Episode 206 - Anja Franz, part 2: Superior Results with Directional Preference Guided Care

Directional Preference Care vs Usual in Military Setting (2).png

Lieutenant Anja Franz PT, Dip MDT

In episode 206 we conclude the re-airing of episode 71 from nearly three years ago with Lt. Anja Franz.  Following, we conclude our more recent discussion on her paper comparing directional preference care versus usual care and the results including pain relief, function change, adherence to home program, work status and more.  This week on MCF!

Show Notes


Materials and Methods

She had a comparatively smaller sample size (n= 44) which were consecutive military members, and a 1 month and 3 month follow up in her data collection. Subjects in the groups were very similar in baseline demographics and the therapists involved in the study had significant number of years in clinical experience and well recognized in the community of providers.

Due to her setting and population of her research study and the limited time period of her Master’s program  Anja was unable to have a long term follow up to determine recurrence rates (2 years time frame is what studies recommend).

Assignment to study groups was done by a receptionist who had no medical background and was based on convenience. 

Some clinical outcome measures included pain intensity and RMDQ (Ronald Morris Disability Quotient); but she also used a VAS (0-10) for adherence to treatment. 

Other than the usual directional preference exercises and education on posture which are the usual components of management, strengthening exercises that are the norm for this population were matched to the directional preference of the subject. 

Core stabilization was prescribed to about 95% of the study group. Manual therapy (mobilization and manipulation) and electrotherapy was included in the usual care group. One of the reasons for inclusion of electrotherapy was that despite the fact that it lacks evidence of effectiveness in management, it still is routinely prescribed in clinical practice. 



Anja determined presence of directional preference in subjects over a period of few visits and not just on day one, to simulate a real-life clinical assessment. She makes reference to Werneke 2002 study where he gives a time frame of up to 7 visits. 

Prevalence of directional preference (73%) on day 1, which was very similar to the Long 2008 study (74%). With subsequent visits (day 2-3), the prevalence went up to 90% (20 out of 22 patients in the group). 

6 out of 22 subjects needed hands-on interventions (force progressions) which was interestingly close to the numbers in Robin McKenzie’s textbook (1/3rd of patients need hands-on interventions). 

Her finding of successful “hands-off” management is significant to her population where military personnel are on a ship and have no access to a physiotherapist but can self-manage. It also lends support to tele-health medicine. 

4 subjects in the usual care group had peripheralization during the study period but none in the directional preference group. Anja states that in a pragmatic study design, it is difficult to determine cause of such a finding, as there can be potential biases present. 

Usual care group had a total of 10 visits and Directional Preference group had about 6 visits in total in 3 months, though not statically significant, is an advantageous finding for personnel that have a high rate of deployment. 

Outcome measures in the usual care group at end of 3 months were inferior to those when compared to the directional preference group at end of 1 month. 


Cost-effectiveness of Interventions

Per se, she did not calculate the cost effectiveness of the study interventions, but quoting numbers and statistics, Anja determines that indirect losses (approx 1.25 million) are huge secondary to low back pain in a small organization like the Canadian armed forces. These do not even come close to the cost of management of these patients. 


Conclusion and Implications

Findings of rapid improvements and the patient's ability to self-manage with overall less number of visits may prove especially advantageous in deployed settings. Superior outcomes compared to usual care and ability to return to work quickly helps reduce monetary and skill loss. 

 This helps provides useful data to military policymakers and clinicians on optimal management for CAF members. 


Links to References

Anja Franz 2017 study



Long et al 2008 study