Clinic Wellness Team. A key factor to spine or back pain conditions is staying healthy. Overall wellness involves a balanced diet, appropriate exercise, physical activity, restful sleep, and a healthy lifestyle. The term has been applied in many ways. But overall, the definition is as follows.
It is a conscious, self-directed, and evolving process of achieving full potential. It is multidimensional, bringing together lifestyles both mental/spiritual and the environment in which one lives. It is positive and affirms that what we do is, in fact, correct.
It is an active process where people become aware and make choices towards a more successful lifestyle. This includes how a person contributes to their environment/community. They aim to build healthier living spaces and social networks. It helps in creating a person’s belief systems, values, and a positive world perspective.
Along with this comes the benefits of regular exercise, a healthy diet, personal self-care, and knowing when to seek medical attention. Dr. Jimenez’s message is to work towards being fit, being healthy, and staying aware of our collection of articles, blogs, and videos.
Have you ever experienced low back pain? If you haven’t already, there’s a high probability you will present at least one case of back pain sometime during your lifetime. Back pain is one of the most prevalent spine health issues reported among the population of the United States, affecting up to 80 percent of Americans at some point in their lives. Back pain is not a specific disease, rather it is a symptom which may develop as a result of a variety of injuries and/or conditions.�Although most cases typically resolve on their own, the effective treatment of acute low back pain is essential towards preventing chronic low back pain.
Chiropractors and physical therapists frequently utilize a similar series of treatment methods, such as spinal adjustments and manual manipulations as well as massage and physical therapy, to help treat symptoms of back and low back pain. Many healthcare professionals, however, have started using the McKenzie method to manage acute back pain. The purpose of the following article is to educate patients on the effectiveness of the McKenzie method for acute non-specific low back pain.
The McKenzie Method for the Management of Acute Non-Specific Low Back Pain: Design of a Randomised Controlled Trial
Abstract
Background
Low back pain (LBP) is a major health problem. Effective treatment of acute LBP is important because it prevents patients from developing chronic LBP, the stage of LBP that requires costly and more complex treatment.
Physiotherapists commonly use a system of diagnosis and exercise prescription called the McKenzie Method to manage patients with LBP. However, there is insufficient evidence to support the use of the McKenzie Method for these patients. We have designed a randomised controlled trial to evaluate whether the addition of the McKenzie Method to general practitioner care results in better outcomes than general practitioner care alone for patients with acute LBP.
Methods/Design
This paper describes the protocol for a trial examining the effects of the McKenzie Method in the treatment of acute non-specific LBP. One hundred and forty eight participants who present to general medical practitioners with a new episode of acute non-specific LBP will be randomised to receive general practitioner care or general practitioner care plus a program of care based on the McKenzie Method. The primary outcomes are average pain during week 1, pain at week 1 and 3 and global perceived effect at week 3.
Discussion
This trial will provide the first rigorous test of the effectiveness of the McKenzie Method for acute non-specific LBP.
Background
In Australia, low back pain (LBP) is the most frequently seen musculoskeletal condition in general practice and the seventh most frequent reason for consulting a physician[1,2]. According to the Australian National Health Survey, 21% of Australians reported back pain in 2001; additionally, the Australian Bureau of Statistic’s 1998 Survey of Disability, Ageing and Carers estimated that over one million Australians suffer from some form of disability associated with back problems[1].
LBP poses an enormous economic burden to society in countries such as the USA, UK and The Netherlands[3]. In the largest state in Australia, New South Wales, back injuries account for 30% of the cost of workplace injuries, with a gross incurred cost of $229 million in 2002/03[4]. It is expected that most people with an acute episode of LBP will improve rapidly, but a proportion of patients will develop persistent lower levels of pain and disability[5,6]. Those patients with chronic complaints are responsible for most of the costs[6]. Effective treatment of acute LBP is important because it prevents patients from developing chronic LBP, the stage of LBP that requires costly and more complex treatment.
There is a growing concern about effectiveness of treatments for LBP, as reflected in the large number of systematic reviews published in the last 5 years addressing this issue. [7-12]. Despite the large amount of evidence regarding LBP management, a definitive conclusion on which is the most appropriate intervention is not yet available. A comparison of 11 international clinical practice guidelines for the management of LBP showed that the provision of advice and information, together with analgesics and NSAIDs, is the approach consistently recommended for patients with an acute episode[13]. Most guidelines do not recommend specific exercises for acute LBP because trials to date have concluded that it is not more effective than other active treatments, or than inactive or placebo treatments[8]. However, some authors have suggested that the negative results observed in trials of exercises are a consequence of applying the same exercise therapy to heterogeneous groups of patients. [14-16]. This hypothesis has some support from a recent high-quality randomised trial in which treatment based on a diagnostic classification system led to larger reductions in disability and promoted faster return to work in patients with acute LBP than the therapy recommended by the clinical guidelines[17].
In 1981, McKenzie proposed a classification system and a classification-based treatment for LBP labelled Mechanical Diagnosis and Treatment (MDT), or simply McKenzie Method[18]. Of the large number of classification schemes developed in the last 20 years [19-26], the McKenzie Method has the greatest empirical support (e.g. validity, reliability and generalisability) among the systems based on clinical features[27] and therefore seems to be the most promising classification system for implementation in clinical practice.
Physiotherapists commonly adopt the McKenzie Method for treating patients with LBP[28,29]. A survey of 293 physiotherapists in 1994 found that 85% of them perceived the McKenzie Method as moderately to very effective[28]. Nevertheless, a recent systematic review concluded that there is insufficient evidence to evaluate the effectiveness of the McKenzie Method for patients with LBP [30]. A critical concern is that most trials to date have not implemented the McKenzie Method appropriately. The most common flaw is that all trial participants are given the same intervention regardless of classification, an approach contradictory to the principles of McKenzie therapy.
The primary aim of this trial is to evaluate whether the addition of the McKenzie Method to general practitioner (GP) care results in better outcomes than GP care alone for patients with acute non-specific LBP when effect is measured in terms pain, disability, global perceived effect, and persistent symptoms.
Methods
The University of Sydney Human Research Ethics Committee granted approval for this study.
Study Sample
One hundred and forty eight participants with a new episode of acute non-specific LBP who present to GPs will be recruited for the study. A new episode of LBP will be defined as an episode of pain lasting longer than 24 hours, preceded by a period of at least one month without LBP and in which the patient did not consult a health care practitioner[31]. Participants will be screened for eligibility at their first appointment with the GP according to the inclusion and exclusion criteria.
Inclusion Criteria
To be eligible for inclusion, participants must have pain extending in an area between the twelfth rib and buttock crease (this may or may not be accompanied by leg pain); pain of at least 24 hours duration; pain of less than 6 weeks duration; and they need to be eligible for referral to private physiotherapy practice within 48 hours.
Exclusion Criteria
Participants will be excluded if they have one of the following conditions: nerve root compromise (defined as 2 positive tests out of sensation, power and reflexes for the same spinal nerve root); known or suspected serious spinal pathology; spinal surgery within the preceding 6 months; pregnancy; severe cardiovascular or metabolic disease; or inability to read and understand English.
Recruiting GPs will record the number of patients who are invited to participate, the number who decline to participate, and the number of screened patients who are ineligible and their reasons for declining participation or ineligibility. Written consent will be obtained for each participant.
Subjects who volunteer to participate and satisfy the eligibility criteria will receive baseline treatment and then be randomly allocated to one of the study groups. To ensure equal-sized treatment groups, random permuted blocks of 4�8 participants will be used[32]. Randomisation will be stratified by Workcover compensation status. The stratified random allocation schedule will be generated by a person not otherwise involved in recruitment, assessment or treatment of subjects and the randomisation sequence will be placed in sequentially numbered, sealed envelopes. The flow of participants through the study is detailed in Figure ?1.
Figure 1: Flow of participants through the study. Legend: GP � General practitioner; NRS � Numeric pain rating scale; PSFS � Patient-specific functional scale; RMQ � Roland-Morris questionnaire; GPE � Global perceived effect; LBP � Low back pain.
Dr. Alex Jimenez’s Insight
In the management of low back pain, the attitudes, beliefs and treatment preferences of chiropractors, as well as that of physical therapists, can determine the most effective outcome measures in the care of patients with different types of spinal health issues. According to the following evidence-based research studies, the McKenzie method has been deemed to be one of the most useful treatment approaches for managing symptoms in patients with back and low back pain. Exercise and physical activity is also one of the most common treatment preferences for improving an individual’s strength, mobility and flexibility. Every healthcare professional varies in respect to their specific treatment preferences. These variations emphasize the need to identify the most effective treatment approach to guarantee proper treatment of LBP.
Outcome Measures
The McKenzie protocol is thought to promote rapid symptom improvement in patients with LBP[33,34] and this is one of the reasons that therapists choose this therapy. Therefore it is important to focus assessment on short-term outcomes. The primary outcomes will be:
Usual pain intensity over last 24 hours recorded each morning in a pain diary over the first week. Pain will be measured on a 0�10 numerical rating scale (NRS). The unit of analysis will be the mean of the 7 measures[35];
Usual pain intensity over last 24 hours (0�10 NRS) recorded at 1 and 3 weeks[35];
Global perceived effect (0�10 GPE) recorded at 3 weeks.
The secondary outcomes will be:
Global perceived effect (0�10 GPE) recorded at 1 week;
Patient-generated measure of disability (Patient-Specific Functional Scale; PSFS) recorded at 1 and 3 weeks[36];
Condition-specific measure of disability (Roland Morris Questionnaire; RMQ) recorded at 1 and 3 weeks[37];
Number of patients reporting persistent back pain at 3 months.
Following the screening consultation in which the inclusion and exclusion criteria are assessed, the GP will supervise the baseline measurement of pain. All patients will then receive an assessment booklet and a pre-paid envelope in which all other self-assessed outcome measures are to be recorded and sealed. One member of the research team will contact patients by telephone within 24 hours of the consultation with the GP in order to give explanations regarding the appropriate form of filling in the assessment booklet. At this time, other baseline outcomes will be recorded and then the patient will be randomised to study groups. The patient will be advised to keep the booklet at home, to seal it into the pre-paid envelope after the final assessment and mail the sealed envelope to the research team. To ensure the proper use of the assessment booklet and to avoid loss of data due to non-returned booklets, a blinded assessor will contact all patients by telephone 9 and 22 days after the consultation with the GP to collect patient’s answers from the 1st week and 3rd week assessments, respectively.
The procedure for obtaining outcome data will be followed for all participants, regardless of compliance with trial protocols. At 3 months, data regarding the presence of persistent (chronic) symptoms will be collected by telephone. Participants will be asked to answer the following yes-no question: “During the past 3 months have you ever been completely free of low back pain? By this I mean no low back pain at all and would this pain-free period have lasted for a whole month”. Those answering no will be considered to have persistent LBP. Information on additional treatment and the direct costs with low back pain management will also be collected at 3 months.
A secondary analysis will be performed on predictors of response to McKenzie treatment and prediction of chronicity. This will involve the measurement of participants’ expectation about the helpfulness of both treatments under investigation as well as information on the occurrence of the centralisation phenomenon. Expectation will be recorded prior to randomisation according to the procedures described by Kalauokalani et al[38].
Treatments
All participants will receive GP care as advocated by the NHMRC guideline for the management of acute musculoskeletal pain[2]. Guideline-based GP care consists of providing information on a favourable prognosis of acute LBP and advising patients to stay active, together with the prescription of paracetamol. Patients randomised to the experimental group will be referred to physiotherapy to receive the McKenzie Method. A research assistant not involved in the assessment or treatment of subjects will be responsible for the randomisation process and will contact therapists and patients to arrange the first physiotherapy session. The McKenzie treatment will be delivered by credentialed physiotherapists who will follow the treatment principles described in McKenzie’s text book[18]. All therapists will have completed the four basic courses taught by the McKenzie Institute International. To ensure the appropriate implementation of the McKenzie’s classification algorithm, a training session with a member of McKenzie’s educational program will be conducted prior to the commencement of the study. The treatment frequency will be at the discretion of the therapist with a maximum of 7 sessions over 3 weeks. We chose to restrict the McKenzie treatment to a maximum of 7 sessions based on the study of Werneke and colleagues[39], which concluded that further reductions in pain and function are not expected if favourable changes in pain location are not present until the seventh treatment visit. Treatment procedures from the McKenzie Method are summarised in the Appendix.
Participants randomised to the control group will continue their GP care as usual. All participants regardless of intervention group will be advised not to seek other treatments for their low back pain during the treatment period. Physiotherapists will be asked to withhold co-interventions during the course of the trial.
Several mechanisms will be used to ensure that the trial protocol is applied consistently. Protocol manuals will be developed and all involved researchers (GPs, physiotherapists, assessor, and statistician) will be trained to ensure that screening, assessment, random allocation and treatment procedures are conducted according to the protocol. A random sample of treatment sessions will be audited to check that treatment is being administered according to the protocol.
Data Analysis
Power was calculated based on the primary outcome measures (pain intensity and global perceived effect). A sample size of 148 participants will provide 80% power to detect a difference of 1 unit (15%) on a 0�10 pain scale (SD = 2.0) between the experimental and control groups, assuming alpha of 0.05. This allows for loss to follow-up of 15%. This sample size also allows the detection of a difference of 1.2 units (12%) on a 0�10 global perceived effect scale (SD = 2.4).
Data will be analysed by a research member blinded to group status. The primary analysis will be by intention-to-treat. In order to estimate treatment effects, between-group mean differences (95%CI) will be calculated for all outcome measures. In the primary analysis these will be calculated using linear models that include baseline values of outcome variables as covariates to maximise precision.
Discussion
We have presented the rationale and design of an RCT evaluating the effects of the McKenzie Method in the treatment of acute non-specific LBP. The results of this trial will be presented as soon as they are available.
Competing Interests
The author(s) declare that they have no competing interests.
Authors’ Contributions
LACM, CGM and RDH were responsible for the design of the study. HC was responsible for recruiting McKenzie therapists and she will also participate as a clinician in the trial. LACM and JMc will act as trial coordinators. All authors have read and approved the final manuscript.
Appendix
Clinical picture and treatment principles according to the McKenzie Method
This table summarises the procedures involved in the McKenzie Method (Table 1). For detailed description of all procedures and progressions, refer to McKenzie’s text book. This is particularly important for Derangement syndrome since the treatment is extremely variable and complex and the full description of procedures would not be appropriate for the purposes of this paper.
