Lumbar Trials

Al-Obaidi S, Al-Sayegh N,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, Phys Med Rehab, Vol 3 (7): 637-646, 2011

133 of 237 patients with chronic LBP demonstrated centralization; 62, who all demonstrated centralisation, met inclusion criteria and consented to participate and were followed up 5 and 10 weeks after completion of treatment. There were improvements in fear-avoidance and disability beliefs, pain and physical performance measures at 5 weeks, that mostly remained stable at 10 weeks.

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Albert HB, Manniche C., The efficacy of systematic active conservative treatment for patients with severe sciatica. A single-blinded randomized controlled trial., Spine, 37:7:531-542, 2011

181 patients with severe sciatica were randomised to directional preference exercises or sham non-back related exercises, with both groups being provided with information and advice to stay active. A mean of 4.8 treatment sessions was given. Both groups improved over time, and there were significant difference that favoured the directional preference exercises group in terms of global assessment of improvement, and improvement in neurological signs; and a trend to better outcomes in leg pain.

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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

A randomised clinical trial comparing manipulation, stabilisation and directional preference exercises, but also analysing results according to whether patients were treated by classification sub-group or not. Classification sub-groups were determined by clinical features gathered at baseline. There were no significant differences between randomised treatment groups, but there were significant differences between patients matched with their classification sub-group and those unmatched.

Broetz D, Hahn U, Maschke E, Wick W, Kueker W and Weller M, Lumbar disc prolapse: Response to mechanical physiotherapy in the absence of changes in magnetic resonance imaging. Report of 11 cases., NeuroRehabilitation, 23(3): 289-294, 2007

11 patients with MRI confirmed disc prolapse with over half having weakness and sensory loss were treated with repeated end-range movements and re-evaluated after 5 treatment sessions. Centralisation occurred in 8 of 11 and all patients showed improvements in signs and symptoms, but no changes in MRI features.

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Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, Grimm RH, Owens EF, Garvey TA, Transfeldt EE., Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial., Spine J, 11:585-598, 2011

Comparison of stabilisation exercises, chiropractic spinal manipulation and advice and home exercises, which appeared to focus on extension in lying exercises, in 301 patients with chronic low back pain. The stabilisation exercise group had higher levels of satisfaction and greater gains in trunk muscle endurance, but there were no significant differences between groups in pain and disability both short and long-term.

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

About 300 patients evaluated for eligibility of who 63 met inclusion criteria: back pain with referral below the buttock, plus centralization with 10 repeated extension exercises in standing or lying. These 63 patients were randomised to an extension protocol (extension exercises and posterior-to-anterior mobilisation) or strengthening programme for flexors and extensors. There were significant differences at 1 and 4 weeks and at 6 months for Oswestry scores favouring the extension protocol group, but only in pain scores at 1 week. There were significant differences in centralization of symptoms favouring the extension protocol group.

 

Chen J, Philips Amy, Ramsey M, Schenk R., A case study examining the effectiveness of Mechanical Diagnosis and Therapy in a patient who met the clinical prediction rule for spinal manipulation., J Man Manip Thera, 17.216-220, 2010

Case study of patient who met 4/5 of clinical prediction rule for manipulation criteria who failed to respond to 2 sessions of manipulation, but then responded to repeated movements.

 

Delitto A, Piva S, Moore C, Fritz J, Wisniewski S, Josbeno D, Fye M, Welch W, Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis, Annals of Internal Medicine, 162,7, 2014

This RCT compared surgical decompression to physical therapy for patients with spinal stenosis. 169 patients participated with a 2 year follow up. The PT group were given flexion based exercises, general conditioning and education. Both groups improved and there were no differences in outcome between the two groups for function or pain. However, there were a significant number of crossovers between the PT and surgical group

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Donelson R, Long A, Spratt K, Fung T., Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica., Phys Med Rehabil, 23:4(9):667-81, 2012

Secondary analysis of data from Long et al. (2004) of patients with a directional preference and treated with directional preference exercises to see if there was any difference in outcomes across duration of pain or between QTF categories (1 = low back pain only; 2 = plus thigh pain; 3 = plus calf pain; 4 = plus neurological signs and symptoms). For patients with acute, subacute and chronic there were no significant difference in 5 / 6 outcomes at 2 weeks, but patients with chronic pain had less reduction in back pain intensity. Across different QTF groups there were no significant differences in all 6 outcomes at 2 weeks.

