The effectiveness of McKenzie method compared to manual therapy for treating chronic low back pain: a systematic review.

The aim of this study was to evaluate the effectiveness of the McKenzie method compared to manual therapy in the management of patients with chronic low back pain (CLBP). Randomised controlled trials evaluating the McKenzie method in treating CLBP in adults compared to manual therapy (MT) were searched in MEDLINE, CINAHL, Cochrane Library, and PEDro. The primary outcomes were pain and disability. Five trials were eligible for inclusion in the review, of which, most had a score of 8 out of 11 on the PEDro scale. At 2-3 months, all studies reported significant improvement in the pain level in the McKenzie group, and more than that in the MT group. At 6 months, significant improvements had occurred in the disability index reported by two trials in the McKenzie group than the MT group. At 12 months follow-up, there were no significant differences in measures of LBP, but three studies reported that the McKenzie method group had a better disability level than the MT group. In patients with CLBP, many pain measures showed that the McKenzie method is a successful treatment to decrease pain in the short term, while the disability measures determined that the McKenzie method is better in enhancing function in the long term.

The most common classification in the mechanical diagnosis and therapy for patients with a primary complaint of non-acute knee pain was Spinal Derangement: a retrospective chart review.

Objectives: To preliminarily investigate in patients with a primary complaint of non-acute knee pain for ≥ 1 month: 1) the proportion of patients with non-acute knee pain classified by Mechanical Diagnosis and Therapy (MDT) as Spinal Derangements, 2) the number of sessions taken to identify the concluding classification, and 3) the ability of MDT classifications, demographics, and symptomatic baselines to predict pain reduction at 1-month follow-up.Methods: This study reviewed data from outpatients managed with MDT. For modeling knee pain reduction at the 1-month follow-up, 3 MDT provisional or concluding classifications (Spinal Derangement, Knee Derangement, and Non-Derangement) and the following variables were included: 1) gender, 2) symptom duration, 3) presence of low back pain (LBP), 4) the Japanese Knee Osteoarthritis Measure, 5) average pain intensity at the initial session using a 0-10 numerical rating scale, and 6) the Kellgren-Lawrence grade.Results: Data from 101 patients were extracted. The percentage of patients with the concluding classification of Spinal Derangement was 44.6%. This was greater in those patient's reporting concomitant LBP (p = .002) and without radiographic findings of knee osteoarthritis (p < .001). A concluding classification was determined by the fourth session in 80% of patients. Multiple regression modeling demonstrated that only the concluding classification significantly predicted the knee pain reduction at the 1-month follow-up.Discussion: These findings suggest the importance of careful screening assessments of the lumbar spine and the importance of detecting Derangements throughout the follow-up sessions for patients with a primary complaint of knee pain.

Effects of McKenzie and stabilization exercises in reducing pain intensity and functional disability in individuals with nonspecific chronic low back pain: a systematic review.

[Purpose] The purpose of this review is to compare the effect of McKenzie and stabilization exercises in reducing pain and disability in individuals with chronic nonspecific low back pain. [Methods] A systematic literature review of randomized controlled trials (RCTs) were performed using 6 databases. The quality of reviewed articles were assessed by the risk of bias using the Cochrane collaboration's tool. [Results] A total of 829 articles were found from the databases, of which 10 were finally selected to be included in this review. The overall risk of bias assessment indicated that the risk of bias was low in one study and high in the other nine studies. One study reported reduced pain and two studies reported reduced functional disability in the McKenzie exercise group compared to other exercises. Two studies reported reduced pain and three studies reported reduced functional disability in the stabilization exercise group compared to other exercises. In two studies, the stabilization exercise group was as effective as McKenzie exercise group in reducing pain and functional disability in patients with chronic nonspecific low back pain. [Conclusion] Only two studies compared stabilization and McKenzie exercises in the management of chronic nonspecific low back pain. Therefore, insufficient evidence is available to draw any conclusive comparison on the effects of McKenzie and stabilization exercises in chronic nonspecific low back pain. However, both McKenzie and stabilization exercises was better than conventional exercise programs in reducing functional disability in patients with chronic nonspecific low back pain.

McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up.

