Lumbar: Systematic Reviews

Choi BKL, Verbeek JH, Tam WWS, Jiang JY, Exercises for prevention of recurrences of low-back pain, Cochrane Library, Issue 3. www.thecochraneibrary.com, 2010

13 articles were included in the review, 2 of which involved McKenzie exercises. Overall there was moderate quality evidence that exercises were effective at reducing recurrences at one year and the number of recurrences; but no evidence of difference between McKenzie and back pain education.

Clare HA, Adams R, Maher CG, A systematic review of efficacy of McKenzie therapy for spinal pain., Aust J Physiother, 50(4):209-16, 2004

Systematic review of 5 trials deemed to be truly evaluating McKenzie method with pooled data showing greater pain relief (8.6 on a 100 scale) and greater reduction in disability (5.4 on 100 scale) than comparison at short-term (less than 3 months). At 3 to 12 months results were unclear.

Cook C, Hegedus EJ, Ramey K, Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature, J Man & Manip Ther, 13:152-162, 2005

This review uniquely only includes exercise trials for back pain in which patients were classified into exclusive, patient response groups based on physical examination findings. Given these inclusion criteria only 5 trials were included, 4 of these included elements of the McKenzie method, all included centralisation as part of the assessment process. All articles scored 6 or more by PEDro rating (suggesting high quality). 4 / 5 found that a PT directed exercise programme implemented according to patient response was significantly better than control or comparison groups. Authors note a positive trend, but that few studies have investigated this phenomenon.

Crawford C, Lee C, May T et al., Physically oriented therapies for the self-management of chronic pain symptoms., Pain Med, 15:S54-S65, 2014

This review looked at patient-centred complementary and integrative medicine that acknowledged the patients role in their own healing. The review included 10 studies investigating acupressure, self-correcting exercises (including McKenzie exercises), and TENS. Results were promising, but more evidence is required.

Dunsford A, Kumar S, Clarke S, Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain., J Multidisciplinary Healthcare, 4.393-402, 2011

A systematic review that included 4 high quality studies that showed that directional preference exercises were an effective intervention in 3 / 4, showing significant differences compared to a range of controls, regardless of duration of symptoms. They also presented a case study of a patient with back and leg pain who demonstrated directional preference in response to repeated extension.

Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hersmeyer J, Andersson G., The role of classification of chronic low back pain., Spine, 36:S19-S42, 2011

A review of 28 classification systems: 16 diagnostic, 7 prognostic, and 5 treatment-based systems. They found the McKenzie system had strong evidence for reliability, and moderate evidence for effectiveness. Reliability increased with training and experience with a classification system.

Fersum KV, Dankaets W, O'Sullivan PB., Integration of sub-classification strategies in RCTs evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review., Br J Sports Med, 44:14:1054-64, 2010

Only 5 out of 68 studies sub-classified patients. Meta-analysis showed a statistically significant difference in favour of classification-based treatment over control for reduction in pain (p=0.004) and disability (p=0.0005).

Goode, A, Hegedus, EJ, Sizer Jr, P, Brismee, J-M, Linberg, A, Cook, CE, Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility, JMMT, 16(1) 25-38, 2007

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Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N, Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain, Eur Spine J, 16:1539-1550, 2007

28 studies investigated the disc, 8 the facet joint and 7 the SIJ. Various features on MRI were suggestive of disc pathology: high intensity zone likelihood ratio (LR) 1.5 to 5.9, disc degeneration 1.6 to 4.0, endplate changes 0.6 to 5.9. Centralisation and likelihood of disc pathology had LR of 2.8. Single tests of SIJ were uninformative; multiple pain provocation tests had LR of 3.2 and negative LR of 0.29. None of the facet tests were found to be informative.

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Hettinga DM, Jackson A, Klaber Moffett J, May S, Mercer C, Woby SR, A systematic review and synthesis of higher quality evidence of the effectiveness of exercise interventions for non-specific low back pain of at least 6 weeks duration., Phys Ther Rev, 12:221-232, 2007

This systematic review found that higher quality evidence supported the use of strengthening exercises, organised aerobic exercise, general exercises, hydrotherapy and McKenzie exercises for back pain of at least 6 weeks duration.