The authors thank the physiotherapists credentialed in the McKenzie Method for their participation in this project.
Managing Low Back Pain: Attitudes & Treatment Preferences of Physical Therapists & Chiropractors
Abstract
Background and Purpose:�Researchers surveyed physical therapists about their attitudes, beliefs, and treatment preferences in caring for patients with different types of low back pain problems.
Subjects and Methods: Questionnaires were mailed to all 71 therapists employed by a large health maintenance organization in western Washington and to a random sample of 331 other therapists licensed in the state of Washington.
Results: Responses were received from 293 (74%) of the therapists surveyed, and 186 of these claimed to be practicing in settings in which they treat patients who have back pain. Back pain was estimated to account for 45% of patient visits. The McKenzie method was deemed the most useful approach for managing patients with back pain, and education in body mechanics, stretching, strengthening exercises, and aerobic exercises were among the most common treatment preferences. There were significant variations among therapists in private practice, hospital-operated, and health maintenance organization settings with respect to treatment preferences, willingness to take advantage of the placebo effect, and mean number of visits for patients with back pain.
Conclusions and Discussion: These variations emphasize the need for more outcomes research to identify the most effective treatment approaches and to guide clinical practice.
In conclusion,�the effective treatment of acute low back pain is essential because it can potentially help prevent the development of chronic low back pain. A growing number of chiropractors and physical therapists, including other healthcare professionals, have utilized the McKenzie method to help manage acute non-specific low back pain in patients. According to the research study, further evidence is required to support the use of the McKenzie method for LBP, however, the outcome measures of the research study regarding the effectiveness of the McKenzie method for low back pain are promising. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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Organic Diet: It seems our moms were right; we are what we eat. Unfortunately in today’s marketplace, there are many valid worries about the foods we consume. Antibiotics, pesticides, and foods tainted with dangerous diseases are a top concern for many Americans. In addition, processed and genetically modified foods and artificial ingredients contribute to a number of health issues from obesity to cancer.
Our diet is one of the most important facets of maintaining overall good health for the long term. Farmer’s markets, small grocery stores, and the movement toward organic labeling shows the trend toward making healthier food choices.
If you are thinking about adding a few organic foods to your meal plan, or chucking all processed foods altogether, you are moving toward a healthier, higher performing body with fewer health issues.
Organic Diet: Five Reasons Why
#1: Fewer Chemicals
The practice of using a variety of pesticides in non-organic farming is widespread in the United States. No matter how fastidiously you wash them, foods with these toxins are harmful to your body. A recent article in The Huffington Post stated that toxic pesticides are present in 70% of the food found in grocery stores!
Many large, traditional farms aim to produce as much food as possible, as cheaply as they can. They turn to pesticides and herbicides to make the crops grow faster and last longer. It’s a sad fact, but the American public ends up paying a price anyway. An organic diet offers a respite from these chemically laden foods.
#2: Tastes Better
You may not even realize the taste you DON’T get when eating processed foods. Toxins that make them grow and keep them fresh deplete the taste dramatically.
Growing from properly maintained soil without the presence of pesticides, organic foods deliver a richer, more engaging flavor. Individuals who eat organic often eat less and are better satisfied with their meals because of the increased taste.
#3: More Nutrient Density
According to The Ideal Bite, organic foods contain up to 50% more nutrients than their non-organic counterparts. Depleted soil quality from over farming is a key reason for this situation. This means a person needs to eat less organic food to maintain the necessary dietary vitamins and minerals that ensures good health, offsetting the initial higher cost of choosing organic.
#4: Less Antibiotic Exposure
Large food manufacturing farms often choose to pump their animals full of antibiotics to reduce illness and promote rapid growth. Obviously, these make their way into the end product that we end up eating.
Too much exposure to antibiotics causes everything from early puberty in children to antibiotic resistance. If you become ill and require antibiotic medical treatment, long-term consumption of non-organic meat could literally hinder you from responding.
#5: Supports The Local Economy
In addition to building a strong body and mind, choosing organic contributes to the local community by supporting the small farmer. The small farmer is able to adopt to organic standards with less effort, and is more likely to embrace healthy soil practices and other ethical farming traits in the first place. Seek out local establishments for the widest variety of the freshest, locally grown food.
There are an assortment of reasons to choose an organic diet. In a nutshell, it is proven to offer great benefits to your long-term overall health. If you can’t commit to an entirely organic diet, substitute a few organic choices from your present food selections. Even changing small areas of your diet will provide better taste, greater nutrition, and stronger well-being.
Have more questions? We�re here for you! Simply ask our Doctor of Chiropractic during your next visit how eating organic foods can benefit you.
Good Nutrition & Chiropractic Care Contribute To Overall Well-Being
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Sternocleidomastoid (SCM)
Assessment for Shortness of Sternocleidomastoid�(see also Box 4.10)
Assessment for SCM is as for the scalenes � there is no absolute test for shortness but observation of posture (hyperlordotic neck, chin poked forward) and palpation of the degree of induration, fibrosis and trigger point activity can all alert to probable shortness of SCM. This is an accessory breathing muscle and, like the scalenes, will be shortened by inappropriate breathing patterns which have become habitual. Observation is an accurate assessment tool.
Box 4.10 Notes on Sternocleidomastoid
Sternocleidomastoid (SCM) is a prominent muscle of the anterior neck and is closely associated with the trapezius. SCM often acts as postural compensator for head tilt associated with postural distortions found elsewhere (spinal, pelvic or lower extremity functional or structural inadequacies, for instance) although they seldom cause restriction of neck movement.
SCM is synergistic with anterior neck muscles for flexion of the head and flexion of the cervical column on the thoracic column, when the cervical column is already flattened by the prevertebral muscles. However, when the head is placed in extension and SCM contracts, it accentuates lordosis of the cervical column, flexes the cervical column on the thoracic column, and adds to extension of the head. In this way, SCM is both synergist and antagonist to the prevertebral muscles (Kapandji 1974).
SCM trigger points are activated by forward head positioning, �whiplash� injury, positioning of the head to look upwardly for extended periods of time and structural compensations. The two heads of SCM each have their own patterns of trigger point referral which include (among others) into the ear, top of head, into the temporomandibular joint, over the brow, into the throat, and those which cause proprioceptive disturbances, disequilibrium, nausea and dizziness. Tenderness in SCM may be associated with trigger points in the digastric muscle and digastric trigger points may be satellites of SCM trigger points (Simons et al 1998).
Simons et al (1998) report: When objects of equal weight are held in the hands, the patient with unilateral trigger point [TrP] involvement of the clavicular division [of SCM] may exhibit an abnormal Weight Test. When asked to judge which is heaviest of two objects of the same weight that look alike but may not be the same weight (two vapocoolant dispensers, one of which may have been used) the patient will [give] evidence [of] dysmetria by underestimating the weight of the object held in the hand on the same side as the affected sternocleidomastoid muscle. Inactivation of the responsible sternocleidomastoid TrPs promptly restores weight appreciation by this test. Apparently, the afferent discharges from these TrPs disturb central processing of proprioceptive information from the upper limb muscles as well as vestibular function related to neck muscles.
Lymph nodes lie superficially along the medial aspect of the SCM and may be palpated, especially when enlarged. These nodes may be indicative of chronic cranial infections stemming from a throat infection, dental abscess, sinusitis or tumour. Likewise, trigger points in SCM may be perpetuated by some of these conditions (Simons et al 1998).
Lewit (1999) points out that tenderness noted at the medial end of the clavicle and/or at the transverse process of the atlas is often an indication of SCM hypertonicity. This will commonly accompany a forward head position and/or tendency to upper chest breathing, and will almost inevitably be associated with hypertonicity, shortening and trigger point evolution in associated musculature, including scalenes, upper trapezius and levator scapula (see crossed syndrome notes in Ch. 2).
Since SCM is only just observable when normal, if the clavicular insertion is easily visible, or any part of the muscle is prominent, this can be taken as a clear sign of tightness of the muscle.�If the patient�s posture involves the head being held forward of the body, often accompanied by cervical lordosis and dorsal kyphosis (see notes on upper crossed syndrome in Ch. 2), weakness of the deep neck flexors and tightness of SCM is suspected.
Functional SCM Test (see Fig. 5.14A, B)
The supine patient is asked to �very slowly raise your head and touch your chin to your chest�. The practitioner stands to the side with his head at the same level as the patient. At the beginning of the movement of the head, as the patient lifts this from the table, the practitioner would (if SCM were short) note that the chin was lifted first, allowing it to jut forwards, rather than the forehead leading the arc-like progression of the movement. In marked shortness of SCM the chin pokes forward in a jerk as the head is lifted. If the reading of this sign is unclear then Janda (1988) suggests that a slight resistance pressure be applied to the forehead as the patient makes the �chin to chest� attempt. If SCM is short this will ensure the jutting of the chin at the outset.
MET Treatment of Shortened SCM (Fig. 4.35)
The patient is supine with the head supported in a neutral position by one of the practitioner�s hands. The shoulders rest on a cushion or folded towel, so that when the head is placed on the table it will be in slight extension. The patient�s contralateral hand rests on the upper aspect of the sternum to act as a cushion when pressure is applied during the stretch phase of the operation (as in scalene and pectoral treatment). The patient�s head is fully but comfortably rotated, contralaterally.
Figure 4.35 MET of sternocleidomastoid on the right.
The patient is asked to lift the fully rotated head a small degree towards the ceiling, and to hold the breath. When the head is raised there is no need for the practitioner to apply resistance as gravity effectively provides this.
After 7�10 seconds of isometric contraction (ideally with breath held), the patient is asked to slowly release the effort (and the breath) and to place the head (still in rotation) on the table, so that a small degree of extension occurs.
The practitioner�s hand covers the patient�s �cushion� hand (which rests on the sternum) in order to apply oblique pressure/stretch to the sternum, to ease it away from the head and towards the feet.
The hand not involved in stretching the sternum caudally should gently restrain the tendency the head will have to follow this stretch, but should not under any circumstances apply pressure to stretch the head/neck while it is in this vulnerable position of rotation and slight extension.
The degree of extension of the neck should be slight, 10�15� at most.
This stretch, which is applied as the patient exhales, is maintained for not less than 20 seconds to begin the release/stretch of hypertonic and fibrotic structures. Repeat at least once. The other side should then be treated in the same manner.
CAUTION: Care is required, especially with middle aged and elderly patients, in applying this useful stretching procedure. Appropriate tests should be carried out to evaluate cerebral circulation problems. The presence of such problems indicates that this particular MET method should be avoided.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
Muscular energy techniques, or METs, are considered to be some of the most valuable tools any healthcare professional can have and there are several reasons for it. METs have a wide application range and essential modifications can be made for each of them for a variety of injuries and/or conditions. Muscular energy techniques also represent an important aspect of rehabilitation. Furthermore, METs are both gentle and effective. But most importantly, METs actively involve the patient in the recovery process. Unlike other types of treatment therapies, the patient is involved in every step, contracting at the appropriate time, relaxing at the appropriate time, engaging in eye movement, and even breathing when instructed by the healthcare professional.
Muscular energy techniques have been used with other treatment modalities, such as the McKenzie method, to improve the outcome measures of injuries or conditions. The following research study demonstrates clinical and experimental evidence on the impact of the McKenzie method with METs for low back pain, one of the most common complaints affecting spine health. The purpose of the article is to educate and advice patients with low back pain on the use of METs with the McKenzie method.
Impact of McKenzie Method Therapy Enriched by Muscular Energy Techniques on Subjective and Objective Parameters Related to Spine Function in Patients with Chronic Low Back Pain
Abstract
Background: The high incidence and inconsistencies in diagnostic and therapeutic process of low back pain (LBP) stimulate the continuing search for more efficient treatment modalities. Integration of the information obtained with various therapeutic methods and a holistic approach to the patient seem to be associated with positive outcomes.The aim of this study was to analyze the efficacy of combined treatment with McKenzie method and Muscle Energy Technique (MET), and to compare it with the outcomes of treatment with McKenzie method or standard physiotherapy in specific chronic lumbar pain.
Material/Methods: The study included 60 men and women with LBP (mean age 44 years). The patients were randomly assigned to 1 of 3 therapeutic groups, which were further treated with: 1) McKenzie method and MET, 2) McKenzie method alone, or 3) standard physiotherapy for 10 days. The extent of spinal movements (electrogoniometry), level of experienced pain (Visual Analogue Scale and Revised Oswestry Pain Questionnaire), and structure of the spinal discs (MRI) were examined prior to the intervention, immediately thereafter, and 3 months after the intervention.
Results: McKenzie method enriched with MET had the best therapeutic outcomes. The mobility of cervical, thoracic, and lumbar spine normalized at levels corresponding to 87.1%, 66.7%, and 95% of respective average normative values. Implementation of McKenzie method, both alone and combined with MET, was associated with a significant decrease in Oswestry Disability Index, significant alleviation of pain (VAS), and significantly reduced size of spinal disc herniation.
Conclusions: The combined method can be effectively used in the treatment of chronic LBP.
MeSH Keywords:Low Back Pain, Manipulation, Chiropractic, Manipulation, Spinal
Background
Low back pain (LBP) is the most prevalent form of musculoskeletal disorder. According to published statistical data, 70�85% of people experience LBP at some stage of their lives [1�7]. Only 39�76% of the patients recover completely after an acute episode of pain, suggesting that a considerable fraction of them develop a chronic condition [8].
The goals of physiotherapy in patients with chronic LBP include elimination of pain, restoration of the lost extent of movements, functional improvement, and improvement of the quality of life. These objectives are achieved by various protocols of exercise, manipulation, massage, relaxation techniques, and counselling. Although numerous previously published studies have dealt with various therapeutic modalities of LBP, the evidence of their efficacy is highly inconclusive [9�12]. At present the management of chronic LBP still raises many controversies. Inconsistency of established diagnoses and implemented protocols of management points to the importance of the problem in question. Despite extensive research, the issue of spinal pain management still constitutes a challenge for physicians, physiotherapists, and researchers [8,13].