 

Ford J, Hahne A, Surkitt L, Chan A, Richards M, Slater S, Hinman R, Pizzari T, Davidson M, Taylor N, Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial , Br J Sports Med, 50, 237-245, 2016

This RCT recruited patients with low back and /or leg symptoms who met the criteria for one of five pathoanatomical based subgroups. Patients were randomised into individualised therapy for the particluar subgroup for 10 sessions or guideline based advice for 2 sessions. Outcomes were significantly better for function and for back and leg pain, but the differences were less than the MCID. One component of the intervention were directional preference exercises and postural education.

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Fritz JM, Delitto A, Erhard RE, Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. A RCT., Spine, 28:1363-1372, 2003

78 patients with acute back pain randomised to AHCPR guidelines or care based on classification by therapist. Patients in classification group had significantly better functional outcomes at 4 weeks, and less work loss in follow-up year.

 

Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, Swalberg A, Rodriquez B, Is there a subgroup of patients with low back pain likely to benefit from mechanical traction?, Spine, 32:E793-E800, 2007

64 patients with leg pain and signs of nerve root compression were randomised to extension oriented treatment by itself or with mechanical traction. Percentages demonstrating centralisation and peripheralisation in response to different movements were presented. The traction group had some greater improvements at 2, but not at 6 weeks, but received twice amount of treatment. Subjects who peripheralised with extension were more likely to improve with traction; subjects who centralised with extension did better what ever treatment was given.

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Garcia A, Costa L, Hancock M, Souza F, Gomes G, Oliveira de Almeida M, Costa L, McKenzie Method of MDT was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific LBP: a randomised placebo controlled trial with short and long-term follow-up, Br J Sports Med, Online July 12, 2017

This RCT studied 148 patients with chronic low back pain. It compared The McKenzie Method with ‘placebo’. Both groups also received ‘The Back Book’ for educational purposes. The single treating therapist for the McKenzie group had only completed McKenzie Part A, 3 years prior to the trial. Only a short term difference in pain was found between the groups in favour of the McKenzie Method.

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Garcia AN, Costa LCM, da Silva TM, Gondo LFB, Cyrillo FN, Costa RA, Costa LOP, Effectiveness of back school versus McKenzie exercises in low back pain, Phys Ther, 93(6):729-47, 2013

A randomised controlled trial with 148 chronic back pain patients with follow-up at 1, 3 and 6 months who received either 4 group back school standardised intervention or individualised McKenzie exercises based on directional preference. There was a clinically important difference in terms of disability, but not pain, for the McKenzie method short-term, but not long-term. It documents that roughly the same percentage had a directional preference (approximately 66.5%), but it is not documented how this was assessed, nor how this shaped management in the back school group. It is documented that the therapists who gave the McKenzie management were fully certified, but in fact had only attained part A course.

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Halliday M, Pappas E, Hancock M, Clare H, PT, Pint R, Robertson G PT, Ferreira P, A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People With Chronic Low Back Pain and a Directional Preference , J Orth Sports Phys Ther, 46, 7, 514-522, 2016

In a LBP population with the classification of Derangement, this RCT primarily compared MDT to motor control exercises for the restoration of muscle recruitment. Muscle thickness recovered equally in both groups. The only significant difference in any secondary outcome was with Global Perceived Improvement, which favoured the McKenzie group

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Hebert J, Fritz J, Koppenhaver S, Thackeray A, Kjaer P , Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables , Eur Spine J, 25, 310-7, 2015

This study looked at the pre-op predictors of a successful outcome post lumbar surgery. Pre-operative peripheralisation was associated with greater improvements in pain and disability after multivariate analysis 10 weeks post-op. Per-op multifidus function was not associated with clinical outcome.

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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, 2001

314 male conscripts randomised into 2 groups: one group received theory session based on TYOB, disc model, tape to back, and instructed to do 15 EIL X 2 a day for period of military duty. 214 (68%) completed follow-up at 12 months. 1-year prevalence LBP in experimental group 33%, compared to 51% in control. Numbers seeking medical help for LBP also significantly less (9% to 25%). In those who had reported LBP at baseline 1-year prevalence 45% to 80%.

