SPINE Volume 31, Number 9, pp E254 E262 2006, Lippincott Williams & Wilkins, Inc.

The McKenzie Method for Low Back Pain

A Systematic Review of the Literature With a Meta-Analysis Approach
Luciana Andrade Carneiro Machado, BScPT (Honours),* Marcelo von Sperling de Souza, BScPT (Honours),* Paulo Henrique Ferreira, PhD,* and Manuela Loureiro Ferreira, PhD
results of conservative care in randomized controlled trials (RCTs) are a consequence of applying the same therapy to heterogeneous groups of patients.35 Nevertheless, a gold-standard subgrouping scheme for LBP is still lacking, as most available classication systems have weak evidence for their validity and reliability.6 8 In 1981, Robin McKenzie proposed a classication system and a classication-based treatment for LBP labeled Mechanical Diagnosis and Therapy, or simply the McKenzie method.9 Of the large number of classication schemes developed in the last 20 years,10 16 the McKenzie method has the greatest empirical support (e.g., validity, reliability and generalizability) among the systems based on clinical features.8 According to this method, the classication of LBP patients is based on patterns of pain response noted during the assessment.9 The centralization phenomenon is the most important pattern of pain response observed in McKenzies assessment, as well as the most studied feature of the McKenzie method.1723 Centralization is dened as the situation in which referred pain arising from the spine is reduced and transferred to a more central position when movements in specic directions are performed (also called directional preference).9 Although the main role of McKenzies classication system is to guide treatment selection, many RCTs on the effectiveness of the McKenzie method have overlooked this principle by assigning patients of unknown classication to the same intervention.24 28 In this review, we name this approach to the McKenzie method generic McKenzie. In contrast, we call the McKenzie method based on patient classication (as advocated in the McKenzie textbook9) classication-based McKenzie. It has been suggested that the use of a generic approach is responsible for the underestimation of the effectiveness of the McKenzie method in previous studies.29 Misconception of the McKenzie method is observed in a systematic review evaluating the effectiveness of exercise therapy for LBP,30 in which this method was equated to extension exercises. This is incorrect because with the McKenzie method the direction of exercise is not always extension but instead is dictated by the directional preference. In a prospective, multicenter study including 145 patients with nonspecic LBP, Donelson et al31 reported a clear directional preference in nearly one half of patients. Of these patients, 40% improved with extension exercises, whereas 7% improved with exion exercises.31 The higher incidence of extension as the di-

Study Design and Objectives. Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP). Summary of Background Data. The McKenzie method is a popular classication-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials. Methods. MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie. Results. Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, 4.16 points; 95% condence interval, 7.12 to 1.20) and disability (WMD on a 0- to 100-point scale, 5.22 points; 95% condence interval, 8.28 to 2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% condence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis. Conclusions. There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classication-based McKenzie is yet to be established. Key words: low back pain, effectiveness, exercise, systematic review, meta-analysis. Spine 2006;31:E254 E262

The diagnosis and treatment of low back pain (LBP) is surrounded by substantial controversy.1 Although LBP is frequently managed as a single condition (nonspecic LBP),2 it has recently been hypothesized that negative
From the *Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Back Pain Research Group, School of Physiotherapy, University of Sydney, Sydney, Australia; and Pontifcia Universidade Catolica de Minas Gerais, Belo Horizonte, Brazil. Acknowledgment date: May 13, 2005. First revision date: July 27, 2005. Second revision date: September 7, 2005. Acceptance date: September 12, 2005. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benets in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Luciana Andrade Carneiro Machado, BScPT, School of Physiotherapy, University of Sydney, PO Box 170, Lidcombe NSW 1825, Australia; E-mail: lmac3689@mail. usyd.edu.au

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McKenzie Method for LBP Machado et al E255

rectional preference in LBP patients may explain why many researchers make faulty assumptions by equating the McKenzie method to extension exercises. Although the McKenzie method is a promising classication scheme to be implemented in the management of LBP, the evidence for its effectiveness is unclear. A systematic review of the literature was conducted to evaluate whether the McKenzie method is more effective than other reference treatments for acute or chronic nonspecic LBP. Methods Studies and Participants. RCTs published in English, Portuguese, and Spanish were included. Trials reporting on treatment of nonspecic LBP of any duration were included. LBP was dened as pain extending between the lower rib cage and gluteal folds, with or without radiation.32 Trials on specic pathologic entities (e.g., spondylolisthesis, infection, or inammatory processes) were excluded.

