Evidence in Support of Management

The randomised controlled trial is the optimal study design for evaluating therapy efficacy, with systematic reviews used to analytically summarise this evidence. Several systematic reviews have investigated the efficacy of exercise in general for back pain, with some including an analysis of McKenzie trials and others focusing particularly on the McKenzie technique.

Belanger et al. (1991) discovered three scientifically admissible’ McKenzie approach trials, all of which preferred the strategy for acute back pain, but these were questioned for a lack of randomization, blinding, and the use of a control group. Koes et al. (1991) examined sixteen randomised controlled trials (RCTs) on exercise for back pain and concluded that no conclusion could be drawn about whether exercise therapy is better than other conservative treatments for back pain or whether a specific type of exercise is more beneficial. Faas (1996) updated the preceding review by Koes et al. (1991) by reviewing eleven RCTs from the literature between 1991 and 1995. Exercise was considered unsuccessful in patients with acute back pain; however, two trials supported McKenzie therapy above the reference therapy. Because both received poor method scores, it was determined that additional trials were required to determine the system’s efficacy.

Rebbeck (1997) discovered twelve clinical trials that used the McKenzie regime in the literature. Seven people were eliminated from the review, and five of them thought the system was better than the comparison regime. Failure to be included was due to the absence of a pure McKenzie method or publication in a peer-reviewed journal. Four of the five approved trials showed statistically significant improvements over the reference therapy. Because the trials in acute patients did not include a control group and because many patients recover quickly, it is not certain that the McKenzie regime is superior to natural history. In chronic patients, there is more evidence of a favourable benefit. In a review of all twelve trials, the McKenzie regime was found to be significantly better than flexion regimes, a small back school, traction, an NSAID, or a non-specific exercise plan for reducing back and leg pain. It was not, however, superior to a combination of extension, flexion, and manipulation, or chiropractic manipulation. Overall, there were too few trials and of inadequate methodological quality to offer firm judgements.

Maher et al. (1999) examined sixty-two trials to try to answer the question: What works for activity prescription for low back pain? A few relevant trials revealed that exercises were more beneficial than the control treatment for acute and subacute back pain. The McKenzie approach was utilised in the only clinical research that did show an improvement, with exercises augmented with posture correction and postural guidance (Stankovic and Johnell 1990, 1995), the advantages of which were rather large in specific outcomes. According to the analysis, patients with acute back pain should be urged to avoid bed rest and return to normal activities, using time rather than pain as a guide. This advice can be enhanced with McKenzie treatment or manipulative therapy. There is considerable evidence to support the use of intense general workouts for chronic back pain. They also discovered solid evidence that exercise can help avoid future back discomfort.

Van Tulder et al. (2000a) found 39 trials in the Cochrane Library for their systematic review of exercises for back pain. Their findings were consistent with previous reviews: for acute back pain, exercise appears to be no more effective than other treatments; however, for chronic back pain, exercise appears to be beneficial. They also reported on flexion and extension exercises, including the McKenzie method. Three low-quality studies on flexion exercises for acute back pain found that they were unsuccessful or provided worse results than comparative trials. Two high-quality studies (Cherkin et al., 1998; Malmivaara et al., 1995) and two low-quality studies (Stankovic and Johnell, 1990, 1995; Underwood and Morgan, 1998) assessed extension exercises in acute back pain. Three of them failed to demonstrate a meaningful difference in favour of the extension exercises, while one demonstrated that they were significantly less effective than comparative therapies. They came to the somewhat perplexing conclusion that extension exercises are more beneficial than flexion exercises, but both are ineffective in the treatment of acute back pain. There were no trials for chronic back pain that evaluated the role of flexion or extension exercises compared to other treatments, and the three comparisons between the two types of exercise showed contradictory results.