 

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

Following a mechanical evaluation all patients who demonstrated directional preference (DP) (230/312, 74%) were randomised to receive exercise matched to DP (1), exercise opposite to DP (2) or evidence-based management (3). Over 30% of groups 2 and 3 withdrew because of failure to improve or worsening, compared to none in group 1. Over 90% of group 1 rated themselves better or resolved at 2 weeks, compared to just over 20% (group 2) and just over 40% (group 3). There were further significant differences between the groups in back and leg pain, functional disability, depression and QTF category.

 

Long A, Donelson R, Fung T, Spratt K, Are acute, chronic, back pain-only, and sciatica-with neural deficit valid low back subgroups? Not for most patents., Spine J, 7;5:63S-64S, 2007

Sub-group analysis from previous RCT (Long et al 2004) of 80 with directional preference who were treated with exercises matched to directional preference. There were no significant differences in outcomes between QTF groups 1-4, and in 5 of 7 outcomes between acute and chronic groups, but chronic patients reported significantly less reduction of pain. (abstract only)

 

Long A, May S, Fung T, Specific directional exercises for patients with low back pain: a case series., Physio Canada, 60.307-317, 2008

Further analysis from previous trial (Long et al 2004), in which patients (N = 96) who were worse, unchanged or wanted additional treatment at the end of the 2-weeks original trial were offered alternate directional preference exercises for 2 weeks. Outcomes were analysed after the original 2-week period (unmatched treatment) and then between 2 and 4 weeks (matched directional preference treatment). A few minor clinically unimportant changes became statistically and clinically important across all outcomes when patients received treatment that matched their directional preference.

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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

Comparison of trained GP care (advice, reassurance, and paracetamol) with trained GP care plus McKenzie care delivered by therapists with credentialed qualification over 3 weeks. There were significant differences favouring the McKenzie group in pain over the first few weeks, though these differences were clinically small, but there were no significant differences in perceived effect, function or persistent symptoms. Patients in the McKenzie group sought significantly less additional care.

 

Manca A, Dumville JC, Torgerson DJ, Klaber Moffett JA, Mooney MP, Jackson DA, Eaton S, Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis., Rheumatology, 46:1495-15010, 2007

This was an economic analysis of the Klaber-Moffett et al (2007) trial. Despite a mean of one additional visit in the McKenzie group and being more expensive the McKenzie group had additional benefit and was deemed to be cost-effective in regard to acquiring additional Quality Adjusted Life Years.

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Matsudaira K, Hiroe M, Kikkawa M, Sawada T, Suzuki M, Isomura T, Oka H, Hiroe K, Hiroe K., Can standing back extension exercise improve or prevent low back pain in Japanese care workers?, J Man Manip Ther, DOI 10.11729/2042618614Y, 2015

64 care workers received an exercise manual and advice to do extension in standing exercise on a regular basis, especially after lifting or being flexed for long periods; workers in the control group (N = 72) were only given the manual; there were no baseline differences in the two groups. In the intervention group 43% reported subjective improvement in back pain, compared to 15% in the control group (p=0.003); in the intervention group 83% reported compliance with the exercise, compared to 9% in the control group.

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Mbada C, Ayanniyi O, Ogunlade S, Comparative efficacy of three active treatment modules on psychosocial variables in patients with long-term mechanical low- back pain: a randomized-controlled trial, Archives of Physiotherapy, 5,10, 2015

This randomised conrolled trial looked at 'McKenzie Protocol'(extension only) alone and in combination with strengthening on psychosocial outcomes. At 4 and 8 weeks all groups demonstrated significant improvements on all measures of beliefs and fear avoidance

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Mbada C, Ayanniyi O, Ogunlade S,, Rehabilitation of Back Extensor Muscles’ Inhibition in Patients with Long-Term Mechanical Low-Back Pain, ISRN Rehabilitation, 928956, 2013

This RCT with 84 patients with LBP compared 3 treatment groups; 'McKenzie Protocol' (extension exercises), McKenzie + static back endurance exercises and McKenzie + dynamic back extensor exercises at 4 and 8 weeks. Physical performance tests, including static and dynamic endurance, were used as the outcome. The 'McKenzie Protocol' alone or in cimbination with the other exercises were effective in improving muscular endurance

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Mbada CE, Ayanniyi O, Ogunlade SO, Orimolade EA, Oladiran AB, Ogundele AO., Rehabilitation of back extensor muscles inhibition in patients with long-term mechanical low-back pain., Rehabilitation, 2013: 928956, 2013

84 patients randomised to 3 groups all receiving an MDT protocol; in addition 2 groups received static back endurance exercises or dynamic endurance exercises as well; same trial as above. The outcomes only related to muscle endurance and muscle fatigue, with no recording of pain or function. All groups showed significant improvements in endurance and fatigue, but the MDT plus dynamic endurance exercise group showed significantly better outcomes at 4 and 8 weeks.

