Specific Directional Exercises for Patients with Low Back Pain: A Case Series

Abstract

Purpose: To determine whether outcomes could be changed after poor response to non-specific exercise therapy when the prescription was changed to specific, directional-preference exercises (McKenzie method). Methods: Patients who participated in a randomized clinical trial (RCT) and the alternative care phase immediately following formed the cohort for this case series. In an earlier RCT, patients with directional preference were randomized to exercises/advice matched to their individual directional preference or to one of two unmatched protocols. The primary inclusion criterion for our case series was patient reports of being unchanged or worse following 2 weeks’ treatment in the RCT. The secondary inclusion criterion was patient requests for “a change to one of the other stretching protocols to see if I can achieve better pain control.” Patients meeting either of these criteria were offered matched exercises/advice if they had not previously received this intervention. Two-way repeated-measures ANOVA and McNemar tests compared outcomes during two consecutive time intervals: baseline to 2 weeks and 2 weeks to discharge. Dropouts were included in the intention-to-treat analysis. Results: Four patients from the matched group met the primary inclusion criterion of “unchanged” (none reported being worse); 10 additional patients requested alternative treatment for better pain control (secondary criterion). Eighty-five patients from the two unmatched treatment groups met all the inclusion criteria, and an additional 22 patients met only the secondary criterion. These patients were offered matched treatment, and 96 consented. Those reporting improvement or resolution of symptoms were 22 % in the first two weeks of unmatched care (during the RCT) compared to 84 % with matched care. Statistically significant and clinically meaningful changes occurred in all outcomes (p < 0.001) after receiving matched care, compared to clinically unimportant changes with previous unmatched care during the RCT. Conclusions: Poor outcomes from non-specific/unmatched exercise protocols appeared to reverse when patients with directional preference were given sub-group-matched, direction-specific exercises. Because of the limitations of our study design, replication with a control group and longer-term follow-up are required to validate the findings.