Effects of Extension Biased External Limb Loading in Addition to McKenzie Extension Protocol in Lumbar Derangement Syndrome
Condition: Sciatica; Low Back Pain; Low Back Pain, Mechanical
MeSH terms: Sciatica; Back Pain; Low Back Pain
Study type: Interventional

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.
    

Intervention name(s): Extension Biased External Limb Loading Exercises; McKenzie Extension Exercise Protocol; Moist Heat
Intervention type(s): Other; Other; Other
Intervention description(s): Begin in the quadruped position and progress the intensity by
Flexing one upper extremity
Extending one lower extremity with a leg slide
Extending one lower extremity by lifting it off the mat
Flexing one upper extremity while extending contralateral lower extremity and then alternate to opposite extremities.
Progress to prone position:
Extending one lower extremity
Extending both lower extremity; Static:
Lying Prone
Lying prone in extension
Sustained extension
Posture correction
Dynamic:
Extension in lying
Extension in lying with clinician overpressure
Extension mobilization
Extension in standing; Moist Heating for 10 minutes at lumbar spine in prone position using moist heat packs, heated via hydro-collator.
Other intervention name(s): Core stability exercises
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: exercise; manipulation, spinal; rehabilitation; therapy, manual; manual therapy