Stratified Care for Low Back Pain

Original Editor - Rachael Lowe

Top Contributors - Admin, Tarina van der Stockt, Simisola Ajeyalemi, Kim Jackson, Robin Tacchetti, Jess Bell, Rachael Lowe, Alexander Chan, WikiSysop and Vidya Acharya  

Introduction

Stratified care is the matching of subgroups of patients to specific treatments. 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. Sub-grouping may also help reduce inefficient variability in treatment and provide a helpful communication tool. In the physiotherapy profession several classification approaches that focus on directing specific treatment have emerged. Treatment of patients based on sub-grouping results in better outcomes than treatment based on clinical guidelines.  However, currently there is no clear consensus as to which classification system to use.

Karayannis et al report that in physiotherapy there is low use of classification schemes despite evidence that treatment of patients based on sub-grouping 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) to 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 and the following interventions are recommended:
   1. advice and analgesia
   2. other interventions - exercise, manual therapy, acupuncture

Generally, decisions about the care for patients with non-specific LBP is made on the intuition from the first-line practitioner, this is considered to be inefficient and leads to inconsistent treatment. Alternatively, when all patients with non-specific LBP are referred for treatment the cost is very high and might be "unnecessary, impractical, and inefficient".

Stratified care has been suggested as an appropriate way to manage LBP.  Although not yet in clinical guidelines stratified care is a way of targeting treatment to subgroups of patients based on characteristics.

Stratification of Care

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

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 models of Stratified Care (approaches to sub-grouping low back pain patients)

1. Patient prognosis - matching treatment to patient's risk of poor outcome (i.e. likelihood of persistent pain and disability). This approach allows us to make early decisions about amount of therapy and broad direction of therapy a patient receives. Proven to be both clinically and cost effective. Low risk patients are not over treated or medicalised and supported to self manage with advice, reassurance, medication.  At risk patients get access to the right person early on with evidence based physiotherapy and enhanced comprehensive care including is given to complex cases - psychologically informed physiotherapy with enhanced skills and more time.  Examples of this are:
   • Orebro Screening Tool (aims to identify patients who are at risk of developing work disability due to back and neck pain)
   • Chronic Pain Risk Prognostic Screen
   • STarT Back Approach and Matched Treatments
     • This tool is validated for non-specific LBP
     • In the STarT Back Approach, treatments are matched with a low back pain patient's risk profile
     • Using the STarT Back approach individuals with back pain may be categorised as:
       1. Low risk – These patients can be taught self management with the possibility of discharge after 1 session. Medication management is often part of the treatment. Prognosis is good for these patients. They have a low level of disability and are able to continue with daily activities. Further testing/imaging not likely necessary for management. These may be up to 56% of all LBP patients that present to the doctor.
       2. Medium risk - Physiotherapy management is utilised to decrease symptoms, levels of pain and disability/function. This may consist of exercise with or without manual therapy. Typically patients have up to 6 physiotherapy treatment sessions in the UK. This number may vary based on clinical setting or health care system/location of treatment.
       3. High risk – These patients struggle with persistent pain and disability. Psychosocial barriers to recovery exist and typically include depression, anxiety, and/or fear avoidant behaviours. Physiotherapy management and management of psychosocial obstacles is key with emphasis on addressing psychological contributions. In some cases, patients may work with a psychologist.
2. Responsiveness to treatment - matching treatments to patients who would benefit from that particular treatment. This approach is about identifying categories of interventions that have evidence for their effectiveness such as manual therapy and exercise, specific directional exercises, stabilisation exercises, traction.  Most of the evidence is in acute and sub-acute LBP.
   • Treatment Based Classification of Low Back Pain - The primary purpose of the TBC approach is to identify features at baseline that predict responsiveness to four different treatment strategies.
   • STOPS Approach
3. Underlying mechanisms - matching treatment to pathology or diagnosis. Thus matching treatment to mechanisms that drive pain and disability (pathology, pain mechanisms, provocative behaviours, negative thoughts/distress). It has been tested and makes sense in chronic back pain patients:
   • Pathoanatomical Based Classification
   • Mechanical Diagnosis and Treatment
   • Multidimensional Behavioural Approach including Cognitive Functional Therapy (CFT)
     • CFT is not for red Flags, acute radiculopathy, acute trauma

Conclusion

Emerging evidence indicates that stratified care of low back pain (LBP) may result in better clinical outcome and reduced healthcare costs, compared to usual care . There are overlaps between these three different approaches, a perfect sub-grouping approach would include all of these approaches. Hancock suggests that the STarT Back approach and/or treatment based approach is appropriate for acute/subacute non-specific LBP unless there is no recovery, in that case the cognitive functional therapy approach should be considered whilst the cognitive functional therapy approach makes most sense in chronic LBP. 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 should be explored judiciously in clinical practice in appropriate settings 

Though evidence suggests stratified care for LBP is effective in European health systems, this can’t be said for the United States of America. A large pragmatic trial in acute LBP that consisted of identifying high-risk patients using prognostic screening (STartBack tool) and randomly assigning into either usual care or usual care + psychologically informed physical therapy did not result in reducing the rate of transition to chronic LBP at six months (51% and 48% of patients in the intervention and usual care groups, respectively). Opioid prescription and diagnostic imaging rates were not in agreement with the clinical guidelines for acute LBP for both treatment groups. Future investigations of the stratified approach should focus on the challenges of implementing the referral in primary care and in the delivery of appropriate care by providers such as physical therapists.