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Effect of Mckenzie Therapy and Lumbar strengthening program in Lumabr Spine Derangement Syndrme

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EFFECT OF MCKENZIE THERAPY AND LUMBAR STRENGTHENING PROGRAM IN
LUMBAR SPINE DERANGEMENT SYNDROME 1.
Gopal Nambi Subash Chandra Bose1* and Divya Gohill2
*1Asst. Professor, Dept of Physical Therapy and Rehabilitation, College of Applied Medical Sciences, Prince Sattam
Bin Abdul Aziz University, Al-Kharj, Saudi Arabia.
2Asst. Professor, Dr. D.Y Patil College of Physiotherapy, D.y Patil Vidyapeeth, Pimpri, Pune, India.
Article Received on 27/12/2017 Article Revised on 17/01/2018 Article Accepted on 07/02/2018
INTRODUCTION
Low back pain (LBP) is a condition that continues to
place a great deal of stress on the healthcare systems of
industrialized societies. Low back pain affects
approximately 80% of individuals and represents the
most common reason of activity limitation in individuals
under 45 years of age.[1]
About two thirds of adults suffer from low back pain at
some time. Low back pain is second to upper respiratory
problems as a symptom-related reason for visits to a
physician. There are wide variations in care, a fact that
suggests there is professional uncertainty about the
optimal approach.[2]
Among such disciplines McKenzie is one of the methods
to classify low back pain.[7, 8] The McKenzie method
exists of 3 steps: evaluation, treatment and prevention.
The symptoms of the lower limbs and lower back are
classified into 3 subgroups: derangement syndrome,
dysfunction syndrome and postural syndrome.[3]
Derangement classification is the most common
syndrome that presents clinically. Derangement
syndrome is the situation in which the normal resting
position of the articular surfaces of two adjacent vertebra
is disturbed as a result of change in the position of the
fluid nucleus between these surfaces.[4]
In the lumbar spine, if in no other area, disturbance of the
intervertebral disc mechanism is responsible for the
production of symptoms in as many as ninety-five
percent of patients with LBP & patients with low back
pain caused by derangement are commonly between
twenty and fifty-five years of age.[5] In derangement
syndrome 1, due to minor posterior migration of the
nucleus and its invasion of a small radial fissure in the
inner annulus, there is a minimal disturbance of disc
material. This causes mechanical deformation of
structures posteriorly within and about the disc, resulting
in central or symmetrical low back pain.[5]
SJIF Impact Factor 4.897
Research Article
ISSN 2394-3211
EJPMR
EUROPEAN JOURNAL OF PHARMACEUTICAL
AND MEDICAL RESEARCH
www.ejpmr.com
ejpmr, 2018,5(3), 160-164
*Corresponding Author: Gopal Nambi Subash Chandra Bose
Asst. Professor, Dept of Physical Therapy and Rehabilitation, College of Applied Medical Sciences, Prince Sattam Bin Abdul Aziz University,
Al-Kharj, Saudi Arabia.
ABSTRACT
Introduction: Low back pain affects approximately 80% of individuals, and represents the most common reason
of activity limitation in individuals less than 45 years of age. Objective: To determine the efficacy of a Lumbar
Strengthening Program in Lumbar Spine Derangement Syndrome 1. Methods: In a 2-week intervention study, 40
patients with lumbar spine derangement syndrome-1 were studied. Patients were randomly divided in two Groups:
Group-A (n=20) who were given McKenzie exercises; Group-B (n=20) performed the McKenzie exercises &
performed Resistance Training for the Lumbar Extensors. Both groups were submitted to two consecutive weeks of
treatment consisting of six times weekly. A Visual Analogue scale (VAS), Modified Oswestry Back Pain Disability
Questionnaire (MOQ) was administered at pretest and posttest. Wilcoxon signed ranks test was used for the
comparison between the pre and posttest values within Group A and Group B. Mann Whitney U test was used for
comparison between the posttest values of two groups. Results: A significant reduction in the pain intensity
(p<0.05), and increase in the functionality (p< 0.05) between pre & post treatment stages in both groups were
found. Both groups showed significant differences as to the pre & post treatment stages in the McKenzie therapy
and Resistance training for the Lumbar Extensor Muscle exercises, wherein Group B showed a more significant
improvement when compared to Group A. Conclusion: McKenzie therapy with resistance training for lumbar
extensors muscles produced a significantly greater decline in the pain intensity and improvement in function, when
compared to Mckenzie exercises alone.
