10 2519@jospt 2016 6379

Journal of Orthopaedic & Sports Physical Therapy
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Copyright ${year} Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
A Randomized Controlled Trial Comparing the McKenzie Method to Motor

Control Exercises in People With Chronic Low Back Pain and a Directional
Preference.
AUTHORS:
Mark H. Halliday, PT1
Evangelos Pappas, PT, PhD2
Mark J. Hancock, PhD3
Helen A. Clare, PT, PhD4
Rafael Z. Pinto, PhD5
Gavin Robertson PT, BaSc1
Paulo H. Ferreira, PhD2
INSTITUTIONAL AFFILIATIONS:
1
Concord Repatriation General Hospital, Sydney, New South Wales, Australia.
2
Discipline of Physiotherapy, Faculty of Health Sciences, the University of Sydney,
Lidcombe, New South Wales, Australia
3
Faculty of Medicine and Health Science, Macquarie University, North Ryde, New
South Wales, Australia
4
Physiotherapy Private Practice, Sydney, Australia.
5
Departamento de Fisioterapia, Faculdade de Cincais e Tecnologia, UNESP - Univ
Estadual Paulista, Presidente Prudente, So Paulo, Brasil.
FUNDING:
This trial received competitive funding from the International MDT Research
Foundation. We also received financial support from Disability Services at Student
Support from the University of Sydney.
INSTITUTIONAL REVIEW BOARD:
The study protocol was approved by the Sydney Local Health District Human Ethics
Committee.
TRIAL REGISTRATION:
The trial was registered with the Australian New Zealand Clinical Trials Registry,
registration number: CTRN12611000971932.

A Randomized Controlled Trial Comparing the McKenzie Method to Motor

Control Exercises in People With Chronic Low Back Pain and a Directional
Preference.
STATEMENT OF FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST:
This trial received competitive funding from the International MDT Research
Foundation and a donation of 35 copies of Treat Your Own Back by Robin
McKenzie. Back Care Products Australia supplied the McKenzie lumbar rolls used in
the trial. Disability Support at the University of Sydney provided funding for a
research assistant to support the principal researcher. The International MDT
Research Foundation, Spinal Publications New Zealand Ltd. Back Care Products
Australia and Disability Support at the University of Sydney took no part in the
design, implementation, analysis or production of the manuscript for this trial. Helen
Clare is currently a member of the McKenzie Institute International Board of Trustees
and is currently the International Director of Education for the McKenzie Institute
International. The authors certify that they have no affiliations with or financial
involvement in any organization or entity with a direct financial interest in the subject
matter or materials discussed in the article.
Acknowledgements:
Dr Steven May and Mark Werneke assisted with creation of working definitions for
the inclusion criteria related to the mechanical assessment of patients prior to
admission. David Roberts and Tim Morcombe provided treatment and Margarita
Otero managed randomization.

ABSTRACT:
STUDY DESIGN: Randomized clinical trial.
BACKGROUND: Motor control exercises are believed to improve co-ordination of
the trunk muscles. It is unclear if increases in trunk muscle thickness can be
facilitated by approaches such as the McKenzie method. Furthermore it is unclear if
either approach is superior regarding clinical outcomes.
OBJECTIVES: The primary aim was to compare the effects of the McKenzie method
and motor control exercises on trunk muscle recruitment in people with chronic low
back pain (LBP) classified with a directional preference. Secondary aims included a
10
between group comparison for pain, function, and global perceived effect.
11
METHODS: Seventy people with chronic LBP demonstrating a directional
12
preference using the McKenzie assessment were randomized to receive 12
13
treatments over 8 weeks with the McKenzie or motor control approaches. All
14
outcomes were collected at baseline and at 8-week follow-up by blinded assessors.
15
RESULTS: No significant between group difference was found for trunk muscle
16
thickness of the transversus abdominis [-5.8%, 95% CI -15.2 to 3.7], obliquus
17
internus [-0.7%, 95% CI -6.6 to 5.2] and obliquus externus [1.2%, 95% CI -4.3 to
18
6.8]. Perceived recovery was slightly superior in the McKenzie group (-0.8, 95% CI -
19
1.5 to -0.1] on a -5 to +5 scale. No significant between-group differences were
20
found for pain or function [p= 0.99, 0.26, respectively].
21
CONCLUSION: We found no statistically significant effect for treatment group for
22
trunk muscle thickness. Participants reported a slightly greater sense of perceived
23
recovery with the McKenzie method than with the motor control approach.
24
LEVEL OF EVIDENCE: Therapy, level 1b-

25
26
Key words: core stability exercises, Mechanical Diagnosis and Therapy, muscle
27
thickness, transversus abdominis, ultrasound imaging
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

