Spine (Phila Pa 1976) 2011 (Nov 15); 36 (24): 1999-2010 ~ FULL TEXT
Petersen, Tom PT, PhD; Larsen, Kristian PT, PhD; Nordsteen, Jan DC, MPH; Olsen, Steen PT; Fournier, Gilles MD, DC, BSc; Jacobsen, Soren MD, DrMsci
Back Center Copenhagen,
Study design: Randomized controlled trial.
Objective: To compare the effects of the McKenzie method performed by certified therapists with spinal manipulation performed by chiropractors when used adjunctive to information and advice.
Summary of background data: Recent guidelines recommend a structured exercise program tailored to the individual patient as well as manual therapy for the treatment of persistent low back pain. There is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies to clinical subgroups of patients in primary care.
Methods: A total of 350 patients suffering from low back pain with a duration of more than 6 weeks who presented with centralization or peripheralization of symptoms with or without signs of nerve root involvement, were enrolled in the trial. Main outcome was number of patients with treatment success defined as a reduction of at least 5 points or an absolute score below 5 points on the Roland Morris Questionnaire. Secondary outcomes were reduction in disability and pain, global perceived effect, general health, mental health, lost work time, and medical care utilization.
Results: Both treatment groups showed clinically meaningful improvements in this study. At 2 months follow-up, the McKenzie treatment was superior to manipulation with respect to the number of patients who reported success after treatment (71% and 59%, respectively) (odds ratio 0.58, 95% confidence interval [CI] 0.36 to 0.91, P = 0.018). The number needed to treat with the McKenzie method was 7 (95% CI 4 to 47). The McKenzie group showed improvement in level of disability compared to the manipulation group reaching a statistical significance at 2 and 12 months follow-up (mean difference 1.5, 95% CI 0.2 to 2.8, P = 0.022 and 1.5, 95% CI 0.2 to 2.9, P = 0.030, respectively). There was also a significant difference of 13% in number of patients reporting global perceived effect at end of treatment (P = 0.016). None of the other secondary outcomes showed statistically significant differences.
Conclusion: In patients with low back pain for more than 6 weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.
From the FULL TEXT Article:
Disability related to low back pain (LBP) is a major
problem in the Western World. [1, 2] About 60% to 65% of the Nordic population are likely to experience LBP during their lifetime and 45% to 55% of adults will experience pain within a 12–month period.  Studies from a variety of countries investigating the long-term course of LBP show that
most patients will improve rapidly.  Further improvement is apparent until about 3 months. Thereafter, levels for pain, disability,
and return to work remains almost constant. Six months after an episode of LBP, 60% to 70% of patients will have experienced
relapses of pain and 16% will be sick-listed. As much as 62% will still be experiencing pain after 12 months. [4, 5]
The most recent published consensus reports for the treatment
of patients with persistent nonspecific low back pain (NSLBP)
recommend a program that focuses on self-management after
initial advice and information. These patients should also be
offered a structured exercise program tailored to the individual
patient and other methods such as manipulation. [6, 7]
Previous studies have compared the effect of the McKenzie
method, also called Mechanical Diagnosis and Therapy (MDT), with that of manipulation in mixed populations of patients with acute and subacute symptoms of NSLBP and found no difference in outcome. [8, 9]
Recently, the need for studies testing the effect of treatment
strategies for diagnostic subgroups of patients with NSLBP in
primary care has been emphasized [10–12] based on the hypothesis
that subgrouping methods improve decision-making toward the most effective management strategies. Although initial data show promise, there is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies in primary care. 
Three randomized studies have tested the effects of the
McKenzie method versus spinal manipulation in a subgroup
of patients with predominantly acute or subacute NSLBP that
responded favorably to end range motions during physical
examination. [13–15] The conclusions drawn from these studies were not in concurrence and they were limited by a low methodologic quality. To pursue the idea of subgrouping further, we wanted to focus on a more homogeneous clinical subgroup of patients by the inclusion of patients with NSLBP characterized by centralization or peripheralization of symptoms during physical examination. To control for the benign natural course of LBP in the early phases, patients with persistent pain were targeted. In addition, we wanted to increase the relevance of the study for daily practice by incorporating the latest recommendations regarding self-management in both the treatment arms.