Kent P, Mjøsund HL, Petersen D, Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review., BMC Medicine, 8:22, 2010

A systematic review of targeted versus non-targeted exercise or manual therapy that included 4 studies; 1 McKenzie and 3 treatment-based classification system based. There was a statistically significant effect short-term for directional preference exercises. Overall there was only very cautious evidence supporting targeted treatment improves patient outcome.

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Kolber MJ, Hanney WJ, The dynamic disc model: a systematic review of the literature., Phys Ther Rev, 14:181-189, 2009

Review of the dynamic disc model that suggests that the nucleus pulposus migrates in response to movement and positions. Twelve articles were located that demonstrated in vitro and in vivo that the nucleus migrated anteriorly during extension ad posteriorly during flexion. There was limited and contradictory data to support this model in the symptomatic and degenerated disc.

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Oliveira VC, Ferreira PH, Maher CG, Pinto RZ, Refshauge KM, Ferreira ML, Effectiveness of self-management of low back pain: systematic review with meta-analysis, Arthrit Care Res, 64:1739-1748, 2012

A review of 13 trials with moderate evidence that showed that self-management is effective for improving pain and disability. The effect size short and long-term was respectively 3.2% and 4.8% for pain, and 2.3% and 2.1% for disability.

Petersen T, Laslett M, Juhl C, Clinical classification in low back pain: best- evidence diagnostic rules based on systematic reviews, BMC Musculoskeletal Dis, 18:188, 2017

This systematic review examined the latest evidence for the patho-anatomic diagnosis in the lumbar spine. There was 'sufficient evidence' to suggest a clinical diagnostic rule in some cases, but not in others. The presence, or lack of, centralisation was a key assessment finding in the diagnostic process for the disc and for the SIJ.

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Slade SC, Keating J, Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with non-specific chronic low back pain: a systematic review., J Manipulative Physiol Ther, 30:301-311, 2007

A review of unloaded exercises facilitating lumbar spine movement compared to a no-treatment control or other treatment; of the 6 studies located 4 used the McKenzie system. Strong evidence was found that such exercises improve pain and function compared to no exercise. The evidence slightly favoured McKenzie when compared to strengthening and stabilisation exercises.

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Steffens D, Maher C, Pereira L, Stevens M, Oliveira V, Chapple M, Teixeira-Salmela L, Hancock M, Prevention of Low Back Pain A Systematic Review and Meta-analysis , JAMA Intern Med, 176(2):199-208, 2016

This is a systematic review and meta-analysis of the RCTs that have evaluated low back pain prevention strategies. The main finding was that the current evidence suggests that exercise alone or in combination with education is effective for preventing LBP, other interventions showed no preventative value.

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Stynes S, Konstantinou K, Dunn K, Classification of patients with low back-related leg pain: a systematic review , BMC Musculoskeletal Dis, 17:226, 2016

This review looks at the relevant literature that classify / subgroup populations with low back-related leg pain, and how leg pain due to nerve root involvement is described and diagnosed in the various systems. The McKenzie System scored the highest of any system on criteria based upon validity, feasibility, reliability and generalisability.

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Surkitt LD, Ford JJ, Hahne AJ, Pizzari T, McMeeken JM., Efficacy of directional preference management for low back pain: a systematic review., Phys Ther, 2012:92:652-665, 2012

Six trials involving directional preference management were included in this systematic review; 5 deemed to be of high quality. Results were mixed, but there was moderate evidence that directional preference exercises were more effective than a range of comparison treatments short, medium and long-term. No trials found these were less effective.

Swinkels A, Cochrane K, Burt A, Johnson L, Lunn T, Rees AS, Exercise interventions for non-specific low back pain: an overview of systematic reviews., Phys Ther Rev, 14:247-259, 2009

Only 4 systematic reviews were included, 27 were excluded. 3 / 4 were of high quality, and provided strong evidence that exercise programmes reduce sick-leave and improve pain and disability in people with non-acute non-specific back pain. The clinical value of this conclusion is reduced by the diversity of exercise interventions.