There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy. The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice. Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews

1. SPECIFIC TREATMENT OF PROBLEMS
OF THE SPINE (STOPS) TRIALS
Dr Jon Ford (PhD, MPhysio, BAppSciPhysio)
Dr Andrew Hahne (PhD, BPhysio)
Luke Surkitt (BPhysio)
Alex Chan (BPhysio)
Matt Richards (BPhysio)
Sarah Slater (BPhysio)

2. Clinical scenario
• Patient reports
– “My backs out”
– “The doctor says it’s a muscle strain”
– “The doctor says I’ll get better but its now 6 weeks”
• Clinical questions
– Does it matter which treatment I provide?
– How do I diagnose the problem?
– What treatment can I provide that is specific to the diagnosis?
– Is there evidence to support these clinical decisions?

3. Clinical practice guidelines
• Syntheses of CPGs (Dagenais et al 2010, Koes et
al 2010)
• High quality guidelines from last 10 years
(average 4 years old)

4. Recommendations
• Identify “flags”

7. What is “organic pathology”
• Typically regarded as disc herniation with
associated radiculopathy (DHR)
– Conservative trial followed by surgery if non-responsive
– MRI not indicated unless surgery being seriously
considered
• Potential counter-productive effect of attempting
to identify pathoanatomical cause of the pain
(beyond serious pathology including DHR)

8. Specific treatment
recommendations
• Specific treatment for organic pathology other
than DHR not provided
• Treatment specific to the flag identified not
clearly stated
• Due to low level evidence on the efficacy of
specific treatment
– eg Which treatment is most effective for
• High fear avoidance beliefs?
• Disc herniation with associated radiculopathy?

9. Generic treatment
recommendations
• Advice/reassurance for acute LBP ± medication
for short term relief
• Chronic LBP
– Exercise
– Cognitive behavioural approach
– Multi-disciplinary intervention
– Acupuncture
– Opiates
• Variable recommendations for manual therapy
due to lack of consistent evidence

10. Lack of evidence
• Diagnostic injection
• Therapeutic blocks
• Pilates
• Massage therapy
• Specific treatment (eg SIJ, O’Sullivan, McKenzie,
motor control, etc)

11. And there’s more…
• Treatment effects are small (less than 0.5) when
compared to “minimal intervention” or “usual
care”
– Borderline clinical meaningfulness
• Non-significant treatment effects comparing one
treatment to another

12. Classification issues (aka lumping
and splitting)
• False assumption of sample
homogeneity
• Application of generic
treatment protocols
• Dilution of the effect of
specific treatment

13. Are these treatments appropriate
for all “non-specific LBP” cases?
• Motor control
• Manual therapy
• Pilates
• McKenzie
• Functional restoration/graded activity
• Cognitive-behavioural approach
• Neurophysiological education
• Treatment of signs and symptoms

14. Systema(c
reviews
• Based
on
the
premise
of
uniden(fied
subgroups
dilu(ng
the
treatment
effect
in
RCTs
to
date
our
group
conducted
a
number
of
systema(c
reviews
• Our
results
showed
that
there
are
some
individual
trials
that
show
larger
effects
when
Rx
is
applied
to
specific
subgroups
but
the
level
of
evidence
was
generally
low
or
moderate
at
best

15. Classification based RCTs

16. Classification RCTs
The effectiveness of physiotherapy functional
restoration for post-acute low back pain (Richards,
Ford et al 2012) – in press

17. Recent advances in classification
• Peter O’Sullivan
– Movement and control impairment subgroups
– Exercise, motor control, cognitive-behavioural Rx
• STaRT Back
– Orebro based subgroups of low, mod and high risk
– Advise/functional restoration/cognitive behavioural Rx
• Tom Petersen/Mark Laslett
– Pathoanatomical subgroups
– McKenzie treatment for discogenic pain

18. Identified issues
• Mixing populations
• Reinventing the wheel – what about manual
therapy?
• Complexity (O’Sullivan)
• Poorly described and non-reproducible treatment
protocols
• “Forcing” patients into one subgroup (O’Sullivan
and McKenzie)

