic LBP and a directional preference. Clinical Trials Registration number CTRN12611000971932.

Effectiveness of McKenzie Method-Based Self-Management Approach for the Secondary Prevention of a Recurrence of Low Back Pain (SAFE Trial): Protocol for a Pragmatic Randomized Controlled Trial.

BACKGROUND: Although many people recover quickly from an episode of low back pain (LBP), recurrence is very common. There is limited evidence on effective prevention strategies for recurrences of LBP. OBJECTIVE: The purpose of this study was to determine the effectiveness of a McKenzie method-based self-management approach in the secondary prevention of LBP. DESIGN: This will be a pragmatic randomized controlled trial. SETTING: Participants will be recruited from the community and primary care, with the intervention delivered in a number of physical therapist practices in Sydney, Australia. PARTICIPANTS: The study will have 396 participants, all of whom are at least 18 years old. INTERVENTION: Participants will be randomly assigned to either the McKenzie method-based self-management approach group or a minimal intervention control group. MEASUREMENTS: The primary outcome will be days to first self-reported recurrence of an episode of activity-limiting LBP. The secondary outcomes will include: days to first self-reported recurrence of an episode of LBP, days to first self-reported recurrence of an episode of LBP leading to care seeking, and the impact of LBP over a 12-month period. All participants will be followed up monthly for a minimum of 12 months or until they have a recurrence of activity-limiting LBP. All participants will also be followed-up at 3, 6, 9, and 12 months to assess the impact of back pain, physical activity levels, study program adherence, credibility, and adverse events. LIMITATIONS: Participants and therapists will not be masked to the interventions. CONCLUSIONS: To our knowledge, this will be the first large, high-quality randomized controlled trial investigating the effectiveness of a McKenzie method-based self-management approach for preventing recurrences of LBP. If this approach is found to be effective, it will offer a low-cost, simple method for reducing the personal and societal burdens of LBP.

A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People With Chronic Low Back Pain and a Directional Preference.

Study Design Randomized clinical trial. Background Motor control exercises are believed to improve coordination of the trunk muscles. It is unclear whether increases in trunk muscle thickness can be facilitated by approaches such as the McKenzie method. Furthermore, it is unclear which approach may have superior clinical outcomes. Objectives The primary aim was to compare the effects of the McKenzie method and motor control exercises on trunk muscle recruitment in people with chronic low back pain classified with a directional preference. The secondary aim was to conduct a between-group comparison of outcomes for pain, function, and global perceived effect. Methods Seventy people with chronic low back pain who demonstrated a directional preference using the McKenzie assessment were randomized to receive 12 treatments over 8 weeks with the McKenzie method or with motor control approaches. All outcomes were collected at baseline and at 8-week follow-up by blinded assessors. Results No significant between-group difference was found for trunk muscle thickness of the transversus abdominis (-5.8%; 95% confidence interval [CI]: -15.2%, 3.7%), obliquus internus (-0.7%; 95% CI: -6.6%, 5.2%), and obliquus externus (1.2%; 95% CI: -4.3%, 6.8%). Perceived recovery was slightly superior in the McKenzie group (-0.8; 95% CI: -1.5, -0.1) on a -5 to +5 scale. No significant between-group differences were found for pain or function (P = .99 and P = .26, respectively). Conclusion We found no significant effect of treatment group for trunk muscle thickness. Participants reported a slightly greater sense of perceived recovery with the McKenzie method than with the motor control approach. Level of Evidence Therapy, level 1b-. Registered September 7, 2011 at www.anzctr.org.au (ACTRN12611000971932). J Orthop Sports Phys Ther 2016;46(7):514-522. Epub 12 May 2016. doi:10.2519/jospt.2016.6379.

A randomized controlled trial comparing McKenzie therapy and motor control exercises on the recruitment of trunk muscles in people with chronic low back pain: a trial protocol.

OBJECTIVE: To investigate if McKenzie exercises when applied to a cohort of patients with chronic LBP who have a directional preference demonstrate improved recruitment of the transversus abdominis compared to motor control exercises when measurements were assessed from ultrasound images. DESIGN: A randomized blinded trial with a 12-month follow-up. SETTING: The Physiotherapy department of Concord Hospital a primary health care environment. PARTICIPANTS: 70-adults with greater than three-month history of LBP who have a directional preference. INTERVENTIONS: McKenzie techniques or motor control exercises for 12-sessions over eight weeks. MAIN OUTCOME MEASURES: Transversus abdominus thickness measured from real time ultrasound images, pain, global perceived effect and capacity to self-manage. DISCUSSION: This study will be the first to investigate the possible mechanism of action that McKenzie therapy and motor control exercises have on the recruitment of the transversus abdominus in a cohort of low back pain patients sub-classified with a directional preference. Patients receiving matched exercises according to their directional preference are believed to have better outcomes than those receiving unmatched exercises. A better understanding of the mechanism of action that specific treatments such as motor control exercises or McKenzie exercises have on patients classified with a directional preference will allow therapist to make a more informed choice about treatment options.

Construct validity of lumbar extension measures in McKenzie's derangement syndrome.

