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Clare et al: A systematic review of efficacy of McKenzie therapy for spinal pain
A systematic review of efficacy of McKenzie therapy for
spinal pain
Helen A Clare, Roger Adams and Christopher G Maher
The University of Sydney
A systematic review of randomised clinical trials was conducted to investigate the efficacy of McKenzie therapy in the treatment
of spinal pain. Databases searched included DARE, CINAHL, CENTRAL, EMBASE, MEDLINE and PEDro. To be eligible for
inclusion trials had to provide treatment according to McKenzie principles and report on one of the following outcomes: pain,
disability, quality of life, work status, global perceived effect, medication use, health care contacts, or recurrence. Six trials were
found to be eligible, all comparing McKenzie therapy to a comparison treatment. These included NSAIDS, educational booklet,
back massage and back care advice, strength training, and spinal mobilisation and general exercises. The data from five lumbar
trials were pooled at short term (less than three months) and from three at intermediate (3–12 months) follow-up. At short term
follow-up the McKenzie therapy provided a mean 8.6 point greater pain reduction on a 0 to 100 point scale (95% CI 3.5 to 13.7)
and a 5.4 point greater reduction in disability on a 0 to 100 point scale (95% CI 2.4 to 8.4) than comparison. At intermediate
follow-up, relative risk of work absence was 0.81 (0.46 to 1.44) favouring McKenzie, however the comparison treatments
provided a 1.2 point greater disability reduction (95% CI -2.0 to 4.5). In the one cervical trial, McKenzie therapy provided similar
benefits to an exercise program. The results of this review show that for low back pain patients McKenzie therapy does result in a
greater decrease in pain and disability in the short term than other standard therapies. Making a firm conclusion on low back pain
treatment effectiveness is difficult because there are insufficient data on long term effects on outcomes other than pain and
disability, and no trial has yet compared McKenzie to placebo or no treatment. There are also insufficient data available on neck
pain patients.
[Clare H, Adams R and Maher CG (2004): A systematic review of efficacy of McKenzie therapy for spinal
pain.
Australian Journal of Physiotherapy
50: 209–216]
Key Words: Spine; Lumbar Pain; Cervical Pain; Exercises; Meta-analysis; Physical Therapy (Specialty)
Introduction
indicators of the efficacy of the McKenzie method as
described in McKenzie’s texts (McKenzie 1981, McKenzie
1990, McKenzie and May 2003).
The McKenzie method is popular amongst physiotherapists
as a management approach for spinal pain (Battie et al 1994,
Foster et al 1999, Hurly et al 2000). The McKenzie method
utilises an assessment process which aims to identify
subgroups of patients within the non-specific spinal pain
population whose symptoms behave in a similar way when
subjected to mechanical forces. The classification into
subgroups then directs treatment (McKenzie and May 2003).
A key aspect of the McKenzie approach is that the patients
receive individualised treatment based upon their clinical
presentation.
While a number of narrative reviews (Rebbeck 2002, Maher
et al 1999, Danish Institute for Health and Technology
Assessment 1999) have concluded that the McKenzie method
is effective for low back pain, the conclusions of systematic
reviews are preferred as they theoretically provide less biased
estimates of the effects of therapy. Additionally these existing
reviews do not provide a quantitative analysis and so do not
reveal information on the size of the treatment effect.
Accordingly we felt it was appropriate to undertake a new
review.
At present the efficacy of McKenzie therapy is unclear. Many
clinical trials that purport to evaluate McKenzie treatment
provide treatment in a generic rather than individualised
fashion, and include elements not part of the McKenzie
approach. For example in the trial by Stankovic and Johnell
(1990) all patients in the McKenzie group received the same
treatment: extension exercise for two weeks then commence-
ment of flexion exercise. Whilst extension is commonly the
direction of movement that is prescribed, other patients are
prescribed flexion or lateral movements (McKenzie and May
2003, Donelson et al 1991). In a trial by Delitto and
colleagues (1993), which was described as using the
McKenzie method, a sacroiliac joint manipulation procedure
was part of the ‘McKenzie’ treatment whereas this treatment
technique is not described in either the first or second edition
of the McKenzie lumbar spine text (McKenzie 1981,
McKenzie and May 2003). Accordingly some trials that
appear to evaluate McKenzie therapy may not be valid
The aim of this systematic review was to investigate the
efficacy of the McKenzie method of management of non-
specific spinal pain. The specific questions to be investigated
were:
1. What is the comparative efficacy of McKenzie therapy in
relation to inactive treatment (placebo or sham) or no
treatment?