50
INTRODUCTION
51
Low back pain (LBP) is a complex multifactorial condition affecting most people at
52
some point in their life. It has been identified as the leading contributor to years of
53
life lived with disability in the world including the United States.(36,51) Increased
54
comorbidities and economic burden have been found in people with chronic LBP
55
compared to healthy controls.(18) In Australia LBP is estimated to reduce gross
56
domestic product by $3.2 billion annually and is the leading cause of early medical
57
retirement for older working people.(42) Evidence suggests that the burden of LBP is
58
likely to spiral, compelling health providers to utilize treatments that are both effective
59
and promote independent management to reduce this burden.
60
61
Exercise therapy has been shown to have beneficial effects for the management of
62
chronic LBP.(43,52) Two popular forms of exercise used to manage LBP are
63
Mechanical Diagnosis and Therapy referred to as the McKenzie method and motor
64
control exercises, both of which are recommended by the American Physical
65
Therapy Association Clinical Guidelines.(12) There is evidence for the use of the
66
McKenzie method or motor control exercises in people reporting chronic LBP. There
67
is no evidence to suggest that either approach is superior to other standard
68
therapies.(8,20,29,30,44) Currently, no study has compared the McKenzie method and
69
motor control exercises for any physiological or clinical outcomes in a population with
70
chronic LBP and a directional preference.(21)
71
72
Directional preference classification is characterized by a reduction in distal pain
73
and/or observation of the centralization phenomenon with the application of repeated
74
or sustained end range loading strategies to the spine that remain better after
75
assessment.(3,35) Centralization is defined as a progressive change in pain from a
76
more distal location to a more proximal location that remains better after applying
77
repeated or sustained end range movements to the spine.(35,54,56) Directional
78
preference is a hallmark characteristic of the McKenzie derangement
79
classification.(33,35)

80
81
Measurements of TrA thickness taken from ultrasound images have shown a
82
correlation with electromyographic recordings of recruitment of the TrA.(16) This
83
suggests that ultrasound is a valid measure of trunk muscle thickness. Some
84
investigations using real time ultrasound have demonstrated that the cross sectional
85
area of the TrA is smaller and has altered recruitment patterns in people with acute
86
and chronic LBP compared to healthy individuals.(10,16,27,38) However, others have
87
found considerable variance in size and recruitment of TrA in healthy
88
individuals.(32,49,50) There is some evidence that improvement in size and recruitment
89
of deep muscles of the spine including TrA is associated with improved function in
90
the short term when patients with LBP receive motor control exercises compared to
91
general exercise or spinal manipulation.(14,17) However, increases in TrA and lumbar
92
multifidus thickness using real time ultrasound have also been observed
93
immediately and one week following spinal manipulation in people with LBP,
94
suggesting that increases in TrA recruitment may not be specific to motor control
95
exercises.(28,39) It is not known if the McKenzie method when applied to a population
96
of people with chronic LBP sub-classified with a directional preference has any
97
effect on trunk muscle thickness as pain and function respond to repeated end range
98
movements of the spine.(21)
99

100
The proposed mechanism of action for motor control exercises is based on improved
101
co-ordination of deep muscles of the spine and trunk such as the TrA.(7,23,25) From a
102
societal perspective some people reporting LBP have reported beliefs that
103
strengthening the muscles of the trunk is necessary to improve their back pain.(13)
104
The primary purpose of this study was to compare the effects of the McKenzie
105
method to motor control exercises in the recruitment of the trunk muscles, assessed
106
by real time ultrasound in a population with a greater than 3-month history of LBP
107
and a directional preference classification.(21) The secondary aims of the study were
108
to compare these approaches in terms of pain, function and patients perceived
109
recovery.(21)
110
111
METHODS
112
Design: This study was a randomized, assessor-blinded, clinical trial with an eight
113
week follow-up (FIGURE 1). Ethics approval was granted by the Sydney Local
114
Health District Human Ethics Committee. The study was registered retrospectively
115
with the Australian New Zealand Clinical Trials Registry, trial number
116
CTRN12611000971932. The published protocol was established prior to public
117
registration. The protocol has not been altered since commencement of data
118
collection.(21) All participants gave written informed consent prior to admission.
119
Participants rights were protected throughout all aspects of the trial. The study was
120
conducted in the Physiotherapy department of Concord Repatriation General
121
Hospital which is a major metropolitan public hospital in Sydney, Australia.
122
123
Participants: Consecutive presentations of people with a referral for treatment of
124
their low back pain to the Physiotherapy department were invited to participate in the
125
trial. Inclusion criteria were: a greater than 3-month history of LBP and a directional
126
preference observed with a mechanical assessment based on the McKenzie
127
method. The area of pain could be localized between the twelfth rib and the buttock
128
crease. Patients reporting referred pain into one or both legs with or without sensory
129
and or motor changes were also included.(21)