McKenzie method is 1 of many treatment modalities of LBP. It is a system of mechanical diagnosis and management of spinal pain syndromes, based on comprehensive and reproducible evaluation, knowledge of symptoms patterns, directional preference, and centralization phenomenon. This method is focused on the spinal disc disorders [14]. McKenzie method is based on the phenomenon of movement of the nucleus pulposus inside the intervertebral disc, depending on the adopted position and the direction of the movements of the spine. The nucleus pulposus that is exposed to the pressure from both surfaces of the vertebral bodies takes the shape of a spherical joint. This means that it has the ability to perform 3 rotary movements in all directions and has 6 degrees of freedom of movement. The nucleus pulposus performs the movements of flexion, extension, lateral bend (left and right), rotation (right and left), linear displacement (slip) along the sagittal axis, linear displacement along the transverse axis and the separation or approximation along the vertical axis [15].Numerous studies have shown that during forward bend of the spine it is possible to observe extension of the rear surface of the fibrous ring, compressing of the front part of the intervertebral disc and the shift of nucleus pulposus to the dorsal side. When stretching, the mechanism is the opposite [16].
The musculoskeletal system is vital for the maintenance of the balanced tension of the body. Musculofascial disorders can be associated with various problems, pain, or even loss of some motor function. Muscle Energy Techniques (MET) are among the most popular therapeutic modalities aimed at the improvement of elasticity in contractile and non-contractile tissues [17].
High incidence, inconsistencies in diagnostic and therapeutic process, and huge costs associated with the management of chronic spinal disorders stimulate the continuing search for more efficient treatment modalities. This requires the knowledge of neurophysiological processes, proper interpretation of pain, identification of unfavorable motor and postural patterns, holistic approach to the patient, and integration of the information obtained with various therapeutic methods [18].
The aim of this study was to analyze the efficacy of combined treatment with McKenzie method and MET, and to compare it with the outcomes of treatment with McKenzie method or standard physiotherapy in chronic lumbar pain. We evaluated the effect exerted by each of the interventions on the extent of movements, level of experienced pain, and structure of the spinal discs as assessed by means of magnetic resonance imaging.
Material and Methods
Patients
The randomized study included 60 men and women with mean age of 44 years. All individuals were diagnosed by a specialist physician and referred for rehabilitation. The protocol of the study was approved by the Local Bioethical Committee of the Poznan University of Medical Sciences (decision no. 368/0). All patients were diagnosed with chronic spinal pain persisting for longer than 1 year. The inclusion criteria of the study were: 1) documented magnetic resonance imaging (MRI) of the spine, 2) confirmed protrusion or bulging in the lumbosacral spine, 3) intermittent lumbosacral pain, 4) projection of pain to the buttock or thigh, 5) unilateral character of the symptoms. The exclusion criteria were: 1) confirmed extrusion or sequestration of nucleus pulposus of the spinal disc, 2) symptoms manifesting below the knee, 3) history of spinal surgery, 4) structural disorders of spinal discs in more than 2 spinal segments, 5) evident stenosis of the spinal canal, 6) focal lesions of the spinal cord, and 7) spondylolisthesis.
Patients showed great interest and all completed the study.
Protocol
The following tests were used to determine the baseline (i.e. pre-intervention) parameters of the studied patients: 1) electrogoniometric determination of the extent of movement in all spinal segments and angular values of physiological curvatures, 2) Oswestry questionnaire, and 3) Visual Analogue Scale (VAS). Subsequently, the patients were randomly assigned to 1 of 3 therapeutic groups (20 persons each), which were further treated with: 1) McKenzie method and MET, 2) McKenzie method alone, 3) standard physiotherapy. Each of the 3 therapeutic protocols included 10 daily sessions, performed during 5 consecutive weekdays. 24 hours following the last therapeutic session, the same parameters as at the baseline were determined by the investigator blinded to the treatment assignment. Moreover, all patients were subjected to repeated magnetic resonance.
Therapeutic Intervention
McKenzie group One session lasted 30 minutes. On the basis of the McKenzie spinal pain classification, the derangement syndrome was diagnosed in all patients [14]. The therapy included hyperextension techniques, hyperextension with self-pressure or pressure by the therapist, and hyperextensive mobilization. These techniques were applied in the sagittal plane, following the rule of force progression [14]. Moreover, the patients were asked to self-perform the therapeutic procedure at home (5 cycles per day with 2-hour intervals, 15 repetitions each).
McKenzie + MET group The classic McKenzie method enriched with Muscle Energy Technique was implemented. McKenzie protocol in both groups (McKenzie McKenzie + MET) was the same. All patients in this therapeutic group were also diagnosed with the derangement syndrome. A technique of post-isometric relaxation was used at the end of each therapeutic session. It was characterized by the following parameters: 1) time of contraction equal to 7�10 seconds, 2) intensity of contraction corresponding to 20�35%, 3) beginning in the intermediate extent of movement for a given patient, 4) 3 seconds of interval between consecutive contraction phases, 5) 3 repetitions, 6) contraction of antagonist muscle at the terminal phase of the procedure, 7) passive return to the baseline position. The procedure involved relaxation of the erector spinae muscle group and was performed in a sitting position. The exercise was performed in an anterior and lateral flexion, and in rotation. The therapy involved bilateral parts of the erector spinae so as to balance the muscular tension [17]. The duration of 1 combined session was 40 minutes. Patients treated with the combined method were also asked to exercise at home (5 cycles per day with 2-hour intervals, 15 repetitions each).
Standard treatment group Individuals randomized to this therapeutic group were treated with classical massage, laser therapy, and transcutaneous electrical nerve stimulation (TENS) applied to the lumbosacral region. Additionally, the patients were asked to perform general exercises strengthening spinal and abdominal muscles (once a day at home). The exercises were to be performed for 15 minutes, in a prone, supine, and lateral position. The aim of the training was to strengthen the muscles stabilizing the pelvic girdle, i.e. the erector spinae, quadratus lumborum, rectus abdominis, oblique abdominal, gluteal, and iliopsoas muscles. The classical massage lasted 20 minutes. The laser therapy was conducted with a contact technique with Lasertronic LT-2S device. The duration of laser therapy was 80 seconds (2�40 s). The treatment was applied on both sides of the spinous processes of the lumbar spine. The parameters of the procedure were as follows: energy 32 J, power of radiation 400 mW, wavelength 810 nm, continuous mode. TENS electrotherapy was performed with Diatronic DT-10B device. The electrodes were placed on both sides of the lumbosacral spine. The parameters of the TENS procedure were as follows: duration 15 minutes, frequency 50 Hz, current 20�30 mA (subjectively adjusted), duration of a single impulse 50 microseconds. The total time per session=36 min 20 sec + 15 min as home exercises once a day.
Evaluation of Therapeutic Effect
Electrogoniometry The extent of movements and the angles of spinal curvatures were determined with tensiometric Penny & Giles electrogoniometer in Boocok�s modification [19], which prevents potential measurement bias associated with shifting skin and soft tissues in relation to bones. The electrogoniometer enables linear measurement with a bias no greater than 1�. The measurements were taken according to Lewandowski�s methodology [20]. The reliability of these measurements was previously verified by Szulc et al.21 The reference values used in our study were calculated on the basis of Lewandowski�s measurements taken in a group of about 20 000 individuals [20].
Revised Oswestry pain questionnaire The degree to which the dysfunction of the lumbar spine limited the performance of the activities of daily living was determined with the Revised Oswestry Pain Questionnaire [22,23]. We used the revised version of the questionnaire as it is the only variant of this instrument which examines the changes in the level of lumbar pain. The survey was conducted twice, prior to and after the therapy.
Visual analogue scale (VAS) To verify the efficacy of the therapy, the participants were examined with the visual analogue scale (VAS) at the baseline (prior to the intervention) and 24 hours after completing the treatment [24].
Magnetic resonance imaging The degree of degeneration of the spinal discs and the therapeutic outcome were verified on magnetic resonance imaging performed prior to and after the intervention, at the same time of the day. The examination was conducted in sagittal and axial planes, and used T1- and T2-weighted images. The displacement of the nucleus pulposus was expressed in mm. The methodology of examination was described previously by Fazey et al. [25].
Statistical Analysis
Statistical analysis was conducted with Statistica 10.0 software. Bivariate analysis of variance (AVOVA) with 1 intergroup factor (type of intervention) and 1 intragroup factor (measurement prior to intervention, 24 hours and 3 months after the intervention) was used to analyze the differences in studied parameters resulting from the type of the implemented therapy, and to verify the efficacy of various therapeutic protocols. The significance of differences in multiple comparisons was verified with the Scheff�s post-hoc test.
Dr. Alex Jimenez’s Insight
Low back pain is a common symptom that can be treated in a number of ways. Chiropractic care is one of the most common alternative treatment options for LBP, however, healthcare professionals have started using other treatment modalities to help improve symptoms of low back pain. Physical therapy and exercise have commonly been used together, alongside well-known treatment modalities, to help speed up the patient’s recovery process. The research study aims to determine how the McKenzie method and muscular energy techniques can improve low back pain and promote overall health and wellness. As a doctor of chiropractic, the positive effects of physical therapy and exercise is reflected on the recovery of patients.
Results
The significant effects of bivariate interaction (method � time) suggest that the implemented therapeutic methods exerted variable time-dependent effect on the functional parameters of the spine, Oswestry questionnaire scores, values of visual analog scale, and the results of magnetic resonance imaging in patients with chronic low back pain.
Data on the mobility of various spinal segments prior to the intervention, and 24 hours and 3 months after the intervention suggests that the implementation of McKenzie method enriched with MET was reflected by better therapeutic outcome compared to classical McKenzie method and standard physiotherapy. Mobility of various spinal segments in all axes and planes improved significantly as a result of the therapy with McKenzie method enriched in MET. In contrast, the least pronounced improvement of spinal mobility was documented in the case of standard physiotherapy (Tables 1?�3).
Table 1: Basic statistical characteristics and significance of differences between the angular values of the cervical spine mobility depending on the phase of the study and type of implemented therapeutic method.
Table 2: Basic statistical characteristics and significance of differences between the angular values of the thoracic spine mobility depending on the phase of the study and type of implemented therapeutic method.
Table 3: Basic statistical characteristics and significance of differences between the angular values of the lumbar spine mobility depending on the phase of the study and type of implemented therapeutic method.
The analysis of the anterior flexion of the cervical spine revealed that the improvement of mobility was most pronounced in McKenzie + MET group (?%=42.02). The lack of significant difference between the measurement taken immediately after the intervention and 3 months thereafter suggests that the therapeutic effect was persistent. Less pronounced, albeit significant, improvement of the mobility was also documented in the case of McKenzie method alone (?%=14.79); also this effect persisted after 3 months. In contrast, no significant changes in the extent of anterior flexion of the cervical spine were documented in the group subjected to standard physiotherapy (Figure 1).
Figure 1: Mean angular values of the anterior flexion of the cervical spine determined at various phases of the study in patients treated with three different therapeutic methods (McKenzie method + MET, McKenzie method alone, standard physiotherapy).
Also, the analysis of changes in the degree of thoracic and lumbar spine anterior flexion revealed variability in the outcomes of the studied methods (Figures 2, ?3).
Figure 2: Mean angular values of the anterior flexion of the thoracic spine determined at various phases of the study in patients treated with three different therapeutic methods (McKenzie method + MET, McKenzie method alone, standard physiotherapy).
Figure 3: Mean angular values of the anterior flexion of the lumbar spine determined at various phases of the study in patients treated with three different therapeutic methods (McKenzie method + MET, McKenzie method alone, standard physiotherapy).
The greatest improvement of the mobility, equal to ?%=80.34 and ?%=40.43 in the thoracic and lumbar segment, respectively, was documented in the McKenzie + MET group. The lack of significant difference between the measurements of both the segments taken immediately after the intervention and 3 months thereafter suggests that the therapeutic effect was persistent (Tables 2, ?3). The changes in the remaining functional spinal parameters followed a similar pattern and are summarized in Tables 1?�3.
The degree of mobility in various spinal segments observed after implementation of studied therapeutic methods was compared with respective average normative values published by Lewandowski [20[ (Figures 4?�6). Implementation of McKenzie method enriched with MET was reflected by the most pronounced improvement in the spinal mobility, which fit within the respective normative ranges. The functional parameters of cervical, thoracic, and lumbar spine normalized at levels corresponding to 87.1%, 66.7%, and 95% of respective average normative values.
Figure 4: Functional parameters of the cervical spine (CL � cervical lordosis; CAF � cervical anterior flexion; CPF � cervical posterior flexion; CRF � cervical right flexion; CLF � cervical left flexion; CRR � cervical right rotation; CLR � cervical left rotation) � comparison between values determined in patients treated with three different therapeutic methods and respective normative values published by Lewandowski.
Figure 5: Functional parameters of the thoracic spine (ThK � thoracic kyphosis; ThAF � thoracic anterior flexion; ThPF � thoracic posterior flexion; ThRF � thoracic right flexion; ThLF � thoracic left flexion; ThRR � thoracic right rotation; ThLR � thoracic left rotation) � comparison between values determined in patients treated with three different therapeutic methods and respective normative values published by Lewandowski.
Figure 6: Functional parameters of the lumbar spine (LL � lumbar lordosis; LAF � lumbar anterior flexion; LPF � lumbar posterior flexion; LRF � lumbar right flexion; LLF � lumbar left flexion; LRR � lumbar right rotation; LLR � lumbar left rotation) � comparison between values determined in patients treated with three different therapeutic methods and respective normative values published by Lewandowski.
Irrespective of the therapeutic method and timing of measurement, the angular values of all spinal curvatures fit within the respective normative values and no significant inter- and intragroup differences were documented (Table 4).
Table 4: Basic statistical characteristics and significance of differences between the angular values of the physiological spinal curvatures depending on the phase of the study and type of implemented therapeutic method.
The scores of Oswestry questionnaire also differed depending on the type of implemented intervention. Implementation of McKenzie method, both alone and combined with MET, was reflected by a significant decrease in Oswestry Disability Index. No significant differences were documented between the outcomes of these 2 methods. In contrast, standard physiotherapy had the least pronounced effect on the Oswestry Disability Index (Table 5).
Table 5: Basic statistical characteristics and significance of differences between the Oswestry questionnaire scores, values of visual analogue scale, and magnetic resonance imaging findings depending on the phase of the study and type of implemented therapeutic method.
The analysis of visual analogue scale values suggests that both McKenzie method enriched with MET and classical McKenzie method produced the strongest therapeutic effects, i.e. alleviation of pain. Implementation of both these methods was reflected by marked augmentation of experienced pain, without any significant intergroup differences. In contrast, standard physiotherapy reduced pain to a minimal extent, and no significant differences were observed between VAS scores obtained prior to and after this intervention (Table 5).
