Influence of Mckenzie protocol and two modes of endurance exercises on health-related quality of life of patients with long-term mechanical low-back pain

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Effectiveness of mechanical diagnosis and therapy in patients with non-specific chronic low back pain: a literature review with meta-analysis

OBJECTIVE

To determine the effectiveness of mechanical diagnosis and therapy (MDT) in patients with chronic low back pain (CLBP) compared to other traditional physical therapy interventions.

METHODS

Randomized controlled trials investigating the effect of MDT compared to other traditional physical therapy interventions in individuals with CLBP were considered eligible. For the purpose of this review, MDT was compared to active and passive physical therapy interventions. Independent reviewers assessed the eligibility of studies, extracted data, and assessed the risk of bias. The primary outcomes investigated were pain and disability.

RESULTS

Fourteen studies were included in the review. Of these, 11 provided data to be included in the meta-analyses. Our findings showed that MDT was no more effective in decreasing pain (standardized mean difference [SMD]=0.01, 95% confidence interval [CI]: -0.44, 0.46) and disability (SMD=0.08, 95% CI: -0.53, 0.68) than other active treatments. Similar results were found when comparing MDT to other passive treatments for pain (SMD=-0.39, 95% CI: -0.90, 0.11) and disability (SMD=-0.13, 95% CI: -0.29, 0.03).

CONCLUSION

There is low to moderate quality evidence that MDT is not superior than other traditional physical therapy interventions in improving pain and disability in people with CLBP.

Effects of Mulligan Mobilization and Low-Level Laser Therapy on Physical Disability, Pain, and Range of Motion in Patients with Chronic Low Back Pain: A Pilot Randomized Controlled Trial

This study aimed to determine the combined treatment effects of Mulligan sustained natural apophyseal glides (SNAGs) and low-level laser therapy (LLLT) on function, pain, and range of motion (ROM) in patients with chronic low back pain. A total of 49 adults participated in this study and were randomly divided into three groups (SNAGs with LLLT group, SNAGs group, and control group). The participants in the SNAGs with LLLT group received SNAGs for 10 min, LLLT for 10 min, and electrotherapy for 10 min. The SNAGs group received SNAGs for 10 min and electrotherapy for 20 min. The control group received electrotherapy for 30 min. All participants received the assigned treatment for 30 min a day, 3 times a week, for 4 weeks. We used the visual analogue scale (VAS) to measure pain, the modified-modified Schober test (MMST) to measure ROM, and the Roland Morris disability questionnaire (RMDQ) to measure physical disability. Compared to the pre-intervention values, the VAS and MMST scores significantly increased after the intervention in the SNAGs with LLLT group (p = 0.000) and the SNAGs group (p = 0.000). The RMDQ score significantly improved in the SNAGs with LLLT (p = 0.000), SNAGs (p = 0.000) and control (p = 0.025) group after the intervention. The inter-group differences were greater for the SNAGs with LLLT and SNAGs groups than for the control group (p = 0.001), and the difference was greater for the SNAGs with LLLT than for the SNAGs (p = 0.001) with respect to the VAS, MMST, and RMDQ scores. These results indicate that significant improvement in pain, function, and ROM may be achieved by a combination of SNAGs and LLLT to treat chronic low back pain.

Mapping evidence on the prevalence, incidence, risk factors and cost associated with chronic low back pain among adults in Sub-Saharan Africa: a systematic scoping review protocol

BACKGROUND

Globally, low back pain (LBP) is a major public health problem affecting mainly adults of the working class and is the leading cause of disability. The estimated lifetime prevalence of LBP is 50 to 80%. From 1990 to 2015, the years lived with disability caused by LBP have scaled up by 54% with the greatest increase observed in low-middle-income countries (LMICs). LBP poses a significant socio-economic burden to the society regardless of all the technological advancement in diagnosis and intervention approaches in recent years. Despite an increase in the literature of LBP in LMICs, chronic low back pain (CLBP) is poorly investigated yet it is responsible for the largest amount of burden. The purpose of this scoping review is to map the existing evidence on the prevalence, incidence, mortality, risk factors, and cost associated with CLBP among adults in Sub-Saharan Africa (SSA).

METHODS

We will conduct a scoping review to explore, describe, and map literature on the prevalence, incidence, mortality, risk factors, and costs associated with CLBP among adults in SSA. The search will be performed using the EBSCOhost platform by searching the following databases within the platform: Academic search complete, health source: nursing/academic edition, CINAHL with full text, Embase, PubMed, MEDLINE, Science Direct databases, Google Scholar, and the World Health Organization library databases. The search will include peer-reviewed, review articles, and gray literature. The first (title and abstract) and the second (full text) screening phases will be performed by two independent reviewers, with the third reviewer employed to adjudicate discrepancies. The reference list of all included articles will also be searched for eligible articles. This scoping review will be reported in accordance to the MOOSE and PRISMA-ScR guidelines. The NVivo 12 data analysis software will be used to generate themes, and a thematic content analysis will be used to give the narrative account of the review.

DISCUSSION

The study anticipates finding relevant literature on the prevalence, incidence, risk factors, mortality, and cost associated with CLBP among adults in SSA. The study outcomes will aid in identifying research gaps, planning, informing policy, commissioning of future research, and funding prioritization.

Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis

Objective

Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP).

Design

Network meta-analysis (NMA).

Data sources

MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL.

Eligibility criteria

Exercise training randomised controlled/clinical trials in adults with NSCLBP.

Results

Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): −1.86 (–2.54 to –1.19)), resistance (SUCRA=80%; −1.14 (–1.71 to –0.56)) and stabilisation/motor control (SUCRA=80%; −1.13 (–1.53 to –0.74)) for physical function and resistance (SUCRA=80%; −1.26 (–2.10 to –0.41)) and aerobic (SUCRA=80%; −1.18 (–2.20 to –0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (–0.71 to 0.89)) and physical function (SUCRA=20%; −0.31 (–0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; −0.31 (–1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria.

Summary/conclusion

There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.

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.

Impact of McKenzie Method Therapy Enriched by Muscular Energy Techniques on Subjective and Objective Parameters Related to Spine Function in Patients with Chronic Low Back Pain

Background

The high incidence and inconsistencies in diagnostic and therapeutic process of low back pain (LBP) stimulate the continuing search for more efficient treatment modalities. Integration of the information obtained with various therapeutic methods and a holistic approach to the patient seem to be associated with positive outcomes.

The aim of this study was to analyze the efficacy of combined treatment with McKenzie method and Muscle Energy Technique (MET), and to compare it with the outcomes of treatment with McKenzie method or standard physiotherapy in specific chronic lumbar pain.

Material/Methods

The study included 60 men and women with LBP (mean age 44 years). The patients were randomly assigned to 1 of 3 therapeutic groups, which were further treated with: 1) McKenzie method and MET, 2) McKenzie method alone, or 3) standard physiotherapy for 10 days. The extent of spinal movements (electrogoniometry), level of experienced pain (Visual Analogue Scale and Revised Oswestry Pain Questionnaire), and structure of the spinal discs (MRI) were examined prior to the intervention, immediately thereafter, and 3 months after the intervention.

Results

McKenzie method enriched with MET had the best therapeutic outcomes. The mobility of cervical, thoracic, and lumbar spine normalized at levels corresponding to 87.1%, 66.7%, and 95% of respective average normative values. Implementation of McKenzie method, both alone and combined with MET, was associated with a significant decrease in Oswestry Disability Index, significant alleviation of pain (VAS), and significantly reduced size of spinal disc herniation.

Conclusions

The combined method can be effectively used in the treatment of chronic LBP.

Translation, cross-cultural adaptation and psychometric evaluation of yoruba version of the short-form 36 health survey

Background and objective

The Short-Form Health Survey (SF-36) is a valid quality of life tool often employed to determine the impact of medical intervention and the outcome of health care services. However, the SF-36 is culturally sensitive which necessitates its adaptation and translation into different languages. This study was conducted to cross-culturally adapt the SF-36 into Yoruba language and determine its reliability and validity.

Methods

Based on the International Quality of Life Assessment project guidelines, a sequence of translation, test of item-scale correlation, and validation was implemented for the translation of the Yoruba version of the SF-36. Following pilot testing, the English and the Yoruba versions of the SF-36 were administered to a random sample of 1087 apparently healthy individuals to test validity and 249 respondents completed the Yoruba SF-36 again after two weeks to test reliability. Data was analyzed using Pearson’s product moment correlation analysis, independent t-test, one-way analysis of variance, multi trait scaling analysis and Intra-Class Correlation (ICC) at p < 0.05.

Results

The concurrent validity scores for scales and domains ranges between 0.749 and 0.902 with the highest and lowest scores in the General Health (0.902) and Bodily Pain (0.749) scale. Scale-level descriptive result showed that all scale and domain scores had negative skewness ranging from −2.08 to −0.98. The mean scores for each scales ranges between 83.2 and 88.8. The domain scores for Physical Health Component and Mental Health Component were 85.6 ± 13.7 and 85.9 ± 15.4 respectively. The convergent validity was satisfactory, ranging from 0.421 to 0.907. Discriminant validity was also satisfactory except for item ‘1’. The ICC for the test-retest reliability of the Yoruba SF-36 ranges between 0.636 and 0.843 for scales; and 0.783 and 0.851 for domains.

Conclusion

The data quality, concurrent and discriminant validity, reliability and internal consistency of the Yoruba version of the SF-36 are adequate and it is recommended for measuring health-related quality of life among Yoruba population.

Prevention of occupational Back Pain

This paper reviews scientific research on occupational back pain and focuses on prevention of this problem. It discusses some of the challenges of translating the evidence of this multi-factorial condition into policy. Medical science is currently unable to clearly distinguish between back pain caused by work and that possibly due to other causes but which affects the individual's capacity to work. Back pain affects the vast majority of people at some point in their lives and is very costly to both the health care system and the industry. Evidence suggests that heavy lifting, driving, and vibration of the whole body are linked to occupational back pain. Once the risk factors for occupational back pain are identified, an otherwise chronic and disabling condition can be prevented in the majority of patients. As explained in this article, three levels of prevention for occupational back pain have been reported as effective. Failure to implement preventive measures may lead to a high incidence of occupational back pain.