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The disability burden due to low back pain (LBP) continues to increase despite increased healthcare costs. There is growing interest in better targeting care for LBP, rather than adopting a ‘one size fits all’ approach, in order to optimally manage the well-recognised heterogeneity of patients with LBP.1–4
This challenge of patient heterogeneity has been approached in different ways. Stratified care, where patients are classified based on certain characteristics and then matched to appropriate treatment pathways, is one relatively simple and efficient method of targeting care.2 Subgrouping approaches based on identifying common clinical features, usually within a single dimension (ie, pain characteristics, movement patterns, psychological profiles), have also been proposed as a way to target care.5 Individualised care goes one step further with each person, as opposed to groups of people, receiving personally tailored care.1 ,3 ,4 However, what does individualised care actually mean?
Many clinicians would argue that they always provide individualised care. However, what this looks like in clinical practice is probably biased by our professional backgrounds, beliefs and training. For example, while LBP can involve a range of factors across different domains (eg, pathoanatomical, lifestyle, physical, social, psychological), the expertise and knowledge clinicians have across these domains will vary. Understandably, many clinicians are happier to focus within their own professional ‘comfort zone’, without exploring other domains. Consequently, most attempts at targeting care have adopted a relatively unidimensional subgrouping approach targeting only one or two domains (eg, physical factors or cognitive).1 ,5 It could be argued that this may be adequate, as when one or two important aspects improve (eg, physical activity levels, and/or pain beliefs), the whole clinical picture (across multiple domains) may also improve. This might also minimise concerns about ‘scope of practice’, such as when a physiotherapist discusses psychological issues, such as mood or fear, with a person with LBP.
However, systematic reviews6 suggest that the effects of unidimensional care are typically small to moderate at best. In addition, there is strong evidence that more complex and disabling LBP presentations typically include recognisable barriers across several domains (eg, pathoanatomical, lifestyle, physical, social, psychological), which might impair clinical recovery.2 This concern is magnified by the recognition that these patients are likely to be the very group for whom targeted care is most critical, due to their increased risk of prolonged disability, absence from work/sport and higher healthcare costs.7
One way of potentially optimising outcomes is by making individualised care for LBP more multidimensional. The ability of an individual clinician to manage LBP is complicated by the large number of interacting factors that may be relevant for an individual, and which may fluctuate over time for that individual. If only a relatively small number of common cross-domain combinations (phenotypes) existed, this would allow for them to be described and the modifiable factors for each phenotype to be identified and targeted by care in a relatively standardised manner.
However, it is likely that the number of different cross-domain phenotype combinations is large. Consequently, we propose that the clinician needs to use multidimensional screening tools and develop clinical skills across multiple domains. This requires significant decision latitude and flexibility in order to determine (1) which specific combination of clinically relevant cross-domain factors are present in a given individual, and (2) how they should be targeted in order to enhance self-management and functional restoration. This process should be directed by empirical evidence, shared goals and facilitated by a strong therapeutic alliance.
Currently, it is unclear where, if anywhere, along this continuum from more prescriptive subgrouping-directed care, to more freestyle individualised care, is the optimal ‘sweet spot’ in terms of efficacy and efficiency. For example, would greater manualisation (formalised structuring of assessment and treatment) of individualised care enhance consistency, quality and teaching methods or would it restrict flexible clinical reasoning? Additionally, there is a lack of clarity about which patients, if any, should be referred for multidisciplinary pain management, and when. This is critical since the additional benefit gained from a typically non-individualised pain management programme is very small,8 and these programmes are unlikely to be available in large parts of the public and private health service. Finally, individualised care might involve targeting care based on the initial presentation7 or a more adaptive model of care,4 where the clinically relevant factors may change during the clinical course in response, or non-response, to treatment.
In conclusion, while some promising data3 ,4 suggests that individualised care for LBP might enhance the typically modest outcomes observed in LBP trials,8 these trials have all had some methodological shortcomings, requiring further investigation to better understand the potentials and limitations of individualised care. This knowledge is critical in order to train a healthcare work force to both optimise and rationalise care for people with LBP, as well as other complex, costly musculoskeletal disorders.
Contributors All authors contributed to this editorial, with the lead taken by KOS.
Competing interests All four authors have been, or are currently, been involved in trials examining individualised care for LBP. Three of the authors (POS, KOS and KVF) receive honoraria for providing lectures/workshops on the management of LBP.
Provenance and peer review Not commissioned; externally peer reviewed.
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