Part 6 of Blog Series Investigating Clinical Research Regarding 2 Common Low Back Pain Treatment Methods


All 5 studies reviewed demonstrated patient improvement in response to the prescribed interventions. After carefully reviewing the studies and recording all statistically significant results, the 5 studies were assigned into categories of ‘Support for McKenzie’, ‘Support for Core Stabilization’, or ‘Support for Both’. 2 studies were determined to provide support for McKenzie, 2 studies provided support for both, and 1 study provided support for core stabilization.

Timing of intervention was not consistent across all studies included in this review. Studies varied in time of initiation of treatment for low back pain symptoms. Examples range from less than 7 days (Long, et al., 2004) to 12 weeks or more (Garcia et al., 2013). Further research is necessary to determine the time range of McKenzie physical therapy that is most effective for treatment of low back pain.

In these studies McKenzie treatment is prescribed in the absence of additional physical therapy interventions that may be indicated for individual patient cases, which may be unrealistic in a clinical setting. Further research could investigate the combination of McKenzie treatment with pain relieving modalities, such as ultrasound, which could potentially promote improved performance of the McKenzie exercises.

The McKenzie approach relies heavily on patient self-care after receiving instructions and education for their specific pathology. With this in mind, patient adherence to completion of home exercises is a crucial variable in determining the efficacy of McKenzie treatment. Current literature could improve its methodology of objectively recording home exercise compliance, with current methods relying largely on patient self-report. A more accurate measure of patient compliance with home exercises would be to video record completion of home exercises every day, and this could allow for investigation regarding the efficacy of McKenzie treatment for patients who are 100% compliant. This research could then be utilized during patient education as motivation to increase home compliance.

Limitations of this literature review include that identical core stability exercises were not prescribed in all of the studies, and many studies included hip and thigh stretches in addition to core stabilization. Also the prescription of McKenzie exercises appears to have been improper during one of the studies.


The results of this literature review provide greater support for the effectiveness of McKenzie physical therapy treatment as compared to core stabilization for reduction of low back pain and maximization of functional mobility in patients with low back pain. This is especially true for studies of shorter duration, and for patients who demonstrate a direction of preference.

Of the 5 studies included, 2 studies supported McKenzie interventions, 1 study supported core stabilization interventions (with significant concerns regarding the improper prescription of McKenzie treatment in this study), and 2 studies yielded results that provide comparable support for both interventions. Based on these results, the author of this literature review recommends that physical therapists include repeated motion testing for direction of preference as part of their physical examination for patients with low back pain, as evidence indicates it would be a favorable prognostic sign when treated with McKenzie interventions. Further research is indicated to improve the understanding within the medical community of how to more effectively and efficiently treat low back pain in order to provide greater outcomes in less time for patients who suffer from this pathology.


Costa, L. M., Maher, C., Hancock, M., McAuley, J., Herbert, R., Costa, L. O., (2012). The prognosis of acute and persistent low-back pain: a meta-analysis. Canadian Medical Association Journal, 184(11), 613-624.

Garcia, A., Costa, L., da Silva, T., Gondo, F., Cyrillo, F., Costa, R., &; Costa, L. (2013). Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical Therapy, 93(6), 729-

Hosseinifar, M., Akbari, M., Behtash, H., Amiri, M., & Sarrafzadeh, J. (2013). The effects of stabilization and McKenzie exercises on transverse abdominis and multifidus muscle thickness, pain, and disability: a randomized controlled trial in nonspecific chronic low back pain. Journal of Physical Therapy Science, 25(12), 1541-1545.

Long, A., Donelson, R., Fung, T. (2004). Does it matter which exercise. Spine, 29(23), 2593-

Long, A., May, S., &; Fung, T. (2008). The comparative Prognostic Value of Directional Preference and Centralization: a useful tool for frontline clinicians. The Journal of Manual & Manipulative Therapy, 16(4), 248-254.

McKenzie, R., May, S., (2003). The Lumbar Spine Mechanical Diagnosis and Therapy. Vol 1.(2 nd ed.). Waikanae, New Zealand: Spinal Publications.

Miller, E., Schenk, R., Karnes, J., & Rousselle, J. (2005). A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain. Journal Of Manual &; Manipulative Therapy, 13(2), 103-112.

Moldovan, M. (2012). Therapeutic Considerations and Recovery in Low Back Pain: Williams vs McKenzie. Timisoara Physical Education & Rehabilitation Journal, 5(9), 58-64.

Walker, B. (2000). The prevalence of low back pain; a systematic review of the literature from 1966 to 1998. Journal of Spinal Disorders, 13, 205-217.

