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Study Design and Objectives. Meta-analysis of randomized controlled trials to evaluate the effectiveness of
the McKenzie method for low back pain (LBP).
Summary of Background Data. The McKenzie method
is a popular classification-based treatment for LBP. The
faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials.
Methods. MEDLINE, EMBASE, PEDro, and LILACS were
searched up to August 2003. Two independent reviewers
extracted the data and assessed methodologic quality.
Pooled effects were calculated among homogeneous trials
using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie.
Results. Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, 4.16 points; 95%
confidence interval, 7.12 to 1.20) and disability (WMD
on a 0- to 100-point scale, 5.22 points; 95% confidence
interval, 8.28 to 2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction
in disability favored advice (WMD on a 0- to 100-point
scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at
12 weeks of follow-up. Heterogeneity prevented pooling
of studies on chronic LBP as well as pooling of studies
included in the sensitivity analysis.
Conclusions. There is some evidence that the McKenzie
method is more effective than passive therapy for acute
LBP; however, the magnitude of the difference suggests
the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic
LBP. The effectiveness of classification-based McKenzie is
yet to be established.
Key words: low back pain, effectiveness, exercise, systematic review, meta-analysis. Spine 2006;31:E254 E262
E254
results of conservative care in randomized controlled trials (RCTs) are a consequence of applying the same therapy to heterogeneous groups of patients.35 Nevertheless, a gold-standard subgrouping scheme for LBP is still
lacking, as most available classification systems have
weak evidence for their validity and reliability.6 8
In 1981, Robin McKenzie proposed a classification
system and a classification-based treatment for LBP labeled Mechanical Diagnosis and Therapy, or simply the
McKenzie method.9 Of the large number of classification
schemes developed in the last 20 years,10 16 the McKenzie method has the greatest empirical support (e.g., validity, reliability and generalizability) among the systems
based on clinical features.8 According to this method, the
classification of LBP patients is based on patterns of pain
response noted during the assessment.9 The centralization phenomenon is the most important pattern of pain
response observed in McKenzies assessment, as well as
the most studied feature of the McKenzie method.1723
Centralization is defined as the situation in which referred pain arising from the spine is reduced and transferred to a more central position when movements in
specific directions are performed (also called directional
preference).9
Although the main role of McKenzies classification
system is to guide treatment selection, many RCTs on the
effectiveness of the McKenzie method have overlooked
this principle by assigning patients of unknown classification to the same intervention.24 28 In this review, we
name this approach to the McKenzie method generic
McKenzie. In contrast, we call the McKenzie method
based on patient classification (as advocated in the McKenzie textbook9) classification-based McKenzie. It has
been suggested that the use of a generic approach is responsible for the underestimation of the effectiveness of
the McKenzie method in previous studies.29
Misconception of the McKenzie method is observed
in a systematic review evaluating the effectiveness of exercise therapy for LBP,30 in which this method was
equated to extension exercises. This is incorrect because
with the McKenzie method the direction of exercise is
not always extension but instead is dictated by the directional preference. In a prospective, multicenter study including 145 patients with nonspecific LBP, Donelson et
al31 reported a clear directional preference in nearly one
half of patients. Of these patients, 40% improved with
extension exercises, whereas 7% improved with flexion
exercises.31 The higher incidence of extension as the di-
Results
Study Selection
The MEDLINE, EMBASE, PEDro, and LILACS
searches identified 364, 195, 90, and 56 studies, respectively. Of these, only 11 trials published in 12 papers
were included.24 28,44 50 Agreement between reviewers
for study eligibility was 84.25%, 82.57%, 85.06%, and
98.21% for MEDLINE, EMBASE, PEDro, and LILACS,
respectively. The main reasons for exclusions were the
use of interventions dissimilar from the McKenzie
method (e.g., dynamic strengthening exercises,5153
Participants
Interventions
Outcomes
Cherkin44 (1998)*
8/10
Delitto48 (1993)
4/10
Dettori24 (1995)
6/10
Elnaggar25 (1991)
4/10
Erhard45 (1994)*
5/10
Gillan46 (1998)
4/10
Table 1. Continued
Study
PEDro Score/10
Participants
Interventions
Outcomes
Malmivaara26 (1995)
7/10
Petersen47 (2002)*
6/10
Schenk50 (2003)*
5/10
Stankovic27 (1990)
6/10
Stankovic28 (1995)
3/10
Underwood49 (1998)*
6/10
LBP low back pain; I intervention (e.g., McKenzie method); R reference treatment; RMQ Roland-Morris Questionnaire ; OSW Oswestry Disability
Questionnaire; VAS visual analogue scale.
