Stratified Care for Low Back Pain

Original Editor - Rachael Lowe

Top Contributors - Admin, Tarina van der Stockt, Simisola Ajeyalemi, Kim Jackson, Jess Bell, Robin Tacchetti, 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. 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. Treatment of patients based on subgrouping 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 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) 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

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 approaches to subgrouping low back pain patients that have good evidence:

1. Patient prognosis - matching treatment to patients 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:
   • STarT Back Approach
   • Orebro Screening Tool
   • Chronic Pain Risk Prognostic Screen
2. Responsiveness to treatment - matching treatments to patients who would benefit from that particular treatment. This approach is about identifing 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
   • 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
   • Mechanical Diagnosis and Treatment
   • Multidimensional Behavioural Approach

The Future

There are overlaps between these three different approaches. Perfect subgrouping 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 when should use cognitive functional therapy approach. 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 they do warrant judicious exploration in clinical practice in appropriate settings 

Recent Related Research (from Pubmed)

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