Magnetic resonance imaging performed prior to and after the intervention confirmed that McKenzie method enriched with MET produced the best therapeutic outcome manifested by a reduced size of spinal disc herniation. Smaller, albeit significant, improvement of this parameter was also documented in the case of classical McKenzie method. These 2 therapeutic methods did not differ significantly in terms of the post-intervention size of the spinal disc herniation. In contrast, no reduction in the size of the spinal disc herniation was documented after implementation of standard physiotherapy (Table 5).
Discussion
The number of studies validating the efficacy of combined therapeutic methods and techniques is sparse [3,21,26,27]. Wilson et al. [26] concluded that MET is an optimal adjunct technique for other therapeutic modalities [26].
Many studies confirmed the positive effects of McKenzie method [28�36]. Similarly, a body of evidence confirms the therapeutic value of MET [37�44]. Moreover, positive outcomes of both these techniques were documented in patients with spinal pain, including LBP [45,46]. However, to the best of our knowledge, none of the previous studies verified whether the combination of these methods improves the therapeutic outcome.
Noticeably, both the therapies are based on different concepts and involve different therapeutic techniques. The McKenzie method is oriented at the management of all structural abnormalities of the spinal discs. The aim of this therapy is to eliminate pain and normalize function of the affected spinal segment [14]. Therefore, McKenzie method focuses on the treatment of spinal disc pathologies as the principal cause of pain. Takasaki et al. [35] documented positive changes in the spinal disc, i.e. the resolution of herniation, in patient treated with McKenzie method.
However, various injuries and other medical conditions, as well as repetitive negative motor pattern, are also reflected by the disorders of the musculofascial system. This can be reflected by the development of certain compensatory mechanisms, accumulation of muscular tension, motor limitation, and functional disorders [17,40,42]. In contrast, the treatment of the musculofascial system is not included in the concept of McKenzie method. Therefore, the aim of including the muscle energy techniques in the proposed protocol of combined therapy was to potentiate its therapeutic effect through the relaxation and stretching of contracted musculature, strengthening of weakened muscles, reduction of passive muscular tension, improvement of joint mobility, and normalization of motor function [26,43].
The differences observed with regards to the mobility of various spinal segments prior to and after the intervention point to better therapeutic outcome of the combined methods. Noticeably, improved mobility was documented not only in the lumbar spine but also in the cervical and thoracic segment. Therefore, the implementation of MET improved the scope of the combined method (McKenzie + MET) as compared to the classical McKenzie method. Our findings suggest that musculofascial disorders may to a large extent be responsible for limited spinal mobility in patients with chronic LBP. In their papers on the therapeutic effects of manual therapy, Pool et al. [12] and Zaproudina et al. [47] emphasize the importance of limitations in spinal mobility as a sensitive marker of pathological changes.
The magnetic resonance findings documented in patients treated with combined McKenzie method and MET suggest that this combination has no negative effect on the size of spinal disc herniation (Figure 7). This confirms the safety of MET and plausibility of its application in patients with spinal disc pathologies [26]. Of note, relatively large subjective and objective improvements were achieved despite the short duration of the treatment, which included only 10 sessions throughout a 2-week period.
Figure 7: Magnetic resonance images of the structural changes of the L5�S1 spinal disc: (A) prior to, and (B) after the combined therapy (McKenzie method + MET).
Furthermore, control electrogoniometry conducted 3 months after the intervention confirmed the persistent effect of the combined treatment. Moreover, a slight improvement was documented in the case of some functional parameters examined immediately after the intervention and 3 months thereafter. Perhaps, this phenomenon reflected proper education of our patients and further prophylactic self-exercising according to McKenzie method.
Chronic low back pain (CLBP) has a multifactorial etiology [18], and as such requires multimodal treatment. The evidence of therapeutic effects should not be limited to the diagnostic imaging, but mostly be reflected by functionality of a patient, level of experienced pain, extent of movements, and normalization of motor function.
Conclusions
The following conclusions can be formulated on the basis of our findings:
Comparison of the subjective and objective outcomes of 3 therapeutic methods � standard physiotherapy, McKenzie method alone, and McKenzie method combined with MET � in patients with chronic low back pain suggests that the combined method is the most effective.
The use of the combined method (McKenzie + MET) exerts a positive effect on structural (resolution of spinal disc herniation documented on MRI) and functional parameters (improved mobility of various spinal segments), improves the quality of life, and reduces the level of experienced pain.
Acknowledgements
The study was conducted under the auspices of the University School of Physical Education in Poznan. The authors express their gratitude to the owners of the Private Rehabilitation Practice �Antidotum� for consent to perform the study in their facility.
Footnotes
Source of support: The study was supported by the resources from the Ministry of Science and Higher Education for the statutory activity of the Department of Anatomy of the University School of Physical Education in Poznan
Conflict of interest: None declared.
In conclusion, the research study demonstrating clinical and experimental evidence on the impact of the McKenzie method with METs for low back pain, one of the most common complaints affecting spine health, concluded that the combined treatment modalities were effectively used in the improvement of chronic low back pain. The purpose of the article was to educate and advice patients with low back pain on the use of METs with the McKenzie method. Furthermore, the use of the combined treatment modalities demonstrated a positive effect on structural and functional parameters, improving the patient’s quality of life and reducing the level of pain they experienced. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
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14. McKenzie R, May S. The lumbar spine: mechanical diagnosis and therapy. 2nd ed. Waikanae: Spinal Publications; 2003.
15. Kanpandji AI. Anatomia funkcjonalna staw�w. Tom 3.6 ed. Wroc?aw: Elsevier Urban & Partners; 2010. [in Polish]
16. Alexander LA, Hancock E, Agouris I, et al. The response of the nucleus pulposus of the lumbar intervertebral discs to functionally loaded positions. Spine. 2007;32(14):1508�12. [PubMed]
17. Chaitow L. Muscle energy techniques. 3rd ed. Edinburgh: Churchill Livingstone; 2006.
18. O�Sullivan P. It�s time for change with the management of non-specific chronic low back pain. Br J Sports Med. 2012;46:224�27. [PubMed]
19. Boocock MG, Jackson JA, Burton AK, et al. Continuous measurement of lumbar posture using flexible electrogoniometers. Ergonomics. 1994;37:175�85. [PubMed]
20. Lewandowski J. Formation of physiological curvatures and segmental mobility of the human spine aged from 3 to 25 years in electrogoniometric studies. 1st ed. Poznan: AWF Poznan; 2006.
21. Szulc P, Lewandowski J, Marecki B. Verification of selected anatomic landmarks used as reference points for universal goniometer positioning during knee joints mobility range measurements. Med Sci Monit. 2001;7:312�15. [PubMed]
22. Fairbank JC, Pynsent PB. The Oswestry disability index. Spine. 2000;25:2940�52. [PubMed]
23. Hicks GE, Manal TJ. Psychometric properties of commonly used low back disability questionnaires: are they useful for older adults with low back pain? Pain Med. 2009;10:85�94. [PMC free article] [PubMed]
24. Mudgalkar N, Bele SD, Valsangkar S, et al. Utility of numerical and visual analog scales for evaluating the post-operative pain in rural patients. Indian J Anaesth. 2012;56:553�57. [PMC free article] [PubMed]
25. Fazey PJ, Takasaki H, Singer KP. Nucleus pulposus deformation in response to lumbar spine lateral flexion: an in vivo MRI investigation. Eur Spine J. 2010;19(11):1115�20. [PMC free article] [PubMed]
26. Wilson E, Payton O, Donegan-Shoaf L, et al. Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop Sports Phys Ther. 2003;33:502�12. [PubMed]
27. Bronfort G, Goldsmith CH, Nelson CF, et al. Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial. J Manipulative Physiol Ther. 1996;19:570�82. [PubMed]
28. Bybee RF, Olsen DL, Cantu-Boncser G, et al. Centralization of symptoms and lumbar range of motion in patients with low back pain. Physiother Theory Pract. 2009;25:257�67. [PubMed]
29. Chen J, Phillips A, Ramsey M, et al. A case study examining the effectiveness of mechanical diagnosis and therapy in a patient who met the clinical prediction rule for spinal manipulation. J Man Manip Ther. 2009;17:216�20. [PMC free article] [PubMed]
30. Garcia AN, Gondo FL, Costa RA, et al. Effects of two physical therapy interventions in patients with chronic non-specific low back pain: feasibility of a randomized controlled trial. Rev Bras Fisioter. 2011;15:420�27. [PubMed]
31. Hosseinifar M, Akbari M, Behtash H, et al. The effects of stabilization and Mckenzie exerciseson transverse abdominis and multifidus muscle thickness, pain, and disability: A randomized controlled trial in nonspecific chronic low back pain. J Phys Ther Sci. 2012;25:1541�45. [PMC free article] [PubMed]
32. Mbada CE, Ayanniyi O, Ogunlade SO, et al. Influence of Mckenzie protocol and two modes of endurance exercises on health-related quality of life of patients with long-term mechanical low-back pain. Pan Afr Med J. 2014;17(Supp 1):5. [PMC free article] [PubMed]
33. Garcia AN, da Cunha Menezes Costa L, Hancock MJ, et al. Efficacy of the McKenzie method in patients with chronic nonspecific low back pain: a protocol of randomized placebo-controlled trial. Phys Ther. 2015;95:267�73. [PubMed]
34. Schenk RJ, Jozefczyk C, Kopf A. A randomized trial comparing interventions in patients with lumbar posterior derangement. J Man Manip Ther. 2003;11:95�102.
35. Takasaki H, May S, Fazey PJ, et al. Nucleus pulposus deformation following application of mechanical diagnosis and therapy: a single case report with magnetic resonance imaging. J Man Manip Ther. 2010;18:153�58. [PMC free article] [PubMed]
36. Williams B, Vaughn D, Holwerda T. A mechanical diagnosis and treatment (MDT) approach for a patient with discogenic low back pain and a relevant lateral component: a case report. J Man Manip Ther. 2011;19:113�18. [PMC free article] [PubMed]
37. Chugh R, Kalra S, Sharma N, et al. Effects of muscle energy techniques and its comparison to self stretch of bilateral ankle plantarflexors on performance of balance scores in healthy elderly subjects. Physiother Occup Ther J. 2011;4:61�71.
38. Fryer G, Ruszkowski W. The influence of contraction duration in muscle energy technique applied to the atlanto-axial joint. J Osteopath Med. 2004;7:79�84.
39. Fryer G, Pearce AJ. The effect of muscle energy technique on corticospinal and spinal reflex excitability in asymptomatic participants. J Bodyw Mov Ther. 2013;17(4):440�47. [PubMed]
40. Gugliotti M. The use of mobilization, muscle energy technique, and soft tissue mobilization following a modified radical neck dissection of a patient with head and neck cancer. Rehabil Oncol. 2011;29:3�8.
41. K???k?en S, Yilmaz H, Sall? A, U?urlu H. Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: Randomized controlled trial with 1-year follow-up. Arch Phys Med Rehabil. 2013;94:2068�74. [PubMed]
42. Moore SD, Laudner KG, McLoda TA, et al. The immediate effects of muscle energy technique on posterior shoulder tightness: a randomized controlled trial. J Orthop Sports Phys Ther. 2011;41:400�7. [PubMed]
43. Rajadurai V. The effect of muscle energy technique on temporomandibular joint dysfunction: a randomized clinical trail. Asian J Sci Res. 2011;4:71�77.
44. Shadmehr A, Hadian MR, Naiemi SS, et al. Hamstring flexibility in young women following passive stretch and muscle energy technique. J Back Musculoskelet Rehabil. 2009;22:143�48. [PubMed]
45. Day JM, McKeon P, Nitz A. The efficacy of cervical/thoracic active range of motion for detecting changes associated with individuals receiving muscle energy techniques. Phys Ther Rev. 2010;15:453�61.
46. Day JM, Nitz AJ. The effect of muscle energy techniques on disability and pain scores in individuals with low back pain. J Sport Rehabil. 2012;21:194�98. [PubMed]
47. Zaproudina N, Hietikko T, Hanninen OO, et al. Effectiveness of traditional bone setting in treating chronic low back pain: a randomised pilot trial. Complement Ther Med. 2009;17:23�28. [PubMed][/accordion]
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Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Scalenes
Box 4.9 Notes on Scalenes
The scalenes are a controversial muscle since they seem to be both postural and phasic (Lin et al 1994), their status being modified by the type(s) of stress to which they are exposed (see Ch. 3 for discussion of this topic).
Janda (1988) reports that �spasm and/or trigger points are commonly present in the scalenes as also are weakness and/or inhibition�.
The attachment sites of the scalene muscles vary, as does their presence. The scalene posterior is sometimes absent, and sometimes blends with the fibres of medius.
Scalene medius is noted to frequently attach to the atlas (Gray 1995) and sometimes extend to the 2nd rib (Simons et al 1998).
The scalene minimus (pleuralis), which attaches to the pleural dome, is present in onethird (Platzer 1992) to three-quarters (Simons et al 1998) of people, on at least one side and, when absent, is replaced by a transverse cupular ligament (Platzer 1992).
The brachial plexus exits the cervical column between the scalenus anterior and medius. These two muscles, together with the 1st rib, form the scalene hiatus (also called the �scalene opening� or �posterior scalene aperture�) (Platzer 1992). It is through this opening�that the brachial plexus and vascular structures for the upper extremity pass. When scalene fibres are taut, they may entrap the nerves (scalene anticus syndrome) or may elevate the 1st rib against the clavicle and indirectly crowd the vascular, or neurologic, structures (simultaneous compromising of both neural and vascular structures is rare) (Stedman 1998). Any of these conditions may be diagnosed as �thoracic outlet syndrome�, which is �a collective title for a number of conditions attributed to compromise of blood vessels or nerve fibers (brachial plexus) at any point between the base of the neck and the axilla� (Stedman 1998).
Assessment of Shortness in Scalenes (14)
Assessment of cervical sidebending (lateral flexion) strength. This involves the scalenes and levator scapulae (and to a secondary degree the rectus capitis lateralis and the transversospinalis group).
The practitioner places a stabilising hand on the top of the shoulder to prevent movement and the other on the head above the ear, as the seated patient attempts to flex the head laterally against this resistance. Both sides are assessed.