Clare et al. (2004) reported that in the short term, there was an 8.6% greater decrease in pain and a 5.4% greater reduction in disability than in controls. Cook et al. (2005) came to the conclusion that four out of five were significantly better than the control group. Machado et al. (2006) reported that in the short run, there was a 4.2% greater reduction in pain and a 5.2% greater reduction in disability than in controls. Slade and Keating (2007) concluded that McKenzie had a 0.36-0.63 short-term mean difference for pain and a 0.45-0.47 short-term mean difference for function. Fersum et al. (2010) concluded that sub-classification systems considerably reduced pain (p = 0.004) and disability (p = 0.0005) in the short term but not in the long term (p = 0.001). According to Kent et al. (2010), one study found that the McKenzie technique had considerably better short-term results. Slater et al. (2012) concluded that the classification-based treatment had significant treatment effects on pain and impairment in the short and medium term when compared to controls. Surkitt et al. (2012) reached the conclusion that there is moderate evidence that DP is significantly more effective than controls in the short and long run.

In Delitto A, et al. (2012) It was recommended that therapists utilise certain repeated movements to increase centralization in patients with acute, subacute, or chronic LBP, with the suggestion based on Grade A, strong evidence’.

In Stynes S. et al. (2016), 22 systems that categorise people with low back-related leg pain were reviewed. MDT received the greatest score of any method based on characteristics such as purpose, validity, practicality, reliability, and generalizability.

Lam O. et al. (2018) reported According to the findings of this review, MDT is superior to alternative rehabilitation therapies for pain and impairment in individuals with chronic LBP.

In Holliday M, et al. (2019) review divided MDT RCTs into those that adhered to MDT fundamental concepts and those that did not, and compared treatment effect sizes. Those studies that adhered to the basic MDT principles demonstrated a considerably larger reduction in pain and disability, suggesting that when the approach adopted is congruent with the fundamental MDT principles, better outcomes are attained.

Finally, systematic reviews are only as good as the trials that they are based on; therefore, it would be valuable to consider the individual trials included in the reviews as well as additional research that was not included.

Ponte et al. (1984) randomly allocated twenty-two acute patients to either Williams’ flexion exercises and postural instructions or a McKenzie exercise and posture programme consisting of extension, lateral, or flexion exercises. Pain, sitting tolerance, forward flexion, and straight leg raise improved much more in the McKenzie group, with 67% pain-free at the post-treatment examination versus 10% in the Williams group. Patients in the McKenzie group had 7.7 treatment sessions on average, compared to 10.4 in the other group; this difference was similarly significant.

Nwuga and Nwuga (1985) studied 62 women who had recently developed disc protrusions and root compression, which had been validated by studies. These were randomly assigned to either McKenzie extension exercises and postural instructions or Williams’ flexion exercises. A blinded assessor did a re-evaluation of patients after six weeks. Pain, sitting endurance, and straight leg raising improved significantly in the McKenzie group but not in the Wilhams group, and the mean treatment duration was much shorter in the McKenzie group.

Stankovic and Johnell (1990) assigned 100 patients with acute back and leg pain to either a McKenzie protocol containing extension exercises, followed by lateral correction if necessary, and flexion exercises, or a “mini back school.” This included information, counselling on resting positions, and being as active as possible while avoiding activities. Three weeks and one year later, there were substantial differences between the groups at various stages. In the McKenzie group, all patients had returned to work after six weeks, compared to eleven weeks in the other group. At three and fifty-two weeks, the McKenzie group experienced much less discomfort, had fewer recurrences, and required less medical attention.

This trial’s 89 subjects were followed up on five years later (Stankovic and Johnell, 1995). Differences were substantially smaller than earlier but remained significant in terms of recurrences of back pain and sick leave. There were no differences in the groups’ abilities to seek health care or self-help. Pain was reported by 64% of those in the McKenzie group and 88% of those in the other group.

Elnaggar et al. (1991) investigated the effects of flexion and extension exercises on patients suffering from chronic back pain. Postural instructions were not given, exercises were only conducted once a day for two weeks, and a McKenzie routine was not used. Both groups saw a significant reduction in pain following therapy; however, there was no statistical difference between the groups.

In 56 patients with chronic back pain and particular radiographic abnormalities, Spratt et al. (1993) investigated the use of extension and flexion exercises and postures, including braces, and a no-treatment control group. Spondylolisthesis, retrodisplacement, and normal sagittal translation were among them. After a month, the extension group’s pain score was significantly better than the other two groups, and it was the only one that demonstrated a meaningful improvement over time. The treatment response pattern was consistent across all translation subgroups.

