John,

Thanks for coming up with evidence, and lifting this discussion (further)
up. [Of course I would not be so grateful if I wouldn't have something
substantial in response to your message. :-)))]

Concerning the reliability of the McKenzie assessment, Riddle & Rothstein
(1) indeed found a dramatically low reliability. Now, I think reliability
studies should be done with <credentialled> McKenzie therapists only,
because "postgraduate training" can mean that the respective therapists had
done only part A, and while virtually sleeping (remember that no tests are
taken after the separate parts). But let's leave that out, and let's assume
that Riddle & Rothstein's study was a high-quality study with respect to
design (I don't have the full text here, so I don't know for sure, but I'll
fully go along with the abstract-mentioned results for now).

Riddle later took part in another study (2) on the reliability of the
McKenzie assessment, in which it was suggested that the previously found
unreliability could well be due to the way in which a lateral component was
determined. They found: "The kappa value for [just visual] determinations of
the presence and direction of lateral shifts was .00, indicating very poor
reliability. The kappa value for the determination of the presence of a
positive side-glide test sequence was .74, indicating high reliability. The
role of lateral shift assessment in the McKenzie system should be
reconsidered". In pain English: there's a chance the reliability of the
McKenzie assessment improves if the visual determination of the (relevance
of the) latshift is replaced with the side-gliding test.

Now, the absence or presence of a lateral component determines whether a
derangement syndrome should be called D3 versus D4, or D5 versus D6, so this
is important when it comes to the (non-weighted) kappa value, which as you
know determines the reliability. (With, for those who don't know,  - 1 =
couldn't be worse, 0 = as good as, but no better than, flipping a coin, and
1 = perfect.)

With the results of the latter study being available, a number of other
(independent) teams again looked at the reliability. Fritz et al (3) found:
"Interrater reliability was excellent for the total sample of examiners
(kappa = .793)"; Razmjou et al (4) found: "Intertester agreement on syndrome
categories in 17 patients under 55 years of age was excellent, with kappa =
1.00", using "physical therapists trained in the McKenzie evaluation
system"; Kilpikoski et al (5) found: "When patients with low back pain were
classified into the McKenzie main syndromes and into specific subgroups,
agreement was 95% (kappa = 0.6; P < 0.000) and 74% (kappa = 0.7; P < 0.000),
respectively [...] when the examiners had been trained in the McKenzie
method." Note that even the most critical statisticians (as I am) regard a
kappa value of 0.6 as clinically sufficient. Most think a kappa of 0.4 is
sufficient, but I disagree because that depends on the circumstances.

You decide, John, on the conclusion when it comes to the reliability of the
McKenzie assessment, given that the visual determination of the (relevance
of the) latshift has been replaced with the side-gliding test. What is clear
in my view, is that its reliability by far exceeds that of manually
determining the mobility of segments, which has even been denounced by a
number of chiropractors (6). (Some chiropractic colleges nowadays even teach
that that is unreliable, and you know how reluctant they can be to
incorporate that sort of evidence, since their diagnosis largely depends on
it.) Why I mention this is that Henry still seems to live in the stone age,
with all due respect.

Then, when it comes to the Cochrane review: that's an invalid review when it
comes to determening the efficacy of the McKenzie method. It looked at
whether extension OR flexion exercises are more efficacious in LBP. Whether
the LBP was acute, subacute or chronic, and whether with or without
radiation. Why is that invalid? That's simple. If a McKenzie-trained
therapist finds that the patient is a flexion-responder, s/he won't give
extension exercises, but flexion exercises. Is that relevant in terms of
percentages? Yes, it is. Donelson et al (7) found that "Forty percent of
individual subjects had a clear preference for extension and 7% a clear
preference for flexion", with "preference" meaning "centraliz[ing] referred
pain". Now, Donelson et al limited the results to <immediate>, one-session
outcomes. That can be important, since Werneke & Hart (8) found that
judgement of the preference over several treatments was more valid than
immediate judgement (they sent the patients home with the exercises most
probable to centralize the pain). This would mean that 80% of patients would
be extension-responders, but 14% flexion-responders. Give 14% of a study
cohort the opposite exercise as that one should give, and the results will
change significantly (28%).

