Professional Documents
Culture Documents
e-Letters
E-mail alerts
Research Report
Effectiveness of Back School Versus
McKenzie Exercises in Patients With
Chronic Nonspecific Low Back Pain:
A Randomized Controlled Trial
Alessandra Narciso Garcia, Lucola da Cunha Menezes Costa,
Tatiane Mota da Silva, Francine Lopes Barreto Gondo, Fabio Navarro Cyrillo,
Renata Alqualo Costa, Leonardo Oliveira Pena Costa
Background. Back School and McKenzie methods are popular active treatment
approaches that include both exercises and information for patients with chronic
nonspecific low back pain.
Objective. The purpose of this study was to compare the effectiveness of Back
School and McKenzie methods in patients with chronic nonspecific low back pain.
Setting. The study was conducted in the outpatient physical therapy clinic in Sao
Paulo, Brazil.
Patients. The study participants were 148 patients with chronic nonspecific low
back pain.
Limitations. It was not possible to monitor the home exercise program. Therapists and participants were not blinded.
A.N. Garcia, Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao
Paulo, Sao Paulo, Brazil.
L.C.M. Costa, Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao
Paulo.
T.M. da Silva, Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao
Paulo.
F.L.B. Gondo, Physical Therapy
Department, Universidade Cidade
de Sao Paulo.
F.N. Cyrillo, Physical Therapy
Department, Universidade Cidade
de Sao Paulo.
R.A. Costa, Physical Therapy
Department, Universidade Cidade
de Sao Paulo.
L.O.P. Costa, PT, PhD, Masters
and Doctoral Programs in Physical
Therapy, Universidade Cidade de
Sao Paulo, Rua Cesario Galeno
448, CEP 03071-000, Tatuape,
Sao Paulo, Brazil, and Musculoskeletal Division, The George Institute for Global Health, Level 7,
341 George St, Sydney, New
South Wales, Australia. Address all
correspondence to Dr Costa at:
lcos3060@gmail.com.
[Garcia AN, Costa LCM, da Silva
TM, et al. Effectiveness of Back
School versus McKenzie exercises
in patients with chronic nonspecific low back pain: a randomized
controlled trial. Phys Ther. 2013;
93:729 747.]
2013 American Physical Therapy
Association
Published Ahead of Print:
February 21, 2013
Accepted: February 14, 2013
Submitted: October 7, 2012
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
729
Supervised exercise therapy1,8 associated with an educational component9 has been considered one of the
most effective interventions in
reducing pain and disability in
730
Physical Therapy
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Method
Design Overview
This study was a prospectively registered, 2-arm randomized controlled
trial with a blinded assessor. All
methodological steps of this study
are described in detail in the published protocol.46
Setting and Participants
This study was conducted in the outpatient physical therapy clinic of the
Universidade Cidade de Sao Paulo,
Brazil, between July 2010 and July
2012. To be eligible for inclusion,
patients seeking care had to have
nonspecific low back pain of at least
June 2013
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
731
McKenzie Method
First week
Second week
Third week
Fourth week
Physical Therapy
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
733
Construct
Description
Pain intensity
Roland-Morris Disability
Questionnaire (RMDQ)54,55
Disability
Quality of life
Inclinometer56
(NRS)53
Results
From a total of 182 patients who
were seeking care for low back pain
in the physical therapy clinic of the
Universidade Cidade de Sao Paulo,
148 were considered eligible and
were included in the study between
July 2010 and February 2012 (Figure). The reasons for ineligibility
were cardiorespiratory illnesses
(n8), age over 80 years (n5),
acute low back pain (n4), nerve
root compromise (n4), neck pain
(n3), grade II spondylolisthesis
(n2), vertebral fracture (n1), rib
fracture (n1), deep vein thrombosis (n1), abdominal tumor (n1),
advanced osteoporosis (n1), metabolic myopathy (n1), colitis (n1),
and urinary tract infection (n1).
734
Physical Therapy
All participants received the treatments as allocated. Of these participants, 146 (98.6%) completed the
follow-up at 1 month for the primary
outcome measures of pain and disability and for the secondary outcome measure of quality of life.
However, 4 participants (5.5%) in
the McKenzie group and 8 participants (10.8%) in the Back School
group could not be followed up for
the secondary outcome measure of
trunk flexion range of motion at 1
month due to an inability to attend
the clinic. All participants completed
the 3-month follow-up, and only
one loss to follow-up in the Back
School group occurred for all outcomes at 6 months (ie, 99.3% followup) (Figure).
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Excluded (n=34)
Randomization (n=148)
74 patients analyzed
Patient
allocation
Follow-ups
Analysis
74 patients analyzed
Figure.
Flow diagram of participants in the study. Asterisk indicates it was not possible to collect data for range of motion in 8 participants
(10.8%) in the Back School group and for 4 participants (5.5%) in the McKenzie group at 1 month due to inability to attend the clinic.