PEDro scale (www.pedro.fhs.usyd.edu.au/scale_item.html). The PEDro scale is an 11-item checklist in which one point is awarded for each satised item, except for the rst that pertains to external validity. In literature, consensus scores among raters for the total PEDro score has shown good reliability (ICC 0.68).34 When a trial had already been rated according to PEDro scale and its score conrmed on the Physiotherapy Evidence Database (www.pedro.fhs.usyd.edu.au), this score was used. Consensus was used to solve disagreements between reviewers, and a third reviewer (L.A.C.M.) arbitrated if consensus could not be reached. Data Extraction and Analysis. Two reviewers (L.A.C.M., M.vS.S.) independently extracted data using a standardized form. Mean scores and standard deviations were estimated from tables and/or graphs when necessary. Consensus was used to solve disagreements, and a third reviewer (P.H.F.) arbitrated if consensus could not be reached. Although the levels of evidence approach have been commonly used to summarize the evidence in previous systematic reviews,30,3539 this approach lacks power and the different criteria available can lead to different conclusions on treatment efcacy based on the same group of studies.40 Therefore, we used a meta-analysis approach based on the random effects model to calculate weighted mean differences (WMDs) and 95% condence intervals (CIs). The treatment effects of individual trials were calculated by the mean and 95% condence interval either for between-group differences in endpoints, or for within-group change scores, according to available data.41 Continuous data were converted to a 0- to 100-point scale to analyze the pooled effect of similar outcomes measured by different scales. Relative risks and 95% condence intervals were calculated for dichotomous data.42 Pooling was not attempted where there was statistical heterogeneity or clinical heterogeneity consisting of relevant differences with regards to population, reference treatments, outcome measures, and follow-up. The tree plots of trial outcomes were inspected to make a decision on whether relevant heterogeneity was present when the number of studies was not sufcient to use the 2 test. Because patients under treatment with the McKenzie method can experience rapid improvement in symptoms,31 we decided to present outcomes at the precise time point rather than collapsing time points to short-term ( 3/12); intermediate (312/12), and long-term follow-up ( 12/12).33 To evaluate the effectiveness of the McKenzie method as a classication-based treatment, a sensitivity analysis excluded trials in which a generic McKenzie approach was used. The RevMan software43 was used for the measurement of statistical heterogeneity and pooled effects.

Interventions. Trials were included when the term McKenzie method or a synonym (McKenzie therapy, Mechanical Diagnosis and Therapy) was used to name one of the interventions. Additionally, trials in which the term McKenzie method was not mentioned were included if the intervention reected McKenzie principles, e.g., repeated passive spine movements or sustained positions performed in specic directions. Trials in which cointerventions had been given were included, since this pragmatic approach matches closely the usual physiotherapy practice. Trials were excluded when the experimental group consisted of dynamic strengthening exercises as this intervention does not represent either the classication-based McKenzie or the generic McKenzie approach. Outcome Measures. Trials were included if one of the following outcome measures had been reported: pain, disability, quality of life, return to work/sick leave, or recurrence. Search Strategy for Identication of Studies. We searched the MEDLINE, EMBASE, PEDro, and LILACS databases up to August 2003. A combination of terms to search for RCTs and low back pain (as described by the Cochrane Back Review Group33), and the words McKenzie, extension exercises, exion exercises, exercise therapy, active therapy, and centralization were used as search terms. A manual search of reference lists of previous systematic reviews and relevant trials was conducted. The reference list from the McKenzie International Institute was also screened (www.mckenziemdt.org). Personal communication with content experts completed the search strategy. Methods of the Review
Study Selection. Two reviewers (L.A.C.M. and M.vS.S.) independently conducted the search strategy and applied the selection criteria based on titles, abstracts, and key words. The full text of studies considered eligible or potentially eligible was retrieved. Consensus was used to solve disagreements, and a third reviewer (P.H.F.) arbitrated if consensus could not be reached. Methodologic Quality Assessment. Two independent reviewers (P.H.F., M.L.F.) assessed methodologic quality using the

