The Specific Treatment for Problems of the Spine (STOPS) trial was completed in 2013 with the recruitment of 300 patients. It is the first randomised controlled trial showing moderate to large effects favouring the specific physiotherapy. The treatment evaluated was the same used by the Advance Healthcare team that is used with patients on a daily basis.  Our research team in association with La Trobe University is currently working to publish this paper in a high quality journal.  You can see some of the results in the graph below.  It shows that specific physiotherapy is 50% more likely to result in a 50% improvement in daily activity capability compared to standard and guideline-based treatment. The evidence is clear; the treatment program developed and used by Advance Healthcare works!

STOPS back pain

WHAT ABOUT THE DIAGNOSIS?

Current guidelines advise that diagnosing back pain is not possible (Koes et al 2010).  Some even suggest that thinking about the injured structure when treating back pain may cause more harm than good (Dagenais et al 2010).  However there is now reasonable evidence, that using clinical methods developed by the Advance Healthcare team that injuries such as disc related pain can be identified and treated (Ford et al 2013). Part of this evidence is provided by an outstanding paper from Michael Adams that recommends practitioners think about the disc in the lumbar spine and how different treatments can actually increase the rate of healing. Some still doubt that healing in the disc is relevant to treating back pain. But look at the picture above; it is a cross section of an injured disc where a blood vessel has grown and is laying down scar tissue. A variety of physiotherapy methods can accelerate this healing process. These methods have been proven as successful in the STOPS trial.


SOMETHING FOR PRACTITIONERS

There were 5 different treatment types in the STOPS trials. As we want to help as many people with back pain as possible, its important that these complex treatments were published for practitioners to access. Our papers (approximately 10,000 words each) have all been published in Physical Therapy Reviews and are available on our practitioner education website KALSI.com.au.

This flow chart is an example of some of the decision making rules used in the STOPS trial to help practitioners negotiate difficult treatment scenarios. The example outlines clinical reasoning strategies when a person presents with back pain that has recently worsened.


MORE ON DIAGNOSIS

This is another paper we have published on how to diagnose back pain; this time using an expert panel to establish diagnostic features. The paper, written by one of my PhD students Viktoria Wilde and Jon Ford, showed which features were more likely to be diagnostic of the zygaphophyseal (or facet) joint as the cause of a person's back pain. The results of this study converge with a range of other evidence to support the diagnostic features we use clinically and in the STOPS trial.


TREATING BACK PAIN IS COMPLEX

This figure is from a paper Jon Ford published on the complexity of treating back pain. In it, we urged practitioners of all disciplines to act professionally by using a progressive "building block" approach to acquiring evidence-based knowledge. We wrote this out of concern for some practitioners picking up on the latest "trends" in back pain research, rather than integrating new evidence with established current clinical practice. The aim of our approach to back pain is to provide practitioners with a clear and structured approach to dealing with complex clinical problems.

REFERENCES

1.     Adams MA, Stefanakis M, Dolan P. Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain. Clin Biomech 2010; 25(10): 961-71.

2.     Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010; 19(12): 2075-94.

3.     Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine Journal 2010; 10(6): 514-29.

PAPERS FROM OUR GROUP

Full text copies of articles listed below are available at stops.physio - click to view

1.     Surkitt LD, Ford JJ, Chan AYP, Richards MC, Slater SL, Pizzari T, et al. Effects of individualised directional preference management versus advice for reducible discogenic pain: A pre-planned secondary analysis of a randomised controlled trial. Manual Therapy. 2016;25:69-80.

2.     Chan AYP, Ford JJ, Surkitt LD, Slater SL, Hahne AJ, Davidson M. Individualised functional restoration plus guideline-based advice versus advice alone for non-reducible discogenic low back pain: a randomised controlled trial. Physiotherapy. In press

3.     Warby S, Ford JJ, Pizzari T, Watson L, Hahne AJ. The Effect of Exercise Based Management on Multidirectional Instability of the Glenohumeral Joint: A Pilot Randomised Controlled Trial. BMJ Open. In press 

4.     Individualised-physiotherapy as an adjunct to guideline-based advice for low-back-disorders in primary care: a randomised controlled trial.  British Journal of Sports Medicine.  In press.  (Impact Factor 5.025 – December 2014)

5.     Freitag, J, Ford, JJ et al (2015)  Adipose derived mesenchymal stem cell therapy in the treatment of isolated knee chondral lesions : design of a randomised controlled pilot study comparing arthroscopic microfracture versus arthroscopic microfracture combined with post operative mesenchymal stem cell injections.  British Medical Journal Open.  In press.  (Impact Factor 2.271 – December 2014)