Observation assessment (a) There is no easy test for shortness of the scalenes apart from observation, palpation and assessment of trigger point activity/tautness and a functional observation as follows:
In most people who have marked scalene shortness there is a tendency to overuse these (and other upper fixators of the shoulder and neck) as accessory breathing muscles.
There may also be a tendency to hyperventilation (and hence for there to possibly be a history of anxiety, phobic behaviour, panic attacks and/or fatigue symptoms).
These muscles seem to be excessively tense in many people with chronic fatigue symptoms.
The observation assessment consists of the practitioner placing his relaxed hands over the patient�s shoulders so that the fingertips rest on the clav-icles, at which time the seated patient is asked to inhale deeply. If the practitioner�s hands noticeably rise towards the patient�s ears during inhalation then there exists inappropriate use of scalenes, which indicates that they are stressed, which also means that, by definition, they will have become shortened and require stretching treatment.
Observation assessment (b) (Fig. 4.33) Alternatively, during the history taking interview, the patient can be asked to place one hand on the abdomen just above the umbilicus and the other flat against the upper chest.
Figure 4.33 Observation assessment of respiratory function. Any tendency for the upper hand to move cephalad, or earlier than the caudad hand, suggests scalene overactivity.
On inhalation, the hands are observed: if the upper hand initiates the breathing process and rises significantly towards the chin, rather than moving forwards, a pattern of upper chest breathing can be assumed, and therefore stress, and therefore shortness of the scalenes (and other accessory breathing muscles, notably sternomastoid).
MET Treatment of Short Scalenes (Fig. 4.34A, B, C)
Patient lies supine with a cushion or folded towel under the upper thoracic area so that, unless supported by the practitioner�s contralateral hand, the head would fall into extension. The head is rotated contralaterally (away from the side to be treated). There are three positions of rotation required:
Full contralateral rotation of the head/neck produces involvement of the more posterior fibres of the scalenes
A contralateral 45� rotation of the head/neck involves the middle fibres
A position of only slight contralateral rotation involves the more anterior fibres.
The practitioner�s free hand is placed on the side of the patient�s head to restrain the isometric contraction which will be used to release the scalenes. The patient�s head is in one of the above degrees of rotation, supported by the practitioner�s contralateral hand.
Figure 4.34A MET for scalenus posticus. On stretching, following the isometric contraction, the neck is allowed to move into slight extension while a mild stretch is introduced by the contact hand which rests on the second rib, below the lateral aspect of the clavicle.
Figure 4.34B MET treatment for the middle fibres of scalenes. The hand placement (thenar or hypothenar eminence of relaxed hand) is on the 2nd rib below the centre of the clavicle.
Figure 4.34C MET treatment of the anterior fibres of the scalenes; hand placement is on the sternum
The patient is instructed to try to lift the forehead a fraction and to attempt to turn the head towards the affected side, with appropriate breathing cooperation, while resistance is applied by the practitioner�s hand to prevent both movements (�breathe in and hold your breath as you �lift and turn�, and hold this for 7�10 seconds�). Both the effort and, the counter-pressure should be modest and painless at all times.
After a 7�10 second contraction, the head is placed into extension and one hand remains on it to prevent movement during the scalene stretch.
The patient�s contralateral hand is placed (palm down) just inferior to the lateral end of the clavicle on the affected side (for full rotation of the head, posterior scalenes). The practitioner�s hand which was acting to produce resistance to the isometric contraction is now placed onto the dorsum of the patient�s �cushion� hand.
As the patient slowly exhales, the practitioner�s contact hand, resting on the patient�s hand, which is itself resting on the 2nd rib and upper thorax, pushes obliquely away and towards the foot on that same side, following the rib movement into its exhalation position, so stretching the attached musculature and fascia. This stretch is held for at least 20 seconds after each isometric contraction. The process is then repeated at least once more.
The head is rotated 45� contralaterally and the �cushion� hand contact, which applies the stretch of the middle scalenes, is placed just inferior to the middle aspect of the clavicle. When the head is in the almost upright facing position for the anterior scalene stretch, the �cushion� hand contact is on the upper sternum itself.
In all other ways the methodology is as described for the first position above.
NOTE: It is important not to allow heroic degrees of neck extension during any phase of this treatment. There should be some extension, but it should be appropriate to the age and condition of the individual.
A degree of eye movement can assist scalene treatment and may be used as an alternative to the �lift and turn� muscular effort described above. If the patient makes the eyes look caudally (towards the feet) and towards the affected side during the isometric contraction, she will increase the degree of contraction in the muscles. If during the resting phase, when stretch is being introduced, she looks away from the treated side, with eyes looking towards the top of the head, this will enhance the stretch of the muscle.
This whole procedure should be performed bilaterally several times in each of the three head positions. Scalene stretches, with all their variable positions, clearly also influence many of the anterior neck structures.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
Acknowledging statistical data, low back pain can be the result of a variety of injuries and/or conditions affecting the lumbar spine and its surrounding structures. Most cases of low back pain, however, will resolve on their own in a matter of weeks. But when symptoms of low back pain become chronic, its essential for the affected individual to seek treatment from the most appropriate healthcare professional. The McKenzie method has been used by many healthcare specialists in the treatment of low back pain and its effects have been recorded widely throughout various research studies. The following two articles are being presented to evaluate the McKenzie method in the treatment of LBP in comparison to other types of treatment options.
Efficacy of the McKenzie Method in Patients With Chronic Nonspecific Low Back Pain: A Protocol of Randomized Placebo-Controlled Trial
Presented Abstract
Background: The McKenzie method is widely used as an active intervention in the treatment of patients with nonspecific low back pain. Although the McKenzie method has been compared with several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain.
Objective: The purpose of this trial is to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain.
Design: An assessor-blinded, 2-arm, randomized placebo-controlled trial will be conducted.
Setting: This study will be conducted in physical therapy clinics in S�o Paulo, Brazil.
Participants: The participants will be 148 patients seeking care for chronic nonspecific low back pain.
Intervention: Participants will be randomly allocated to 1 of 2 treatment groups: (1) McKenzie method or (2) placebo therapy (detuned ultrasound and shortwave therapy). Each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks).
Measurements: The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale) and disability (measured with the Roland-Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity; disability and function; kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization; and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor.
Limitations: Therapists will not be blinded.
Conclusions: This will be the first trial to compare the McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. The results of this study will contribute to better management of this population.
Subject:Therapeutic Exercise, Injuries and Conditions: Low Back, Protocols
Issue Section:Protocol
Low back pain is a major health condition associated with a high rate of absenteeism from work and a more frequent use of health services and work leave entitlements.[1] Low back pain recently was rated by the Global Burden of Disease Study as one of the 7 health conditions that most affect the world’s population,[2] and it is considered a debilitating health condition that affects the population for the greatest number of years over a lifetime.[2] The point prevalence of low back pain in the general population is reported to be up to 18%, increasing to 31% in the last 30 days, 38% in the last 12 months, and 39% at any point in life.[3] Low back pain also is associated with high treatment costs.[4] It is estimated that in European countries, the direct and indirect costs vary from �2 to �4 billion a year.[4] The prognosis of low back pain is directly related to the duration of the symptoms.[5,6] Patients with chronic low back pain have a less favorable prognosis compared with patients with acute low back pain[5,7] and are responsible for most of the costs for management of back pain, generating the need for research aimed at finding better treatments for these patients.
There is a great variety of interventions for the treatment of patients with chronic low back pain, including the McKenzie method developed by Robin McKenzie in New Zealand in 1981.[8] The McKenzie method (also known as Mechanical Diagnosis and Therapy [MDT]) is an active therapy that involves repeated movements or sustained positions and has an educational component with the purpose of minimizing pain and disability and improving spinal mobility.[8] The McKenzie method involves the assessment of symptomatic and mechanical responses to repeated movements and sustained positions. Patients’ responses to this assessment are used to classify them into subgroups or syndromes called derangement, dysfunction, and posture.[8�10] Classification according to one of these groups guides the treatment principles.
Derangement syndrome is the largest group and characterized by patients who demonstrate centralization (transition of pain from distal to proximal) or disappearance of pain[11] with repeated movement testing in one direction. These patients are treated with repeated movements or sustained positions that could reduce pain. Patients classified as having dysfunction syndrome are characterized by pain that occurs only at the end of the range of motion of only one movement.[8] The pain does not change or centralize with repeated movement testing. The treatment principle for patients with dysfunction is repeated movements in the direction that generated the pain. Finally, patients classified as having postural syndrome experience intermittent pain only during sustained positioning at the end of the range of motion (eg, sustained slumped sitting).[8] The treatment principle for this syndrome consists of posture correction.[11]
The McKenzie method also includes a strong educational component based on the books titled The Lumbar Spine: Mechanical Diagnosis & Therapy: Volume Two[11] and Treat Your Own Back.[12] This method, unlike other therapeutic methods, aims to make the patients as independent of the therapist as possible and thus capable of controlling their pain through postural care and the practice of specific exercises for their problem.[11] It encourages patients to move the spine in the direction that is not harmful to their problem, thus avoiding movement restriction due to kinesiophobia or pain.[11]
Two previous systematic reviews have analyzed the effects of the McKenzie method[9,10] in patients with acute, subacute, and chronic low back pain. The review by Clare et al[9] demonstrated that the McKenzie method showed better results in short-term pain relief and improvement of disability compared with active interventions such as physical exercise. The review by Machado et al[10] showed that the McKenzie method reduced pain and disability in the short term when compared with passive therapy for acute low back pain. For chronic low back pain, the 2 reviews were unable to draw conclusions about the effectiveness of the McKenzie method due to the lack of appropriate trials. The randomized controlled trials that have investigated the McKenzie method in patients with chronic low back pain[13�17] compared the method with other interventions such as resistance training,[17] the Williams method,[14] unsupervised exercises,[16] trunk strengthening,[15] and stabilization exercises.[13] Better results in reducing pain intensity were obtained with the McKenzie method compared with resistance training,[17] the Williams method,[14] and supervised exercise.[16] However, the methodological quality of these trials[13�17] is suboptimal.
It is known from the literature that the McKenzie method yields beneficial results when compared with some clinical interventions in patients with chronic low back pain; however, to date, no studies have compared the McKenzie method against a placebo treatment in order to identify its actual efficacy. Clare et al[9] highlighted the need to compare the McKenzie method with placebo therapy and to study the effects of the method in the long term. In other words, it is not known whether the positive effects of the McKenzie method are due to its real efficacy or simply to a placebo effect.
The objective of this study will be to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain using a high-quality randomized placebo-controlled trial.
Method
Study Design
This will be an assessor-blinded, 2-arm, randomized placebo-controlled trial.
Study Setting
This study will be conducted in physical therapy clinics in S�o Paulo, Brazil.
Eligibility Criteria
The study will include patients seeking care for chronic nonspecific low back pain (defined as pain or discomfort between the costal margins and the inferior gluteal folds, with or without referred symptoms in the lower limbs, for at least 3 months[18]), with a pain intensity of at least 3 points as measured with the 0- to 10-point Pain Numerical Rating Scale, aged between 18 and 80 years, and able to read Portuguese. Patients will be excluded if they have any contraindication to physical exercise[19] or ultrasound or shortwave therapy, evidence of nerve root compromise (ie, one or more motor, reflex, or sensation deficits), serious spinal pathology (eg, fracture, tumor, inflammatory and infectious diseases), serious cardiovascular and metabolic diseases, previous back surgery, or pregnancy.
Procedure
First, the patients will be interviewed by the study’s blinded assessor, who will determine eligibility. Eligible patients will be informed about the objectives of the study and asked to sign a consent form. Next, the patient’s sociodemographic data and medical history will be recorded. The assessor will then collect the data related to the study outcomes at the baseline assessment, after completion of 5 weeks of treatment, and 3, 6, and 12 months after randomization. With the exception of baseline measurements, all other assessments will be collected over the telephone. All data entry will be coded, entered into an Excel (Microsoft Corporation, Redmond, Washington) spreadsheet, and double-checked prior to the analysis.
Outcome Measures
The clinical outcomes will be measured at the baseline assessment, after treatment, and 3, 6, and 12 months after random allocation. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale)[20] and disability (measured with the Roland-Morris Disability Questionnaire)[21,22] after completion of 5 weeks of treatment. The secondary outcomes will be pain intensity and disability 3, 6, and 12 months after randomization and disability and function (measured by the Patient-Specific Functional Scale),[20] kinesiophobia (measured with the Tampa Scale of Kinesiophobia),[23] and global perceived effect (measured with the Global Perceived Effect Scale)[20] after treatment and 3, 6, and 12 months after randomization. On the day of the baseline assessment, each patient’s expectancy for improvement also will be assessed using the Expectancy of Improvement Numerical Scale,[24] followed by assessment using the McKenzie method.[8] Patients may experience an exacerbation of symptoms after the baseline assessment due to the MDT physical examination. All measurements were previously cross-culturally adapted into Portuguese and clinimetrically tested and are described below.
Pain Numerical Rating Scale
The Pain Numerical Rating Scale is a scale that assesses the levels of pain intensity perceived by the patient using an 11-point scale (varying from 0 to 10), in which 0 represents �no pain� and 10 represents the �worst possible pain.�[20] The participants will be instructed to select the average of pain intensity based on the last 7 days.
Roland-Morris Disability Questionnaire
This questionnaire consists of 24 items that describe daily activities that patients have difficulty performing due to low back pain.[21,22] The higher the number of affirmative answers, the higher the level of disability associated with low back pain.[21,22] The participants will be instructed to complete the questionnaire based on the last 24 hours.
Patient-Specific Functional Scale
The Patient-Specific Functional Scale is a global scale; therefore, it can be used for any part of the body.[25,26] The patients will be asked to identify up to 3 activities that they feel unable to perform or that they have difficulty performing due to their low back pain.[25,26] Measurement will be taken using Likert-type, 11-point scales for each activity, with higher average scores (ranging from 0 to 10 points) representing better ability to perform the tasks.[25,26] We will calculate the average of these activities based on the last 24 hours, with a final score ranging from 0 to 10.
