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Does It Matter Which Exercise ?. A RCT of Exercise for Low Back Pain Spine 2004;29(23):2593-2602 Long BScPT, Dip MDT R. Donelson, MD MSc T. Fung, PhD. Mechanical assessment identifies reliable, validated subgroups.

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Does it matter which exercise l.jpg
Does It Matter Which Exercise?

  • A RCT of Exercise for Low Back PainSpine 2004;29(23):2593-2602

    Long BScPT, Dip MDT

    R. Donelson, MD MSc

    T. Fung, PhD


Mechanical assessment identifies reliable validated subgroups l.jpg
Mechanical assessment identifiesreliable, validated subgroups

  • Pain location and intensity changes from repeated endrange test movements and positions.

    McKenzie’81, ‘03, & Donelson’90

  • Inter-examiner reliability established.

    Razmjou’00, Werneke’99, Kilpikoski’02 Clair’05

  • Outcome predictive validity well-established.

    Donelson’90, Long’91, Sufka’93, Karas’97, Werneke’99, Werneke’01


Directional preference subgroup l.jpg
Directional Preference Subgroup

  • A single direction of posture or movement that decreases, centralizes, or abolishes symptoms and typically eliminates prior limitation of movement.

    McKenzie-’03, Donelson-’91

  • Reliability: Kappa 0.9 Kilpikoski-Spine-’02


Purpose l.jpg
Purpose

  • To determine if this subgroup of patients would report different outcomes if treated with different exercise protocols:

    • Match the DP (McKenzie)

    • Opposite the DP

    • EBC “Control” Group


Study design l.jpg

MechanicalAssessment

DirectionalPreference

Extension

Lateral

Flexion

Random-ization

Random-ization

Random-ization

DirectionalTreatments

Opposite

Matched

EBG

Mechanical Assessment

Excluded

Study Design

Directional Preference

No Directional Preference


Slide6 l.jpg

Results

N=191 (83%)

N=16 (7%)

N=23 (10%)

Extension

Lateral

Flexion

Random-ization

Random-ization

Random-ization

Matched

EBG

Opposite

N=72

N=63

N=68

Mechanical Assessment

N=312

N=230 (74%)

N=82 (26%)

Directional Preference

No Directional Preference

Excluded

No-Return: 29 (12.6%)

No significant differences between the directional subgroups at baseline.


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Analytical Methods

  • Sample size calculation

  • Descriptive statistics

  • Frequency distributions(includes multiple responses)

  • Two-way Anova

  • Chi-square tests


Side effects l.jpg

34.8%*

32.8%*

0.0%

Side Effects

  • Early Completions

  • Stopped exercises prior to 2 weeks

    • Self –worse or no better

    • Therapist - peripheralizing

50%

40%

30%

20%

p<.001

10%

*included in analysis

0%

1

2

3


Results l.jpg

100%

95%

80%

Worse

No Change

60%

Better

42%

40%

Resolved

23%

20%

0%

Matched

Opposite

EBG

Results

  • Global Rating Improvement

p<.001


Results10 l.jpg
Results

p<.001

p=.003


Results11 l.jpg
Results

p=.016

p=.009


Results12 l.jpg
Results

p<.001

p<.009


Discussion l.jpg
Discussion

  • The clinical intent of directional exercises is “pain control”, that secondarily improves patient function, medication use, depression, and satisfaction with care.

  • Prior studies have established the reliability in identifying this subgroup, along with its validity as a predictor of both good and, in it’s absence, poor outcomes.


Discussion14 l.jpg
Discussion

  • The clinical intent of directional exercises is “pain control”, that secondarily improves patient function, medication use, depression, and satisfaction with care.

  • RCTs of non-specific LBP using non-specific exercise treatments will likely continue to result in equivocal results and misleading conclusions.


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Does It Matter Which Exercise?

  • Conclusions

    • Yes! A mechanical assessment by credentialed MDT therapist can identify a large subgroup for which effective, ineffective, and even counterproductive exercises exist.

    • Early pain reduction using patient-specific directional exercises significantly decreased the need for medication, while improving all outcome measures.

    • Replication needed!


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