EFFECTIVENESS OF THE MCKENZIE METHOD OF MECHANICAL DIAGNOSIS AND THERAPY FOR TREATING LOW BACK PAIN: LITERATURE REVIEW WITH META-ANALYSIS
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[ research report ]
OLIVIER T. LAM, PT1 • DAVID M. STRENGER, PT2 • MATTHEW CHAN-FEE, PT3
PAUL THUONG PHAM, PT4 • RICHARD A. PREUSS, PT, PhD5 • SHAWN M. ROBBINS, PT, PhD5
Effectiveness of the McKenzie Method
of Mechanical Diagnosis and Therapy
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for Treating Low Back Pain: Literature
Review With Meta-analysis
L
ow back pain (LBP) is the worldwide leading cause of years lived A variety of clinical practice guide-
with disability, with an estimated point prevalence of 9.4% and lines have been developed for the treat-
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
a lifetime prevalence of up to 39%.25,52,62 This negatively impacts ment of LBP.6,29,43 These guidelines
propose a shift away from treatment of
the psychosocial health of those affected.48 Moreover, with an
LBP primarily based on pathoanatomi-
aging population, LBP is expected to become more widespread.26 cal principles in favor of a classification-
based approach. This suggestion is
UUSTUDY DESIGN: Literature review with meta- patients with acute LBP, there was no significant largely based on several studies report-
analysis. difference in pain resolution (P = .11) and disability ing that classifying patients led to im-
UUBACKGROUND: The McKenzie Method of
(P = .61) between MDT and other interventions. In proved clinical results.14,15,31 However, a
patients with chronic LBP, there was a significant
Mechanical Diagnosis and Therapy (MDT), a recent review has questioned the clinical
difference in disability (SMD, –0.45), with results
classification-based system, was designed to effectiveness of subgrouping claims, due
Journal of Orthopaedic & Sports Physical Therapy®
favoring MDT compared to exercise alone. There
classify patients into homogeneous subgroups to to trials that were underpowered and the
were no significant differences between MDT and
direct treatment.
manual therapy plus exercise (P>.05) for pain and poor quality of reporting.55
UUOBJECTIVES: To examine the effectiveness of disability outcomes. The McKenzie Method of Mechani-
MDT for improving pain and disability in patients UUCONCLUSION: There is moderate- to high- cal Diagnosis and Therapy (MDT) is a
with either acute (less than 12 weeks in duration) quality evidence that MDT is not superior to other
or chronic (greater than 12 weeks in duration) low
well-studied classification system. This
rehabilitation interventions for reducing pain and
back pain (LBP). assessment and treatment model has
disability in patients with acute LBP. In patients
UUMETHODS: Randomized controlled trials with chronic LBP, there is moderate- to high-quality demonstrated good interexaminer reli-
examining MDT in patients with LBP were identi- evidence that MDT is superior to other rehabilita- ability when classifying patients with
fied from 6 databases. Independent investigators tion interventions for reducing pain and disability; LBP; however, evidence of its treatment
assessed the studies for exclusion, extracted data, however, this depends on the type of intervention effectiveness continues to be challenged.
and assessed risk of bias. The standardized mean being compared to MDT.
The MDT was designed to classify pa-
difference (SMD) and 95% confidence interval UULEVEL OF EVIDENCE: Therapy, level 1a. tients into 3 mechanical subgroups
were calculated to compare the effects of MDT to J Orthop Sports Phys Ther 2018;48(6):1-15.
(derangement, dysfunction, or postural
those of other interventions in patients with acute doi:10.2519/jospt.2018.7562
syndrome) or an “other” subgroup, by
UUKEY WORDS: centralization, classification,
or chronic LBP.
UURESULTS: Of the 17 studies that met the inclu-
which to direct treatment.23,36 Derange-
directional preference, lumbar spine, manual
sion criteria, 11 yielded valid data for analysis. In therapy ment, the most common subgroup, is
associated with a rapid change in symp-
1
Physiotherapy Department, Faculty of Medicine and Health Science, Sherbrooke University, Sherbrooke, Canada. 2Physiotherapy at Concordia Physio Sport, Montreal, Canada.
3
Physiotherapy at Physio Multiservices, Chateauguay, Canada. 4Physiotherapy private practice, Saint-Laurent, Canada. 5Centre for Interdisciplinary Research in Rehabilitation,
Constance Lethbridge Rehabilitation Centre, and the School of Physical and Occupational Therapy, McGill University, Montreal, Canada. The Edith Strauss Rehabilitation
Research Project at McGill University provided grants to support its authors. The Edith Strauss Rehabilitation Research Project of McGill University took no part in the design,
implementation, analysis, or production of the manuscript for this meta-analysis. The authors certify that they have no affiliations with or financial involvement in any organization
or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Olivier Tri-Thinh Lam, 7985 Salomon, Brossard,
Quebec, Canada J4X 1J2. E-mail: olivierlam.qc@gmail.com t Copyright ©2018 Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | ahead of print | 1[ research report ]
toms secondary to performance of a METHODS www.jospt.org). The first search was per-
“directional-preference” exercise.36 The formed on November 12, 2015. A second
T
directional preference of a patient is the he methodology for this review search was performed on May 26, 2016,
direction in which a repeated movement was based on the PRISMA state- and a third search was performed on Sep-
and/or sustained position produces ment,39 and the data extraction form tember 6, 2017 to provide an update of
an improvement in symptoms. Those was informed by the Cochrane meta- articles published since the first search.
improvements may include centraliza- analysis guidelines.27 Additionally, references from the includ-
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tion, a phenomenon in which symptoms ed studies and from previous systematic
down the lower extremity are progres- Eligibility Criteria reviews/meta-analyses were searched
sively abolished in a distal to proximal Randomized controlled trials that exam- manually, along with publications on the
direction.64 The presence of centraliza- ined the effectiveness of MDT for pain and McKenzie Institute International website
tion is associated with good prognosis disability in patients with LBP were in- (www.mckenzieinstitute.org).
in patients with LBP.64 Furthermore, re- cluded. There was no limit on publication
cent studies have shown that direction- date, and studies could be written in Eng- Study Selection
al preference and centralization, when lish or French. Exclusion criteria included Titles and abstracts were screened in-
matched with adequate MDT treatment, duplicated data from other studies, other dependently by 2 reviewers (O.L., D.S.).
result in better patient outcomes than interventions combined with MDT where When disagreements between reviewers
treatment with general range-of-motion the effects could not be partitioned, and occurred, they discussed the relevant ab-
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
exercise.31,47,50 studies published in non–peer-reviewed stract to reach a consensus. A third re-
The latest meta-analysis to examine journals. Only trials in which therapists viewer (S.R.) made the decision when a
the effectiveness of MDT for LBP found were MDT trained were included. To be consensus could not be reached. The full
limited evidence to support the use of considered MDT trained, therapists were articles were obtained for the selected
MDT.32 However, additional random- required to have participated in at least 1 abstracts and were reviewed again inde-
ized controlled trials have since been course offered by the McKenzie Institute pendently by 2 reviewers (O.L., D.S.). As
published. 31,33,47 Moreover, the previ- International focused on applying MDT before, a third reviewer (S.R.) made the
ous meta-analysis did not consider to patients with LBP. This criterion was decision to include the study in the analy-
acute and chronic LBP separately. Be- based on evidence that trained therapists sis if a consensus could not be reached by
cause acute and chronic forms of LBP are more reliable in classifying patients the 2 initial reviewers.
