Level of McKenzie Education
Functional Outcomes
and Utilization
in Patients with Low Back Pain
Daniel Deutscher, PT, PhD
FOTO 15th Annual Outcomes Conference
2015
JOSPT Dec 2014;44(12):925-936.
Background
• Common use of PT and MDT in treating LBP (Battie 1994;
Foster 1999; McKenzie & May 2003; Byrne 2006 )
• Recommendation for classification based treatment
(Delitto 1995; Brennan 2006; Fritz 2007…)
McKenzie = Mechanical Diagnosis and Therapy (MDT)
Background
• Deutscher et al: Arch Phys Med Rehabil 2009; Associations between
treatment processes, patient characteristics, and outcomes in outpatient
physical therapy practice
– Self-exercise compliance predicts higher outcomes
– Lower self exercise compliance in patients with spinal
impairments (lumbar & Cervical) compared to peripheral
impairments (shoulder & knee)
– Therapeutic exercise prescribed more to patients with
peripheral impairments
Background
• Therapists’ confidence in prescribing exercises to
peripheral compared to spinal joints…?
• Need for more education on effectiveness of
exercises for spinal impairments…?
Background
• Supervised and home exercise therapy customized to
a patient’s clinical presentation for LBP have been
suggested as effective means to improve outcomes
• These therapy principles are important components
of the McKenzie treatment-based classification
system
Maccabi initiates an intensive MDT
educational program
Background
McKenzie Training process and data collection period
Background: McKenzie Classification System
Purpose
Examine associations between Level of McKenzie
post-graduate training (A-D and post certification) and:
– Functional status at discharge
– Utilization (number of PT visits)
controlling for patient and therapists risk factors at
admission
Methods: Design
• Practiced based evidence (PBE)
• Prospective
• No alteration of normal treatment
• Patient informed consent exempt by IRB
Methods: Patients
• 18 years old or older
• Selected lumbar area as primary impairment between
April 2006 to December 2012
• Two or more visits
• Intake FS data; N=36,348
– 93% Participation rate
• Intake & Discharge FS data; N=20,882
– 57% Completion rate
• No exclusion criteria!!!
Methods: Clinicians
• 72 outpatient clinics throughout Israel
• 195 Therapists with no prior MDT education
• Took at least Part A
• Had at least one year of experience treating patients
with LBP
• >= 40% overall completion rate per therapist
• >= 30 complete episodes per therapist
• Same therapist throughout the episode of care
Methods: Patients & Clinician
Methods: Analysis
• Descriptive statistics to examine categorical and
continuous measures.
• Assess possible patient selection bias by comparing
patients with complete vs. incomplete outcomes data
• Hierarchical linear regression models with patients
nested within therapists.
• Assess associations between MDT educational levels
& FS outcomes & number of visits after controlling for
patient risk factors
Results…
Results…
Patients with complete or incomplete data had higher
values or prevalence for characteristics predictive of
both lower and higher FS change
No support for a systematic patient selection bias
Results: Outcomes measures
Results: Functional Status Change
MCII=5
(Hart et al 2010)
FS change(SD) during 2005-2008=11.1(12.9), N=7,216
(Deutscher et al 2009)
Results: Risk Adjusted FS Outcomes
R2=35%
Results: Risk Adjusted FS Outcomes
Results: Risk Adjusted FS Outcomes
Results: Risk Adjusted FS Outcomes
Results: Utilization
Results: Utilization
R2=6%
Study limitations
• Possible patient selection bias not supported but still
exists
– 57% completion rate, 31% dropout (57/69=83%)
– Imbalances in group characteristics, some in favor of the
selected group, and some in favor of the group not selected
– Negligible potential selection bias probably not differing by
level of McKenzie education
Study limitations
• Possible therapists selection bias
– Generalizability to other countries with differing physical
therapy education?
– Level of professional commitment for therapists engaged in
continuing education?
– Most therapists did not take all levels of education
– Non-formal education between therapists with different
levels of education
Study limitations
• Causal factors related to better outcomes are not
known due to the observational design
– Possible time confounder (better outcomes over time due to
the passage of time and general experience), although
therapists with no McKenzie education were treated during
most of the study period
– Missing confounders (patient education, socioeconomic
levels, psychosocial factors, patient-therapist working
alliance)
– Interventions were not included
Main results – Functional Status
• Potential for improved FS outcomes after engaging in
a post-graduate McKenzie educational program
• Improvement in FS was modest
• Similar FS outcomes between educational levels Part
A to CRD
Main results – Utilization
• Significant decrease in utilization associated with
McKenzie training
• 11-13% decrease in number of visits at advance levels
(Part C and above), 7-9% decrease in number of visits
at basic levels (Parts A & B)
• Lower utilization associated with higher outcomes
after adjusting for significant patient risk factors
• Potential of 1.5-3% improvement in the overall
physical therapy service efficiency due to patients
with lumbar impairments only (~20% of all patients).
Implications
McKenzie education
may lead to a small improvement
in functional outcomes
over a shorter episode of care
Future research
• McKenzie education impact on clinician practice
behaviors (intervention) and outcomes
• Outcomes at diplomat postgraduate training level
(Rodeghero 2015: PT fellowship-higher outcomes than residency or none)
• Impact of a modified educational process?
– More active student involvement in classification &
treatment decisions?
– Long term post-course implementation
– Ongoing follow-up training between courses
– Interactive learning in small groups (audit circles)
– Additional accreditation requirements
Future research
• Specific therapists’ responses to MDT (or other)
education?
– Improved outcomes
– No change
Therapists explained
2.2% of variance
(P<.001)
– Decreased outcomes
• Therapist-Patient working alliance influence on
outcomes (Hall et al 2010)
• Reflection, collaborative clinical reasoning, and
patient empowerment influence on outcomes (Resnik &
Hart 2003)
Thank You
195 participating therapists
PT Clinic & District managers
District PT directors of R&D
PT Dept. head directors
(Moshe Gutvirtz & Ditza Gottlieb)
McKenzie Inst. Instructors
Co-authors:
Mark Werneke, Dr. Linda Resnik,
Dr. Julie Fritz and Ditza Gottlieb