KEYWORDS: Lumbar spine derangement syndrome 1, McKenzie therapy, Visual analog scale, Modified
oswestry low back pain disability questionnaire.
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A systematic review by Machado LAC et al. with a
meta-analysis approach spine on The McKenzie method
for low back pain concluded that there is evidence that
the McKenzie method is more effective than passive
therapies for acute back pain.[6] A systematic review by
Helen A Clare et al on efficacy of McKenzie therapy for
spinal pain concluded that for low back pain patients
(Postural, Dysfunction & Derangement syndromes)
McKenzie therapy does result in a greater decrease in
pain and disability in the short term than do other
standard therapies.[7]
Chronic low back pain is most often related to
insufficient muscle strength and deconditioning.[8]
Although some of these factors may have lead to a
development of LBP, the consensus is that these factors
arise as a consequence of the pain, associated inactivity
and the subsequent onset of the disease process.[9]
A study by Sherry V. R et al. on lumbar strengthening in
chronic low back pain patients examining the effect of
exercise for isolated lumbar extensors muscles have
concluded that lumbar extension exercise is beneficial
for strengthening the lumbar extensors and results in
decreased pain and perception of physical and
psychological functioning in chronic low back pain
patients.[10]
A study by Chidozie E. Mbada, Olusola Ayanniyi,
Samuel O. Ogunlade on examining the effect of static
and dynamic back extensor muscles exercise on pain
intensity, activity limitation and participation restriction
in patients with long-term mechanical low-back pain
treated with the McKenzie Protocol (MP) had concluded
that McKenzie protocol as well as the addition of static
or dynamic back extensors exercises are effective & thus
recommended in reducing pain and disability in patients
with long-term mechanical low-back pain & that
McKenzie protocol plus dynamic back extensors
exercise resulted in better decrease in participation
restriction.[11]
Conflicting results were demonstrated by Brian E.
Udermann et al, to evaluate the effect of McKenzie
therapy combined with resistance training for the lumbar
extensors (RTLE) on pain, disability, and psychosocial
functioning in CLBP patients where participants in one
group received McKenzie therapy combined with RTLE,
and the other group received McKenzie therapy only
concluded that McKenzie therapy is effective at
improving physiological as well as psychosocial
variables in CLBP patients, but the addition of RTLE, at
the level prescribed for this investigation, provided no
added benefit.[12]
This effort of mine is to determine whether the inclusion
of a strengthening program for the lumbar extensor
muscles along with McKenzie therapy program is
effective in the management of low back pain & thereby
yield best results & greater benefits for the population.
METHODS
A Quasi experimental study involving 40 patients with
lumbar spine derangement syndrome1 was conducted,
The participants were attending the outpatient
physiotherapy department of the college, C.U.Shah
physiotherapy college, Surendranagar, Gujarat, India
respectively. Inclusion criteria for this study were as
follows: Patients fulfilling the criteria according to the
McKenzie lumbar spine assessment, Patients with
Derangement syndrome 1, (central or symmetrical pain
across L4/5, rarely buttock or thigh pain, no deformity),
Chronic low back pain (>3months), Age: 20- 55 year and
other than this features excluded from the study.
The data was collected by assessing the patients.
Subjects, who fulfilled the selection criteria, were
informed about the study and requested to sign written
informed consent forms. Experiments were conducted on
20 patients in Group A and on 20 patients in Group B.
All the subjects completed a detailed orthopedic,
McKenzie lumbar spine assessment.
Randomization into groups was achieved through
odd/even assignment: the first patient was assigned to
Group A, the second patient was assigned to Group B,
the third patient was assigned to Group A, the fourth
patient was assigned to Group B, and so forth through
the 39th being assigned to Group A and the 40th patient
being assigned to Group B. Group A was given
McKenzie therapy. Group B was given lumbar extensor
muscles strengthening program along with McKenzie
therapy.