Mihaela O, Mihaela C, McKenzie training in patients with early stages of ankylosing spondylitis (AS): results of a 24-week controlled study., Euro J Phys Rehab Med, in press, 2015

52 patients with early lumbar AS were randomly assigned to McKenzie training or classic kinetic exercises and a number of functional and movement outcomes were registered at baseline, 12, and 24 weeks. There were significant differences in both groups, more in the McKenzie group; but there were significant differences in all groups that favoured the McKenzie group (p=0.001).

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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

29/30 patients with very chronic low back pain completed 6 weeks of either intervention depending on randomisation. Both groups improved from baseline, but there were no significant differences between the groups.

 

Moffett JK, Jackson DA, Gardiner ED et al, Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: 'McKenzie' vs brief physiotherapy pain management., Rheumatology, Dec;45:1514-1521, 2006

315 patients (219 with back pain 96 with neck pain) were randomised to either: McKenzie approach or a cognitive behavioural approach and were followed for 12 months, with the main outcome being the Tampa Scale of Kinesiophobia (TSK). Both groups reported modest but clinically important functional improvements, but there were few differences between the groups. Except greater TSK Activity-Avoidance improvement at 6 months and greater satisfaction in the McKenzie group; and greater change in one aspect of Health Locus of Control measure in the cognitive behavioural approach plus The Back or Neck Book.

 

Murtezani A, Govori V, Meka V, Rrecaj S, Gashi S, A comparison of mckenzie therapy with electrophysical agents for the treatment of work related low back pain: A randomized controlled trial, J Back Musculoslelet Rehabil, 28(2):247-53., 2015

This RCT on chronic LBP patients randomised to a McKenzie and a electrophysical agents group. Results at 3 months showed greater improvements in the McKenzie group

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Olusola A, Arinola S, Olusegun O, Effects of the McKenzie protocol on pregnancy-related back pain, Journal of Experimental and Integrative Medicine, 6,3, 2016

This RCT recruited 466 pregnant women with back pain and randomised them into a McKenzie group plus usual care and a usual care group. The participants were treated over 6 weeks and there was a low drop out rate. The McKenzie group had significantly less back pain and disability. The McKenzie Method was recommended in the management of pregnancy related back pain.

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Paatelma M, Kilpikoski S, Simonen R, Heinonen A, Alen M, Videman T, Orthopaedic manual therapy, McKenzie method or advice only for low back pain in working adults: a randomized controlled trial with 1 year follow-up., J Rehabil Med, Nov;40(10):858-63, 2008

134 recruits were randomised to one of 3 treatment arms and outcomes were gathered at baseline and 3, 6 and 12 months. All groups improved significantly at 3 months, but there were no significant differences between groups. At 6 and 12 months there were significant differences favouring the McKenzie group over the advice only group. There were no significant differences between the McKenzie and orthopaedic manual therapy group at any point.

Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S., 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., Spine, Aug 15;27(16):1702-9, 2001

260 patients with chronic back pain followed up at 2 and 8 months after 8 week treatment period. With intention to treat analysis both groups improved modestly, McKenzie group favoured at 2 months. Outcomes were better and differences favouring McKenzie group were more significant in those who actually completed treatment.

Petersen T, Larsen K, Jacobsen S, One-year follow-up comparison of the effectiveness of McKenzie treatment and strength training for patients with chronic low back pain., Spine, 32.2948-2956, 2007

Long-term follow up of previous trial showing no significant differences between groups and examined factors associated with good and bad outcomes.

