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SPECIFIC TREATMENT OF PROBLEMS OF THE SPINE (STOPS)

In-Service 10 Feb 2017

Elizabeth Evans

BACKGROUND

Low back disorders (LBD) are a prevalent and costly.

Treatment is generally more effective than placebo or no treatment, but the effect sizes are commonly small and limited studies on treatment options.

Researchers have emphasised the importance of identifying groups for classification in future RCTs

STOPS, first RCT showing moderate to large effect sizes (particularly on back and leg pain) favouring specific Physical Therapy.

Established 2009 by Dr Jon Ford

Series of 5 x RCTs investigating the effectiveness of specific physiotherapy compared to evidence-based advice for specific subgroups of participants with sub-acute LBD.

  • STOPS –published in 2015 BJSM

Modified version of the original published paper – Physical Therapy Reviews

  • Clinical Dx and Treatment including imaging requirements is a current topic
  • EBP research to clinic, filling the gap

 

Identifying Subgroup classifications, Criteria/ Clinical presentation and assessment features

Prognostic vs Diagnosis (likely to respond)

Clinical Protocols/Treatment Protocols for each subgroup, specific and detailed

Papers: Algorithms (limited for complex cases), treatment steps with clinical reasoning, exercise programs, taping methods Response and algorithms for same/ better/ worse scenarios

 

4 Part Series:

  • Z joint pain – treated with Maitland type manual therapy
  • RDP reducible discogenic pain – treated with a McKenzie approach
  • NRDP discogenic injury – treated with Functional Restoration and motor control
  • MFP multifactorial persistent pain – treated with Functional Restoration and a cognitive-behavioural approach

 

% of participants with pain improving by at least 50% at 10 weeks.
This data refers to participants in the reducible discogenic pain subgroup that received directional preference management (DPM)

 

 

 

% of participants very satisfied with specific manual therapy at 10 weeks
This data refers to participants in the zygapophyseal joint dysfunction subgroup that received specific manual therapy.

In-service Scope: Insight into research available, Subgroup Classifications and Criteria and Treatment Protocols.

 

SUB GROUPS CATEGORIES OF LOWER BACK PAIN

A CLASSIFICATION AND TREATMENT PROTOCOL FOR LOW BACK DISORDERS PART 1: SPECIFIC MANUAL THERAPY

  • Z JOINT PAIN (lumbar zygapophyseal joint)

Ability to produce Pain ?? controversial

Combined Movement Theory (Brain Edwards)

Regular compression pattern observed during active lumbar extension and lateral flexion was first described by BrianEdwards based on a hypothesis of intra-articular compression of the lumbar facets reproducing the patient’s typical Symptoms.

CRITERIA

At least 3 positive, out of the following:

  1. Unilateral symptoms
  • Symptoms greater on one side of the spine compared to centrally or the opposite side
  1. A regular compression pattern:
  • Extension in standing reproducing ‘the pain’
  • Ipsilateral lateral flexion or quadrant in standing reproducing ‘the pain’
  • Contralateral movements showing either greater range of movement or a lesser degree/different type of pain compared to ipsilateral movements
  1. Comparable palpatory findings:
  • Reproduction of pain on ipsilateral passive PA PAM applied through the TP or the z jt joint at one or two segments
  • Pain to be greatest at the palpated segment compared to other segments in the lumbar spine
  1. A positive response to assessment of the comparable palpatory finding // Change after palpation

TREATMENT

  • Manual Therapy unilateral (Maitland)
  • Mobs and manipulations high velocity
  • Progressed into Edwards Combined Movements approach and Maitland style,

(Neural, Add Range, Add Trq) 

Detailed Treatment explanations

As the symptoms are unilateral and presumed to be arising from the lumbar zygapophyseal joint, techniques with a unilateral bias are recommended in the treatment manual.

These techniques comprised rotation, ipsilateral posterior-anterior mobilisation or transverse mobilisation towards the side of pain.

High velocity thrust in a rotation direction was also recommended as a treatment technique. The grade (intensity) and duration of the technique were determined according to whether pain or resistance was the primary problem at the comparable palpatory finding. Treatment was twice weekly in the early stages.

Progression

If the participant reported a lack of progress five weeks into the treatment program and a readministered Orebro Musculoskeletal Pain Questionnaire score was over 105/210, the treatment focus shifted away from a pathoanatomical and DPM emphasis. Instead the participant received education regarding increased neural sensitivity, pacing strategies and graded activity. Cognitive restructuring and behavioural modification principles were also employed by the trial physiotherapist. There is moderate evidence supporting this approach in sub-acute LBD with suspected psychosocial factors.