The objective of this study was to compare the effects of
the McKenzie method with those of spinal manipulation when used adjunctive to information and advice in a clinical subgroup of patients with LBP of more than 6 weeks duration.
In both the McKenzie and the manipulation group, longterm
improvements were observed. Although between-group differences were not particularly large at all follow-ups, the McKenzie method appeared to be the more favorable method of treatment. The sensitivity analysis showed that the results were robust and the between-group differences remained after adjustment for predefined prognostic variables. The difference in number of patients reporting success after treatment was slightly below the predefined clinical relevant level of 15% and furthermore the difference in reduction of disability was below the 2.5 points recommended by others. 
Number of patients with treatment success was chosen as
the main outcome measure in this trial based on the belief
that clinicians need to be able to tell patients what their
chances are of obtaining a specific outcome. The reports of
mean improvement are useful, but around every mean value
there will be patients who fare better than the mean and those
who fare worse. In our definition of treatment success, we
used a strict definition of minimal clinical important difference on RMDQ in the upper end of the recommended interval
from 2.5 to 5 points.  A lack of a nontreatment control group in this study means that conclusions cannot be drawn as to whether our results can be explained by the natural history of back pain or nonspecific effects such as extra attention. However, the long pretreatment duration of symptoms and the minimal change in disability across two baseline measures in the Regression to The Mean analysis suggest that the patient sample was in a stable condition and that an important improvement without intervention should not
be expected. Furthermore, an attempt was made to distribute
attention bias evenly between groups by securing that all
practitioners were dedicated to the type of treatment they
performed and the patients in both groups received the same
amount of contact. A limitation of the study is a relatively
high withdrawal rate during intervention.
The withdrawal rate covers patients who decided to discontinue treatment during the course as well as patients that were excluded by decision of the practitioner. The majority withdrew or was excluded for reasons likely to be related to lack of treatment effect (43 patients in the manipulation group vs.  in the
McKenzie group). The difference in withdrawal rate between
groups supports the conclusion that the McKenzie treatment
was the most suitable for our patient sample. A difference in
proportions of this magnitude is not likely to be explained
by an unequal distribution of candidates for The McKenzie
method and Manipulation withdrawal/exclusion as an effect
of randomization especially because the patients’ expectations
to improvement were similar in the groups. Most of these
patients responded to follow-up questionnaires and were
included in the intention-to-treat analysis. This procedure
appears reasonable also from a clinical perspective, inasmuch
as there was a large difference between groups in the number
of patients withdrawing or already excluded after the first
visit (16 patients in the manipulation group vs. 1 patient in the McKenzie group) (data not presented).
Unfortunately, the enrolment of patients had to be stopped
before the planned sample size was reached due to a change in
overall patient care politics by decision of the management of
the Back Center Copenhagen. Although the study was slightly
underpowered at long-term follow-up, the narrowness of
confidence intervals suggests that type II error is unlikely.
This trial compared the effectiveness of treatments commonly
used in primary care. However, the generalizability of
our treatment results might be hampered by the fact that clinical decision making was performed without standardization
by highly skilled clinicians.
What is new in this study is the inclusion of patients with
persistent LBP and a changeable symptomatology, that is,
both centralizers and peripheralizers during initial screening.
Based on a randomized study it has been concluded that centralizers do better than noncentralizers when treated with the McKenzie method compared to other types of treatment.  However, the poor outcome reported among noncentralizers in that study might be related to patients with no change in symptoms during initial examination. In our post hoc analysis of interaction, centralization was not a treatment effect modifier. Also the value of centralization as a prognostic factor for outcome (regardless of treatment) shown in earlier studies  has been challenged by recent published data. [38, 39] The question remains: are centralization and peripheralization prognostic factors regardless of treatment or are they treatment effect modifiers related to a specific treatment?
We used particularly strict criteria for centralization or
peripheralization of symptoms 16 because these have demonstrated
an association with positive discography.  We recognize that the diagnostic value of discography is controversial,  however, when performed with determination of a control disc, there appears to be no other means of directly challenging the intervertebral disc to detect if it is the source of LBP.  The majority of patients were classified as reducible
disc syndromes based on the finding of centralization
of symptoms from a distal to a more proximal body part.