Journal of Orthopaedic & Sports Physical Therapy®
manifest differently, the treatment ef- (κ = 0.7-0.9) than are therapists without
fect could be different. 19,44,51 A cutoff certification (κ = 0.17-0.39).28,49,65 Stud- Data Extraction
of 12 weeks to differentiate acute from ies in which an MDT classification was Data extraction was performed by 2 in-
chronic LBP has been used in previous not completed prior to the treatment vestigators (P.T.P., M.C.F.), who each
systematic reviews and clinical prac- were excluded, as a priori classification independently extracted the data from
tice guidelines. 4,37 Also, the previous is an essential characteristic of the MDT all studies with the use of an extraction
meta-analysis compared MDT to pas- approach.36 Last, the comparator inter- form. A customized data extraction form
sive therapy, which included a variety of vention had to be a typical rehabilitation was developed for each of the 2 outcomes
interventions that might have different intervention, such as manual therapy, ex- of interest, pain and disability. The data
effects. Because the relative effective- ercise, or education. There was no review extraction form was a Microsoft Ex-
ness of MDT could change based on the protocol published for this meta-analysis. cel spreadsheet designed according
comparator intervention, MDT should to the Cochrane meta-analysis guide-
be compared to each intervention type Information Sources lines and adjusted to the needs of this
separately. The level of MDT training Six electronic databases (MEDLINE, meta-analysis.27
should also be considered, as it may Embase, CINAHL, Cochrane Database The following information was ex-
impact interventions and risk-adjusted of Systematic Reviews, PsycINFO, and tracted from each study: (1) charac-
functional outcomes. 10 The objective the Physiotherapy Evidence Database teristics of the study (study duration,
of this meta-analysis was to determine [PEDro]) were searched using 3 pri- therapist MDT training, and the number
the effectiveness of MDT provided by mary search strings: (1) MDT therapy, of patients allocated to each group) and
trained therapists compared to that of (2) low back/lumbar pain, and (3) ran- inclusion criteria, (2) type of intervention
different types of comparator interven- domized controlled trials. Related terms (including duration and frequency of the
tions for improving pain and disability were included for each search string, different interventions), and (3) type of
in patients with acute and chronic LBP and an example for the MEDLINE outcome measures (including pain scores,
separately. search is provided (APPENDIX, available at disability scores, definitions and time of
2 | ahead of print | journal of orthopaedic & sports physical therapydata collections). Where the study sample obtained from the PEDro website when erogeneity was present. RevMan 5.3 (The
included a mix of individuals with chron- available. Articles not indexed in the PE- Nordic Cochrane Centre, The Cochrane
ic and acute LBP, the average duration of Dro database were assessed by 2 raters Collaboration, Copenhagen, Denmark)
LBP symptoms was used to determine (O.L., D.S.) and a third reviewer (S.R.) was used for all statistical analyses.
whether they were acute or chronic. The made the final decision if a consensus When a study had 2 intervention
comparison interventions were classified could not be reached. groups that were compared to MDT (eg,
into “other interventions,” placebo, or a The Grading of Recommendations, manual therapy and education), the in-
Downloaded from www.jospt.org at Grand Valley State University on April 12, 2018. For personal use only. No other uses without permission.
subdivision of other interventions. Other Assessment, Development and Evalua- tervention that was considered to con-
interventions were defined as nonsurgi- tion (GRADE) approach was used to as- tribute most (eg, manual therapy) was
cal and noninvasive interventions within sess the quality of the body of evidence included in the primary analysis. How-
the scope of physical therapy practice (eg, for each outcome of this meta-analysis ever, in these cases, a sensitivity analysis
exercise, manual therapy, and education). (pain and disability).27 This evaluation was completed where the comparator
These interventions could be performed was conducted by 2 raters (D.S., P.T.P.), groups were substituted. Both compara-
by physical therapists or other health and a third reviewer (O.L.) made the tor groups could not be included in the
professions. Other interventions were final decision if a consensus could not same analysis to avoid artificially inflat-
further subdivided into manual therapy, be reached. The quality of evidence was ing the sample size. When medians and
exercise, a combination of manual ther- initially considered “high” and could be interquartile ranges (first and third)
apy and exercise, or education. Chronic downgraded based on the following 5 were provided, means were calculated by
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
LBP was defined as pain in the lumbar factors: (1) limitation of design, (2) in- summing the median, first interquartile
spine lasting more than 12 weeks. Acute directness of evidence, (3) inconsistency range, and third interquartile range and
LBP was defined as having a duration of results, (4) imprecision of results, and then dividing by 3. Standard deviation
of pain less than 12 weeks. After hav- (5) high probability of publication bias. estimates were calculated from inter-
ing completed the extraction process, Studies that did not reach a score of 5 on quartile values and consideration of the
the investigators compared results and the PEDro scale could be downgraded study sample size.63
reached consensus on any discrepancies. for a limitation of design41; studies that
A third investigator (S.R.) resolved dis- possessed differences in populations, in- RESULTS
agreements if a consensus could not be terventions, outcome measures, and in-
T
reached. Once the extraction form was direct comparisons could be downgraded he literature search resulted
Journal of Orthopaedic & Sports Physical Therapy®
completed, the 2 investigators indepen- for indirectness; studies with effect esti- in the identification of 758 publi-
dently tested the form with the first 3 mates that were heterogeneous could be cations, 678 from databases and
included studies. The results were then downgraded for inconsistency; and stud- 80 from reference lists (FIGURE 1). After
compared to ensure uniformity of the ies that had fewer than 400 participants removing duplicates, 2 independent
extraction process. When relevant data could be downgraded for imprecision. reviewers screened 354 abstracts and
were missing from a study, the authors selected 51 articles for full-text review.
