Practitioners and patients have witnessed a disconnect between research and clinical practice over the past 30 years. While our knowledge base has greatly improved, sufferers of low back pain (LBP) have not significantly benefitted.
A major failing of the "evidence-based" approach to LBP has been insufficient consideration of clinical complexity. The lumbar spine has a large number of potential pain generators in a location that is both anatomically small and difficult to access for diagnostic and treatment purposes. Practitioners must choose from a vast array of management options across a spectrum of pathoanatomical, psychosocial and neurophysiological dimensions. Many randomised controlled trials have evaluated treatments of inadequate precision that have been overly simplistic.
The Specific Treatment of Problems of the Spine (STOPS) trial were established in 2009 by Dr Jon Ford to prove that high quality Physical Therapy is effective. To achieve this goal we made a number of strategic decisions including:
- Focusing on early persistent LBP where spontaneous recovery has "run its course" but the complexities of entrenched persistent LBP has not yet set in
- Evaluating widely used Physical Therapy treatments specific to common subgroups of LBP
- Selection of subgroups including reducible discogenic pain (treated with a McKenzie approach), Z joint pain (treated with Maitland type manual therapy), other discogenic injury (treated with Functional Restoration and motor control) and multifactorial persistent pain (treated with Functional Restoration and a cognitive-behavioural approach)
- Comparing specific Physical Therapy to advice which is currently recommended by guidelines for subacute LBP
The STOPS trial was completed in 2013 with the recruitment of 300 participants and published in the British Journal of Sports Medicine in 2015. It is the first randomised controlled trial showing moderate to large effect sizes (particularly on back and leg pain) favouring specific Physical Therapy compared to evidence-based advice in subacute non-compensable low back disorders (LBD). A range of secondary outcome measures (global perceived effect, satisfaction with the treatment) also showed clinically meaningful effects. The evidence from the STOPS trial is clear; specific Physical Therapy for early persistent LBD works! Below are just some of the data in graphical form from this groundbreaking research.
|% of participants with pain improving by at least 50% at 10 weeks.|
These data refer 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|
These data refer to participants in the zygapophyseal joint dysfunction subgroup that received specific manual therapy.
The STOPS results prove that specific Physical Therapy works provided it adheres to certain quality requirements. Our detailed clinical protocols and British Journal of Sports Medicine paper are now available for practitioners.
Further research on the validity of the STOPS classification system is being conducted. For those interested in being involved in this exciting area of research please contact us.
If you are interested in the STOPS trial why not ask our expert practitioners a question on our Practitioner Advice Line. Alternatively go to our Clinical Education page to explore some of the innovative online and face to face education options we have available.