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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
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
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
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
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

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

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.

analytical methods
Analytical Methods
  • Sample size calculation
  • Descriptive statistics
  • Frequency distributions(includes multiple responses)
  • Two-way Anova
  • Chi-square tests
side effects

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

100%

95%

80%

Worse

No Change

60%

Better

42%

40%

Resolved

23%

20%

0%

Matched

Opposite

EBG

Results
  • Global Rating Improvement

p<.001

results10
Results

p<.001

p=.003

results11
Results

p=.016

p=.009

results12
Results

p<.001

p<.009

discussion
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
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.
does it matter which exercise15
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!