Each patient was evaluated prior to the first session, after
every week of treatment and after the last session, for:
Pain: Pain was assessed by the Visual Analogue Scale
(VAS) ranging from 0 to 10 cm. Function: Functional
ability was assessed using the Modified Oswestry low
back pain disability questionnaire.
Group- A (McKenzie therapy) (EIL- Extension in lying,
EIS Extension in sitting, FIL- Flexion in lying, FIS
Flexion in sitting).
Typical treatment progression as for Derangement
Syndrome 1;
- lying prone followed by lying prone in extension
followed by 5 6 sets of EIL
For maintenance of reduction of the posterior
derangement,
- If the patients were improving, EIL was replaced with
EIS whenever necessary.
- If there was no improvement, the following progression
was applied.
Progression 1
Extension mobilization combined at intervals with,
rotation mobilization in extension were applied (in
affected segment, the segment above & below),
immediately followed by, Extension in Lying. If
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improvement occurred, progression 1 was repeated. If
there was no improvement following 24 hours of
application of progression1, progression 2 was applied.
Progression 2
Extension mobilization applied to each of the appropriate
segments. After 10 repetitions, continuous pressure was
maintained at the affected level, & the patient was asked
to perform EIL. The patients were instructed to continue
lying prone, lying prone in extension. If the progress was
satisfactory, the same program was continued. If there
was no improvement, progression 3 was applied.
Progression 3
Extension mobilization, Rotation mobilization in
extension was applied to relax patient & to provide with
pre-manipulative information. Once centralization
occurred, self-treatment program as on day 1 was
followed. Once pain free for three days, EIL was reduced
to 3times/day and replaced by EIS whenever necessary
during the day.
Since the function to be restored in patients with lumbar
derangement syndrome 1 is flexion, flexion procedures
were begun. Once the patients condition proved stable,
FIL was gradually increased. When no further gain was
obtained with FIL, progression to FIS day was done,
always followed by, EIL. Patients were instructed to
discontinue FIS, when full flexion was recovered. &
continue, EIL, FIL, EIS, The patients were treated &
were not permitted to obtain any other forms of manual
therapy, electrotherapy, or other technique (e.g.
analgesics, acupuncture, injection therapy, or taping)
during the intervention period other than the designated
protocol. All the patients were able to complete the 2
weeks treatment program.
Group- B (McKenzie therapy + Lumbar extensor
muscles strengthening program).
The participants began the exercise training program
with the first exercise position and progressed to the next
exercises at their own pace when they could hold a given
position for 10 seconds. On reaching the fifth
progression, they continued with the fifth progression
until the end of the exercise program.
The five exercise progressions
1. Participant was instructed to lie in the prone position
with both arms by the sides of the body and lifted the
head and trunk off the plinth from neutral to extension.
2. Participant lay in prone position with the hands
interlocked at the occiput so that shoulders were
abducted to 90° and the elbows flexed, and lifted the
head and trunk off the plinth from neutral to extension.
3. Participant lay in prone position with both arms
elevated forwards, and lifted the head, trunk and elevate
arms off the plinth from neutral to extension.
4. Participant lay in prone position and lifted the head,
trunk and contralateral arm and leg off the plinth from
neutral to extension.
5. Participant lay in prone position with both shoulders
abducted and elbows flexed to 90°, and lifted the head,
trunk and both legs (with knees extended) off the
plinth44.
Dosage: 10 repetitions for static hold in each exercise
position for 10 seconds x 3sets/session.
Dynamic Back Extensors exercise.
Instead of the static posturing of the trunk in the prone
lying position the participant were asked to move the
trunk and the suspended limbs 10 times.
RESULTS
The mean age (mean ± SD) of the patients were 42.2 ±
13.37 and 42.55 ± 13.17 in Group A & Group B
respectively. Group A comprised of 9 males (45%) and
11 females (55%) & Group B comprised of 10 males
(50%) and 10 females (50%).
Table-1: Pre and post values of VAS and MOQ in Group-A and Group-B.