2. What is the comparative efficacy of McKenzie treatment in
relation to other standard therapies (including non-
physiotherapy treatment)?
For this systematic review we chose to exclude studies with
co-interventions so that the efficacy of McKenzie therapy
could be investigated more clearly. Similarly, trials where the
treatment was contrary to McKenzie principles were
excluded.
Australian Journal of Physiotherapy 2004 Vol. 50
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Clare et al: A systematic review of efficacy of McKenzie therapy for spinal pain
Method
Table 1.
Sources of references.
Criteria for considering trials for the review
To be included,
a study had to fulfil several criteria. Only randomised or
quasi-randomised controlled trials were accepted. There were
no language restrictions. Subjects of all age groups and of
either gender were included. Studies were included if the
subject’s primary complaint was non-specific low back pain
or neck pain with or without radiation to the extremities.
Trials that recruited patients with the following specific spinal
pathologies were excluded: cauda equina syndrome, cord
compression, infection, fracture, neoplasm, inflammatory
disease, pregnancy, any form of headache, whiplash-
associated disorders, vertigo/dizziness, and vertebro-basilar
insufficiency. Any duration of symptoms was allowed.
Database searched Records
Records
Included
located
screened
in review
Cinahl
35
5
1
Cochrane Database
3
0
0
of Systematic reviews
DARE
3
0
0
Embase
25
6
4
Medline
23
5
4
PEDro
11
9
4
McKenzie Institute
43
20
5
reference list/McKenzie
Faculty
Trials of primary prevention, where the subjects were
symptom-free at the time of the trial, were excluded. For the
clinical trial to be included it needed to investigate the
efficacy of the McKenzie method/McKenzie treatment in
comparison to no treatment, sham treatment, or another
treatment. Trials where McKenzie therapy was provided with
a co-intervention were excluded.
contrast thought to be of more relevance to current Australian
physiotherapy practice was selected. In the Cherkin et al
(1998) study the educational booklet vs McKenzie contrast
was selected (rather than McKenzie vs chiropractic) and in
the Kjellman and Oberg (2002) study the McKenzie vs
general exercise contrast was selected (rather than McKenzie
vs low dose ultrasound).
Three criteria were used to describe the study regarding the
McKenzie therapy. Studies were required to meet Criteria 1
and 2 to be included in the review:
•
Trial specifies individualised patient treatment.
•
Trial specifies treatment according to the McKenzie
principles.
Data were extracted for ‘short term’, ‘intermediate’, and
‘long term’ follow-up based upon the criteria advocated by
the Cochrane Back Review group (van Tulder et al 2003).
Short term follow-up was defined as less than three months
from randomisation, and if there were multiple eligible time
points the time point closest to six weeks was chosen.
Intermediate was defined as greater than three months and
less than 12 months from randomisation. If there were
multiple eligible time points the time point closest to six
months was chosen. Long term was greater than or equal to
12 months. If there were multiple eligible end points we
chose the time point closest to 12 months.
•
Trial specifies that the treating therapists had formal
training in the McKenzie method.
Trials were required to have reported at least one of the
following outcome measures: pain, disability, quality of life,
work status, global perceived effect, medication use, medical
visits, or recurrence.