and coauthors were contacted via e-mail Statistical Analysis After review, 17 articles were retained for
to request the missing information. If Analyses were completed separately for the meta-analysis; however, of these 17
the data could not be obtained, the study patients with acute and chronic LBP. The studies, 4 did not provide sufficient data
was excluded from the analyses. For each effectiveness of MDT compared to other to be included in the statistical analy-
study, pain and disability measures were interventions, subdivisions of other in- ses. These 4 studies are summarized in
extracted immediately after the MDT in- terventions, or placebo were examined TABLE 1.1,20,46,53 No significant between-
tervention or the comparison interven- using random-effects models with sta- group differences were observed in pain
tion, when the intervention was assumed tistical significance set at P[ research report ]
a greater effect has been shown when a significant difference (P = .61) in disabil- in pain after the intervention period, with
directional-preference exercise is given ity after the intervention period between results favoring MDT (SMD, –0.74; 95%
to centralizers.66 Also, because the mod- MDT and other physical therapy inter- CI: –1.45, –0.03). Ratings were downgrad-
ification occurred following allocation, ventions (SMD, –0.07; 95% CI: –0.34, ed because of imprecision of results. For
the study could not be considered a ran- 0.20). The analysis included manipula- the disability analysis, all 3 studies were
domized controlled trial. In this study, tions, with home exercises as the com- included and tests of heterogeneity were
the findings of a significant between- parator intervention from the study that not significant (FIGURE 3B).3,54,55 There was
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group difference in improvement in pain included 2 comparator interventions.3 moderate evidence of no significant differ-
and disability favoring MDT should be When the education booklet was includ- ence (P = .36) in disability after the inter-
interpreted with caution.41 One study ed instead, no significant differences re- vention period between MDT and manual
with a mix of individuals with acute and mained (P = .16). therapy plus exercise (SMD, –0.24; 95%
chronic LBP45 was included in the data CI: –0.77, 0.28). Ratings were also down-
analyses for chronic LBP, because most Acute LBP: Subgroup Analysis graded because of imprecision of results.
participants had recurrent episodes of MDT Versus Manual Therapy Plus Ex- MDT Versus Exercise None of the in-
LBP. For 1 study, medians and inter- ercise Three studies compared MDT cluded studies compared MDT to exer-
quartile ranges were converted to means to manual therapy plus exercise.3,54,55 cise alone in participants with acute LBP.
and standard deviations, respectively, as Comparator interventions included spi- MDT Versus Education Two studies
described in the Methods.63 A summary nal manipulative thrusts with lumbar compared MDT to an intervention that
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of the meta-analysis is shown in TABLE 2. range-of-motion exercises,54 joint mo- included only education in participants
bilizations,55 and manipulations with with acute LBP.3,33 In 1 study, education
Acute LBP: Primary Analysis home exercises.3 Only 2 of 3 studies were was described as “first line care,” and in-
of MDT Versus Other Interventions included in the pain intensity analysis.54,55 cluded advice to avoid bed rest and to
Four studies compared MDT to other Tests of heterogeneity were not signifi- remain active, assurance of a favorable
interventions in participants with acute cant (FIGURE 2B). There was moderate evi- prognosis, and advice to take acetamino-
LBP.3,33,54,55 The other interventions in- dence of a significant (P = .04) difference phen.33 This first-line care was provided
cluded spinal manipulative thrusts,
lumbar range-of-motion exercise,54 joint
MEDLINE, Embase, CINAHL, Cochrane, McKenzie Institute lumbar spine trials,
mobilizations,55 and first-line care (eg,
Journal of Orthopaedic & Sports Physical Therapy®
PsycINFO, PEDro, n = 678 including articles from Machado et
advice to remain active and take acet- al32 meta-analysis, n = 80
aminophen, and assurance of a favorable
prognosis).33 Another study compared
MDT to 2 other interventions: manipula-
tions with strength and stretching home Records screened after duplicates Records excluded, n = 303
exercises, and an education booklet.3 removed, n = 354 • Not MDT interventions, n = 111
• Not a randomized controlled trial, n = 188
Only 3 of 4 studies were included in • Not an English or French article, n = 4
the analysis of pain intensity.33,54,55 The
fourth study examined the bothersome-
Full-text articles excluded, n = 34
ness of pain, numbness, and tingling, Full-text articles assessed for
• Not MDT interventions, n = 19
which was considered a different con- eligibility, n = 51
• Not MDT trained, n = 4
struct.3 For the 3 included studies, tests • Not a randomized controlled trial, n = 6
of heterogeneity were not significant • Not an English or French article, n = 5
(FIGURE 2A). There was moderate-quality
evidence of no significant (P = .11) differ- Included studies in qualitative • Lack of data for analysis, n = 5
ence in pain after the intervention period synthesis (meta-analysis), n = 17
(SMD, –0.45; 95% CI: –0.99, 0.10) be-
tween MDT and the other interventions.
Ratings were downgraded because of im- Full-text articles excluded, n = 5
precision of results. Full-text articles assessed for • Insufficient data for meta-analysis, n = 4
For the disability analysis, all 4 studies eligibility, n = 12 • Noncentralizers excluded from MDT group
post allocation, n = 1
were included and tests of heterogene-
ity were not significant (FIGURE 3A).3,33,54,55
FIGURE 1. Flow diagram of search strategy and results. Abbreviation: MDT, Mechanical Diagnosis and Therapy.
There was high-quality evidence of no
4 | ahead of print | journal of orthopaedic & sports physical therapyto both the MDT group and the com- intervention,3 and had disability as an improvement (0.7 on an 11-point numeric
parison group, who received no other outcome measure, but not pain intensity. pain-rating scale; adjusted values) in pain
treatments. The outcome variables for As only 1 study assessed pain intensi- intensity compared to first-line care only.
