514

Agrawal Int J Med Res Health Sci. 2014;3(3):514-520

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886
Received: 20
th
Feb 2014 Revised: 24
th
Mar 2014 Accepted: 28
th
Apr 2014
Research Article
EFFECT OF REPETITIVE MCKENZIE LUMBAR SPINE EXERCISES ON CARDIOVASCULAR
SYSTEM
*Agrawal Sonal S
Assistant Professor, Department of Physiotherapy, V.S.P.M.s College of Physiotherapy, Nagpur, Maharashtra, India
*Corresponding author email:sonalagrawal2408@gmail.com
ABSTRACT
Background& Purpose:McKenzie exercises for the lumbar spine, which are done repeatedly, such as flexion in
standing (FIS), extension in standing flexion in lying (FIL) & extension in lying (EIL) have been used in the
management of low back pain for over three decades. The cardiovascular effects of exercises that involve postural
stabilization, arm exercises and of exercises performed in lying are well known, but there are seldom studies
performed to assess the cardiovascular effects of these commonly used McKenzie exercises. Therefore the study
focused on evaluating the effects of 4 commonly used McKenzie exercises on the cardiovascular system.Methods:
80 subjects in the age group of 20-59 years were randomly assigned into 4 groups according to their age, such that
such that each group comprised of an equal number of subjects & equal number of males & females. Each subject
performed all the 4 exercises (FIS, EIS, FIL & EIL) for 10, 15 & 20 repetitions respectively. Heart rate, blood
pressure & rate pressure product were recorded before & after each set of repetitions & after each type of
exercise. Results: Repetitive McKenzie lumbar spine exercises had cardiovascular effects in apparently healthy
subjects (both male & female). Exercises performed in lying were hemodynamically more demanding than that
performed in standing, also exercises involving flexion of the lumbar spine elicited greater cardiovascular demand
as compared to extension exercises i.e. FIL>EIL>FIS>EIS irrespective of the number of repetitions, 10, 15 or 20.
The cardiovascular demand for a given subject increased as the number of repetitions increased, for all the 4
exercises. Conclusion: McKenzie exercises when done repetitively have cardiovascular effects in healthy subjects.
Keywords: McKenzie, low back pain, cardiovascular system
INTRODUCTION
Low back pain is a condition that continues to place a
great deal of stress on the health care system of the
industrialized societies. Low back pain affects
approximately 80% of individuals in community
1
. It
is the second most common cause for patient visits to
physicians.
1
Globally whether viewed in terms of
disability allowances, industrial injury claims, or
frequency of patients visiting physician, low back
pain is the most costly musculoskeletal condition.
2
Low back pain can be extremely challenging to
prevent, diagnose and treat since its etiology is
diverse and cause often undetermined.
3
Patients
suffering from low back pain as well as health care
providers who treat them are often frustrated by the
lack of progress realized during treatment &
rehabilitation programs. One reason for this may be
that treatment and rehabilitation recommendations for
low back pain vary greatly across health care
providers.
4
Additionally, many of the common
treatment interventions prescribed to treat low back
pain patients have little scientific validation of their
efficacy.
5
It has been suggested that several factors can
predispose people to the development of low back
DOI: 10.5958/2319-5886.2014.00388.9
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Agrawal Int J Med Res Health Sci. 2014;3(3):514-520
pain which includes; smoking, obesity, drug abuse,
ageing, genetic predisposition, lack of physical
conditioning, occupation involving excessive
vibrating movements or positions that involve very
little movement (i.e. sedentary occupations),
occupations that involve lifting, bending and twisting.
Also poor posture, frequency of forward bending and
loss of low back extension are predisposing factors
for low back pain.
6
Many low back pain treatment and rehabilitation
protocols throughout the mid and late twentieth
century, primarily utilized passive modalities such as
bed rest, ultrasound, electrical stimulation, hot packs
and medication despite their being little validation of
their efficacy. However, one of the current treatment
interventions that utilize a more active approach to
treating and rehabilitating low back pain is McKenzie
therapy.
5
Forthe last three decades, McKenzie lumbar spine
exercises are being prescribed for the management of
patients with low back pain. These comprise of
repeated lumbar flexion and extension movements as
a part of routine lumbar spine assessment and
exercise program.