Results Study Selection The MEDLINE, EMBASE, PEDro, and LILACS searches identied 364, 195, 90, and 56 studies, respectively. Of these, only 11 trials published in 12 papers were included.24 28,44 50 Agreement between reviewers for study eligibility was 84.25%, 82.57%, 85.06%, and 98.21% for MEDLINE, EMBASE, PEDro, and LILACS, respectively. The main reasons for exclusions were the use of interventions dissimilar from the McKenzie method (e.g., dynamic strengthening exercises,5153

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Table 1. Characteristics of Included Studies

Study PEDro Score/10 Cherkin44 (1998)* 8/10 Participants 321 patients with acute LBP, with or without radiation, 168 men and 155 women, ages 2064 yr; 2 subjects excluded after randomization Interventions (I1) McKenzie exercises aiming for centralization, avoidance of peripheralization, lumbar roll, McKenzie book, max 9 visits over 1 mo at discretion of therapist (n 133) (R1) Chiropractic manipulation, shortlever, high velocity thrust, exercise sheet emphasizing stretching and strengthening, other treatments (ice packs, massage, exercises in the ofce or at home), max 9 visits over 1 mo, at discretion of chiropractor (n 122) (R2) Educational booklet (n 66) (I1) Prone press-ups, lumbar roll, postural instruction, sacroiliac joint manipulation, physical therapist supervision, 3 visits, self-treatment at home (n 14) (I2) Williams exion exercises, physical therapist supervision, 3 visits, selftreatment at home (n 10) (I1) Prone press-ups, lumbar roll, ice pack, booklet, trunk shift correction, home exercises, ibuprofen tablets, physical therapist supervision (n 60, after 2 wk, n 30) (I2) Flexion exercises, pelvic tilt, partial sit-ups, double knee to chest, ice pack, booklet, home exercises, ibuprofen tablets, physical therapist supervision (n 60; after 2 wk, n 30) (I3) Same as I1, exion exercises added after 2 wk (n 30) (I4) Same as I2, extension exercises added after 2 wk (n 30) (R) Ice pack while laying prone, no exercise or postural instruction (n 30) (I1) 6 types of extension exercises, 10 reps each, 30min everyday sessions, 2 wk, 6 sessions supervised by physical therapist, and 8 home sessions (n 28) (I2) 6 types of exion exercises, 10 reps each, 30min everyday sessions, 2 wk, 6 sessions supervised by physical therapist, and 8 home sessions (n 28) (I1) Prone press-ups, lumbar roll, postural instruction, supervised by physical therapist, 3 visits, selftreatment at home (n 12) (I2) Sacroiliac joint manipulation, handheel rocking exercises, supervised by physical therapist, 3 visits, selftreatment at home (n 12) (I) McKenzie Method, no treatment details, 2 to 3 times during the 1st wk, further sessions at discretion of therapist (n 11) (R) Nonspecic back massage and standard back care advice (n 14) Outcomes Mean pain improvement (11-point bothersomeness scale) after 4 and 12 wk: R1 signicantly more improved than R2 after 4 wk Mean disability (RMQ) after 4 and 12 wk: no signicant differences after adjustment for non-normal distribution I1 and R1 rated care better than R2 after 1 and 4 wk; recurrence after 2 yr: no signicant differences

Delitto48 (1993) 4/10

24 patients with acute or subacute LBP, with or without radiation, classied into extensionmobilization category, 14 men and 10 women, ages 1450 yr

Mean disability (OSW) after 3 and 5 days: I1 signicantly more improved than I2

Dettori24 (1995) 6/10

149 patients with acute LBP, with or without radiation, 120 men and 29 women, mean age 28.4 yr

