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Does It Matter Which Exercise ?

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. Mechanical assessment identifies reliable, validated subgroups.

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Does It Matter Which Exercise ?

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  1. Does It Matter Which Exercise? • A RCT of Exercise for Low Back PainSpine 2004;29(23):2593-2602 Long BScPT, Dip MDT R. Donelson, MD MSc T. Fung, PhD

  2. Mechanical assessment identifiesreliable, 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

  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

  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

  5. MechanicalAssessment DirectionalPreference Extension Lateral Flexion Random-ization Random-ization Random-ization DirectionalTreatments Opposite Matched EBG Mechanical Assessment Excluded Study Design Directional Preference No Directional Preference

  6. Results N=191 (83%) N=16 (7%) N=23 (10%) Extension Lateral Flexion Random-ization Random-ization Random-ization Matched EBG Opposite N=72 N=63 N=68 Mechanical Assessment N=312 N=230 (74%) N=82 (26%) Directional Preference No Directional Preference Excluded No-Return: 29 (12.6%) No significant differences between the directional subgroups at baseline.

  7. Analytical Methods • Sample size calculation • Descriptive statistics • Frequency distributions(includes multiple responses) • Two-way Anova • Chi-square tests

  8. 34.8%* 32.8%* 0.0% Side Effects • Early Completions • Stopped exercises prior to 2 weeks • Self –worse or no better • Therapist - peripheralizing 50% 40% 30% 20% p<.001 10% *included in analysis 0% 1 2 3

  9. 100% 95% 80% Worse No Change 60% Better 42% 40% Resolved 23% 20% 0% Matched Opposite EBG Results • Global Rating Improvement p<.001

  10. Results p<.001 p=.003

  11. Results p=.016 p=.009

  12. Results p<.001 p<.009

  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.

  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.

  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!

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