Classification of back pain (STOPS) 2012


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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

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Classification of back pain (STOPS) 2012

  1. 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. 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. 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. 4. Recommendations•  Identify “flags”
  5. 5. 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)
  6. 6. 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?
  7. 7. 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
  8. 8. Lack of evidence•  Diagnostic injection•  Therapeutic blocks•  Pilates•  Massage therapy•  Specific treatment (eg SIJ, O’Sullivan, McKenzie, motor control, etc)
  9. 9. 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
  10. 10. Classification issues (aka lumping and splitting)•  False assumption of sample homogeneity•  Application of generic treatment protocols•  Dilution of the effect of specific treatment
  11. 11. 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
  12. 12. 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  
  13. 13. Classification based RCTs
  14. 14. Classification RCTsThe effectiveness of physiotherapy functionalrestoration for post-acute low back pain (Richards,Ford et al 2012) – in press
  15. 15. 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
  16. 16. 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)
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. Classification
  22. 22. Classification process•  Full assessment (60 minutes)•  Data entered into a purpose built excel spreadsheet•  Classification subgroup automatically calculated
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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)
  28. 28. Ford et al 2012
  29. 29. Ford et al 2012
  30. 30. 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
  31. 31. 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
  32. 32. Results    •  See  IFOMPT  presenta(on  •  12  month  results  will  be  published  mid  2013  •  Results  show  that  specific  physiotherapy   works!  
  33. 33. Contact  E:  W:  T:    @stopsbackpain  
  34. 34. Our papersHahne A, Ford J. Functional restoration for a chronic lumbar disk extrusion withassociated radiculopathy. Physical Therapy. 2006;86:1668-80.Ford J, et al. Classification systems for low back pain: a review of the methodology fordevelopment and validation. Physical Therapy Reviews. 2007;12:33-42.Heymans M, et al. Exploring the contribution of patient-reported and clinician basedvariables for the prediction of low back work status. Journal of OccupationalRehabilitation. 2007;17:383–97.Wilde V, et al. Indicators of lumbar zygapophyseal joint pain: survey of an expert panelwith the Delphi Technique. Physical Therapy. 2007;87:1348–61.Ford J, et al. The test retest reliability and concurrent validity of the SubjectiveComplaints Questionnaire for low back pain. Manual Therapy. 2009;14 283-91.Hahne A, et al. Outcomes and adverse events from physiotherapy functionalrestoration for lumbar disc herniation with associated radiculopathy. Disability andRehabilitation. 2010;Early Online:1-11.Hahne A, et al. Conservative management of lumbar disc herniation with associatedradiculopathy: a systematic review. Spine. 2010;35:E488-E504.
  35. 35. Ford J, et al. A classification and treatment protocol for low back disorders. Part 2:directional preference management for reducible discogenic pain. Physical TherapyReviews. 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 arandomised controlled trial comparing specific physiotherapy versus advice for peoplewith subacute low back disorders. BMC Musculoskeletal Disorders. 2011;12:104.Ford J, Hahne A. Pathoanatomy and classification of low back disorders ManualTherapy. 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 TherapyReviews. 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 persistentpain. 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 backpain: A systematic review. Manual Therapy. 2012;17:201-12.Surkitt LD, et al. Efficacy of directional preference management for low back pain: asystematic review. Physical Therapy. 2012;92:652-65.
  36. 36. Other referencesDagenais S, et al. Synthesis of recommendations for the assessmentand management of low back pain from recent clinical practiceguidelines. The Spine Journal. 2010;10:514-29.Koes BW, et al. An updated overview of clinical guidelines for themanagement of non-specific low back pain in primary care. Eur SpineJ. 2010;19:2075-94.Petersen T, et al. The McKenzie method compared with manipulationwhen used adjunctive to information and advice in low back painpatients presenting with centralization or peripheralization. Spine.2011.Hill JC, et al. Comparison of stratified primary care management forlow back pain with current best practice (STarT Back). Lancet. 2011.