this study included both pain intensity ty,33 no meta-analysis was performed. This For the disability analysis, based on
and disability. The second study used study found that MDT plus first-line care 2 studies,3,33 tests of heterogeneity were
an education booklet as the comparison resulted in a significant (P = .02), but small, not significant (FIGURE 3C). There was
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Summary of Inclusion and Exclusion Criteria,
TABLE 1
Intervention Groups, and Outcome Measures
Acute Pain
Study Participants (12 wk) Intervention of Training Outcomes
Bonnet et al1 n = 28; men, n = n = 26 Nonspecific LBP Mix MDT: directional-preference exer- Parts A and B Pain: visual analog
(7/10)† 17; women, n men, n = 12; women, with or without cises, can modify positions and/or scale
= 11; age, 48.8 n = 14; age, 45.9 ± radiation to lower add manual techniques Disability: Oswestry
± 4.75 y; mean 5.1 y; mean symptom extremity, ≥18 y Manual therapy plus exercise: active Disability Question-
symptom dura- duration, 49.2 mo of age mobilizations in weight bearing naire
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tion, 46.1 mo and non–weight bearing, lower Outcomes evaluated
extremity stretching, propriocep- after 1 wk
tion in weight bearing, massage,
TENS
Cherkin et n = 133; men, n = Education: n = 66; men, LBP with pain 7 d Acute MDT: directional-preference Credentialed Bothersomeness of
al3 (8/10) 71; women, n n = 38; women, n = 28; after initial physi- exercises, avoid symptom back/leg pain,
= 62; age, 41.8 age, 40.1 ± 11.2 y; mean cian visit, 20-64 peripheralizing movements, home numbness/tingling:
± 11.5 y; mean symptom duration, y of age exercise program, education book, numeric rating
symptom 72%[ research report ]
Summary of Inclusion and Exclusion Criteria,
TABLE 1
Intervention Groups, and Outcome Measures (continued)
Acute Pain
Study Participants (12 wk) Intervention of Training Outcomes
Machado n = 73; men, n = n = 73; men, n = 38; wom- Acute nonspe- Acute MDT: first-line care, directional- Credentialed Pain: numeric rating
et al33 35; women, n en, n = 35; age, 45.9 ± cific LBP, pain preference exercises, postural scale
(8/10) = 38; age, 47.5 14.9 y; mean symptom between the 12th correction and education, Treat Disability: Roland-
± 14.4 y; mean duration, 67%Summary of Inclusion and Exclusion Criteria,
TABLE 1
Intervention Groups, and Outcome Measures (continued)
Acute Pain
Study Participants (12 wk) Intervention of Training Outcomes
Petersen n = 132; men, n = n = 128; men, n = 72; LBP with or without Mix MDT: directional-preference exer- Credentialed, Pain: back and leg
et al46 70; women, n women, n = 56; median leg pain of >8 cises, can modify positions and/or parts A-D pain, Low Back Pain
(7/10)† = 62; median (10th, 90th percentiles) wk; radiograph, add manual techniques Rating Scale
(10th, 90th per- age, 35 y (24.0, 51.6 CT scan, or MRI Exercise: stationary bike and Disability: Low Back
centiles) age, y); median symptom taken within the low-resistance exercises for Pain Rating Scale
34.5 y (23.0, duration (10th, 90th preceding 2 y; lumbopelvic muscles, dynamic Outcomes evaluated
52.1 y); median percentiles), 14 mo (2.7, 18-60 y of age back strengthening exercises, after 2, 4 , and 12
(10th, 90th 113.5 mo) stretching trunk and hip muscles mo
percentiles) Both groups: asked to continue
symptom dura- exercising for a minimum of 2 mo
tion, 8 mo (2.0, after intervention
95.7 mo)
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Petersen n = 175; men, n= n = 175; men, n = 83; LBP, with or without Chronic MDT: directional-preference exercise, Screening Pain: numeric rating
et al47 72; women, n women, n = 92; age, 37 leg pain, >6 wk; no manual vertebral mobiliza- preran- scale
(7/10) = 103; age, 38 ± 9.4 y; symptom dura- able to speak tions, educational booklet and/or domization: Disability: Roland-
± 10.4 y; symp- tion, 94 ± 181 wk and understand lumbar roll at therapist discretion diploma Morris Disability
tom duration, Danish; clinical Manual therapy plus exercise: manu- Treatment: cre- Questionnaire
97 ± 230 wk signs of disc-re- al techniques at therapist discre- dentialed SF-36
lated symptoms; tion (eg, vertebral mobilization/ Outcomes evaluated
18-60 y of age manipulation), self-manipulation, after 3, 5, and 12
flexion/extension exercises and mo
stretching, educational booklet
Both groups: given stabilization/
strengthening exercises at
Journal of Orthopaedic & Sports Physical Therapy®
therapist discretion, given home
exercise plan and encouraged to
continue post intervention
Sakai et al53 n = 25; men, n = Control: n = 25; men, n = LBP, without radiat- Chronic MDT: MDT approach, no further Credentialed Pain: visual analog
(4/10)† 25; women, 25; women, n = 0; age, ing leg pain or details given scale, Faces Pain
n = 0; age, 44.4 ± 13.9 y; symptom numbness in Control: compress, no exercise Scale-Revised
47.9 ± 13.1 duration, 20.3 ± 18.7 lower extremity, Medication: 50 mg eperisone Disability: SF-36
y; symptom mo of >6 mo; male hydrochloride, 3 times a day after Outcomes evaluated
duration, 25.3 Medication: n = 24; men, >20 y of age meals for 4 wk after 2 and 4 wk
± 17.5 mo n = 24; women, n = All groups: educational booklet, heat
0; age, 44.2 ± 12.2 y; therapy, ultrasound, electrical
symptom duration, muscle stimulation, traction, no
23.9 ± 20.4 mo use of NSAID or anti-inflamma-
tory agent
Schenk n = 19; men, n = n = 12; men, n = 5; LBP, at least 3 of 5 Acute MDT: directional-preference exer- Credentialed Pain: numeric rating
et al54 7; women, n = women, n = 7; mean selection criteria cises, home exercise program scale
(5/10) 12; mean age, age, 46 y; mean symp- from clinical Manual therapy plus exercise: Disability: Oswestry
39 y; mean tom duration, 15 d prediction rules, regional lumbopelvic thrust Disability Index
symptom dura- ≥18 y of age technique, hand-heel rock range- Outcomes evaluated
tion, 18 d of-motion exercise after 2 and 4 wk
Both groups: as of third session,
directional-preference exercises
at home on an hourly basis,
exercise log
Table continues on page 8.
journal of orthopaedic & sports physical therapy | ahead of print | 7[ research report ]
high-quality evidence of no significant One study included in the review, de- Chronic LBP: Primary Analysis
(P = .45) difference in disability after the spite lacking data for analysis, compared of MDT Versus Other Interventions
intervention period between participants MDT to education20 and found no sig- Seven studies compared MDT to other
treated with MDT or education (SMD, nificant between-group differences for interventions in participants with chron-
–0.09; 95% CI: –0.31, 0.14). changes in disability. ic LBP.17,22,31,38,40,45,47 Exercise, combined
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Summary of Inclusion and Exclusion Criteria,
TABLE 1
Intervention Groups, and Outcome Measures (continued)
Acute Pain
Study Participants (12 wk) Intervention of Training Outcomes
Schenk n = 15; men, n = 7; n = 10; men, n = 8; Lumbar radiculopa- Acute MDT: directional-preference exercises Credentialed Pain: visual analog
et al55 women, n = 8; women, n = 2; mean thy: symptoms Manual therapy plus exercise: scale
(5/10) mean age, 40.1 age, 44.8 y; symptom originating in mobilization: passive movement Disability: Oswestry
y; symptom duration, 7 d to 7 wk disc, peripheral to spinal segments Disability Question-
duration, 7 d to to lumbar region, Both groups: postural correction, naire
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7 wk with or without ambulation on treadmill Outcomes evaluated
neurological after third visit
symptoms;
posterior
derangement
Miller et al38 n = 14; men, n = n = 15; men, n = 8; Chronic LBP for >7 Chronic MDT: postural correction, directional- Credentialed Pain: short-form McGill
(5/10) 7; women, n = women, n = 7; age, 54 wk, 18 y of age or preference exercises, and manual Pain Questionnaire
7; age, 44 ± 16 ± 15 y; symptom dura- older techniques Disability: Functional
y; symptom tion, 32 ± 58 mo Exercise: spine stabilization exercises Status Question-
duration, 20 ± (transversus abdominis and lum- naire
30 mo bar multifidus) Outcomes evaluated
Both groups: home exercise program after 6 wk
Journal of Orthopaedic & Sports Physical Therapy®
according to grouping
Halliday n = 35; men, n = n = 35; men, n = 7; LBP localized Chronic MDT: directional-preference Credentialed Pain: visual analog
et al22 7; women, n = women, n = 28; age, between the exercises, postural education scale
(7/10) 28; age, 48.8 ± 48.3 ± 14.2 y; median 12th rib and the and lumbar roll, Treat Your Own Disability: Patient-
12.1 y; median symptom duration, 37.7 buttock crease, Back book Specific Functional
symptom dura- wk (IQR, 28.8) with or without Exercise: motor control exercises of Scale
tion, 26.6 wk referred pain deep lumbar stabilizers, home Outcomes evaluated
(IQR, 22.3) into one or both exercise program after 8 wk
legs and with or
without sensory
and or motor
changes, for >3
mo; directional
preference
Garcia et al18 n = 74; men, n = n = 73; men, n = 19; Chronic nonspe- Chronic MDT: directional-preference exer- Part A Pain: numeric pain-
(8/10) † 16; women, n = women, n = 54; age, cific LBP, pain cises, specific end-range motion rating scale
58; age, 57.5 ± 55.5 ± 13.7 y; symptom intensity of 3/10 exercise, postural education, Disability: modified
12.2 y; symp- duration, 48 ± 96 mo on a numeric home exercise program, and Treat Roland-Morris
tom duration, pain-rating scale, Your Own Back book Disability Question-
36 ± 102 mo 18-80 y of age, Placebo: detuned pulsed ultrasound, naire
and able to read detuned shortwave diathermy Outcomes evaluated
Portuguese Both groups: given educational after 5 wk and 3, 6,
booklet The Back Book and 12 mo
Abbreviations: CT, computed tomography; IQR, interquartile range; LBP, low back pain; MDT, Mechanical Diagnosis and Therapy; MRI, magnetic resonance
imaging; NA, not available; NSAID, nonsteroidal anti-inflammatory drug; PEDro, Physiotherapy Evidence Database; SF-36, Medical Outcomes Study 36-
Item Short-Form Health Survey; TENS, transcutaneous electrical nerve stimulation.
