Effects of Extension Biased External Limb Loading in Addition to McKenzie Extension Protocol in Lumbar Derangement Syndrome

NCT ID: NCT04155450

Last Updated: 2021-12-20

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 30 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2019-11-01
• Study Completion Date: 2020-05-01

Brief Summary

Low back pain is one of the most common problem affecting one's daily living activities.

McKenzie Method of Mechanical Diagnostic Therapy (MDT) is an appealing modality of treatment. McKenzie classified the lumbar back pain into three categories i.e. lumbar postural syndrome, lumbar dysfunction syndrome and lumbar derangement syndrome.

Progressive extension bias limb loading exercises at lumbar region emphasizes on lumbar extensor musculature. The purpose of the current study is to determine the effects of extension biased lumbar limb loading exercises along with McKenzie extension protocols in the management of patients with lumbar derangement syndrome, which will also be a cost effective management option. It will also add to the existing pool of knowledge in the fields of conservative low back pain treatment, physical therapy, orthopedic manual therapy and musculoskeletal medicine.

Detailed Description

Low back pain is one of the most common problem affecting one's daily living activities.

Back pain results from multifactorial etiology with anatomical, psychological, physiological and social consequences and it is often classified as acute, sub-acute and chronic according to pain duration. Upto 71% of people with acute low back pain in primary care report persistent symptoms and therefore there is requirement for effective treatments in those who have not recovered after acute phase. Therapeutic exercises, manual therapy, functional training, modalities, traction, endurance training of back extensors, Kinesio-taping, trigger point therapy, deep friction massage are some of the procedures being safely and effectively applied by physical therapists to combat back discomfort or disorder.

McKenzie Method of Mechanical Diagnostic Therapy (MDT) approach was developed by Robin McKenzie who was a physical therapist from New Zealand back in 1950s. MDT is an appealing modality of treatment focusing on five areas of benefit-including reliable assessment, early prognosis, self-treatment, better outcomes and prevention of recurrence. The evaluation also determine who will get benefit from treatment and who will require another treatment protocols. McKenzie classified the lumbar back pain into three categories i.e. lumbar postural syndrome, lumbar dysfunction syndrome and lumbar derangement syndrome based on symptomatic or mechanical responses observed during repeated lumbar end range movements. The McKenzie Institute Lumbar Spine Assessment will be used to classify the patients into different syndromes and to choose the desired one fulfilling the inclusion criteria of study.

When normal tissues are deformed over a prolonged period it ends with postural syndrome like slouched posture and the postural syndrome may lead to dysfunction or derangement syndromes. Deformation of structures and tissues that causes pain at end ranges of available motion is characterized as dysfunction syndrome. Derangement syndrome is related to displacement of intervertebral disc with or without involvement of radiating pattern of pain along with back pain and fluctuations in symptoms or pain with directional movements can be observed due to force changes on affected intervertebral disc.

Centralizing and Peripherilizing are two important concepts with a strong association towards derangement syndrome. Centralizing reveals that movements or loading moves the most distal pain proximally while Peripherilizing shows movements or loading moves the pain more distally. McKenzie lumbar extension exercises results in reduction, abolition or centralization of symptoms. In Lumbar derangement syndromes following MDT classification system, a subgroup in which symptoms improve with lumbar extension is labeled as posterior derangement syndrome whereas the subgroup in which symptoms improve with lumbar flexion is labeled as anterior derangement syndrome. Work of many researchers, like Peterson, Machado and Paatelma, provided the strongest evidence regarding the validity of McKenzie method of treatment.

Progressive limb loading exercises at lumbar region fall under two categories, one group emphasis on abdominal musculature and the second group emphasize on lumbar extensor musculature. Patient begins from quadruped position and progress towards prone position initiating with low intensity training and progressing towards greater intensity along with spinal compression in case of lumbar extensors. Progression towards prone position at the end range of motion requires greater control of neutral spine thus providing excellent stabilization of lumbar extensors.

A randomized controlled trial on McKenzie treatment approach in people with chronic low back pain conducted by M.H Halliday et al. provide preliminary evidence that treatment effects of McKenzie Exercises are greater when the core principles are followed with significant reduction in pain and disability of 15.2 [95% CI 7.6 to 22.7] and 11.7 [95% CI 5.4 to18.0]. Srivastav et al. conducted a study at mechanical low back pain with significant improvement having p<0.05 at NPRS & MODI after application of lumbar stabilization exercises along with conventional physical therapy.

An international survey conducted in 15 different countries in 2019 regarding McKenzie classification system involving 64.8% lumbar, 29.6% cervical, 5.6% thoracic spine of 750 patients fulfilling MDT criteria revealed 0.1% postural syndrome, 1.7% dysfunction syndrome, 75.4% derangement and 22.8% other. In derangement syndrome 82.5% were extension biased thus Derangement is the most commonly encountered pain syndrome and extension is so far the most common directional preference.

With the help of this study the investigators can determine the effects of extension biased lumbar limb loading exercises along with McKenzie extension protocols in the management of patients with lumbar derangement syndrome, which will also be a cost effective management option. It will add to the existing pool of knowledge in the fields of conservative spinal management, physical therapy, orthopedic manual therapy and musculoskeletal medicine.