The McKenzie treatment model advocates extension-based treatments for sub-groups of low back pain (LBP) patients and an improvement in extension range is seen as a positive outcome. The treatment model states that patients who fit the McKenzie derangement classification respond faster than other patients. The validity of this treatment model and of the clinical measures of extension has not yet been established. Fifty patients with LBP were classified as derangement (n=40) or non-derangement (n=10) based on a McKenzie assessment and then treated with extension procedures. Lumbar extension was measured in two positions, standing and prone, with three methods, inclinometer, Schober and finger tip to floor, on Day 1 and Day 5 of treatment. Patients completed a global perceived effect (GPE) scale on Day 5. Construct validity was tested, by comparing extension improvement and the GPE scores between the two groups. Responsiveness of the six extension measures was calculated. All patients gained extension range however the derangement group had significantly higher GPE scores and greater improvement in extension range. The modified Schober method in standing was the most responsive method for measuring lumbar extension. The results of this study support the measurement of lumbar extension, for patients, treated with extension procedures and provides evidence for the construct validity of one aspect of the McKenzie treatment model. The modified Schober method is the preferred protocol for a clinical setting.

Reliability of McKenzie classification of patients with cervical or lumbar pain.

BACKGROUND: In the McKenzie system, patients are classified first into syndromes, then into subsyndromes. At present, the reliability of classification with this system is unclear. No study has included patients with cervical pain, and the studies to date have reported conflicting results. OBJECTIVE: The aim of the study is to investigate the interexaminer reliability of the McKenzie classification system for patients with cervical or lumbar pain. SUBJECTS: Fifty patients with spinal pain (25 with lumbar pain and 25 with cervical pain) were included in the study. METHOD: The patients were assessed simultaneously by 2 physical therapists (14 in total) trained in the McKenzie method. Agreement was expressed using the multirater kappa coefficient and percent agreement for classification into (i) syndromes and (ii) subsyndromes. RESULTS: The reliability for syndrome classification was kappa = 0.84 with 96% agreement for the total patient pool, kappa = 1.0 with 100% agreement for lumbar patients, and kappa = 0.63 with 92% agreement for cervical patients. The reliability for subsyndrome classification was kappa = 0.87 with 90% agreement for the total patient pool, kappa = 0.89 with 92% agreement for lumbar patients, and kappa = 0.84 with 88% agreement for the cervical patients. CONCLUSION: The McKenzie assessment performed by persons trained in the McKenzie method may allow for reliable classification of patients with lumbar and cervical pain.

A systematic review of efficacy of McKenzie therapy for spinal pain.

A systematic review of randomised clinical trials was conducted to investigate the efficacy of McKenzie therapy in the treatment of spinal pain. Databases searched included DARE, CINAHL, CENTRAL, EMBASE, MEDLINE and PEDro. To be eligible for inclusion trials had to provide treatment according to McKenzie principles and report on one of the following outcomes: pain, disability, quality of life, work status, global perceived effect, medication use, health care contacts, or recurrence. Six trials were found to be eligible, all comparing McKenzie therapy to a comparison treatment. These included NSAIDS, educational booklet, back massage and back care advice, strength training, and spinal mobilisation and general exercises. The data from five lumbar trials were pooled at short term (less than three months) and from three at intermediate (3-12 months) follow-up. At short term follow-up the McKenzie therapy provided a mean 8.6 point greater pain reduction on a 0 to 100 point scale (95% CI 3.5 to 13.7) and a 5.4 point greater reduction in disability on a 0 to 100 point scale (95% CI 2.4 to 8.4) than comparison. At intermediate follow-up, relative risk of work absence was 0.81 (0.46 to 1.44) favouring McKenzie, however the comparison treatments provided a 1.2 point greater disability reduction (95% CI -2.0 to 4.5). In the one cervical trial, McKenzie therapy provided similar benefits to an exercise program. The results of this review show that for low back pain patients McKenzie therapy does result in a greater decrease in pain and disability in the short term than other standard therapies. Making a firm conclusion on low back pain treatment effectiveness is difficult because there are insufficient data on long term effects on outcomes other than pain and disability, and no trial has yet compared McKenzie to placebo or no treatment. There are also insufficient data available on neck pain patients.

Reliability of detection of lumbar lateral shift.

BACKGROUND AND PURPOSE: The poor reliability of lateral shift detection has been attributed to lack of rater training, biologic variation, and test reactivity. This study aimed to remove the potential confounding arising from biological variation and test reactivity and control the level of rater experience/training in making judgments of lateral shift. SUBJECTS: One hundred forty-eight raters with 3 levels of clinical physical therapy experience and training in the McKenzie method participated. METHOD: The raters viewed photographic slides of 45 patients with low back pain. Slides were judged on a numerical scale for presence and direction of a shift. Intrarater reliability was evaluated using the intraclass correlation coefficient (ICC) and interrater reliability was evaluated using both the ICC and kappa statistic. RESULTS: Reliability of shift judgments was only moderate for all groups (eg, ICC [2,1] values ranged from 0.48 to 0.64). CONCLUSION: Lateral shift judgements have only moderate reliability, even when trained raters judge stable stimuli. We propose that the photo model employed can be used to explore the source of error in this process.