Lumbar: Observational studies

Apeldoorn A, van Helvoirt H, Meihuizen H, Tempelman H, Vandepu D, Knol D, Kamper S, Ostelo R, The influence of centralization and directional preference on spinal control in patients with nonspecific low back pain , J Orth Sports Phys Ther, 46(4):258-69, 2016

This study explored whether clinical signs of impaired spinal control changed in relation to the outcome of an MDT assessment, it used a test-retest design. Of those patients that centralised 43% and 50% showed improvement in aberrant movements and ASLR respectively. Only < 10% improved in the non directional preference group. Clinical signs of poor motor control can be reduced spontaneously following an MDT assessment.

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Deutscher D, Werneke M, Gottlieb D, Fritz, J, Resnik L, Physical Therapists' level of McKenzie education, functional outcomes, and utilization in patients with LBP, JOSPT, 44:12:925936, 2014

The study looked at the associations between Mckenzie training, functional status at discharge and number of visits for LBP patients. 20,882 patienst were treated and discharged in this observational cohort study. Patients treated by McKenzie therapists had better outcomes and fewer visits compared to those treated by other therapists. This suggests improved cost-effectiveness of advanced MDT training levels.

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Elden H , Gutke A, Kjellby-Wendt G, Fagevik-Olsen M, Ostgaard H, Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study, BMC Musculoskeletal Dis, 17:276, 2016

The longitudinal study looked at the predictors of those women who would have long term pelvic girdle pain following pregnancy. MDT was used in combination with SIJ tests for classification.

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Elenburg JL, Foley BS, Roberts K, Bayliss AJ., Utilization of mechanical diagnosis and therapy (MDT) for the treatment of lumbar pain in the presence of known lumbar transverse process fractures: a case study., J Man Manip Ther, DOI 10.11729/2042618614Y, 2015

Case report of a 24-year old woman with multiple transverse process fractures sustained 10-weeks earlier as a pedestrian in a motor vehicle accident who was classified as a derangement. She demonstrated considerable improvement with a change in Oswestry function score from 22% to 6% from initial presentation to discharge.

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Franz A, Lacasse A, Donelson R, Tousignant-Laflamme Y, Effectiveness of Directional Preference to Guide Management of Low Back Pain in Canadian Armed Forces Members: A Pragmatic Study, Mil Med, 182, e1957-e1966, 2017

This pragmatic trial with 44 consecutive military personnel with low back pain looked at the effectiveness of MDT versus 'usual care'. At 1 and 3 months 'DP-guided management' was found to be more effective for both pain and function

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Gard G, Gille KA, Degerfeldt L, McKenzie method and functional training in back pain rehabilitation. A brief review including results from a four-week rehabilitation programme., Phys Ther, 5; 107-115, 1999

Uncontrolled study of 40 patients treated with McKenzie and functional rehabilitation; 14 pain free afterwards. 36 /40 derangements; 18 / 36 demonstrated centralisation.

Hammer C, Degerfeldt L, Denison E, Mechanical diagnosis and therapy in back pain: compliance and social cognitive theory., Advances in Physio, 9.190-197, 2007

Study of 58 patents being treated with MDT that examined self-efficacy and compliance. Self efficacy was rated high; compliance tended to decrease over time, but at 2 months was still 64%. Pain and disability decreased over 5 visits and remained minimal at 2-month follow-up.

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Hefford C, McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference., Manual Therapy, 13.75-81, 2007

Survey of over 300 consecutive patients with cervical, thoracic and lumbar pain from over 30 therapists, which describes mechanical classification, pain patterns and directional preference of reducible derangements. Over 90% were classified with a mechanical syndrome and more than 80% with derangement. Extension was the commonest directional preference by far, especially amongst patients with central or symmetrical symptoms, but also in over 50% of patients symptoms in the arm or leg.

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Karayannis N, Jull G, Hodges P, Movement-based subgrouping in low back pain: synergy and divergence in approaches, Physiotherapy, 102(2):159-69, 2016

This cross-sectional cohort study of low back pain patients aimed to explore the overlap between different classification systems (including MDT) in 102 participants. They concluded that there was 'overlap' and 'discordance' between the different approaches and proposed some means of future integration

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Karayannis N, Jull G, Nicholas M, Hodges P, Psychological Features and Their Relationship to Movement-Based Subgroups in People Living With LBP, Archives PMR, 99, 121-8, 2017

This observational study subgrouped patients into MDT, TBC and O'Sullivan classifications and then looked at scores on various psychosocial measures. There was an unusually high number of 'irreducible' Derangements and Dysfunctions reported. However, high catastrophising was more associated with the 'irreducble' Derangement classification and the TBC 'stabilisation' subgroup.