130
131
Two experienced physiotherapists with formal training in the McKenzie method
132
conducted a mechanical assessment of the lumbar spine to identify a directional
133
preference. The assessment consisted of repeated or sustained end range loading
134
strategies in standing or lying postures, including therapist over pressure when
135
necessary.(21,35)
136
in a blank body diagram indicating all the areas of pain they were experiencing while
137
standing immediately before and again after the mechanical assessment. A
138
standardized translucent body diagram with a grid dividing the lumbar spine and
139
lower limbs into six segments (segment one correlated to the central lumbar spine to
140
segment six over the foot) was placed across the body diagrams. If the location of
141
pain shifted proximally by at least one segment when comparing the post-
142
assessment diagram to the pre-assessment diagram centralization was considered
143
to have occurred. This procedure has been described and used previously with high
144
inter-rater reliability (ICC = 0.96).(54,55,56) Participants reporting no pain prior to the
145
mechanical assessment demonstrated centralization by producing pain on the first
146
movement and then abolishing this pain with repeated or sustained loading
147
strategies in the opposite direction from the provocative movement that remained
148
better when re-evaluating the provocative movement. Participants who reported
149
pain immediately prior to mechanical assessment but the location of the symptoms
8
Centralization was objectively measured by participants shading
150
did not change with testing but their most distal pain reduced by two points on an 11-
151
point numeric pain rating scale following mechanical assessment were classified as
152
a non-centralizer with a directional preference and were included.(21)

153
154
Participants were excluded if they were classified as not having a directional
155
preference, were under 18 or over 70 years of age, lacked adequate comprehension
156
of English language skills to comply with treatment or read the study materials.
157
Participants were also excluded if they reported metastatic disease, a history of
158
spinal fracture, previous spinal surgery or known osteoporosis. Pregnancy was also
159
an exclusion criteria and if a woman reported becoming pregnant during the study
160
they were withdrawn.(21)
161
162
Randomization: The randomization sequence was created using computer
163
generated numbers by a researcher not involved with data collection. Following
164
baseline data collection patients were randomized to treatment allocation by a
165
research assistant who was unaware of the randomization sequence. This process
166
was conducted.by opening sequentially numbered, opaque sealed envelopes.
167
168
Interventions: Following randomization, patients were provided with an
169
appointment to see a physiotherapist to commence treatment according to
170
allocation. Treatment frequency was guided by the clinical judgment of the treating
171
physiotherapist. Patients were not allowed to receive more than 12 treatment
172
sessions over an 8-week period with no minimum number of treatments required.
173
Interventions were delivered according to the participants clinical needs based on
174
the principles of treatment to which the patient was allocated.

9

175
176
McKenzie method: The McKenzie method was prescribed according to the
177
principles described by McKenzie and May.(35) Treatment was delivered by two
178
therapists who had obtained the level of Credentialed Therapist from the McKenzie
179
Institute International. Treatment involved mechanical therapy including patient and
180
therapist generated forces utilizing repeated or sustained end range loading
181
strategies in loaded or unloaded postures according to the patients directional
182
preference. The force and loading strategy was guided by symptom response. The
183
aim was to reduce, centralize and abolish peripheral symptoms. In patients with
184
central symptoms only, the aim was to reduce and abolish their pain. Once
185
symptoms had centralized any movement loss was then treated with repeated end
186
range movements in the direction of movement loss. Postural education was taught
187
throughout the treatment program including provision of a standard McKenzie lumbar
188
roll when an extension preference was identified. All participants randomized to the
189
McKenzie arm received a copy of Treat Your Own Back by Robin McKenzie(34) to
190
supplement treatment and self-management.
191
192
Motor control exercises The protocol for motor control exercises used in this study
193
was based on principles proposed by Hodges et al.(23) Physiotherapists delivering
194
motor control exercises received training from an experienced therapist who had
195
used the protocol for motor control exercises in previous trials.(14,17) Patients were
196
progressed after meeting specific criteria for each phase. Initially promotion of
197
independent contraction of the deep stabilizing muscles such as TrA and multifidus
198
were facilitated by pelvic floor contraction leading to their co-contraction, while
199
instructions to control breathing by maintaining resting tidal volumes throughout deep

