Stepped care for back pain: Activating approaches for primary care

Interventions that encourage return to normal function and reduce fear of p hysical activity have been shown to improve outcomes for patients with back pain, but routine medical care for back pain often does not provide such i nterventions. This paper proposes a stepped-care approach that addresses th e functional outcomes of back pain. Step 1, which is relevant to most patie nts, addresses the common fears of patients with back pain and encourages p atients to resume normal activities. Step 2, which targets the substantial minority of patients who require more than simple advice to resume activiti es, provides brief, structured interventions that support physical exercise and return to normal activities. Step 3 targets patients who require more intensive interventions, including treatment of psychological illness when present, before they can return to normal activities in work and family lif e. Patient needs relevant to these three levels of care are delineated. Thi s stepped-care approach provides a framework for sequencing progressively m ore intensive interventions and coordinating the efforts of primary care ph ysicians, allied health professionals, behavioral health clinicians, and pa tients to improve functional outcomes in patients with back pain.