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!

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

Ford et al - Physical Therapy Reviews 2013 — Ford et al (Physical Therapy Reviews 2013)

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.

Wilde, Ford et al (Physical Therapy 2007)

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.

Research Outcomes And Impact

Research Publications

(Full text research paper available from http://www.stops.physio/our-research )

1. Liew, B. X. W., J. J. Ford, M. Scutari and A. J. Hahne (2021). How does individualised physiotherapy work for people with low back pain? A Bayesian Network analysis using randomised controlled trial data. PLoS One, 16(10). doi:10.1371/journal.pone.0258515

2. Ford, J. J., S. E. Bower, I. Ford, M. M. de Mello, S. R. Carneiro, A. P. Balasundaram and A. J. Hahne (2020). Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review. Musculoskeletal Science and Practice, 50: 102276. (Impact Factor 1.911 – June 2019)

3. Ford, J. J., Kaddour, O., Gonzales, M., Page, P., & Hahne, A. J. (2020). Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy. BMC Musculoskeletal Disorders, 21(1), 567. doi:10.1186/s12891-020-03590-x (Impact Factor 2.002 – June 2018)

4. Teychenne, M., Miller, C., Ford, J., Hahne, A., Main, L., Rantalainen, T., . . . Belavy, D. (2020). Randomized Trial of General Strength and Conditioning Versus Motor Control and Manual Therapy for Chronic Low Back Pain on Physical and Self-Report Outcome. Journal of Clinical Medicine, 9, 1726. (Impact Factor 5.583 – June 2018)

5. Ford, J. J., Kaddour, O., Page, P., Richards, M. C., McMeeken, J. M., & Hahne, A. J. (2020). A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy. British Journal of Neurosurgery, 1-7. doi:10.1080/02688697.2020.1742288 (Impact Factor 1.481 – June 2018)

6. Owen, P. J., Miller, C. T., Rantalainen, T., Simson, K. J., Connell, D., Hahne, A. J., . . . Belavy, D. L. (2020). Exercise for the intervertebral disc: a 6-month randomised controlled trial in chronic low back pain. European Spine Journal. doi:10.1007/s00586-020-06379-7 (Impact Factor 1.368 – June 2018)

7. Ford J, Hahne A, Surkitt L, Chan A, Richards M. The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain. Journal of Clinical Medicine. 2019;8(9). (Impact Factor 5.583 – June 2018)

8. Teychennel, M, Lamb, K.E, Main, L, Miller, C, Hahne, A, Ford, J, Rosenbaum, S, Belavy, D (2019). General strength and conditioning versus motor control with manual therapy for improving depressive symptoms in chronic low back pain: a randomised feasibility trial. PLOS ONE (Impact Factor 2.776 – June 2018)

9. Ford, J. J., Slater, S. L., Richards, M. C., Surkitt, L. D., Chan, A. Y. P., Taylor, N. F., & Hahne, A. J. (2018). Individualised manual therapy plus guideline-based advice versus advice alone for people with clinical features of lumbar zygapophyseal joint pain: A randomised controlled trial. Physiotherapy. doi:10.1016/j.physio.2018.07.008 (Impact Factor 2.534 – June 2018)

10. Ford, J. J., Hahne, A. J., Surkitt, L. D., Chan, A. Y. P., Richards, M. C., Slater, S. L., . . . Taylor, N. F. (2018). STOPS trial versus Costa et al: a more accurate analysis. Br J Sports Med. doi:10.1136/bjsports-2017-098821 (Impact Factor 7.867 – July 2018)

11. Ford, J. J., Richards, M. C., Surkitt, L. D., Chan, A. Y. P., Slater, S. L., Taylor, N. F., & Hahne, A. J. (2018). Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy. Arch Phys Med Rehabil. doi:10.1016/j.apmr.2018.04.026

12. Warby, S. A., Ford, J. J., Hahne, A. J., Watson, L., Balster, S., Lenssen, R., & Pizzari, T. (2018). Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial. Am J Sports Med, 46(1), 87-97. doi:10.1177/0363546517734508. (Impact Factor – 5.673 – July 2017)

13. Simson, K. J., Miller, C. T., Ford, J., Hahne, A., Main, L., Rantalainen, T., . . . Belavy, D. L. (2017). Optimising conservative management of chronic low back pain: study protocol for a randomised controlled trial. Trials, 18(1), 184. doi:10.1186/s13063-017-1913-8