Define Inflammation

Determine whether clinical evidence exists of inflammation.

At least 2 of: constant symptoms, getting out of bed at night due to the pain, morning symptoms > 60 minutes

Initial Sessions 1 & 2 – outline of treatment with supporting Rationale:

Concept of the “mini-treatment” based on a number of principles fundamental to the Maitland approach. The mini-treatment is a method of minimising the risk of masking the effects of positive Session 1 techniques.

The mini-treatment should be sufficient to create a within but not between session change. In this way treatment techniques can be trialled in Session 1 with minimal risk of positive effects of a technique being masked. Typically, the mini-treatment is of 10-20 seconds duration depending on severity and irritability of the condition

The clinical reasoning principles upon which the mini-treatment were based are consistent with the Maitland approach and clinical reasoning theory. To further minimise risk to the participant, only a single mini-treatment was provided as opposed to Maitland’s recommendation of up to four in a single consultation.

 

A CLASSIFICATION AND TREATMENT PROTOCOL FOR LOW BACK DISORDERS PART 2: DIRECTIONAL PREFERENCE MANAGEMENT FOR REDUCIBLE DISCOGENIC PAIN

  • REDUCIBLE DISCOGENIC PAIN (RDP)

Reducible discogenic pain (RDP) is a LBD subgroup with specific clinical features including a positive response to specific movements and postures, called mechanical loading strategies (MLS).

The term“reducible” refers to the intra-discal phenomenon of displaced and symptom provoking nucleus pulposus material being reduced by MLSs to a more central and less symptom provoking position/ promote more rapid recovery

(painful annular tear where the position of the nucleus pulposus influenced by MLS)

9 clinical features of discogenic pain AND a positive response to Mechanical Loading

CRITERIA

AND

Positively respond after 10reps to at least one of 4 MLS:

  • REI – standing
  • REI lying
  • Positioning in prone lying (with or without pillows under the stomach)
  • Sustained extension.

“Respond” any of the following:

  • Increase ROM of MLS during application by at least 50%
  • Increase in lumbar AROM in any movement by at least 50% after application
  • Increase ROM in PPIVM
  • Decrease pain 1scale VAS 1min post
  • Reduced lateral shift postural abnormality that lasted for at least 1 minute after

application

If a positive response was not observed, the MLS were combined with side gliding movements/positioning to evaluate the presence/absence of a “lateral component” to the directional preference.

TREATMENT

Treatment for RDP named directional preference management (DPM) and defined as involving: regular patient application of helpful MLSs, education, postural advice, lumbar taping techniques and in some cases therapist applied forces applied during MLSs.

 “To our knowledge, such a precisely defined and highly specific treatment protocol, with close monitoring of treatment integrity for the DPM of RDP has not been published”

A CLASSIFICATION AND TREATMENT PROTOCOL FOR LOW BACK DISORDERS: PART 3 – FUNCTIONAL RESTORATION FOR INTERVERTEBRAL DISC RELATED DISORDERS

  • NON-REDUCIBLE DISCOGENIC PAIN (NRDP)

Irreducible or nonreducible discogenic pain (NRDP) has been proposed as an additional LBD subgroup where clinical features of reducible discogenic pain are present (some), in the absence of a positive response to MLS. There have been no clinical trials on the effectiveness of conservative treatment for people with NRDP.

The clinical features and mechanisms of NRDP have been further explored in a recent international Delphi survey of 21 expert physiotherapists. The experts reached consensus on a number of features including worsening of symptoms in response to certain MLS, constant pain, symptoms being difficult to control, positive discography findings and an increase in symptoms with most lumbar movements.

Evidence also exists suggesting symptomatic discs may be rendered non-responsive to treatment due to an increased density and/or chemical sensitisation of nociceptive afferents in the degenerated annulus fibrosis. Typically MLS involve lumbar extension which compresses the posterior annulus fibrosis. It is plausible that an inflamed posterior annular tear particularly in the presence of a greater density of nociceptive afferents would most likely be aggravated, and certainly not improved by such movements or postures. These proposed clinical features and mechanisms of NRDP are consistent with the clinical observations and basic science interpretations of other experts.

CRITERIA

Have four out of a possible nine clinical features of RDP

  • Presence of lumbar pain ± leg symptoms
  • Symptoms being aggravated by prolonged sitting
  • Symptoms being aggravated by lifting
  • Symptoms being aggravated by forward bending
  • Symptoms being aggravated by sit to stand
  • Symptoms being aggravated by cough/sneeze
  • History of working in a job with heavy manual handling
  • The mechanism of injury being associated with flexion/rotation and/or compression loading
  • Symptoms much worse the next morning or day after onset of injury.