19. The STOPS approach
• The right population - sub-acute, non-
compensable
• Well accepted/validated subgroups
– Reducible discogenic pain
– Disc herniation with associated radiculopathy
– Z-joint dysfunction
– Non-reducible discogenic pain
– Multi-factorial persistent pain
• A sophisticated but well described and
reproducible assessment and classification
system

20. Evidence-based and time honoured
specific treatment
Subgroup
Specific
treatment
DHR
and
NRDP
Manage
inflamma(on,
motor
control,
pacing/posture,
pain
con(ngent
graded
func(onal
restora(on,
educa(on
RDP
Mechanical
loading
strategies,
pacing/posture,
tape
à
motor
control
Z-­‐joint
Unilateral
manual
therapy
with
Maitland
style
clinical
reasoning
à
motor
control
MFP
Time
con(ngent
graded
func(onal
restora(on,
cogni(ve-­‐
behavioural
approach,
pain
educa(on
Ford et al 2011a,b
Ford et al 2012a,b

21. Design
• Specific physiotherapy treatment program for
each subgroup vs “evidence-based advice”
• 300 participants randomly allocated
• Follow-ups at 5-weeks, 10-weeks, 6-months, 12-
months, 24-months

22. Inclusion/exclusion criteria
• Inclusion criteria
– Aged 18-65
– New episode of lumbar related pain between 6 weeks and 6
months
• Exclusion criteria
– Compensable clients
– Post-surgery
– Epidural in the previous 6 weeks
– Cauda equina syndrome

23. Classification

24. Classification process
• Full assessment (60 minutes)
• Data entered into a purpose built excel
spreadsheet
• Classification subgroup automatically calculated

25. Z-joint subgroup
• Unilateral symptoms
• A regular compression pattern (Edwards 1992)
– Extension in standing reproducing the participant’s
clinical pain
– Ipsilateral lateral flexion or quadrant in standing
reproducing the participant’s clinical pain
• Comparable palpatory findings
• A positive response to assessment of the
comparable palpatory finding

26. RDP
• Positive on at least 4 of 9 subjective features of discogenic
pain (Chan et al 2012)
• Positive response to repeated movement or sustained
positioning (MLS) defined as an:
– Increase in range of motion of the MLS during application by at
least 50% or
– Increase in AMT in any movement by at least 50% after
application or
– Increase in observed segmental intervertebral motion during
AMT after application or
– Improvement in resting pain and/or centralisation (>1min
– Reduction in an observed lateral shift postural abnormality

28. Treatment
• 14 clinics across metropolitan Melbourne
• 10 SMC treating physiotherapists
• 10 sessions of specific Rx over 10 weeks
• 2 sessions of advice over 10 weeks (Indahl et al 1995)
• Treatment integrity
– 240 page treatment manual
– 2 day training
– Clinical notes submitted at 3 and 7 weeks
– Monthly telephone hook up

29. Participant info sheets
• Diagnosis
• Dealing with an increase in
• Program
(meframes
pain
• Treatment
op(ons
• Inflammation
• Motor
control
training
• Pain versus function
• Direc(onal
preference
exercises
• Pain management
• Func(onal
restora(on
exercises
strategies (2)
• Posture
• Goal
seOng
• Pacing
and
graded
ac(vity
• Relaxation
• Sleep

31. Treatment protocols
• Algorithmic, sophisticated yet reproducible
• Detailed protocols published (Ford et al 2012a, b,
c, d)
• Adhering to the key principles of the original
developers (Maitland 1987, McKenzie 1981,
Mayer et al 1985, Saal and Saal 1989)

32. Ford et al 2012

34. Ford et al 2012

35. Outcome measures
• Primary outcomes:
– Activity limitation (Oswestry)
– Leg pain intensity (0-10 numerical rating scale)
– Back pain intensity (0-10 numerical rating scale)
• Secondary outcomes
– Sciatica frequency and bothersomeness scales
– Global rating of change (7-point scale)
– Satisfaction with physiotherapy treatment (and results)
– Psychosocial status (Orebro)
– Quality of life (EuroQol-5D)
– Number of work days missed
– Interference with work
• Other measures
– Co-interventions
– Medication