Although previous studies [37, 42] have used more liberal definitions of centralization, results of those studies might indicate
that such a subgroup of patients would profit the most from
the McKenzie method. On the other hand, a recent review
concluded that patients with signs of a possible lumbar disc
disease with or without nerve involvement often undergo spinal
manipulative treatment in practice and the hypothesis that
high-velocity spinal manipulation may be effective in these
patients is supported by current evidence. 
In our study, the number of patients with clinical signs of
nerve root involvement was distributed evenly between treatment
groups, but more patients in the manipulation group were referred to surgical evaluation for this reason (nine
patients in the manipulation group vs. five in the McKenzie group) (Table 2). Although this small number of patients is not likely to influence the overall outcomes, this finding suggests that the McKenzie method should be recommended as the first choice for the treatment of these patients.
The within-group results of our study might indicate that
the manipulative approach to patients with centralization of
peripheralization of symptoms should be considered, if the
McKenzie method fails to provide improvement.
The most apparent differences between the treatments
compared in this study were as follows: treatment by the
McKenzie method was mainly performed by patient generated
force using repeated or static movements to end range
of motion in a direction that relieves the patient’s symptoms
during physical examination, where as spinal manipulation
was mainly performed by manually generated force using a
single thrust movement with low amplitude in a direction of
restricted movement as judged by clinical examination. Both
treatment methods, however, intended to mobilize intervertebral
spinal joints, and both were monitored by the patient’s
pain response during the course of treatment. Thus, both
treatments are likely to influence the same pain mechanism.
This might be one of the possible explanations for the relatively modest difference between treatments in our patients.
Evidence from randomized trials in clinical subgroups
of patients comparable to ours have provided promising
results in patients with predominantly acute and subacute
LBP. [13, 14, 37, 42] Those studies did not intent to suggest a possible pathoanatomical condition, but rather to delineate a subgroup of patients with increased chance of responding to a specifi c intervention. They have included a broader group of patients with a directional preference, that is, a favorable response to end range motion tests during physical examination regardless of whether the response was centralization or just an improvement in intensity of symptoms. The study by Long et al  with 2 weeks follow up found greater improvement by the McKenzie method when compared with general mobilizing and stretching exercises. The study by Browder et al  with 6 months follow-up suggests substantial benefit of the McKenzie method compared with lumbar strengthening exercises.
Schenk et al 14 found greater improvement by the McKenzie method as compared with that of spinal manipulation, where as Erhard et al  reached the opposite conclusion. Both of the latter studies, however, were hampered by a low methodologic quality (small sample size, only short-term follow-up, and/or blinding of investigator uncertain). In addition, all of the four abovementioned studies are subjected to the risk of intervention bias inasmuch as the same practitioner performed both of the treatments compared. In a recent study, Kilpikoski et al  performed a secondary analysis of data from their earlier published trial  comparing the McKenzie method with manipulation. Only patients classified as centralizers were included. Although it suffered from small sample size, the study found a tendency in favor of the McKenzie method compared with manipulation that reached a statistical significance only in reduction of disability at 6 months follow-up.
Given the promising preliminary results in the literature
and the improvement rate achieved in both our treatment
groups, a future research area would be to explore clinical
findings that identify which patients respond better to the
McKenzie method or manipulation in patients with acute,
subacute, or chronic LBP. Furthermore it seems worthwhile
to test the effects of a combination of the two treatments as
suggested by the results of a series of case reports. 
The McKenzie-method and spinal manipulation are recommended treatments for patients with persistent nonspecific LBP. Preliminary evidence from
low-quality studies comparing the two interventions
is promising although results from those studies have
only been reported in populations with acute or subacute
low back and mainly for short-term outcomes.
In patients with persistent LBP showing centralization or peripheralization of symptoms, this study
found the McKenzie-method to be more effective
than spinal manipulation when applied adjunctive to
information and advice, although clinical relevance is
The between-group differences in outcome were
most apparent 2 and 12 months after the completion
of treatment. However, differences were not particularly
The results of this study support the value of a classification approach based on clinical examination
fi ndings in the management of patients with LBP in
Pain in Europe. 2007. Available at:
Accessed June 2011.