Delitto et al. (1993) and Erhard et al. (1994) studied workouts in small groups of patients who were classified as extension responders based on a decrease or centralization of symptoms with extension and a worsening of symptoms with flexion. Following this classification, twenty-four patients were randomly assigned to either a manipulation treatment followed by extension exercises or a flexion exercise regimen. The manipulation/extension group improved much more than the control group in terms of the Oswestry disability score (Delitto et al. 1993). In the second study (Erhard et al. 1994), twenty-four patients were randomly assigned to either an extension group or a group that received a manipulation followed by a spinal flexion or extension exercise. Only two of the first group satisfied the discharge requirements after a week, while nine of the second group did. One-month follow-up was only 50%, but it favoured the manipulation group.

Dettori et al. (1995) recruited 149 troops suffering from severe back and leg discomfort. These were divided into three groups: extension, flexion, and control; however, at the conclusion of week two, half of each active exercise group also performed the other activity. Exercises were performed three times per day, and patients were given postural counselling based on their group. The control group lied prone with an ice pack wrapped around their lumbar spine. Over the eight weeks of the trial, all groups improved rapidly, with no statistically significant differences in pain or function. There was a trend for both exercise groups to exhibit a better restoration of function in the first week, while the control group showed very little change; when the two exercise groups were combined and compared, this was Significant at this point. Recurrences of back pain were similar in all groups, at more than 60%, over the six-to twelve-month follow-up. Patients in the control group, on the other hand, were more likely to seek medical care than those who had exercised, and those in the extension group, in particular, were less likely to require medical care and job limitations.

Underwood and Morgan (1998) randomly assigned 75 patients with acute back pain to either a single back class lasting up to one hour with one to five patients in which the ‘instruction was as described by McKenzie’ or conventional therapy. There were no statistical differences in pain or Oswestry scores between the two groups during the year of follow-up. At one year, there was a statistically significant difference when 50% of the class group reported ‘back discomfort with no problem’ in the previous six months, compared to 14% of the control group.

Gillan et al. (1998) aimed to investigate the natural history of lateral shift and its relationship to McKenzie management. The trial enrolled forty patients who were randomly assigned to either the McKenzie group or a non-specific back massage and conventional back advice group. Patients were checked in at 28, 90, and 180 days, although 37% of them had died by the time they were checked in. The McKenzie group resolved shifts more frequently, with a significant difference after ninety days. There was, however, no difference in functional outcome at any phase.

Cherkin et al. (1998) assigned 323 patients with acute back pain to one of three groups: a McKenzie regime, chiropractor manipulation, or a control group that received an instructional pamphlet. This was the first study to acknowledge the significance of using skilled clinicians; however, instead of using experienced McKenzie doctors, they were trained prior to the study. Because of exclusion restrictions, the trial only enrolled 8.5% of patients who visited their primary care physician with back pain. At four weeks, the chiropractic and McKenzie groups had fewer severe symptoms than the booklet group, but their Roland-Morris disability ratings were not different. There were no significant changes in symptoms or function between the three groups after twelve weeks, and there had been no further improvement in outcomes. Recurrences and care-seeking were similar in all groups throughout the next two years. The booklet group had significantly lower costs, but satisfaction with care was significantly lower than in the other two interventions.

Long (2004): This high-quality RCT supported the benefit of employing MDT to sub-classify patients, determine directional preference (DP), and match specific workouts based on these findings. All patient outcomes were much better in the group when the exercises were matched to the DP, including pain, function, and medication use.

Petersen (2011): This study compared two alternative therapies over a one-year period. The study indicated that MDT was more effective than manipulation, which lends support to the method’s classification-based approach.

Albert (2012) stated that the participants in this study exhibited symptoms that would ordinarily necessitate surgery. Patients who received DP exercises based on MDT improved significantly more in terms of overall improvement, sick leave, vocational status, root compression symptoms, and patient satisfaction.

Fritz (2020): This RCT with 220 patients compared an exercise-based strategy based on MDT concepts, including force progressions, to ‘usual care’. At one year, the MDT group demonstrated larger gains in function, discomfort, and self-reported success.

