Programma educativo McKenzie: Parte D

OBIETTIVI DEL CORSO

Questo corso, della durata di quattro giorni, è impostato in sessioni pratiche ed enfatizza la partecipazione degli studenti alla risoluzione di problematiche avanzate riguardanti la classificazione ed il trattamento dei pazienti con disturbi vertebrali più complessi e cronici. Il corso include le basi biomeccaniche delle tecniche del terapista di livello intermedio ed avanzato. E’ compresa anche una approfondita discussione sulle controindicazioni all’utilizzo delle tecniche del terapista di livello intermedio ed avanzato all’interno del concetto di “progressione di forze” secondo McKenzie. Viene insegnata e messa in pratica l’appropriata applicazione di tali tecniche. Il corso prevede un limitato numero di partecipanti per assicurare un adeguato rapporto istruttore/studente nella risoluzione dei problemi nei casi clinici e nell’apprendimento delle tecniche. Questo corso serve anche per la preparazione del Credentialling Examination e per la successiva possibilità di partecipare al Programma di Diploma.

Obiettivi della Parte D: .a seguito dell’attenta partecipazione e del suo completamento, questo corso fornirà ai partecipanti una conoscenza approfondita, la capacità ed abilità nel:

1. Identificare e correggere, ad un livello avanzato, le problematiche incontrate nella valutazione iniziale e nella classificazione dei pazienti con problemi alla colonna vertebrale secondo il metodo McKenzie.
2. Identificare e correggere, ad un livello avanzato, le problematiche incontrate nella progressione dei trattamenti nei pazienti con disturbi della colonna vertebrale.
3. Identificare le indicazioni cliniche nell’utilizzo delle tecniche del terapista di livello intermedio ed avanzato sulla colonna cervicale, toracica e lombare.
4. Identificare le controindicazioni cliniche all’utilizzo delle tecniche del terapista di grado intermedio ed avanzato sulla colonna cervicale, toracica e lombare.
5. Eseguire selezionate tecniche del terapista di livello intermedio ed avanzato sulla colonna vertebrale.

Tutte le tecniche del terapista (eccetto le manipolazioni) descritte ed illustrate nei due libri di testo McKenzie saranno trattate nei dettagli.


Durata: 4 giorni
Orario: 8.30 - 17.00
Costo: 435.00 + IVA 20% per fisioterapisti/ € 535.00 +IVA 20% per medici
Numero Partecipanti: minimo 21 - massimo 23
Requisito richiesto: attestato di frequenza ai corsi
McKenzie Parte A, Parte B, Parte C


1° GIORNATA

08.30 Registrazione
09.00 Introduzione
09.30 Indicazioni, fasi e regole delle tecniche del terapista.
10.15 Sessione pratica – shift lombare, deviazione in flessione
10.30 Intervallo
10.45 Lavoro di gruppo : cautele e controindicazioni, punti di repere, test speciali e test differenziali
12.00 Sessione pratica – trazione lombare
12.30 Intervallo
13.30 Sessione pratica – tecniche lombari
14.00 Valutazione e trattamento del I° paziente
15.30 Intervallo
15.45 Valutazione e trattamento del II° paziente
16.45 Discussione e domande
17.00 Conclusione


2° GIORNATA

09.0 Lavoro di gruppo : Discussione sulle valutazioni dei 2 pazienti
10.00 Sessione pratica - tecniche lombari
10.30 Intervallo
10.45 Sessione pratica - tecniche lombari
12.00 Lavoro di gruppo : Discussione sulle cautele e controindicazioni
12.30 Intervallo
13.30 Sessione pratica – tecniche lombari
14.00 Rivalutazione e trattamento dei pazienti
15.30 Intervallo
15.45 Lavoro di gruppo : casi clinici – progressione del trattamento
16.00 Pratica – presentazione al gruppo dei casi clinici
16.45 Discussione e domande
17.00 Conclusione


3° GIORNATA

09.00 Lavoro di gruppo : punti di repere cervicali, test speciali e test differenziali
09.30 Sessione pratica – test cervicali
10.30 Intervallo
10.45 Sessione pratica – trazione e tecniche cervicali
12.30 Intervallo
13.30 Sessione pratica – tecniche cervicali
14.00 Rivalutazione e trattamento dei pazienti
14.30 Sessione pratica – tecniche cervicali
15.30 Intervallo
15.45 Sessione pratica – tecniche cervicali
16.45 Lavoro di gruppo : quiz sulla classificazione dei sintomi
17.00 Conclusione


4° GIORNATA

09.00 Lavoro di gruppo – Dorsale. Punti di repere, test speciali e differenziali
09.30 Sessione pratica – trazione dorsale
10.30 Intervallo
10.45 Sessione pratica – tecniche dorsali
11.45 Sessione pratica – tecniche addizionali : cervicali
12.30 Intervallo
13.30 Rivalutazione e trattamento dei pazienti
14.30 Sessione pratica – Valutazione e trattamento dell’articolazione Sacro Iliaca
15.30 Intervallo
15.45 Lavoro di gruppo : progressioni del trattamento cervicale; discussione e pratica
16.30 Compilazione dei questionari – quiz fine corso, giudizio sul corso
17.00 Discussione e conclusione


INDICE

SEZIONE UNO: INTRODUZIONE
SEZIONE DUE: APPLICAZIONE DELLE TECNICHE DEL TERAPISTA NELLA DIAGNOSI E TERAPIA MECCANICA
SEZIONE TRE: CAUTELE E CONTROINDICAZIONI
SEZIONE QUATTRO: TECNICHE LOMBARI
SEZIONE CINQUE: TECNICHE CERVICALI
SEZIONE SEI: PROCEDURE TORACICHE
SEZIONE SETTE: ARTICOLAZIONE SACRO-ILIACA
SEZIONE OTTO: SOLUZIONE DEI PROBLEMI IN DIAGNOSI E TERAPIA MECCANICA
SEZIONE NOVE: CASI STUDIO
SEZIONE DIECI: BIBLIOGRAFIA



SEZIONE 2

Applicazione delle Tecniche del Terapista nella Diagnosi e Terapia Meccanica

Indicazioni per l’Utilizzo delle Tecniche del Terapista

La sola indicazione per l’utilizzo delle tecniche del terapista nel processo di Diagnosi e Terapia Meccanica, si presenta quando la diagnosi di Derangement riducibile e/o Dysfunction è stata formulata e confermata. Con l’eccezione della correzione manuale dello shift in presenza di uno shift laterale lombare acuto, e l’utilizzo occasionale della mobilizzazione da parte del terapista per le altre deformità acute, le tecniche del terapista verranno applicate quando le forze generate dal paziente non ottengono un cambiamento duraturo nei sintomi. La tecnica del terapista è considerata una progressione di forze.