BACKGROUND: The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with placebo in patients with chronic LBP. METHODS: This was a prospectively registered, two-arm randomised placebo controlled trial, with a blinded assessor. A total of 148 patients seeking care for chronic LBP were randomly allocated to either MDT (n=74) or placebo (n=74). Patients from both groups received 10 treatment sessions over 5 weeks. Patients from both groups also received an educational booklet. Clinical outcomes were obtained at the end of treatment (5 weeks) and 3, 6 and 12 months after randomisation. Primary outcomes were pain intensity and disability at the end of treatment (5 weeks). We also conducted a subgroup analysis to identify potential treatment effect modifiers that could predict a better response to MDT treatment. RESULTS: The MDT group had greater improvements in pain intensity at the end of treatment (mean difference (MD) -1.00, 95% CI -2.09 to -0.01) but not for disability (MD -0.84, 95% CI -2.62 to 0.93). We did not detect between-group differences for any secondary outcomes, nor were any treatment effect modifiers identified. Patients did not report any adverse events. CONCLUSION: We found a small and likely not clinically relevant difference in pain intensity favouring the MDT method immediately at the end of 5 weeks of treatment but not for disability. No other difference was found for any of the primary or secondary outcomes at any follow-up times. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT02123394).

Directional preference of the extremity: a preliminary investigation.

Background: Mechanical diagnosis and therapy (MDT) is a specific classification-based musculoskeletal examination and intervention system that uses repeated end range and sustained movement to classify patients into mechanical syndromes. Research has recently demonstrated increased prevalence, reliability, and efficacy of MDT syndromes in varied peripheral musculoskeletal populations. There is currently no research analyzing if predictive variables exist for establishing directional preference in peripheral joints, other than the wrist. The aim of this study was to examine the clinical application of predictive variables for establishing directional preference and spinal referral in patients with isolated peripheral joint pain. Case Description: Thirty-seven consecutive patients with isolated peripheral pain were evaluated and classified using MDT assessment. Secondary analysis of predetermined variables was performed for association with directional preference and identification of spinal referral in Derangement syndrome. Results: All 37 patients were classified using MDT assessment. Thirty-three (89.2%) were classified as Derangement syndrome: 17 as spinal Derangement (45.9%) and 16 as peripheral Derangement (43.2%). One peripheral derangement also had an underlying Articular Dysfunction. Additionally, there were four patients classified as Other (10.8%). Discussion: Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference or spinal referral. Mechanical stress was found to be the most associated factor in predicting directional preference. No peripheral movement loss, paresthesia, and constant pain were more associated with spinal referral. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes. Level of Evidence: 4.

Diagnosis of cervical and thoracic musculoskeletal spinal pain receptive to mechanical movement strategies: a multicenter observational study.

Background: The McKenzie's Mechanical Diagnosis and Therapy (MDT), which uses a combination of repeated movements and sustained positions to affect signs and symptoms, is commonly used for the conservative evaluation and management of cervical and thoracic spinal conditions. Objective: Report a consecutive cohort of neck and thoracic pain patients managed using MDT and to record their classifications and physiotherapy management strategies. Methods: Therapists provided demographic data on themselves and the patients, clinical data on the patients, and Neck Disability Index scores at baseline and final visit. Results: Sixteen therapists collected data on 138 patients at baseline, of who 120 (87%) were followed up three to five visits later; these were patients with 131 cervical and seven thoracic problems. The therapists and patients are described. Regarding MDT classifications 83% were recorded as cervical and 100% as thoracic Derangement; there was a Directional Preference for extension in 80% of cervical spine patients, and 100% of thoracic spine patients. In addition, 13% of cervical spine patients were classified as OTHER, for which specific classifications were given. Classifications remained stable between initial and discharge sessions in 94% of patients. Neck Disability Index scores reduced from a mean of 24-12 at discharge (P < 0.001). Conclusions: Routinely collected data can describe both therapists and patients involved, demonstrate the MDT classification clinical utility in terms of prevalence and stability between visits, provide information on the clinical course of this patients' population, which could help establish treatment efficacy. Randomized controlled trials are needed to test for efficacy.

Pain pattern classification and directional preference are associated with clinical outcomes for patients with low back pain.