6, 7
Moreover,less effort is made to explain about the
cautions for increasing stress on the cardiovascular
system because of these exercises. Thus,
understanding the cardiovascular responses to
McKenzie exercises can be useful for clinicians using
these exercises fordiagnostic purpose and as an
intervention.
Aim: The aim of this study was to examine the
cardiovascular effects of four common McKenzie
exercises lumbar spinal flexion and extension in
standing and lying, when these exercises are repeated
10, 15 and 20 times
Objectives:
To study the cardiovascular effects of 4 common
McKenzie exercises: Flexion in standing (FIS),
extension in standing (EIS), flexion in lying
(FIL)&extension in lying (EIL).
To study the difference in the effects after 10, 15
and 20 repetitions of 4 McKenzie exercises.
To compare the cardiovascular effects between
different exercises i.e. FIS, EIS, FIL&EIL
To compare the cardiovascular effects of these
exercises between males and females
MATERIAL AND METHODS
Study design:The study commenced after obtaining
permission from the head of the institution and the
ethical committee of the college. The study is a cross
sectional design, with the subjects parameters
measured before and after the designed exercise
protocol. The independent variables - 4 types of
McKenzie exercises i.e. FIS, EIS, FIL and EIL; while
the dependent variables - heart rate, blood pressure
(both systolic and diastolic), rate pressure product.
Study setting: Out-patient department V.S.P.M.
College of Physiotherapy
Subjects: Population of 80 subjects in the age group
of 20-59 years was selected as participants for the
study as per the inclusion criteria. Each participant
performed the complete exercise protocol to examine
the cardiovascular effects of 4 common McKenzie
exercises as described earlier.
Sample size: Subjects were equally recruited
maintaining an equal number of males and females.
All the participants were subjected to the complete
exercise protocol.
Inclusion criteria:Apparently healthy and
asymptomatic subjects, age group 20 to 59 years
According to McKenzie this age range represents
individuals at risk for pathology of the spine,
specifically postural syndrome (30 years and
younger), dysfunction syndrome (30 years and older)
and derangement syndrome (20 to 55 years)
6
.
Exclusion criteria: Cardiovascular conditions,
pulmonary conditions, anemia, recent
musculoskeletal injury, low back pain, intervertebral
or facet joint pathology, metabolic disorders,
smoking, any neurological deficit, cognitive disorders
Outcome measures:The main outcome measures used
were heart rate in beats per minute, blood pressure
both systolic and diastolic in mm of Hg and RPP
Pre-exercise protocol:The study purpose was
informed to all the participants. They were made
aware of the risks and their right to terminate
participation at any time. All subjects acknowledged
their understanding of the study and their willingness
to participate by signing a written consent.
An interview was completed by positioning the
subjects in a relaxed sitting position in a firm
armchair for 5 minutes, which elicited information
about the subjects activity and fitness levels. The
activities of subjects were rated on a 3 point scale to
establish whether the sample was homogenous
concerning activity and fitness level. The resting HR
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and BP were recorded in a relaxed sitting position in
an armchair.
9,10
The arterial BP was obtained with an
aneroid sphygmomanometer applied to the left arm in
accordance with the American Heart Association
Standards.
10
The resting HR was determined by palpating the left
radial arterial pulse. The pulse was counted for 30
seconds using a stop watch. The value was then
multiplied by 2 to obtain a minute rate.
8
Individuals were familiarized with the patterns of the
exercises by verbal instructions, demonstration and
practice. Care was taken to see that the practice
session did not bring about any training effect to
avoid biasing of the study.
Exercise procedure was, according to standard
McKenzie protocol.
11
Fig-1: McKenzie Lumbar spine exercises
Each subject performed all 4 types of above
mentioned exercises for 10, 15 and 20 repetitions
respectively in a single sitting. Subject was supposed
to return to the resting position within 30 seconds.
8
The HR and BP of the subjects were then recorded.
Care was taken that the parameters were recorded
within 2 minutes.
10
The RPP (Rate pressure product)
was calculated by multiplying the product of HR and
Systolic BP by 10
-2.
The subjects were instructed to perform the exercises
in a continuous rhythm. The rhythm was dictated by
the therapist such that on average, each subject could
complete 20 repetitions in 1 minute.