Identification and selection of studies
The following
databases were searched up to September 2003: MEDLINE,
EMBASE, DARE, CINAHL, PEDro, the Cochrane Register
of Clinical Trials (CENTRAL), and the Cochrane Database of
Systematic Reviews. Search words used were
McKenzie
therapy, McKenzie treatment, McKenzie method
. Titles and
abstracts of the search output were inspected by the primary
author and clearly ineligible papers were deleted. Full copies
of potentially eligible papers were retrieved and two
reviewers independently screened these trials using the
criteria described above. Members of the McKenzie Faculty
were contacted, and the reference list of the McKenzie
Institute was inspected to locate additional papers.
Unpublished articles were included if they met the criteria for
inclusion.
Data analysis
Pain and disability scores were transformed to
a score ranging from 0 to 100. To describe the effect of
treatment for individual studies we calculated the mean and
95% confidence interval for the between-group differences
(Herbert 2000). Between-group differences in either end
points or within-group change scores were used according to
the data provided in each trial (Green et al 2001). Where
numerical data were not provided they were interpolated from
graphs provided. Where the standard deviation was not
provided, we calculated it from the 95% confidence interval
or standard error (Roberts 1991, Cherkin et al 1998, Gillan et
al 1998) or if there were no data available to do this, we
estimated it as one quarter of the range (Petersen et al 2002,
Schenk et al 2003).
Studies meeting the eligibility criteria were assessed for
methodological quality using the PEDro scale (Maher et al
2003). PEDro scores were extracted from the PEDro database
and where an article had not previously been scored it was
reviewed and scored by an experienced PEDro rater.
For continuous data we estimated the size of the treatment
effect (the difference between group means) and its 95%
confidence interval. For each trial that presented dichotomous
data we estimated the size of the treatment effect as the
relative risk, along with the 95% confidence interval. Trials
with similar outcome measures and time points were grouped
together for pooling. We used a random effects model to
obtain pooled estimates of the difference between groups and
ran a test of statistical heterogeneity of the trial outcomes.
The analyses used algorithms taken from Fleiss (1993).
Data extraction
Data were independently extracted from
each included study by two investigators using a standardised
data extraction form. Disagreements were resolved by
consensus.
In trials with more than two treatment groups, the treatment
210
Australian Journal of Physiotherapy 2004 Vol. 50
Clare et al: A systematic review of efficacy of McKenzie therapy for spinal pain
Table 2.
Excluded studies.
Trial
Reasons for exclusion
Not RCT
Ponte et al 1984 Not an RCT
Borrows et al 1994 Not an RCT
Trial not described as McKenzie therapy: also judged ineligible by reviewers
Williams et al 1991 Posture correction only used
Donelson et al 1991 Assessment with repeated movements only
Malmivaara et al 1995 Back extension and lateral bending exercises given
Buswell 1982 Non-McKenzie procedures included e.g., hip extension in side lying
Erhard et al 1994 All patients were given extension exercises
Dettori et al 1995 All patients were given extension exercises. Lateral shifts corrected manually first
Trial described as McKenzie therapy but included a co-intervention
Elnagger et al 1991 Included active spinal extension exercises
Delitto et al 1993 SIJ manipulation prior to extension exercises
Trial described as McKenzie therapy: treatment according to McKenzie principles but no individualised patient treatment
provided
Nwuga and Nwuga 1985
No individual assessment used, all patients in the McKenzie group given extension exercises
Stankovic et al 1990, 1995
No individual assessment used, all patients given extension exercises
Underwood et al 1998
No individual assessment used, patients treated in a class situation, given extension
exercises and advice
Other
Rosenfield 2000 Not non-specific LBP or neck pain or whiplash-associated disorders
Vanharanta et al 1986 Unable to obtain data
Golby 1995 Unable to obtain data
Kay and Helewa 1994 Unable to obtain data
Larsen et al 2002 Prevention study. Not non-specific LBP/neck pain
RCT = randomised controlled trial, SIJ = sacroiliac joint, LBP = low back pain
Results
reduced activity, number of recurrences (Cherkin et al 1998),
number using pain medication, number visiting general
practitioner, and global change (Petersen et al 2002) (Table
3).