Petersen T, Larsen K, Nordsteen J, Olsen S, Fournier G, Jacobsen S, The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralisation or peripheralisation. A randomised controlled trial, Spine, 36.1999-2010, 2011

574 patients were screened and 53% demonstrated centralisation, and 7% peripheralisation. These 350 patients with back pain for at least 6 weeks were randomised to MDT or chiropractic manipulation. Both groups improved, but there were significant differences that favoured the MDT group in terms of numbers reporting success after treatment, and disability at 2 and 12 months.

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Ponte DJ, Jensen GJ, Kent BE, A Preliminary Report on the use of the McKenzie protocol versus Williams Protocol in the treatment of Low Back Pain., J Orthop Sports Phys Ther, Vol. 6:2; 130-139, 1983

In LBP patients, the McKenzie protocol was superior to the Williams protocol in decreasing pain and hastening the return of pain free range of motion.

Santolin SM, McKenzie diagnosis and therapy in the evaluation and management of a lumbar disc derangement syndrome: a case study, J Chiro Med, 2.60-65, 2003

Patient with back and buttock pain who initially responded to lateral forces and then extension forces.

Schenk R, Dionne C, Simon C, Johnson R, Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation., J Man Manip Ther, 20:(1):43-9, 2012

31 patients who met at least 3 out of 5 of the clinical prediction rules for improvement with manipulation were randomised to receive either manipulation or MDT management. At 4 weeks there were significant improvements in both groups, but no significant differences between groups.

Schenk R, Jozefczyk, Kopf A, A randomised trial comparing interventions in patients with lumbar posterior derangement., J Man & Manip Ther, 11:95-102, 2003

25 patients with lumbar radiculopathy classified as derangement then randomised to McKenzie or mobilisation therapy. Significantly better outcomes pain and function for McKenzie group short-term.

Schenk R, Lawrence H, Lorenzetti J, Marshall W, Whelan G, Zeiss R., The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy., J Man Manip Ther, DOI 10.11729/2042618614Y, 2015

49 patients were treated with mechanical diagnosis and therapy and were assessed with FOTO function score at baseline, at two weeks and at discharge. Mean FOTO scores improved from 49 points to 68, indicating improvement, in a mean of eight treatment sessions. There was no correlation between QTFC and change in FOTO, except there was a significant difference based on acuity (p=0.003), with patients with chronic pain less likely to improve.

Sheeran L, van Deursen R, Catterson B, Sparkes V., Classification-guided versus generalized postural intervention in subgroups of nonspecific chronic low back pain., Spine, 38:1613-1625, 2013

29 patients with chronic low back pain with flexion pattern (made worse with flexion and better with extension) and 20 with extension pattern (made worse by extension and better with flexion) were randomised to a classification based treatment approach or a generalised postural intervention. The classification based treatment produced significantly better outcomes in pain and function at short-term.

Sheets C, Machado LAC, Hancock M, Maher C., Can we predict response to the McKenzie method in patients with acute low back pain? A secondary analysis of a randomized controlled trial., Eur Spine J, 21(7):1250-6, 2012

Secondary analysis of a previous RCT between first-line care only, or first-line care plus McKenzie to see if any of 6 variables explained better response to latter: baseline, mechanical, leg, or constant pain, worse with flexion, preference for McKenzie. None were predictors of a more favourable response.

Snook SH, Webster BS, McGorry RW, The reduction of chronic, non-specific low back pain through the control of early morning lumbar flexion: 3-year follow-up., J Occup Rehab, 12.13-19, 2002

3-year follow-up of previous study with 62% of subjects still restricting bending activities in the early morning and claiming benefit.

Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB, The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. A randomized controlled trial., Spine, Dec 1;23(23):2601-7, 1997

Education in the control of early morning flexion produced significant reductions in pain intensity, days in pain, disability and medication use. High drop-out rates show the difficulty of getting people to make such behavioural changes.

Stankovic R, Johnell O, Conservative treatment of acute low back pain. A 5-year follow-up study of two methods of treatment, Spine, 20(4):469-472, 1994

Difference between 2 treatments at 5 years was much less, however McKenzie group had significantly less recurrences of pain and episodes of sick leave.

Stankovic R, Johnell O., Conservative treatment of acute low-back pain. A prospective randomized trial: McKenzie method of treatment versus patient education in "mini back school"., Spine, Feb;15(2):120-3, 1989

100 acute back patients randomised to McKenzie or back school; significantly better outcomes in McKenzie group in pain, function, sick leave, recurrences, and further health care.