14. Chan, A. Y., Ford, J. J., Surkitt, L. D., Richards, M. C., Slater, S. L., Davidson, M., & Hahne, A. J. (2016). Individualised functional restoration plus guideline-based advice vs advice alone for non-reducible discogenic low back pain: a randomised controlled trial. Physiotherapy. doi:10.1016/j.physio.2016.08.001

15. Warby, S. A., Watson, L., Ford, J. J., Hahne, A. J., & Pizzari, T. (2017). Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management. J Hand Ther, 30(2), 175-181. doi:10.1016/j.jht.2017.03.005

16. Hahne, A. J., Ford, J. J., Richards, M. C., Surkitt, L. D., Chan, A. Y., Slater, S. L., & Taylor, N. F. (2017). Who Benefits Most from Individualized Physiotherapy or Advice for Low Back Disorders? A Pre-Planned Effect Modifier Analysis of a Randomized Controlled Trial. Spine (Phila Pa 1976). doi:10.1097/brs.0000000000002148

17. Hahne, A. J., Ford, J. J., Surkitt, L. D., Richards, M. C., Chan, A. Y., Slater, S. L., & Taylor, N. F. (2017). Individualized Physical Therapy Is Cost-Effective Compared With Guideline-Based Advice for People With Low Back Disorders. Spine (Phila Pa 1976), 42(3), E169-E176. doi:10.1097/BRS.0000000000001734

18. Hahne, A. J., Ford, J. J., Hinman, R. S., Richards, M. C., Surkitt, L. D., Chan, A. Y., . . . Taylor, N. F. (2017). Individualized functional restoration as an adjunct to advice for lumbar disc herniation with associated radiculopathy. A preplanned subgroup analysis of a randomized controlled trial. Spine J, 17(3), 346-359. doi:10.1016/j.spinee.2016.10.004

19. Surkitt, L. D., Ford, J. J., Chan, A. Y. P., Richards, M. C., Slater, S. L., Pizzari, T., & Hahne, A. J. (2016). Effects of individualised directional preference management versus advice for reducible discogenic pain: A pre-planned secondary analysis of a randomised controlled trial. Manual Therapy, 25, 69-80. doi:10.1016/j.math.2016.06.002

20. Warby, S. A., Ford, J. J., Hahne, A. J., Watson, L., Balster, S., Lenssen, R., & Pizzari, T. (2016). Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol. BMJ Open, 6(9), e013083. doi:10.1136/bmjopen-2016-013083

21. Ford, J. J., Hahne, A. J., Surkitt, L. D., Chan, A. Y., Richards, M. C., Slater, S. L., . . . Taylor, N. F. (2015). Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial. Br J Sports Med. doi:10.1136/bjsports-2015-095058. (Impact Factor 7.867 – July 2018)

22. Freitag, J., Ford, J., Bates, D., Boyd, R., Hahne, A., Wang, Y., . . . Shah, K. (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 postoperative mesenchymal stem cell injections. BMJ Open, 5(12). doi:10.1136/bmjopen-2015-009332. (Impact Factor 2.271 – December 2014)

23. Warby, S. A., Pizzari, T., Ford, J. J., Hahne, A. J., & Watson, L. (2016). Exercise-based management versus surgery for multidirectional instability of the glenohumeral joint: a systematic review. Br J Sports Med, 50(18), 1115-1123. doi:10.1136/bjsports-2015-094970. (Impact Factor 5.025 – December 2014)

24. Warby, S. A., Pizzari, T., Ford, J. J., Hahne, A. J., & Watson, L. (2014). The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review. J Shoulder Elbow Surg, 23(1), 128-142. doi:10.1016/j.jse.2013.08.006. (Impact Factor 2.69 – December 2014)

25. Chan, A. Y., Ford, J. J., McMeeken, J. M., & Wilde, V. E. (2013). Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique. Physiotherapy, 99, 212-220. doi:10.1016/j.physio.2012.09.007. (Impact Factor 1.57 – July 2013)

26. Ford, J. J., & Hahne, A. J. (2013a). Complexity in the physiotherapy management of low back disorders: clinical and research implications. Manual Therapy, 18, 438–442. doi:10.1016/j.math.2013.01.007. (Impact Factor 2.24 – July 2013)

27. Ford, J. J., & Hahne, A. J. (2013b). Pathoanatomy and classification of low back disorders. Manual Therapy, 18(2), 165-168. doi:10.1016/j.math.2012.05.007. (Impact Factor 2.24 – July 2013)

28. Ford, J. J., Hahne, A. J., Chan, A. Y. P., & Surkitt, L. D. (2012). A classification and treatment protocol for low back disorders. Part 3: functional restoration for intervertebral disc related disorders. Phys Ther Rev, 17(1), 55-75.

