Managing musculoskeletal pain can be complex.  STOPS.physio connects physiotherapists with expertise and information to STOP persistent pain problems.  The key is learning how to identify and provide specific treatment that targets barriers to recovery including the pathoanatomical, impairment, psychosocial or neurophysiological in nature. This website houses a wealth of full text papers and associated resources to help physiotherapists provide specific and effective treatment!

pathoanatomy

Understanding potential nociceptive drivers (eg discogenic pain) of musculoskeletal pain is essential in some patients.  Recent research suggests physiotherapists are able to identify clinical patterns indicative of pathoanatomical problems    

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impairment

Physical factors can be relevant barriers to recovery independent of pathoanatomy.  Treating these barriers (eg muscle length) lies within the traditional realm of physiotherapy and is often a key component of managing musculoskeletal pain

psychosocial

Psychological (eg depression, fear avoidance beliefs) and social (eg work/home situation) factors can adversely impact on recovery.  Valid tools are now available for identifying and treating specific psychosocial factors

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neurophysiology

Neurophysiological factors such as central sensitisation or neuropathic pain requires specific education and in some cases medical management.  Physiotherapists have an important role in diagnosing and treating these barriers to recovery

Specific diagnosis of back pain

 

There is emerging evidence that it is possible to make provisional or clinical based diagnoses of back pain problems.  Following a thorough initial assessment the following diagnoses can be confirmed.

  • Disc herniation with associated radiculopathy - based on below knee symptoms, CT/MRI confirmed disc herniation (having at least nerve root contact = greater certainty) and at least one of a positive straight leg raise or lower limb neurological sign
  • Reducible discogenic pain – positive to at least 4 of the following features (higher number = greater certainty): aggravating factors of sitting, forward bending, lifting, sit to stand, cough/sneeze, worse next morning following injury, history of manual handling job, flexion/rotation mechanism of injury and positive response to mechanical loading strategies (most often extension in lying)
  • Non-reducible discogenic pain – positive to at least 4 of the discogenic features and not responsive to mechanical loading strategies
  • Zygapophyseal joint pain – at least 3 of the following features: unilateral and localised symptoms, a regular “compression” pattern reproducing symptoms during active movement testing (extension + ipsilateral lateral flexion), a comparable z-joint finding on lumbar palpation and positive response to mini-treatment
  • Sacro-iliac joint pain - at least 3 of the following features: pain provocation with distraction test, compression test, thigh thrust test, Gaenslen's test, sacral thrust test or active straight leg raise test
  • Multi-factorial persistent pain – not fitting any of the pathoanatomical subgroups and having an Örebro score of above 105/210 (high score = greater certainty)

The easiest way of learning how to provide specific treatment for back pain is by downloading the STOPS.physio summary for back pain.  

 

 
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Specific treatment of back pain

 

Specific treatment begins with a provisional or clinical diagnosis that can then be linked to effective treatment.  The results from the STOPS trials show that people with:

  • Disc herniation + radiculopathy or non-reducible discogenic pain respond well to specific muscle activation leading to a functional motor control program
  • Reducible discogenic pain respond well to directional preference management and a motor control program
  • Z-joint pain respond well to specific manual therapy using Maitland based clinical reasoning and a motor control program
  • An absence of a pathoanatomical diagnosis and higher levels of psychosocial factors require a time contingent graded activity program

However specific treatment goes beyond diagnosis by understanding that pain is multifactorial.  By developing a prioritised list of barriers to recovery the application of specific treatment becomes more efficient and effective.  Further information on barriers to recovery including an illustrative case study can be seen here.

 

To find out more on how to apply specific treatment go to Our Research and the Resources page where you can download detailed treatment protocols, clinical tools and research papers