*Values are mean ± SD unless otherwise indicated.
†
Not included in meta-analysis.
8 | ahead of print | journal of orthopaedic & sports physical therapymanual therapy and exercise, and educa- comparator groups.45 When education electrical muscle stimulation, and inter-
tion were the comparator interventions. was included instead, significant differ- ferential current),42,53 found significant
One of the studies compared combined ences remained (P = .03). between-group differences for changes in
MDT and balneotherapy to combined Disability was measured in all 7 stud- pain, with results favoring MDT; only 1 of
exercise, manual therapy, and balneo- ies.17,22,31,38,40,45,47 Tests for heterogeneity these studies42 found a significant differ-
therapy.40 Another study had 2 compara- were not significant (FIGURE 5A). There ence in change in disability, with results
tor groups, manual therapy with exercise was high-quality evidence of a signifi- favoring MDT.
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and education.45 cant (P[ research report ]
current analysis. All 4 studies measured Risk-of-Bias Assessment no difference in improvement in disabil-
pain intensity, and tests of heterogeneity and Strength of Evidence ity was found between MDT and either
were significant (FIGURE 4C).17,22,31,38 There The articles’ scores on the PEDro scale manual therapy plus exercise or educa-
was moderate evidence of no significant were all obtained through the PEDro da- tion. In those with acute LBP, the qual-
difference in pain after the intervention tabase and ranged from 4 to 8 out of 10. ity of evidence assessed with the GRADE
period between interventions (SMD, There were 15 studies with a PEDro score ratings was moderate and high for the
–0.38; 95% CI: –0.82, 0.05). Ratings of at least 5, and 2 studies with a score of outcome of pain and disability, respec-
Downloaded from www.jospt.org at Grand Valley State University on April 12, 2018. For personal use only. No other uses without permission.
were downgraded because of impreci- less than 5. Due to the nature of the inter- tively; therefore, there is good-quality
sion of results. These 4 studies also ex- ventions, the providers could not be blind- evidence showing that MDT is not clini-
amined disability. Tests of heterogeneity ed to the interventions in any of the studies, cally superior to other interventions in
were not significant (FIGURE 5C). There which lowered the PEDro scores of the acute LBP to improve pain or disability.
was high-quality evidence of a signifi- included articles. Blinding of the patients In patients with chronic LBP, (1) MDT
cant difference (Puting to statistical analysis. A PEDro scale investigated separately. Chronic pain and meta-analysis. The basis of the MDT
score of 5 or higher is used as a common acute pain manifest differently, because approach relies on the classification of a
cutoff to evaluate the quality of a study.7 psychosocial factors are potentially more patient before providing treatment, such
The current findings were different dominant in patients with chronic pain.68 as directional-preference exercises. Thus,
from those of the previous meta-analysis, Second, the current meta-analysis only patients should be classified into 1 of the
which concluded that the MDT approach included studies in which therapists re- subgroups (derangement, dysfunction,
did not produce clinically significant dif- ceived MDT standardized training. When postural, or other) prior to receiving a spe-
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ferences in pain and disability in patients providing care based on MDT principles, cific treatment to be considered an MDT
with LBP. Nine studies included in the trained therapists obtained better treat- treatment. The classification process was
current study were published after the last ment outcomes than untrained thera- omitted in 5 of the included studies in the
meta-analysis,32 published in 2006 (TABLE pists.10 From the previous meta-analysis, previous systematic review.9,11,35,57,60 Thus,
1).1,18,22,33,40,45,47,53,54 There are 4 main differ- 2 studies included therapists who were the current findings provided an updated
ences between the previous and current not trained in MDT.5,12 Third, only stud- meta-analysis of the effectiveness of MDT,
meta-analyses. First, in the current me- ies in which classification was conducted and ensured that the included studies
ta-analysis, acute and chronic LBP were a priori were included in the current more closely followed the MDT program
as intended.
A In patients with acute LBP, we ob-
Study Weight SMD IV, Random (95% CI) served statistically significantly greater
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Cherkin et al3 45.4% 0.09 (–0.16, 0.34) improvement in pain intensity when
Machado et al33 35.0% 0.02 (–0.32, 0.35) utilizing the MDT approach compared
Schenk et al55 9.5% –0.61 (–1.43, 0.21) to the combination of manual therapy
Schenk et al54 10.1% –0.58(–1.37, 0.22) and exercise. Two studies in which di-
Total 100.0% –0.07 (–0.34, 0.20) rectional-preference exercises were the
primary means of treatment in the MDT
–2 –1 0 1 2
Favors MDT Favors other interventions group were analyzed.54,55 Directional
Heterogeneity: τ = 0.03, χ = 4.60, df = 3 (P = .20), I = 35%.
