McKenzie Exercise and Back Pain

by LMatthews on September 2, 2011

McKenzie method and back painBack pain patients are frequently prescribed physical therapy for their spinal stenosis symptoms and, increasingly, the McKenzie Method for back pain is being recognized as particularly effective in correcting postural problems, easing chronic and acute back pain, and improving function. The McKenzie Method is also known as ‘mechanical diagnosis and therapy’ (MDT) and is a philosophy of active patient involvement and education whereby the patient learns to manage their pain themselves and to self-treat in some regards. Many physiotherapists use the McKenzie Method in their care of spinal stenosis patients as it can be helpful not only for back pain but also for neck and extremity problems caused by spinal abnormalities.

The origins of the McKenzie Method are found in New Zealand, with a physiotherapist, Robin McKenzie devising the system of evaluation and treatment for disorders of the spine. The practice has spread across the world over the last few years and aims to prevent back pain, and other pain, from reoccurring. Patients are given personalized exercise programs and lessons in the importance of posture and an active lifestyle. In the initial assessment of a patient the McKenzie therapist will observe the changes in pain upon specific repeated movements in order to determine the likely cause of the pain. It is important that patients find a certified McKenzie therapist with accreditation in MDT as unqualified practitioners claiming to carry out the teaching of the technique may do more harm than good by exacerbating spinal stenosis symptoms with inappropriate movements.


Support for McKenzie Therapy for Back Pain

There are a number of studies supporting the use of the McKenzie Method for patients with back pain, many of which report that accurate classification of patient subgroups is important in aiding those with ‘non-specific’ low back pain. Another finding of a number of studies into MCT is that patients tend to achieve significant pain relief earlier in therapy, even if the method is comparable at the two-year mark with other physical therapies (Kilpikoski, et al, 2009).

A military study, conducted by Larsen (et al, 2002),looked at physical therapy owing much to the McKenzie Method in the treatment of 314 military conscripts and their rates of lower back pain over twelve months compared to a control group not receiving treatment. The recruits receiving the therapy had initial theory training and the requirement to do specific extension exercises every day for the period of military duty. This treatment group had a lower incidence of lower back pain (33%) at the twelve month mark, compared to 51% in the control group. The number of recruits seeking treatment for lower back pain was also lower in the treatment group at just 9% compared to 25% of controls, and of those with existing lower back pain at the start of the study the rates were 45% and 80% for treated patients and controls respectively.

mckenzie exercises backThe disadvantage of such a study however is that there was no comparison to another method of physical therapy, thereby not controlling for a placebo effect by receiving any attention or education on lower back pain. Additionally, the cause of patients’ lower back pain was not elucidated in this study, making it difficult to extrapolate the results in any meaningful fashion to those with spinal stenosis, back muscle strain, or other condition.

Long, et al (2004), carried out a study looking at patients with low back pain who were assessed for directional preference and then randomized into three groups for treatment. The first group were given exercises matched to their directional preference, the second group had exercises opposed to their directional preference, and the third were given evidence-based management for low back pain. Nearly a third of the patients in the second and third groups dropped out of the study citing failure to improve or worsening of their conditions. None of the first group withdrew from the study and over 90% rated themselves as better or having had their pain resolved at the two week mark, in comparison to just over a fifth of group two and 40% of group three. The researchers noted that patients in the group receiving treatment similar to the McKenzie Method also had significant improvements in back and leg pain, functional disability, depression, and QTF (Quebec Task Force – a chronic back pain assessment scale) category.


Patients with acute back pain also seem to do well with the McKenzie Method as shown in a short trial carried out by Machado, et al (2010). In this study, patients with acute low back pain were given either normal GP care (advice, reassurance, and paracetamol), or GP care plus McKenzie therapy over three weeks. Pain reduction was small but significant in the group given both first line care and McKenzie therapy, although other differences, such as function, perceived effect, or persistent symptoms, were not significant. Patients receiving McKenzie therapy sought less additional care, suggesting that they felt their low back pain to be manageable or resolved with the treatment. Hospital workers receiving McKenzie therapy as part of a trial looking at back pain also felt the benefits of the treatment protocol, with ramifications for staffing costs in the healthcare system as a whole. This study, by Owen, et al (2000), involved the introduction of a McKenzie therapist to manage hospital employees and resulted in a 52% reduction in days lost due to back pain, with the number of staff off because of back pain falling by 27%.

McKenzie Therapy – Are Improvements in Back Pain Sustained?

Other studies, such as Miller, et al (2005), found no differences between McKenzie therapy and specific spine stabilization programs for chronic low back pain however. A criticism of many of these studies is that the treatment period is very short (just six weeks in Miller’s study) making it possible that the improvements seen with McKenzie therapy may be sustained long-term in contrast to other interventions due to the educational aspect involved in the therapy.

