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
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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 patient’s 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
Group-A
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

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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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