2 2 2
preference implies a rapid improve-
Test for overall effect: z = 0.51 (P = .61).
ment in patient symptoms in response
B to a specific exercise.36 This could ex-
Journal of Orthopaedic & Sports Physical Therapy®
plain the differences observed when
Study Weight SMD IV, Random (95% CI)
comparing a symptom-based approach
Schenk et al55 24.0% –0.61 (–1.43, 0.21)
to a nonspecific exercise regimen, such
Schenk et al54 24.8% –0.58 (–1.37, 0.22)
as range-of-motion exercises, which may
Cherkin et al3 51.2% 0.09 (–0.16, 0.34)
not address pain immediately. Analysis
Total 100.0% –0.24 (–0.77, 0.28)
of the 2 included studies showed sta-
–2 –1 0 1 2 tistically significant differences in pain
Favors MDT Favors manual plus exercise
Heterogeneity: τ2= 0.12, χ2= 4.57, df = 2 (P = .10), I2 = 56%. favoring MDT (FIGURE 2), with an SMD
Test for overall effect: z = 0.91 (P = .36). of 0.74 and a nonstandardized differ-
ence of 1.86 on the visual analog scale
C (analysis not presented), which would be
Study Weight SMD IV, Random (95% CI) considered clinically meaningful.21 For
MMachado et al33 46.0% 0.02 (–0.32, 0.35) acute LBP, no difference was observed
Cherkin et al3 54.0% –0.18 (–0.48, 0.13) for change in disability across the dif-
Total 100.0% –0.09 (–0.31, 0.14) ferent methods of intervention, includ-
ing education (FIGURE 3). This could be
–2 –1 0 1 2
Favors MDT Favors education explained by the nature of acute LBP,
Heterogeneity: τ2 = 0.00, χ2 = 0.69, df = 1 (P = .41), I2 = 0%. in that most patients have a favorable
Test for overall effect: z = 0.75 (P = .45).
prognosis, and that rapid reductions in
FIGURE 3. Forest plot of the effectiveness of MDT for improving disability in patients with acute low back pain in both pain and disability are noted with-
comparison to (A) other physical therapy interventions, (B) a combination of manual therapy with exercise, and in 6 weeks of symptom onset.37 For pa-
(C) education. The other physical therapy interventions included a combination of manual therapy with exercise tients with acute LBP, MDT seemed to
or education. Abbreviations: CI, confidence interval; IV, independent variable; MDT, Mechanical Diagnosis and be more effective at reducing pain than
Therapy; SMD, standardized mean difference.
manual therapy plus exercise; however,
journal of orthopaedic & sports physical therapy | ahead of print | 11[ research report ]
therapists should be careful when us- ing pain and disability in patients with derangement subgroup for the MDT
ing MDT exclusively, as the effect size chronic LBP. intervention, whereas others included
was moderate for a small sample size, However, there were some method- all 3 mechanical syndromes. The fact
and other treatment approaches could ological issues in the included studies. that the 3 different subgroups had dif-
yield similar results for disability in this Lower PEDro scale scores were often ferent prognoses could have impacted
population. due to the nature of the studies: not al- MDT’s effectiveness. Furthermore,
For patients with chronic LBP, MDT lowing for blinding of the therapists and MDT was not compared to other clas-
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provided greater improvements in pain patients. The intention to treat was not sification approaches that tailor treat-
and disability compared to other in- met for 4 studies, and it was not clear ments based on clinical characteristics
terventions and exercise alone, but how participants who dropped out rather than pathoanatomical diagnoses,
had similar outcomes compared to the were accounted for statistically.1,20,22,38 such as treatment-based classification
combination of manual therapy and ex- Also, some studies included only the and movement system impairments.13,27
ercise. The SMD values represented a
small treatment effect for the compari- A
son of MDT to other interventions for Study Weight SMD IV, Random (95% CI)
pain (SMD, –0.33) and disability (SMD, Miller et al38 9.6% –0.63 (–1.38, 0.12)
–0.28); therefore, despite statistical sig- Halliday et al22 14.5% –0.04 (–0.54, 0.46)
nificance, the clinical significance of the Paatelma et al45 16.7% –0.53 (–0.94, –0.13)
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
difference may be less meaningful. Other Long et al31 18.8% –0.81 (–1.13, –0.49)
symptom-matched approaches have also Garcia et al17 18.8% –0.09 (–0.41, 0.23)
demonstrated similar findings in patients Petersen et al47 21.6% –0.04 (–0.25, 0.17)
with chronic LBP.2,56 Total 100.0% –0.33 (–0.63, –0.03)
Although effective in treating chronic
–2 –1 0 1 2
LBP, MDT might not be any better than Favors MDT Favors other interventions
combined manual therapy plus exercise. Heterogeneity: τ = 0.10, χ = 19.81, df = 5 (P = .001), I = 75%.
2 2 2
It has been shown in treatment-based Test for overall effect: z = 2.19 (P = .03).
classification that patients who may ben-
B
efit from specific exercise may also benefit
Journal of Orthopaedic & Sports Physical Therapy®
Study Weight SMD IV, Random (95% CI)
from spinal manipulation.58 Also, small
Paatelma et al45 43.5% –0.53 (–0.94, –0.13)
treatment effects could be credited to the
Petersen et al47 56.5% –0.04 (–0.25, 0.17)
fact that a large group of patients may not
Total 100.0% –0.26 (–0.73, 0.22)
fall into a distinct subgrouping and may
benefit from a more generalized exercise –2 –1 0 1 2
Favors MDT Favors manual plus exercise
program.59 These patients are likely to be
Heterogeneity: τ = 0.09, χ = 4.46, df = 1 (P = .03), I = 78%.
2 2 2
classified into the “chronic pain” category Test for overall effect: z = 1.05 (P = .30).
of the MDT classification. Because the
meta-analysis did not evaluate each MDT C
subgroup separately, definite conclusions Study Weight SMD IV, Random (95% CI)
regarding the different treatment effec- Miller et al38 17.2% –0.63 (–1.38, 0.12)
tiveness outcomes are unknown. This Halliday et al22 24.0% –0.04 (–0.54, 0.46)
latter subgroup is largely based on the Long et al31 29.4% –0.81 (–1.13, –0.49)
presence of psychological factors and on Garcia et al17 29.4% –0.09 (–0.41, 0.23)
patients not responding to mechanical- Total 100.0% –0.38 (–0.82, 0.05)
type treatments.36 Also, MDT does not
–2 –1 0 1 2
explicitly account for pain systems theory, Favors MDT Favors exercise
specifically differentiating between pain Heterogeneity: τ2 = 0.14, χ2 = 12.09, df = 3 (P = .007), I2 = 75%.
Test for overall effect: z =1.73 (P = .08).
that is central or peripheral in origin, and
for a wider spectrum of psychological fac- FIGURE 4. Forest plot of the effectiveness of MDT for improving pain in patients with chronic low back pain in
tors that could be present in patients with comparison to (A) other physical therapy interventions, (B) a combination of manual therapy with exercise, and (C)
chronic LBP.44,51 Regardless, although the exercise. The other physical therapy interventions included either a combination of manual therapy with exercise
treatment effects are small to moderate, or exercise alone. Abbreviations: CI, confidence interval; IV, independent variable; MDT, Mechanical Diagnosis and
Therapy; SMD, standardized mean difference.