Fasi Pre-Manipolative nella Terapia Meccanica

Pratica delle Prese e delle Mobilizzazioni


SEZIONE 3:

Cautele e controindicazioni


SEZIONE 4:

Tecniche lombare

Riferirsi al libro di testo:
The Lumbar Spine. Mechanical Diagnosis and Therapy
2° Edizione, Volumi 1 e 2
R.A. McKenzie e Stephen May
Spinal Publications, Waikanae, New Zealand, 2003


La Colonna Lombare: Tecniche del Terapista


SEZIONE 5: Tecniche Cervicali

Riferirsi al libro di testo:
R.A. McKenzie e S. May
The Cervical and Thoracic Spine. Mechanical Diagnosis and Therapy
Spinal Publications, New Zealand, 2006


SESSIONE 6: Procedure Toraciche

Riferirsi al testo

THE CERVICAL AND THORACIC SPINE. MECHANICAL DIAGNOSIS AND THERAPY

R. A. McKenzie
Spinal Publications, Waikanae, New Zealand, 1990,
THORACIC SPINE: CLINICIAN TECHNIQUES

LA COLONNA CERVICALE E TORACICA DIAGNOSI E TERAPIA MECCANICA

R.A. McKenzie
Spinal Publications Italia, 1998
COLONNA TORACICA: TECNICHE DEL CLINICO


SEZIONE 7: ARTICOLAZIONE SACRO-ILIACA

TEST DI PROVOCAZIONE DI DOLORE PER L’ARTICOLAZIONE SACRO-ILIACA

Laslett M, Williams M. (1994) The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 19: 1243-1249.

Laslett M, Young S, April C, McDonald B. (2003) Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 49: 89-97

Laslett M, April C, Mc Donald B, Young S (2005) Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy 10: 207

SEZIONE 8:Soluzione dei Problemi nella Diagnosi e Terapia Meccanica

La soluzione dei problemi nella Diagnosi e Terapia Meccanica (MDT) è un processo di analisi clinica che permette di migliorare l’efficacia (outcome) e l’efficienza (tempo ed utilizzo di risorse). Per utilizzare al meglio le tecniche di soluzione dei problemi è necessario che il clinico sia estremamente disciplinato nell’utilizzo della terminologia (come è definita ed usata nel contesto della MDT), nella esecuzione delle procedure diagnostiche-terapeutiche e nel porre le domande al paziente.
SEZIONE 10: BIBLIOGRAFIA

LETTURA RILEVANTE PER IL METODO MCKENZIE
COLONNA LOMBARE

SYSTEMATIC REVIEWS

Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms – a systematic review. Manual Therapy 9.134-143,2004.
Systematic review of 14 studies into centralisation. Prevalence 70% in 731 sub-acute back pain patients and 52% in 325 chronic back pain patients. Centralisation was reliably assessed (kappa values 0.51 to 1.0). Centralisation was consistently associated with good outcomes, and failure to centralise with poor outcomes. Association was confirmed by high quality studies.
Clare HA, Adams R, Maher CG (2004). A systematic review of efficacy of McKenzie therapy for spinal pain. Aus J Physio 50.209-216.
Systematic review of 5 trials deemed to be truly evaluating McKenzie method with pooled data showing greater pain relief (8.6 on a 100 scale) and greater reduction in disability (5.4 on 100 scale) than comparison at short-term (less than 3 months). At 3 to 12 months results were unclear.
Cook C, Hegedus EJ, Ramey K (2005). Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature. J Man & Manip Thera 13: 152-162.
This review uniquely only includes exercise trials for back pain in which patients were classified into exclusive, patient response groups based on physical examination findings. Given these inclusion criteria only 5 trials were included, 4 of these included elements of the McKenzie method, all included centralisation as part of the assessment process. All articles scored 6 or more by PEDro rating (suggesting high quality). 4 / 5 found that a PT directed exercise programme implemented according to patient response was significantly better than control or comparison groups. Authors note a positive trend, but that few studies have investigated this phenomenon.
REVIEWS

Donelson R. Evidence-based low back pain classification. Eur Med Phys 40.37-44, 2004.
Review of literature supporting Mechanical Diagnosis and Treatment – includes the value of a non-specific classification system, the value of establishing directional preference, its reliability as an assessment system, and the prevalence of centralisation in the back pain population.
Wetzel FT, Donelson R: The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. Spine Journal 2003; 3:146-154.
Review of current literature regarding usefulness of dynamic mechanical assessment for diagnosis and management of reversible discogenic pathology; and identification of irreversible pathology that may benefit from surgery.