Part 5 of Blog Series Investigating Clinical Research Regarding 2 Common Low Back Pain Treatment Methods

Miller, Schenk, Karnes, & Rousselle (2005) conducted a randomized controlled trial that compared the effectiveness of the McKenzie approach to a spinal stabilization program for treatment of chronic low back pain.

29 subjects (14 females and 15 males, ages 19-87 years with a mean of 47 years) who were experiencing greater than 7 weeks (mean of 26.4 months) of chronic low back pain were referred by their primary physician to an outpatient physical therapy clinic. Once informed consent to participate in the research study was received, patients were randomly assigned to the Spinal Stabilization group (15 subjects) or the McKenzie group (14 subjects).

Subjects were excluded from participation in the study if they were under 18 years of age, diagnosed with psychological illness, diagnosed with systemic inflammatory disease, currently pregnant, Workman’s Compensation recipients, had litigation involvement with present injury, had received at least one lumbar surgery, or could not understand English.

Subjects were measured along the criteria of Functional Status Questionnaire (FSQ), McGill Pain Questionnaire (MPQ), and pain-free passive straight leg raise motion in the supine position. Subjects in both groups received 6 weeks of physical therapy treatment, with 10-15 minutes of home exercises assigned to be completed each day. The interventions in the Spinal Stabilization group focused on strengthening lumbar multifidus and transverse abdominis muscles, while the McKenzie group received exercises determined by their classification in either postural, derangement, dysfunction, or “other” (non-mechanical) categories. Prior to intervention, Mann Whitney U-tests indicated no statistically significant differences between the groups’ baseline measurements. Within-groups comparison was completed using Wilcoxin Signed-Ranks tests. Statistical significance was considered to be P<0.05.

Results indicate a statistically significant reduction in present pain in both the McKenzie and Spinal Stabilization groups. However, the Spinal Stabilization group had slightly superior results which also yielded statistically significant reduction in pain descriptor scores, as well as a statistically significant improvement in pain-free passive straight leg raise motion in the supine position. Both groups demonstrated improvement in all areas of measurement, however no statistically significant differences in final outcomes were detected between the McKenzie and Spinal Stabilization groups.

This study provides slightly greater evidence for the efficacy of spinal stabilization interventions than McKenzie interventions. However, there were no statistically significant differences in final outcomes between groups. In clinical practice a combination of both treatment approaches could be utilized. Future studies could explore the combination of both treatment methodologies applied together, in comparison to each intervention being applied alone. Furthermore, this study would have benefited from a larger number of subjects.

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Part 4 of Blog Series Investigating Clinical Research Regarding 2 Common Low Back Pain Treatment Methods

Moldovan (2012) conducted a randomized controlled trial which compared the effects of the McKenzie and Williams Flexion Exercises therapeutic interventions for low back pain. Williams exercises involve promoting lumbar flexion, avoiding lumbar extension, and improving the muscular stability of the core by strengthening the abdominal and gluteal musculature.

Specific examples of Williams exercises are pelvic tilts, single knee to chest, double knee to chest, partial sit-up, hamstring stretch, hip flexor stretch, and squat. 22 subjects who were between the ages of 21 and 55 years and experiencing limitation of flexion, extension, and lateral movement, with low back pain of non-severe (no fracture, infection, or nerve root compromise) origin lasting a minimum of 3 weeks were randomly assigned to participation in either McKenzie (10 subjects) or Williams (12 subjects) programs for treatment of low back pain. Measurements of outcomes included a pain scale from 1 to 10 with higher numbers indicating greater pain, duration of time patient is able to sit comfortably without pain, forward flexion, lateral flexion, and a passive straight leg raise test. Each group received 11 sessions of instruction in exercises respective to either the McKenzie or Williams approach to treatment of low-back pain.

Percentage improvement between pre-treatment and post-treatment was measured across multiple variables. In the first variable, subjective report of pain, the McKenzie group improved by 88.4% as compared to the Williams group which improved 47.4%. The second variable, minutes spent sitting without pain, yielded greater results for the McKenzie group: 89.8% improvement as compared to 26.5% improvement in the Williams group. In the third variable, centimeters of forward flexion, the McKenzie group demonstrated 82% improvement, as compared to 25.9% in the Williams group. The fourth variable, lateral flexion right produced results of 8.8% improvement for the McKenzie group and 5.7% improvement for the Williams group. In the fifth variable, lateral flexion left, results indicate 11% improvement in the McKenzie group, as compared to 6% improvement in the Williams group. In the sixth and final variable, degrees of passive straight leg raise, the McKenzie group achieved 54.9% improvement, as compared to 47.3% improvement in the Williams group. It is noteworthy that significantly fewer treatment sessions were required by the McKenzie group to achieve greater outcomes than the Williams group. 67% of subjects in the McKenzie group reported no pain at the end of treatment, as compared to 10% of subjects in the Williams group.