This long-term benefit is suggested in a Kuwaiti study into chronic low back pain using the McKenzie Method. Unfortunately, the researchers in this study failed to provide a control group, thus weakening the results of the trial which found that patients’ physical performance and pain scores were improved by the treatment. Al-Obaidi, et al (2011), reported results at five and ten weeks following McKenzie therapy for sixty-two with chronic low back pain at outpatient orthopaedic physical therapy clinics. The patients completed initial questionnaires into pain and related fear and disability, had McKenzie mechanical assessment, and physical performance examinations. Measurements involved repeated sit to stand time, trunk forward bending, and walking tests, along with reported and anticipated pain. Patients saw improvements in physical performance, pain, and fear and disability beliefs at the five week mark and improvements remained stable ten weeks after therapy.

Interestingly, a study carried out in Dubai suggests that initial McKenzie therapy is more beneficial than a Brunkow exercise program for improving spinal mobility but may be particularly helpful if then followed by Brunkow therapy so as to help strengthen the spine. The 2004 study by Skikić, et al, observed sixty-four patients, thirty-three of whom had McKenzie therapy for their low back pain and the rest who undertook a Brunkow exercise program. The improvements in each group were statistically significant and the McKenzie treatment had a statistically significant advantage over the exercise program for improvements in extension, and right and left side flexion. Undergoing McKenzie therapy first helped to reduce patients’ pain and increase mobility, thus making it easier to carry out the Brunkow exercises to strengthen the paravertebral muscles (back muscles).

The McKenzie Method appears helpful, therefore, for patients with both acute and chronic low back pain, which can be a result of conditions such as spinal stenosis. Assessment by a qualified McKenzie therapist can help a patient uncover the likely cause of their back pain and work out an exercise program to improve flexibility, strength, mobility, and reduce back pain. With the McKenzie Method also providing long-term benefits for patients as regards education about pain management and back health, it also appears to be a cost-effective treatment that is increasingly likely to become part of regular physical therapy and conventional treatment for spinal stenosis and back pain. Therapeutic improvements also include reductions in fear and beliefs about disability related to back pain translating to better quality of life, along with the welcome effects of McKenzie therapy on back pain itself.


References

Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE ; Identifying subgroups of patients with acute/sub acute “non-specific” low back pain. Spine; 31:623-631, 2006.

Kilpikoski S, Alen M, Paatelma M, Simonen R, Heinonen A, Videman T ; Outcome comparison among working adults with centralizing low back pain: secondary analysis of a randomized controlled trial with 1-year follow-up. Advances in Physio; DOI: 10.1080/14038190902963087, 2009.

Browder DA, Childs JD, Cleland JA, Fritz JM; Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther; 87.1608-1618, 2007.

Larsen K, Weidick F, Leboeuf-Yde C.; Can passive prone extensions of the back prevent back problems?: a randomized, controlled intervention trial of 314 military conscripts. Spine; Dec 15;27(24):2747-52, 2002.

Long A, Donelson R, Fung T; Does it matter which exercise? A randomized control trial of exercises for low back pain. Spine; Dec 1;29(23):2593-2602, 2004.

Machado LAC, Maher CG, Herbert RD, Clare H, McAuley JH; The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med; 8:10, 2010.

Miller ER, Schenk RJ, Karnes JL, Rousselle JG ; A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain J Man & Manip Ther; 13:103-112, 2005.

Owen JE, Orpen N, Ayris K, Birch NC; Very early McKenzie protocol intervention for back pain in hospital workers. JBJS ; 82B. Supp III. 212 (abstract), 2000.

Al-Obaidi SM, Al-Sayegh NA, Ben Nakhi H, Al-Mandeel M., Evaluation of the McKenzie Intervention for Chronic Low Back Pain by Using Selected Physical and Bio-Behavioral Outcome Measures. PM R. 2011 Jul;3(7):637-46.

Skikić EM, Suad T., The effects of McKenzie exercises for patients with low back pain, our experience. Bosn J Basic Med Sci. 2003 Nov;3(4):70-5.

Skikić EM, Trebinjac S, Sakota S, Avdić D., he effects of McKenzie and Brunkow exercise program on spinal mobility comparative study. Bosn J Basic Med Sci. 2004 Feb;4(1):62-8.

{ 3 comments… read them below or add one }

Medical-rights September 28, 2011 at 8:01 am

If I may submit an answer for lower back pain it would be that of stretching the ham strings. A personal trainer informed me that this is, in large part, a common reason for that condition. I tried it. Stretching hamstrings worked for me.

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Juliana February 13, 2012 at 10:06 am

I think you should check the results from the study of Machado et al (2010) as this information is wrong: “Pain relief was much more significant in the McKenzie group”.

Actually the correct is: The addition of the McKenzie method to first-line care produced statistically significant but small reductions in pain when compared to first-line care alone.

Reply

LMatthews March 13, 2012 at 4:56 pm

Thanks Juliana,

Should have reiterated the combined intervention of first line GP care and Mckenzie therapy. Thanks for pointing out the possibility of confusion!

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