10

200
trunk activation maneuvers was used. Progression was achieved when mastery of
201
contraction in static tasks was achieved progressing to implementation of deep
202
muscle contraction during dynamic tasks. Therapists provided feedback on the
203
performance of exercises while less prompting was provided as the patient mastered
204
the skill. Objectively skill mastery of TrA recruitment was measured by palpation and
205
visual assessment for a reduction of over activity of the superficial trunk muscles
206
during static and dynamic tasks. Patients were instructed to practice exercises daily
207
at home for 30-minutes. Patients were encouraged to attend twice a week for the
208
first four weeks and once per week for the remaining four weeks even if their
209
symptoms resolved during the treatment episode.
210
211
Data collection: Baseline demographic data for age, sex, work participation and
212
symptom length were collected from all the participants. Data describing the
213
mechanical characteristics of the cohort was collected at the initial mechanical
214
assessment. This included the rate of centralization and those whose symptoms did
215
not centralize but displayed a directional preference. We also obtained data
216
reporting the direction of movement and whether the symptom response was elicited
217
by patient or therapist generated forces. All baseline data were collected prior to
218
treatment allocation by a researcher not involved with randomization.
219
220
The primary outcome measurement was recruitment of the trunk muscles TrA,
221
obliquus externus (OE) and obliquus internus (OI) expressed as percentage changes
222
in muscle thickness increases from base line to eight week follow-up.
223
Measurements of trunk muscle thickness were obtained from real time ultrasound
224
images. The reliability for this outcome measure has been shown to be good to
11

225
excellent for single measurements and poor to good for changes in thickness from
226
baseline measurements.(9) Primary outcomes were collected at intake and following
227
treatment discharge at eight weeks. The research assistant responsible for the
228
collection of ultrasound images was blinded to group allocation. The assistant
229
received training from an experienced operator prior to commencement of the trial
230
that then assessed the quality of the images with 10 healthy individuals.
231
232
Twelve ultrasound Images were collected at each time point using a 5cm T5 MHz
233
linear array transducer using settings for musculoskeletal exam, depth 6 focus 2.8.
234
Patients were instructed to lay supine on a plinth with their arms crossed over the
235
chest wall with their knees supported in a harness suspended from a frame. The hips
236
and knees were positioned at 50 and 70 flexion respectively. The feet were
237
supported on a bar connected to a spring balance. The ultrasound transducer was
238
placed laterally on the abdominal wall. The operator of the ultrasound instructed
239
participants to perform low load isometric knee flexion and knee extension
240
movements in a random fashion. This maneuver was performed to produce a 7.5%
241
body weight target. Body weight was self-reported. Investigations of self-reporting of
242
body weight have shown less than a 2kg error which for this protocol was not
243
significant.(11,41,45) When the desired amount of force was achieved facilitating
244
automatic recruitment of the deep trunk muscles a row of lights were illuminated and
245
the images were obtained. If excessive force was used a buzzer sounded, verbal
246
feedback was provided to help achieve the desired maneuver. The ultrasound
247
transducer was placed transversely across the left abdominal wall along a line mid-
248
way between the inferior angle of the costal margin and the iliac crest. The medial
249
edge of the transducer was positioned so that the medial edge of TrA was aligned in
12

250
the left-hand one-third of the ultrasound image when the subject was relaxed. The
251
images were stored for analysis. For each leg task (isometric knee flexion and knee
252
extension tasks), static ultrasound images were collected consecutively at rest (rest
253
image) and once the target isometric knee flexion or extension force (contraction
254
image) had been reached. A total of twelve images, three pairs of rest/contraction
255
images for each direction of leg movement were taken. This process is described in
256
detail elsewhere.(16)
257
258
Images were randomized by a research assistant prior to analysis. Image analysis
259
was conducted by a blinded researcher who had previous experience with
260
ultrasound analysis of trunk muscle thickness.(37) Customized software was used to
261
analyze all six pairs of images. Measurements were taken of muscle thickness in the
262
center and one cm to the left and right of the muscle center from both resting and
263
contracted images. Thickness change was used in our analysis. The change in
264
thickness in each pair of rest/contraction images was expressed as a proportion of
265
the thickness at rest. This normalization procedure was conducted to help control for
266
between-subject differences in resting muscle thickness and has been used
267
previously.(16,22,47) A final measure of muscle thickness change was established by
268
calculating the average of the change in thickness considering all six pairs of
269
images, three from each direction of leg movement.
270
271
Secondary outcomes included patients perception of function measured by the
272
Patient Specific Functional Scale (3-30 point scale),(46) which has been recently
273
shown to be a valid measure of aggregated data for between group comparisons,(2)

13
274
global improvement measured by the Global Perceived Effect Questionnaire (-5 to
275
5). (40) and pain intensity using the Visual Analogue Scale (11-point scale). Data
276
were collected by a blinded researcher at enrolment and following treatment
277
discharge.

