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J. Phys. Ther. Sci. 31: 590–597, 2019
The Journal of Physical Therapy Science The Journal of Physical Therapy Science
Review Article
Effects of McKenzie and stabilization exercises
in reducing pain intensity and functional
disability in individuals with nonspecific
chronic low back pain: a systematic review
1, 2) 3) 4) 4)*
AnAs MohAMMed AlhAkAMi , sAlly dAvis , MohAMMed QAsheesh , Abu shAphe ,
4)
Aksh ChAhAl
1) Oxford Brookes University, UK
2) King Faisal Medical City for Southern Region, Saudi Arabia
3) Faculty of Health & Life Sciences, Oxford Brookes University, UK
4) Jazan University, Saudi Arabia
Abstract. [Purpose] The purpose of this review is to compare the effect of McKenzie and stabilization exercises
in reducing pain and disability in individuals with chronic nonspecific low back pain. [Methods] A systematic lit-
erature review of randomized controlled trials (RCTs) were performed using 6 databases. The quality of reviewed
articles were assessed by the risk of bias using the Cochrane collaboration’s tool. [Results] A total of 829 articles
were found from the databases, of which 10 were finally selected to be included in this review. The overall risk of
bias assessment indicated that the risk of bias was low in one study and high in the other nine studies. One study
reported reduced pain and two studies reported reduced functional disability in the McKenzie exercise group com-
pared to other exercises. Two studies reported reduced pain and three studies reported reduced functional disability
in the stabilization exercise group compared to other exercises. In two studies, the stabilization exercise group was
as effective as McKenzie exercise group in reducing pain and functional disability in patients with chronic nonspe-
cific low back pain. [Conclusion] Only two studies compared stabilization and McKenzie exercises in the manage-
ment of chronic nonspecific low back pain. Therefore, insufficient evidence is available to draw any conclusive
comparison on the effects of McKenzie and stabilization exercises in chronic nonspecific low back pain. However,
both McKenzie and stabilization exercises was better than conventional exercise programs in reducing functional
disability in patients with chronic nonspecific low back pain.
Key words: Low back pain, McKenzie exercises, Stabilization exercises
(This article was submitted Jan. 20, 2019, and was accepted Apr. 22, 2019)
INTRODUCTION
Low Back Pain (LBP) is considered as one of the commonest problems, in which pain felt in the lumbosacral spinal and
paraspinal regions which encompass the buttocks and upper thigh1). LBP is one of most common medical problems that lead
to absence from work, the disability arising from this pain resulting in significant economic impact2). In addition, LBP can
lead to activity restrictions such as carrying objects, sitting or standing for a long time, twisting and squatting, which can
3). A previous
result in participation limitation (work, recreation activities, family and community) and functional disability
4) reported the point prevalence of LBP is estimated at 21−33% and 22–65% for one-year prevalence. It
systematic review
has been reported that lifetime prevalence of low back pain globally is as high as 84%5). Homaid et al.6) reported that global
*Corresponding author. Abu Shaphe (E-mail: mshaphe@jazanu.edu.sa; shaphe72@yahoo.com)
©2019 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives
(by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)
590
prevalence of LBP is 45% in Saudi Arabia, and the prevalence of LBP is estimated to be 18%. Heyman and Dekel7) stated
that back pain problems occur more in adults and detailed that the frequency of low back pain amongst females is more than
males and increases with age across both genders.
Previous study defined chronic low back pain (CLBP) as a “back pain problem that has persisted for at least three months
and has resulted in pain on at least half the days in the past 6 months”8). Only few cases of CLBP have specific causes of pain
and they are defined as symptoms caused by a known pathophysiologic mechanism, for instance infection, herniated nuclei
9–11)
pulposus, rheumatoid arthritis, osteoporosis, tumor or fracture . However, patients in the other group with no specific
12). Many clinical guidelines reported that patients
pathophysiologic mechanism are commonly known as “nonspecific LBP”
13–16)
can control and deal with chronic LBP by patient instruction and help with self-care . Moreover, there was strong em-
phasis on encouraging patients to be active partners in the treatment of their health situation, for instance, during instruction
17). However, treatment that focuses on exercise and education instead of medication is amongst the
and exercise programmes
18). Furthermore, active rehabilitation programmes can help in enhancing body function, decreasing pain,
best of treatments
reducing disability, improving walking and self-efficacy19, 20). Although there are many methods to treat or manage chronic
low back pain (CLBP), the current study bases its focus on two methods.
