Alessandra Narciso Garcia

Effectiveness of Back School Versus McKenzie Exercises in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

Background Back School and McKenzie methods are popular active treatment approaches that include both exercises and information for patients with chronic nonspecific low back pain. Objective The purpose of this study was to compare the effectiveness of Back School and McKenzie methods in patients with chronic nonspecific low back pain. Design The study was a prospectively registered, 2-arm randomized controlled trial with a blinded assessor. Setting The study was conducted in the outpatient physical therapy clinic in São Paulo, Brazil. Patients The study participants were 148 patients with chronic nonspecific low back pain. Interventions The 4-week treatment program (one session/week) was based on the Back School (delivered to the group) or McKenzie (delivered individually) principles. The participants also were instructed to perform a daily set of home exercises. Measurements Clinical outcomes were assessed at follow-up appointments at 1, 3, and 6 months after randomization. Primary outcome measures were pain intensity (measured by the 0–10 pain numerical rating scale) and disability (measured by the 24-item Roland-Morris Disability Questionnaire) 1 month after randomization. Secondary outcome measures were pain intensity and disability at 3 and 6 months after randomization, quality of life (measured by the World Health Organization Quality of Life–BREF instrument) at 1, 3, and 6 months after randomization, and trunk flexion range of motion measured by an inclinometer at 1 month after randomization. The data were collected by a blinded assessor. Results Participants allocated to the McKenzie group had greater improvements in disability at 1 month (mean effect=2.37 points, 95% confidence interval=0.76 to 3.99) but not for pain (mean effect=0.66 points, 95% confidence interval=−0.29 to 1.62). No between-group differences were observed for all secondary outcome measures. Limitations It was not possible to monitor the home exercise program. Therapists and participants were not blinded. Conclusions The McKenzie method (a more resource-intensive intervention) was slightly more effective than the Back School method for disability, but not for pain intensity immediately after treatment in participants with chronic low back pain.

Effects of two physical therapy interventions in patients with chronic non-specific low back pain: feasibility of a randomized controlled trial

BACKGROUND Chronic non-specific low back pain is both a health and a socio-economic problem which is associated with disability as well as with emotional distress. The Mckenzie and Back Schools techniques have been shown to be effective in the treatment of this condition. OBJECTIVES to perform a preliminary analysis of the effects of these treatments in patients with chronic non specific low back pain for the following outcomes: pain, disability and trunk flexion range of motion and to test the feasibility of randomized controlled trial testing these interventions on this population. METHODS the participants were assessed by a blinded assessor and randomly assigned into one of the treatment groups. The data analysis was performed in only 18 patients and the study is still ongoing, so the results are restricted to these patients, as a single group. RESULTS the patients improved for the outcomes pain intensity (mean difference of 2.4 points and 95% CI 0.84 to 3.93) and disability (5.2 points and 95% CI 2.55 to 7.78), but no improvement in range of motion in flexion was observed (7.2 degrees 95% CI -1.82 to 16.29). CONCLUSION the Mckenzie and Back Schools approaches may be beneficial for the treatment of patients with chronic non specific low back pain for the outcomes pain intensity and disability. We also concluded that the study is feasible and we will continue performing the current study without any adjustments of the original research protocol. This study was prospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12610000435088.

Effectiveness of the back school and mckenzie techniques in patients with chronic non-specific low back pain: a protocol of a randomised controlled trial

BackgroundChronic low back pain is a highly prevalent condition, which is associated with high direct and indirect costs to the society. Although this condition is highly prevalent, it is still extremely difficult to treat. Two potentially useful treatments for patients with chronic low back pain are called the McKenzie and Back School treatment programs. These programs have good biological plausibility, are widely available and have a modest cost. Although these treatments are already available for patients, the evidence that supports their use is largely based on low quality methodological studies. Therefore, a high-quality randomised controlled trial is required to compare, for the first time, the effectiveness of these treatments in patients with chronic low back pain.Methods/designOne hundred and forty-eight patients will be randomly allocated to a four-week treatment program based upon the McKenzie or Back School principles. Clinical outcomes (pain intensity, disability, quality of life, and trunk flexion range of motion) will be obtained at follow-up appointments at 1, 3 and 6 months after randomisation. The data will be collected by an assessor who will be blinded to the group allocation.DiscussionThis will be the first study aimed to compare the McKenzie and Back School approaches in patients with chronic low back pain. The results of this trial may help in the decision-making process of allied health providers for the treatment of chronic low back pain and reduce the health-related costs of this condition.Trial RegistrationACTRN12610000435088

Identifying Patients With Chronic Low Back Pain Who Respond Best to Mechanical Diagnosis and Therapy: Secondary Analysis of a Randomized Controlled Trial.