Mean disability (RMQ) after 1 wk: I1 I2 signicantly more improved than R; no signicant differences after 8 wk Mean pain (6-point scale) after 1, 2, 4, and 8 wk: no signicant difference between groups Return to work after 1 wk: I1 I2 signicantly more improved than R; no signicant difference after 8 wk

Elnaggar25 (1991) 4/10

56 patients with chronic LBP, 28 men, 28 women, ages 2050 yr

Mean pain (McGill Pain Questionnaire) after 2 wk: no signicant difference

Erhard45 (1994)* 5/10

24 patients with acute or subacute LBP, with or without radiation, classied in an extensionmobilization category, 15 men and 9 women, ages 1473 yr

Mean disability (OSW) after 3 and 5 days: I2 signicantly more improved than I1

Gillan46 (1998) 4/10

25 patients with acute or subacute LBP, with or without radiation, lateral, shift of lumbosacral spine, 12 men and 13 women, ages 2658 yr

Disability (OSW) after 28 and 90 days: signicant lower scores for both groups; no signicant difference between I and R (Table continues)

McKenzie Method for LBP Machado et al E257

Table 1. Continued
Study PEDro Score/10 Malmivaara26 (1995) 7/10 Participants 186 patients with acute LBP, with or without radiation (sciatica excluded), 62 men and 124 women, 16 subjects withdrawn after randomization Interventions (I1) Repeated extension and lateral bending exercises plus advice to stay active, individual instruction by physical therapist in 1st session, written recommendations for home exercises every hour until the pain subsided (n 42) (I2) Bed rest, only essential walking allowed, advice on resting position (semi-Fowler), resume activities as tolerated after 2 days of complete rest (n 62) (R1) Advice to stay active (n 61) (I1) McKenzie treatment planned individually after assessment, self-mobilizing repeated movement or sustained positions, manual overpressure, mobilization by the therapist, max 15 sessions for 8 wk (n 132) (I2) Strengthening training, 510 min stationary bike, 10-min warm-up exercises (10 reps of lowresistance lumbopelvic exercises), intensive dynamic back strengthening program, groups of 6, guidance of physical therapist, max 15 sessions for 8 wk (n 228) (I1) Postural correction, 20-min walk on treadmill, extension exercises or extension with hips offset, 5 sets of 10 reps, 3 visits (n 15) (I2) Postural correction, 20-min walk on treadmill, spinal joint mobilization based on assessment, 5 sets of 10 mobilizations, 3 visits (n 10) (I) 5 min lying prone plus 5 min sustained lying prone in extension on the elbows, prone press-ups, correction of lateral shift; after 2 wk exion in lying, followed by exion in sitting and in standing, postural and ergonomic instructions, home exercises (n 50) (R) Mini Back School, 45-min lesson on back care including anatomy and function of the back, rest position, avoidance of inactivity, and ergonomic instructions (n 50) (I) McKenzie Method plus general advice, educational leaet, groups up to 5 subjects, 1-hr session, return for a further session if pain recurred, home exercises, cointerventions allowed (n 35) (R) Advice, usual general practice care (n 40) Outcomes Mean sick-leave after 3 and 12 wk: R1 signicantly more improved than I1 and I2 Mean pain (11-point scale) after 3 and 12 wk: no signicant differences Mean disability (OSW) after 3 and 12 wk: R1 signicantly more improved than I1 after 3 wk, and R1 signicantly more improved than I2 after 12 wk

Petersen47 (2002)* 6/10

260 patients with subacute or chronic LBP, with or without radiation, 142 men and 118 women, ages 1860 yr

Median disability (15-item scale) post treatment, and after 2 and 8 mo: trend favoring I1 at 2 mo follow-up Median pain (060 scale) posttreatment, and after 2 and 8 mo: no signicant difference

Schenk50 (2003)* 5/10

25 patients with subacute LBP, with radiculopathy, derangement syndrome, 10 men and 15 women, ages 2176 yr

Mean change on pain (VAS) at 3rd visit: I1 signicantly more improved than I2 Mean change on disability (OSW) at 3rd visit: I1 signicantly more improved than I2