 

  • DISC HERNIATION WITH ASSOCIATED RADICULOPATHY (DHR)

 

Disc herniation involves a localized displacement of intervertebral disc material beyond the normal margins of the disc space. When a disc herniation damages a spinal nerve root via mechanical and/or chemical irritation, radicular leg pain and/or clinical signs of radiculopathy (impaired reflexes, sensation or strength) are commonly observed. While various surgical and conservative treatments have been proposed for the management of disc herniation with associated radiculopathy (DHR), it is not clear which conservative treatments are most effective.

CRITERIA

  1. Pain, paraesthesia, or numbness below the knee (for L3/4, L4/5, or L5/S1 herniations) or in the anterior thigh (for L1/2, L2/3 or L3/4 herniations). Bilateral symptoms allowable provided they are worse on one side.

AND

  1. At least one of the following tests positive:
  1. i) Positive provocative neurodynamic testing including straight leg raise (for L3/4, L4/5, L5/S1 herniations) or prone knee flexion test (for L1/2, L2/3 or L3/4 herniations) defined by at least one of the participant’s usual leg symptoms being reproduced in the affected leg at any angle of elevation of either leg (ie standard or crossed straight leg raise)
  1. ii) A deficit on reflex testing including ankle jerk (for L4/L5 or L5/S1 herniations) or knee jerk (for L2/3 or L3/4 herniations) defined as being absent or reduced on the affected side compared to the non-affected side

iii) A deficit on sensory testing at the anterior thigh for L1 and L2 nerve roots, medial aspect of the knee for L3, medial aspect of foot for L4, dorsum of foot for L5 and lateral aspect of the foot for S1. A deficit was defined as reduced sensation on the affected side compared to the non-affected side involving the segment of the exiting nerve root corresponding to the level of disc herniation on imaging or one of the two next descending nerve roots. For example, an L4/5 herniation would need a deficit in at least one of the L4, L5 or

S1 nerve roots

  1. iv) A deficit on motor testing the strength of the hip flexors for L1 and L2 nerve roots, knee extensor strength for L3, ankle dorsiflexor strength for L4, extensor hallucis longus strength for L5 and ankle evertor or calf strength for S1. A deficit was defined using the same method of nerve root determination as for sensory testing.

AND

Radiological evidence of a lumbar disc herniation based on the radiologist reports of CT or MRI scans. The reported results have to satisfy the following criteria.

Radiology Cont..

  1. A description using specific language of either a lumbar disc herniation, protrusion, extrusion, sequestration or prolapse in at least one of the lumbo-sacral segments. The use of the term disc bulge alone was insufficient.
  1. A description of a posterior (or central), postero-lateral (or para-central), or lateral disc herniation. For posterolateral or lateral herniations the direction of the laterality had to correlate with the side of primary leg symptoms. In these cases nerve root contact was not required. For posterior herniations, there had to be at least nerve root contact, of any degree, on the side of primary leg symptoms, or bilateral nerve root contact. Contact with the theca or thecal sac alone was insufficient.

TREATMENT SUBGROUPS 3 & 4

The term functional restoration (FR) was first coined by Mayer who defined it as “a multimodal pain management program that employs a comprehensive cognitive-behavioural treatment orientation to help patients better cope with, and manage, their pain while undergoing the sports medicine physical approach to correct functional deficits.”

The key features of FR include:

  • An overall aim to restore reasonable capacity for activities of daily living including work
  • Negotiation of meaningful goals at program commencement
  • Development of graded exercise and non-exercise based activity schedules
  • The graded exercise program approximating functional tasks in a safe and supervised clinical environment to

increase psychological and physical tolerances

  • A focus on increasing strength, flexibility and cardiovascular fitness
  • A cognitive-behavioural approach to address psychosocial barriers to achieving goals there is currently a lack of consistent evidence supporting the effectiveness of FR programs for subacute and chronic LBD.
  • Functional restoration program (reps as tolerated)
  • Specific motor control training

The goal of the specific motor control program is to retrain the core muscles of the lumbar spine, comprising transversus abdominis, lumbar multifidus and the pelvic floor, to maintain a tonic and automatic contraction at less than 30% of maximum voluntary contraction in daily activities

  • Postural self management principles to assist in disc tissue healing
  • Conservative approach to exercise progression to avoid exacerbation of significant pathology
  • Education regarding recovery timeframes and the aggressive management of inflammation -tape, medications, posture advice

The subgroups of NRDP and DHR both have the lumbar intervertebral disc as the primary cause of LBD. Discherniation with associated radiculopathy can also be considered as a progression from NRDP where asymptomatic annular tear has extended further into, with or without penetration, of the outer annular wall resulting in a focal herniation and nerve root irritation. Both subgroups have inflammation and nerve related factors as a likely driver of greater severity, complexity and poorer responsiveness to standard methods of treatment, including generic FR. Because of these commonalities, both subgroups received a FR program focusing on treatment strategies specific to the pathoanatomical mechanisms of symptom generation.

