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Excerpt
In the systematic review on “Exercise Therapy for Low Back Pain” by van Tulder et al., 13 one of the authors’ conclusions is that there is a lack of RCT-evidence that flexion or extension exercises are effective in the treatment of acute low back pain (LBP). The analysis leading to this conclusion, however, needs further review.
A number of RCTS reviewed in this study state that McKenzie interventions were utilized. However, most made basic, faulty assumptions by equating McKenzie care with extension exercises, as though it was just the opposite of Williams’ flexion exercises. This is not an unusual misconception and it should then not be surprising if the van Tulder group unknowingly perpetuated this same inaccuracy.
If not extension exercises, what is “McKenzie”? Some background is essential at this point. It is first and foremost patient assessment, a fact unmistakably clear in McKenzie’s original 1981 text 11 and in the thousands of educational courses taught by the McKenzie Institute over many years. It is so clear that it is somewhat mystifying how so many researchers, and now systematic reviews, could have such an incomplete understanding.
The McKenzie assessment focuses on identifying reproducible, distinct patterns of immediate, patient-reported pain response when patients load their spine asymmetrically and repeatedly, i.e., repeated end-range flexion tests performed in both the standing position or supine (knees-to-chest). Other directions (extension, left, and right lateral-bending, sometimes left and right flexion-rotation) are similarly tested repeatedly to end-range in both loaded (upright) and unloaded (recumbent) positions until a positive or negative pain response occurs with each direction of testing.
One of the most common and meaningful patterns of pain response is “centralization,” defined as a patient’s referred or radiating pain (whether just slightly off the midline, into the buttock, or all the way to the toes) promptly reversing, returning to the center of the back, and then usually also abolishing. At least 10 peer-reviewed published studies have reported the high prevalence with which “centralization” occurs during this McKenzie assessment, 2–6,8,9,12,14,15 in 70%–80% of acute LBP assessments 5,8,12,14 and in 45%–50% of chronic LBP patients. 3,9 Of equal or greater importance, five of these studies then tracked treatment outcomes, all reporting that the outcomes of “centralizers” were superior to those in whom no direction of testing exposed this pain response, i.e., noncentralizers. 5,8,9,12,14 Furthermore, strong reliability of identifying centralization during patient assessment (kappa = 0.823) has been shown as well. 7
Consequently, Denmark’s recently published Back Pain Guidelines were the first to acknowledge that McKenzie assessment is different from McKenzie treatment, as well as assigning to McKenzie assessment their highest recognition of scientific support. 10 Their report states, “this method has value as both a diagnostic tool and a prognostic indicator...for both acute and chronic pain syndromes.”
Identifying this centralization response, or lack thereof, impacts clinical care in two important ways. First, as mentioned, is its predictive value. Centralization indicates that the underlying pain-generator is apparently reversible, usually rapidly so, independent of whether the patient’s pain is acute or chronic, or what diagnostic label has been previously applied. Second and more relevant to exercise therapy RCTs and the van Tulder review, centralization identifies whether or not there is a single direction of beneficial treatment strategy for that specific patient. Treatment for any single individual could therefore be flexion or extension, or right or left lateral or rotational end-range motion, or no specific direction at all.
In van Tulder’s review, every study but one 1claimed to use McKenzie methods but instead used extension exercises for everyone.