Global Perceived Effect Scale
The Global Perceived Effect Scale is a Likert-type, 11-point scale (ranging from ?5 to +5) that compares the patient’s current condition with his or her condition at the onset of symptoms.[20] Positive scores apply to patients who are better and negative scores apply to patients who are worse in relation to the onset of symptoms.[20]
Tampa Scale of Kinesiophobia
This scale assesses the level of kinesiophobia (fear of moving) by means of 17 questions that deal with pain and intensity of symptoms.[23] The scores from each item vary from 1 to 4 points (eg, 1 point for �strongly disagree,� 2 points for �partially disagree,� 3 points for �agree,� and 4 points for �strongly agree�).[23] For the total score, it is necessary to invert the scores of questions 4, 8, 12, and 16.[23] The final score can vary from 17 to 68 points, with higher scores representing a higher degree of kinesiophobia.[23]
Expectancy of Improvement Numerical Scale
This scale assesses the patient’s expectancy for improvement after treatment in relationship to a specific treatment.[24] It consists of an 11-point scale varying from 0 to 10, in which 0 represents �no expectancy for improvement� and 10 represents �expectancy for the greatest possible improvement.�[24] This scale will be administered only on the first day of assessment (baseline) before the randomization. The reason for including this scale is to analyze whether the expectation of improvement will influence the outcomes.
Random Allocation
Before the treatment begins, the patients will be randomly allocated to their respective intervention groups. The random allocation sequence will be implemented by one of the researchers not involved with recruiting and assessing the patients and will be generated on Microsoft Excel 2010 software. This random allocation sequence will be inserted into sequentially numbered, opaque, sealed envelopes (to ensure that allocation is concealed from the assessor). The envelopes will be opened by the physical therapist who will treat the patients.
Blinding
Given the nature of the study, it is not possible to blind the therapists to the conditions of treatment; however, the assessor and the patients will be blinded to the treatment groups. At the end of the study, the assessor will be asked whether the patients were allocated to the real treatment group or to the placebo group in order to measure assessor blinding. A visual representation of the study design is presented in the Figure.
Figure 1: Flow Diagram of the Study.
Interventions
The participants will be allocated to groups receiving 1 of 2 interventions: (1) placebo therapy or (2) MDT. Participants in each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks). The studies on the McKenzie method do not have a standard number of sessions given that some studies propose low doses of treatment,[16,17,27] and others recommend higher doses.[13,15]
For ethical reasons, on the first day of treatment, patients from both groups will receive an information booklet called The Back Book,[28] based on the same recommendations as the existing guidelines.[29,30] This booklet will be translated into Portuguese so that it can be completely understood by the study’s participants, who will receive additional explanations regarding the content of the booklet, if needed. Patients will be asked in each session if they have felt any different symptom. The chief investigator of the study will periodically audit the interventions.
Placebo Group
The patients allocated to the placebo group will be treated with detuned pulsed ultrasound for 5 minutes and detuned shortwave diathermy in pulsed mode for 25 minutes. The devices will be used with the internal cables disconnected to obtain the placebo effect; however, it will be possible to handle them and adjust doses and alarms as if they were connected to simulate the pragmatism of clinical practice as well as to increase credibility of use of these devices on the patients. This technique has been used successfully in previous trials with patients with low back pain.[31�35]
McKenzie Group
The patients of the McKenzie group will be treated according to the principles of the McKenzie method,[8] and the choice of therapeutic intervention will be guided by the physical examination findings and classification. Patients also will receive written instructions from the Treat Your Own Back[12] book and will be asked to perform home exercises based on the principles of McKenzie method.[11] The descriptions of the exercises that will be prescribed in this study are published elsewhere.[27] Adherence to home exercises will be monitored by means of a daily log that the patient will fill in at home and bring to the therapist at each subsequent session.
Statistical Methods
Sample Size Calculation
The study was designed to detect a difference of 1 point in pain intensity measured with the Pain Numerical Rating Scale[20 ](estimate for standard deviation=1.84 points)[31] and a difference of 4 points in disability associated with low back pain measured with the Roland-Morris Disability Questionnaire[21,22] (estimate for standard deviation=4.9 points).[31] The following specifications were considered: statistical power of 80%, alpha level of 5%, and follow-up loss of 15%. Therefore, the study will require a sample of 74 patients per group (148 in total).
Analysis of the Effects of Treatment
The statistical analysis of our study will follow intention-to-treat principles.[36] The normality of the data will be tested by visual inspection of histograms, and the characterization of the participants will be calculated using descriptive statistical tests. The between-group differences (effects of treatment) and their respective 95% confidence intervals will be calculated by constructing mixed linear models[37] using interaction terms of treatment groups versus time. We will conduct a secondary exploratory analysis to assess whether patients classified as having derangement syndrome have a better response to the McKenzie method (compared with placebo) than those with other classifications. For this assessment, we will use a 3-way interaction for group, time, and classification. For all of these analyses, we will use the IBM SPSS software package, version 19 (IBM Corp, Armonk, New York).
Ethics
This study was approved by the Research Ethics Committee of the Universidade Cidade de S�o Paulo (#480.754) and prospectively registered at ClinicalTrials.gov (NCT02123394). Any protocol modifications will be reported to the Research Ethics Committee as well as to the trial registry.
Dr. Alex Jimenez’s Insight
Low back pain is one of the most common reasons people seek immediate medical attention for every year. Although many healthcare professionals are qualified and experienced in the diagnosis of the source of the patient’s low back pain, finding the right healthcare specialist who can provide the proper treatment for the individual’s LBP can be the real challenge. A variety of treatments can be used to treat low back pain, however, a wide array of healthcare professionals have started utilizing the McKenzie method in the treatment of patients with nonspecific low back pain. The purpose of the following article is to evaluate the effectiveness of the McKenzie method for low back pain, carefully analyzing the data of the research study.
Discussion
Potential Impact and Significance of the Study
The existing randomized controlled trials investigating the McKenzie method in patients with chronic low back pain have all used an alternative intervention as the comparison group.[14�17] To date, no study has compared the McKenzie method with a placebo treatment in patients with low back pain in order to identify its real efficacy, which is an important gap in the literature.[9] Interpretation of the previous comparative effectiveness studies is limited by the lack of knowledge of the efficacy of the McKenzie method for people with chronic low back pain. This study will be the first to compare McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. A proper comparison against a placebo group will provide more unbiased estimates of the effects of this intervention. This type of comparison has already been done in trials aiming to assess the efficacy of motor control exercises for patients with chronic low back pain,[31] spinal manipulative therapy and diclofenac for patients with acute low back pain,[38] and exercise and advice for patients with subacute low back pain.[39]
Contribution to the Physical Therapy Profession and for Patients
The McKenzie method is one of the few methods used in physical therapy that advocates for the independence of patients.[8,12] This method also provides patients with tools to promote their autonomy in managing the current pain and even future recurrences.[12] We expect that patients treated with the McKenzie method will benefit more than the patients treated with the placebo treatment. If this hypothesis is confirmed in our study, the results will contribute to better clinical decision making of physical therapists. Moreover, the approach has the potential to reduce the burden associated with the recurrent nature of low back pain if patients can better self-manage future episodes.
Strengths and Weaknesses of the Study
This trial contemplates a substantial number of patients to minimize bias, and it was prospectively registered. We will use true randomization, concealed allocation, blinded assessment, and an intention-to-treat analysis. The treatments will be conducted by 2 therapists who were extensively trained to perform the interventions. We will monitor the home exercise program. Unfortunately, due to the interventions, we will not be able to blind the therapists to the treatment allocation. It is known from the literature that the McKenzie method yields beneficial results when compared with some clinical interventions in patients with chronic low back pain.[14�17] To date, however, no studies have compared the McKenzie method with a placebo treatment in order to identify its actual efficacy.
Future Research
The intention of this study group is to submit the results of this study to a top-level, international peer-reviewed journal. These published results may provide a basis for future trials that investigate the effectiveness of the McKenzie method when delivered at different doses (different numbers of sets, repetitions, and sessions), which is still unclear in the literature. Our secondary exploratory analysis aims to assess whether patients classified as having derangement syndrome have a better response to the McKenzie method (compared with placebo treatment) than those with other classifications. This assessment will contribute to a better understanding of possible subgroups of patients with chronic low back pain who respond best to specific interventions. This is an important issue, as exploring subgroups is currently considered the most important research priority in the field of low back pain.[40]
This study was fully funded by S�o Paulo Research Foundation (FAPESP) (grant number 2013/20075-5). Ms Garcia is funded by a scholarship from the Coordination for the Improvement of Higher Education Personnel/Brazilian Government (CAPES/Brazil).
The study was prospectively registered at ClinicalTrials.gov (trial registration: NCT02123394).
Predicting a Clinically Important Outcome in Patients with Low Back Pain Following McKenzie Therapy or Spinal Manipulation: A Stratified Analysis in a Randomized Controlled Trial
Presented Abstract
Background: Reports vary considerably concerning characteristics of patients who will respond to mobilizing exercises or manipulation. The objective of this prospective cohort study was to identify characteristics of patients with a changeable lumbar condition, i.e. presenting with centralization or peripheralization, that were likely to benefit the most from either the McKenzie method or spinal manipulation.
Methods: 350 patients with chronic low back pain were randomized to either the McKenzie method or manipulation. The possible effect modifiers were age, severity of leg pain, pain-distribution, nerve root involvement, duration of symptoms, and centralization of symptoms. The primary outcome was the number of patients reporting success at two months follow-up. The values of the dichotomized predictors were tested according to the prespecified analysis plan.
Results: No predictors were found to produce a statistically significant interaction effect. The McKenzie method was superior to manipulation across all subgroups, thus the probability of success was consistently in favor of this treatment independent of predictor observed. When the two strongest predictors, nerve root involvement and peripheralization, were combined, the chance of success was relative risk 10.5 (95% CI 0.71-155.43) for the McKenzie method and 1.23 (95% CI 1.03-1.46) for manipulation (P?=?0.11 for interaction effect).
Conclusions: We did not find any baseline variables which were statistically significant effect modifiers in predicting different response to either McKenzie treatment or spinal manipulation when compared to each other. However, we did identify nerve root involvement and peripheralization to produce differences in response to McKenzie treatment compared to manipulation that appear to be clinically important. These findings need testing in larger studies.
Electronic supplementary material: The online version of this article (doi:10.1186/s12891-015-0526-1) contains supplementary material, which is available to authorized users.
Keywords:Low back pain, McKenzie, Spinal manipulation, Predictive value, Effect modification
Background
The most recent published guidelines for the treatment of patients with persistent non-specific low back pain (NSLBP) recommend a program focusing on self-management after initial advice and information. These patients should also be offered structured exercises tailored to the individual patient and other modalities such as spinal manipulation [1,2].
Previous studies have compared the effect of the McKenzie-method, also known as Mechanical Diagnosis and Therapy (MDT), with that of spinal manipulation (SM) in heterogeneous populations of patients with acute and subacute NSLBP and found no difference in outcome [3,4].
Recently, the need for studies testing the effect of treatment strategies for subgroups of patients with NSLBP in primary care has been emphasized in consensus-papers [5,6] as well as the current European guidelines [7], based on the hypothesis that subgroup analyses, preferably complying with the recommendations of �Prognostic Factor Research�[8], will improve decision making towards the most effective management strategies. Although initial data show promising results, there is presently insufficient evidence to recommend specific methods of subgrouping in primary care [1,9].
Three randomized studies, comprising patients with predominantly acute or subacute low back pain (LBP), have tested the effects of MDT versus SM in a subgroup of patients that presented with centralization of symptoms or directional preference (favorable response to end range motions) during physical examination [10-12]. The conclusions drawn from these studies were not in concurrence and the usefulness was limited by a low methodological quality.
Our recent randomized study, comprising patients with predominantly chronic LBP (CLBP), found a marginally better overall effect of MDT versus SM in an equivalent group [13]. In order to pursue the idea of subgrouping further, it was part of the study plan to explore predictors based on patient characteristics that could assist the clinician in targeting the most favorable treatment to the individual patient.
The objective of this study was to identify subgroups of patients with predominantly CLBP, presenting with centralization or peripheralization, which were likely to benefit from either MDT or SM two months after the completion of treatment.
Methods
Data Collection
The present study is a secondary analysis of a previously published randomized controlled trial [13]. We recruited 350 patients from September 2003 through May 2007 at an outpatient back care centre in Copenhagen, Denmark.
Patients
Patients were referred from primary care physicians for treatment of persistent LBP. Eligible patients were between 18 and 60 years of age, suffering from LBP with or without leg pain for a period of more than 6 weeks, able to speak and understand the Danish language, and fulfilled the clinical criteria for centralization or peripheralization of symptoms during initial screening. Centralization was defined as the abolition of symptoms in the most distal body region (such as the foot, lower leg, upper leg, buttocks, or lateral low back) and peripheralization was defined as the production of symptoms in a more distal body region. These findings have previously been found to have acceptable degree of inter-tester reliability (Kappa value 0.64) [14]. The initial screening was performed prior to randomization by a physical therapist with a diploma in the MDT examination system. Patients were excluded if they were free of symptoms at the day of inclusion, demonstrated positive non-organic signs [15], or if serious pathology, i.e. severe nerve root involvement (disabling back or leg pain in combination with progressive disturbances in sensibility, muscle strength, or reflexes), osteoporosis, severe spondylolisthesis, fracture, inflammatory arthritis, cancer, or referred pain from the viscera, was suspected based on physical examination and/or magnetic resonance imaging. Other exclusion criteria were application for disability pension, pending litigation, pregnancy, co-morbidity, recent back surgery, language problems, or problems with communication including abuse of drugs or alcohol.
The trial population had predominantly CLBP lasting on average 95 weeks (SD 207), mean age was 37 years (SD10), mean level of back and leg pain was 30 (SD 11.9) on a Numeric Rating Scale ranging from 0 to 60, and mean level of disability was 13 (SD 4.8) on Roland Morris Disability Questionnaire (0-23). Our method of pain measurement reflects that back pain is often a fluctuating condition where pain location and severity might vary on a daily basis. Therefore, a validated comprehensive pain questionnaire [16] was used in order to guarantee that all aspects of back and leg pain intensity were recorded. The scales are outlined in the legend to Table 1.
After baseline measures were obtained, randomisation was carried out by a computer-generated list of random numbers in blocks of ten using sealed opaque envelopes.
Ethics
Ethical approval of the study was granted by Copenhagen Research Ethics Committee, file no 01-057/03. All patients received written information about the study and gave their written consent prior to participation.