TRIALS USING “MCKENZIE” OR FLEXION/EXTENSION REGIMES

Cherkin DC, Deyo RA, Battie MC, Street JH, Hunt M, Barlow W, A Comparison of Physical Therapy, Chiropractic Manipulation or an educational booklet for the treatment for low back pain. NEJM 339; 1021-1029, 1998.
McKenzie therapy and chiropractic manipulation are equally effective and both are slightly superior to the booklet in terms of patient satisfaction and short-term symptom reduction. The long-term outcome measures were the same in all 3 groups, including recurrences and care-seeking. The cost of the booklet group was considerably less than the 2 other groups.
Gillan mg, ross jc, mclean ip, porter rw. The natural history of trunk list, its associated disability and the influence of mckenzie management. Euro spine j 7.6.480-483, 1998.
Patients with a trunk list were randomised to McKenzie protocol or non-specific back care. At 90 days there was a significantly greater reduction of list in the McKenzie group, but no clinical difference. List and functional disability were poorly correlated.
Kopp J R, Alexander A H, Turocy R H, Levrini M G, Litchman D M: The use of Lumbar Extension in the Evaluation and Treatment of Patients with Acute Herniated Nucleus Pulposus. A preliminary Report. Clinical Orthopaedics 202:211-218, January 1986.
67 patients with disc herniations and nerve root signs were given extension exercises. Of those who improved, 34/35 (97%) achieved full extension. 32 came to surgery, of which only 2 (6%) were able to extend. The ability to achieve full passive extension correlated with good response to conservative treatment, and this was mostly achieved in a few days. Sequestrations were found in 56% of those who came to surgery.
Larsen K, Weidick F, Leboeuf-Yde C: Can passive prone extensions of the back prevent back problems? A randomized, controlled intervention trial of 314 military conscripts. Spine 27 (24) 2002: 2747-2752.
314 male conscripts randomised into 2 groups: one group received theory session based on TYOB, disc model, tape to back, and instructed to do 15 EIL X 2 a day for period of military duty. 214 (68%) completed follow-up at 12 months. 1-year prevalence LBP in experimental group 33%, compared to 51% in control. Numbers seeking medical help for LBP also significantly less (9% to 25%). In those who had reported LBP at baseline 1-year prevalence 45% to 80%.
Long A, Donelson R, Fung T (2004). Does it matter which exercise? A randomized control trial of exercises for low back pain. Spine 29.2593-2602.
Following a mechanical evaluation all patients who demonstrated directional preference (DP) (230/312, 74%) were randomised to receive exercise matched to DP (1), exercise opposite to DP (2) or evidence-based management (3). Over 30% of groups 2 and 3 withdrew because of failure to improve or worsening, compared to none in group 1. Over 90% of group 1 rated themselves better or resolved at 2 weeks, compared to just over 20% (group 2) and just over 40% (group 3). There were further significant differences between the groups in back and leg pain, functional disability, depression and QTF category.
Miller ER, Schenk RJ, Karnes JL, Rousselle JG (2005). A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain. J Manual Manip Ther 13.103-112.
29/30 patients with very chronic low back pain completed 6 weeks of either intervention depending on randomisation. Both groups improved from baseline, but there were no significant differences between the groups.
Nwuga G, Nwuga V: Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. Physiotherapy Practice 1:99-105, 1985.
A treatment trial of McKenzie versus Williams protocol favours the McKenzie approach in patients with a diagnosis of disc prolapse.
Owen JE, Orpen N, Ayris K, Birch NC: Very early McKenzie protocol intervention for back pain in hospital workers. JBJS 82B.Supp III. 212 (abstract), 2000.
Following introduction of a McKenzie trained therapist to manage hospital employees days lost due to back pain fell be 52%, number of staff off due to back pain fell by 27%, and number of episodes of absenteeism due to back pain fell by 30%.
Petersen, Kryger, Ekdahl, Olsen, Jacobsen (2002). The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain. A RCT. Spine 27.1702-1709.
260 patients with chronic back pain followed up at 2 and 8 months after 8 week treatment period. With intention to treat analysis both groups improved modestly, McKenzie group favoured at 2 months. Outcomes were better and differences favouring McKenzie group were more significant in those who actually completed treatment.
Ponte D J, Jensen G J, Kent B E: A Preliminary Report on the use of the McKenzie protocol versus Williams Protocol in the treatment of Low Back Pain. Journal Orthop & Sports Phys Ther 6:2;130-139., 1984
In LBP patients, the McKenzie protocol was superior to the Williams protocol in decreasing pain and hastening the return of pain free range of motion.
Rasmussen C, Nielsen GL, Hansen VK, Jensen OK, Schioettz-Christensen B (2005). Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine 30: 2469-2473.
In region in Denmark following introduction of spine clinics there was a significant decrease in spine surgery that was not found in the rest of Denmark during the same period. The clinics were based on Indahl and McKenzie principles and patients were treated by McKenzie trained physical therapists. English language peer-reviewed publication of previous entry.
Schenk R, Jozefczyk, Kopf A (2003). A randomised trial comparing interventions in patients with lumbar posterior derangement. J Man & Manip Ther 11.95-102.
25 patients with lumbar radiculopathy classified as derangement then randomised to McKenzie or mobilisation therapy. Significantly better outcomes pain and function for McKenzie group short-term.
Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB: The reduction of Chronic Nonspecific Low Back pain through the control of early Morning Lumbar Flexion. RCT. Spine 23:2601-2607, 1998.
Education in the control of early morning flexion produced significant reductions in pain intensity, days in pain, disability and medication use. High drop-out rates show the difficulty of getting people to make such behavioural changes.
Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H: Efficacy of Flexion and Extension Treatments Incorporating Braces for Low-Back Pain Patients with Retrodisplacement, Sponylolithesis, or Normal Sagittal Translation. Spine 18:13;1839-1849, 1993.
Improvement in the extension group was significantly greater, regardless of type of radiographic abnormality, than flexion or control group.
Stankovic R, Johnell O: Conservative treatment of Acute Low-Back Pain. A Prospective Randomized Trial: McKenzie Method of Treatment versus patient Education in “Mini Back School”. Spine 15:2, 1990.
100 acute back patients randomised to McKenzie or back school; significantly better outcomes in McKenzie group in pain, function, sick leave, recurrences, and further health care.
Stankovic R, Johnell O: Conservative Treatment of Acute Low Back Pain. A 5-Year Follow-up Study of Two Methods of Treatment. Spine 20:4;469-472,1995.
Difference between 2 treatments at 5 years was much less, however McKenzie group had significantly less recurrences of pain and episodes of sick leave.
Underwood MR, Morgan J. The use of a back class teaching extension exercises in the treatment of acute low back pain in primary care. Family Pract 15.1.9-15, 1998.
In an acute group of patients randomised to usual GP care or a one off back class according to McKenzie principles there were no significant differences in outcome, except one difference at one year, when more of the back class group reported ‘back pain no problem in previous 6 months’.
Udermann BE, Spratt KF, Donelson RG, Mayer J, Graves JE, Tillotson J. Can a patient educational book change behavior and reduce pain in chronic low back pain patients? Spine J 4.425-435, 2004.
Long-term (18 month) uncontrolled cohort study of effect of TYOB on 48 of 62 chronic back pain volunteers. There were significant differences in reductions in pain and pain episodes and perceived benefit over time. Significant differences remained even with a worst-case model to account for those lost to follow-up. Compliance with exercise and posture advice was reported by about 80% long-term.