Variables
p-value
Group-B
p-value
Pre
Post
Pre
Post
VAS
7.2 ± 1.10
5.1 ± 0.96
0.000
7.2 ± 0.96
3.55 ± 0.94
0.000
OSW
29 ± 4.87
16.9 ± 4.56
0.000
29.25 ± 4.56
11.45 ± 2.68
0.000
The analysis of pre values of outcome measures in group
A & B described in Table -1 & Figure-1 did not evidence
statistically significant difference between groups,
showing that these were both homogenous in terms of
age & gender.
Figure-1: Pre and post values of VAS in Group-A and
Group-B.
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Figure-2: Pre and post values of MOQ in Group-A
and Group-B.
Table-1 and Figure-1&2 shows the intra group
comparison of VAS and MOQ of Group A, where the p
value of all variables was 0.000 (p<0.05). So, a
statistically significant difference was found after
treatment for all variables, suggesting lumbar
strengthening exercise is effective in reducing pain and
improving function in patient with derangement
syndrome 1. It also shows the intra group comparison of
all variables of Group B, where the p value of all
variables was 0.000 (p<0.05). So, a statistically
significant difference was found after treatment for VAS
and MOQ, McKenzie exercise is effective in reducing
pain and improving function in patient with derangement
syndrome 1.
Inter group comparison of VAS & MOQ in group-A and
B shows significant difference in pain intensity
(p=0.001) and functional capacity (p=0.000). There is
statistically significant reduction of pain & improvement
in function between Group- A & B. There is significant
decline in the intensity of pain & improvement in
function in Group B when compared to Group A. In this
experimental study, null hypothesis was rejected.
DISCUSSION
The results found in this study disclosed that after a two
week treatment program, both the groups, Group A,
which received McKenzie protocol and Group B which
received a lumbar extensor muscles strengthening
program along with the McKenzie protocol, attained a
significant reduction in the pain intensity and
improvement in the performance of functional activities.
The findings are in accordance with the results of
Machado et al (2006) in their study to evaluate the
effectiveness of the McKenzie method for low back pain
(LBP) had concluded that there is evidence that the
McKenzie method is more effective than passive therapy
for acute LBP reducing pain and disability & the studies
by, Brian E. Udermann et al (2004) on patients with
lumbar posterior derangement that received therapeutic
exercise as described by the McKenzie method whose
results indicated that exercises based on repeated
movements is more beneficial in terms of pain reduction
and recovery of function, significant improvements in
range of motion, as well as in a variety of health-related
quality-of-life measures in LBP patients than joint
mobilization or the addition of resistance training for the
lumbar extensors in the early stage of recovery from
lumbar disc derangement & that repeated movement
examination that were found to have decreased the
patients complaints when utilized as therapeutic exercise,
there by leading support for the McKenzie approach in
the treatment of lumbar derangement.
Adding further strength to the results of this study are the
results & conclusions of the systematic review by Helen
A Clare, et al (2004) investigating the efficacy of
McKenzie therapy in the treatment of spinal pain where
the authors had concluded that for low back pain patients
McKenzie therapy does result in a greater decrease in
pain and disability in the short term than do other
standard therapies & the randomized study by Brian M.
Busanich et al (2004) determining the efficacy of the
McKenzie method/McKenzie treatment in comparison
with no treatment, sham treatment, or another treatment
have concluded that the review provides evidence that
McKenzie therapy is effective & results in a decrease in
short-term (< 3 months) pain and disability for low back
pain patients compared with other standard treatments,
such as nonsteroidal anti-inflammatory drugs,
educational booklet, back massage with back care
advice, strength training with therapist supervision, and
spinal mobilization. Two weeks of McKenzie therapy
produced a better improvement in terms of pain
reduction & functional performance than with
stabilization & traction in patients with lumbar
derangement syndrome 1.
The McKenzie protocol (MP) is one of the most
frequently used types of physical therapy for back pain in
various countries and has the potential advantage of
encouraging self-help. Nonetheless, there is limited
evidence in term of randomized trials to support its
effectiveness in long-term LBP. The McKenzie protocol
(MP) identifies with the school of thought that spinal
joint dysfunction such as disc protrusion, loss of joint
play; stress and strain among others are the major causes
of back pain. Another school of thought is that weak
muscles and/or trunk extensor to-flexor muscles
imbalance are major contributors to aetiology of back
pain.