Pain Pattern Classification (PPC) and Directional Preference (DP) have shown merit as reliable and predictable clinical solutions to help reduce the burden posed by low back pain (LBP). We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes. We hypothesized that (1) patients who demonstrated DP Centralization (CEN) would have lower pain intensity and disability at follow-up than patients who demonstrated Non-DP Non-CEN, and (2) the prevalence of DP at first examination would be lowest for patients with chronic LBP and are greater than 65 years old. First examination and follow-up data were completed by 639 patients. Clinical outcome measures, including pain intensity and disability, were collected at first examination and follow-up. Baseline comparisons were made between groups with first examination data only and groups with first examination data and follow-up data. A Pearson's chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used for the continuous variables. A Turkey's range test was used to determine differences in follow-up pain intensity and disability for LBP dual-classifications. Multiple regression was used to investigate DP prevalence considering risk adjusted factors. Overall prevalence of DP was 84.5% and prevalence was lowest for patients with sub-acute symptoms. No significant difference existed for the prevalence of DP for patients based on age. Patients classified as DP CEN had, on average, 1.99 pain intensity units less than patients classified as Non-DP Non-CEN at follow-up. Patients classified as DP CEN had, on average, 3.43 RMDQ units less than patients classified as Non-DP Non-CEN at follow-up.These findings support previous reports, verifying the association between LBP dual-classification schemes and clinical outcomes.

Directional preference constructs for patients' low back pain in the absence of centralization.

Objectives: A detailed description of how Directional Preference (DP) constructs are measured could accelerate research to practice translation and improve research findings for Mechanical Diagnosis and Therapy (MDT) stakeholders. A secondary analysis of a prospective, observational cohort study was conducted to understand (1) the type and prevalence of DP constructs at first examination and (2) the relationships between DP constructs and clinical outcomes at follow-up. Methods: Data were collected and analyzed from 1485 consecutive patients who presented to outpatient, private practice clinics with primary complaints of non-specific low back pain (LBP); 400 patients met the inclusion criteria and completed first examination and follow-up data. Statistical analysis determined prevalence and the relationships between DP constructs at first examination and clinical outcomes at follow-up. Results: The primary findings in this investigation were that (1) the most prevalent DP constructs at first examination were related to range of motion (ROM) and pain intensity (Patient Reported Improvement in ROM (74.8%), Increase in Spine ROM (29.5%), and Pain Intensity Change (17.3%)), (2) all groups improved and made clinically meaningful improvements in disability and pain intensity at follow-up, (3) no clinically significant differences in disability or pain intensity were found between the groups at follow-up, and (4) 26.5% and 6.5% of patients exhibited a relative increase in lumbar spine extension and flexion ROM, respectively, post repeated movement testing on the first examination. Discussion: The findings in this study assist providers in making assessment and treatment decisions with their patients by offering insight regarding the most prevalent DP constructs typically found at the first examination and their subsequent association with outcome when Centralization (CEN) does not occur. Recommendations for researchers have been made to further explore the DP framework used in this study.

Provider reliability with interventions for knee impairments: a preliminary investigation to facilitate development of an MDT-based knee intervention taxonomy.

Objectives: The lack of a standardized intervention taxonomy in comparative effectiveness research trials has led to uncertainty regarding the management of individuals with knee impairments. Inconsistently and poorly defined interventions affect frontline-care providers' abilities to understand and assimilate research findings into practice. An intervention taxonomy could help overcome the lack of treatment specificity commonly found in research trials. Methods: In the present study, we aimed to develop a Mechanical Diagnosis and Therapy (MDT)-based taxonomy and test the levels of reliability between providers who currently manage individuals with knee impairments in a rehabilitation setting. A total of 182 participants accessed the study during the study period, in which 180 consented to participate and 59 completed the survey (98.9% participation rate; 32.7% completion rate). Results: A total of 89.8% of the participants who completed the survey were physical therapists. Fleiss kappa values for the primary, secondary, and tertiary categories were 0.90, 0.89, and 0.71, respectively. The results of our investigation suggest substantial to almost perfect levels of reliability for identifying diverse MDT-based knee interventions displayed in video and vignette format within a sample population primarily of physical therapists who currently manage individuals with knee impairments in a rehabilitation setting. Discussion: Our findings show acceptable levels of reliability and provide support for using this standardized MDT-based intervention taxonomy as a way to improve intervention specificity and generalizability in comparative effectiveness research. Level of Evidence: 5.

Pain pattern classification and directional preference for patients with neck pain.