278
279
Statistical analysis: A power analysis was conducted a priori and determined a
280
sample size of 70 participants would provide 80% power for detecting a 7%
281
difference between groups for TrA muscle thickness assessed with ultrasonography.
282
A 7% between group difference in TrA thickness is based on previous studies of
283
ultrasonography for deep trunk muscles and has been shown to be a clinically
284
important difference between treatment groups.(17) These calculations assume a
285
worst-case loss to follow-up of 10%. The sample size of n=70 provides adequate
286
statistical power to detect medium or higher effect sizes for the secondary variables.
287
288
All analyses were conducted by intention-to-treat in the sense that all patients with
289
available follow-up data were analyzed in the group to which they were randomized
290
regardless of compliance with treatment protocol. Analyses were performed using
291
complete data (no-imputation was performed) due to the low loss to follow-up. A
292
blinded statistician was provided with coded grouped data. We used linear
293
regression models adjusted for baseline values for all the primary and secondary
294
outcomes to determine if any between group differences were found at follow-up.
295
There were no adjustments for any other covariates. The level was set a priori at
296
0.05. Analyses were conducted with SPSS software version 22.0 (Chicago, IL, USA).
297
298
RESULTS
14
299
Recruitment commenced in April 2011 and was completed by March 2013. A total of
300
133 people who had been referred to physiotherapy for treatment of their LBP
301
underwent an assessment for inclusion. A sample size of 70 participants met all
302
inclusion criteria progressing to data collection and randomization, with 35
303
participants being allocated to each treatment group (FIGURE 1).

304
305
Data describing baseline demographics and mechanical characteristics of
306
participants is presented in TABLE 1. Both groups were similar for baseline
307
variables except for symptom length, with the McKenzie group reporting a mean of
308
26.6 weeks (SD 22.3) while those in the motor control group reported 37.7 weeks
309
(SD 28.8). Baseline measurements for muscle thickness were available for 34
310
participants in both groups. Baseline data for secondary outcomes was available for
311
34 participants in the McKenzie group and 35 in the motor control group (TABLE 2).
312
313
Participants allocated to the McKenzie method group attended an average of 5.4 [SD
314
2.5] treatment sessions over an average of 38.6 [SD 18.8] treatment days, while
315
participants in the motor control group attended an average of 6.5 [SD 2.7] treatment
316
sessions over 47.3 [SD 22.7] treatment days. Eight participants [11.4%] were not
317
available for data collection for the primary outcomes at eight weeks follow-up, with
318
three participants belonging to the McKenzie group and five to the motor control
319
group. Reasons for being unavailable for data collection included: time constraints
320
[n=5], dissatisfaction with treatment [n=2], and inability to attend treatment sessions
321
[n=1].
322
15
323
Primary outcomes: There was no statistically significant difference between
324
treatment groups on the recruitment of the three abdominal muscles TrA [-5.8%,
325
95% CI -15.2 to 3.7, p=0.23], OI was [-0.7%, 95% CI -6.6 to 5.2, p=0.82] and OE
326
[1.2%, 95% CI -4.3 to 6.8, p=0.65] [TABLE 2].

327
328
Secondary outcomes: A statistically significant between group difference was
329
found for Global Perceived Effect scores at 8 weeks [-0.8, 95% CI -1.5 to -0.1,
330
p=0.03] on a -5 to +5 scale favoring the McKenzie method [TABLE 2]. No statistically
331
significant differences were observed for any of the other secondary outcomes for
332
pain and function [TABLE 2].
333
334
DISCUSSION
335
This study is the first to compare the effect of the McKenzie method and motor
336
control exercises on trunk muscle recruitment and patient rated clinical outcomes in
337
a cohort of people with chronic LBP classified with a directional preference according
338
to the McKenzie classification system.(21)
339
340
The main findings of this study are that there was no statistically significant effect for
341
treatment group for muscle thickness of the TrA, OI and OE at an eight week follow-
342
up in a population of people reporting chronic LBP classified with a directional
343
preference. Global perceived improvement was the only secondary outcome that
344
demonstrated a significant between group difference favoring the McKenzie method.
16