Under this paradigm, muscle strength and endurance
training are believed to be important in the management
of LBP.
The inclusion of a lumbar extensor muscles
strengthening program along with the McKenzie
protocol resulted in a significant reduction in the pain
intensity, and improvement in the performance of
functional activities.
This study was conducted on forty patients with the
mean age of 42.37±13.10 (mean ±SD) with derangement
syndrome 1. The patients were divided into two groups.
Control Group A received Mckenzie therapy &
experimental Group B received resistance training for
Nambi et al. European Journal of Pharmaceutical and Medical Research
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164
lumbar extensors (RTLE) along with Mckenzie therapy
for 6 days a week for 2 weeks and a re-evaluation taken
after 2 weeks of treatment.
The results showed a significant decline in the pain
intensity (p<0.05) & a significant improvement in
function (p<0.05) in the post treatment stage in
comparison to the pretreatment stage.
By comparing the post treatment variables in both
experimental groups, the results revealed that there was
significant difference between the groups A & B. There
was a significant decline in intensity of pain (p=0.000) &
improvement in function (p=0.00) in group B when
compared to group A.
In the experimental conditions used in this study, though
both McKenzie therapy, & McKenzie therapy &
resistance training for lumbar extensors muscles,
produced a significant decline in the pain intensity and
improvement in function, McKenzie therapy with
resistance training for lumbar extensors muscles
produced a significantly greater decline in the pain
intensity and improvement in function, when compared
to Mckenzie exercises alone.
Ethical Approval
The study received the ethical approval from Deanship
of scientific research and the study was conducted
according to the ethical guidelines and principles of the
Declaration of Helsinki.
ACKNOWLEDGEMENT
The author is thankful to all the participants and the
assistants who have participated in the study.
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Article
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Introduction: Long-Term Mechanical Low-Back Pain (LMLBP) constitutes a serious challenge to clinicians and researchers. This study evaluated the effect of static and dynamic back extensor muscles endurance exercise on pain intensity, activity limitation and participation restriction in patients with LMLBP treated with the McKenzie Protocol (MP). Materials and Methods: Eighty four patients with LMLBP participated in this single-blind controlled trial. The participants were assigned to one of three groups; the MP Group (MPG), MP plus Static Back Endurance Exercise Group (MPSBEEG) and MP plus Dynamic Endurance Exercise Group (MPDBEEG) using permuted randomized block. Treatment was applied thrice weekly for 8 weeks and outcomes were measured in terms of pain intensity, activity limitation and participation restriction at the end of 4th and 8th week of study using Quadriple Visual Analogue Scale (QVAS), Roland - Morris Back Pain Questionnaire (RMBPQ), and Oswestry Low-back Disability Questionnaire (OLBDQ). Data were analyzed using descriptive and inferential statistics at 0.05 alpha level. Results: Sixty seven participants whose ages ranged between 38 and 62 years completed the study comprising of 25, 22 and 20 in MPG, MPSBEEG and MPDBEEG respectively. The groups were comparable in age, physical characteristics and baseline outcome measures (p>0,05). Within-group comparison across the three time-points of the study revealed that the different treatment regimens had significant effects on all the outcome measures (p<0,05). There were no significant differences in the mean change scores on QVAS (p=0,579) and OLBDQ (p=0,755) at across the groups at week 4 and 8 respectively. Post-hoc analysis showed that MP-DEEG had higher mean change in RMBPQ (p=0,001) at week 4 only. Conclusion: McKenzie protocol as well as the addition of static or dynamic back extensors endurance exercises are effective in reducing pain and disability in patients with long-term mechanical low-back pain. However, four weeks of McKenzie protocol plus dynamic back extensors endurance exercise resulted in better decrease in participation restriction.
