Part 3 of Blog Series Investigating Clincial Research Regarding 2 Common Low Back Pain Treatment Methods

Garcia, A., Costa, L., da Silva, T., Gondo, F., Cyrillo, F., Costa, R., & Costa, L. (2013) conducted a randomized controlled trial that compared the effectiveness of McKenzie exercises with back school exercises for the treatment of chronic nonspecific low back pain.

Back school exercises involve stretching and strengthening of LE musculature, and exercises to promote core stability by strengthening abdominal and paraspinal musculature. 148 patients who were diagnosed with chronic nonspecific low back pain participated in this randomized controlled study which took place in an outpatient physical therapy clinic. The inclusion criteria for these participants were presence of low back pain for 12 weeks or more with no specific cause. Furthermore, participants were required to be of ages 18 to 80 years. 34 patients with conditions that would cause contraindication to exercise, as described by the American College of Sports Medicine, were excluded from this study. Some of these conditions include tumors, previous spinal surgeries, inflammatory diseases, vertebral fractures, spondylolisthesis, nerve root compromise, cardiorespiratory illness, and pregnancy. The participants were randomly assigned to 2 intervention groups based on the back school or McKenzie treatment approaches.

Both groups met at an outpatient clinic once per week for 4 weeks, and were prescribed daily home exercises. Assessment of outcomes was completed by an individual who was blinded to the participants’ intervention assignment groups.

Results of the study were measured by a pain scale of 0-10, disability as described by the Roland-Morris Disability Questionnaire’s 24 functional tasks, trunk flexion range of motion, and the World Health Organization Quality of Life BREF instrument. Statistical analysis was completed with an alpha coefficient of .05, power of 80%, and 95% confidence intervals for differences between groups. Results taken during a follow-up visit after 1 month indicated that participants in the McKenzie group demonstrated significantly greater improvements in disability (2.37 points is the mean difference, with a 95% confidence interval of 0.76 to 3.99) than the Back School group, with a p-value of 0.004. However, the participants within the McKenzie group did not report significantly different levels of pain from the Back School group.

After 3 months, the McKenzie group had better outcomes, with 39/74 subjects achieving the minimal clinically important difference of 5 points in the Roland-Morris Disability Questionnaire, as compared to only 22/74 subjects in the Back School group. Furthermore, results at 3 months indicate that the McKenzie group had 43 subjects report at least 2 point improvement in pain intensity, which is the minimal clinically important difference for intensity of pain, as compared to 42 subjects in the Back School group. At the assessment of patients 6 months post intervention, outcome results converged and no statistically significant differences were found. It is likely that exercise compliance during the 6 months would have significant influence on these results, but this variable was not recorded as part of the study. The only adverse event that was observed during the course of intervention was a transient (1 week) exacerbation of pain experienced by 1 participant in the Back School group.

Limitations identified by Garcia, et al., (2013) include that both interventions employed home exercise programs that did not allow for monitoring. Also, the therapists providing the intervention, as well as the subjects, were not blinded as to which group they were in. The study would have benefitted from monitoring utilization of a daily log for patients in order to gather more accurate data regarding participation in home exercise program. Furthermore, subjects in the McKenzie intervention group were instructed individually, while subjects in Back School group were instructed in a group setting, which could have an effect on outcomes. Another limitation of the study is that it did not include measurement of co-interventions that participants may have sought from other health care professionals or holistic methods during the course of the study.

Overall, this study provides support for the efficacy of the McKenzie approach to treating back pain. After 3 months, almost double the amount of subjects in the McKenzie group (39) achieved the minimally clinically important difference for disability, as compared to the Back

School group (22). It is noteworthy that these results were produced in 4 visits, once per week for 4 weeks, indicating efficient use of healthcare resources. The reduction of pain due to the McKenzie approach was not significantly different from the Back School group, but this is less clinically important than reducing disability and improving function, especially in patients with chronic pain.

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