Surkitt L, Ford J, Chan A, Richards M, Slater S, Pizzari T, Hahne A, Effects of individualised directional preference management versus advice for reducible discogenic pain A pre-planned secondary analysis of a randomised controlled trial, Manual Therapy, 25, 69-80, 2016

This was a secondary analysis from a multicenter RCT looking at directional preference management versus advice for ‘reducible discogenic pain’. Directional preference management was significantly better at pain reduction and other outcomes up to 10 weeks, but improvements were not sustained. Satisfaction with care was significantly better in the directional preference group up to 52 weeks.

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Surkitt, L, Ford J, Chan A, Richards M, Slater S, Pizzari T, Hahne A, Effects of Individualised Directional Preference Management Versus Advice For Reducible Discogenic Pain: A Pre-Planned Secondary Analysis of A Randomised Controlled Trial , Manual Therapy, 25, 69-80, 2016

This was a secondary analysis of an RCT comparing directional preference management to guideline based advice for LBP. It looked at a 'reducible discogenic subgroup' and found significantly less back and leg pain in the directional preference group at 10 weeks, but not at 26 or 52 weeks. There was no difference in functional outcomes, but significantly more DP patients reached the threshold for clinical meaningful improvement at 52 weeks.

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Svensson GL, Wendt GL, Thomee R., A structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery: a prospective cohort study., J Rehab Med, 46(3)233-40, 2014

This was planned as a randomised controlled trial, but due to problems with recruitment ended up as a cohort study of 41 patients given a structured physiotherapy programme, consisting of an MDT intervention and then stabilisation exercises for patients who qualified for lumbar disc surgery. There was a significant improvement in pain and function at three months that was maintained at 24 months.

Szulc P, Wendt M, Waszak M, Tomczak M, Cieslik K, Trzaska T, Impact of McKenzie Method Therapy Enriched by Muscular Energy Techniques on Subjective and Objective Parameters Related to Spine Function in Patients with Chronic Low Back Pain , Medical Science Monitor, 21,2918-2932, 2015

This randomised trial compared 'McKenzie' (extension exercises ONLY), to 'McKenzie' + Muscle Energy to conventional physiotherapy in 60 patients with chronic LBP over 3 months. The 'McKenzie' group regardless of the addition of MET or not had significantly better pain and functional outcomes than the conventional physiotherapy group. Multiple measures of ROM were also documented with varying degrees of change reported. No limitations were discussed and there is no description of the therapist's training, sample size calculation or drop out rate.

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Udermann BE, Mayer JM, Donelson RG, Graves JE, Murray SR, Combining lumbar extension training with McKenzie therapy: effects on pain, disability, and psychosocial functioning in chronic low back pain patients., Gundersen Lutheran Med J, 3:7-12, 2004

18 patients received McKenzie therapy or McKenzie plus resistance training. There were no significant difference between groups at 4 weeks, but strength, endurance, range of movement and quality of life measures on the SF36 had significantly improved in both groups.

Udermann BE, Spratt KF, Donelson RG, Mayer J, Graves JE, Tillotson J, Can a patient educational book change behavior and reduce pain in chronic back pain patients?, Spine J, 4.425-435, 2004

Long-term (18 month) uncontrolled cohort study of effect of TYOB on 48 of 62 chronic back pain volunteers. There were significant differences in reductions in pain and pain episodes and perceived benefit over time. Significant differences remained even with a worst-case model to account for those lost to follow-up. Compliance with exercise and posture advice was reported by about 80% long-term.

Underwood MR, Morgan J., The use of a back class teaching extension exercises in the treatment of acute low back pain in primary care., Fam Pract, Feb;15(1):9-15, 1998

In an acute group of patients randomised to usual GP care or a one off back class according to McKenzie principles there were no significant differences in outcome, except one difference at one year, when more of the back class group reported back pain no problem in previous 6 months.

Williams B, Vaughn D, Holwerda T, A mechanical diagnosis and treatment (MDT) approach for a patient with discogenic low back pain and a relevant lateral component: a case report., J Man Manip Ther, 19.113-118, 2011

Case study of patient with back and referred pain with MRI showing large postero-lateral disc extrusion with no lateral shift who worsened in response to extension-based therapy, but improved rapidly in response to frontal plane exercises.