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Background Chronic low back pain (CLBP) is a condition that continues to place considerable strain on the healthcare resources of industrialized societies. Clinicians and researchers strive to develop and assess potential intervention strategies to effectively treat CLBP. Therefore, the purpose of this investigation was to evaluate the effect of McKenzie (McK) therapy combined with resistance training for the lumbar extensors (RTLE) on pain, disability, and psychosocial functioning in CLBP patients. Methods Participants were randomly assigned to 1 of 2 groups that received McK therapy. One group received McK therapy combined with RTLE (McK + RTLE), and the other group received McK therapy only. Data were collected at a university musculoskeletal research laboratory. Results
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Background: Back School and McKenzie methods are popular active treatment approaches that include both exercises and information for patients with chronic nonspecific low back pain. Objective: The purpose of this study was to compare the effectiveness of Back School and McKenzie methods in patients with chronic nonspecific low back pain. Design: The study was a prospectively registered, 2-arm randomized controlled trial with a blinded assessor. Setting: The study was conducted in the outpatient physical therapy clinic in São Paulo, Brazil. Patients: The study participants were 148 patients with chronic nonspecific low back pain. Interventions: The 4-week treatment program (one session/week) was based on the Back School (delivered to the group) or McKenzie (delivered individually) principles. The participants also were instructed to perform a daily set of home exercises. Measurements: Clinical outcomes were assessed at follow-up appointments at 1, 3, and 6 months after randomization. Primary outcome measures were pain intensity (measured by the 0-10 pain numerical rating scale) and disability (measured by the 24-item Roland-Morris Disability Questionnaire) 1 month after randomization. Secondary outcome measures were pain intensity and disability at 3 and 6 months after randomization, quality of life (measured by the World Health Organization Quality of Life-BREF instrument) at 1, 3, and 6 months after randomization, and trunk flexion range of motion measured by an inclinometer at 1 month after randomization. The data were collected by a blinded assessor. Results: Participants allocated to the McKenzie group had greater improvements in disability at 1 month (mean effect=2.37 points, 95% confidence interval=0.76 to 3.99) but not for pain (mean effect=0.66 points, 95% confidence interval=-0.29 to 1.62). No between-group differences were observed for all secondary outcome measures. Limitations: It was not possible to monitor the home exercise program. Therapists and participants were not blinded. Conclusions: The McKenzie method (a more resource-intensive intervention) was slightly more effective than the Back School method for disability, but not for pain intensity immediately after treatment in participants with chronic low back pain.
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Chronic low back pain is a highly prevalent condition, which is associated with high direct and indirect costs to the society. Although this condition is highly prevalent, it is still extremely difficult to treat. Two potentially useful treatments for patients with chronic low back pain are called the McKenzie and Back School treatment programs. These programs have good biological plausibility, are widely available and have a modest cost. Although these treatments are already available for patients, the evidence that supports their use is largely based on low quality methodological studies. Therefore, a high-quality randomised controlled trial is required to compare, for the first time, the effectiveness of these treatments in patients with chronic low back pain. One hundred and forty-eight patients will be randomly allocated to a four-week treatment program based upon the McKenzie or Back School principles. Clinical outcomes (pain intensity, disability, quality of life, and trunk flexion range of motion) will be obtained at follow-up appointments at 1, 3 and 6 months after randomisation. The data will be collected by an assessor who will be blinded to the group allocation. This will be the first study aimed to compare the McKenzie and Back School approaches in patients with chronic low back pain. The results of this trial may help in the decision-making process of allied health providers for the treatment of chronic low back pain and reduce the health-related costs of this condition. ACTRN12610000435088.