Treatments
The practitioners performing the treatments had no knowledge of the results of the initial screening. The treatment programs were designed to reflect daily practice as much as possible. Detailed information on these programs have been published earlier [13].
The MDT treatment was planned individually following the therapist�s pre-treatment physical assessment. Specific manual vertebral mobilization techniques including high velocity thrust were not allowed. An educational booklet describing self care [17] or a �lumbar roll� for correction of the seated position was sometimes provided to the patient at the discretion of the therapist. In the SM treatment, high velocity thrust was used in combination with other types of manual techniques. The choice of combination of techniques was at the discretion of the chiropractor. General mobilizing exercises, i.e. self-manipulation, alternating lumbar flexion/extension movements, and stretching, were allowed but not specific exercises in the directional preference. An inclined wedged pillow for correction of the seated position was available to the patients if the chiropractor believed this to be indicated.
In both treatment groups, patients were informed thoroughly of the results of the physical assessment, the benign course of back pain, and the importance of remaining physically active. Guidance on proper back care was also given. In addition, all patients were provided with a Danish version of �The Back Book� which previously has been shown to have beneficial effect on patients� beliefs about back pain [18]. A maximum of 15 treatments for a period of 12 weeks were given. If considered necessary by the treating clinician, patients were educated in an individual program of self-administered mobilizing, stretching, stabilizing, and/or strengthening exercises at the end of the treatment period. Treatments were performed by clinicians with several years of experience. Patients were instructed to continue their individual exercises at home or at a gym for a minimum of two months after completion of the treatment at the back center. Because the patients suffered predominantly from CLBP we expected this period of self administered exercises to be necessary for the patients to experience the full effect of the intervention. Patients were encouraged not to seek any other kind of treatment during this two months period of self-administered exercises.
Outcome Measures
The primary outcome was the proportion of patients reporting success at follow-up two months after end of treatment. Treatment success was defined as a reduction of at least 5 points or a final score below 5 points on the 23-item modified Roland Morris Disability Questionnaire (RMDQ) [19]. A validated Danish version of RMDQ was used [20]. The definition of treatment success was based on the recommendations by others [21,22]. A sensitivity analysis using 30% relative improvement on RMDQ as definition of success was also performed. In accordance with the protocol [13], we considered a relative between-group difference of 15% in the number of patients with successful outcome to be minimal clinically important in our analysis of interaction.
Prespecified Predictor Variables
In order to reduce the likelihood of spurious findings [23], we restricted the number of candidate effect modifiers in the dataset to six. To increase the validity of our findings, a directional hypothesis was established for each variable according to the recommendations of Sun et al. [24] Four baseline variables have previously been suggested in randomized studies to be predictive of long term good outcome in patients with persistent LBP following MDT in comparison with strengthening training: centralization [25,26], or following SM in comparison to physiotherapy or treatment chosen by a general practitioner: age below 40 years [27,28], duration of symptoms more than 1 year [27], and pain below the knee [29]. As recommended by others [30], another two variables were added based on the participating experienced clinicians� judgments of which characteristics they would expect to predict good outcome from their treatment compared to the other. The additional variables prioritized by the physiotherapists in the MDT group were signs of nerve root involvement and substantial leg pain. The additional variables prioritized by the chiropractors in the SM group were no signs of nerve root involvement and not substantial leg pain.
In a supplementary analysis, we took the opportunity to explore whether the inclusion of further six baseline variables, assumed to have prognostic value for good outcome in either of the treatment groups, would appear to have an effect modifying effect as well. To our knowledge, no further variables from previous one arm studies have been reported to have prognostic value of long term good outcome in patients with persistent LBP following MDT, whereas three variables have been reported to have prognostic value following SM: male gender [28], mild disability [28], and mild back pain [28]. Another three variables were agreed upon by the clinicians to be included in the supplementary analysis as they were assumed by experience from clinical practice to have prognostic value for good outcome regardless of treatment with MDT or SM: low number of days on sick leave past year, high patient expectations to recovery, and high patient expectations about coping with work tasks six weeks after initiation of treatment.
Dichotomization of possible predictor variables were made to allow for comparisons to be made with those of earlier studies. In cases where no cut off values could be found in the literature, dichotomization was performed above/below the median found in the sample. Definitions of variables are presented in the legend to Table 1.
Statistics
The entire intention-to-treat (ITT) population was used in all the analyses. The last score was carried forward for subjects with missing two months RMDQ scores (7 patients in the MDT group and 14 patients in the SM group). In addition, a post hoc per protocol analysis was carried out comprising only those 259 patients that completed the full treatment. The analysis plan was agreed in advance by the trial management group.
The possible predictors were dichotomized and the chance of success was investigated by estimating the relative risk (RR) of success in each of the two strata. The impact of the investigated predictors was estimated by comparing the chance of success between the treatment groups when divided into the two strata. To test for treatment effect modification of the predictors we performed chi-squared tests for interaction between intervention and the two different strata for each of the predictors. This is basically the same as an interaction from a regression model. Confidence intervals were also inspected for potential clinically important effects.
Following the univariate analysis, a multivariate analysis was planned including effect modifiers with a p-value below 0.1.
Dr. Alex Jimenez’s Insight
Low back pain can occur due to several types of injuries and/or conditions and its symptoms may be acute and/or chronic. Patients with low back pain can benefit from a variety of treatments, including chiropractic care. Chiropractic treatment is one of the most common alternative treatment options utilized to treat low back pain. According to the article, the results of the improvement of LBP with spinal adjustments and manual manipulations, along with the use of exercise, vary considerably among the participants. The focus of the following research study is to determine which patients are most likely to benefit from the McKenzie method as compared to spinal adjustments and manual manipulations.
Results
Participants were similar with respect to socio-demographic and clinical characteristics at baseline in the treatment groups. An overview of the distribution of the included dichotomized variables at baseline is provided in Table 1. No differences were found between the treatment groups.
Overall, the post hoc per protocol analysis did not produce outcome results that were different from the results of the ITT analysis and therefore only the results of the ITT analysis will be reported.
Figure 1 presents the distribution of predictors with regards to effect modification in the MDT group versus SM. In all subgroups, the probability of success with MDT was superior to that of SM. Because of low sample size, confidence intervals were wide and none of the predictors had a statistically significant treatment modifying effect. The predictors with a clinically important potential effect in favor of MDT compared to SM were nerve root involvement (28% higher proportion of patients with success when nerve root involvement was present than when absent) and peripheralization of symptoms (17% higher proportion of patients with success in case of peripheralization than in case of centralization). If present, nerve root involvement increased the chance of success following MDT 2.31 times compared to that of SM and 1.22 times if not present. This means that for the subgroup of patients with nerve root involvement receiving MDT, compared to those receiving SM, the relative effect appeared to be 1.89 times (2.31/1.22, P?= 0.118) higher than for the subgroup with no nerve root involvement.
Figure 1: Treatment effect modified by predictors. The top point estimate and confidence intervals indicate overall effect without subgrouping. Subsequent pairs of point estimates and confidence intervals show the chances of treatment success.
Figure 2 presents the modifying effect of a composite of the two predictors with a clinically important potential effect. If signs of nerve root involvement and peripheralization were present at baseline, the chance of success with MDT compared to SM appeared 8.5 times higher than for the subgroup with no centralization and nerve root involvement. The number of patients was very small and the differences were not statistically significant (P?=?0.11).
Figure 2: Impact of the two clinically important predictors combined on treatment effect. RR?=?Relative Risk with Yates correction.
None of the prognostic candidate variables explored in the supplementary analysis appeared to have any clinically important modifying effect (Additional file 1: Table S1).
The results from the sensitivity analysis using 30% relative improvement on RMDQ as definition of success were not markedly different from those presented above (Additional file 2: Table S2).
Discussion
To our knowledge, this is the first study trying to identify effect modifiers when two mobilizing strategies, i.e. MDT and SM, are compared in a sample of patients with as changeable condition characterized by centralization or peripheralization.
Our study found that none of the potential effect modifiers were able to statistically significantly increase the overall effect of MDT compared to that of SM. However, the between-group difference for two of the variables exceeded our clinically important success-rate of 15% in number of patients with successful outcome, so our study is likely to have missed a true effect and, in that sense, did not have a large enough sample size.
The most apparent finding is that in our small subgroup of patients with signs of nerve root involvement, the relative chance of success appeared 1.89 times (2.31/1.22) higher than in patients with no nerve root involvement when treated with MDT, compared to those treated with SM. The difference was in the expected direction.
Although not statistically significant in our small sample, the variable peripheralization exceeded our clinically important success-rate of 15%, but was found not to be in the expected direction. No previous studies have assessed the effect modification of centralization or peripheralization in patients with CLBP. The RCT by Long et al. [25,26] concluded that patients with directional preference, including centralization, fared better 2 weeks after baseline than patients with no directional preference when treated with MDT in comparison with strengthening training. However, the outcome among peripheralizers was not reported, so the poor outcome reported in patients with no directional preference might be related to the subgroup of patients who responded with no change in symptoms during initial examination and not to those that responded with peripheralization. An alternative explanation might be that the effect modifying impact of centralization or peripheralization on MDT is dependent on the control treatment. Our findings suggest that future studies in this area need to involve predictive value of peripheralization as well as centralization.
When a composite of the two most promising predictors, peripheralization and signs of nerve root involvement, were present at baseline, the relative chance of success with MDT compared to SM appeared 8.5 times higher than for the subgroup with no centralization and nerve root involvement. The number of patients was very small and the confidence interval was wide. Therefore only a preliminary conclusion about interaction can be drawn and it calls for a validation in future studies.
In our study, there appeared to be no characteristic by which SM had better results compared to MDT. Thus, we could not support the results of two studies with a similar design as ours (two arms, sample of patients with persistent LBP, and outcome reported in terms of reduction of disability at long term follow up) [27,29]. In those studies, Nyiendo et al. [29] found a modifying effect of leg pain below knee on treatment by SM compared to that of the general practitioner six months after baseline, and Koes et al. [27] found a modifying effect of age below 40 years and symptom duration more than a year on treatment by SM compared to that of physiotherapy 12 months after baseline. However, results from those, as well as other previous RCTs comprising patients with persistent LBP, have supported our findings regarding the lack of effect modification of age [27,29,31], sex [29,31], baseline disability [27,29,31], and duration of symptoms [31], on SM when measured on reduction of disability 6-12 months after randomization. So, although evidence is emerging in patients with acute LBP regarding subgroup characteristics predictive of better results from SM compared to other types of treatment [32], we are still in the dark with respect to patients with persistent LBP.
The usefulness of choosing a criterion for success by combining an improvement of at least 5 points or an absolute score below 5 points on RMDQ is debatable. A total of 22 patients were considered successful based on score below 5 at follow up without having an improvement of at least 5 points. We therefore performed a sensitivity analysis using a relative improvement of at least 30% as criterion of success as recommended by others [22] (see Additional file 2: Table S2). As a result, the percentage of patients with successful outcome in the MDT group remained the same whereas 4 more patients were defined as successes in the SM group. Overall the sensitivity analysis did not produce outcome results that were markedly different from those of the primary analysis and therefore only those have been discussed above.
Strengths and Limitations
This study used data from a RCT, whereas many others have used single arm designs not suitable for the purpose of evaluating treatment effect modification [33]. In accordance with the recommendations by the PROGRESS group [8] we prespecified the possible predictors and also the direction of the effect. Furthermore, we limited the number of predictors included in order to minimize the chance of spurious findings.
The main limitation in secondary studies to previously conducted RCTs is that they are powered to detect overall treatment effect rather that effect modification. In recognition of the post hoc nature of our analysis, reflected in wide confidence intervals, we must emphasize that our findings are exploratory and require formal testing in a larger sample size.
Conclusions
In all subgroups, the probability of success with MDT was superior to that of SM. Although not statistically significant, the presence of nerve root involvement and peripheralization appear promising effect modifiers in favour of MDT. These findings need testing in larger studies.
Acknowledgements
The authors thank Jan Nordsteen and Steen Olsen for clinical expert advice, and Mark Laslett for comments and language correction.
This study was in part supported by grants from The Danish Rheumatism Association, The Danish Physiotherapy Organization, The Danish Foundation for Chiropractic Research and Continuous Education, and The Danish Institute for Mechanical Diagnosis and Therapy. RC/The Parker Institute acknowledge the funding support from the Oak Foundation. The funds were independent of the management, analyses, and interpretation of the study.
Footnotes
Competing interests: The authors declare that they have no competing interests.
Authors� contributions: All authors were involved in the data analysis and the writing process, and the requirements for authorship have been met. All analyses were conducted by TP, RC, and CJ. TP conceived and led the study and was responsible for writing the first draft of the paper, but the other authors have participated throughout the writing process and have read and approved the final version.
In conclusion,�the above two articles were presented in order to evaluate the McKenzie method in the treatment of LBP in comparison to other types of treatment options. The first research study compared the McKenzie method with placebo therapy in patients with low back pain, however, the results of the study still need additional evaluations. In the second research study, no significant results could predict a different response in the use of the McKenzie method. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
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[/accordions]
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
Low back pain, or LBP, is a very common condition which affects the lumbar spine, or the lower section of the spine. Approximately more than 3 million cases of LBP are diagnosed in the United States aline every year and about 80 percent of adults worldwide experience low back pain at some point during their lifetime. Low back pain is generally caused by injury to a muscle (strain) or ligament (sprain) or due to damage from a disease. Common causes of LBP include poor posture, lack of regular exercise,�improper lifting, fracture, herniated discs and/or arthritis. Most cases of low back pain may often go away on their own, however, when LBP becomes chronic, it may be important to seek immediate medical attention. Two therapeutic methods have been utilized to improve LBP. The following article compares the effects of Pilates and McKenzie training on LBP.
A Comparison of the Effects of Pilates and McKenzie Training on Pain and General Health in Men with Chronic Low Back Pain: A Randomized Trial
Abstract
Background: Today, chronic low back pain is one of the special challenges in healthcare. There is no unique approach to treat chronic low back pain. A variety of methods are used for the treatment of low back pain, but the effects of these methods have not yet been investigated adequately.
Aim: The aim of this study was to compare the effects of Pilates and McKenzie training on pain and general health of men with chronic low back pain.