CENTRALISATION – LUMBAR & CERVICAL

Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms – a systematic review. Manual Therapy 9.134-143, 2004.
Systematic review of 14 studies into centralisation. Prevalence 70% in 731 sub-acute back pain patients and 52% in 325 chronic back pain patients. Centralisation was reliably assessed (kappa values 0.51 to 1.0). Centralisation was consistently associated with good outcomes, and failure to centralise with poor outcomes. Association was confirmed by high quality studies.
Brotz D, Kuker W, Maschke E, Wick W, Dichgans J, Weller M: A prospective trial of mechanical physiotherapy for lumbar disk prolapse. J Neurol 2003; 250: 746-749.
Retrospective review of 50 / 150 patients with suspected disc herniation who responded to first 5 daily sessions with centralisation and were then treated with mechanical therapy. Exclusions: 64 disc herniation not confirmed on neuroimaging; 36 referred for surgery. There were immediate reductions in severe pain, and at 1-year high rates of recovery on all outcomes, with 5 patients who came to surgery.
Donelson R, Murphy K, Silva G: Centralisation Phenomenon: Its usefulness in evaluating and treating referred pain. Spine 15:3, 211-213, 1990.
The centralisation phenomenon is found to be a reliable predictor of good or excellent treatment outcome. In 87 patients centralisation occurred in 87% - with centralisation occurring in 100% of 59 patients with excellent outcomes.
Donelson R, Grant W, Kamps C, Medcalf R: Pain Response to Sagittal End-Range spinal Motion: A Prospective, Randomized Multicentered Trial. Spine 16:6S;S206-S212, 1991.
Donelson found that 47% of low back pain patients with or without referred pain displayed a directional preference to end range sagital spinal movement – 40% preferred extension, 7% preferred flexion.
George SZ, Bialosky JE, Donald DA (2005). The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise. JOSPT 35.580-588.
Secondary analysis of 28 patients who were classified as specific exercise category and observed for the effects of prognostic variables at baseline on outcomes at 6 months. Centralisation and fear-avoidance at work both independently and significantly predicted disability at 6 months. Only centralisation significantly predicted pain at 6 months.
Laslett M, Oberg B, Aprill CN, McDonald B (2005). Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 5.370-380.
83 patients with chronic low back pain underwent a full or partial mechanical examination and discography and the results were compared. The prevalence of positive discography was 75%, and of centralisation 32%. Sensitivity of centralisation to predict discogenic pain was weak (about 40%), but specificity was high and 100% in patients without severe distress or disability.
Long A, The Centralisation Phenomenon. Its usefulness as a predictor of outcome in conservative treatment of chronic low back pain. Spine, 20, 23, 2513-2521, 1995.
A pilot study indicating that centralisation is useful as an outcome predictor in chronic patients. There was a superior outcome comparing centralisers to non-centralisers in an interdisciplinary work-hardening programme.
Karas R, McIntosh G, Hall H, Wilson L, Meles T: The Relationship Between Nonorganic Signs and Centraliazation of Symptoms in the Prediction of Return to Work for Patients with Low Back pain. Physical Therapy 77:4;354-360, 1997.
Inability to centralize indicated a decreased probability of returning to work, regardless of the Waddell score. A high Waddell score predicted a poor chance of returning to work regardless of the patients’ ability to centralize symptoms. Waddell scores appear to be a better predictor of poor outcomes.
Lisi AJ: The centralization phenomenon in chiropractic spinal manipulation of discogenic low back pain and sciatica. J Manip & Physiol Thera 24;9, 596-602, 2001.
3 case studies demonstrating value of centralisation. 2 patients displayed centralisation and responded to mobilisation / manipulation treatment. One patient only able to peripheralise came to surgery.
Rathore S (2003). Use of McKenzie cervical protocol in the treatment of radicular neck pain in a machine operator. J Can Chiropr Assoc 47.291-297.
Case study of patient with cervical radicular pain, demonstrating centralisation in response to retraction and extension, categorised as derangement and treated with retraction and extension exercises.
Skytte L, May S, Petersen P: Centralization: Its prognostic value in patients with referred symptoms and sciatica. Spine 2005; 30:E293-E299.
60 patients with referred symptoms and sciatica following a mechanical evaluation were classified as centralisers (25) or non-centralisers (35). Patients then followed a standardised management pathway that involved surgery if there was a failure to improve. Both short and long-term the centralisation group had significantly better outcomes for pain and disability. Non-centralisers were 6 times more likely to have surgery.
Sufka A, Hauger B, Trenary M, Bishop B, Hagen A, Lozon R, Martens B: Centralisation of Low Back Pain and Perceived Functional Outcome. JOSPT 27:205-212, 1998.
Of 36 patients 70% centralised within 14-day test period – centralisation was less amongst those with chronic symptoms and those with more referred pain. Centralisation was associated with significantly more improvement on one of the functional outcome measures used.
Werneke M, Hart DL, Cook D: A descriptive study of the Centralisation Phenomenon. A Prospective Analysis. Spine 24.676-683, 1999.
Of 289 patients with acute neck and back pain 31% centralised during repeated movement testing in the clinic and achieved abolition of symptoms on an average of 4 sessions; 46% showed some centralisation or reduction of symptoms on an average of 8 sessions (partial response); 23% showed no change in symptom site or intensity over an average of 8 sessions. The authors question whether in the partial response group changes were a product of the natural history or exercise programme. Both centralisers and partial responders showed significant improvement in pain intensity and function, whilst the non-response group did not. Assessment of initial pain location was reliably assessed.
Werneke M, Hart DL: Centralization phenomenon as a prognostic factor for chronic pain or disability. Spine 26.758-765, 2001.
In 225 patients with acute back pain 24 psychosocial, somatic and demographic variables were recorded at initial assessment. Patient outcomes at one year were predicted by a range of independent variables. When all these variables were entered in a multivariate analysis only pain pattern classification (centralisation or partial centralisation v non-centralisation), and leg pain at intake were significant predictors of chronic pain and disability.
Werneke M, Hart DL: Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomic pain patterns. Spine 28 (2), 2003: 161-166.
Re-analysis of data from earlier study comparing prognostic usefulness of classifying patients as centralisers on the first visit compared to during subsequent visits. At first visit 130 (45%) were classified as centralisers, only 4 became non-centralisers, but 43 became partial centralisers. At first visit 157 (55%) were classified as non-centralisers – of these 95 (60%) became partial or full centralisers at later sessions.
Werneke MW, Hart DL; Categorizing patients with occupational low back pain by use of the Quebec Task Force Classification system versus pain pattern classification procedures: discriminant and predictive validity Phys Ther; 84:243-254, 2004.
Re-analysis of previously collected data comparing different methods of classifying back pain patients for their ability to predict outcome. QTF 3 or 4 predicted high levels of pain and disability at intake, but only centralisation / non-centralisation categories predicted pain and disability at discharge. Non-centralisation was stronger predictor of work status at 1 year than fear-avoidance. Predictive value of centralisation / non-centralisation stronger when followed through rehabilitation period, than just at intake.
Werneke M, Hart DL (2005). Centralization: association between repeated end-range pain responses and behavioural signs in patients with acute non-specific low back pain. J Rehabil Med 37: 286-290.
Re-analysis of data from previous study to determine association between centralisation category and psychosocial variables. Non-centralisation patients were significantly more likely to have positive non-organic signs, overt pain behaviour, fear of work activities and somatisation, but no difference was found between centralisation category regarding depression, fear of physical activity, disability or pain intensity.
Williams M M, Hawley J A, McKenzie R A. Van Wijmen P M: A Comparison of the Effects of Two Sitting Postures on Back and Referred Pain. Spine 16:10; 1185-1191, 1991.
Over a 24-48 hour period 2 groups of patients with back and referred pain were encouraged to sit in lordosis or in a kyphotic posture. Lordotic sitting group had back and leg pain significantly reduced and pain centralised compared to kyphotic group.