21) 22)
The first is McKenzie exercises, devised by Robin McKenzie , also known as diagnostic and mechanical therapy . This
23). Additionally, Kuppusamy
is a common method used among physiotherapists as a treatment method for handling back pain
3) reported that the McKenzie exercises are considered to be frequently used by physiotherapists in the treatment of LBP.
et al.
Improvement in symptoms is successively measured in terms of ‘centralization’, a phenomenon that has been commonly
used24). It combines recurrent end range actions by examination; the classification of direction for exercise is contingent
upon the patient’s response to those recurring actions. Posture correction ensuring the maintaining of the correction is a vital
3).
characteristic of the McKenzie exercise
The second method is stabilization exercises because the decrease in spinal stability it is one of the major causes of
recurrent LBP25). As a result, there is more emphasis on training the localized stabilizer muscles; transverse abdominis (TrA)
and multifidus muscles (MF)26). Moreover, people with CLBP are more likely to have inadequate control in TrA muscles
and atrophy has been found in the MF muscle27). The main goals of the stabilization exercises are deep motor control of
deep trunk muscles (TrA and MF) restoration and increase in thickness of these stabilizer muscles that result in improved
27). A study was carried out by O’Sullivan et al.28) on patients with CLBP and showed that the pain intensity in
spine stability
patients in receipt of TrA and MF muscle training for 10 weeks decreased and that functional disability, in turn, improved.
The current systematic review aimed to assess the efficacy of the McKenzie exercises in comparison with the stabiliza-
tion exercises in individuals with chronic nonspecific low back pain by systematically and critically assessing the research
evidence.
METHODS
Six databases were used to attain high quality resources, guarantee the dependability and check the rationality of studies
and references found. Moreover, the use of these databases is crucial as they contain health and social care and medical
journals. These databases include Web of Science, PubMed/ MEDLINE, Cochrane Library online, National Rehabilitation
Information Centre (NARIC), ProQuest Medical Library, and PEDro during the period from its inception to current date.
Search terms and Boolean operators that are utilized by the author are “chronic” AND “nonspecific” AND “low back pain”
OR “lumbar spine” AND “stabilization” OR/AND “McKenzie” AND “exercise” OR “method” OR “training” OR “therapy”
AND “transverses abdominus” AND “multifidus”. Search strategies for three databases including PubMed, Web of Science,
and Cochrane library were given in Table 1. All the articles that have been selected depend on the following specific inclusion
and exclusion criteria (Table 1). Two reviewers participated All studies that have been selected in this literature review are
RCTs. The risk of bias was evaluated with the Cochrane collaboration’s tool. The allocation concealment, sequence genera-
tion, blinding, absence of selective outcome reporting, and completeness of outcome data domains were assessed. Risk of
bias was indicated as low, high, and unclear in each domain.
RESULTS
A total of 829 articles were identified in the title search after excluding the duplicates (n=407) (Fig. 1). A total of 10 articles
were included in this qualitative review. Table 2 details the study characteristics. All 10 studies are RCTs; additionally, all of
these trials target people that have chronic nonspecific low back pain. All of them are comparison trials that compared McK-
enzie exercise with other kinds of exercises, compare stabilization with other kinds of treatments and compare McKenzie
exercise with stabilization. For instance, there are five studies which compared McKenzie exercise with other sorts of exer-
cises, such as Back School exercise, mat-based Pilates, intensive strengthening training, manual therapy and electrophysical
3, 29–32) 33, 34)
methods , while two studies compared McKenzie exercise with stabilization exercise . Furthermore, three studies
compared stabilization exercise to other types of exercises. For instance, dynamic strengthening exercises for lumbar region,
27, 35, 36).
