Stratified Care for Low Back Pain Management with Nadine Foster

Professor Nadine Foster is faculty at Keele University. She studies management of non-specific back pain and her specialty is Stratified Care for Low Back Pain.

In this interview Nadine discusses how research has evolved over the past twenty years in regards to treating non-specific low back pain. Previously, physical therapy involved a lot of passive therapies such as traction or electromodalities. Currently it is much more interactive and she identifies exercise and manual therapy as key components for treating low back pain in modern day care in appropriate populations.

Stratified care for low back pain is Nadine’s specialty she has been very involved in the development of StaRT Back approach to LBP.  STarT Back is an example of a stratified care approach, it match patients to treatments based on prognosis or risk of poor clinical outcome.  It identifies patients who are appropriate for physical therapy and that should do well. Self management is key in prognosis and long term management. Identifying risks for PT failure and trying to match to appropriate care for better outcomes ultimately will assist the patient in being in the proper treatment category.

Using the STarT Back approach individuals with back pain may be categorised as:

  1. Low risk – These patients can be taught self management. 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.
  2. Medium risk -Physiotherapy management is utilised to decrease levels of pain and disability. This many 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.

Nadine notes we need to be careful in using any subgrouping for patients. We should identify the most important systems for teaching new therapists but later educating on other systems after gaining clinical experience. Nadine notes its important to continue to research multiple subgroupings and integrating it into various clinical settings, countries, and implementation.

Selected Publications:


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