345
346
The results from this study are similar to recent studies investigating deep muscle
347
recruitment using ultrasonography to obtain images of the TrA, OI and OE which
348
have found small or non-significant differences in trunk muscle thickness increases
349
when comparing motor control exercises with other interventions when treating
350
LBP.(4,31,50) Only one previous study has investigated the effect of the McKenzie
351
method on trunk muscle recruitment using changes in trunk muscle thickness
352
measured with real time ultrasound images as an outcome compared to motor
353
control exercises.(26) This study reported that the McKenzie method had no
354
significant effect on increasing trunk muscle thickness while a significant increase
355
was found for people receiving motor control exercises.(26) A possible explanation
356
for the lack of differences in muscle thickness in our study is the relatively small
357
number of treatments attended by participants in the motor control group. Exercise
358
dosage has been found to be the only significant factor related to treatment effect
359
when using exercise for management of LBP.(15) The motor control group in our
360
study attended for an average of 6.5 sessions, while in other studies that showed
361
some benefit for motor control exercises for trunk muscle thickness, participants
362
typically attended for a greater number of treatment sessions.(17,26,31) Hossienifar et
363
al(26) reported participants in their study attended for 18 sessions of treatment. This
364
suggests that Increases in the cross sectional area of the trunk muscles may depend
365
more on exercise dosage rather than any other factors.
366
17
367
A further confounding factor that may have contributed to a lack of between group
368
difference is the test re-test reliability for ultrasound measurements of trunk muscle
369
thickness which has been shown to be poor to good for repeat measures.(9)

370
371
Results from our study showed a small but statistically significant benefit for global
372
improvement favoring the McKenzie method when compared to motor control
373
exercises. It is important to note that even though the difference between groups
374
was small, the change within groups exceeded what has been reported as large
375
change.(1) These results are similar to other studies investigating people with chronic
376
LBP who received matched exercises according to their classification, which have
377
shown some benefit for global improvement outcomes.(5) Results from our study
378
suggest that in patients with a directional preference, receiving exercises matched to
379
their directional preference is likely to produce a greater sense of improvement than
380
receiving motor control exercises. However, Guyatt et al.(19) suggested that changes
381
in Global Perceived Effect questionnaires should correlate with other treatment effect
382
outcome measures to be meaningful. Thus the outcome for perceived recovery may
383
need to be considered cautiously considering that all other secondary outcomes
384
demonstrated no significant between group differences. We found no statistically
385
significant difference for the outcomes of pain and function between groups which is
386
similar to other studies and systematic reviews comparing motor control exercises to
387
other interventions.(6,31,44) A recent study of patients with chronic LBP compared the
388
McKenzie method with motor control exercises and reported superior outcomes
389
favoring motor control exercises.(26) This study did not classify patients for symptom
390
response prior to randomization while all the patients in the McKenzie arm only
18
391
received lumbar extension exercises. Hence some patients receiving the McKenzie
392
method may not have been appropriate for the treatment provided.

393
394
Secondary analysis was conducted using a linear regression model adjusted for
395
symptom length. Between group differences for all the primary and secondary
396
outcomes were not significant. This suggests symptom length did not have any
397
significant effect on these outcomes. We did not directly test whether symptom
398
duration was an effect modifier for response to the interventions.
399
400
A further analysis was conducted to assess within-group changes using a paired
401
samples t test. This analysis demonstrated no significant within-group increases for
402
trunk muscle thickness. However, significant improvements were found for all
403
secondary outcomes. These findings are concurrent with Wong et al who found that
404
morphological changes in TrA were not related to improvement in clinical
405
outcomes.(57) Though as results for this study reported no significant difference
406
between groups for the secondary outcomes of pain and function but within-group
407
improvements were significant for all secondary outcomes in a cohort of people
408
demonstrating a directional preference, suggests both groups may have had a
409
better prognosis as people with a directional preference have been shown to have
410
better outcomes.(56) Though it is unclear if motor control exercises have better
411
prognosis in people who have a directional preference compared to those who do
412
not have a directional preference.
413
19

414
Limitations: Therapists providing treatment were not blinded to allocation. The
415
results reported for the Patient Specific Functional Scale must be considered with
416
care as we applied a 10-point (1-10) scale for each nominated activity(47) rather than
417
the traditional 11-point scale.(46) Finally, even though a power analysis was
418
performed, the sample size provided adequate power only to detect medium or
419
higher effect sizes of the primary outcome. It is possible that we failed to detect
420
smaller effects; however, the relatively narrow confidence intervals for between
421
group differences suggest it is unlikely we missed any important effects. We
422
prospectively selected change in muscle thickness as the primary outcome for this
423
study. This is a potential weakness of the study as this measure is not clinically
424
important to patients; however, we chose this primary outcome as we wanted to
425
focus on better understanding how the interventions might be working. Patient
426
reported outcomes of pain and disability are clearly more important than muscle
427
thickness changes for investigating the clinical importance of different interventions.
428
429
Implications for clinicians or policymakers: As the mechanism of functional and
430
pain improvement is likely not to be related to improvements in abdominal muscle
431
thickness, and clinical outcomes for pain and function were not different between
432
groups, clinicians managing patients with chronic LBP and a directional preference
433
may consider using either method. However, our study suggests that in this
434
population slightly greater improvements of perceived recovery are achieved through
435
the McKenzie method in the short term. It is unclear if this change is maintained in
436
the long term.
437
20