And if one has a patient load with a high average age, it certainly is! The
higher the average age of one's patient load, the greater the percentage of
patients will be that will <worsen> with extension, due to the higher
prevalence of bony stenosis and/or facet arthrosis at higher age.

Finally, one could ask: "Well, that's nice, but you yourself wrote that
extension exercises (after checking the side-gliding) plus the 'SS & SL &
SR' advice plus static strengthening of the extensors will probably be
(cost-)efficacious in first-time, acute LBP (9). So, why would that be if a
significant percentage of acute LBP patients are not extension-responders?".
The reason is threefold:

1. In the studies using real first-time acute LBP patients, they did improve
substantially with extension exercises, over the control groups.
2. The randomization in Malmivaraa et al's study (10) was problematic: as
Table 1 of the full text shows, 52% of the exercise group had had back
symptoms in the previous 12 months for more than 30 days, while only 22% of
the control group had had that (27/52 versus 15/67). So, the study did not
(evenly) use real, first-time, acute LBP sufferers: the exercise group was
significantly worse at baseline.
3. I advocate strengthening exercises additional to the extension exercises.
The strenghtening exercise have been proven to be highly efficacious (11).

With respect to the latter topic, the McKenzie method has not incorporated
it officially yet, due to lack of comparative evidence when it comes
McKenzie with and McKenzie without strengthening. But that does not mean the
institute is not open to the idea: during the Orlando McKenzie Conference
2001, there were several presentations about the probable positive effects
of strengthening. And it can be incorporated perfectly: in
extension-responders exercises to strengthen the extensors, in
flexion-responders strengthen the flexors. The lateral flexors will probably
be sufficiently co-strengthened in both cases.

But let's not get distracted: it's about Ben's patient. You say: "If you are
concerned of permanent neurological loss i would make the appropriate
surgical referral.". I say: Donelson et al found that the McKenzie
assessment (which includes neuro-tests) more validly determined the discal
integrity that MRI did. Send the patient to a credentialled McKenzie
therapist.


References:
1. Riddle DL, Rothstein JM, Intertester reliability of McKenzie's
classifications of the syndrome types present in patients with low back
pain. Spine 1993 Aug;18(10):1333-44.
2. Donahue MS, Riddle DL, Sullivan MS, Intertester reliability of a modified
version of McKenzie's lateral shift assessments obtained on patients with
low back pain. Phys Ther 1996 Jul;76(7):706-16.
3. Fritz JM, Delitto A, Vignovic M, Busse RG, Interrater reliability of
judgments of the centralization phenomenon and status change during movement
testing in patients with low back pain. Arch Phys Med Rehabil 2000
Jan;81(1):57-61.
4. Razmjou H et al, Intertester reliability of the McKenzie evaluation in
assessing patients with mechanical low-back pain.
J Orthop Sports Phys Ther 2000 Jul;30(7):368-83.
5. Kilpikoski S et al, Interexaminer reliability of low back pain assessment
using the McKenzie method. Spine 2002 Apr 15;27(8):E207-14.
6. Harrison DE et al, A normal spinal position: It's time to accept the
evidence. Journal of Manipulative and Physiological Therapeutics 2000;
23(9): 623-644.
7. Donelson R et al, Pain response to sagittal end-range spinal motion. A
prospective, randomized, multicentered trial.
Spine 1991 Jun;16(6 Suppl):S206-12.
8. Werneke M, Hart DL, Discriminant Validity and Relative Precision for
Classifying Patients With Nonspecific Neck and Back Pain by Anatomic Pain
Patterns. Spine 2003; 28(2):161-166.
9. Conijn FJJ, Acute LBP: The basic substrate of most cases has finally been
proven!. Physical Therapist's Literature Update 2001; Editorial June (freely
available: www.ptlitup.com | Archive & Search | Editorial June 2001 [&
Editorial January 2002]).
10. Malmivaara A et al, The treatment of acute low back pain--bed rest,
exercises, or ordinary activity? N Engl J Med 1995 Feb 9;332(6):351-5.
11. Hides JA et al, Long-term effects of specific stabilizing exercises for
first-episode low back pain. Spine 2001 Jun 1;26(11):E243-8.

