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Published on : Dec 06, 2013
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Slide 1 - 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
Slide 2 - Mechanical assessment identifies reliable, 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
Slide 3 - 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
Slide 4 - 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
Slide 5 - Mechanical Assessment Directional Preference No Directional Preference Study Design Excluded
Slide 6 - Mechanical Assessment Directional Preference No Directional Preference N=312 N=82 (26%) N=230 (74%) No significant differences between the directional subgroups at baseline. Excluded No-Return: 29 (12.6%) Results
Slide 7 - Analytical Methods Sample size calculation Descriptive statistics Frequency distributions (includes multiple responses) Two-way Anova Chi-square tests
Slide 8 - Side Effects Early Completions Stopped exercises prior to 2 weeks Self –worse or no better Therapist - peripheralizing 0% 10% 20% 30% 40% 50% 1 2 3 p<.001 *included in analysis
Slide 9 - Results Global Rating Improvement p<.001
Slide 10 - Results p<.001 p=.003
Slide 11 - Results p=.016 p=.009
Slide 12 - Results p<.001 p<.009
Slide 13 - 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.
Slide 14 - 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.
Slide 15 - 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!