SURVEYS OF MCKENZIE REGIMES & USE OF MCKENZIE METHOD

Battie MC, Cherkin DC, Dunn R, Ciol MA, Wheeler KJ: Managing Low Back Pain: Attitudes and Treatment Preferences of Physical Therapists. Physical Therapy 74. 219-226, 1994.
A survey of therapists in USA when presented with hypothetical back pain patients. The McKenzie method was deemed the most useful method of managing patients, and was said to be a very common means of evaluating patients.
Foster NE, Thompson KA, Baxter GD, Allen JM: Management of Nonspecific Low Back Pain by Physiotherapists in Britain and Ireland. A Descriptive Questionnaire of Current Clinical Practice. Spine 24.1332-1342, 1999.
The McKenzie method was said to be the second most common treatment approach used by therapists. The Maitland approach was used by 59%, McKenzie method by 47%,, multiple other approaches were used as well with less frequency – combined approaches were common.
Gracey JH, McDonough SM, Baxter GD: Physiotherapy management of low back pain. A survey of current practice in Northern Ireland. Spine 27;4,406-411, 2002.
Details of management of over 1,000 patients by 157 therapists over 12-month period. McKenzie was used in over 70% of patients, usually in combination, and was one of the most commonly used approaches. McKenzie course attendees ranged from 76% for A to 16% for D.
Jackson DA: How is low back pain managed? Retrospective study of the first 200 patients with low back pain referred to a newly established community-based physiotherapy department. Physiotherapy 87;11, 573-581, 2001.
In 58% of patients McKenzie approach was used, usually in combination with other therapies. Electrotherapy was commonly used also.
Laslett M, Michaelsen DJ, Williams MM: A survey of patients suffering mechanical low back pain syndrome OR sciatica treated with the “McKenzie method”. NZ J Physiotherapy 24-32, August 1991.
A retrospective postal survey of patients’ opinions about the success of treatment in dealing with their present pain, and enabling them to deal with recurrences showed high levels of satisfaction. Derangements 1 & 3 required fewer treatment sessions than Derangements 4,5,6.
McKenzie R A: Prophylaxis in Recurrent Low Back Pain. NZMedJ no 627, 89:22-23, 1979.
Frequent restoration of the lumbar lordosis and avoidance of flexion were seen as critical factors in prophylactic education for prevention of recurrent LBP. McKenzie reports on 318 patients - onset, aggravating and relieving factors, deformity, and the success of treatment in reducing further attacks as reported by the patients.
Sullivan MS, Kues JM, Mayhew TP: Treatment categories for low back pain: a methodological approach. JOSPT 24.359-364.
From this survey of PTs in USA 7 different treatment categories were proposed, which explained 62% of treatment variance. McKenzie treatment category was the most commonly used, explaining 21% of variance.
STUDIES INTO ASSESSMENT PROCEDURES, TESTS & TECHNIQUES

