McKenzie Method as Lackluster as Back School for Back Pain

Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Garcia AN, Costa Lda C, da Silva TM, Gondo FL, Cyrillo FN, Costa RA, Costa LO. Physical Therapy. 2013 Jun;93(6):729-47.

Abstract
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.

My comments:
This was a pretty good study and I think the researchers findings and conclusions are reasonable. They reported McKenzie Method was slightly more effective at reducing disability (2.37 points better on a 24 point scale) but not pain in comparison to Back School. The authors noted that McKenzie Method required one on one training while the back school didn’t, such that if a cost benefit analysis were done they suspected the back school would win out.

Both programs consisted of patient education emphasizing maintaining good postures while sitting and at work, which while details were not given I do agree that good postures when sitting and moving are a good thing for back pain. However looking over the exercise programs in each group, I’m of the impression that the postural advice might be what resulted in the bulk of the pain reductions (which were minimal at that). I would expect neither programs exercises to have much benefit with regards to decreasing back pain. This would stand to reason, given a meta-analysis of McKenzie Method concluded it had an “absence of clinically worthwhile effects” and was less effective than advice to just stay active.

When I read McKenzie’s books I thought general postural advice was quite good so maybe it’s the exercises themselves that got in the way as in this study they were just spine stretching exercises and a lateral shift that don’t result in any increased fitness. The Back School exercises were just diaphragmatic breathing, spine and hip stretches, pelvic tilts, crunches and single leg lifts, which I would expect to have minimal, at best, effects on fitness levels or back pain. Pain in both the McKenzie Method and Back School programs decreased from ~6/10 to 4/10 in a month but at 3 and 6 months had returned back up to 5/10. Low back pain being reduced from a 6/10 to a 5/10 is hardly worth leaving home for. Thus I think physical therapists, AND PHYSICAL THERAPY SCHOOLS should be embracing newer research findings rather than clinging to and teaching the past so their students can pass worn out board exams. Speaking of worn out material, where’s my file on PNF?

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

 

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