Objectives: Pain Pattern Classification (PPC) and Directional Preference (DP) have been shown to be predictive of health care outcomes and serve to guide orthopedic clinical decision making. We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes. Methods: Clinical outcome measures including pain intensity and disability were completed at first examination and follow-up by 335 patients. A Pearson's chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used to determine differences in rates for the continuous variables. A Tukey's range test was used to determine differences in follow-up pain intensity and disability for neck pain dual-classification schemes. Results: The prevalence of DP was 82.4%. The prevalence of CEN, Non-CEN, and Non-Classifiable (NC) was 15.2%, 42.1%, and 25.1%, respectively. The prevalence of DP was lowest for patients with sub-acute symptoms and who were <45 years old. Patients classified as DP CEN had, on average 2.62 NDI units less than patients classified as Non-DP. Patients classified as DP CEN had, on average, 0.90 pain intensity units less than patients classified as Non-DP at follow-up. Patients who demonstrated DP CEN did not have clinically significant lower pain intensity or disability at follow-up than patients who demonstrated Non-DP. Discussion: The results of this investigation need to be interpreted with caution with respect to the study design and it's subsequent strengths and limitations. Level of Evidence: 1b.

The application of Mechanical Diagnosis and Therapy to the ankle-foot complex: a case series.

BACKGROUND: Pain at the ankle-foot complex is a common musculoskeletal condition that can lead to dysfunction. Mechanical Diagnosis and Therapy (MDT) is an orthopedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained movement. There has been no investigation of the association between MDT and patients diagnosed with ankle-foot complex pain. CASE DESCRIPTION: This report presents four patients with a primary complaint of pain in the ankle-foot complex. Three patients had a medical diagnosis while the other was self-referred through direct access. All received classification and treatment by clinicians trained in MDT solely utilizing MDT principles. OUTCOMES: Short- and long-term (4-12 months) outcomes were excellent, demonstrating rapid abolishment of symptoms and return to prior levels of function in an average of six visits over 21 days (4-8 visits over 14-33 days) without the use of modalities, strength, or proprioceptive training. The patients demonstrated the ability to prevent and manage re-occurrence of symptoms independently without seeking further health care at long-term follow-up. DISCUSSION: The rapid speed of recovery and return to functional activities demonstrated in this case series, raises questions about whether or not the pathologies traditionally associated with the etiology of ankle-foot injuries are actually at fault or understood. Moreover, it demonstrates that specific movements can rapidly worsen or improve symptoms challenging the current generalized rehabilitation protocols. This report provides preliminary evidence that MDT may be capable of providing more effective short-term outcomes in the management of ankle-foot complex injuries. LEVEL OF EVIDENCE: 4.

Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study.

OBJECTIVES: The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification. METHODS: International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed. RESULTS: The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The Derangement and Spinal classifications had significantly higher UEFI scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The frequency of discharge at week 2 was 37% for both Derangement and Spinal classifications, with no discharges for the Dysfunction classification at this time point. The frequency of discharge at week 4 was 83, 82 and 15% for the Derangement, Spinal and Dysfunction classifications, respectively. DISCUSSION: Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.Level of Evidence: 2b.

Directional preference of the wrist: a preliminary investigation.

BACKGROUND: Directional preference is a phenomenon that occurs in musculoskeletal disorders. It is associated with improved symptomatic and functional outcomes. Research has shown a 90% increase in the identification of directional preference in the peripheral joints between 2006 and 2012. There is currently no research analyzing if predictive variables exist for establishing directional preference. CASE DESCRIPTION: This report presents 19 consecutive patients with wrist pain. These patients were evaluated using a mechanical diagnosis and therapy (MDT)-based assessment. Patients were classified into the mechanical syndromes Derangement, Dysfunction, Postural, and Other. Patients classified with wrist Derangement were assessed for the presence of directional preference. Secondary analysis of predetermined variables was performed for association with directional preference. One case description was included to demonstrate MDT assessment, treatment, and clinical reasoning. RESULTS: Of the 19 patients evaluated, 15 (79%) were classified as having wrist Derangement. All patients with wrist Derangement demonstrated directional preference. Eight movements were found to establish directional preference. Each was unique with varying degrees of direction, load, and force. DISCUSSION: This report found directional preference to be higher (79%) than previously reported values. Historical and physical examination findings were analyzed to determine if there were associated variables of directional preference. Excessive mechanical stress was found to be the most associated factor in predicting directional preference. These findings may lead to a greater understanding of peripheral MDT assessment, which may lead to increased identification of directional preference and improved patient outcomes. LEVEL OF EVIDENCE: 4.

Inter-rater reliability of the McKenzie System of Mechanical Diagnosis and Therapy in the examination of the knee.