*Classification-based McKenzie.
movements performed in multiple, nonspecific directions,54,55 multiple muscle strengthening and/or stretching, 56 59 lumbar stabilization exercises 60 ); quasirandomized trials61,62; inclusion of patients with specific
pathology63; and insufficient report of data on main outcomes.64
Study Characteristics
The characteristics of the included studies are presented
in Table 1. Five trials reported on acute LBP (6 weeks
duration),24,26 28,44,49 one reported on subacute LBP
(from 6 weeks to 3 months duration),50 and one trial
reported on chronic LBP (3 months duration).25 Four
trials reported on a mixed population of patients.45 48
Eight trials included patients who had LBP with or
without radiating symptoms,24,26 28,44 48 one included
patients with pain restricted to the lower back,49 one
included patients presenting radiculopathy,50 and one
trial did not report the location of the symptoms.25
No placebo-controlled trials were located. Different
types of interventions were used as reference treatments:
educational booklet,44 ice packs,24 massage,46 bed
rest,26 advice to stay active,26,49 flexion exercises,24,25,48
spinal manipulative therapy,44,45,50 back school,27,28
and back-strengthening exercises.47 For analysis purposes, the following reference treatments were considered under the label passive therapy: educational
booklet, ice packs, massage, and bed rest. A similar approach was used in a previous review in which these
interventions were labeled as inactive.30
Two trials did not use the term McKenzie method or a
synonym to name the intervention.24,26 However, the
repeated, direction-specific, passive spine movements
used in the studies of Dettori et al24 and Malmivaara et
al26 reflect McKenzie principles9; therefore, both studies
were included in this review. Four trials delivered the
McKenzie method together with passive or active cointerventions such as manipulation,48 ice packs,24 educational booklets,24,49 and walk on treadmill.50
In six trials,44,45,4750 the intervention was based on a
classification of patients according to the directional
preference (classification-based McKenzie); 2 of them
were published in the last 3 years.47,50 Among the trials
reporting on a generic McKenzie approach,24 28,46 the
treatment consisted of extension exercises,25 or the use
of extension exercises together with lateral bending,26
and with flexion exercises.24,27,28 One trial did not report treatment details.46
Although the studies of Delitto et al,48 Erhard et al,45
Schenk et al,50 and Underwood and Morgan49 clearly
used extension exercises for all participants, this approach was not considered generic McKenzie because all
participants were classified before randomization as exhibiting directional preference for extension.
Methodologic Quality
Nine papers had already had their methodologic quality
previously assessed using PEDro scale.24 28,44 46,48 Two
reviewers (P.H.F., M.L.F.) independently assessed the quality of the other three trials using the same instrument.47,49,50 Eight papers scored 5 points or more and were
considered of high quality24,26,27,44,45,47,49,50 (Table 1).
Treatment Effects
Clinical and statistical heterogeneity prevented the pooling of trials in which the McKenzie method was compared with flexion exercises24,25,48 and spinal manipulative therapy.44,45,50 Pooling was also not possible for
trials in which the contrast therapy consisted of back
school27,28 and back-strengthening exercises47 because
of the absence of multiple studies. For the comparisons
with passive therapy and advice to stay active, a metaanalysis based on the random effects model was performed.
McKenzie Versus Passive Therapy. Four trials24,26,44,46 of
McKenzie Versus Strengthening Exercises. Only one highquality trial compared McKenzie to strengthening exercises. Petersen et al47 found no statistically significant
differences on pain (mean difference on a 0- to 100-point
scale, 7 points; 95% CI, 22 to 9) or disability (mean
difference on a 0- to 100-point scale, 1 point; 95% CI,
14 to 12) when McKenzie was compared with
strengthening exercises at 8 weeks follow-up for patients
with subacute and chronic LBP. At 10 and 32 weeks
follow-up, the differences were also nonsignificant.
