Low Back Pain: Does it Matter Which Exercise?

Long A. et al.  Does It Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine: 2004
  • The Cochrane Back Review Group has referred to the identification of subgroups and predictors of chronicity as “the Holy Grail” of LBP 
  • One subgroup classification method (McKenzie Method) often referred to as Mechanical Diagnosis and Therapy (MDT), has demonstrated strong interrater reliability and other clinically useful properties: predicting outcome and discogenic pathology, and providing preliminary evidence of patient-specific treatments based on assessment findings 
  • An important feature of the MDT assessment is the identification of a patient’s “directional preference” (DP). DP is identified when posture or repeated end-range movements in a single direction (flexion, extension, or side-glide/rotation) decrease or abolish lumbar midline pain, or cause referred pain emanating from the extremities to appear to progressively retreat in a proximal direction back toward the lumbar midline 
  • The objective of this study is to determine if a subject-specific exercise prescription concordant with a study participant’s DP will achieve better outcomes than non-concordant exercises. 
  • The three treatment protocols are summarized as follows: 1) Matched: Subjects were taught unidirectional end-range lumbar exercises matching the direction of their DP identified during baseline assessment. 2) Opposite: Subjects were also taught unidirectional end-range exercises, but in a direction opposite to their DP. 3) Evidence-based care (EBC): Subjects were taught commonly prescribed multidirectional, midrange lumbar exercises, and stretches for the hip and thigh muscles 
  • Both the opposite and EBC groups were provided education consistent with LBP clinical guidelines, including advice aimed at minimizing fear avoidance behavior and to remain active. Members of the matched group were likewise instructed to remain active but also to avoid activities and positions that increase intensity or radiation of symptoms. 
  • Outcome Measures. Primary outcomes included back and leg pain intensity ratings using an 11-point visual analogue scale,the 24-item Roland Morris Disability Questionnaire. Secondary outcome measures included a rating of activity interference at work and home (0–5) the 21-item Beck Depression Inventory and the Quebec Task Force severity scale 
  • The matched group had statistically significantly greater improvement than the other two treatment groups in all five areas of satisfaction with care: return to work, home and recreational activity, perceived need for further treatment, and self-rated improvement 
  • Exercises concordant with patients’ DP significantly improved outcomes compared with nonconcordant exercises and advice, and appear to be an effective pain control/elimination treatment strategy. This refutes prior systematic reviews concluding that specific exercises are not warranted.
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