OBJECTIVE: The McKenzie System of Mechanical Diagnosis and Therapy (MDT) is a widely used method of classification and management of musculoskeletal problems. Although MDT has been investigated for its reliability and efficacy in the management of spinal pain, few studies have evaluated the system when applying it to musculoskeletal problems in the extremities, in particular the knee. The purpose of this study was to investigate the inter-rater reliability of MDT when classifying clinical vignettes describing patients with musculoskeletal knee pain. METHODS: This study was divided into two phases. First, 10 clinicians experienced in the use of MDT were recruited to write a total of 60 clinical vignettes based upon the initial assessment of their past patients with knee pain. Second, six different MDT raters were recruited to rate 53 selected vignettes and reliability was determined using Fleiss Kappa. RESULTS: There was 'substantial agreement' among six MDT raters classifying the clinical vignettes into one of four categories (κ = 0.72). There was no statistically significant difference between therapists with different levels of training. DISCUSSION: MDT demonstrated acceptable reliability among trained raters to classify clinical vignettes describing patients with musculoskeletal knee pain. To generalize the use of the system to more users, future research should continue to investigate the reliability of MDT using raters with lower levels of training and experience and assess reliability in real patients. LEVEL OF EVIDENCE: 5.

A Comparison of the Effects of Pilates and McKenzie Training on Pain and General Health in Men with Chronic Low Back Pain: A Randomized Trial.

BACKGROUND: Today, chronic low back pain is one of the special challenges in healthcare. There is no unique approach to treat chronic low back pain. A variety of methods are used for the treatment of low back pain, but the effects of these methods have not yet been investigated adequately. AIM: The aim of this study was to compare the effects of Pilates and McKenzie training on pain and general health of men with chronic low back pain. MATERIALS AND METHODS: Thirty-six patients with chronic low back pain were chosen voluntarily and assigned to three groups of 12 each: McKenzie group, Pilates group, and control group. The Pilates group participated in 1-h exercise sessions, three sessions a week for 6 weeks. McKenzie group performed workouts 1 h a day for 20 days. The control group underwent no treatment. The general health of all participants was measured by the General Health Questionnaire 28 and pain by the McGill Pain Questionnaire. RESULTS: After therapeutic exercises, there was no significant difference between Pilates and McKenzie groups in pain relief (P = 0.327). Neither of the two methods was superior over the other for pain relief. However, there was a significant difference in general health indexes between Pilates and McKenzie groups. CONCLUSION: Pilates and McKenzie training reduced pain in patients with chronic low back pain, but the Pilates training was more effective to improve general health.

The relationship between Quebec Task Force Classification and outcome in patients with low back pain treated through mechanical diagnosis and therapy.

OBJECTIVE: To determine the correlation between the Quebec Task Force Classification (QTFC) system and outcome in patients with non-specific low back pain (LBP). METHODS: Forty-nine patients who were treated in outpatient physical therapy clinics of Catholic Health System (CHS) of Western New York (WNY) were classified according to the QTFC at the initial examination by physical therapists (PTs) with training in Mechanical Diagnosis and Therapy (MDT). The patient's perceived level of function was assessed with the Focus On Therapeutic Outcomes (FOTO) tool at the initial examination, 2 weeks following the initiation of physical therapy and again at discharge. RESULTS: A linear regression model between acuity and change in FOTO score was performed and demonstrated statistical significance (P<0·05) as the more favorable outcome was found with the more acute patients. Spearman correlations between change in FOTO score and QTFC, duration of treatment and acuity of condition, and number of visits and change in FOTO score were not found to be statistically significant. CONCLUSIONS: The patients treated in this study demonstrated functional improvement in an average of eight visits, indicating efficacious care. Future research is needed to determine prioritized intervention strategies for designated LBP classifications.

Immediate improvement in the cranio-cervical flexion test associated with MDT-based interventions: a case report.

The patient in this case study presented with constant idiopathic neck pain and left lower scapular pain (greater than 3 months) and was treated based on the principles of Mechanical Diagnosis and Therapy (MDT). Retraction exercises produced centralization of the lower scapular pain to the upper part of the scapula at the initial visit. At the first visit, the performance level on the Cranio-Cervical Flexion Test (CCFT) was ≤20 mmHg before the treatment. At the conclusion of the treatment during which centralization occurred, the CCFT level improved to 24 mmHg. At the second visit, all symptoms were abolished and cervical range of motion (ROM) was fully restored by performing repeated extension in lying from a retracted position with clinician's traction. The CCFT levels before and immediately after the treatment were 24 and 26 mmHg, respectively. At the third visit (1 week after the initial visit), he noted that all daily activities could be performed without pain. The CCFT level was maintained at 26mmHg. The patient in this study showed immediate improvement in the CCFT through the treatments based on MDT. This suggests a possible link between MDT interventions and motor control of the cervical spine and a need to further investigate this relationship.

