Tom Petersen

The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain - A randomized controlled trial

STUDY DESIGN A randomized controlled comparative trial with an 8-month follow-up period was conducted. OBJECTIVE To compare the effect of the McKenzie treatment method with that of intensive dynamic strengthening training in patients with subacute or chronic low back pain. SUMMARY OF BACKGROUND DATA Randomized studies indicate that the efficacy of the McKenzie method in the treatment of patients with acute or subacute low back pain is debatable. Currently, no randomized studies examining the effects of this method for patients with chronic low back pain have been published. METHODS For this study, 260 consecutive patients with low back pain and at least 8 weeks duration of symptoms (85% of the patients had more than 3 months duration of symptoms) were randomized into two groups: Group A was treated with the McKenzie method (n = 132), and Group B was treated with intensive dynamic strengthening training (n = 128). The treatment period for both groups was 8 weeks at an outpatient clinic, followed by 2 months of self-training at home. Treatment results were recorded at the end of the treatment period at the clinic, then 2 and 8 months after. In both groups, 30% of the patients were lost to follow-up evaluation. An intention-to-treat analysis of the main effect variables, disability, and pain was performed for all the patients included in the study. A supplementary analysis of the 180 patients who completed the full treatment program also was undertaken. RESULTS Intention-to-treat analysis showed a tendency toward a difference in reduction of disability in favor of the McKenzie group at the 2-month follow-up assessment (P = 0.04), but no differences at the end of treatment and at the 8-month follow-up evaluation. No differences in reduction of pain were observed at any time between the groups. The supplementary analysis of the patients who had completed the full intervention showed a tendency toward a difference in favor of the McKenzie method in reduction of pain at the end of treatment (P = 0.02). This difference reached statistical significance at the 2-month follow-up assessment (P = 0.01), but no difference was found after 8 months. The supplementary analysis showed no differences between the groups with regard to reduction of disability. CONCLUSION The McKenzie method and intensive dynamic strengthening training seem to be equally effective in the treatment of patients with subacute or chronic low back pain.

Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain

Most patients referred to physiotherapy with low back pain are without a precise medical diagnosis. Identification of subgroups of non-specific low back pain patients may improve clinical outcomes and research efficiency. A pathoanatomic classification system has been developed, classifying patients with non-specific low back pain into 12 different syndromes and three subcategories based on history and physical examination. The purpose of this study was to estimate the inter-tester reliability of clinical tests used as criteria for classifying patients. Ninety patients with chronic low back pain were each examined by two physiotherapists. A total of four physiotherapists conducted the assessments. Examination findings were recorded independently by the two examiners. Percentage of agreement and kappa coefficients were calculated for each category. The overall rate of agreement was 72% and the kappa coefficient was 0.62 for the mutually exclusive syndromes in the classification system. Agreement rates for each of the syndromes ranged from 74% to 100% and kappa coefficients ranged from 0.44 to 1.00. The findings suggest the inter-tester reliability of the system is acceptable. The relatively modest level of total agreement (39%) for the system as a whole might indicate that the utility of the system for general screening purposes is limited, compared with the utility in identification of particular syndromes. Due to low prevalence of positive findings in some of the syndromes, future work should focus on testing reliability on a larger sample of patients, and testing of validity and feasibility of the system.

The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial.

Study Design. Randomized controlled trial. Objective. To compare the effects of the McKenzie method performed by certified therapists with spinal manipulation performed by chiropractors when used adjunctive to information and advice. Summary of Background Data. Recent guidelines recommend a structured exercise program tailored to the individual patient as well as manual therapy for the treatment of persistent low back pain. There is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies to clinical subgroups of patients in primary care. Methods. A total of 350 patients suffering from low back pain with a duration of more than 6 weeks who presented with centralization or peripheralization of symptoms with or without signs of nerve root involvement, were enrolled in the trial. Main outcome was number of patients with treatment success defined as a reduction of at least 5 points or an absolute score below 5 points on the Roland Morris Questionnaire. Secondary outcomes were reduction in disability and pain, global perceived effect, general health, mental health, lost work time, and medical care utilization. Results. Both treatment groups showed clinically meaningful improvements in this study. At 2 months follow-up, the McKenzie treatment was superior to manipulation with respect to the number of patients who reported success after treatment (71% and 59%, respectively) (odds ratio 0.58, 95% confidence interval [CI] 0.36 to 0.91, P = 0.018). The number needed to treat with the McKenzie method was 7 (95% CI 4 to 47). The McKenzie group showed improvement in level of disability compared to the manipulation group reaching a statistical significance at 2 and 12 months follow-up (mean difference 1.5, 95% CI 0.2 to 2.8, P = 0.022 and 1.5, 95% CI 0.2 to 2.9, P = 0.030, respectively). There was also a significant difference of 13% in number of patients reporting global perceived effect at end of treatment (P = 0.016). None of the other secondary outcomes showed statistically significant differences. Conclusion. In patients with low back pain for more than 6 weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.

One-year follow-up comparison of the effectiveness of McKenzie treatment and strengthening training for patients with chronic low back pain: outcome and prognostic factors.