Twenty-four publications were retrieved with six trials
eligible for inclusion in the review (Cherkin et al 1998, Gillan
et al 1998, Kjellman and Oberg 2002, Petersen et al 2002,
Roberts 1991, Schenk et al 2003). The yield from each
database is shown in Table 1. The eighteen excluded papers
and the reasons for exclusion are listed in Table 2. Fifteen
studies were ineligible because they did not meet the
inclusion criteria and three were excluded because we were
unable to retrieve data (one author unable to be contacted,
two authors contacted who stated they could not access
original data). Five of the eligible trials studied patients with
low back pain whilst one reported on neck pain (Kjellman and
Oberg 2002).
In the study that recruited cervical patients (Kjellman and
Oberg 2002) data were provided on changes in pain intensity,
the number reporting continuous pain, and changes in
disability in the short, intermediate, and long term. The
number of patients seeking health care was also provided for
the first six months and for the six to 12 month period.
Methodological quality of the individual trials
The
methodological quality of each trial is described in Table 4
The total PEDro scores ranged from four (Gillan et al 1998)
to eight (Cherkin et al 1998). The most common
methodological flaws were failure to blind the patient and the
therapist (six out of the six trials), however this would be
difficult to achieve in a trial evaluating McKenzie therapy.
Failure to blind the assessor occurred in four of six studies
and failure to explicitly use an intention to treat analysis
occurred in four of six studies
.
Assessment of outcome
From the low back pain trials, three
provided data on changes in pain in the short term (Cherkin et
al 1998, Petersen et al 2002, Schenk et al 2003) but none
provided data beyond this. Five trials reported data on short-
term disability (Roberts 1991, Cherkin et al 1998, Gillan et al
1998, Petersen et al 1998, Schenk et al 2003) whilst two
reported data for intermediate disability (Cherkin et al 1998,
Petersen et al 2002). No long-term pain or disability data
were provided. Data on work absence between three and 12
months were provided in two studies (Cherkin et al 1998,
Petersen et al 2002). The pain, disability, and work absence
data were pooled. Data provided that were unable to be
pooled because they were provided in a single trial included:
Treatment efficacy
The effect sizes of the individual lumbar
trials and pooled results are shown in Table 5. None of the
tests for statistical heterogeneity was significant (all
p
>
0.10). At short term follow-up, for both pain and disability
outcomes, the individual trial results mostly favoured
McKenzie therapy. Both pooled results revealed a statistically
significant, though small, between-group difference
Australian Journal of Physiotherapy 2004 Vol. 50
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Clare et al: A systematic review of efficacy of McKenzie therapy for spinal pain
Table 3.
Summary of included trials.
Trial
Setting
Duration
Pain type
Interventions
Outcomes measured and
follow-up
Roberts
Hospital
Pain less
Nerve root
1. McKenzie physiotherapy
St Thomas questionnaire,
1990
clinic
than 3 weeks entrapment
assessment, treatment based
visual analogue scale at 7
excluded
on McKenzie method.
weeks, 6 months and 12
Lumbar roll and written
months, work absence 7
instructions given.
weeks and 6 months,
2. Ketoprofen Slow Release
recurrence of back pain at 6
200 mg 28 days.
months.
Cherkin
Primary care Pain longer
Subjects with
1. Physical therapy – McKenzie Roland disability scale,
et al 1998
clinics
than 7 days
sciatica (not assessment, patients classified, bothersomeness at 4 and 12
defined) excluded treated accordingly. Book
weeks, 1 and 2 years,
Treat Your Own Back
and
sought care at 2 years,
lumbar support provided.
quality of care at 4 weeks.
2. Chiropractic manipulation
and assessment, short lever
high-velocity thrust manipulations.
Exercise sheet given.
3. Educational booklet provided
Gillan
Hospital
LBP less than Pain distribution.
1. McKenzie management –
Trunk list and straight leg
et al 1998
setting
12 weeks
not stated.
assessment and individualised raise at 7, 14, 28, and 90
Trunk list
treatment.
days.
essential
2. Non-specific back massage Oswestry scale at 28 and
and back care advice.
