What is Stepped Care?


(May 2001) Stepped Care for Back Pain: Activating Approaches for Primary Care

Interventions that encourage return to normal function and reduce fear of physical activity have been shown to improve outcomes for patients with back pain, but routine medical care for back pain often does not provide such interventions. This paper proposes a stepped-care approach that addresses the functional outcomes of back pain. Step 1, which is relevant to most patients, addresses the common fears of patients with back pain and encourages patients to resume normal activities. Step 2, which targets the substantial minority of patients who require more than simple advice to resume activities, 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 life.

Do you notice something missing in this approach to treatment?  Shouldn’t there be a goal to treat and reduce pain?  By pushing (forcing) patients to return to normal activities, isn’t that creating a potential for more damage and pain?


The paper points out that the VA has not lived up to its own standards.

Minnesota U.S. Rep. Tim Walz, a veteran, rightly points out that the Veterans Health Administration has failed to fully implement a best-practices medical treatment blueprint — the Stepped Care Model of Pain Management — that was established by a system wide “Pain Directive” in 2009. Walz authored the 2008 legislation that led to the pain directive’s creation.

Nimmo pointed out in his op-ed, Here at Huntington, we are offering complementary and alternative therapies, including acupuncture, animal-assisted therapy and art therapy.

Chiropractic services are available through the Veteran’s Choice program. We have an interdisciplinary pain team working with providers to find alternative treatments that will help reduce a veteran’s long-term dependence on opioids…

Do you notice something missing here?  The goal should be to treat and reduce pain, not just to reduce long-term dependence on opioids (which is another way to say addiction).


(May 2015) Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan Conflicts: A Randomized Clinical Trial

2 thoughts on “What is Stepped Care?

  1. you are totally right. the outcomes they are trying to reach are outcomes regarding the VA using opiates as sparingly as possible. the outcome that they should be trying to reach is acceptable pain management by the patient standard for best possibility for them to resume employment and be involved in family life. the VA’s focus is on its own goals, not the goals of the patients they are treating, and that is just plain wrong.

    Liked by 1 person

    • It’s wrong because it doesn’t work. It’s funny, there are overlapping goals between the VA and the patients it serves — I mean, patients also want to be able to resume employment and involvement in family life. Sure, there are probably a small percentage who would prefer to live off of disability, but c’mon, we’re talking about veterans. I can’t imagine there are too many veterans who would prefer not to work. And if they can’t work, I’m sure there’s a good reason.

      The whole disability system is so adversarial and it just makes people feel worse about themselves. Always having to defend our pain, illness, disability. I can see the future… where patients have to submit to a polygraphs, fingerprinting, or DNA testing to obtain access to certain medications.

      How does someone prove that they deserve all options for treatment? If veterans are good enough to be treated fairly, everyone else should be too.

      Sorry this response is so long. 🙂

      Liked by 1 person

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