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Objectives: To compare selected physical and bio-behavioral improvements following McKenzie intervention in individuals with discogenic chronic low back pain (CLBP) demonstrating centralization and partial centralization of pain. Design: Prospective cohort study with three assessments; at base line and two follow-ups. Setting: Two out-patient orthopedic Physical Therapy clinics. Participants: 105 volunteers with CLBP (52 men and 53women) average ages 41.9 and 37.1 years. Methods: Subjects filled out pain and related fear and disability questionnaires, performed selected physical tests then underwent a McKenzie assessment protocol. McKenzie assessment protocol utilizes directional preference exercises to determine the pain centralization-phenomenon. Subjects were divided into 2-groups; completely centralized group (CCG) and partially centralized group (PCG), and underwent a McKenzie intervention. Outcome measurements were repeated at the end of the 5 th and 10 th weeks after completing the treatment Outcome Measurements: Pain related fear and disability beliefs were assessed using the Fear Avoidance Belief Questionnaires (FABQ) and Disability Belief Questionnaire (DBQ). The time of sit-to-stand, forward bending, and customary and fast walking was recorded. Pain (anticipated vs. actual perception), were measured before and after each physical task. Descriptive statistics, Chi-square, paired t-tests, repeated measures ANOVA were used for longitudinal comparisons across assessment intervals at p<0.05 level. Results: Significant improvements in patient physical performance times and bio-behavioral variables were observed on the 5 th week following the intervention, but tended to regress thereafter. Conclusions: In this cohort study of CLBP both CCG and PCG patients demonstrated significant measurable improvements in physical performances that remained stable for 10 weeks as a result of improved pain and related fear and disability beliefs.
Article
The McKenzie approach to evaluating and treating low back and neck pain is an exciting development in clinical medicine. A thorough mechanical assessment as described by McKenzie is informative and appropriate for all such patients and identifies an individualized self-treatment program that is often dramatically successful. Despite its world-wide use, this comprehensive discipline of evaluation and treatment is misunderstood or unappreciated by most medical practitioners. The assessment process and McKenzie's classification of low back pain syndromes--postural, dysfunctional, and derangement--are described. Therapeutic regimens emphasizing patient self-treatment for the current episode are presented, with the long-range goal of preventing recurrences.
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Development of a new testing machine, which stabilizes the pelvis, allowed us to evaluate the lumbar extensor muscles before and after training. Fifteen healthy subjects (29.1 +/- 8 years of age) trained 1 day per week for 10 weeks and 10 healthy subjects (33.7 +/- 16 years of age) acted as controls. Training consisted of 6 to 15 repetitions of full range of motion variable resistance lumbar extension exercise to volitional fatigue and periodic maximal isometric contractions taken at seven angles through a full range of motion. Before and after the 10 week training period, subjects completed a maximum isometric strength test at seven angles through a 72 degrees range of motion (0 degrees, 12 degrees, 24 degrees, 36 degrees, 48 degrees, 60 degrees, and 72 degrees of lumbar flexion). The training group significantly improved in lumbar extension strength at all angles (P less than or equal to 0.01). The result at 0 degrees (full extension) showed an increase from 180.0 +/- 25 Nm to 364.1 +/- 43 Nm (+102%) and at 72 degrees (full flexion) from 427.4 +/- 44.1 to 607.4 +/- 68 (+42%) Nm. Results from the control group showed no change (P greater than or equal to 0.05). The magnitude of gain shown by the training group reflects the low initial trained state of the lumbar extensor muscles. These data indicate that when the lumbar area is isolated through pelvic stabilization, the isolated lumbar extensor muscles show an abnormally large potential for strength increase.
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Measuring psychosocial responses to health problems poses a unique challenge for the clinician searching for empirical indicators of these abstract constructs. Subjective phenomena such as pain, craving, or well-being vary in levels of intensity and are often difficult for the individual to describe in concrete terms. Visual analogue scales provide a valid and reliable solution to this challenging measurement problem.
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Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain, partly because of a lack of agreement about definition. Chronic back pain is sometimes defined as back pain that lasts for longer than 7-12 weeks. Others define it as pain that lasts beyond the expected period of healing, and acknowledge that chronic pain may not have well-defined underlying pathological causes. Others classify frequently recurring back pain as chronic pain since it intermittently affects an individual over a long period. Most national insurance and industrial sources of data include only those individuals in whom symptoms result in loss of days at work or other disability. Thus, even less is known about the epidemiology of chronic low-back pain with no associated work disability or compensation. Chronic low-back pain has also become a diagnosis of convenience for many people who are actually disabled for socioeconomic, work-related, or psychological reasons. In fact, some people argue that chronic disability in back pain is primarily related to a psychosocial dysfunction. Because the validity and reliability of some of the existing data are uncertain, caution is needed in an assessment of the information on this type of pain.