Conditions

Sciatica; Low Back Pain; Low Back Pain, Mechanical

Keywords

exercise; manipulation, spinal; rehabilitation; therapy, manual; manual therapy

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: SINGLE

Study Groups

McKenzie Extension with External Limb Loading Protocol

Moist Heat Pack for 10 mins

McKenzie Extension Exercise Protocol

Static:

1. Lying Prone

2. Lying prone in extension

3. Sustained extension

4. Posture correction

Dynamic:

5. Extension in lying

6. Extension in lying with clinician overpressure

7. Extension mobilization

8. Extension in standing

Limb loading for basic stabilization progression of the lumbar extensors. Begin in the quadruped position and progress the intensity by

1. Flexing one upper extremity

2. Extending one lower extremity with a leg slide

3. Extending one lower extremity by lifting it off the mat

4. Flexing one upper extremity while extending contralateral lower extremity and then alternate to opposite extremities.

Progress to prone position:

5. Extending one lower extremity

6. Extending both lower extremity

Group Type: EXPERIMENTAL

Extension Biased External Limb Loading Exercises

Intervention Type: OTHER

Begin in the quadruped position and progress the intensity by

1. Flexing one upper extremity

2. Extending one lower extremity with a leg slide

3. Extending one lower extremity by lifting it off the mat

4. Flexing one upper extremity while extending contralateral lower extremity and then alternate to opposite extremities.

Progress to prone position:

5. Extending one lower extremity

6. Extending both lower extremity

McKenzie Extension Exercise Protocol

Intervention Type: OTHER

Static:

1. Lying Prone

2. Lying prone in extension

3. Sustained extension

4. Posture correction

Dynamic:

5. Extension in lying

6. Extension in lying with clinician overpressure

7. Extension mobilization

8. Extension in standing

Moist Heat

Intervention Type: OTHER

Moist Heating for 10 minutes at lumbar spine in prone position using moist heat packs, heated via hydro-collator.

McKenzie Extension Group

Moist Heat Pack for 10 mins

McKenzie Extension Protocol Sequence

Static:

1. Lying Prone

2. Lying prone in extension

3. Sustained extension

4. Posture correction

Dynamic:

5. Extension in lying

6. Extension in lying with clinician overpressure

7. Extension mobilization

8. Extension in standing

Group Type: ACTIVE_COMPARATOR

McKenzie Extension Exercise Protocol

Intervention Type: OTHER

Static:

1. Lying Prone

2. Lying prone in extension

3. Sustained extension

4. Posture correction

Dynamic:

5. Extension in lying

6. Extension in lying with clinician overpressure

7. Extension mobilization

8. Extension in standing

Moist Heat

Intervention Type: OTHER

Moist Heating for 10 minutes at lumbar spine in prone position using moist heat packs, heated via hydro-collator.

Interventions

Extension Biased External Limb Loading Exercises

Begin in the quadruped position and progress the intensity by

1. Flexing one upper extremity

2. Extending one lower extremity with a leg slide

3. Extending one lower extremity by lifting it off the mat

4. Flexing one upper extremity while extending contralateral lower extremity and then alternate to opposite extremities.

Progress to prone position:

5. Extending one lower extremity

6. Extending both lower extremity

Intervention Type: OTHER

McKenzie Extension Exercise Protocol

Static:

1. Lying Prone

2. Lying prone in extension

3. Sustained extension

4. Posture correction

Dynamic:

5. Extension in lying

6. Extension in lying with clinician overpressure

7. Extension mobilization

8. Extension in standing

Intervention Type: OTHER

Moist Heat

Moist Heating for 10 minutes at lumbar spine in prone position using moist heat packs, heated via hydro-collator.

Intervention Type: OTHER

Other Intervention Names

Core stability exercises

Eligibility Criteria

Inclusion Criteria

• Patients of age 30 to 50 years
• Patients of both Gender i.e. Male & Female
• Lumbar Derangement Syndrome
• Centralization or Peripheralization phenomenon
• Constant or Intermittent pain worsening on repeated movements
• Somatic, radicular or combination of both patterns of pain
• Positive Radicular signs & symptoms

Exclusion Criteria

• Lumbar Postural syndrome
• Lumbar Dysfunction syndrome
• Post laminectomy/discectomy
• Spondylolisthesis
• Osteoporosis/Fractures
• Cauda equine syndrome
• Recent history of spinal trauma or surgery
• Lumbar myelopathy
• Patients with known metabolic diseases
• Participants having less than 20% ODI scoring

• Minimum Eligible Age: 30 Years
• Maximum Eligible Age: 50 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Foundation University Islamabad

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Shoaib Kayani, DPT, MS-OMPT*

Role: PRINCIPAL_INVESTIGATOR

Foundation University Islamabad

Muhammad Osama, DPT, MSOMPT, CHPE, ACMEd, PhD*

Role: STUDY_DIRECTOR

Foundation University Islamabad

Locations

Foundation University Islamabad

Islamabad, Federal, Pakistan

Shafi International Hospital

Islamabad, Federal, Pakistan

Countries

Pakistan

Other Identifiers

FUI/CTR/2019/2

Identifier Type: -

Identifier Source: org_study_id