Utilization of mechanical diagnosis and therapy (MDT) for the treatment of lumbar pain in the presence of known lumbar transverse process fractures: a case study.

BACKGROUND: Spinal fractures are typically considered a contraindication to mechanical diagnosis and therapy (MDT). OBJECTIVE AND IMPORTANCE: The purpose of this case study is to illustrate how MDT was used safely and effectively to treat lumbar pain in a patient with multiple lumbar transverse process fractures. CLINICAL PRESENTATION: The subject was a 24-year-old female with left L2-5 transverse process fractures, sustained 10 weeks prior in a pedestrian versus motor vehicle accident. INTERVENTION AND TECHNIQUE: After collaboration with her physiatrist, an MDT examination revealed a presentation consistent with the lumbar derangement syndrome. CONCLUSION: After three visits, utilizing patient generated forces with the extension principle of treatment, her pain, Oswestry disability index (ODI) score, and function all improved.

Lumbar lateral shift in a patient with interspinous device implantation: a case report.

BACKGROUND: Lumbar lateral shift (LLS) is a common clinical observation but has rarely been described in a patient with a history of lumbar surgery. The purpose of the current case report was to describe the use of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) in the multi-modal treatment of a patient with an LLS and a history of multiple surgical procedures in the lumbar spine, including interspinous process device (IPD) implantation. CASE DESCRIPTION: A 72-year-old female with chronic low back pain (LBP) and a surgical history in the lumbar spine was referred to physical therapy for radiating leg pain and presented with a right LLS. Her chief complaints included sitting for long periods, vacuuming and ascending stairs into her home. OUTCOMES: The patient was treated during eight visits over 30 days. Treatment interventions included manual shift correction, self-correction and management, joint mobilisation below the level of IPD implantation ,neurophysiology education, and development of a home exercise programme. At discharge, her leg pain was resolved and all goals had been met. The patient reported maintenance of gains at 6-month follow-up. DISCUSSION: Utilisation of the MDT approach, including LLS correction, produced positive outcomes in a complex patient with previous IPD implantation. Future research should investigate treatment and outcomes after invasive spinal procedures in similar patient populations to better inform clinical management. LEVEL OF EVIDENCE: 4.

McKenzie treatment versus mulligan sustained natural apophyseal glides for chronic mechanical low back pain.

BACKGROUND AND OBJECTIVE: Chronic mechanical low back pain is common among different age groups and genders. Different manual therapy techniques combined with exercise therapy and electrotherapy modalities play an important role in its management. Our objective was to compare the effects of McKenzie extension exercisesprogram (EEP) versus Mulligan Sustained Natural Apophyseal Glides (SNAGs) for chronic mechanical low back pain (CMLBP). METHODS: This randomized control trial (RCT) was conducted at Riphah Physical Rehabilitation Centre, Pakistan Railways General Hospital Rawalpindi, from 1(st) July to 31(st) December 2014. The inclusion criteria was patients of both gender and age range 30-70 years with minimum 4 weeks history of CMLBP. A total of 37 patients were screened out as per inclusion criteria and randomly placed into two groups. Twenty patients in group A were treated with Mulligan SNAGs and 17 patients in group B with McKenzie EEP for four weeks at two session per week and single session per day. Visual Analogue Scale (VAS), Oswestry Disability Scale (ODI) and lumber Range of Motion (ROM) were used as an assessment tools and were measured at baseline and at the completion 4 weeks intervention. The data was analyzed with SPSS to draw the statistical and clinical significance of both interventions. RESULTS: At the completion of 4 weeks intervention the pre and post statistical analysis revealed that clinically the McKenzie EEP improved pain (mean 9.12 to 1.46) and disability (73.82 to 6.24) slightly more than Mulligan SNAGs (pain: from 8.85 to 2.55, disability 73.75 to 7.05), while the Mulligan SNAGs improved lumbar ROM more effectively than McKenzie EEP in all directions including flexion, extension, side bending and rotation. Statistically there was no significant difference between the effects of two interventions in managing pain and disability, and improving Lumber ROM. CONCLUSION: McKenzie EEP is clinically slightly more effective in the management of pain and disability as compared with Mulligan SNAGs, while Mulligan SNAGs are more effective in the improvement of lumbar ROM as compared with Mechanize EEP in the management of CMLBP.