The results of this study indicate that the McKenzie approach is more effective than the Williams method at reducing low back pain, increasing range of motion, and improving tolerance for the sitting position. Furthermore, the McKenzie group was able to achieve these superior results in fewer visits, which reflects a more efficient use of patient time and money.

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

Long, A., Donelson, R., Fung, T. (2004) conducted a multicentered randomized controlled trial which investigated treatment for 312 patients with acute, subacute, and chronic low back pain and sciatica who demonstrate a direction of preference consistent with MDT during their initial evaluation.

Acute back pain was defined as less than 7 days, subacute as less than 7 weeks, and chronic as greater than 7 weeks. The majority of patients reported having at least 1 previous episode of low back pain. The patients who demonstrate direction of preference were then randomly assigned to 1 of 3 of treatment groups in order to compare the effects of performing McKenzie exercises consistent with the patient’s demonstrated direction of preference, McKenzie exercises opposite from the patient’s demonstrated direction of preference, and core stabilization exercises of multidirectional midrange lumbar exercises with stretches for hip and thigh muscles.

The 3 treatment groups were allowed a minimum of 3 visits and a maximum of 6 visits over a period of 2 weeks. leg symptoms, with or without one neurological sign, age between 18 and 65 years, and demonstration of directional preference during the mechanical assessment.

Exclusion criteria for the study include cauda equina, 2 or more neurological signs, spinal fractures, post-surgical, off work for 1 year or more due to low back pain, medical causes (examples include severe osteoporosis, and inflammatory or infectious conditions), uncontrolled medical conditions (including diabetes, angina, and hypertension), pregnancy, no directional preference demonstrated during initial evaluation, as well as patients who had prior knowledge of, or specific physician referral for, the McKenzie method of diagnosis and treatment; visual analogue scale, disability as indicated by the 24 item Roland Morris Disability Questionnaire, medication use in total number of pills taken daily, pain location and neurologic symptoms using the Quebec Task Force severity rating on a 1-4 scale, degree of recovery, depression using the 21 item Beck Depression Inventory, and 0-5 rating of home and work activity interference. preference.

These directions were 191 (83%) extension, 16 (7%) flexion, 23 (10%) lateral. 24 patients who demonstrated a direction of preference for extension experienced positive results only after their pelvis was offset from midline prior to prone extension.

All 3 treatment groups (McKenzie exercises consistent with the patient’s demonstrated direction of preference, McKenzie exercises opposite from the patient’s demonstrated direction of preference, and core stabilization exercises of multidirectional midrange lumbar exercises with stretches for hip and thigh muscles) demonstrated improvement in all outcome measures after 2 weeks.

Statistically significantly greater improvement (p-values ranging 0.016 to p<0.001) was achieved by the group which performed McKenzie exercises consistent with the patient’s demonstrated direction of preference, as measured by all outcome variables. causes” which includes examples of severe osteoporosis, and inflammatory or infectious conditions, as well as the exclusion category of “uncontrolled medical conditions” with examples of this including diabetes, angina, and hypertension.

Furthermore, patients were excluded for the factors of pregnancy, no directional preference demonstrated during initial evaluation, and patients with prior knowledge of, or specific physician referral for, the McKenzie method of diagnosis and treatment. These relatively extensive exclusion criteria limit the clinical applicability of the result because patients often present with one or more of these factors in addition to low back pain.

Another limitation is that 29 subjects (12.6%) dropped out from the study and did not provide data at 2 weeks. A total of 201 subjects (68%) returned compliance questionnaires, making analysis of this crucial variable less accurate. Additionally, subjects were blinded from their diagnosed direction of preference, however the MDT trained PTs were not blinded as to which treatment group the patient was placed into. This created a potential for the PTs to demonstrate bias during their interaction with the patients. Lastly, the core stabilization exercises in this article were not described in great detail, which limits the replicability of the study.

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Part 1 of Blog Series Investigating Clinical Research Regarding 2 Common Low Back Pain Treatment Methods

Beginning of series of blog posts comparing efficacy of McKenzie interventions and Core Stabilization for Treatment of Low Back Pain.