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Kongsted A, Kent P, Hestbaek L, Vach W, Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery or constant pain. A latent class analysis of longitudinal data., The Spine Journal, 885-894, 2014

This prospective cohort study on over 1000 LBP patients explored subgroups for clinical course patterns. It identified 12 patterns and found that the majority did not become pain free within a year, but with only a minority developing chronic severe pain

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Mansfield C, Bleacher J, Tadak P, Briggs M, Differential examination, diagnosis and management for tingling in toes: fellow’s case problem, J Man Manip Ther, 25, 5, 294-299, 2016

This case study reported the lumbar involvement of symptoms post-fasciotomy. Symptoms resolved with use of MDT and the extension principle

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May S, Classification by McKenzie mechanical syndromes: A survey of McKenzie-trained faculty., J Manipulative Physiol Ther, Oct;29:637-642, 2006

Survey of 57 therapists in 18 countries and details of 607 consecutively discharged spinal patients and their mechanical syndrome classification. Individually each therapist recorded a mechanical classification in 82% of their patients, in total 83% of 607 patients had a mechanical classification - derangement 78%, dysfunction 3%, adherent nerve root (1%) and postural syndrome (1%). 'Other' was recorded in 17% of patients, most commonly mechanically inconclusive, chronic pain state and post surgery.

Mbada CE, Ayanniyi O, Ogunlade SO., Patterns of McKenzie syndromes and directional preference in patients with long-term mechanical low-back pain., Romanian J Phys Ther, 19:62-68, 2013

89 patients with low back pain for at least 3 months were classified by credentialed therapists using a repeated movements McKenzie assessment and based on symptom response: 80%, 7%, and 13% were classified with derangement, dysfunction and postural syndrome respectively.

McKenzie RA, A Prophylaxis in Recurrent Low Back Pain, New Zealand Med J, No. 627, 89:22-23, 1978

Frequent restoration of the lumbar lordosis and avoidance of flexion were seen as critical factors in prophylactic education for prevention of recurrent LBP. McKenzie reports on 318 patients - onset, aggravating and relieving factors, deformity, and the success of treatment in reducing further attacks as reported by the patients.

Melbye M, An adherent nerve root-Classification and exercise therapy in a patient diagnosed with lumbar disc prolapse., Man Ther, 15:126-129, 2010

Case report of a patient diagnosed as lumbar disc prolapse who in fact responds to flexion repeated movements and for whom the real classification is adherent nerve root.

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Monk C, Measurement of the functional improvement in patients receiving physiotherapy for musculoskeletal conditions., NZ J Physiotherapy, 34:50-55, 2006

Consecutive case series over a one month period of patients with back pain (N=29) or lower limb problems (N=39) treated according to MDT philosophy with record of before/after functional disability outcomes; 11 additional patients were excluded. Patients received an average of 5.1 treatment sessions; back pain patients improved by 71%, lower limb patients by 69% 

Ojha H, Egan W, Crane P., The addition of manipulation to an extension-oriented intervention for a patient with chronic LBP, J Man Manip Ther, 21:40-47, 2013

Case study of a patient with chronic low back pain who demonstrated centralization and 4 / 5 of the clinical prediction rules for manipulation. These combined treatments saw an improvement in outcomes after 7 treatment sessions.

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), 1999

Following introduction of a McKenzie trained therapist to manage hospital employees days lost due to back pain fell be 52%, number of staff off due to back pain fell by 27%, and number of episodes of absenteeism due to back pain fell by 30%.

Padmanabhan G, Sambasivan A, Desai MJ, Three-step treadmill test and McKenzie mechanical diagnosis and therapy to establish directional preference in a patient with lumbar spinal stenosis: a case report., J Man Manip Ther, 19:35-41, 2011

Case study of a patient with apparent neurogenic claudication and degenerative spinal stenosis and spondylolisthesis on imaging, but had failed to respond to flexion exercises or epidural injections. As initially there was an improvement in walking time with repeated extension movements, he was started on an extension exercise programme and after 2-3 weeks there were major improvements in function, walking distance, and leg symptoms.

 

Petersen T, Christensen R, Carsten J, 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, BMC Musculoskeletal Dis, 2015:16:74,

An analysis of a previous RCT with 350 patients looked at any factors that predicted outcome. There were no prdictore, Mckenzie Method was superior to manipulation across all subgroups. The two strongest preditors of success with MDT were nerve root involvement and peripheralisation.

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Peterson S, Hodges C, Lumbar lateral shift in a patient with interspinous device implantation: a case report, J Man Manip Ther, 24(4):215-22, 2016

This case report describes the successful MDT management of a patient with a history of lumbar surgery and a lumbar lateral shift deformity.