Stankovic27 (1990) 6/10 Stankovic28 (1995) 3/10

100 patients with acute LBP, with or without radiation, 77 men and 23 women, mean age 34.4 yr (9.7 yr)

Underwood49 (1998)* 6/10

75 patients with acute LBP, without radiation, no peripheralization after 10 spine extensions, 45 men and 30 women, ages 1670 yr

Pain (graphic scale) after 3 and 52 wk: I signicantly more improved than R Mean days on sick leave: I signicantly more improved than R Subjects on sick leave in the preceding 4 yr: I signicantly more improved than R Recurrences after 1 yr and in the preceding 4 yr signicantly lower in (I) than (R) Mean days on sick leave during recurrences: no signicant difference Mean change on pain (100 mm scale) at 1, 2, 4, 8, 12, and 52 wk: no signicant difference Mean change on disability (OSW) at 1, 2, 4, 8, 12, and 52 wk: no signicant difference Subjects recording LBP no problem in previous 6 mo: I signicantly better than R after 1 yr
Oswestry Disability

LBP low back pain; I intervention (e.g., McKenzie method); R Questionnaire; VAS visual analogue scale. *Classication-based McKenzie.

reference treatment; RMQ

Roland-Morris Questionnaire ; OSW

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Figure 1. Comparison of McKenzie and passive therapy on pain at 1 week.

movements performed in multiple, nonspecic directions,54,55 multiple muscle strengthening and/or stretching, 56 59 lumbar stabilization exercises 60 ); quasirandomized trials61,62; inclusion of patients with specic pathology63; and insufcient report of data on main outcomes.64 Study Characteristics The characteristics of the included studies are presented in Table 1. Five trials reported on acute LBP ( 6 weeks duration),24,26 28,44,49 one reported on subacute LBP (from 6 weeks to 3 months duration),50 and one trial reported on chronic LBP ( 3 months duration).25 Four trials reported on a mixed population of patients.45 48 Eight trials included patients who had LBP with or without radiating symptoms,24,26 28,44 48 one included patients with pain restricted to the lower back,49 one included patients presenting radiculopathy,50 and one trial did not report the location of the symptoms.25 No placebo-controlled trials were located. Different types of interventions were used as reference treatments: educational booklet,44 ice packs,24 massage,46 bed rest,26 advice to stay active,26,49 exion exercises,24,25,48 spinal manipulative therapy,44,45,50 back school,27,28 and back-strengthening exercises.47 For analysis purposes, the following reference treatments were considered under the label passive therapy: educational booklet, ice packs, massage, and bed rest. A similar approach was used in a previous review in which these interventions were labeled as inactive.30 Two trials did not use the term McKenzie method or a synonym to name the intervention.24,26 However, the repeated, direction-specic, passive spine movements used in the studies of Dettori et al24 and Malmivaara et al26 reect McKenzie principles9; therefore, both studies were included in this review. Four trials delivered the McKenzie method together with passive or active cointerventions such as manipulation,48 ice packs,24 educational booklets,24,49 and walk on treadmill.50 In six trials,44,45,4750 the intervention was based on a classication of patients according to the directional preference (classication-based McKenzie); 2 of them were published in the last 3 years.47,50 Among the trials reporting on a generic McKenzie approach,24 28,46 the treatment consisted of extension exercises,25 or the use of extension exercises together with lateral bending,26 and with exion exercises.24,27,28 One trial did not report treatment details.46 Although the studies of Delitto et al,48 Erhard et al,45 Schenk et al,50 and Underwood and Morgan49 clearly