R.,
Frank

F.J.J. Conijn, PT
Editor, Physical Therapist's Literature Update
The Internet Journal of Updates for Clinicians in Non-Operative Orthopaedic
Medicine
www.ptlitup.com


----- Oorspronkelijk bericht -----
Van: John Dufton
Aan: [log in to unmask]
Verzonden: zaterdag 25 januari 2003 1:18
Onderwerp: Re: LBP & neuro signs dilemma


perhaps a certified mckenzie therapist(or at least one that has postgraduate
training) may not be necessary, considering reference and abstract below.

Riddle DL. Rothstein JM. Intertester reliability of McKenzie's
classifications of the syndrome types present in patients with low back
pain.[comment]. [Journal Article. Multicenter Study] Spine. 18(10):1333-44,
1993 Aug.

Abstract
The McKenzie system for examining and treating patients with low back pain
is frequently used by clinicians. The primary purpose of this multicenter
study was to determine the intertester reliability of assessments of
patients with low back pain when physical therapists used the McKenzie
method. A second purpose was to determine if previous postgraduate training
in the McKenzie system affects reliability. Some therapists had previously
undertaken postgraduate training in the McKenzie system. All therapists were
given written descriptions of the McKenzie method and the criteria used to
classify patients. Classifications were made on 363 patients with low back
pain by randomly paired physical therapists in eight clinics. The Kappa
value on agreement of patient classification was 0.26, which suggests poor
reliability. Therapists agreed on which syndrome was present 39% of the
time. Previous postgraduate training did not improve reliability. The
results suggest that assessments of the syndrome present in patients with
low back pain appear to be unreliable when using the McKenzie system.

In addition, the cochrane evalution of this method did not turn out too
favourable. Other that stating it may be better than flexion exercises with
those with prolapsed iv discs. (portion of cochrane review below)

Tulder MW, van. Malmivaara, A. Esmail, R. Koes, BW. Exercise therapy for low
back pain. [Systematic Review] Cochrane Back Group Cochrane Database of
Systematic Reviews. Issue 4, 2002.

3.1.2 Extension exercises.

Four studies in 684 acute low back pain patients compared extension
exercises to an active or inactive treatment; 2 high quality (Cherkin et al
1998; Malmivaara et al 1995) and 2 low quality studies (Stankovic & Johnell
1990, 1995; Underwood & Morgan 1998). The two high quality studies showed
that extension exercises were not significantly different from chiropractic
and an educational booklet with regard to bothersomeness of symptoms or
functional status (Cherkin et al 1998), and that extension exercises were
significantly less effective compared to ordinary activity on pain,
functional status and return to work (Malmivaara et al 1995). Therefore,
there is strong evidence (level 1) that extension exercises are not
effective in the treatment of acute low back pain.

3.1.3 Flexion versus extension exercises.

Two small studies in 86 acute low back pain patients compared flexion to
extension exercises (Delitto et al 1993; Nwuga & Nwuga 1985). One of these
studies was considered high quality and reported a significantly larger
decrease of pain with extension exercises compared with flexion exercises in
patients with prolapsed intervetebral discs (Nwuga & Nwuga 1985). The other
study was of low quality and reported a better improvement regarding
functional status with extension exercises in patients with and without
sciatica (Delitto et al 1993). Therefore, there is moderate evidence (level
2) that extension exercises are more effective than flexion exercises.

3.2 Chronic low back pain (more than 12 weeks).

3.2.1 Flexion exercises.

As no RCTs were identified comparing flexion exercises with active or
inactive treatments, there is no evidence (level 4) on the effectiveness of
flexion exercises for chronic low back pain.

3.2.2 Extension exercises.

As no RCTs were identified comparing flexion exercises with active or
inactive treatments, there is no evidence (level 4) on the effectiveness of
extension exercises for chronic low back pain.

3.3.3 Flexion versus extension exercises.

Three small low quality studies in 153 chronic low back pain patients
compared extension to flexion exercises (Buswell 1982; Elnaggar et al 1991;
Kendall & Jenkins 1968). Two studies reported no differences in pain
intensity (Buswell 1982; Elnaggar et al 1991), while one study reported a
better global improvement with flexion exercises (Kendall & Jenkins 1968).
Therefore, there is conflicting evidence (level 3) about which type of
exercise, extension or flexion exercises, is more effective for chronic low
back pain.

If you are concerned of permanent neurological loss i would make the
appropriate surgical referral.  if you are not manage with some type of
conservative therapy, of which mckenzie seems to be one option.

cheers,
john dufton






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