6.     Warby SA, Pizzari T, Ford JJ et al (2014). The effect of exercise-based management compared to surgery for multidirectional instability of the glenohumeral joint: a systematic review. British Journal of Sports Medicine.  In press.  (Impact Factor 5.025 – December 2014)

7.     Warby SA, Pizzari T, Ford JJ et al (2014)  The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review. J Shoulder Elbow Surg 2014;23(1):128-142. (Impact Factor 2.69 – December 2014)

8.     Chan AY, Ford JJ, McMeeken JM, Wilde VE. Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique. Physiotherapy 2013; 99: 212-20. (Impact Factor 1.57 – July 2013)

9.     Ford JJ, Hahne AJ. Complexity in the physiotherapy management of low back disorders: clinical and research implications. Manual Therapy 2013; 18: 438–42. (Impact Factor 2.24 – July 2013)

10.  Ford, J. J. and A. J. Hahne (2013). "Pathoanatomy and classification of low back disorders." Manual Therapy 18(2): 165-168. (Impact Factor 2.24 – July 2013)

11.  Ford, J., A. Hahne, et al. (2012). "A classification and treatment protocol for low back disorders.  Part 3: functional restoration for intervertebral disc related disorders." Physical Therapy Reviews 17(1): 55-75.

12.  Ford, J., M. Richards, et al. (2012). "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 17(5): 322-334.

13.  Slater, S. L., J. J. Ford, et al. (2012). "The effectiveness of sub-group specific manual therapy for low back pain: a systematic review." Manual Therapy 17(3): 201-212.

14.  Surkitt, L. D., J. J. Ford, et al. (2012). "Efficacy of directional preference management for low back pain: a systematic review." Physical Therapy 92(5): 652-665 (Impact Factor 2.78 – July 2013).

15.  Richards, M. C., J. J. Ford, S. L. Slater, A. J. Hahne, L. D. Surkitt, M. Davidson and J. M. McMeeken (2012). "The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review." Manual Therapy 18(1): 4-25. (Impact Factor 2.24 – July 2013)

16.  Ford, J., L. Surkitt, et al. (2011). "A classification and treatment protocol for low back disorders.  Part 2: directional preference management for reducible discogenic pain." Physical Therapy Reviews 16(6): 423-437.

17.  Ford, J., S. Thompson, et al. (2011). "A classification and treatment protocol for low back disorders. Part 1: specific manual therapy." Physical Therapy Reviews 16(3): 168-177.

18.  Hahne, A. J., J. J. Ford, et al. (2011). "Outcomes and adverse events from physiotherapy functional restoration for lumbar disc herniation with associated radiculopathy." Disability and Rehabilitation 33(17-18): 1537-1547 (Impact Factor 1.54 – July 2013).

19.  Hahne, A. J., J. J. Ford, et al. (2011). "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 12: 104 (Impact Factor 1.89 – July 2013).

20.  Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: A systematic review. Spine 2009;35:E488-504 (Impact Factor 2.16 – July 2013).

21.  Ford JJ, Story I, McMeeken JM. The test-retest reliability and concurrent validity of the subjective complaints questionnaire for low back pain.  Manual Therapy 2009;14:283-291

22.  Stanhope, M, Ford JJ.  Practical implementation of treatment guidelines in a workers’ compensation environment: A new approach.  The Journal of the International Association of Industrial Accidents Boards and Commissions 2008;45:207-223.

23.  Heymans MW, Ford JJ, de Vet HCW, McMeeken JM, Chan A, van Mechelen W.  Exploring the contribution of self reported and clinical variables for the prediction of low back problem work status following physiotherapy functional restoration.  The Journal of Occupational Rehabilitation 2007;17:383–397.

24.  Wilde V, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: surveying of an expert panel using the Delphi Technique.  Physical Therapy 2007;18:1348-1361.

25.  Ford JJ, Story I, O’Sullivan P, McMeeken JM.  Classification systems for low back pain: A review of the methodology for development and validation.  Physical Therapy Reviews 2007;12:33-42.

26.  Stanhope M, Ford JJ.  The critical role of evidence-based decision support systems to deliver the intended benefits of treatment guidelines in workers’ compensation.  The Journal of the International Association of Industrial Accidents Boards and Commissions 2006; Autumn:35-60.

27.  Ford JJ.  Pathological and psychosocial considerations in massage of the lumbar spine.  Journal of the Australian Association Massage Therapists 2007;Spring:14-18.

28.  Hahne A, Ford JJ.  Functional restoration for a chronic lumbar disc extrusion with associated radiculopathy.  Physical Therapy 2006;86:1668 –1680

29.    Ford, J and Bennell, K. Effectiveness of a physiotherapy functional restoration programme compared to patient-selected treatment on chronic compensable low back Moving in on Occupational Injury. Butterworth-Heinemann: Oxford