Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model?

The overall quality of care for musculoskeletal pain conditions is suboptimal, partly due to a considerable evidence-practice gap. In osteoarthritis and low back pain, structured models of care exist to help overcome that challenge. In osteoarthritis, focus is on stepped care models, where treatment decisions are guided by response to treatment, and increasingly comprehensive interventions are only offered to people with inadequate response to more simple care. In low back pain, the most widely known approach is based on risk stratification, where patients with higher predicted risk of poor outcome are offered more comprehensive care. For both conditions, the recommended interventions and models of care share many commonalities and there is no evidence that one model of care is more effective than the other. Limitations of existing models of care include a lack of integrated information on social factors, comorbid conditions, and previous treatment experience, and they do not support an interplay between health care, self-management, and community-based activities. Moving forwards, a common model across musculoskeletal conditions seems realistic, which points to an opportunity for reducing the complexity of implementation. We foresee this development will use big data sources and machine-learning methods to combine stepped and risk-stratified care and to integrate self-management support and patient-centred care to a greater extent in future models of care.
Competing Interests: The authors declare there are no conflicts of interest. A. Kongsted's position at the University of Southern Denmark is partly financed by an unrestricted grant from the Foundation for Chiropractic Research and Postgraduate Education. J.C. Hill, S.T. Skou, and A. Kongsted are, respectively, part of the groups that developed the STarT Back Screening Tool, the GLA:D program for knee/hip, and the GLA:D program for LBP. A. Kongsted is an associate editor of the BMC Chiropractic and Manual Therapy journal. S.T. Skou is an associate editor of the Journal of Orthopaedic & Sports Physical Therapy, and has received grants from The Lundbeck Foundation and personal fees from Munksgaard, all of which are outside the submitted work. S.T. Skou is currently funded by grants from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (grant agreement No 801790) and from Region Zealand (Exercise First), both unrelated to the current study. J.G. Quicke is partly funded by a NIHR Clinical Research Network West Midlands, Research Scholar Fellowship, and is a member of the NICE OA guideline committee. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health and Social Care, or NICE.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
(Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.)