90 days.
Kjellman & Private
Duration of
Neck pain with
1. McKenzie management – Pain frequency, intensity,
Oberg 2002 practice
neck pain not or with-out
assessment and individualised Neck Disability Index
specified
radiation
treatment. 2 sessions per week at 2, 6 and 12 months,
for 8 weeks. Home exercises
sought care at 6 and 12
given.
months.
2. General exercises for cervical
mobility and strength, 2 sessions
per week for 8 weeks. Home
exercises given
Petersen
Hospital
LBP for longer LBP with or
Standard protocol:
Disability – Manniche’s Low
et al 2002
setting
than 8 weeks without leg
Home exercises for a minimum . Back Pain rating scale, pain
pain
of 2 months. Maximum of 15 score, global change, using
visits in 8 weeks. pain medication, sick leave,
1. McKenzie – assessment and sought care at 2 and 8
individualised treatment.
months.
2. Strengthening – group
sessions, intensive dynamic
back strengthening in flexion
and extension, stretching for
hip and trunk.
Schenk
Setting
LBP for 7
Lumbar
Standard protocol:
Visual analogue scale.
et al 2003
not
days but less radiculopathy
Postural correction and 20 mins Oswestry scale at 3rd visit.
specified
than 7 weeks with or without
x 3 visits, treadmill. 5 sets of 10
neurological
interventions.
signs
1. Exercise group – individual
exercises based on assessment
findings.
2. Mobilisation group – passive
movements based on the
assessment findings.
LBP = low back pain
favouring McKenzie therapy.
At intermediate follow-up the between-group differences of
most individual studies and the pooled result for disability
were small and not statistically significant. Work absence at
the intermediate time point favoured McKenzie therapy but
the effect was not statistically significant.
In the cervical study the McKenzie group had less pain and
disability at short and intermediate follow-up however the
effect sizes were small and not statistically significant. The
effects on pain were: -8.0 (-21 to 5) and -2.0 (-15 to 11). The
effects on the Neck Disability Index were: -5.0 (-13.2 to 3.2)
and -2.0 (-10.7 to 6.7). The McKenzie group had fewer health
care contacts in the following 12 months than the exercise
groups (relative risk 0.86, 0.29 to 2.54) however the effect
was not statistically significant.
Sensitivity analysis
To determine if excluding trials where
212
Australian Journal of Physiotherapy 2004 Vol. 50
Clare et al: A systematic review of efficacy of McKenzie therapy for spinal pain
Table 4.
Methodological quality of trials (PEDro score).
Study
1
2
3
4
5
6
7
8
9
10
11
Score
Roberts 1991
-
3 33
-
-
-
3
-
3 3
6
Cherkin 1998
3333
-
-
33333
8
Gillian 1998
3 3
-
3
-
-
3
-
-
3
-
4
Kjellman 2002
3333
-
-
-
3
-
33
6
Petersen 2002
3 333
-
-
-
-
3 33
6
Schenk 2003
33
-
3
-
-
-
3
-
33
5
PEDro items:
1 Eligibility criteria; 2 Random allocation; 3 Concealed allocation; 4 Comparability at baseline; 5 Patient blinding;
6 Therapist blinding; 7 Assessor blinding; 8 At least 85% follow-up; 9 Intention to treat analysis; 10 Between-group statistical
comparisons; 11 Point measures and measures of variability.
Item 1 not included in PEDro score
individualised treatment was not provided affected the
results, a sensitivity analysis was conducted including the
data from these trials (Nwuga and Nwuga 1985, Stankovic
and Johnell 1990, Underwood and Morgan 1998). Two of the
studies reported data on short-term pain (Nwuga and Nwuga
1985, Underwood and Morgan 1998), and one on short-term
disability (Underwood and Morgan 1998) which were pooled
with the other low back pain trials. Other data which could
not be pooled were long-term pain and disability (Underwood
and Morgan 1998), recurrence at one year and number on sick
leave at one year (Stankovic and Johnell 1990). The pooling
of these data with the other low back pain trials did not
significantly alter the conclusion of the review, with the short-
term pain effect increasing slightly to -11.4 (-17.2 to -5.6) and
short-term disability increasing to -5.6 (-8.3 to -2.9) with both
effects favouring McKenzie.
