Skip to main content

16-03-2014 | Pain medicine | Article

Stratified care highly successful in managing low back pain


Free abstract

medwireNews: Using risk-stratification to guide the care of patients with low back pain in primary care has major benefits and does not increase costs, say the authors of a population-based study.

Writing in the Annals of Family Medicine, Nadine Foster (Keele University, UK) and colleagues report that stratified care improved disability outcomes and reduced time off work, findings that support wider implementation of the approach.

Under stratified care, patients with low back pain are classified as being at low, medium or high risk for persistent disability and treated accordingly.

Specifically, low-risk patients receive a single session of intervention comprising assessment, education and support for self-management. Medium-risk patients receive physical therapy interventions that focus on reducing pain and disability, encouraging physical exercise and facilitating early return to work.

Meanwhile, high-risk patients receive “psychologically informed” physical therapy that integrates cognitive behavioural techniques with traditional physical therapy to reduce pain and disability, improve psychological functioning and facilitate self-management.

The IMPaCT Back Study was designed to evaluate this approach by comparing outcomes in 368 patients given usual care for 6 months with outcomes in 554 patients given stratified care for 12 months. The same pool of 64 primary care physicians and physical therapy specialists delivered both forms of care.

Within the group of patients assigned to stratified care, 38% were classified as low risk, 42% as medium risk and 20% as high risk.

The study’s primary endpoint was change in Roland-Morris Disability Questionnaire score between baseline and 6-month follow-up. This value increased (indicating a reduction in disability) by 2.2 points with usual care and by 2.7 points with stratified care, a statistically significant difference with an estimated effect size of 0.71. The effect size was even greater, at 2.3, in the subgroup of high-risk patients.

Other benefits associated with stratified care as compared with usual care included significantly more risk-appropriate referrals to physical therapy, a 39% relative reduction in sickness certifications, a 50% relative reduction in time off work sick, a decrease in use of nonopioid medications and concurrent increase in use of mild opioids.

Finally, economic analyses indicated that stratified care offered a mean cost-saving of £34 (€ 41; US$ 57) per patient, rising to £400 (€ 480; US$ 665) in employed patients, and an incremental quality-adjusted life–years estimate of 0.003.

The researchers conclude: “Stratified care is associated with benefits for patients and more targeted use of health care resource without increasing health care costs and should be implemented more widely.”

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2014

By Joanna Lyford, Senior medwireNews Reporter