used extension exercises for all participants, this approach was not considered generic McKenzie because all participants were classied before randomization as exhibiting directional preference for extension. Methodologic Quality Nine papers had already had their methodologic quality previously assessed using PEDro scale.24 28,44 46,48 Two reviewers (P.H.F., M.L.F.) independently assessed the quality of the other three trials using the same instrument.47,49,50 Eight papers scored 5 points or more and were considered of high quality24,26,27,44,45,47,49,50 (Table 1). Treatment Effects Clinical and statistical heterogeneity prevented the pooling of trials in which the McKenzie method was compared with exion exercises24,25,48 and spinal manipulative therapy.44,45,50 Pooling was also not possible for trials in which the contrast therapy consisted of back school27,28 and back-strengthening exercises47 because of the absence of multiple studies. For the comparisons with passive therapy and advice to stay active, a metaanalysis based on the random effects model was performed.
McKenzie Versus Passive Therapy. Four trials24,26,44,46 of

mostly high-quality reporting on acute LBP compared McKenzie with passive therapy (educational booklets, bed rest, ice packs, and massage). Two trials were both clinically and statistically homogeneous when assessing pain and disability at 1 week,24,44 and three trials were homogeneous when assessing disability at 4 weeks follow-up.24,44,46 The pooled results show a statistically signicant decrease in pain (WMD on a 0- to 100-point scale, 4.16 points; 95% CI, 7.12 to 1.20) and disability (WMD on a 0 100 point scale, 5.22 points; 95% CI, 8.28 to 2.16) favoring McKenzie at 1-week follow-up when compared with passive therapy (Figures 1, 2). No difference in disability was found between groups at 4 weeks follow-up (Figure 3).
McKenzie Versus Advice to Stay Active. Two high-quality studies reporting on acute LBP compared McKenzie with advice to stay active. The trials were clinically and statistically homogeneous when assessing pain and disability at 12 weeks follow-up.26,49 Both interventions were similar when assessing pain (Figure 4). The pooled results in Figure 5 indicate a statistically signicant decrease in disability (WMD on a 0- to 100-point scale, 3.85 points; 95% CI, 0.30 to 7.39) favoring advice at 12 weeks follow-up.

McKenzie Method for LBP Machado et al E259

Figure 2. Comparison of McKenzie and passive therapy on disability at 1 week.

McKenzie Versus Flexion Exercises. One high-quality24

and two low-quality studies25,48 compared McKenzie with exion exercises. Because of clinical and statistical heterogeneity, the pooled effect was not measured on this comparison. When analyzing the results of individual trials, McKenzie was as effective as exion exercises at 2 weeks for chronic pain (mean difference on a 0- to 100point scale, 2 points; 95% CI, 4 to 8),25 and marginally better than exion exercises for acute pain at 8 weeks follow-up (mean difference on a 0- to 100-point scale, 2 points; 95% CI, 3 to 1).24 Delitto et al48 reported a large effect on acute disability (mean difference on a 0to 100-point scale, 22 points; 95% CI, 26 to 18) favoring McKenzie when compared with exion exercises after 5 days.
McKenzie Versus Spinal Manipulative Therapy. Three highquality trials reporting on acute LBP compared McKenzie to spinal manipulative therapy.44,45,50 Again, clinical and statistical heterogeneity prevented the pooling of trials on this comparison. Individual trials showed contradictory results. Schenk et al50 reported a large reduction in pain (mean difference on a 0- to 100-point scale, 21 points; 95% CI, 41 to 1) favoring McKenzie at the third visit, whereas Erhard et al45 reported a large reduction in disability favoring spinal manipulative therapy after 5 days (mean difference on a 0- to 100-point scale, 17 points; 95% CI, 8 to 27) and 4 weeks (mean difference on a 0- to 100-point scale, 22 points; 95% CI, 10 to 33). McKenzie Versus Back School. The evidence for the effectiveness of McKenzie when compared with back school is based on a single trial. Stankovic and Johnel27,28 reported lower pain scores favoring McKenzie at shortterm follow-up (high-quality paper27) and long-term follow-up (low-quality paper28). However, no data were provided to support these ndings. In the same study, McKenzie resulted in a higher return to work rate (relative risk, 2.05; 95% CI, 1.43 to 2.95).

McKenzie Versus Strengthening Exercises. Only one highquality trial compared McKenzie to strengthening exercises. Petersen et al47 found no statistically signicant differences on pain (mean difference on a 0- to 100-point scale, 7 points; 95% CI, 22 to 9) or disability (mean difference on a 0- to 100-point scale, 1 point; 95% CI, 14 to 12) when McKenzie was compared with strengthening exercises at 8 weeks follow-up for patients with subacute and chronic LBP. At 10 and 32 weeks follow-up, the differences were also nonsignicant.

