McKenzie treatment for acute back pain added to first-line care does not result in appreciable clinical improvements.
Summary of: Machado LAC et al (2010) The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial BMC Medicine 8: 10. [Prepared by Julia Hush, CAP Editor.]
Question: Does the addition of McKenzie treatment to first-line care improve symptoms and function for patients with acute low back pain? Design: A randomised controlled trial with concealed allocation and blinded outcome assessment Setting: 27 primary care medical practices in Sydney, Australia. Participants: Patients aged between 18 to 80 years seeking medical care from a primary care physician for a new episode of acute nonspecific low back pain. Nerve root compromise, serious spinal pathology, and recent spinal surgery were exclusion criteria. Randomisation of 148 participants allotted 73 to the McKenzie treatment and first-line care group, and 73 to a first-line care only group. Interventions: Both groups received the following recommended first-line care for acute low back pain: advice to remain active and avoid bed rest, reassurance of a favourable prognosis and instructions to take paracetamol. In addition, the intervention group received McKenzie therapy, commenced within 48 h of their physician consultation. Treatment was provided by 15 accredited McKenzie therapists. Treatment for most patients encouraged directions of movement and postures that centralised pain. Patients received up to 6 treatment sessions over 3 weeks. They were provided with the book Treat Your Own Back, prescribed home exercises, and most were prescribed lumbar rolls. Outcome measures: Primary outcomes were pain and global perceived effect. Pain was measured during the first 7 days, and at Weeks 1 and 3, with the Numerical Rating Scale scored from 0 (no pain) to 10 (worst pain possible), with a between-group difference of 1 unit considered clinically important. Patient-rated global perceived effect was assessed at 3 weeks on a -5 to 5 scale, anchored at 'vastly worse' and 'completely recovered.' Secondary outcome measures were disability, function, global perceived effect at 1 week, persistent low back pain at 3 months, and use of additional health care services. Results: 138 participants provided data at 3 months. At Week 1, pain was less in the McKenzie treatment group by 0.4 points (95% CI -0.1 to -0.8). At Week 3, pain was less in the McKenzie treatment group by 0.7 points (95% CI -1.2 to -0.1). The groups did not differ on other outcomes. However, patients receiving McKenzie treatment sought less additional health care than those receiving only firstline care (p = 0.002). Conclusion: When added to the recommended first-line care of acute low back pain, a McKenzie treatment program did not produce clinically significant additional short-term improvements in pain, disability, function or global perceived effect but resulted in patients seeking less additional health care.
Despite evidence that exercise therapy is of limited value for patients with acute low back pain (pain of less than 6 weeks) (Hayden et al 2005, Chou et al 2007), many physiotherapists continue to use treatment approaches that incorporate exercise. This trial investigated whether shortterm pain outcomes were improved by adding McKenzie treatment to recommended first-line care for patients with acute low back pain.
The trial has many merits, including the attention to working with highly trained McKenzie therapists to deliver the intervention, the blinded outcome assessments, the high follow-up rates, the attention to the measurement of adherence to the McKenzie exercise program, and recruitment of patients consulting their family doctor about their low back pain. The results show small but statistically significant differences in pain at 1 and 3 weeks, the clinical importance of which the research team quite appropriately question. Their pre-set level of difference between groups was a difference of 1 (on a 0 to 10 scale of pain) and the differences they saw (0.4 and 0.7 at 1 and 3 weeks respectively) were smaller than this. Overall, the trial concludes that a treatment program based on the McKenzie method does not produce clinically important short-term improvements in pain but it did seem to reduce health care use in the follow-up period through to 3 months.
Given that we know the course of low back pain tends to follow a recurrent pattern (Dunn et al 2006), it is a pity that this trial stopped follow-up at only 3 months. It could be hypothesised that many of the 148 patients recruited will proceed to future recurrences and, for some, long term persistence. One might argue that patients treated with the McKenzie approach to self-management might be equipped to manage their own low back pain. This is partially supported by the short-term data on lower health care use in the group receiving the McKenzie intervention in this trial. Future trials of the McKenzie approach could usefully incorporate longer-term data collection with robust health economic analyses.
This trial encourages us to think about which patients with back pain we target with which treatments. The results suggest there seems little point in providing McKenzie treatment to all patients with acute low back pain seeking primary care, and thus there is a need to better identify those patients who would benefit most from treatment options.
Chou et al (2007) Ann Inter Med 147: 478-491.
Dunn et al (2006) Am J Epidemiol 163:754-761.
Hayden et al (2005) Ann Inter Med 142: 765-775.
Arthritis Research UK Primary Care Centre, Keele