MDT remains a viable option in reduc-
12 | ahead of print | journal of orthopaedic & sports physical therapyThese approaches have yielded simi- CONCLUSION interventions for reducing pain and dis-
larly modest results, finding statistically ability; however, this depends on the
T
insignificant improvements in outcome here is moderate- to high- type of intervention being compared to
measures for both the classification-spe- quality evidence that MDT is not MDT, and the effect sizes were generally
cific and the non–classification-specific superior to other rehabilitation considered small to moderate, which
groups.24,61 However, this current review interventions for reducing pain and means clinical significance needs to be
did find a significant difference between disability in patients with acute LBP. determined. Although some evidence
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patient-matched treatment and generic In patients with chronic LBP, there is supported the use of MDT for assessing
exercise for disability in the short term moderate- to high-quality evidence that and treating LBP, therapists should be
for chronic LBP, albeit moderate. MDT is superior to other rehabilitation careful when using this approach exclu-
sively, because other treatments have
A
shown similar effectiveness, and a pa-
tient’s values and preferences should be
considered. t
Study Weight SMD IV, Random (95% CI)
Moncelon and Otero40 2.3% –0.11 (–1.16, 0.94)
Miller et al38 4.4% –0.64 (–1.39, 0.11)
KEY POINTS
Halliday et al22 9.1% –0.32 (–0.82, 0.18)
FINDINGS: For reducing pain and dis-
Paatelma et al 45
13.4% 0.00 (–0.40, 0.40)
ability in patients with acute low back
Garcia et al17 18.5% –0.36 (–0.68, –0.03)
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
pain (LBP), the McKenzie Method of
Long et al 31
19.3% –0.55 (–0.86, –0.23)
Mechanical Diagnosis and Therapy
Petersen et al47 33.0% –0.14 (–0.35, 0.07)
(MDT) is not superior to other rehabili-
Total 100.0% –0.28 (–0.44, –0.12)
tation interventions. In patients with
–2 –1 0 1 2
Favors MDT Favors other interventions chronic LBP, however, MDT is superior
Heterogeneity: τ2 = 0.01, χ2 = 7.44, df = 6 (P = .28), I2 = 19%. to other rehabilitation interventions for
Test for overall effect: z = 3.38 (P = .0007). reducing pain and disability; however,
this depends on the type of intervention
B being compared to MDT. The treatment
Study Weight SMD IV, Random (95% CI) effect for MDT was generally small to
Journal of Orthopaedic & Sports Physical Therapy®
Moncelon and Otero40 3.0% –0.11 (–1.16, 0.94) moderate.
Paatelma et al45 21.0% 0.00 (–0.40, 0.40) IMPLICATIONS: To treat patients with LBP,
Petersen et al47 76.0% –0.14 (–0.35, 0.07) MDT may be used, although other inter-
Total 100.0% –0.11 (–0.29, 0.07) vention methods might offer a similar
–2 –1 0 1 2 benefit.
Favors MDT Favors manual plus exercise CAUTION: Although statistically signifi-
Heterogeneity: τ2 = 0.00, χ2 = 0.38, df = 3 (P = .83), I2 = 0%.
cant, clinical significance of MDT effects
Test for overall effect: z = 1.20 (P = .23).
needs to be determined because the ef-
C fect sizes found were small to moderate.
Study Weight SMD IV, Random (95% CI)
Miller et al38 7.0% –0.64 (–1.39, 0.11) ACKNOWLEDGMENTS: Jose Correa and Joe
Halliday et al22 15.7% –0.32 (–0.82, 0.18) Ornelas provided advice on statistics. Jill
Garcia et al17 37.5% –0.36 (–0.68, –0.03) Boruff provided assistance with developing
Long et al31 39.7% –0.55 (–0.64, –0.25) the literature search.
Total 100.0% –0.45 (–0.86, –0.23)
–2 –1 0 1 2 REFERENCES
Favors MDT Favors exercise
Heterogeneity: τ = 0.00, χ = 1.18, df = 3 (P = .76), I = 0%.
2 2 2
1. Bonnet F, Monnet S, Otero J. Short-term effects
Test for overall effect: z = 4.39 (P[ research report ]
approach in a subgroup of subjects with low of a proposed treatment-based classifica- review of the global prevalence of low back pain.
back pain: a randomized clinical trial. Phys Ther. tion system for patients receiving physical Arthritis Rheum. 2012;64:2028-2037. https://doi.
2007;87:1608-1618. https://doi.org/10.2522/ therapy interventions for neck pain. Phys Ther. org/10.1002/art.34347
ptj.20060297 2007;87:513-524. https://doi.org/10.2522/ 26. Hoy D, March L, Brooks P, et al. The global bur-
3. Cherkin DC, Deyo RA, Battie M, Street J, Barlow ptj.20060192 den of low back pain: estimates from the Global
W. A comparison of physical therapy, chiropractic 15. F ritz JM, Delitto A, Erhard RE. Comparison Burden of Disease 2010 study. Ann Rheum
manipulation, and provision of an educational of classification-based physical therapy with Dis. 2014;73:968-974. https://doi.org/10.1136/
booklet for the treatment of patients with low therapy based on clinical practice guidelines annrheumdis-2013-204428
Downloaded from www.jospt.org at Grand Valley State University on April 12, 2018. For personal use only. No other uses without permission.
back pain. N Engl J Med. 1998;339:1021-1029. for patients with acute low back pain: a ran- 27. Karayannis NV, Jull GA, Hodges PW. Physiother-
https://doi.org/10.1056/NEJM199810083391502 domized clinical trial. Spine (Phila Pa 1976). apy movement based classification approaches
4. Chou R, Qaseem A, Snow V, et al. Diagnosis 2003;28:1363-1371; discussion 1372. https://doi. to low back pain: comparison of subgroups
and treatment of low back pain: a joint clinical org/10.1097/01.BRS.0000067115.61673.FF through review and developer/expert survey. BMC
practice guideline from the American College 16. F urlan AD, Pennick V, Bombardier C, van Tulder Musculoskelet Disord. 2012;13:24. https://doi.
of Physicians and the American Pain Society. M. 2009 updated method guidelines for system- org/10.1186/1471-2474-13-24
Ann Intern Med. 2007;147:478-491. https://doi. atic reviews in the Cochrane Back Review Group. 28. Kilpikoski S, Airaksinen O, Kankaanpaa
org/10.7326/0003-4819-147-7-200710020-00006 Spine (Phila Pa 1976). 2009;34:1929-1941. M, Leminen P, Videman T, Alen M. Interex-
5. Delitto A, Cibulka MT, Erhard RE, Bowling RW, https://doi.org/10.1097/BRS.0b013e3181b1c99f aminer reliability of low back pain assess-
Tenhula JA. Evidence for use of an extension- 17. G arcia AN, Costa LC, da Silva TM, et al. Ef- ment using the McKenzie method. Spine
mobilization category in acute low back syn- fectiveness of back school versus McKenzie (Phila Pa 1976). 2002;27:E207-E214. https://doi.
