Purpose: The purpose of this case study and evidence-based analysis is to determine the efficacy of manual therapy (MT) versus exercise, including McKenzie therapy (MDT)/directional preference, in promoting functional outcomes and decreasing pain in adult patients with chronic low back pain. Background: Low back pain that has been present for greater than three months is considered to be chronic. Chronic low back pain (CLBP) varies in type and severity and has been described as bone pain, nerve pain or muscle pain. Each type of pain then carries its own set of descriptors. Chronic low back pain may originate from disease, injury, and stresses placed on different structures of the body. In the physical therapy setting, there are several methods to treating CLBP such as education, posture training, behavioral modifications, exercises, modalities, (biofeedback, electrical stimulation, laser therapy, traction, ultrasound, etc.), manual therapy and massage. The most efficacious physical therapy treatment for chronic low back pain is imperative to find to offset an increasing CLBP population leading to decreased function, loss of work and increased medical expenses. Case Description: A thirty-two-year-old male patient with a history of chronic low back pain of greater than seven years received physical therapy (PT) for two months prior to a right (R) sided L5-S1 surgery. A right side laminectomy, foraminotomy, and discectomy at L5-S1 level was performed in a minimally-invasive day surgery procedure. One month later he was referred back to physical therapy to increase motor control function and ultimately find ways to cope with his symptoms. Outcomes: The patient had several remarkable gains. These gains included increased range of motion (ROM) and strength of the hip, ankle and trunk musculature, improved balance and proprioceptive awareness, decreased pain, increased function in walking, sitting, bending, sleeping, working, lifting and recreational activities, improved knowledge of diagnosis, symptom management skills and overall improved well-being. Initial treatment consisted of transversus abdominus/core engagement, motor control exercises and education. Progression was assessed weekly and advanced based on ability to complete tasks with control and without symptom increase. Manual therapy was used accordingly to treat hypo mobility, pain and symptom management, sacroiliac (SI) dysfunction and decrease neural tension. Exercise was specific to the patient's impairments, initially with easier low resistance activities and progressing to advanced core strengthening and focusing on dynamic/functional movement. Discussion: A literature review of current research within the past 10 years suggests that both exercise (including McKenzie therapy and directional preference) and manual therapy are both valid options for treating CLBP. There is some evidence to support the use of manual therapy for immediate effects such as pain decrease secondary to an analgesic effect that it may convey. However, when in comparison there is little to no difference between the two. Although there are a variety of articles and systematic reviews that lead to exercise being slightly more beneficial in the intermediate and long-term outcome. Based on the research it is apparent that there is a varied heterogeneity among the studies and many studies and reviews do not give accurate or detailed accounts of the exercise/MT that is being used in order to reproduce the same results among clientele. Other articles imply that using both in combination for CLBP treatment is better than just one or the other. Ultimately, it will come down to therapist and patient preference, which is also based on efficiency, cost-effectiveness and safety of care, which should have the highest priority.


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Document Type


First Advisor

Marybeth Barkocy


Low Back Pain; Exercise Therapy; Patient Preference

Available for download on Monday, March 14, 2118