Discussion
Statement of Principal Findings
The objective of this randomized
controlled trial was to compare the
effectiveness of the Back School and
McKenzie methods in patients with
chronic nonspecific low back pain.
At 1-month follow-up, we observed
a reduction in both pain intensity
and disability in both groups. Most
of the improvements in outcomes
observed at short-term follow-up
were maintained at 3 and 6 months
after randomization for both primary
and secondary outcomes. Participants allocated to the McKenzie
group had greater improvements in
disability, but not pain intensity, at
1-month follow-up compared with
participants allocated to the Back
School group.
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
735
McKenzie Method
Sex
Female
51 (68.9)
Male
58 (78.4)
23 (31.1)
16 (21.6)
Age (y)
54.16 (1.57)
53.70 (1.53)
24 (83)
21 (28)
Weight (kg)
73.73 (1.59)
71.70 (1.59)
Height (m)
1.64 (0.01)
1.61 (0.01)
Marital status
Single
12 (16.2)
17 (23.0)
Married
45 (60.8)
41 (55.4)
Divorced
5 (6.8)
5 (6.8)
Widowed
11 (14.9)
9 (12.2)
1 (1.4)
2 (2.7)
Other
Education status
Elementary degree
27 (36.5)
28 (37.8)
High school
33 (44.6)
33 (44.6)
University
14 (18.9)
12 (16.2)
Illiterate
0 (0)
1 (1.4)
Use of medication
54 (74)
54 (73)
Physically active
27 (36.50)
20 (27)
Smoker
Recent episode of low back pain
Pain intensity (010)
5 (7.10)
8 (11.10)
47 (63.50)
46 (62.20)
6.41 (0.29)
6.77 (0.24)
11.08 (0.68)
11.32 (0.57)
Physical domain
51.48 (1.98)
51.64 (1.68)
Psychological domain
60.11 (1.85)
62.88 (1.82)
Disability (024)
Quality of life (0100)
Social domain
63.51 (2.20)
63.62 (2.12)
Environmental domain
54.74 (1.87)
55.40 (1.58)
78.93 (2.63)
79.28 (2.07)
63 (85.1)
63 (85.1)
5 (6.8)
2 (2.7)
Dysfunction syndrome
2 (2.7)
6 (8.1)
Postural syndrome
2 (2.7)
2 (2.7)
Other
2 (2.7)
1 (1.4)
68 (91.9)
65 (87.8)
Directional preference
Extension
35 (51.5)
31 (47.7)
15 (22.1)
15 (23.1)
13 (19.1)
17 (26.2)
Flexion
4 (5.9)
1 (1.5)
1 (1.5)
0 (0)
0 (0)
1 (1.5)
Categorical variables are expressed as number (%), continuous variables are expressed as mean (SD), and duration of symptoms is expressed as median
(interquartile range).
736
Physical Therapy
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Back School
Method
McKenzie
Method
Baseline
6.41 (2.54)
6.77 (2.12)
1 mo
4.39 (2.73)
4.14 (2.87)
.17
Measure
Pain intensity (010)
3 mo
5.53 (2.78)
5.18 (2.61)
.14
6 mo
5.19 (3.08)
5.09 (2.89)
.32
Baseline
11.08 (5.84)
11.32 (4.95)
1 mo
8.15 (5.79)
6.20 (5.06)
.004
3 mo
8.39 (6.30)
7.12 (5.67)
.06
6 mo
8.12 (6.45)
6.77 (6.02)
.06
51.49 (17.05)
51.64 (14.49)
Disability (024)
59.27 (16.88)
62.45 (16.94)
.12
3 mo
57.43 (17.76)
62.25 (15.37)
.04
6 mo
60.76 (18.87)
61.48 (16.12)
.85
Baseline
60.11 (15.86)
62.88 (15.86)
1 mo
65.12 (13.98)
67.68 (15.15)
.92
3 mo
65.14 (14.14)
67.62 (16.07)
.94
6 mo
66.72 (14.15)
68.00 (14.18)
.46
Baseline
63.15 (18.96)
63.62 (18.27)
1 mo
67.24 (15.96)
67.45 (18.00)
.85
3 mo
65.76 (16.00)
69.03 (16.11)
.21
6 mo
66.09 (15.00)
66.00 (18.74)
.91
Baseline
54.74 (16.09)
55.40 (13.66)
1 mo
57.62 (16.48)
58.57 (14.82)
.77
3 mo
56.16 (14.75)
58.23 (14.65)
.43
6 mo
57.44 (15.00)
57.84 (14.61)
.87
Baseline
78.93 (22.47)
79.28 (17.88)
1 mo
82.92 (18.86)
80.86 (17.67)
.61
Psychological domain
Social domain
Environmental domain
Range of motion ()
Primary outcomes are highlighted in gray. Positive treatment effects favor McKenzie method for the outcomes of pain intensity and disability and negative
scores for quality of life and trunk flexion range of motion. Pain intensity was measured with the pain numerical rating scale, disability was measured with
the Roland-Morris Disability Questionnaire, quality of life was measured with the World Health Organization Quality of LifeBREF (WHOQOL-BREF), and
trunk flexion range of motion was measured with an inclinometer. 95% CI95% confidence interval.