Sensitivity Analysis A sensitivity analysis was attempted to determine if excluding trials reporting on a generic McKenzie approach had any effect on the results. Six trials comparing the classication-based McKenzie with the following reference treatments were included in this sensitivity analysis: educational booklet,44 advice to stay active,49 exion exercises,48 strengthening exercises,47 and spinal manipulative therapy44,45,50 (Table 1). A pooled analysis could not be performed due to insufcient number of trials on each comparison,44,47 49 and also due to clinical and statistical heterogeneity when there were multiple trials on the same comparison.44,45,50 When evaluating treatment effects of individual trials, the classication-based McKenzie was as effective as an educational booklet,44 advice to stay active,49 and strengthening exercises47 at all time points. Comparisons with exion exercises48 and spinal manipulative therapy50 yield statistically signicant differences favoring the classication-based McKenzie. Nevertheless, as described in the main analysis, the evidence for the effectiveness of McKenzie when compared with spinal manipulative therapy is not consistent. Discussion Although research on primary care management of LBP was scarce until the late 1980s, the increase in govern-

Figure 3. Comparison of McKenzie and passive therapy on disability at 4 weeks.

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Figure 4. Comparison of McKenzie and advice to stay active on pain at 12 weeks.

mental funding and the establishment of scientic meetings on this topic have promoted the proliferation of publications in the last decade.65 LBP has been a frequent focus of systematic reviews and meta-analyses evaluating the effectiveness of different types of interventions.30,3539,66 70 Nevertheless, consistent evidence on treatment effectiveness for this condition is still lacking. There is a rising interest in classication systems that could identify homogeneous subgroups of LBP patients more likely to respond to specic interventions.10 16 The current practice is to perform a diagnostic triage, in which patients are classied into one of the following categories: 1) nonspecic LBP, 2) sciatica/radicular syndrome, and 3) suspected serious spinal pathology.71 Although consistently recommended by clinical practice guidelines,2 this diagnostic triage contains little therapeutic information since the former category refers to a large group of patients that may present different pathophysiologic conditions under the label nonspecic.72 The hypothesis that different therapies have their effectiveness underestimated over the years due to difculties in identifying homogeneous groups of LBP patients has found some support recently. Fritz et al73 found that acute LBP patients assigned to a classication-based therapy reported not only lower disability scores at short- and long-term follow-up, but also faster return to work and lower medical expenses when compared with general exercise therapy. The McKenzie method9 is widely used for the management of LBP patients.74,75 Additionally, the McKenzie method has the strongest evidence for validity among the classication systems based on clinical features.8 However, the evidence for the effectiveness of this classication-based treatment for LBP is unclear. We conducted a systematic review with a meta-analysis approach to summarize the available evidence on the McKenzie method for the treatment of LBP. No placebo-controlled trial was located by this review; therefore, the efcacy of the McKenzie method is unknown at this stage. In the main pooled analyses, trials

in which patients were classied according to the centralization phenomenon (directional preference) were analyzed together with trials in which patients of unknown classications received the same intervention (generic McKenzie). The same procedure was used in the Cochrane review of exercise therapy for LBP.30 In a sensitivity analysis, we attempted to evaluate whether the exclusion of trials reporting on a generic McKenzie approach altered the results of the main pooled analysis. According to the main pooled analysis, there were statistically signicant differences in pain and disability favoring the McKenzie method when compared with passive therapy at 1-week follow-up for acute LBP. However, advice to stay active showed larger effects on disability at 12 weeks when compared with McKenzie for the same population. It is difcult to explain the superior effect of advice to stay active over the McKenzie method because both interventions are similar when it comes to advising patients to avoid bed rest and return to normal activities. The difference between these two approaches might lie on the importance of the structural damage (e.g., disc disease) in McKenzies educational program. According to McKenzies conceptual model, the structural pathology is responsible for the symptomatic presentation, and patients are instructed that, by adopting certain postures and performing specic exercises, the damage can be reversed. The biomedical model of explaining LBP in the McKenzie method may contribute to iatrogenic disability71 that could explain the poorer results of this therapy when compared with information emphasizing positive attitudes without focusing on any damage to the spine. However, it is also hypothesized that the direct association of damage-healing and movement strategies in the McKenzie method provides a learning platform that enable patients to feel greater control over their back problems as well as contributes to improve compliance with their exercises.9 The small magnitude of the differences observed in the pooled analysis ( 6 points on a 0- to 100-point disability scale and 5 points on a 0- to 100-point pain scale) may

