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Halliday M1,2, Garcia A3, Anita A1, Machado G4, Hayden J5, Pappas E1, Ferreira P1, Hancock M1,6
1The University of Sydney, Faculty of Health Sciences, Sydney, Australia, 2Concord Repatriation General Hospital, Sydney, Australia, 3Duke University, Division of Physical Therapy, Durham, United States, 4The University of Sydney, Faculty of Medicine and Health, Sydney, Australia, 5Dalhousie University, Department of Community Health & Epidemiology, Faculty of Medicine, Halifax, Canada, 6Macquarie University, Faculty of Medicine and Health Sciences, Sydney, Australia
Background: The McKenzie method, also referred to as Mechanical Diagnosis and Therapy (MDT), is a treatment-based classification system used for the management of low back pain (LBP). The approach is based on three core principles: classification into one of three diagnostic syndromes (Derangement, Dysfunction, and Postural), delivery of directional preference exercises/postural education and force progression according to symptom response. Many randomized controlled trials have investigated the efficacy of MDT for LBP. However, results have varied between trials, with some finding MDT to be significantly superior to other conservative non-pharmacological approaches, while others have found no benefit for MDT. One potential cause may be the inconsistent delivery of MDT across trials, with some studies closely following the core principles of the approach while others report only using some or none of these principles.
Purpose: The purpose of this systematic review with a meta-regression approach was to compare the treatment effect sizes for pain and disability in trials that delivered MDT consistent with the core principles of the approach, to trials that described only using some or none of these principles.
Methods: Electronic databases were searched up to June 2018, using a sensitive search strategy. Only randomized controlled trials were included, that met the following criteria: treatment of people reporting LBP of any duration, with MDT, compared to conservative non-pharmacological controls, for outcomes of pain and disability. Prior to data extraction, trials were classified as either 'original' or 'generic' delivery of MDT. 'Original' classification was defined as meeting all of the three core principles of the approach, while 'generic' delivery of MDT was defined as meeting some or none of MDT principles. Data was then extracted by two independent reviewers for pain and disability outcomes, and for the covariates of symptom duration (less than or greater than 3 months) and control intervention (minimal or active). Meta-regression procedures were used to analyze the effect of delivery mode on clinical outcomes, while adjusting for the covariates of symptom duration and control intervention.
Results: Twenty-four trials were included, 12 classified as 'original' and 12 as 'generic' MDT. Studies reporting delivery of the 'original' MDT approach showed greater reductions for pain and disability of 15.2 (95% CI 7.6 to 22.7) and 10.6 (95% CI 4.0 to 17.3) points respectively on a 100 point scale compared to 'generic' delivery of MDT.
Conclusion(s): Delivery of MDT using the 'original' or core principles of the approach resulted in a greater reduction in pain and disability compared to a 'generic' delivery of the approach in a population of people reporting LBP.
Implications: Our results suggest that physiotherapists who use MDT for the management of LBP should deliver the approach consistent with the core principles. Future research investigating the efficacy of MDT should also use an approach consistent with the core principles. Finally, guidelines for the management of LBP that comment on the efficacy of MDT should only base recommendations drawn from trials and reviews that clearly describe the delivery of MDT that is consistent with the core principles of the approach.
Keywords: Low back pain, McKenzie method, treatment effect size
Funding acknowledgements: this review received no funding
Purpose: The purpose of this systematic review with a meta-regression approach was to compare the treatment effect sizes for pain and disability in trials that delivered MDT consistent with the core principles of the approach, to trials that described only using some or none of these principles.
Methods: Electronic databases were searched up to June 2018, using a sensitive search strategy. Only randomized controlled trials were included, that met the following criteria: treatment of people reporting LBP of any duration, with MDT, compared to conservative non-pharmacological controls, for outcomes of pain and disability. Prior to data extraction, trials were classified as either 'original' or 'generic' delivery of MDT. 'Original' classification was defined as meeting all of the three core principles of the approach, while 'generic' delivery of MDT was defined as meeting some or none of MDT principles. Data was then extracted by two independent reviewers for pain and disability outcomes, and for the covariates of symptom duration (less than or greater than 3 months) and control intervention (minimal or active). Meta-regression procedures were used to analyze the effect of delivery mode on clinical outcomes, while adjusting for the covariates of symptom duration and control intervention.
Results: Twenty-four trials were included, 12 classified as 'original' and 12 as 'generic' MDT. Studies reporting delivery of the 'original' MDT approach showed greater reductions for pain and disability of 15.2 (95% CI 7.6 to 22.7) and 10.6 (95% CI 4.0 to 17.3) points respectively on a 100 point scale compared to 'generic' delivery of MDT.
Conclusion(s): Delivery of MDT using the 'original' or core principles of the approach resulted in a greater reduction in pain and disability compared to a 'generic' delivery of the approach in a population of people reporting LBP.
Implications: Our results suggest that physiotherapists who use MDT for the management of LBP should deliver the approach consistent with the core principles. Future research investigating the efficacy of MDT should also use an approach consistent with the core principles. Finally, guidelines for the management of LBP that comment on the efficacy of MDT should only base recommendations drawn from trials and reviews that clearly describe the delivery of MDT that is consistent with the core principles of the approach.
Keywords: Low back pain, McKenzie method, treatment effect size
Funding acknowledgements: this review received no funding
Topic: Musculoskeletal: spine
Ethics approval required: No
Institution: Not applicable
Ethics committee: Not applicable
Reason not required: This work is a systematic review of previously published results.
All authors, affiliations and abstracts have been published as submitted.