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Rasmussen C, Nielsen GL, Hansen VK, Jensen OK, Schioettz-Christensen B, Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics., Spine, 30: 2469-2473., 2005

In region in Denmark following introduction of spine clinics there was a significant decrease in spine surgery that was not found in the rest of Denmark during the same period. The clinics were based on Indahl and McKenzie principles and patients were treated by McKenzie trained physical therapists.

 

Robinson M, Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report , Physiotherapy Theory and Practice, 32, 4, 315-323, 2016

This case report describes the successful classification and management of a patient with a Derangement and a directional preference of extension. Extension was performed in standing

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Rohlmann A, Consmu ̈ller T, Dreischarf M, Bashkue M, Disch A, Pries E, Duda G, Schmidt K, Measurement of the number of lumbar spinal movements in the sagittal plane in a 24-hour period, Eur Spine J, 23,2375-2384, 2013

This study used sensor strips on 208 non-symptomatic volunteers during daily living to measure sagittal spinal movements over 24 hrs. Volunteers spent much more time in flexion than extension, reaching full flexion 50 times and zero times reaching full extension. This study substantiates the previous data suggestions a great predominance of flexion in everyday life

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Takasaki H, Mechanical diagnosis and therapy enhances attitude toward self-management in people with musculoskeletal disorders: A preliminary evidence with a before–after design, Sage Open Medicine, 5, 1-9, 2017

This study explored whether self-reported skills of self management for patients with musculoskeletal problems (mainly LBP) were affected by a 1 month course of MDT. Self-management and self-monitoring skills were enhanced.

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van Helvoirt H, Apeldoorn A, Knol D, Arts M, Kamper S, van Tulder M, Ostelo R, TFESIs influence MDT pain response classification in candidates for lumbar herniated disc surgery, J Back and Musculo Rehab, 1, 1-9, 2016

This was a second analysis of prospective cohort data previously published which included 8 patients with symptoms less than 12 weeks. Results are similar to the previously published variation of the cohort. The discussion focuses on comparisons in the literature on the reported prognostic value of peripheralisation and centralisation.

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Van Helvoirt H, Apeldoorn AT, Ostelo RW, Knot DL, Arts MP, Kamper SJ, van Tulder MW., Transforaminal epidural steroid injections followed by Mechanical Diagnosis and Therapy to prevent surgery for lumbar disc herniation., Pain Medicine, 15(7):1100-8, 2014

Patients were referred for surgery for disc herniation, confirmed by MRI with two or more neurological signs, after failed conservative care and no signs of centralization; 71 of 132 patients met these criteria. Patients received transforaminal epidural steroid injections (1-4) and then were re-evaluated by MDT clinicians. There were 2 drop outs, and the other patients were classified as follows: 11 resolved; 43 improved and pain now either centralizing or non-centralizing; 15 no improvement and no centralization and underwent surgery.

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Werneke M, Edmond S, Deutscher D, Ward J, Grigsby D, Young M, McGill T, McClenahan B, Weinberg J, Davidow A, Effect of adding McKenzie Syndrome, Centralization, J Orth Sports Phys Ther, 46, 9, 726-741, 2016

This retrospective cohort study analysed the data from 723 lumbar patients. It looked at the value of adding certain MDT classification and psychosocial variables to a risk-adjusted model to see if they helped predict functional outcomes. These variables did not add significantly to the model. However, Diploma therapists achieved significantly better functional scores than non-diplomaed therapists and additional prognostic differences were found between MDT subgroups highlighting the potential for MDT clinicians to predict outcome dependent upon the patient's classification.

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Werneke M, Hart D, Cutrone G et al., Association Between Directional Preference and Centralization in Patients With Low Back Pain, J Orthop Sports Phys Ther, 41(1), 22-31, 2011

The longitudinal cohort study looked at the prevalence of DP and centralisation and their effect on outcomes. Prevalence was 60% and 41% respectively. Outcomes in regard to pain and function were significantly better in the DP and centralisation groups

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Wu D, Rosedale R, The use of Mechanical Diagnosis and Therapy (MDT) in patients with lower urinary tract symptoms (LUTS): case series, Physio Theory and Pract., Online Feb, 2018

This was a case series of 3 male patients with lower urinary tract symptoms. It demonstrated that the screening for, and treatment of lumbar Derangements with this population may lead to simple and self-management solutions

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Yarznbowicz R, Tao M, Owens A, Wlodarski, Doultan J, Pain pattern classification and directional preference are associated with clinical outcomes for patients with low back pain, J Man Manip Ther, 26,1, 18-24, 2017

This prospective cohort study with 639 patients who had complete data, looked at the association between pain pattern classification, directional preference and outcomes. Both centralisers and those with directional preference had better pain and functional outcomes

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