Study Design. A randomized controlled trial with multivariable analyses of prognostic factors. Objective. To report the long-term outcome of McKenzie treatment compared with strengthening training. Further, to determine patient-related factors associated with poor outcome 14 months after completion of treatment. Summary of Background Data. Exercise therapy is widely recommended for patients with chronic low back pain. However, reports vary considerably concerning characteristics of patients who will not respond to treatment. Knowledge of factors associated with poor outcome may assist identification of patients requiring special attention. Methods. A total of 260 patients with chronic low back pain were included in a previously reported randomized controlled trial of McKenzie therapy versus strengthening training. Outcome variables were: functional status, pain level, work status, and use of healthcare services during follow-up. Also, factors associated with withdrawal during the intervention were sought identified. The following factors of possible prognostic significance were determined: levels of pain and disability, pain-distribution, duration of symptoms, smoking habits, leisure activities, workload, job satisfaction, treatment preference, outcome expectations, treatment modality received, compliance with home exercises during follow-up, and demographic variables such as age, gender, work status, and application for pension. Association between variables was examined by multiple logistic regression analysis and odds ratios. Results. No differences in outcomes were found between the treatment groups at 14 months of follow-up. Low level of pain intensity and disability, sick leave at entry, low pretreatment expectations of future work ability, withdrawal during treatment, and discontinuance of exercises after the end of the treatment period were associated with poor outcome. Conclusion. Poor long-term outcome of exercise therapy for chronic low back pain can be explained by a number of patient-related factors. Different prognostic factors were associated with different outcomes. These factors were more important in determining outcome than the exercise-programs studied.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

BackgroundClinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.MethodsA sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.ResultsSixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.ConclusionsThis is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

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

BackgroundReports 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.Methods350 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.ResultsNo 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).ConclusionsWe 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.Trial registrationClinicaltrials.gov: NCT00939107

Early coordinated multidisciplinary intervention to prevent sickness absence and labour market exclusion in patients with low back pain: study protocol of a randomized controlled trial

BackgroundMusculoskeletal disorders account for one third of the long-term absenteeism in Denmark and the number of individuals sick listed for more than four weeks is increasing. Compared to other diagnoses, patients with musculoskeletal diseases, including low back pain, are less likely to return to work after a period of sick leave. It seems that a multidisciplinary intervention, including cooperation between the health sector, the social sector and in the work place, has a positive effect on days off work due to musculoskeletal disorders and particularly low back pain. It is a challenge to coordinate this type of intervention, and the implementation of a return-to-work (RTW)-coordinator is suggested as an effective strategy in this process. The purpose of this paper is to describe the study protocol and present a new type of intervention, where the physiotherapist both has the role as RTW-coordinator and treating the patient.Methods/designA randomized controlled trial (RCT) is currently on-going. The RCT includes 770 patients with low back pain of minimum four weeks who are referred to an outpatient back centre. The study population consists of patients, who are sick-listed or at risk of sick-leave due to LBP. The control group is treated with usual care in a team of a physiotherapist, a chiropractor, a rheumatologist and a social worker employed at the centre. The Intervention group is treated with usual care and in addition intervention of a psychologist, an occupational physician, an ergonomist, a case manager from the municipal sickness benefit office, who has the authority in the actual case concerning sickness benefit payment and contact to the patients employer/work place. The treating physiotherapist is the RTW-coordinator. Outcome will be reported at the end of treatment as well as 6 and 12 months follow up. The primary outcome is number of days off work. Secondary outcomes are disability, pain, and quality of life. The study will follow the recommendations in CONSORT-statement in designing and reporting RCTs.DiscussionThis large RCT is testing the effectiveness of a preventive intervention targeting patients on short term sick leave or at risk being sick listed because of low back pain. We have developed a novel multidisciplinary team structure using the treating physiotherapist as the return to work coordinator, and having the case manager from the municipal sickness benefit office participating in team meetings. The study has the potential to contribute to the knowledge about how to target the challenges in the treatment of LBP. The aim is to prevent sickness absence and labour market exclusion - both on the individual level and economic costs at community level. Short term results will be available in 2014.This study is approved by the Danish Regional Ethics Committee (J.nr: H-C-2008-112) and is registered at.Trial registrationClinicalTrials.gov: NCT01690234

No Effect of Acupuncture as Adjunctive Therapy for Patients with Total Knee Replacement: A Randomized Controlled Trial

Objective Acupuncture is a low risk option in pain management following total knee replacement as an alternative to opioid analgesics. Therefore, the benefit of acupuncture as adjunct to an exercise program was investigated. Furthermore, the modifying effect of previous benefit from acupuncture was explored. Design Three weeks postoperatively, eligible patients were randomized to acupuncture and exercises or exercises alone. Setting An outpatient rehabilitation centre in the municipality of Copenhagen, Denmark. Subjects A total of 172 patients were included. Methods Main outcome was proportion of patients that reported a clinically important change in pain at night following each treatment. Secondary outcomes were change in disability measured after termination of the course of treatment and at three months follow-up. Also consumption of medication and walking distance after termination of the course of treatment were assessed. Results No additional benefit of acupuncture was found on any of the main outcomes. Between-group differences were non-significant in proportions of patients with a clinically important reduction of night pain (Relative Risk: 0.98; 95% Confidence Interval (CI): 0.86-1.11) or evening pain (Relative Risk: 0.94; 95% CI: 0.81-1.0. Conclusions Our results do not support the addition of acupuncture to routine rehabilitation. Previous benefit from acupuncture was not able to identify those likely to respond to acupuncture. Future studies to investigate whether subgroups of patients would benefit from acupuncture are needed.