Clare HA, Adams R, Maher CG: Reliability of detection of lumbar lateral shift. J Manipulative Physiol Thera 2003; 26: 476-480.
148 therapists (students, PTs, PTs with McKenzie training) viewed slides from 45 patients to determine presence, direction, and certainty of lateral shift or absence of shift. ICC values represented fair to good reliability for both intra and inter-tester reliability; kappa values were all < 0.4 (fair reliability).
Clare HA, Adams R, Maher CG (2004). Reliability of the McKenzie spinal pain classification using patient assessment forms. Physiotherapy 90.114-119.
50 completed neck and back assessment forms were sent to 50 credentialed McKenzie therapists to classify - kappa values of 0.56 were recorded for syndromes and 0.68 for sub-syndromes.
Clare HA, Adams R, Maher CG (2005). Reliability of McKenzie classification of patients with cervical and lumbar pain. J Manipulative Physiol Ther 28.122-127.
25 lumbar and 25 cervical patients were assessed simultaneously by pairs of credentialed therapists; 14 in total. Prevalence of derangement was 88%/84%, dysfunction 0%/4%, posture 0%/0%, and ‘other’ 12%/12% for the 2 therapists. Kappa values for lumbar syndromes and sub-syndromes was 1.0 and 0.89, and for cervical syndromes and sub-syndromes 0.63 and 0.84 respectively.
Delaney PM, Hubka MJ: The diagnostic utility of McKenzie clinical assessment for lower back pain. J Manip & Physio Therapeutics 22; 628-630, 1999.
Re-analysis of Donelson (1997, see below) calculating accuracy of McKenzie assessment in diagnosis. Sensitivity and specificity for discogenic pain 94% and 82%; for incompetent annulus 100% and 86%. Compares favourably with most other established tests.
Donahue MS, Riddle DL, Sullivan MS: Intertester Reliability of a Modified Version of McKenzie’ Lateral Shift Assessments Obtained on Patients with Low Back Pain. Physical Therapy 76:7;706-726, 1996.
Determination of a lateral shift by observation was found to be very unreliable. Determination of positive side-gliding test, based on alteration of patient’s pain, was found to be of high reliability.
Donelson R, Aprill C, Medcalf R, Grant W, A prospective study of centralisation of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine, 22, 10, 1115-1122, 1997.
63 chronic patients received a mechanical evaluation and discography, with clinicians blind to the findings of the other assessment. Centralisation (74%) and peripheralisation (69%) were strongly associated with discogenic pain, compared to no change in symptoms (12%). Centralisation (91%) was strongly associated with a competent annulus compared to peripheralisation (54%).
Fiebert I, Keller CD: Are “passive” Extension Exercises Really Passive? JOSPT 19:2;111-115, 1994.
During EIL there is more EMG activity in the Erector Spinae muscles than during standing, EIS, or prone lying.
Fritz JM, Delitto A, Vignovic M, Busse RG. Interrater reliability of judgements of the centralisation phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil 81,57-61, 2000.
40 students and 40 physical therapists reviewed a composite videotape made during assessment of back pain patients and had to make judgements on changes in pain status with movement testing. Intertester reliability was excellent, kappa = 0.79.
George (2002). Characteristics of patients with lower extremity symptoms treated with slump stretching: a case series. JOSPT 32.391-398.
Out of 88 consecutive back pain patients 6 were identified who were considered appropriate for treatment by slump stretching – 4/6 would appear to fit category of ANR.
Hamm L, Mikkelsen B, Kuhr J, Stovring H, Munck A, Kragstrup J (2003). Danish physiotherapists’ management of low back pain. Advances in Physiotherapy 5.109-113.
An audit of 242 Danish PTs (14% of total) during a 4 week period to see if they used recommended treatments. McKenzie was used in 40% of consultations; there was a lot of combination of treatments; 22% of consultations involved non-recommended treatments, such as ultrasound and short-wave. McKenzie was most commonly used in acute back pain with radiation (64%), acute back pain (44%), chronic back pain with radiation (40%), and least in chronic back pain (27%).
Hazard RG, Williams MW, McKenzie RA (1994). Reliability of three methods for measuring prone lumbar extension. NZ J Physio April, 11-13.
Comparison of reliability of skin attraction, inclinometry and flexible ruler to measure extension ROM in 15 patients – ICC were 0.9, 0.83, and 0.62 respectively.
Kilby J, Stigant M, Roberts A: The Reliability of Back Pain Assessment by Physiotherapists, Using a ‘McKenzie Algorithm’. Physiotherapy 76:9;579-583, September 1990.
Kilby presents a McKenzie algorithm which was found to be intertester reliable, except with regard to identifying the presence of a lateral shift or a kyphotic lumbar spine.
Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M: Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 27;8,E207-E214, 2002.
39 patients with back pain were assessed by 2 therapists in turn, clinical and classification decisions were compared using Kappa statistics. Agreement was poorer for presence of lateral shift than relevance of shift or lateral component. Agreement on centralisation, directional preference, and mechanical classification was good to excellent.
Laslett M, Williams M, The reliability of selected pain provocation tests for sacroiliac joint pathology, Spine, 19, 11, 1243-1249, 1994
Five of the seven tests were shown to be reliable, and may be used to detect a sacroiliac cause of low back pain. They were the distraction (or gapping) test, compression test, posterior shear (or thigh thrust) test, left and right pelvic torsion (or Gaenslen’s) test.
Laslett m, young sb, aprill cn, mcdonald b: diagnosing painful sacroiliac joints: a validity study of a mckenzie evaluation and sacroiliac provocation tests. Aus j physio 2003; 49: 89-97.
Using initial Mechanical evaluation to exclude mechanical responders and 3 or more positive pain provocation SIJ tests compared to a double intra-articular injection was more accurate in diagnosing SIJ problems (sensitivity 91%, specificity 87%) than SIJ pain provocation tests only (sensitivity 91%, specificity 78%).
Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B (2005). Agreement between diagnosis reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disorders 6:28. Available at: http://www.biomedcentral.com/1471-2474/6/28
In 216 patients with chronic low back pain structural diagnosis, as defined by intra-articular injections or discography was compared to clinical diagnosis: discogenic pain defined as centralisation or directional preference. Discogenic pain was the commonest diagnosis by both radiographer and physiotherapist, followed by ‘illness behaviour’ and ‘indeterminate’. Diagnoses of SIJ or ‘facet’ joint were rarely made. Agreement between radiographer and clinical examination was weak.
McCarthy CJ, Arnall FA, Strimpakos N, Freemont A, Oldham JA (2004). The biopsychosocial classification of non-specific low back pain: a systematic review. Phys Ther Rev 9.17-30.
Review of 32 classification systems of 4 types: patho-anatomical, clinical, psychological, health / work status. Out of total of 7 quality criteria only 7 systems scored 5 or more, including McKenzie system.
McKenzie R A: Manual Correction of Sciatic Scoliosis. NZMedJ 484, 76:194-199, 1972.