Sensitivity Analysis
A sensitivity analysis was attempted to determine if excluding trials reporting on a generic McKenzie approach
had any effect on the results. Six trials comparing the
classification-based McKenzie with the following reference treatments were included in this sensitivity analysis:
educational booklet,44 advice to stay active,49 flexion
exercises,48 strengthening exercises,47 and spinal manipulative therapy44,45,50 (Table 1).
A pooled analysis could not be performed due to insufficient number of trials on each comparison,44,47 49
and also due to clinical and statistical heterogeneity
when there were multiple trials on the same comparison.44,45,50 When evaluating treatment effects of individual trials, the classification-based McKenzie was as effective as an educational booklet,44 advice to stay active,49
and strengthening exercises47 at all time points. Comparisons with flexion exercises48 and spinal manipulative
therapy50 yield statistically significant differences favoring the classification-based McKenzie. Nevertheless, as
described in the main analysis, the evidence for the effectiveness of McKenzie when compared with spinal manipulative therapy is not consistent.
Discussion
Although research on primary care management of LBP
was scarce until the late 1980s, the increase in govern-
mental funding and the establishment of scientific meetings on this topic have promoted the proliferation of publications in the last decade.65 LBP has been a frequent focus
of systematic reviews and meta-analyses evaluating the effectiveness of different types of interventions.30,3539,66 70
Nevertheless, consistent evidence on treatment effectiveness for this condition is still lacking.
There is a rising interest in classification systems that
could identify homogeneous subgroups of LBP patients
more likely to respond to specific interventions.10 16 The
current practice is to perform a diagnostic triage, in
which patients are classified into one of the following
categories: 1) nonspecific LBP, 2) sciatica/radicular syndrome, and 3) suspected serious spinal pathology.71 Although consistently recommended by clinical practice
guidelines,2 this diagnostic triage contains little therapeutic information since the former category refers to a
large group of patients that may present different pathophysiologic conditions under the label nonspecific.72
The hypothesis that different therapies have their effectiveness underestimated over the years due to difficulties in identifying homogeneous groups of LBP patients
has found some support recently. Fritz et al73 found that
acute LBP patients assigned to a classification-based
therapy reported not only lower disability scores at
short- and long-term follow-up, but also faster return to
work and lower medical expenses when compared with
general exercise therapy.
The McKenzie method9 is widely used for the management of LBP patients.74,75 Additionally, the McKenzie
method has the strongest evidence for validity among the
classification systems based on clinical features.8 However, the evidence for the effectiveness of this classification-based treatment for LBP is unclear. We conducted a
systematic review with a meta-analysis approach to summarize the available evidence on the McKenzie method
for the treatment of LBP.
No placebo-controlled trial was located by this review; therefore, the efficacy of the McKenzie method is
unknown at this stage. In the main pooled analyses, trials
in which patients were classified according to the centralization phenomenon (directional preference) were analyzed together with trials in which patients of unknown
classifications received the same intervention (generic
McKenzie). The same procedure was used in the Cochrane review of exercise therapy for LBP.30 In a sensitivity analysis, we attempted to evaluate whether the exclusion of trials reporting on a generic McKenzie
approach altered the results of the main pooled analysis.
According to the main pooled analysis, there were
statistically significant differences in pain and disability
favoring the McKenzie method when compared with
passive therapy at 1-week follow-up for acute LBP.
However, advice to stay active showed larger effects on
disability at 12 weeks when compared with McKenzie
for the same population. It is difficult to explain the superior effect of advice to stay active over the McKenzie
method because both interventions are similar when it
comes to advising patients to avoid bed rest and return to
normal activities. The difference between these two approaches might lie on the importance of the structural
damage (e.g., disc disease) in McKenzies educational
program. According to McKenzies conceptual model,
the structural pathology is responsible for the symptomatic presentation, and patients are instructed that, by
adopting certain postures and performing specific exercises, the damage can be reversed. The biomedical model
of explaining LBP in the McKenzie method may contribute to iatrogenic disability71 that could explain the
poorer results of this therapy when compared with information emphasizing positive attitudes without focusing
on any damage to the spine. However, it is also hypothesized that the direct association of damage-healing and
movement strategies in the McKenzie method provides a
learning platform that enable patients to feel greater control over their back problems as well as contributes to
improve compliance with their exercises.9
The small magnitude of the differences observed in the
pooled analysis (6 points on a 0- to 100-point disability
scale and 5 points on a 0- to 100-point pain scale) may
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