438
CONCLUSION
439
We found no statistically significant differences between the McKenzie method and
440
motor control approach for increases in muscle thickness for the TrA, OI and OE in a
441
population of people reporting chronic LBP and a directional preference at an eight
442
week follow-up. Participants who received the McKenzie method reported an
443
improved sense of perceived recovery compared to those who received motor
444
control exercises, while changes in pain and function scores were not statistically
445
different between groups. Our results suggest that in this population, clinicians could
446
consider using either method; however the McKenzie method may be more
447
preferable as patients report a more improved sense of recovery in the short term
448
compared to those who received motor control exercises.
449
450
KEY POINTS:
451
Findings: We found no difference for increases in deep trunk muscle recruitment
452
between people who received the McKenzie method or motor control exercises. In
453
this population with a directional preference we found improvements of perceived
454
recovery in those receiving the McKenzie method compared to motor control
455
exercises, but no difference in other patient reported outcomes.
456
Implications: Effective treatment of pain and function in patients with LBP may not be
457
as closely related to muscle recruitment increases.
458
In patients with chronic LBP and a directional preference. McKenzie may produce
459
better perceived improvement than motor control exercise, but the differences in the
460
other assessed outcomes are small and not consistent across outcomes.
21
461
Cautions: These results may not be generalizable to people with chronic low back
462
pain that do not have a directional preference
463

464
465
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26
TABLE 1. Baseline characteristics of participants

Variable
McKenzie method
(n=35)
Motor control exercises

(n=35)
Age (years)
48.8 (12.1)
48.3 (14.2)
Sex (males); n (%)
Males 7 (20.0%)
Males 7 (20.0%)
Work participation; n (%)
27 (77.1%)
20 (57.1%)
Symptom length (weeks)

(median, IQR)
26.6 (22.3)
37.7 (28.8)
Centralizer
26 (74.3%)
25 (71.4%)
Non-centralizer with DP
9 (25.7%)
10 (28.6%)
Extension responders
30 (85.7%)
30 (85.7%)
Flexion responders
1(2.9%)
3 (8.6%)
Lateral responders
4 (11.4%)
2 (5.7%)
Patient generated forces
29 (82.9%)
25 (71.4%)
Therapist generated forces
6 (17.1%)
10 (29.6%)
Values are means (SD) or frequencies (percentages) unless otherwise denoted.

Abbreviations: DP = directional preference
27

Downloaded from www.jospt.org at University of Pennsylvania Library on May 14, 2016. For personal use only. No other uses without permis
TABLE 2. Mean values (standard deviations) for trunk muscle thickness change, function, perceived recovery and pain
Variable
McKenzie method
Motor control
exercises
Transversus abdominis (%)

Baseline (n=68)
Follow-up (n=62)
Change
19.28 (19.32)
21.53 (21.96)
2.25
22.80 (25.20)
19.74.(22.25)
-3.06
Obliquus internus (%)

Baseline (n=68)
Follow-up (n=62)
Change
8.38 (17.30)
7.50 (12.92)
-.88
Obliquus externus (%)

Baseline (n=68)
Follow-up (n=62)
Change
PSFS (3-30)
Baseline (n=69)
Follow-up (n=61)
Change
28
Between-group
p
difference (95% values
CI) from
regression
model adjusted
for baseline
values*
-5.8 (-15.2 to
3.7)
0.23
10.69 (20.22)
7.79 (12.22)
-2.90
-0.7 (-6.6 to 5.2)
0.82
5.90 (10.86)
3.21 (11.82)
-2.69
4.78 (11.77)
5.47 (11.41)
0.69
1.2 (-4.3 to 6.8)
0.65
12.32 (4.35)
22.88 (4.30)
10.56
11.31 (4.46)
21.24 (5.77)
9.93
-1.5 (-4.1 to 1.1)
0.26

Downloaded from www.jospt.org at University of Pennsylvania Library on May 14, 2016. For personal use only. No other uses without permis
GPE (-5-5)
Baseline (n=69)
Follow up (n=62)
Change
-0.8 (3.0)
3.5 (1.0)
4.3
-0.9 (2.4)
2.7 (1.7)
3.69
Pain (0-10)
Baseline (n=69)
Follow up (n=62)
Change
4.5 (2.2)
2.4 (2.2)
2.1
5.4 (2.0)
2.5 (2.4)
2.9
-0.8 (-1.5 to 0.1)
0.03
0.0 (-1.2 to 1.2)
0.99
* Positive between group differences represent greater change [improvement] in the motor control group compared to the
McKenzie group
Abbreviations: PSFS, Patient Specific Functional Scale; GPE, Global Perceived Effect; VAS, visual analogue scale.
Note: Transversus Abdominis, Obliquus Internus and Obliquus Externus data reflect relative change in muscle thickness from
resting to contracted state.
29
FIGURE 1. Trial flow chart

