The McKenzie method for (sub)acute non-specific low back pain

Key Points

1. The McKenzie method provides little to no benefit in pain and disability in people with (sub)acute non-specific low back pain in the short term (≤two weeks) and in the medium term (≤three months), when compared to an educational booklet about back pain.
2. The McKenzie method provides no benefit in pain and disability in people with (sub)acute non-specific low back pain in the short term (≤two weeks) and in the medium term (≤three months), when compared to spinal manipulation or spinal mobilisation.
3. The McKenzie method provides no benefit in pain and disability in people with (sub)acute non-specific low back pain in the short term (closest to two weeks) and in the intermediate term (closest to three months), when compared to massage or advice.

BACKGROUND & OBJECTIVE

The McKenzie Method is a very popular low back pain assessment and treatment method used by physiotherapists worldwide. The method is based on the idea that a patient's symptoms can be alleviated through specific exercises, postures, and movements (clinic and home based) that help to “centralize” pain and improve spinal movement. Like most physiotherapy assessment and treatment methods, the McKenzie method was implemented in clinical practice before any robust assessment of its effectiveness.

A well conducted systematic review recentlypublished in the Cochrane Library examined if the McKenzie method is effective for reducing pain and disability among people with subacute non-specific low back pain.

The McKenzie method was implemented in clinical practice before any robust assessment of its effectiveness.

The overall synthesis of evidence suggests that for low back pain the type of exercise is not important to the outcome.

METHODS

Study design: Systematic review of randomised controlled trials.

Population: Trials had to include adults with an episode of subacute non-specific low back pain, defined as pain lasting from six to shorter than 12 weeks' duration. Non-specific low back pain was defined as pain or discomfort between the lower ribs and the gluteal folds, with or without leg pain, where no specific structural pain driver can be identified.

Intervention: The McKenzie method. The method had to align with that described by the creator of the treatment (e.g. treatment protocol in line with the evaluation and classification, including repeated or sustained end‐range movements of the spine or postural education).

Comparisons: Minimal intervention – e.g waiting list control, placebo or inert controls, or both, brief educational interventions or booklets. Manual therapy – spinal manipulation, spinal mobilization or massage. Other exercise protocols excluding McKenzie method principles.

Outcomes: The major ones were pain intensity and back-specific disability

RESULTS

The review found five clinical trials. Two studies compared the McKenzie method to minimal intervention, three compared it to manual therapy, and one compared it to other interventions (massage and advice).

For McKenzie method versus minimal intervention, the review found that the McKenzie method may result in a slight reduction in pain and disability in the short term.

For McKenzie method versus manual therapy the review found that the McKenzie method may result in little to no effect on pain or disability.

For McKenzie method versus other interventions (back massage and advice) the review found little to no evidence that the McKenzie method reduces disability.

LIMITATIONS

The trials were quite small, leaving uncertainty in the estimates. However, a strength of the review is the focus on true McKenzie protocols. Other reviews of McKenzie have been quite liberal with their definition of McKenzie, muddying the waters of the conclusions.

CLINICAL IMPLICATIONS

• The McKenzie method – like many other physiotherapy approaches to back pain – is a good example of opinions being strongest where the evidence is weakest. The current evidence displays this treatment is not effective, but international courses are still in demand. The burden of proof is on the advocates to show it is effective.At present, it is not listed in clinical practice guidelines as a management option for low back pain. This will remain the same after this review. Physiotherapists should treat claims of effectiveness with scepticism.

• Physical activity and exercise are recommended for subacute and chronic pain and may help prevent recurrence. The overall synthesis of evidence suggests that for low back pain the type of exercise is not important to the outcome. Instead, we should focus our attentions on getting patients engaged with any exercise and building it up over time. Physiotherapists’ choice of exercise should be picked in accordance with patient preferences, goals, and functional limitations. We should not place barriers in the way of patients by recommending one specific exercise program – e.g McKenzie or any other specific regimen (1).

• Education should always play a role in the management of subacute low back pain (2). This could include information about prognosis, risk factors,prevention and self-management strategies.

+STUDY REFERENCE

AlmeidaM, Garcia A, Costa L, van Tulder M, Lin C and MachadoL (2023) The McKenzie method for (sub) acute non‐specific low back pain. Cochrane Database of Systematic Reviews, (4).

SUPPORTING REFERENCE

1. O’Keeffe M, Maher CG, O’Sullivan K. Unlocking the potential of physical activity for back health. British Journal of Sports Medicine. 2017 May 1;51(10):760-1.
2. Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008 Jan 23;2008(1):CD004057.