A key principle of the treatment protocol for NRDP and DHR was the exclusion of any “passive” treatment; that is, modalities or manual therapy delivered by the physiotherapist to alleviate pain.

There is a significant rationale, based on the pathoanatomy of intervertebral disc healing as well as outcome studies, that people with NRDP or DHR have a slower rate of recovery. In such conditions, the use of passive treatment strategies has been hypothesised as falsely reinforcing patient expectations of rapid recovery, where in fact a longer period of self managed rehabilitation is required.

In addition, passive treatment in a condition with a slower recovery time has the potential risk of patients developing a treatment dependence on short term symptomatic relief.

A CLASSIFICATION AND TREATMENT PROTOCOL FOR LOW BACK DISORDERS: PART 4 – FUNCTIONAL RESTORATION FOR LOW BACK DISORDERS ASSOCIATED WITH MULTIFACTORIAL PERSISTENT PAIN

  • MULTI-FACTIONAL PERSISTENT PAIN (MFP)

Neurophysiological and/or psychosocial factors as primary barriers to recovery.

The biopsychosocial model of illness was recommended for use with LBD in a landmark paper by Gordon Waddell. Since that time extensive literature has been published on the predictive value of psychosocial factors and the effectiveness of various treatment options directed at the psychosocial component of LBD.

CRITERIA

For patients who did not have a consistent pathoanatomical pattern, consideration was given to psychosocial risk factors which might place them in the MFP subgroup.

  • Neurophysiological/psychosocial factors present (yellow flags)
  • Orebro Score >105

TREATMENT

  • Timed FR program
  • Maitland/bio psychosocial model
  • Reps with distraction
  • Work through the pain, that will hurt

Summary:  The STOPS classification system

 

COMMON TREATMENT

  • TA, Multifidus, Pelvic Floor
  • Progress into function
  • 2 x 30min weekly
  • Advice remain active, lifting techniques, reassurance, anatomy education

 

FINAL COMMENTS

  • Potential for the clinical protocols to be overly prescriptive.
  • Aim was to develop a structure for clinical decision making based on the principles of the Maitland approach.
  • Adds value through a structured reference point from which individualised patient treatment can be provided.
  • Limitation -In such complex domains it may not be feasible or even appropriate to apply clinical prediction rules.
  • By providing a clear and reproducible clinical protocol for physiotherapists in the STOPS trials we believe readers of the study will be well placed to modify their clinical practice, based on the trial results, in the way that best suits their patient population

 

REFERENCES:

 

  1. APA Webinar #6 2015

 

  1. stopsbackpain.com.au

 

  1. A Classification And Treatment Protocol For Low Back Disorders Part 1: Specific Manual Therapy (2015). Jon J Ford (PhD, MPhysio, BAppScPhysio, CredMDT), Matthew C Richards (BPhysio), Andrew J Hahne (PhD,BPhysioHons)

 

  1. A Classification And Treatment Protocol For Low Back Disorders Part 2: Directional Preference Management For Reducible Discogenic Pain (2015). Jon J Ford (PhD, MPhysio, BAppScPhysio, CredMDT), Luke D Surkitt (BPhysio) and Andrew J Hahne (PhD, BPhysioHons)

 

 

  1. A Classification And Treatment Protocol For Low Back Disorders: Part 3 – Functional Restoration For Intervertebral Disc Related Disorders (2015). Jon J Ford (PhD, MPhysio, BAppScPhysio, CredMDT), Andrew J Hahne (PhD, BPhysioHons), Alex YP Chan (BPhysio) and Luke D Surkitt (BPhysio)

 

  1. A Classification And Treatment Protocol For Low Back Disorders: Part 4 – Functional Restoration For Low Back Disorders Associated Wit Multifactorial Persistent Pain (2015). Jon J Ford (PhD, MPhysio, BAppScPhysio, CredMDT), Sarah L Slater (BScPhysio[Hons]), (PhD, Andrew J Hahne (PhD, BPhysioHons), Alex YP Chan (BPhysio) and Luke D Surkitt (BPhysio)