The Efficacy of McKenzie Versus Core Stabilization Treatment for Low Back Pain


Author: Peter J McGrath, PT, DPT.


The purpose of this research review is to analyze the effectiveness of McKenzie versus Core Stabilization physical therapy treatment for low back pain. A search was conducted for peer-reviewed journal articles consisting of randomized control trials published between the years 2004 to 2015, with keywords being ‘McKenzie’, ‘low back pain’, ‘core stabilization’, and ‘treatment’. 5 studies were selected for critical analysis, with 541 patients included. The results of this literature review provide greater support for the effectiveness of McKenzie physical therapy treatment as compared to core stabilization for reduction of low back pain and maximization of functional mobility in patients with low back pain. This is especially true for studies of shorter duration, and for patients who demonstrate a direction of preference.


Low back pain is a common occurrence in patients throughout the world. It is often linked with disability, psychosocial changes, and time missed from work (Walker, 2000). The prevalence of low back pain makes it an important topic of research in order to identify the most effective treatment methods to improve patient outcomes and maximize the efficient use of time and health care resources.

The McKenzie method, also known as Mechanical Diagnosis and Therapy (MDT), was developed in 1981 by Robin McKenzie, a physiotherapist from New Zealand. This approach involves an examination to classify patients into syndrome categories based on the clinical presentation of their symptoms, as well as syndrome-specific treatment involving instruction in exercises, postural correction, and self-management of symptoms.

A key component of MDT involves the clinician correctly identifying whether or not a patient demonstrates a direction of preference during initial evaluation and ongoing testing. If repeated motions in a specific direction are able to move the patient’s pain from distal to proximal, this is referred to as a centralization, which places a patient in the ‘derangement’ syndrome category, indicating presence of a bulging disc. Demonstration of direction of preference and centralization are considered to be favorable prognostic factors (Long, May, & Fung, 2008).

If a patient experiences pain in a constant location that is perceived at end ranges of a decreased range of motion, they are placed into the ‘dysfunction’ syndrome category which indicates adaptive shortening of tissues has taken place. A patient is placed into the ‘posture’ syndrome, which is associated with suboptimal alignment of the body, if they have normal range of motion but experience end-range pain in a constant location that is associated with prolonged positioning and disappears when force is removed and optimal alignment is restored. If a patient displays positive slump and upper limb tension tests, with intermittent peripheral symptoms that do not change during mechanical testing, they are classified as having ‘adherent nerve root’ syndrome (McKenzie & May, 2003). The rationale behind MDT as treatment for low back pain is that repeated motions into an established direction of preference, when combined with postural correction, can often help to improve range of motion, pain, and function by promoting a more symmetrical balance of forces around the involved joints of the spine. In turn these mechanical changes help to reduce adaptive shortening of soft tissue and promote optimal distribution of the semi-fluid nucleus pulposus centered within the intervertebral discs.

Core stabilization exercises are another commonly prescribed treatment for low back pain. The proposed mechanism of reduction of low back pain achieved through core stabilization exercises is that improvement of strength, endurance, and nervous system recruitment of abdominal and lumbar core musculature (primarily transverse abdominis and multifidi) allows for increased ability of the muscles to prevent shifting of the spine during upright mobility and when changing and maintaining body positions. As these muscles are able to provide more stability and support, the stress and passive stability that must be provided by connective tissue decreases, leading to reduction of low back pain. Core stabilization exercises often include isometric exercises performed within mid-range of motion or neutral spine position.

Treatment of low back pain has been an ongoing topic of research throughout the years, with many therapeutic approaches and philosophies being investigated. However, there continues to be opportunity for further advancement in treatment of this pathology, with the majority of patients experiencing low back pain reporting continuation of their symptoms for a duration greater than 1 year (Costa et al., 2012). The purpose of the current review is to determine the effectiveness of McKenzie versus core stabilization physical therapy treatments for low back pain.


Keywords searched include ‘McKenzie’, ‘core stabilization’, ‘low back pain’, and ‘treatment’. Results were narrowed to include studies published after 2004, in the English language, full-text, randomized controlled trials, referenced by other studies, and scholarly (peer reviewed) journals. Studies were excluded if they did not compare McKenzie interventions with core stabilization exercises, or were determined by the author of this literature review to not provide adequate detail required to critically assess their research methodology. 5 studies were selected and considered on-topic, with a combined total of 541 patients included.

