Henry,

You: "[W]e haven't even got into the theory of the McKenzie model"
Me: The McKenzie model consists of the disc derangement submodel, the
"dysfunction" submodel (the [awkward] McKenzie term for a shortening or
tightening or being immobile of tissues or structures), the SIJ submodel
(diagnosed -- after the regular assessment procedure has not centralized or
peripheralized the pain -- through provocation tests, not palpatory position
or palpatory mobility tests), and a number of other submodels. It is
therefore extremely tricky to speak of "the McKenzie model", and it is plain
wrong to think that the McKenzie model equals the disc derangement model.

You: "I better get Donelson's article out again and have a good read.
But from memory, they compared it to
discograms and there is questions surrounding the
reliability of discography in diagnosing symptomatic discs."
Me: Discography is (indeed) not without doubt when it comes to validity (I
haven't read anything about it not being reproducible enough, though). There
indeed seems to be conflicting evidence. However, Donelson et al used the
exact same gold standard for both the McKenzie assessment <and> MRI. In
other words: the validity of (part of) the assessment versus that of MRI was
judged with the exact same criteria.

You: "Based on what I have read so far, nothing has been shown to be more
effective in terms of managing back pain with or without radicular signs."
Me: "Nothing" is not true. Without having the time to do a more thorough
search, what was found in a (very) recent systematic literature review is
that the efficacy of spinal manipulative therapy alone, when applied to
chronic LBP patients without prior McKenzie assessment is at least
doubtful, if not ineffective (1).


You: "[A] meta-analysis of clinical trials on the efficacy of the McKenzie
Physiotherapy regime presented at the MPAA conference in 1997
has not shown it to be a superior treatment compared to other
therapies."
Me: As you yourself stated: "[A]n absence of evidence does not equal
evidence of absence." And that's especially correct when it
comes to the McKenzie method:
it's hard for an algorithmical method consisting of a dozen or so submethods
to be proven superior if hardly any studies are done that studied the method
as a whole. Up to 1996 (reviews usually take a number of
months to be completed) hardly any studies were done at all, and if there
were, they were not of sufficiently high quality to meet the demands of
systematic literature reviewers. Also, many researchers make the mistake of
thinking McKenzie-method therapy equals passive-extension exercises, as John
(Dufton) again demonstrated. I'll explain it once more, since you (too)
seemingly haven't understood the essence of the method yet: the McKenzie
method consists of specific exercises (<not!> limited to extension),
postural education & aids, mobilization (also of neural tissues),
manipulation, traction in select cases, and in other select cases medication
(the assessment can also come to the conclusion that the pain is primarily
chemically induced in stead of primarily mechanically) and referral for
surgical consultation. The assessment outcome shows What To Do When (and as
is already common practice among experienced McKenzie clinicians, if one is
not sure, one goes with the most probable, and sees what that does over a
three or so days).

You: "I am sure we all have come across studies by Cherkin et al (1998) that
showed no difference between Mckenzie Physiotherapy, chiropractice
manipulations and educational booklet."
Me: Cherkin et al used patients with rather light and primarily (sub-)acute,
non-radiating back, complaints. I doubt that that is a very good group to do
research with, since those patients often heal within a matter of weeks. The
McKenzie method usually appeals to a great deal of self activity by the
patient. Also, they divided them into 3 treatment groups: chiropractic, and
educational booklet and McKenzie-method PT. All three methods (I assume that
they did not use the few remaining chiropractors who think that with <just>
a few simple corrections of a "subluxation" things are solved) contain
advice on posture, in which the lumbar support plays an important role.
Whether the lumbar support was invented by McKenzie I'm not sure of, but it
is surely popular now (look at the design of the seats of modern cars versus
that of old cars, and the design of modern office seats verus old).
Furthermore, significantly more patients from the non-McKenzie group
consumed additional health care than the McKenzie group did, in Cherkin et
al's study, which was not corrected for in the (intention-to-treat)
analysis. All in all, I'm not at all sure that McKenzie-method PT will
do a much better job than chiropractic or an educational booklet, when it
comes to cost-efficacy in simple, (sub-)acute LBP, but I <am> sure that one
should not regard Cherkin's study as <the> study that shows the (relative)
efficacy of McKenzie-method PT, when it comes to LBP in general (acute,
subacute and chronic).

You: "Hsieh et al (Spine, 11 p 1142, 2002) did a study looking at the
effectiveness of four conservative treatments (back school, joint
manipulation, myofascial therapy and combined joint manip/myofascial
therapy) in subacute low back pain. All four treatments were as effective."
Me: Like I said, I'm not sure about the McKenzie method in simple,
(sub)acute LBP, but Stankovic & Johnell, measuring up to 12 months, still
found McKenzie-method PT superior in five out of seven main variables to
"mini back school" (2), even though at five years the differences had become
much smaller.


You (Jull & Moore): "the clinical challenge is to have expertise in a
variety of approaches and to be able to select which patient is responsive
to which approaches for most expedient and effective treatment".
Me: Exactly!! That's why -- as a biomedical approach, although it could even
turn out to already cater for important aspects of the behavioural variables
as well -- I favour the McKenzie (algorithmical) method over methods that
are limited to neural mobilization or manual mobilization/manipulation, and
over methods that give the patient a dozen exercises in the hope that the
really effective one(s) will be among them, as is practice in quite a lot of
back-rehabilitation/fitness centres. (See also my reply to Sam's message
when it comes to behavioural methods.)



References:
1. Ferreira M et al, Does spinal manipulative therapy help people with
chronic low back pain? Aust J Physiother 2002;48(4):277-84.
2. Stankovic R, Johnell O, Conservative treatment of acute low-back pain. A
prospective randomized trial: McKenzie method of treatment versus patient
education in "mini back school". Spine 1990 Feb;15(2):120-3.


R.,
Frank



----- Oorspronkelijk bericht -----
Van: Henry Tsao
Aan: [log in to unmask]
Verzonden: zondag 26 januari 2003 4:14
Onderwerp: Re: LBP & neuro signs dilemma


Ben,

Please let us know what you did with the patient and his progress.

Frank and Sam,

Very interesting debate about McKenzie Physiotherapy and diagnosis... and
we haven't even got into the theory of the McKenzie model. I better get
Donelson's article out again and have a good read. But from memory, they
compared it to discograms and there is questions surrounding the
reliability of discography in diagnosing symptomatic discs.

Based on what I have read so far, nothing has been shown to be more
effective in terms of managing back pain with or without radicular signs.
I am sure we all have come across studies by Cherkin et al (1998) that
showed no difference between Mckenzie Physiotherapy, chiropractice
manipulations and educational booklet. As well, a meta-analysis of
clinical trials on the efficacy of the McKenzie Physiotherapy regime
presented at the MPAA conference in 1997 has not shown it to be a superior
treatment compared to other therapies. Acknowledging the limitions and
restrictions on these and other studies, it does point towards the
question: are manipulative therapy approaches the same? What is the common
denominator.

Hsieh et al (Spine, 11 p 1142, 2002) did a study looking at the
effectiveness of four conservative treatments (back school, joint
manipulation, myofascial therapy and combined joint manip/myofascial
therapy) in subacute low back pain. All four treatments were as effective.

To quote Jull and Moore (Manual Therapy 7(2) p63, 2002):

"The arguments of the superiority of one approach or another seem
redundant. The question we should be asking clinically and in research is
how one technique might stiumulate the central nervous system differently
to another.... the clinical challenge is to have expertise in a variety of
approaches and to be able to select which patient is responsive to which
approaches for most expedient and effective treatment."

Henry***