Stratified Care for Low Back Pain

Introduction

Stratified care is the matching of subgroups of patients to specific treatments.  Treatment of patients based on subgrouping results in better outcomes than treatment based on clinical guidelines 

A major goal over several years has been to divide people with LBP into homogeneous populations or 'subgroups' of similar characteristics in an effort to improve patient outcomes. Subgrouping may also help reduce inefficient variability in treatment and provide a helpful communication tool. In the physiotherpay profession several classification approaches that focus on directing speicfic treatment have emerged.

Karayannis et al report that in physiotherapy there is low use of classification schemes despite evidence that treatment of patients based on subgrouping results in better outcomes than treatment based on clinical guidelines. The prevalence of relatively low use of these classification schemes could be explained by unfamiliarity with these approaches; low perceived value in classification oriented assessment; inability to choose between classification schemes; or a preference for other assessment methods. An alternative reason for the modest implementation of the classification approach may be that assessment schemes do not adequately integrate the multiple dimensions that can contribute to, or perpetuate LBP.

Steps to Stratification

Usual management of LBP is:

1. Diagnostic triage by first contact clinical (physio, doctor) - rule out serious spinal pathology such as inflammatory disorders, metastases, infection or specific conditions such as radiculopathy, caudal equina syndrome
2. After ruling these out a diagnosis of “non-specific” (simple or mechanical) LBP is given:
   1. advice and analgesia  (NICE guidelines - https://www.nice.org.uk/guidance/cg88)
   2. other interventions - exercise, manual therapy, acupuncture (PT guidelines) 

Stratified care has been suggested as an appropriate way to manage LBP and the interventions mentioned above (Foster,N at al. WCPT Congress 2015).  Although not yet in clinical guidleines stratified care is a way of targeting treatment to subgroups of patients based on characteristics.

Stratification of Care

In 2012 Karayannis, Jull and Hodges also identified a group of five dominant movement-based schemes and grouped them into two dominant movement paradigms emerge:

1. Loading strategies aimed at eliciting a phenomenon of centralisation of symptoms
   • Mechanical Diagnosis and Treatment (MDT)
   • Treatment Based Classification (TBC)
   • Pathoanatomic Based Classification (PBC)
2. Modified movement strategies targeted towards documenting the movement impairments associated with the pain state.
   • Movement System Impairment Classification (MSI)
   • O'Sullivan Classification System (OCS)

In 2015 Foster et al identified 3 approaches to subgrouping low back pain patients with matched targeting their treatment that have good evidence:

1. Patient prognosis - matching treatment to patients risk of poor outcome (likelihood of persistent pain and disability). Proven to be both clinically and cost effective. Early decisions about amount of therapy and broad direction of therapy a patient receives. Great in primary care. - low risk patients are not over treated or medicalised - support to self manage with advice, reassurance, medication - at risk patients get access to the right person early on - evidence based physiotherapy - enhanced comprehensive care is given to complex cases - psychologically informed physiotherapy with enhanced skills and more time.  Examples of this are:
   • STarT Back Approach
   • Orebro Screening Tool
2. Responsiveness to treatment - matching treatments to patients who would benefit from that treatment. Main evidence is primarily in acute and sub-acute back pain. - identify categories of interventions that have evidence for their effectiveness, those intervention groups are manual therapy and exercise, specific directional exercises, stabilisation exercises, traction - this approach is built around the concept of clinical prediction rules
   • Treatment Based Classification Approach to Low Back Pain
   • STOPS Approach
3. Underlying mechanisms - matching treatment to mechanisms that drive pain and disability (pathology, pain mechanisms, provocative behaviours, negative thoughts/distress). Been tested and makes sense in chronic back pain patients
   • pathoanatomical based classification approach(Peterson et al 2003 - http://fysio.dk/Upload/Graphics/PDF-filer/Afhandlinger/phd_afhandling/Phd_Petersen_Non-specific_low_back_pain.pdf and http://rgk.kk.dk/sites/rgk.kk.dk/files/Diagnostic%20classification%20of%20non-specific%20low%20back%20pain.pdf) -
   • mechanical diagnosis and treatment approach(McKenzie 2003) - http://www.researchgate.net/publication/8153747_A_systematic_review_of_efficacy_of_McKenzie_therapy_for_spinal_pain 
   • multidimensional behavioural approach(O’Sullivan 2012) - negative beliefs about LBP, fear of movement, increased distress and decreased self efficacy are predictive of disability. Use screening tools and interview to identify beliefs, behaviours and understand of pain. Target these behaviours with a cognitive functional approach - give them a personalised understanding (a biopsychsocial understanding) of LBP drawing out features of their story and reflecting it back in a way that makes sense to them. Goal setting is critical to take people back to things that they value. Retraining functional movement and changing unhealthy lifestyle choices such as activity avoidance to reach goals. (http://www.pain-ed.com/wp-content/uploads/2014/02/Osullivan-and-Lin-Pain-management-today-2014.pdf and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3796866/

The Future

There are overlaps between these three different approaches. Perfect subgrouping approach would include all there of these approaches. We are not there yet.

Hancock suggests that the Start Back approach and/or treatment based approach is appropriate for Acute/subacute NSLBP unless do not recover when should use cognitive functional therapy approach. The cognitive functional therapy approach makes most sense in Chronic NSLBP. Start back tool can also be used but minimal care group is less likely to be effective.

These models don’t replace clinical reasoning or experience but they do warrant judicious exploration in clinical practice in appropriate settings (Foster, N WCPT Congress)