Stepped Care for Back Pain: Activating Approaches for Primary Care

In this paper, we describe a stepped-care approach to the activation of patients with back pain who are seen in primary care settings. This approach is intended to complement medical management. Waddell (1) states, Advice to stay active and to continue ordinary activities as normally as possible is likely to result in faster recovery, faster return to work and less chronic disability. Simply having a physician advise them to resume activities may be sufficient for most patients, but an important minority of patients may need more substantial support to achieve a favorable functional outcome. A smaller group may require intensive intervention to restore function in major social roles related to work and family. A stepped approach allows care to be guided by functional outcome, with intensity being increased until a favorable outcome is achieved whenever possible. Evidence-based guidelines advocate stepped-care approaches for a wide range of chronic conditions (2). Large numbers of patients with back pain seek treatment in primary care settings. Stepped care provides a framework for integrating behavioral interventions aimed at restoring function in work and family life into routine medical care (3). It provides a way to target the limited professional resources for helping patients achieve favorable functional outcomes to the patients who have the greatest needs (4, 5). Stepped care is not an intervention in itself. Rather, it is a way to sequence interventions so that the intensity, complexity, and costs of care are guided by each patient's observed outcome. The objective of stepped care is to give each patient the level and kind of care needed for a favorable outcomeno more and no less. Back pain is a chronicrecurrent condition. Although most patients who seek care for a severe flare-up of back pain improve and return to work quickly, the long-term outcomes of patients with back pain are not as favorable as previously believed. Outcome studies show that in the long run, recurrence is typical. About 30% of patients seen in primary care for back pain have persistent back pain, and 15% to 20% continue to have moderate to severe activity limitations 1 or more years after seeking care (6). One implication is that back pain management should be appropriate for a chronicrecurrent pain condition with highly variable outcomes. Recent systematic reviews of randomized, controlled trials have concluded that activating interventions improve functional outcomes for patients with chronic or recurrent back pain (7-10). In a systematic review, Waddell and colleagues (7) concluded that when physicians avoid prescribing bed rest and advise patients to stay active and to continue normal activities, patients return to work faster and have reduced disability. Turner (8), reviewing cognitivebehavioral interventions for back pain, concluded that cognitive-behavioral treatments were superior to control conditions after treatment on measures of chronic low back pain, pain behavior and disability. However, she did not find evidence showing that cognitivebehavioral therapies were superior to other active treatments on specific outcome measures. Koes and coworkers (9), reviewing randomized trials of back schools, found that schools that emphasized resumption of normal activities were more likely to report positive results than were schools that offered traditional patient education about back anatomy, biomechanics, and posture. Abenhaim and associates (10) concluded that patients with back pain benefit from participation in structured exercise programs. Fear avoidance, which is characterized by the belief that activity and movement can cause back pain and increase risk for re-injury, is believed to be an important determinant of disability in patients with back pain (11-13). Fear-avoidance beliefs are associated with reduced activity and increased disability. Recent randomized, controlled trials of brief interventions have found that addressing fear-avoidance beliefs and encouraging resumption of normal activities have substantial benefits. For example, Malmivaara and colleagues (14) showed that advising patients to avoid bed rest and to continue routine activity as normally as possible resulted in better functional outcomes than either advising them to rest in bed for 2 days or implementing back-mobilizing exercises during acute care. Indahl and coworkers (15) found that reassurance intended to reduce fear of movement, advice to resume normal walking, and the setting of personal goals resulted in reduced work disability. Moffett and associates (16) found that a program of brief education, strengthening and flexibility exercises, and relaxation reduced the number of work days missed over the following year. Linton and Andersson (17) found that a brief cognitivebehavioral program resulted in fewer lost work days. Two randomized, controlled trials conducted by our research group (18, 19) showed that brief activating interventions delivered in a group format reduced worry about back pain and reduced activity limitations among primary care patients with back pain over a 1-year period. Burton and coworkers (20) found that an educational booklet addressing fear-avoidance beliefs reduced fear and yielded a short-term reduction in disability. Overall, these studies suggest that credible activating interventions addressing fear-avoidance beliefs can improve patient outcomes. A Stepped-Care Model Stepped care is based on the principle of starting with low-intensity, low-cost interventions and stepping up to more intense, costly, or complex interventions in patients who show inadequate response (2-5). A possible stepped-care approach for back pain is summarized in Table 1. In the case of back pain, simple and brief educational interventions may be sufficient to address fear-avoidance beliefs and ensure resumption of normal activities for many patients (step 1). However, some patients with back pain continue to have residual activity limitations. These patients may benefit from brief, structured interventions that increase physical exercise and support resumption of normal activities (step 2). A more intense rehabilitative intervention that targets return to work and work-role performance may be appropriate for patients at risk for chronic work-role disability (step 3). At step 3, identification and treatment of comorbid psychological illness (such as major depression), if present, may help improve functional outcomes. Although the intensity of a stepped-care intervention is guided primarily by observed outcome, individualization based on initial evaluation is possible. For example, a patient who cannot work and has no definite plans to resume work at the time of the initial visit might receive a more intensive intervention immediately (3). Table 1. A Stepped-Care Approach for Managing Back Pain in Primary Care Patient Needs at Each Level of Care Drawing on data from studies conducted by our research group (18, 19, 21), we identified patient needs defined in terms of the proposed stepped-care model. Patient Worries and Concerns Addressed at Step 1 As Table 2 shows, 2 months after seeking care for back pain in a primary care setting, a large proportion of patients reported being worried that a wrong movement might injure their back. Patients also frequently reported concern about being unable to do things because of risk for injury and concern that back pain indicates that something is dangerously wrong. Almost one third of patients reported fear of injury with exercise, and one in five reported concern that their back pain might be due to a serious disease. Apparently, fear-avoidance beliefs and related worries are common among primary care patients with back pain, and these concerns are often not laid to rest in the initial medical encounter. Table 2. Percentage of Patients Reporting Specific Worries about Back Pain and Activity Limitations 2 Months after a Primary Care Visit for Back Pain Activity Limitations Addressed at Step 2 It was also common for patients with back pain to report continuing activity limitations 2 months after they had sought care. As Table 2 shows, the proportions of patients who reported that they were doing no housework, were doing less housework, had decreased sexual activity, had difficulty walking short distances, or had difficulty standing for short periods were 23% to 45%. These activity limitations, while not indicative of total disability, suggest that many patients have sustained decrements in quality of life because of back pain. Two months after they had sought care, 44% of participants gave a positive response to 10 or more of the 23 items on the Roland Disability Questionnaire. At 1 year, 26% gave a positive response to 10 or more of the same 23 items. This indicates that substantial activity limitations are often sustained long after the initial primary care visit. Work Disability Addressed at Step 3 The proportion of primary care patients with back pain who reported significant work-role disability was considerably smaller. Using data from a long-term follow-up study of primary care patients with back pain (21), we examined three indicators of work disability. At 1 month to 5 years, 2.0% to 3.8% of primary care patients with back pain reported being unable to work and 1.5% to 3.5% reported receiving worker's compensation for back pain. However, the percentage reporting that they were being kept from usual activities (such as work, school, or housework) for 30 or more days in the previous 6 months because of back pain was considerably greater. At 1 month, 21% reported more than 30 activity limitation days in the previous 6 months; at 1 to 5 years, the percentage was 8% to 10%. These results support the need for educational interventions that address fear-avoidance beliefs and encourage resumption of normal activities for all patients who seek care for back pain (step 1). They also show that large numbers of pr