physiotherapy, exercise program, low back pain

This study was published two days ago in Journal of Physiotherapy and its misleading title 100% offends me.

To give a little of a background, the study looked at 262 participants. Out of which 133 of them saw a physiotherapist twice for McKenzie-based self-management exercise and education programme. The researchers then conducted follow ups with them for a year.

Their conclusion is that the McKenzie method does not reduce risk of lower back pain and has no worthwhile effect in the long term.

The paper title suggests that home exercises do not help with low back pain, which is terribly misleading since the researchers only looked at one specific type of exercises.

At best, the authors can only conclude that McKenzie exercises do not help prevent recurrence of back pain.

This is why research can be so confusing for the average pain patient!

What are McKenzie back exercises?

physiotherapy singapore, SIT, singapore tech

Again, this research only looked specifically at exercises prescribed according to The McKenzie Method for back pain.

To give some context, this exercise protocol was developed by a New Zealander physiotherapist Robin McKenzie in in 1981. His school of thought to pain management is also sometimes known as Mechanical Diagnosis and Therapy (MDT), which is actually quite among physical therapists, personal trainers, and massage therapists alike.

It is not a fluff approach to pain management.

To give some example of their popularity (and perhaps sometimes confused with legitimacy), the Bachelor of Physiotherapy programme at Singapore Institute of Technology (SIT) has a Professor Office who is trained specifically in this. MDT is massively popular and they hold regular workshops all around the world via The McKenzie Institute International.

What is MDT?

back pain, mckenzie exercise, mechanical diagnosis and therapy
Source: The Lumbar Spine: Mechanical Diagnosis & Therapy (p. 147)

The Mechanical Diagnosis and Therapy (MDT) is a four step protocol to spinal pain management. Chiropractors and physiotherapists who are utilise the MDT approach will follow these steps when working with patients:

1. Assess
2. Classify
3. Treat
4. Prevent

Their classification system was a breakthrough back in the day (1980s) because it suggested that treatments can be more specific, tailored, individualised care to patients to help them get better results.

Essentially McKenzie claimed that with his method of physical examination testing, back pain patients can be classified into four clusters. With these clusters in mind, McKenzie practitioners can tailor treatments accordingly for faster/better recovery.

mckenzie extension, cobra pose, forward bend
Source: The Alexander technique vs. the McKenzie method in the treatment of lumbosacral radiculopathy

Most back pain patients who have seen a physiotherapist would be familiar with some of the exercises above (which also doubles up as part of the MDT assessment protocol).

Exercises such as forward bends (A) and McKenzie extensions (D) are strongly associated with pain relief and are often included in online rehabilitation program for back pain.

The approach sells like hotcakes because it promises to be an targeted treatment and all pain sufferers want to address their problem at the root cause.

It sounds all good but is there research to support their claim?

Do McKenzie exercises work?

pain relief, MDT, chiropractor singapore
McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain. Source: British Journal of Sports Medicine (2018)

Before we move on, it should be clarified that recent research has shown that using the classification protocol does not improve treatment outcomes.

A study published in 2018 was able to demonstrate that the McKenzie protocol is superior to placebo. However, the difference is so small that the authors themselves concluded that it’s unlikely for it to be meaningful. That means, the improvement is probably not perceivable by the patients.

That is not to say that McKenzie exercises don’t work.

The study compared the Mechanical Diagnosis and Therapy approach against other generic exercise so what this study is really saying is that:

The classification system doesn’t make you get better faster. 

There is no real advantage to following a MDT protocol vs a generic exercise programme.

So if we were to take the classification step out of their protocol, it becomes a generic step-by-step approach that can be applied to almost all forms of techniques and schools of thought: assess, treat, prevent/maintain.

chronic pain, pain solution

The other shortcoming of the McKenzie method is that it completely ignores the influence of psychosocial factors in pain patients. It is, as the name suggest, a strictly mechanical or biomechanical approach to pain management.

Countless research has demonstrated that the problem-based approach is flawed and very possibly not enough to address the complexity of a pain experience. I have discussed this at the limitation of a problem-focused approach.

Exercise options for chronic pain

cognitive behavioural therapy, lower back pain,

This is a good time to introduce Cognitive Functional Therapy (CFT).

Like McKenzie’s approach, it is also an exercise-based program. However, CFT embodies the biopsychosocial model of pain management.

That means CFT doesn’t only look at your physical (musculoskeletal) health. It also considers that lifestyle and psychological factors may potentially be barriers to recovery:

“A physiotherapy-led individualised intervention called cognitive functional therapy (CFT), that targets physical, lifestyle and psychological barriers to recovery, was developed to help patients self-manage chronic low back pain (CLBP).Rather than adopting a one-size-fits-all approach, CFT provides clinicians with the opportunity to explore the multidimensional nature of LBP through the context of the individual.”

Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain. Source: British Journal of Sports Medicine (2020)

disability, ODI, back pain singapore
CFT reduced disability, but not pain, at 6 and 12 months compared with the group-based exercise and education intervention.

This study is a little challenging to interpret because they compared one-on-one CFT (exercise + education + lifestyle coaching) vs group-based exercise + education.

Essentially the study shows that CFT doesn’t have an advantage over generic exercise + education programmes when it comes to pain intensity.

However, when it comes to disability (i.e. how functional you are on a day-to-day basis), CFT had better long-term outcomes.

Again, this is not saying that CFT doesn’t work. It’s saying CFT doesn’t have an advantage over regular exercises when it comes to pain intensity alone.

In this sense, if you want to look at long-term outcomes, it makes more sense to choose an exercise/treatment protocol that works rather than one that doesn’t work.

To give some context on how robust CFT is at reducing disability, a study last year found that CFT had a positive effect on disability even at three years follow-up (European Journal of Pain, 2019)!

Can exercise be a long-term pain solution?

I don’t know.

The fact is that we cannot conclusively say that exercise is the long-term pain solution because there isn’t data to support that yet.

However, research remains promising in that exercise + education + coaching (three-prong approach) is likely to a long-term pain solution for chronic pain.

For the three-year follow up Cognitive Functional Therapy study, the participants only had four to six sessions (based on my estimate) over a three month period. No maintenance/wellness visits. For the other study, the average participant saw a CFT therapists for five visits.

At the end of the day, research is not as cut and dried as we expect it to be.

Yes, research does us specific answers to specific questions.

However, applying these answers to clinical practice involves taking multiple data points from various research to come to ultimately what is a clinical judgement on what is best for the patient.

If you are tired of snake oil chiropractors or physiotherapists giving you firm solutions that doesn’t make sense, come book in an appointment with me to discover the difference the right care can make. At Square One Active Recovery, I only used the latest clinical guideline recommendations to formulate a personalised treatment for your pain.

Your Recovery Journey Begins Now

Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, chiropractor Jesse Cai founded Square One Active Recovery to deliver recovery goals in just 4 to 7 visits.

Not getting results from your chiropractor, TCM doctor or physiotherapist? Book an appointment to discover the difference the right care can make.

*We do not offer short-term pain solutions such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.

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