A study by Deutscher et al. (2014) found that when MDT principles were applied to the treatment of low back pain, fewer therapy sessions were necessary when done by a clinician with a McKenzie education level of Part C or higher. This suggests that doctors who have not had training can successfully adopt MDT concepts; however, the plan of care may take longer.

Other trails are worth considering

Kopp et al. (1986) assessed the response of 67 individuals with acute disc prolapse who had radicular discomfort and at least one symptom of nerve root irritation to an extension exercise routine. Thirty-five of these patients responded to the extension strategy, with 97% achieving full-range extension in just a few days. Only two patients (6%) were able to accomplish extension after thirty-two patients failed to respond and came to surgery. 75% of patients had a sequestered or bulging disc with nerve root displacement or deformity at the time of surgery. There was no difference in referred pain, positive straight leg lift, or neurological signs and symptoms between the two groups. The authors coined the term “extension sign,” which refers to the failure to achieve extension, as an early indicator of the necessity for surgical intervention. The extension sign predicted a successful response to non-operative treatment in 91% of cases during a six-year follow-up (Alexander et al. 1991).

In a study of 154 individuals with disc herniation, Alexander et al. (1992) reported on 73 patients who were chosen for conservative care based on their ability to achieve full-range extension in laying. The decision to pursue a McKenzie strategy was reached by the sixth day, by which time most of the patients, If they were planning to extend, should have done so. These patients were subsequently discharged and told to keep doing extension exercises. Those whose extension signs remained positive were surgically treated. Thirty-three (45%) of the patients who were conservatively handled were tracked down five years later. Symptoms were resolved or mild in 82% of cases, functional limits were non-existent or minor in 85% of cases, and 94% were satisfied with their treatment. Complete resolution was reported in 47% of individuals who initially had a positive extension sign that became negative, compared to 21% of those who had a negative extension sign at admission and after five days. Patients who had their extension sign change from positive to negative (achieving extension) within five days had consistently better outcomes, and this mechanical presentation was a major predictor of effective conservative therapy (nineteen of thirty-three). This ability to restore extension during the acute period was extremely important in determining the treatment group, whether conservative or surgical. Other criteria, such as neurological indications and symptoms, straight leg lifting, or abnormal imaging scans, were ineffective in distinguishing between the two groups.

Brötz D., et al. (2003) discovered that mechanical physiotherapy was used to treat fifty consecutive patients with neuroradiologically verified lumbar disc prolapse who reacted to the first five daily physiotherapy sessions with pain centralization (McKenzie). There were high rates of patient satisfaction, recovery from neurological impairments, and employment at a median follow-up of 55 weeks, and a low rate of surgical procedures. Mechanical physiotherapy is thus a good diagnostic tool as well as an efficient treatment option for many lumbar disc disease patients.

Fifty consecutive patients with clinically and neuroradiologically confirmed lumbar disc prolapse who responded to the first five daily physiotherapy sessions with pain centralization were prospectively treated with mechanical physiotherapy with repeated end-range spinal movements and leg movements, according to Broetz et al. (2010). Five patients were operated on within one year of discharge from the first cohort of 50 patients (Brötz, D., et al. 2003), and one patient died. Thirteen months after discharge, one patient underwent disc prolapse surgery. Three patients were not followed up on. Until the most recent follow-up, none of the 40 remaining patients had undergone surgery. The authors concluded that pain centralization during the first five mechanical physiotherapy treatment sessions is a useful diagnostic tool for predicting a good long-term outcome. For many individuals with lumbar disc degeneration, mechanical physiotherapy with end-range spinal motions and leg movements is a successful treatment method.

Broetz et al. (2008) published a study that compared clinical and radiological changes. Eleven patients with lumbar disc prolapse were included in the study. Patients were given repeated end-range spinal motions, and MRIs were taken before and after 2–5 sessions. During and after these treatments, all patients experienced a reduction in symptoms and signs of disc prolapse, but none showed any improvement in the MRI features of the prolapses. The authors determined that the positive benefits of specialised mechanical physiotherapy in patients with lumbar disc prolapse radicular syndromes are not mirrored by changes in the MRI appearance of the prolapses. Alternative causes for the early clinical responses in some McKenzie-treated lumbar disc prolapse patients must be found.

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