36. Analysis
• Between-group effects
• Continuous outcomes
– Linear mixed model with baseline score as a covariate
• Ordinal outcomes
– Mann Whitney U test
• Dichotomous outcomes
– Relative risk, risk difference, and number needed to
treat

37. Results
• See
IFOMPT
presenta(on
• 12
month
results
will
be
published
mid
2013
• Results
show
that
specific
physiotherapy
works!

38. Contact
E:
stopsbackpain@gmail.com
W:
www.facebook.com/STOPSbackpain
T:
@stopsbackpain

39. Our papers
Hahne A, Ford J. Functional restoration for a chronic lumbar disk extrusion with
associated radiculopathy. Physical Therapy. 2006;86:1668-80.
Ford J, et al. Classification systems for low back pain: a review of the methodology for
development and validation. Physical Therapy Reviews. 2007;12:33-42.
Heymans M, et al. Exploring the contribution of patient-reported and clinician based
variables for the prediction of low back work status. Journal of Occupational
Rehabilitation. 2007;17:383–97.
Wilde V, et al. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel
with the Delphi Technique. Physical Therapy. 2007;87:1348–61.
Ford J, et al. The test retest reliability and concurrent validity of the Subjective
Complaints Questionnaire for low back pain. Manual Therapy. 2009;14 283-91.
Hahne A, et al. Outcomes and adverse events from physiotherapy functional
restoration for lumbar disc herniation with associated radiculopathy. Disability and
Rehabilitation. 2010;Early Online:1-11.
Hahne A, et al. Conservative management of lumbar disc herniation with associated
radiculopathy: a systematic review. Spine. 2010;35:E488-E504.

40. Ford J, et al. A classification and treatment protocol for low back disorders. Part 2:
directional preference management for reducible discogenic pain. Physical Therapy
Reviews. 2011;16:423-37.
Ford J, et al. A classification and treatment protocol for low back disorders. Part 1:
specific manual therapy. Physical Therapy Reviews. 2011;16:168-77.
Hahne AJ, et al. Specific treatment of problems of the spine (STOPS): design of a
randomised controlled trial comparing specific physiotherapy versus advice for people
with subacute low back disorders. BMC Musculoskeletal Disorders. 2011;12:104.
Ford J, Hahne A. Pathoanatomy and classification of low back disorders Manual
Therapy. 2012;In press.
Ford J, et al. A classification and treatment protocol for low back disorders. Part 3:
functional restoration for intervertebral disc related disorders. Physical Therapy
Reviews. 2012;17:55-75.
Ford J, et al. A classification and treatment protocol for low back disorders. Part 4:
functional restoration for low back disorders associated with multifactorial persistent
pain. Physical Therapy Reviews. 2012;In press.
Richards M, et al. The effectiveness of physiotherapy functional restoration for post-
acute low back pain: a systematic review. In press. 2012.
Slater SL, et al. The effectiveness of sub-group specific manual therapy for low back
pain: A systematic review. Manual Therapy. 2012;17:201-12.
Surkitt LD, et al. Efficacy of directional preference management for low back pain: a
systematic review. Physical Therapy. 2012;92:652-65.

41. Other references
Dagenais S, et al. Synthesis of recommendations for the assessment
and management of low back pain from recent clinical practice
guidelines. The Spine Journal. 2010;10:514-29.
Koes BW, et al. An updated overview of clinical guidelines for the
management of non-specific low back pain in primary care. Eur Spine
J. 2010;19:2075-94.
Petersen T, et al. The McKenzie method compared with manipulation
when used adjunctive to information and advice in low back pain
patients presenting with centralization or peripheralization. Spine.
2011.
Hill JC, et al. Comparison of stratified primary care management for
low back pain with current best practice (STarT Back). Lancet. 2011.