29. Ford, J. J., Richards, M. J., & Hahne, A. J. (2012). A classification and treatment protocol for low back disorders. Part 4: functional restoration for low back disorders associated with multifactorial persistent pain. Phys Ther Rev, 17(5), 322-334.

30. Slater, S. L., Ford, J. J., Richards, M. C., Taylor, N. F., Surkitt, L. D., & Hahne, A. J. (2012). The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Manual Therapy, 17(3), 201-212. doi:10.1016/j.math.2012.01.006

31. Surkitt, L. D., Ford, J. J., Hahne, A. J., Pizzari, T., & McMeeken, J. M. (2012). Efficacy of directional preference management for low back pain: a systematic review. Physical Therapy, 92(5), 652-665. doi:10.2522/ptj.20100251. (Impact Factor 2.78 – July 2013).

32. Richards, M. C., Ford, J. J., Slater, S. L., Hahne, A. J., Surkitt, L. D., Davidson, M., & McMeeken, J. M. (2012). The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review. Manual Therapy, 18(1), 4-25. doi:10.1016/j.math.2012.06.005. (Impact Factor 2.24 – July 2013)

33. Ford, J. J., Surkitt, L. D., & Hahne, A. J. (2011). A classification and treatment protocol for low back disorders. Part 2: directional preference management for reducible discogenic pain. Phys Ther Rev, 16(6), 423-437.

34. Ford, J. J., Thompson, S. L., & Hahne, A. J. (2011). A classification and treatment protocol for low back disorders. Part 1: specific manual therapy. Phys Ther Rev, 16(3), 168-177.

35. Hahne, A., Ford, J. J., Hinman, R., Taylor, N. F., Surkitt, L., Walters, A., & McMeeken, J. (2010). Outcomes and adverse events from physiotherapy functional restoration for lumbar disc herniation with associated radiculopathy. Disability and Rehabilitation, Early Online, 1-11. (Impact Factor 1.54 – July 2013).

36. Hahne, A. J., Ford, J. J., Surkitt, L. D., Richards, M. C., Chan, A. Y., Thompson, S. L., . . . Taylor, N. F. (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 Musculoskelet Disord, 12, 104. doi:10.1186/1471-2474-12-104. (Impact Factor 1.89 – July 2013)

37. Hahne, A. J., Ford, J. J., & McMeeken, J. M. (2010). Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine, 35(11), E488-E504 (Impact Factor 2.16 – July 2013).

38. Ford, J., Story, I., & McMeeken, J. (2009). The test retest reliability and concurrent validity of the Subjective Complaints Questionnaire for low back pain. Manual Therapy, 14 283-291.

39. Stanhope M and 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.

40. Heymans, M., Ford, J., McMeeken, J., Chan, A., de Vet, H., & van Mechelen, W. (2007). Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status. Journal of Occupational Rehabilitation, 17, 383–397 (IF 1.644)

41. Wilde, V., Ford, J., & McMeeken, J. (2007). Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi Technique. Physical Therapy, 87(10), 1348–1361.

42. Ford, J., Story, I., O’Sullivan, P., & McMeeken, J. (2007). Classification systems for low back pain: a review of the methodology for development and validation. Physical Therapy Reviews, 12, 33-42.

43. 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.

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

45. Hahne, A., & Ford, J. (2006). Functional restoration for a chronic lumbar disk extrusion with associated radiculopathy. Physical Therapy, 86(12), 1668-1680.

46. Ford, J., & Bennell, K. (2000). Effectiveness of a physiotherapy functional restoration programme compared to patient-selected treatment on chronic compensable low back pain Moving in on occupational injury. Oxford: Butterworth-Heinemann.