stretching and general exercise
According to all research that was selected in this review, the outcome measures are the same (Pain intensity and Func-
591
Table 1. Search strategies and criteria
Search criteria Search strategies
Inclusion criteria Key words PubMed Web of Cochrane
● Studies which are randomized controlled trials. Science library
● Studies involving patients with nonspecific chronic “Low back pain” OR “Back pain” OR 57,128 60,584 9,441
low back pain. “Lumbar spine pain”
● Studies that include participants with age over 18 years. Chronic OR Nonspecific 1,340,074 1,170,401 49,493
● Studies about McKenzie exercise or stabilization “transverses abdominus” OR 121,350 94,445 4,495
exercise or both together. “multifidus” OR Lumbar OR
● Studies written in the English language. “Core muscles”
● Studies include measurement of pain and functional “stabilization exercise/training” OR 107,113 38,332 11,972
disability outcomes. “McKenzie exercises/training” OR
Exclusion criteria “Physical therapy” OR Physiotherapy
● Clinical practice guidelines. Combined search 580 354 162
● Studies that include participants with acute or sub-acute Total articles after duplication removed 829
low back pain, spinal pathology, history of cancer, serious
neurological problems, pregnancy, sever osteoporosis,
spondylolisthesis, spondylitis, rheumatoid arthritis.
Nonspecific chronic low back pain: It is defined as a “back pain problem that has persisted for at least three months and has resulted in
8, 12)
pain on at least half the days in the past 6 months” with unknown pathophysiologic mechanism .
21)
McKenzie exercise: It is a therapeutic technique comprises assessment and intervention to treat back pain .
Stabilization exercise: It is a type of exercise program targeting the core muscles such as deep abdominal and trunk musculature in the
25)
management of back pain .
tional disability). However, the outcome measure tools
are different; for example, for pain there are four types
of tools (Visual Analogue Scale (VAS), Numeric Rating
Scale (NRS), Mannich Low Back Pain Rating Scale and
McGill Pain Questionnaire (MPQ) and four kinds for dis-
ability (Roland Morris Disability Questionnaire (RMDQ),
Oswestry Disability Questionnaire (ODQ), Functional
Rating Index (FRI) and Functional status Questionnaire
(FSQ).
All the 10 included trials in this review have clear
concentrated questions; in addition, clear objectives
are reported in these trials. Moreover, all the outcome
measures utilized in these selected studies are valid and
reliable and all of them were ethically agreed. According
to the variance, statistical power, consequence of size and
pre-test significance, suitable sample size is assumed to
37). In the current study, five out of the 10
be considered
studies selected in this review have small sample size ac-
3, 27, 31, 33, 36)
cording to each study’s author .
Table 3 details the risk of bias assessment of the includ-
ed studies. Figure 2 presented risk of bias graph of review
authors’ judgments about each risk of bias item presented
as percentages across all included studies. The overall risk
of bias assessment indicated that the risk of bias was low in
29) 3, 27, 30–36)
1 study , and high in other 9 studies . Bias in the
study can be affected by unsuitable masking and inappro-
priate participants38). Blinding of participants can provide
a chance to provide performance bias, particularly in rela- Fig. 1. Results and process of literature search.
tion to subjective results. Patients masking in a study can
aid to avoid the placebo effect; failure to complete this can
39).
result in leaning the findings in favor of the treatment
In all 10 included studies, none of the study fulfils the criteria of complete blinding. However, eight studies have assessor
3, 27, 29, 31, 32, 34–36) and two of them have no blinding30, 33). If there is poor randomization and inadequate concealed
blinding
allocation of the contributors in study, bias will be introduced38). Furthermore, the inclusion and exclusion criteria are ex-
J. Phys. Ther. Sci. Vol. 31, No. 7, 2019 592
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