Background “Mechanical Diagnosis and Therapy” (MDT) (also known as the McKenzie method), like other interventions for low back pain (LBP), has been found to have small effects for people with LBP. It is possible that a group of patients respond best to MDT and have larger effects. Identification of patients who respond best to MDT compared with other interventions would be an important finding. Objective The purpose of the study was to investigate whether baseline characteristics of patients with chronic LBP, already classified as derangement syndrome, can identify those who respond better to MDT compared with Back School. Methods This study was a secondary analysis of data from a previous trial comparing MDT with Back School in 148 patients with chronic LBP. Only patients classified at baseline assessment as being in the directional preference group (n=140) were included. The effect modifiers tested were: clear centralization versus directional preference only, baseline pain location, baseline pain intensity, and age. The primary outcome measures for this study were pain intensity and disability at the end of treatment (1 month). Treatment effect modification was evaluated by assessing the group versus predictor interaction terms from linear regression models. Interactions ≥1.0 for pain and ≥3 for disability were considered clinically important. Results Being older met our criteria for being a potentially important effect modifier; however, the effect occurred in the opposite direction to our hypothesis. Older people had 1.27 points more benefit in pain reduction from MDT (compared with Back School) than younger participants after 1 month of treatment. Limitations The sample (n=140) was powered to detect the main effects of treatment but not to detect the interactions of the potential treatment effect modifiers. Conclusions The results of the study suggest older age may be an important factor that can be considered as a treatment effect modifier for patients with chronic LBP receiving MDT. As the main trial was not powered for the investigation of subgroups, the results of this secondary analysis have to be interpreted cautiously, and replication is needed.

Efficacy of the McKenzie Method in Patients With Chronic Nonspecific Low Back Pain: A Protocol of Randomized Placebo-Controlled Trial

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 São 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.

McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up

Background The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with placebo in patients with chronic LBP. Methods This was a prospectively registered, two-arm randomised placebo controlled trial, with a blinded assessor. A total of 148 patients seeking care for chronic LBP were randomly allocated to either MDT (n=74) or placebo (n=74). Patients from both groups received 10 treatment sessions over 5 weeks. Patients from both groups also received an educational booklet. Clinical outcomes were obtained at the end of treatment (5 weeks) and 3, 6 and 12 months after randomisation. Primary outcomes were pain intensity and disability at the end of treatment (5 weeks). We also conducted a subgroup analysis to identify potential treatment effect modifiers that could predict a better response to MDT treatment. Results The MDT group had greater improvements in pain intensity at the end of treatment (mean difference (MD) −1.00, 95% CI −2.09 to −0.01) but not for disability (MD −0.84, 95% CI −2.62 to 0.93). We did not detect between-group differences for any secondary outcomes, nor were any treatment effect modifiers identified. Patients did not report any adverse events. Conclusion We found a small and likely not clinically relevant difference in pain intensity favouring the MDT method immediately at the end of 5 weeks of treatment but not for disability. No other difference was found for any of the primary or secondary outcomes at any follow-up times. Trial registration number ClinicalTrials.gov (NCT02123394)

Can demographic and anthropometric characteristics predict clinical improvement in patients with chronic non-specific low back pain?

OBJECTIVE To identify potential prognostic factors that may predict clinical improvement of patients treated with different physical therapy interventions in the short-term. METHODS This is a prospective cohort study. A total of 616 patients with chronic non-specific low back pain treated with interventions commonly used by physical therapists were included. These patients were selected from five randomized controlled trials. Multivariate linear regression models were used to verify if sociodemographic characteristics (age, gender, and marital status), anthropometric variables (height, body mass, and body mass index), or duration of low back pain, pain intensity at baseline, and disability at baseline could be associated with clinical outcomes of pain intensity and disability four weeks after baseline. RESULTS The predictive variables for pain intensity were age (β=0.01 points, 95% CI=0.00 to 0.03, p=0.03) and pain intensity at baseline (β=0.23 points, 95% CI=0.13 to 0.33, p=0.00), with an explained variability of 4.6%. Similarly, the predictive variables for disability after four weeks were age (β=0.03 points, 95% CI=0.00 to 0.06, p=0.01) and disability at baseline (β=0.71 points, 95% CI=0.65 to 0.78, p=0.00), with an explained variability of 42.1%. CONCLUSION Only age, pain at baseline and disability at baseline influenced the pain intensity and disability after four weeks of treatment. The beta coefficient for age was statistically significant, but the magnitude of this association was very small and not clinically important.

Reliability of Mechanical Diagnosis and Therapy System in Patients With Spinal Pain: A Systematic Review

• BACKGROUND: An updated summary of the evidence for the reliability of the Mechanical Diagnosis and Therapy (MDT) system in patients with spinal pain is needed. • OBJECTIVE: To investigate the evidence on the intrarater and interrater reliability of MDT in patients with spinal pain. • METHODS: Searches in MEDLINE, CINAHL, Embase, PEDro, and Scopus were conducted for this systematic review. We included any study design as long as reliability of the MDT method was tested in patients with spinal pain. We collected data on the reliability of MDT to identify main and subsyndromes, directional preference, the centralization phenomenon, and lateral shift. The methodological quality of studies was assessed using the Quality Appraisal of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement Studies checklists. • RESULTS: Twelve studies were included (8 studies on back pain, pooled n = 2160 patients; 3 studies on neck pain, pooled n = 45 patients; and 3 studies recruited mixed spinal conditions, pooled n = 389 patients). Studies investigating patients with back pain reported kappa estimates ranging from 0.26 to 1.00 (main and subsyndromes), 0.27 to 0.90 (directional preference), and 0.11 to 0.70 (centralization phenomenon). Kappa estimates for studies investigating neck pain ranged from 0.47 to 0.84 (main and subsyndromes) and 0.46 (directional preference). In mixed populations, kappa estimates ranged from 0.56 to 0.96 (main and subsyndromes). • CONCLUSION: The MDT system appears to have acceptable interrater reliability for classifying patients with back pain into main and subsyndromes when applied by therapists who have completed the credentialing examination, but unacceptable reliability in other therapists. We found conflicting evidence regarding the reliability of the MDT system in patients with neck pain or mixed pain locations.