McKenzie outlines the treatment procedure for manual correction of sciatic scoliosis.
McLean IP, Gillan MGC, Ross JC, Aspden RM, Porter RW: A comparison of methods for measuring trunk list. A simple plumbline is best. Spine 21:1667-1670, 1996.
Of 3 methods evaluated plumbline was the best, being reliable, simple to use, and accurate to within 4mm.
Mulvein K, Jull G: Kinematic analysis of the lumbar lateral flexion and lumbar lateral shift movement techniques. J Manual Manip Ther 3:3;104-109,1995.
Lateral shift technique (side gliding in standing) is found to produce movement with greater specificity to lower lumbar levels compared to lateral flexion. Above L4 either test movements can be used to examine movement abnormalities.
Petersen T, Thorsen H, Manniche C, Ekdahl C: Classification of non-specific low back pain: a review of the literature on classification systems relevant to physiotherapy. Phys Ther Reviews 4:265-281, 1999.
A critical appraisal, using a systematic approach, of 8 classification systems for non-specific back pain. Various types of validity are examined, and despite having weaknesses in reliability and content validity, the McKenzie system is rated as one of the most promising.
Petersen T, Laslett M, Thorsen H, Manniche C, Ekdahl C, Jacobsen S ; Diagnostic classification of non-specific low back pain. A new system integrating patho-anatomic and clinical categories Phys Ther Prac; 19:213-237, 2004.
This classification system for LBP takes the mechanical syndromes of Mechanical Diagnosis and Therapy and adds in a few other categories, such as spinal stenosis, zygapophyseal or sacro-iliac joint pain. A lot of the literature used to demonstrate the validity and reliability of the system relates to studies of the McKenzie approach.
Petersen T, Olsen S, Laslett M, Thorsen H, Manniche C, Ekdahl C, Jacobsen S. Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain. Aus J Physio 50.85-91, 2004.
Reliability study of their classification system, which borrows many aspects from McKenzie system. Kappa values for mechanical syndromes (derangement, dysfunction, postural syndrome) mostly > 0.60.
Pinnington MA, Miller JS, Rose MJ, Stanley IM, Rose GM: New episodes of back pain: how many patients can be classified into McKenzie syndromes? JBJS 82B.Supp III. 211-212 (abstract), 2000.
Of 522 new patients referred 307 (58%) were classified into McKenzie syndromes, while 215 (42%) were not. Significant differences were found between the groups in duration of episode, pain and disability scores, movement loss, and other variables.
Razmjou H, Kramer JF, Yamada R: Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. JOSPT 30,368-389, 2000.
Two physical therapists, one assessor, one observer, both experienced in McKenzie assessed 45 subjects and were analysed on agreements using Kappa statistics. Agreement on syndromes was good (93%), derangement sub-syndrome classification was excellent (97%), presence of lateral shift was moderate (78%), relevance of lateral shift and lateral component was very good/excellent (98%), deformity in sagittal plane was excellent (100%).
Riddle D L, Rothstein JM: Intertester Reliability of McKenzie’s classification of the type of the syndrome types present in patients with low back pain. Spine 18:10;1333-1344, 1993.
369 patients assessed by 49 therapists with no or minimal training in McKenzie. Intertester reliability using author’s version of the system was poor, agreement on classification was 39%.
Riddle DL: Classification and Low Back Pain: A review of the literature and Critical Analysis of Selected Syndromes. Physical Therapy 78:7;708-737, 1998.
Critical analysis of various classification systems used for LBP, including McKenzie’s. Highlights strengths and weaknesses of them according to an established set of criteria for appraising classification systems.
Seymour R, Walsh T, Blankenberg C, Pickens A, Rush H; Reliability of detecting a relevant lateral shift in patients with lumbar derangement: a pilot study J Man & Manip Ther; 10(3):129-135, 2003.
15 patients were examined by 6 therapists to determine reliability of determining if a lateral shift was present and if it was relevant; observed agreement was 73%, kappa 0.56
Stankovic R, Johnell O, Maly P, Willner S: Use of lumbar extension, slump test, physical and neurological examination in the evaluation of patients with suspected herniated nucleus pulposus. A prospective clinical study. Manual Therapy 4:25-32, 1999.
105 patients were diagnosed by CT and/or MRI as having disc hernia (N=52), bulging discs (41), or without positive findings (12). A range of clinical and physical examination findings was generally unable to distinguish between these diagnoses. The only 3 variables that were of diagnostic value were ROM on flexion, side bending, and pain distribution on EIS. Neurological tests, EIL (not reported if single or repeated), and SLR were amongst the numerous variables that failed to be associated with any particular diagnosis.
Tenhula JA, Rose SJ, DelittoA: Association Between Direction of lateral Shift, Movement Tests, and Side of symptoms in Patients with low Back Pain Syndrome. Physical Therapy 70:480-486, 1990.
There was no significant relationship between the side of symptoms and the direction of the shift. Contralateral side bending was significantly more likely to provoke symptoms than ipsilateral. There was perfect agreement on judging presence and direction of shift.
Turner PA, Harby-Owren H, Shackleford F, So A, Fosse T, Whitfield TWA (1999). Audits of physiotherapy practice. Physio Theory Prac 15.261-274.
An audit of physiotherapy notes from NHS hospitals in the UK, including 345 back pain patients. The McKenzie assessment sheets provided better quality records in terms of detail and objectivity. Use of McKenzie: in isolation 11% of notes and in combination a further 39%.
Young S, Aprill C: Characteristics of a mechanical assessment for chronic lumbar facet joint pain. J Manual & Manipulative Therapy 8.78-84, 2000.
Results of diagnostic injections (SIJ, facet, and disc) compared to mechanical evaluation involving McKenzie assessment, SIJ and hip tests in 93 chronic patients. Characteristics from mechanical assessment were compared in the different diagnostic groups.
Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 3.460-465, 2003.
In 81 chronic back pain patients 51 had positive response to diagnostic injection into disc, zygapophyseal or sacro-iliac joints. Centralisation, midline pain, and pain on rising from sitting were significantly associated with a positive discogram. Sacro-iliac joint pain was strongly associated with 3 or more positive pain provocation tests, pain on rising from sitting, unilateral pain and absence of mid-line or lumbar pain. Zygapophyseal pain was associated with absence of pain on rising from sitting.
Pynt J, Higgs J, Mackey M: Seeking the optimal posture of the seated lumbar spine. Physio Theory & Practice 17;5-21, 2001.
A review of the literature on the optimal sitting posture for spinal health, based mostly on cadaveric studies, but some clinical studies. They conclude that the arguments in favour of a kyphotic sitting position are not substantiated by research; and that a lordotic position, interspersed with regular movement, is the optimal sitting posture and assists in preventing back pain.