June 2013
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
737
Physical Therapy
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Conclusion
Patients allocated to the McKenzie
group experienced greater improvements in disability, but not in pain
References
1 Airaksinen O, Brox JI, Cedraschi C, et al.
Chapter 4: European guidelines for the
management of chronic nonspecific low
back pain. Eur Spine J. 2006;15(suppl
2):S192S300.
2 Waddell G. The Back Pain Revolution.
2nd ed. London, United Kingdom:
Churchill Livingstone; 2004.
3 Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low
back pain. Arthritis Rheum. 2012;64:
2028 2037.
4 Walker BF. The prevalence of low back
pain: a systematic review of the literature
from 1966 to 1998. J Spinal Disord. 2000;
13:205217.
5 Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness
studies in the United States and internationally. Spine J. 2008;8:8 20.
6 Costa Lda C, Maher CG, McAuley JH, et al.
Prognosis for patients with chronic low
back pain: inception cohort study. BMJ.
2009;339:b3829.
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
739
740
Physical Therapy
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
June 2013
59 World Health Organization. WHOQOLBREF: introduction, administration, scoring and generic version of the assessment. Available at: http://www.who.int/
mental_health/media/en/76.pdf. Published
December 1996. Accessed October 1,
2012.
60 Saur PM, Ensink FB, Frese K, et al. Lumbar
range of motion: reliability and validity of
the inclinometer technique in the clinical
measurement of trunk flexibility. Spine
(Phila Pa 1976). 1996;21:13321338.
61 Ostelo RW, Deyo RA, Stratford PW, et al.
Interpreting change scores for pain and
functional status in low back pain:
towards international consensus regarding
minimal important change. Spine (Phila
Pa 1976). 2008;33:90 94.
62 Bombardier C, Hayden J, Beaton DE. Minimal clinically important difference; low
back pain: outcome measures. J Rheumatol. 2001;28:431 438.
63 Merrifield A, Smith W. Sample size calculations for the design of health studies: a
review of key concepts for non-statisticians. N S W Public Health Bull. 2012;23:
142147.
64 Aure OF, Nilsen JH, Vasseljen O. Manual
therapy and exercise therapy in patients
with chronic low back pain: a randomized, controlled trial with 1-year follow-up.
Spine (Phila Pa 1976). 2003;28:525531.
65 Cuesta-Vargas AI, Garcia-Romero JC,
Arroyo-Morales M, et al. Exercise, manual
therapy, and education with or without
high-intensity deep-water running for nonspecific chronic low back pain: a pragmatic randomized controlled trial. Am J
Phys Med Rehabil. 2011;90:526 534.
66 Tavafian SS, Jamshidi A, Mohammad K,
Montazeri A. Low back pain education and
short term quality of life: a randomized
trial. BMC Musculoskelet Disord. 2007;8:
21.
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
741
Position
Lying down: From a supine position
with knees and hips flexed, the patient
raises the knees toward the chest,
applying extra pressure using the
hands.
Picture
Series
3 sets of 10 repetitions
Repetitions could be performed
sequentially, with a small break
between repetitions or split into
different times of day, according to
the response of the patient.
(Continued)
742
Physical Therapy
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Position
Trunk
extension
Picture
Series
3 sets of 10 repetitions
Repetitions could be performed
sequentially, with a small break
between repetitions or split into
different times of day, according to
the response of the patient.
(Continued)
June 2013
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
743
744
Position
Picture
Physical Therapy
Series
3 sets of 10 repetitions
Repetitions could be performed
sequentially, with a small break
between repetitions or split into
different times of the day, according
to the response of the patient.
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
June 2013
Position
Picture
Series
Diaphragmatic
breathing
1 set of 10 repetitions
Stretching of the
erector spine
muscles
Hold 30 seconds
Repeat 10 times
Stretching of the
posterior
lower-limb
muscles
Hold 30 seconds
Repeat 10 times
(Continued)
June 2013
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
745
Position
Stretching of the
anterior hip
muscle
Hold 30 seconds
Repeat 10 times
Kinesthetic
training
1 set of 10 repetitions
Strengthening of
the abdominal
muscles
(a) 1 set of 10
repetitions
(b) 1 set of 10
repetitions for each
limb
746
Physical Therapy
Picture
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Series
June 2013
June 2013
Volume 93 Number 6
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapy f
747
Cited by
Subscription
Information
http://ptjournal.apta.org/site/misc/ifora.xhtml