Figure 5. Comparison of McKenzie and advice to stay active on disability at 12 weeks.

McKenzie Method for LBP Machado et al E261

reect the absence of clinical worthwhile effects. It is important to note that our results cannot be generalized to a classication-based McKenzie because trials reporting on generic McKenzie were included in the main analysis. In this review, it was not possible to evaluate the effectiveness of a classication-based McKenzie for LBP due to insufcient number of trials and heterogeneity. Another limitation of the main analysis is the use of cointerventions in two studies included in the pooling.24,49 Although this approach reects the usual physiotherapy practice, it does not permit any conclusion on the effectiveness of the McKenzie method over and above the effects of the cointerventions. The study of Delitto et al48 clearly differs from the other included studies showing a large reduction in disability favoring McKenzie (mean difference on a 0- to 100-point scale, 22 points; 95% CI, 26 to 18). In the Delitto et al study,48 McKenzie was compared with exion exercises and only patients with directional preference for extension were included.48 Therefore, it would be expected that exion exercises had shown poorer outcomes since exercises performed toward the directional preference promote centralization of symptoms, whereas exercises performed in the opposite direction promote worsening (peripheralization) of symptoms.9 The study of Dettori et al24 also compared McKenzie with exion exercises, although no attempt was made to exclude patients that did not present a directional preference for extension, what may have contributed to the underestimation of outcomes in the group assigned to this generic McKenzie approach. Apart from the use of a classication-based McKenzie, the poor methodologic quality from the study of Delitto et al48 prevents any conclusion on the effectiveness of the McKenzie method when compared with exion exercises. As occurred in the study of Delitto et al,48 Schenk et 50 al also found a large effect favoring the McKenzie method. McKenzie reduced pain by 21 points on a 0- to 100-point scale (95% CI, 41 to 1) when compared with spinal manipulative therapy.50 the Schenk et al study50 presents an important distinction from other included studies with regards to the population as it is the only study that included patients presenting with radiculopathy. Because the conceptual model that explains the derangement syndrome (the most common mechanical spinal disorder according to McKenzies classication system9) is primarily based on internal intervertebral disc displacements, one may consider that McKenzie would be more effective for this particular population. However, there is no consensus on what is the best conservative treatment for this population of LBP patients.76 According to our results, there are an insufcient number of trials comparing the McKenzie method to back school or strengthening exercises; therefore, the evidence regarding the effectiveness of the McKenzie method on these comparisons is limited at this time. The insufcient number of trials together with heterogeneity among the available trials also prevented any conclu-

sions on the effectiveness of a classication-based McKenzie for LBP. There is still a need for further research in order to clarify whether the McKenzie method as a classication-based treatment differs from a generic McKenzie approach. Conclusion The results of this meta-analysis suggest that the McKenzie method is more effective than passive therapies, including educational booklets, ice packs, and massage for acute LBP patients. However, the small magnitude of the difference may not be considered clinically worthwhile. The effectiveness of classication-based McKenzie is yet not possible to be estimated. Future studies on the McKenzie method should be aware of classifying patients with LBP before assigning them to treatment. Key Points
A meta-analysis of randomized controlled trials was performed. Many trials apply the McKenzie method in a generic fashion and fail to consider patient classication. The McKenzie method does not produce clinically worthwhile changes in pain and disability when compared with passive therapy and advice to stay active for acute LBP.

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