8
On each
movement, the subject reaches the maximum possible
range for all the movements and maintains the
position for one second before the next
repetition. Breath holding was not allowed during the
exercise. 15 minutes of rest period was allowed after
each set of 10, 15 & 20 repetitions of each of the 4
exercises and also 15 minutes of gap betweenchange
in the type of McKenzie exercise.
Data analysis : Descriptive statistics for the
dependent measures, including means and standard
deviations were calculated for each set of the 4
exercises i.e. Flexion in standing, extension in
standing, flexion in lying and extension in lying and
for each group i.e. 1, 2, 3, and 4.
Statistically the characteristics of the groups and the
results were compared using One- way ANOVA and
Paired and Unpaired t tests.
Statistically the characteristics of the groups and the
results were compared using One- way ANOVA and
Paired and Unpaired t tests.
A one-way analysis of variance (ANOVA) for
repeated measures was used to compare the
dependent measurements after performing all the four
exercises for 10, 15 and 20 repetitions respectively. It
was performed for both male and female subjects.
Paired t- test was used to analyze the difference in the
mean values of RPP within four types of McKenzie
exercises for 10, 15 and 20 repetitions in males.
Unpaired t- test was used to analyze the difference
between the mean RPP values of males and females
after performing four types of McKenzie exercises
for 10, 15 and 20 repetitions.
The level of significance was set at 0.05 for all the
comparisons.
RESULTS
Table 1: Mean & standard deviation for RPP
Exercise
Male Female
10 Repetition 15 Repetition 20 Repetition 10 Repetition 15 Repetition 20 Repetition
FIL 116.946.90 123.956.10 131.348.45 105.166.48 112.076.22 112.076.22
EIL 109.865.04 116.157.23 123.277.71 98.011.20 102.925.32 102.925.32
FIS 104.535.69 111.556.9 117.147.79 93.327.52 97.466.89 97.466.89
EIS 100.265.50 104.436.43 110.358.25 86.146.24 88.897.57 88.897.57
Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL)& extension in lying (EIL).
Table 2: Comparing for the effects of different exercises in males, after applying One-Way ANOVA
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ANOVA Table for Males
Variable Source df F p-value Inference
RPP after
10
repetitions
Between Exercise Groups 3
31.1553
7.74e-16
Highlysignificant
Within Exercise Groups 156
RPP after 15
repetitions
Between Exercise Groups 3 (34.428)
37.1464
< 2.2e-16
Highlysignificant
Within Exercise Groups (156)155
RPP after 20
repetitions
Between Exercise Groups 3 (38.0165)
41.5182
< 2.2e-16 Highlysignificant
Within Exercise Groups (156)154,
The above Table shows that p<0.05, i.e. there is significant difference between the effects of different exercises
on the mean values of RPP of males whatever may be the number of repetitions.
Table3: Comparing for the effects of different exercises in females, after applying One-Way ANOVA
ANOVA Table for Females
Variable Source df F p-value Inference
RPP after
10 repetitions
Between Exercise Groups 3 23.7331 1.044e-12 Highlysignificant
Within Exercise Groups 156
RPP after 15
repetitions
Between Exercise Groups 3 35.4009 < 2.2e-16 Highlysignificant
Within Exercise Groups 156
RPP after 20
repetitions
Between Exercise Groups 3 45.2708 < 2.2e-16 Highlysignificant
Within Exercise Groups 156
The above Table shows that p<0.05, i.e. there is significant difference between the effects of different exercises on the mean
values of RPP of females whatever may be the number of repetitions.
Table 4: Comparison between the effects of exercises in females using paired t-test
Exercise
10 Repetition 15 Repetition 20 Repetition
t value p value t value p value t value p value
EIS vs EIL 9.49 0.000 9.58 0.000 11.45 0.000
EIS vs FIS 5.57 0.000 7.06 0.000 7.74 0.000
EIS vs FIL 3.31 0.001 3.97 0.00015 5.44 0.000
EIL vs FIS 13.36 0.000 14.95 0.000 17.39 0.000
EIL vs FIL 8.90 0.000 9.29 0.000 11.92 0.000
FIS vs FIL 7.54 0.000 9.95 0.000 11.66 0.000
Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL) & extension in lying (EIL).