CERVICAL SPINE

Trials

Abdulwahab SS, Sabbahi M. Neck retractions, cervical root decompression, and radicular pain. JOSPT 30.1.4-12, 2000.
In a group of patients with neck and radicular pain a posture of sustained flexion caused a significant increase in peripheral pain and root compression as measured by H reflex amplitude. Repeated retractions caused a significant decrease in peripheral pain and decrease of nerve root compression.
Hanten WP, Barrett M, Gillespie-Plesko M, Jump KA, Olson SL. Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physio Theory & Pract 13.285-291, 1997.
One session of either intervention caused no significant changes in trigger point sensitivity.
Jull, Trott, Potter et al (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27.1835-1843.
200 patients with cervical headaches randomised to manipulation, exercise, combined, or control group. ‘Exercise’ consisted of craniocervical flexion endurance exercises (ie retraction), postural correction exercises, and isometric rotation exercises. At 12 months all 3 active treatments significantly better than control, combined treatment better, but not significantly.
Kjellman G, Oberg B: A randomised clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain. J Rehabil Med 2002; 34:183-190.
77 patients with acute to chronic neck pain randomised to 1 of 3 treatment arms, 93% follow-up at 12 months. All groups significant improvements in pain and disability, no significant difference between groups. Trend towards greater improvements in McKenzie group compared to controls at certain times. Significant improvements in DRAM scores in McKenzie group only. Recurrence rates similar by 12 months, but additional healthcare usage much less in McKenzie group.
Schmidt I, Rechter L, Hansen VK, Therkelsen K, Rasmussen C: The association of the involvement of financial compensation with the outcome of cervicobrachial pain that is treated conservatively. Rheumatology 40: 552-554, 2001.
Of 60 patients with neck and arm pain treated with the McKenzie approach those involved in financial compensation showed no improvement, whilst those that were not showed a significant improvement.

WHIPLASH – TRIALS

Borchgrevink GE, Kaasa A, McDonagh D et al: Acute treatment of whiplash neck sprain injuries. A randomised trial of treatment during the first 14 days after a car accident. Spine 23:25-31, 1998.
Continuing to engage in normal activities led to fewer symptoms than did sick leave and use of a collar.
McKinney L A: Early mobilisation and outcome in acute sprains of the neck. Brit Med J 299:1006, 1989.
A single advice session produced fewer patients with persistent symptoms at 2 years than a course of manipulative physiotherapy. Prolonged collar wearing is associated with persistence of symptoms.
McKinney L A, Dornan J O, Ryan M: The Role of Physiotheraphy in the management of acute neck sprains following road-traffic accidents. Archives of Emergency Medicine 6:27-33, 1989
Outpatient treatment and advice to mobilise earlier were both more effective than analgesics and a collar in treating acute neck sprains.
Mealy K, Brennan H, Fenelon GCC: Early mobilisation of acute whiplash injuries. BMJ 292: 656-657, March 1986.
Early active mobilisation and exercises produced significantly less pain and improved movement compared to rest and use of a collar.
Rosenfeld M, Gunnarsson R, Borenstein P: Early intervention in whiplash-associated disorders. A comparison of two treatment protocols. Spine 25.1782-1787, 2000.
Nearly 100 acute patients randomised to one of 4 arms: active (1) or standard (2) treatment, within 96 hours (1a, 2a) or after 2 weeks (1b, 2b), with follow-up at 6 months. If symptoms persisted in active treatment group beyond 20 days a McKenzie assessment was conducted and specific, rather than non-specific exercises used. Active treatment was significantly better than standard (initial rest, collar, gentle movements), early treatment better than delayed. Minimal or no symptoms at follow-up: 1a: 48%, 1b: 70%, 2a: 64%, 2b: 91%.
Rosenfeld M, Seferiadis A, Carlsson J, Gunnarsson R (2003). Active intervention in patients with whiplash-associated disorders improves long-term prognosis. A randomised controlled clinical trial. Spine 28.2491-2498.
3-year follow-up of 73 patients (75%) from previous study. Still significant differences between active and standard treatment in pain intensity and sick leave. Only early active treatment group had similar range of movement to matched controls.

EXTREMITIES

Aina A, May S: Case report – A shoulder derangement. Manual Therapy 2005; 10: 159-163.
Case report of a patient with shoulder pain who responds typically as a derangement.
Alfredson H, Pietila T, Jonsson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26:360-366.
15 patients with chronic Achilles tendinosis (contractile dysfunction) treated with eccentric loading make quicker recovery than patients treated with surgery.
Brox JI, Staff PH, Ljunggren AE, Brevik JI: Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ 1993; 307:899-903.
Brox JI, Gjengedal E, Uppheim G et al: Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomised, controlled study in 125 patients with a 2 ½ -year follow-up. J Should Elbow Surg 1999;8:102-111. RCT of loading exercises versus surgery versus placebo for chronic rotator cuff problems (contractile dysfunction) with long-term follow up. Both short and long-term exercise and surgery groups had significantly better outcomes than control group, with no differences between them.
Holmich P, Uhrskou P, Ulnits L et al: Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999;353:439-443.
RCT of loading exercises versus passive interventions and stretches for chronic adductor problems (contractile dysfunction). Of those completing treatment 79% in active group had no residual pain and had returned to same level of sports, compared to 14% in passive treatment group.
Pienimaki TT, Tarvainen TK, Siira PT, Vanharanta H: Progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. Physiotherapy 1996; 82:522-530.
Pienmaki T, Karinen P, Kemila T, Koivukangas P, Vanharanata H: Long-term follow-up of conservatively treated chronic tennis elbow patients. A prospective and retrospective analysis. Scand J Rehab Med 1998; 30:159-166.
RCT of loading exercises versus ultrasound for chronic ‘tennis elbow’ (contractile dysfunction) with long-term follow up. In a range of outcomes, such as return to work, pain, function, and healthcare usage, the actively treated group had significantly better outcomes.
Zalaffi A, Mariottini A, Carangelo B et al: Wrist median nerve motor conduction after end range repeated flexion and extension passive movements in carpal tunnel syndrome. Pilot study. Acta Neurochir 2005; S92: 47-52
38 patients with carpal tunnel syndrome performed repeated movements following which electrophysiological measurements were made. 32% of hands worsened with flexion and extension movements; 22% of hands improved with extension movements and some improved with flexion.