Low back pain (FS-17)

Stratified models of care for low back pain

Nadine E. Foster (United Kingdom), Jonathan C Hill (United Kingdom), Peter B O'Sullivan (Australia), John D Childs (United States of America), Mark J Hancock (Australia)

Focused symposium

Sunday 3 May 2015, 13:45-15:15, Hall 405

Stratified models of care for low back pain

Foster N.E. 1, Hill J.C. 1, O'Sullivan P.B. 2, Childs J.D. 3, Hancock M.J. 4

1Keele University, Arthritis Research UK Primary Care Centre, Keele, United Kingdom, 2Curtin University, School of Physiotherapy and Exercise Science, Perth, Australia, 3US Army-Baylor University, Doctoral Program in Physical Therapy, Texas, United States of America, 4Macquarie University, Faculty of Human Sciences, New South Wales, Australia

Learning objectives

  1. To familiarise delegates with the key principles of stratified care for low back pain
  2. To evaluate three key examples of stratified care that are each underpinned by evidence from randomised trials
  3. To make recommendations for clinical practice, education and research


Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment or underlying mechanisms. It 'fast tracks' patients to appropriate treatment by supporting therapeutic decision-making in order to maximise treatment-related benefit, reduce harm and increase healthcare efficiency. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase healthcare efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the Zeitgeist in research and clinical practice.

In this symposium, we will introduce the key principles of stratified care and summarise the current underpinning evidence about the clinical and cost-effectiveness of matching patients to treatments. Most available studies use designs that cannot differentiate between more general predictors of outcome (prognosis regardless of treatment) and predictors of response to specific treatment (treatment effect modifiers), as very few use the randomised controlled trial design.

We will explain the three broad approaches to stratified care that are available and evaluate one key example of each that is based on at least one high quality randomised trial. One example of each of these three approaches will be presented: stratified care based on patients´ prognosis (Subgrouping for Targeted Treatment (STarT Back developed in the UK), stratified care based on underlying causal mechanisms (Classification based-Cognitive Functional Therapy (CB-CFT) developed in Australia) and stratified care based on treatment responsiveness (Treatment-based Classification developed in the USA). Physiotherapists who have led the development and validation of these stratified care approaches will summarise each approach, consider their merits for implementation in practice and identify the remaining, key research questions. A unique focus of the symposium will be providing clinicians with strategies to determine if it is appropriate to use one or more of the stratification approaches in their clinical practice and specific setting.

Implications / Conclusions

Stratified care is creating considerable scientific and therapeutic excitement but there are important challenges ahead to ensure a) that future care is based on good evidence and b) that we avoid unhelpful confusion in clinical practice. No stratified care approach has yet attempted to subgroup patients across the whole spectrum of available treatments (physical, pharmacological, surgical). Three approaches to stratified care show promising benefits for low back pain patients but the evidence base for each needs further development and it is not yet clear if one approach is superior to others. Research studies providing robust evidence for stratified care in low back pain are challenging to design, fund and conduct. Broad validation studies of the most promising stratified care approaches are needed before widespread implementation.


Low back pain; Stratified care; Subgrouping

Funding acknowledgements

NE Foster is supported through a Research Professorship from the National Institute of Health Research (NIHR). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

Relevance to WCPT and expected audience

Physiotherapists play a key role, world-wide, in the assessment and management of patients with low back pain. From being referred to as the 'Holy Grail' of back pain research over a decade ago, stratified care (or subgrouping patients for targeted treatment) is fast becoming the dominant school of thought in research and clinical practice. We expect this symposium to be of considerable appeal and thus expect a large audience of clinicians, managers, educators and policy-makers.

Target audience

The target audience is broad as stratified care (matching subgroups of back pain patients to treatments) is of interest to clinicians, managers, educators and policy-makers.