Table 5: Comparison between the effects of exercises in males using paired t-test
Exercise
10 Repetition 15 Repetition 20 Repetition
t value p value t value p value t value p value
EIS vs EIL 8.77 0.000 7.63 0.000 7.23 0.000
EIS vs FIS 6.06 0.000 5.24 0.000 4.46 0.000
EIS vs FIL 11.94 0.000 2.87 0.005 3.54 0.0007
EIL vs FIS 4.44 0.000 13.93 0.000 11.24 0.000
EIL vs FIL 5.23 0.000 7.22 0.000 6.92 0.000
FIS vs FIL 8.13 0.000 8.50 0.000 7.82 0.000
Flexion in standing (FIS), extension in standing (EIS), flexion in lying (FIL) & extension in lying (EIL).
Table 6: Comparison between mean RPP values of
males and females using unpaired t-test
Exercise Repetitions t-value p value
10 0.0669 0.47
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FIS 15 1.3468 0.09
20 1.9517 0.02*
EIS
10 1.4104 0.08
15 1.9002 0.03*
20 2.3787 0.009*
FIL
10 0.3629 0.35
15 0.4224 0.33
20 0.8806 0.19
EIL
10 0.4028 0.34
15 0.6745 0.25
20 0.8833 0.19
The Table shows that p values are significant i.e.
p<0.05 only in 3 cases. Therefore it can be concluded
that mean values of RPP does not differ significantly
between males and females except when EIS is
repeated 15 or 20 times and when FIS is repeated 20
times.
Fig 2:Mean RPP increases such that
FIL>EIL>FIS>EIS in females after any number of
repetitions.
Fig 3: Mean RPP increases such that
FIL>EIL>FIS>EIS in males whatever may be the
number of repetitions.
DISCUSSION
As a result of data analysis repetitive McKenzie
exercises for the lumbar spine elicit significant
hemodynamic stress in healthy subjects both males
and females. [p<0.001] These exercises increase the
work of the heart in people with no known spinal
impairments and no cardiovascular or
cardiopulmonary insufficiencies. It was found that the
cardiovascular demand increased as the number of
repetitions for a given type of exercise increased.
Richardson D, stated that the magnitude and
frequency of active muscular contractions also affect
the blood flow. The muscle metabolism increases in
response to voluntary contractions, and therefore
blood flow to the active musculature.
12
Claire P. Kispert, proposed that RPP has been shown
to be a valid predictor of myocardial VO2 for
measurements performed at rest and during exercise.
The measurements of RPP is useful in clinical
settings because both HR and SBP are easily obtained
as noninvasive measurements.
13
Gobel FL, Nordstom LA, et al concluded in their
study that heart rate and rate pressure product, both
are easily measured hemodynamic variables andgood
predictors of mixed venous oxygen saturation
(MVO2) during exercise in ischemic heart disease
patients with normal blood pressure.
14
The results strongly support the idea that these
McKenzie exercises performed within 1 minute
represents a risk for a patient with underlying
cardiovascular dysfunction. The degree to which an
increase in RPP is an index of cardiovascular stress,
represents cardiovascular strain depends on the
underlying path physiology. Thus a given absolute
increase of RPP may be inconsequential in a person
without cardiovascular or pulmonary pathology;
however, it may constitute marked hemodynamic
strain in an individual with such pathology.
13
It was found that mean RPP values were greater after
20 repetitions of each of the 4 exercises when
compared to mean RPP values after 10 and 15
repetitions. The mean RPP values were also greater
during the exercises which were performed in lying
position than in upright position both in male and
female subjects (FIL>EIL>FIS>EIS) . This finding is
consistent with known physiology.
15
Tommy Boonestated that cardiac output increases
when lying down versus standing
16
which is
consistent with the results of the study.
Female
0
5
10
15
20
25
30
35
40
10 15 20
Repetition
I
n
c
r
e
a
s
e
d

M
e
a
n
FIL EIL FIS EIS
Male
0
5
10
15
20
25
30
35
40
10 15 20
Repetition
I
n
c
r
e
a
s
e
d

M
e
a
n
FIL EIL FIS EIS
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The work of a large muscle mass of the upper and
lower extremities, theabdominal muscles, and the
trunk muscles are involved in flexion in lying.