Discussion
worthwhile because it would be sufficient to move a patient
from ‘minimally improved’ to ‘much improved,’ or from
‘much improved’ to ‘very much improved.’
The long term effects of McKenzie therapy on pain outcomes
in patients with low back pain are uncertain because no study
provided data beyond three months. The data on disability
suggest that effect on disability reduction is not clinically
relevant because the upper estimate of the treatment effect,
reduction in disability of 4.5 points out of 100, is probably too
small to be judged as worthwhile by patients. However
judging what effect sizes for disability reduction are clinically
worthwhile is difficult because there is no study analogous to
Farrar et al (2000) for disability outcomes. The effect of
McKenzie therapy on work absence is unclear because only
two studies reported data for work absence, both measured
outcome at intermediate follow-up, and the individual studies
and the pooled result provide very imprecise estimates of the
effect.
Using pre-defined selection criteria, most of the results from
individual studies and the pooled results reveal that
McKenzie therapy was statistically significantly more
effective than other treatments in reducing pain and disability
at short term follow-up. Our results suggest that McKenzie
therapy provides on average 8.6 point greater short term pain
reduction (pain measured on a 0 to 100 point scale) than other
conservative treatments. The sensitivity analysis revealed a
slightly greater effect of 11.4 points.
We did not set a minimum quality score for inclusion in the
review but instead planned to look at the relationship between
trial quality and outcome. However because so few studies
were located it was judged not to be worthwhile to proceed
with this analysis. All of the trials included for analysis scored
above the minimum PEDro score of three set by Ferreira and
colleagues in their review of spinal manipulative therapy
(Ferreira et al 2002). Inspecting the individual quality items
reveals that most studies fared less well on the validated
quality items (randomisation, concealed allocation, blinding).
While it is hard to achieve therapist and patient blinding in
trials of McKenzie therapy, blinding of assessors should be
achievable. Concealed allocation is also achieved relatively
easily, e.g. through the use of sealed opaque envelopes
containing the allocation codes.
Given these results the issue is whether the greater pain
reduction associated with McKenzie therapy, of the order of
10 points on a 0 to 100 point scale, is clinically worthwhile.
Judging what is a clinically worthwhile effect is made
difficult by the fact that there are little data available to
inform the decision. In the 2001 study by Farrar et al, 2700
patients with chronic pain participating in trials of drug
therapy were asked to rate their pain (originally on a 0 to 10
scale but transformed to 0 to 100 to allow comparison to our
review) at baseline and follow-up. They also rated their
global impressions of improvement at follow-up on the
following scale: very much worse, much worse, minimally
worse, no change, minimally improved, much improved, very
much improved. Farrar et al (2001) reported that a pain
improvement of 10 points most accurately detected patients
who considered themselves to be at least ‘minimally
improved,’ 17 points was the best cut-off for ‘much
improved,’ and 28 points for ‘very much improved.’
Accordingly an effect size of the order of 10 points, as we
found for pain in the short term, could be considered
In general the studies suggest that McKenzie therapy is more
effective than the comparison treatment at short term follow-
up. The comparison treatments in the trials included
NSAIDS, educational booklet, back massage and back care
advice, strength training, and spinal mobilisation and general
mobility exercises. We felt that it was appropriate to pool data
from these trials because they are all considered
contemporary treatments for spinal pain. With our strict
inclusion criteria we have studies that are more homogeneous
with regard to the experimental treatment than is usually the
case in systematic reviews because we excluded trials where
co-interventions were permitted and also those trials that did
not provide McKenzie therapy consistent with McKenzie’s
Australian Journal of Physiotherapy 2004 Vol. 50
213
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