The purpose of this paper was to investigate the effectiveness of McKenzie versus core stabilization physical therapy treatments for low back pain. A brief summary of significant findings is as follows. The first article indicated that when core stabilization is compared to improper prescription of McKenzie interventions, core stabilization is more effective. The second article provided significantly greater support for McKenzie interventions when compared to core stabilization in a patient population that demonstrated a direction of preference during initial evaluation. When compared to Back School interventions, McKenzie interventions were more effective at reducing disability and improving function for patients with low back pain persisting for 12 weeks or more. When compared to spinal stabilization interventions, both methods were found to effectively reduce pain and disability, however there were no statistically significant differences in final outcome measures, but the stabilization group showed greater improvements in passive supine straight leg raise and pain description. When compared to the Williams approach, McKenzie interventions were found to be more effective for reducing low back pain with a minimum duration of 3 weeks, increasing range of motion, and improving tolerance for the sitting position. A detailed description of all 5 included studies is provided below.

Hosseinifar, M., Akbari, M., Behtash, H., Amiri, M., & Sarrafzadeh, J. (2013) conducted a randomized controlled trial which investigated the effects of McKenzie versus core stabilization exercises for treatment of patients with chronic nonspecific low back pain. Chronic symptoms were defined as greater than 3 month duration. 30 patients were randomly assigned between 2 groups: 15 subjects in the McKenzie group and 15 subjects in the core stabilization group. Inclusion criteria for this study include age between 18 and 50 years, presence of chronic low back pain between the costal margin and buttocks, with or without reference to the lower extremity. Exclusion criteria for this study include recent history of fracture, trauma or previous surgery in the lumbar region; spondylolysis or spondylolisthesis, spinal stenosis, neurological disorders, systemic diseases, cardiovascular disease, pregnancy, receiving simultaneous treatment with physical therapy modalities or other therapies.

Subjects received 18 treatment sessions of 1 hour duration each, consisting of 3 times per week for 6 weeks. The interventions applied to the stabilization group consisted of a 6 stage progressive exercise program. Stage 1 consisted of segmental control exercises with emphasis on isolated contraction of individual muscles of transverse abdominis, multifidi, and pelvic floor muscles. Stage 2 involved segmental control exercises which emphasized the co-contraction of transverse abdominis, multifidi, and pelvic floor muscles together in supine, prone, and quadruped positions. Stage 3 consisted of closed kinetic chain segmental control exercises. Stage 4 involved open kinetic chain segmental control exercises. Stage 5 consisted of developing segmental control exercises in functional scenarios. Stage 6 involved co-contraction of transverse abdominis and multifidi muscles when an external load is applied, and implementing the co-contraction of transverse abdominis during light aerobic activities such as walking.

The results of this study were evaluated by an assessor who was blinded to the subjects’ group assignments. Data recorded include pain as measured by 0 to 100 visual analogue scale, disability as measured by the Persian version of the 10-item Functional Rating Index which uses a 5-point scale, and muscle thickness of transverse abdominis and multifidi musculature during rest and contraction as measured by ultrasound imaging. Motions utilized to elicit core contraction during imaging include abdominal draw in maneuver and active straight leg raise.

Both groups demonstrated significant reductions in low back pain at the p<0.05 level. Only the core stabilization group demonstrated significant reduction in disability score. The core stabilization group also yielded significantly greater increases in muscle thickness of right transverse abdominis during abdominal draw in maneuver, and the thickness of left transverse abdominis during active straight leg raise. Core stabilization also produced a change resting muscle thickness of left transverse abdominis.

Limitations of this study include significant exclusion factors such as age between 18 and 50 years, which limit the clinical applicability of the findings, as many patients in the clinic present with positive presence of these factors. A home exercise program was not established for the patients, limiting the efficacy of McKenzie interventions which are intended to be performed multiple times throughout every day, rather than 80-100 repetitions within 1 hour, 3 times per week. Furthermore, the study did not specify whether or not the clinicians who were treating with McKenzie interventions were credentialed to be proficient in this area of practice, which brings into question the inter-rater reliability. Additionally, the McKenzie interventions were not performed in a specific, established direction of preference. Instead they were performed with 4 exercises into lumbar extension and 2 exercises into lumbar flexion, without any mention or recognition of possibility of relevant lateral components. McKenzie interventions also traditionally include postural education and often involve patient education regarding use of lumbar roll in sitting for those who demonstrate direction of preference for lumbar extension, which was not mentioned in this study and therefore was presumably not incorporated into the interventions provided to the McKenzie group. Lastly, 18 sessions of 1 hour duration each, occurring 3 times per week, were utilized for delivery of interventions in this study, which limits the applicability of the study to clinical practice in the United States because this scheduling of patient visits is often prevented by reimbursement constraints.

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