Materials and Methods: Thirty-six patients with chronic low back pain were chosen voluntarily and assigned to three groups of 12 each: McKenzie group, Pilates group, and control group. The Pilates group participated in 1-h exercise sessions, three sessions a week for 6 weeks. McKenzie group performed workouts 1 h a day for 20 days. The control group underwent no treatment. The general health of all participants was measured by the General Health Questionnaire 28 and pain by the McGill Pain Questionnaire.
Results: After therapeutic exercises, there was no significant difference between Pilates and McKenzie groups in pain relief (P = 0.327). Neither of the two methods was superior over the other for pain relief. However, there was a significant difference in general health indexes between Pilates and McKenzie groups.
Conclusion: Pilates and McKenzie training reduced pain in patients with chronic low back pain, but the Pilates training was more effective to improve general health.
Keywords:Chronic back pain, general health, Mckenzie training, pain, Pilates training
Introduction
Low back pain with a history of more than 3 months and without any pathological symptom is called chronic low back pain. For patient with chronic low back pain, the physician should take into consideration the likelihood of muscle pain development with spinal origin, in addition to low back pain with unknown origin. This type of pain may be mechanical (increase in pain with movement or physical pressure) or nonmechanical (increase in pain at the rest time).[1] Low back pain or spine pain is the most common musculoskeletal complication.[2] About 50%�80% of healthy people may experience low back pain during their lifetime, and about 80% of the problems are related to the spine and occur in the lumbar area.[3] Low back pain may be caused by trauma, infection, tumors, etc.[4] Mechanical injuries which are caused by overuse of a natural structure, deformity of an anatomical structure, or the injury in the soft tissue are the most common reasons for back pain. From occupational health perspective, back pain is among the most important reasons for the absence from work and occupational disability;[5] in fact, the longer the period of disease,[6] the less likely it is to improve and return to work.[1] Disability due to low back pain in addition to disturbance in doing daily and social activities has a very negative effect, from social and economic perspectives, on the patient and the community, which makes chronic low back pain highly important.[3] Today, chronic low back pain is one of the critical challenges in medicine. Patients with chronic low back pain are responsible for 80% of the costs paid for the treatment of low back pain that is also the reason for mobility restrictions in most people under 45 years.[7] In the developed countries, the overall cost paid for low back pain per year is 7.1 of total share of the gross national product. Clearly, most of the cost is related to counseling and treatment of patients with chronic low back pain rather than with intermittent and recursive low back pain.[8] The existence of various methods of treatment is because of no single cause of low back pain.[9] A variety of methods such as pharmacotherapy, acupuncture, infusions, and physical methods are the most common interventions for treatment of low back pain. However, the effects of these methods remain to be fully known.[6] An exercise program, developed based on the physical conditions of patients, can promote the quality of life in patients with chronic disease.[10,11,12,13,14]
Literature shows that the effect of exercise in controlling chronic low back pain is under study and there is strong evidence about the fact that movement therapy is effective to treat low back pain.[15] However, no specific recommendations exist about the type of exercise, and the effects of certain types of movement therapies have been determined in few studies.[9] Pilates training consists of the exercises that focus on improving flexibility and strength in all the body organs, without increasing the mass of muscles or destroying them. This training method consists of controlled movements that form a physical harmony between the body and brain, and can raise the ability of the body of people at any age.[16] In addition, people who do Pilates exercise would have better sleep and less fatigue, stress, and nervousness. This training method is based on standing, sitting, and lying positions, without intervals, jumping, and leaping; thus, it may reduce injuries resulting from the joint damage because the exercise movements in the ranges of motion in the above three positions are performed with deep breathing and muscle contraction.[17] McKenzie method, also called mechanical diagnosis and therapy and based on the patient’s active participation, is used and trusted by patients and the people who use this method worldwide. This method is based on physical therapy which has been frequently studied. The distinctive characteristic of this method is the principle of initial assessment.[18] This principle is a reliable and safe method to make a diagnosis that makes the correct treatment planning possible. In this way, the time and energy are not spent for costly tests, rather McKenzie therapists, using a valid indicator, quickly recognize that how much and how this method is fruitful for the patient. More appropriately, McKenzie method is a comprehensive approach based on the correct principles whose full understanding and following is very fruitful.[19] In the recent years, non-pharmacological approaches have attracted the attention of physicians and patients with low back pain.[20] Complementary therapies[21] and treatments with holistic nature (to increase physical and mental well-being) are appropriate to manage physical illness.[13] Complementary therapies can slow down disease progression and improve capacity and physical performance. The aim of the present study is to compare the effect of the Pilates and McKenzie training on pain and general health in men with chronic low back pain.
Materials and Methods
This randomized clinical trial was conducted in Shahrekord, Iran. The total study population screened was 144. We decided to enroll at least 25% of the population, 36 individuals, using a systematic random sampling. First, the participants were numbered and a list was developed. The first case was selected using random number table and then one out of four patients was randomly enrolled. This process continued till a desired number of participants were enrolled. Then, the participants were randomly assigned to experimental (Pilates and McKenzie training) groups and control group. After explaining the research purposes to the participants, they were asked to complete the consent form for participation in the study. Furthermore, the patients were ensured that the research data are kept confidential and used only for research purposes.
Inclusion Criteria
The study population included men aged 40�55 years in Shahrekord, South-West Iran, with chronic back pain, that is, history of more than 3 months of low back pain and no specific disease or other surgery.
Exclusion Criteria
The exclusion criteria were low back arch or so-called army back, serious spinal pathology such as tumors, fractures, inflammatory diseases, previous spinal surgery, nerve root compromise in the lumbar region, spondylolysis or spondylolisthesis, spinal stenosis, neurological disorders, systemic diseases, cardiovascular diseases, and receiving other therapies simultaneously. The examiner who assessed the outcomes was blinded to group assignment. Twenty-four hours before the training, a pretest was administered to all three groups to determine pain and general health; and then, the training began after completion of the McGill Pain Questionnaire (MPQ) and the General Health Questionnaire-28 (GHQ-28). The MPQ can be used to evaluate a person experiencing significant pain. It can be used to monitor the pain over time and to determine the effectiveness of any intervention. Minimum pain score: 0 (would not be seen in a person with true pain), maximum pain score: 78, and the higher the pain score the more severe the pain. Investigators reported that the construct validity and the reliability of the MPQ were reported as a test-retest reliability of 0.70.[22] The GHQ is a self-administered screening questionnaire. Test-retest reliability has been reported to be high (0.78�0 0.9) and inter- and intra-rater reliability have both been shown to be excellent (Cronbach’s ? 0.9�0.95). High internal consistency has also been reported. The lower the score is, the better the general health is.[23]
The participants in the experimental groups started training program under supervision of a sports medicine specialist. The training program consisted of 18 sessions of supervised individual training for both groups, with the sessions held three times per week for 6 weeks. Each training session lasted for an hour and was performed at the Physiotherapy Clinic in the School of Rehabilitation of the Shahrekord University of Medical Sciences in 2014�2015. The first experimental group performed Pilates training for 6 weeks, three times a week about an hour per session. In each session, first, a 5-min warm-up and preparation procedures were run; and at the end, stretching and walking were done to return to the baseline condition. In the McKenzie group, six exercises were used: Four extension-type exercises and two flexion-types. The extension-type exercises were performed in prone and standing positions, and the flexion-type exercises in the supine and sitting positions. Each exercise was run ten times. In addition, the participants conducted twenty daily individual training sessions for an hour.[18] After training of both groups, the participants filled out the questionnaires and then the collected data were presented in both descriptive and inferential statistics. Furthermore, the control group without any training, at the end of a period when other groups have completed, filled the questionnaire. Descriptive statistics were used for central tendency indicators such as mean (� standard deviation) and relevant diagrams were used to describe the data. Inferential statistics, one-way ANOVA and post hoc Tukey’s test, were used to analyze the data. Data analysis was done by SPSS Statistics for Windows, Version 21.0 (IBM Corp. Released 2012. IBM Armonk, NY: IBM Corp). P < 0.05 was considered statistically significant.
Dr. Alex Jimenez’s Insight
Alongside the use of spinal adjustments and manual manipulations for low back pain, chiropractic care commonly utilizes therapeutic exercise methods to improve LBP symptoms, restoring the affected individual’s strength, flexibility and mobility as well as promoting a faster recovery. The Pilates and McKenzie method of training, as mentioned in the article, are compared to determine which therapeutic exercise is best for treating low back pain. As�a Level I Certified Pilates Instructor, Pilates training is implemented with chiropractic treatment to improve LBP more effectively. Patients participating in a therapeutic exercise method alongside a primary form of treatment for low back pain can experience additional benefits. McKenzie training can also be implemented with chiropractic treatment to further improve LBP symptoms. The purpose of this research study is to demonstrate evidence-based information on the benefits of Pilates and McKenzie methods for low back pain as well as to educate patients on which of the two therapeutic exercises should be considered to help treat their symptoms and achieve overall health and wellness.
Level I Certified Pilates Instructors at Our Location
Dr. Alex Jimenez D.C., C.C.S.T | Chief Clinical Director and Level I Certified Pilates Instructor
Truide Torres | Director of Patient Relations Advocate Dept. and Level I Certified Pilates Instructor
Results
The results showed no significant difference between the case and control groups regarding the gender, marital status, job, educational level, and income. The results showed changes in pain index and general health in the participants before and after Pilates and McKenzie training in the two experimental and even control groups [Table 1].
A significant difference was seen in pain and general health between the control and the two experimental groups at the pre- and post-test, so that the exercise training (both Pilates and McKenzie) resulted in reduced pain and promoted general health; while in the control group, pain increased and general health declined.
Discussion
The results of this study indicate that back pain reduced and general health enhanced after exercise therapy with both Pilates and McKenzie training, but in the control group, pain was intensified. Petersen et al. study on 360 patients with chronic low back pain concluded that at the end of 8 weeks of McKenzie training and high-intensity endurance training and 2 months training at home, pain and disability decreased in McKenzie group at the end of 2 months, but at the end of 8 months, no differences were seen among the treatments.[24]
The results of another study show that McKenzie training is a beneficial method for reducing pain and increasing the movements of the spine in patients with chronic low back pain.[18] Pilates training can be an effective method for improving general health, athletic performance, proprioception, and reduction of pain in patients with chronic low back pain.[25] The improvements in strength seen in the participants in the present study were more likely to be due to decrease in pain inhibition than to neurological changes in muscle firing/recruitment patterns or to morphological (hypertrophic) changes in the muscle. In addition, neither of the treatments was superior over the other in view of reducing the intensity of pain. In the present study, 6 weeks of McKenzie training led to significant reduction in pain levels in men with chronic low back pain. The rehabilitation of patients with chronic low back pain is aimed to restore strength, endurance, and flexibility of soft tissues.
Udermann et al. showed that McKenzie training improved pain, disability, and psychosocial variables in patients with chronic low back pain, and back stretching training did not have any additional effect on pain, disability, and psychosocial variables.[26] The results of another study show that there is a reduction in pain and disability due to McKenzie method for at least 1 week in comparison with the passive treatment in patients with low back pain, but reduction in pain and disability due to McKenzie method in comparison with the active treatment methods is desirable within 12 weeks after treatment. Overall, McKenzie treatment is more effective than passive methods to treat low back pain.[27] One of the popular exercise therapies for patients with low back pain is McKenzie training program. McKenzie method leads to improvement of low back pain symptoms such as pain in the short-term. Moreover, McKenzie therapy is more effective in comparison with passive treatments. This training is designed to mobilize the spine and to strengthen the lumbar muscles. Previous studies have shown that weakness and atrophy in the body central muscles, particularly the transverse abdominal muscle in patients with low back pain.[28] The results of this research also showed that there was a significant difference in the general health indexes between Pilates and McKenzie groups. In the present study, 6 weeks of Pilates and McKenzie training led to a significant reduction in the level of general health (physical symptoms, anxiety, social dysfunction, and depression) in men with chronic low back pain and the general health in Pilates training group improved. The results of most studies show that exercise therapy reduces pain and improves general health in patients with chronic low back pain. Importantly, the agreement about the duration, type, and intensity of the training remains to be achieved and there is no definite training program that can have the best effect on patients with chronic low back pain. Therefore, more research is needed to determine the best duration and treatment method to reduce and improve general health in patients with low back pain. In the Al-Obaidi et al. study, pain, fear, and functional disability improved after 10 weeks of treatment in patients.[5]
Besides that McKenzie training increases the range of motion of lumbar flexion. Overall, neither of the two methods of treatment was superior over the other.[18]
Borges et al. concluded that after 6 weeks of treatment, the average index of pain in experimental group was lower than the control group. Furthermore, the general health of the experimental group exhibited greater improvement than the control group. The results of this research support recommending Pilates training to patients with chronic low back pain.[29] Caldwell et al. on the university students concluded that Pilates training and Tai chi guan improved mental parameters such as self-sufficiency, quality of sleep, and morality of students but had no effect on physical performance.[30] Garcia et al. study on 148 patients with nonspecific chronic low back pain concluded that treating patients with nonspecific chronic low back pain by McKenzie training and back school caused disability to improve after treatment, but quality of life, pain, and the range of motor flexibility did not change. McKenzie treatment is typically more effective on disability than back school program.[19]
The overall findings of this study are supported by the literature, demonstrating that a Pilates program may offer a low-cost, safe alternative to the treatment of low back pain in this specific group of patients. Similar effects have been found in patients with unspecific chronic low back pain.[31]
Our study had good levels of internal and external validity and thus can guide therapists and patients considering therapies of choice for back pain. The trial included a number of features to minimize bias such as prospectively registering and following a published protocol.
Study Limitation
Small sample size enrolled in this study limits the generalization of the study findings.
Conclusion
The results of this study showed that 6-week Pilates and McKenzie training reduced pain in patients with chronic low back pain, but there was no significant difference between the effect of two therapeutic methods on pain and both exercise protocols had the same effect. In addition, Pilates and McKenzie training improved general health; however, according to the mean general health changes after the exercise therapy, it can be argued that the Pilates training has a greater effect in improving general health.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
In conclusion,�when comparing the effects of Pilates and McKenzie training on general health as well as on painful symptoms in men with chronic low back pain, the evidence-based research study determined that both the Pilates and the McKenzie method of training effectively reduced pain in patients with chronic LBP. There was no significant difference between the two therapeutic methods altogether, however, the mean results of the research study demonstrated that Pilates training was more effective towards improving general health in men with chronic low back pain than McKenzie training.� Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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