Waddell G , Burton AK , Main CJ.
Screening to Identify People at Risk of Long-Term Incapacity for Work.
A conceptual and scientific review.
London : Royal Society of Medicine Press Ltd.; 2003.
Leboeuf-Yde C, Klougart N, Lauritzen T.
How common is low back pain in the Nordic population? Data from a recent
study on a middle-aged general Danish population and four surveys
previously conducted in the Nordic countries.
Pengel, HM, Maher, CG, and Refshauge, KM.
Systematic review of conservative interventions for subacute low back pain.
Clin Rehabil. 2002; 16: 811–820
Hestbaek L , Leboeuf-Yde C , Manniche C.
Low back pain: what is the long term course?
A review of studies of general patient populations.
Eur Spine J 2003; 12 : 149–65.
National Institute for Health and Care Excellence (NICE 2009)
Early Management of Persistent Non-specific Low Back Pain
NICE Clinical Guideline 88. UK
Royal College of General Practitioners Published date: May 2009
Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr., Shekelle P, Owens DK:
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491
Cherkin DC, Deyo RA, Battie M, et al.
A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision
of an Educational Booklet for the Treatment of Patients with Low Back Pain
New England Journal of Medicine 1998 (Oct 8); 339 (15): 1021-1029
Paatelma M , Kilpikoski S , Simonen R , et al.
Orthopaedic manual therapy, McKenzie method or advice only for low back pain
in working adults. A randomized controlled trial with 1 year follow-up.
J Rehabil Med 2008; 40 : 858–63.
Borkan JM , Cherkin DC.
An agenda for primary care research on low back pain.
Spine 1996; 21 : 2880–4.
Foster NE , Dziedzic KS , van Der Windt DA , et al.
Research priorities for non-pharmacological therapies for common
musculoskeletal problems: nationally and internationally agreed recommendations.
BMC Musculoskelet Disord 2009; 10 : 3.
Hancock MJ , Maher CG , Latimer J , et al.
Systematic review of tests to identify the disc,
SIJ or facet joint as the source of low back pain.
Eur Spine J 2007; 10 : 1539–50.
Erhard RE , Delitto A , Cibulka MT.
Relative effectiveness of an extension program and a combined program of
manipulation and flexion and extension exercises in patients with acute low back syndrome.
Phys Ther 1994; 74 : 1093–100.
Schenk RJ , Josefczyk C , Kopf A.
A randomized trial comparing interventions in patients with lumbar posterior derangement.
J Man Manipul Ther 2003; 11 : 95–102.
Kilpikoski S , Alen M , Paatelma M , et al.
Outcome comparison among working adults with centralizing low back pain:
secondary analysis of a randomized controlled trial with 1-year follow-up.
Adv Physiother 2009; 11 : 210–7.
Diagnostic classification of non-specific low back pain.
A new system integrating patho-anatomic and clinical categories.
Physiother Theory Pract 2003; 19 : 213–37.
Petersen T , Olsen S , Laslett M , et al.
Inter-tester reliability of a new diagnostic classification system
for patients with non-specific low back pain.
Aust J Physiother 2004; 50 : 85–94.
Laslett M , Oberg B , Aprill CN , et al.
Centralization as a predictor of provocation discography results in chronic
low back pain, and the influence of disability and distress on diagnostic power.
Spine J 2005; 5 : 370–80.
Waddell G , McCulloch JA , Kummel E , et al.
Nonorganic physical signs in low-back pain.
Spine 1980; 5 : 117–25.
Aina A , May S , Clare H.
The centralization phenomenon of spinal symptoms—a systematic review.
Man Ther 2004; 9 : 134–43.
McKenzie RA , May S.
The Lumbar Spine: Mechanical Diagnosis & Therapy.
Waikanae, New Zealand : Spinal Publications; 2003.
Treat Your Own Back.
New Zealand : Spinal Publications New Zealand Ltd.; 1997.
Burton AK , Waddell G , Tillotson KM , et al.
Information and advice to patients with back pain can have a positive effect.