drome: a prescriptive validation pilot study. Phys exercises in patients with chronic nonspecific low org/10.1097/00007632-200204150-00016
Ther. 1993;73:216-222. https://doi.org/10.1093/ back pain: a randomized controlled trial. Phys 29. K
oes BW, van Tulder MW, Ostelo R, Kim
ptj/73.4.216 Ther. 2013;93:729-747. https://doi.org/10.2522/ Burton A, Waddell G. Clinical guidelines for
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
6. Delitto A, George SZ, Van Dillen LR, et al. Low back ptj.20120414 the management of low back pain in pri-
pain. J Orthop Sports Phys Ther. 2012;42:A1-A57. 18. G arcia AN, Costa LC, Hancock MJ, et al. McKen- mary care: an international comparison. Spine
https://doi.org/10.2519/jospt.2012.0301 zie Method of Mechanical Diagnosis and Therapy (Phila Pa 1976). 2001;26:2504-2513. https://doi.
7. de Morton NA. The PEDro scale is a valid mea- was slightly more effective than placebo for pain, org/10.1097/00007632-200111150-00022
sure of the methodological quality of clinical but not for disability, in patients with chronic 30. Krause P, Forderreuther S, Straube A. TMS motor
trials: a demographic study. Aust J Physiother. non-specific low back pain: a randomised pla- cortical brain mapping in patients with complex
2009;55:129-133. https://doi.org/10.1016/ cebo controlled trial with short and longer term regional pain syndrome type I. Clin Neurophysiol.
S0004-9514(09)70043-1 follow-up. Br J Sports Med. In press. https://doi. 2006;117:169-176. https://doi.org/10.1016/j.
8. DerSimonian R, Laird N. Meta-analysis in clinical org/10.1136/bjsports-2016-097327 clinph.2005.09.012
trials. Control Clin Trials. 1986;7:177-188. https:// 19. G iesecke T, Gracely RH, Grant MA, et al. Evidence 31. Long A, Donelson R, Fung T. Does it matter
doi.org/10.1016/0197-2456(86)90046-2 of augmented central pain processing in idio- which exercise? A randomized control trial of
9. Dettori JR, Bullock SH, Sutlive TG, Franklin RJ, pathic chronic low back pain. Arthritis Rheum. exercise for low back pain. Spine (Phila Pa 1976).
Journal of Orthopaedic & Sports Physical Therapy®
Patience T. The effects of spinal flexion and exten- 2004;50:613-623. https://doi.org/10.1002/ 2004;29:2593-2602. https://doi.org/10.1097/01.
sion exercises and their associated postures in art.20063 brs.0000146464.23007.2a
patients with acute low back pain. Spine (Phila 20. G illan MG, Ross JC, McLean IP, Porter RW. The 32. Machado LA, de Souza M, Ferreira PH, Ferreira
Pa 1976). 1995;20:2303-2312. natural history of trunk list, its associated dis- ML. The McKenzie method for low back pain:
10. Deutscher D, Werneke MW, Gottlieb D, Fritz JM, ability and the influence of McKenzie manage- a systematic review of the literature with a
Resnik L. Physical therapists’ level of McKenzie ment. Eur Spine J. 1998;7:480-483. https://doi. meta-analysis approach. Spine (Phila Pa 1976).
education, functional outcomes, and utiliza- org/10.1007/s005860050111 2006;31:E254-E262. https://doi.org/10.1097/01.
tion in patients with low back pain. J Orthop 21. H agg O, Fritzell P, Nordwall A. The clinical brs.0000214884.18502.93
Sports Phys Ther. 2014;44:925-936. https://doi. importance of changes in outcome scores 33. Machado LA, Maher CG, Herbert RD, Clare
org/10.2519/jospt.2014.5272 after treatment for chronic low back pain. Eur H, McAuley JH. The effectiveness of the McK-
11. Elnaggar IM, Nordin M, Sheikhzadeh A, Spine J. 2003;12:12-20. https://doi.org/10.1007/ enzie method in addition to first-line care
Parnianpour M, Kahanovitz N. Effects of s00586-002-0464-0 for acute low back pain: a randomized con-
spinal flexion and extension exercises on 22. H alliday MH, Pappas E, Hancock MJ, et al. A ran- trolled trial. BMC Med. 2010;8:10. https://doi.
low-back pain and spinal mobility in chronic domized controlled trial comparing the McKenzie org/10.1186/1741-7015-8-10
mechanical low-back pain patients. Spine method to motor control exercises in people with 34. Maher CG, Sherrington C, Herbert RD, Moseley
(Phila Pa 1976). 1991;16:967-972. https://doi. chronic low back pain and a directional prefer- AM, Elkins M. Reliability of the PEDro scale
org/10.1097/00007632-199108000-00018 ence. J Orthop Sports Phys Ther. 2016;46:514- for rating quality of randomized controlled tri-
12. Erhard RE, Delitto A, Cibulka MT. Relative ef- 522. https://doi.org/10.2519/jospt.2016.6379 als. Phys Ther. 2003;83:713-721. https://doi.
fectiveness of an extension program and a com- 23. H efford C. McKenzie classification of mechanical org/10.1093/ptj/83.8.713
bined program of manipulation and flexion and spinal pain: profile of syndromes and directions 35. Malmivaara A, Häkkinen U, Aro T, et al. The
extension exercises in patients with acute low of preference. Man Ther. 2008;13:75-81. https:// treatment of acute low back pain—bed rest,
back syndrome. Phys Ther. 1994;74:1093-1100. doi.org/10.1016/j.math.2006.08.005 exercises, or ordinary activity? N Engl J Med.
https://doi.org/10.1093/ptj/74.12.1093 24. H enry SM, Van Dillen LR, Ouellette-Morton 1995;332:351-355. https://doi.org/10.1056/
13. Fritz J. Disentangling classification systems from RH, et al. Outcomes are not different for NEJM199502093320602
their individual categories and the category- patient-matched versus nonmatched treat- 36. McKenzie R, May S. The Lumbar Spine: Mechani-
specific criteria: an essential consideration ment in subjects with chronic recurrent low cal Diagnosis and Therapy. 2nd ed. Wellington,
to evaluate clinical utility. J Man Manip Ther. back pain: a randomized clinical trial. Spine J. New Zealand: Spinal Publications; 2003.
2010;18:205-208. https://doi.org/10.1179/10669 2014;14:2799-2810. https://doi.org/10.1016/j. 37. Menezes Costa LC, Maher CG, Hancock MJ,
8110X12804993427162 spinee.2014.03.024 McAuley JH, Herbert RD, Costa LO. The prognosis
14. Fritz JM, Brennan GP. Preliminary examination 25. H oy D, Bain C, Williams G, et al. A systematic of acute and persistent low-back pain: a meta-
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