classification of back pain (stops) 2012
DESCRIPTION
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 ReviewsTRANSCRIPT
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)
• 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?
Clinical scenario
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)
Recommendations • Identify “flags”
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)
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?
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
Lack of evidence • Diagnostic injection • Therapeutic blocks • Pilates • Massage therapy • Specific treatment (eg SIJ, O’Sullivan, McKenzie,
motor control, etc)
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
Classification issues (aka lumping and splitting)
• False assumption of sample homogeneity
• Application of generic treatment protocols
• Dilution of the effect of specific treatment
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
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
Classification based RCTs
Classification RCTs
The effectiveness of physiotherapy functional restoration for post-acute low back pain (Richards, Ford et al 2012) – in press
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
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)
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
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
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
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
Classification
Classification process • Full assessment (60 minutes) • Data entered into a purpose built excel
spreadsheet • Classification subgroup automatically calculated
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
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
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
Participant info sheets • Diagnosis • Program (meframes • Treatment op(ons • Motor control training • Direc(onal preference exercises • Func(onal restora(on exercises • Goal seOng • Pacing and graded ac(vity
• Dealing with an increase in pain
• Inflammation • Pain versus function • Pain management
strategies (2) • Posture • Relaxation • Sleep
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)
Ford et al 2012
Ford et al 2012
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
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
Results
• See IFOMPT presenta(on • 12 month results will be published mid 2013 • Results show that specific physiotherapy works!
Contact
E: [email protected] W: www.facebook.com/STOPSbackpain T: @stopsbackpain
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.
Our papers
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.
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.