Patients consented (n=133)
Subjects excluded (n=63)

Non CEN Non DP (n=45)
Not classifiable (n=13)
History of spinal fracture (n=2)
Symptoms not of spinal origin (n=2)
Symptoms >3-months duration (n=1)
Participants randomized (n=70)
Participants allocated to the McKenzie method

(n=35)
Participants allocated to motor control

exercises (n=35)
Follow-up
8 weeks
Number of participants with available data for
analysis at follow-up (n=32)
30
Number of participants with available data for

analysis at follow-up (n=30)

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Journal of Orthopaedic & Sports Physical Therapy

A Randomized Controlled Trial Comparing the McKenzie Method to Motor

Journal of Orthopaedic & Sports Physical Therapy

A Randomized Controlled Trial Comparing the McKenzie Method to Motor

Journal of Orthopaedic & Sports Physical Therapy

STUDY DESIGN: Randomized clinical trial.

BACKGROUND: Motor control exercises are believed to improve co-ordination of

the trunk muscles. It is unclear if increases in trunk muscle thickness can be

facilitated by approaches such as the McKenzie method. Furthermore it is unclear if

either approach is superior regarding clinical outcomes.

METHODS: Seventy people with chronic LBP demonstrating a directional

preference using the McKenzie assessment were randomized to receive 12

outcomes were collected at baseline and at 8-week follow-up by blinded assessors.

thickness of the transversus abdominis [-5.8%, 95% CI -15.2 to 3.7], obliquus

1.5 to -0.1] on a -5 to +5 scale. No significant between-group differences were

found for pain or function [p= 0.99, 0.26, respectively].

CONCLUSION: We found no statistically significant effect for treatment group for

trunk muscle thickness. Participants reported a slightly greater sense of perceived

LEVEL OF EVIDENCE: Therapy, level 1b-

Journal of Orthopaedic & Sports Physical Therapy

Journal of Orthopaedic & Sports Physical Therapy

compared to healthy controls.(18) In Australia LBP is estimated to reduce gross

and promote independent management to reduce this burden.

control exercises, both of which are recommended by the American Physical

is no evidence to suggest that either approach is superior to other standard

therapies.(8,20,29,30,44) Currently, no study has compared the McKenzie method and

chronic LBP and a directional preference.(21)

Directional preference classification is characterized by a reduction in distal pain

and/or observation of the centralization phenomenon with the application of repeated

assessment.(3,35) Centralization is defined as a progressive change in pain from a

repeated or sustained end range movements to the spine.(35,54,56) Directional

preference is a hallmark characteristic of the McKenzie derangement

Journal of Orthopaedic & Sports Physical Therapy

Measurements of TrA thickness taken from ultrasound images have shown a

correlation with electromyographic recordings of recruitment of the TrA.(16) This

suggests that ultrasound is a valid measure of trunk muscle thickness. Some

and chronic LBP compared to healthy individuals.(10,16,27,38) However, others have

found considerable variance in size and recruitment of TrA in healthy

individuals.(32,49,50) There is some evidence that improvement in size and recruitment

general exercise or spinal manipulation.(14,17) However, increases in TrA and lumbar

exercises.(28,39) It is not known if the McKenzie method when applied to a population

movements of the spine.(21)

Journal of Orthopaedic & Sports Physical Therapy

to compare these approaches in terms of pain, function and patients perceived

CTRN12611000971932. The published protocol was established prior to public

collection.(21) All participants gave written informed consent prior to admission.

conducted in the Physiotherapy department of Concord Repatriation General

Hospital which is a major metropolitan public hospital in Sydney, Australia.

Participants: Consecutive presentations of people with a referral for treatment of

preference observed with a mechanical assessment based on the McKenzie

and or motor changes were also included.(21)

Journal of Orthopaedic & Sports Physical Therapy

Two experienced physiotherapists with formal training in the McKenzie method

conducted a mechanical assessment of the lumbar spine to identify a directional

preference. The assessment consisted of repeated or sustained end range loading

strategies in standing or lying postures, including therapist over pressure when

standing immediately before and again after the mechanical assessment. A

assessment diagram to the pre-assessment diagram centralization was considered

inter-rater reliability (ICC = 0.96).(54,55,56) Participants reporting no pain prior to the

mechanical assessment demonstrated centralization by producing pain on the first

better when re-evaluating the provocative movement. Participants who reported

Centralization was objectively measured by participants shading

a non-centralizer with a directional preference and were included.(21)