11
Christensen EH, Astrand PO, in their work concluded
that volume of oxygen consumed during physical
exercise is necessarily dependent upon the load on the
muscles and also on the mass of the muscles at work.
Work with legs can bring the metabolism to a higher
level than can exercise performed by the arms.
17
All
these researches confirm that there is increased
oxygen demand by the contracting muscleswhich in
turn increases the HR, BP, cardiac output and stroke
volume.
11
On the other hand, EILis an exercise that involves the
workof upper extremity muscles while raising the
upper trunk against gravity.
11
Several studies by Bevgard S, Freyschuss V,
Strandell T, Stenberg J, Astrand P O, Astrand I, Asit
G, John W; in their study concluded that arm exercise
in comparison with leg exercise is accompanied by a
large rise in heart rate, blood pressure, pulmonary
ventilation, and arterial lactate concentration and this
difference are attributed to more dominating
sympathetic vasoconstriction tone during arm
exercise.
18
Flexion in lying, however is additionally associated
with inadvertent holding of breath and increased
intrathoracic pressure, leading to increased resistance
to blood returning to the heart and thus there is a
reflex increase in the HR and BP.
11
Thus there is
increased workload on the heart during FIL as
compared to EIL, which is also in accordance with
the results of this study.
The range of motion during back extension is less
than during flexion, therefore there is presumably less
muscle work, and therefore, less work of the heart in
extension compared with flexion, in both standing
and lying positions. This fact was also confirmed by
the results of the current study. (EIS<FIS)
When the mean RPPs of males and females were
compared, it was found that RPP for females were
smaller than their counterpart males except in a few
cases. However, significant differences were found
only when EIS was repeated 15 or 20 times and when
FIS was repeated 20 times.
Bengstsson C
19
,stated that several studies from
industrialized countries have reported age associated
changes in both systolic (SBP) and diastolic (DBP)
blood pressures. These changes in blood pressures
seem to be different for SBP and DBP and have also
been reported to be different in male and female
subjects.Claire P. Kispert
13
in his article stated that, in
general BP is lower for women younger than 40 to 50
years in comparison with men of this age group
which also supports the findings of the present study.
The study indicates that before administering
McKenzie exercises to any patient having spinal
problem cardiovascular status should be examined.
This study recommends that, ruling out
cardiovascular and pulmonary disease by history
taking alone isnot sufficient and cardiac and
pulmonary risk factor assessment should be done
before prescribing McKenzieexercises. The results of
the study suggest that baseline heart rate and blood
pressure should be recorded routinely. Cardiovascular
monitoringshould also be taught to the patient
themselves so that cardiovascular monitoring can be
performed when repetitive McKenzie exercises for
the lumbar spine are performed as a home exercise
program. Also whenpatients are following McKenzie
protocol as home exercise program care should be
taken those they dont exceed the prescribed number
of repetitions. It is also suggested that when
prescribing FIL which was found to have highest
cardiovascular demand, physical therapist should
closely monitor the patient. Patients should
discourage for breath holding or straining during the
exercise. Patients should be taught to self monitor
their cardiovascular parameters who are knownto
have risk factors for cardiovascular disease.
However till date there are seldom studies
documented on the adverse cardiovascular effects of
McKenzie exercises; therefore awareness of their
effects is important for the judicious prescription of
designed exercise protocol.
CONCLUSION
McKenzie exercises for the lumbar spine i.e. FIS,
EIS, FIL, and EIL performed repetitively i.e. for 10,
15 & 20 repetitions at are routinely used in the
assessment & management of low back pain. This
study found that these exercises have cardiovascular
effects in otherwise healthy individuals & who are
within age group of 20-59 years.FIL>EIL>FIS>EISin
males as well as females and this effect is accentuated
with increasing number of repetitions.Further
research is needed to elucidate factors that increase
the risk for a given patient. Electrocardiographic
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Agrawal Int J Med Res Health Sci. 2014;3(3):514-520
studies would help establish the effects of these
exercises on cardiac rhythm and provide a guide for
proper prescription of McKenzie exercises.
Limitation:Only non invasive outcome measures
were used for cardiovascular evaluation
Conflict of interest: Nil
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