A randomized controlled trial of a novel educational booklet in primary care.
Spine 1999; 24 : 2484–91.
Patrick DL , Deyo RA , Atlas SJ , et al.
Assessing health-related quality of life in patients with sciatica.
Spine 1995; 20 : 1899–908.
Albert H , Jensen AM , Dahl D , et al.
Criteria validation of the Roland Morris questionnaire. A Danish translation
of the international scale for the assessment of functional level
in patients with low back pain and sciatica
[Kriterievalidering af Roland Morris Spørgeskemaet - Et oversat internationalt skema til vurdering af ændringer i funktionsniveau hos patienter med lædesmerter ogischias].
Ugeskr Laeger 2003; 165 : 1875–80.
Bombardier C , Hayden J , Beaton DE.
Minimal clinically important difference. Low back pain: outcome measures.
J Rheumatol 2001; 28 : 431–8.
Ostelo RW , de Vet HC.
Clinically important outcomes in low back pain.
Best Pract Res Clin Rheumatol 2005; 19 : 593–607.
Manniche C , Asmussen K , Lauritsen B , et al.
Low Back Pain Rating scale: validation of a tool for assessment of low back pain.
Pain 1994; 57 : 317–26.
van der RN , Ostelo RW , Bekkering GE , et al.
Minimal clinically important change for pain intensity, functional status,
and general health status in patients with nonspecific low back pain.
Spine 2006; 31 : 578–82.
SF-36 health survey update.
Spine 2000; 25 : 3130–9.
Deyo RA , Battie M , Beurskens AJ , et al.
Outcome measures for low back pain research.
A proposal for standardized use.
Spine 1998; 23 : 2003–13.
Ostelo RW , Deyo RA , Stratford P , et al.
Interpreting change scores for pain and functional status in low back pain:
towards international consensus regarding minimal important change.
Spine 2008; 33 : 90–4.
Lauridsen HH , Hartvigsen J , Manniche C , et al.
Responsiveness and minimal clinically important difference
for pain and disability instruments in low back pain patients.
BMC Musculoskelet Disord 2006; 7 : 82.
Morton V , Torgerson DJ.
Effect of regression to the mean on decision making in health care.
BMJ 2003; 326 : 1083–4.
Whitney CW , Von Korff M.
Regression to the mean in treated versus untreated chronic pain.
Pain 1992; 50 : 281–5.
Little P , Lewith G , Webley F , et al.
Randomised controlled trial of Alexander technique lessons,
exercise, and massage (ATEAM) for chronic and recurrent back pain.
BMJ 2008; 337: a884.
Long A , Donelson R , Fung T.
Does it matter which exercise?
A randomized control trial of exercise for low back pain.
Spine 2004; 29: 2593–602.
Christiansen D , Larsen K , Jensen OK , et al.
Pain response classification does not predict long-term
outcome in sick-listed low back pain patients.
J Orthop Sports Phys Ther 2010 ;40:606-15.
Schmidt I , Rechter L , Hansen VK , et al.
Prognosis of subacute low back pain patients according to pain response.
Eur Spine J 2008; 17 : 57–63.
Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, et al.
Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation
for Low Back Pain: An Evidence-based Clinical Practice Guideline
From the American Pain Society
Spine (Phila Pa 1976). 2009 (May 1); 34 (10): 1066–1077
Manchikanti L , Glaser SE , Wolfer L , et al.
Systematic review of lumbar discography as a diagnostic test for chronic low back pain.
Pain Phys 2009; 12 : 541–59.
Browder DA , Childs JD , Cleland JA , et al.
Effectiveness of an extension-oriented treatment approach in a subgroup
of subjects with low back pain: a randomized clinical trial.
Phys Ther 2007; 87 : 1608–18.
Lisi AJ , Holmes EJ , Ammendolia C.
High-velocity low-amplitude spinal manipulation for symptomatic
lumbar disk disease: a systematic review of the literature.
J Manipulative Physiol Ther 2005; 28 : 429–42.
The Centralization Phenomenon in Chiropractic Spinal
Manipulation of Discogenic Low Back Pain and Sciatica
J Manipulative Physiol Ther. 2001 (Nov); 24 (9): 596–602
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