LEARNING OBJECTIVES
1. Understand the practicalities, strengths and limitations in the clinical interpretation of sub-grouping science.
2. Understand uses, limitations and implementation of first contact clinician sub-grouping and individualised-care for musculoskeletal pain disorders
3 Understanding these concepts from the viewpoint of clinicians, consumers/patients and health systems.

DESCRIPTION
Recommendations for the musculoskeletal pain management include calls for sub-grouping. Sub-grouping refers to the practice of placing individuals into categories based on similarities in their clinical profiles. Historically, this involved deriving sub-groups based on single factors, like length of time with a disorder or patterns of pain. Evolution of this concept has led to profiling based on multiple factors, sometimes across multiple health dimensions. These more complicated sub-grouping systems might include factors associated with current clinical status (factors driving pain and disability), or factors associated with prognosis (risk factors for poorer outcomes).

At the clinician level, the argument for sub-grouping is so that management can be targeted to the characteristics of that sub-group, and thus improve management outcomes for people with musculoskeletal pain. More broadly, sub-grouping may inform care pathways through health-care systems and assist with decision making of how to apportion (usually limited) health resources. Ultimately, sub-grouping may influence the behaviours of all those participating in these systems.

However, here is ongoing debate about the use and future of sub-grouping. Does sub-grouping improve treatment fidelity? How does sub-grouping intersect with person-centred care? Does sub-grouping assist in the pursuit of precision medicine? Here we have assembled a group of experts in sub-grouping pain disorders, who have spent significant portions of their careers grappling with the science and implementation of this approach. They will provide a state-of-the art perspective to help clinicians make sense of sub-grouping and individualised-care.

Martin Rabey has profiled 300 people with low back pain on over 100 clinically assessable factors. He has focused on ‘data-driven’ sub-grouping methodology as an attempt to address potential bias from more judgement-based approaches to sub-grouping. He will present the challenges faced in developing a true multidimensional sub-grouping system, the compromises required in this process, and a model for clinician understanding of the broad concept of multidimensionality.

Alice Kongsted will discuss the conceptual idea of individualised care and sub-grouping in care planning and clinical decision making. And importantly, how do we know if sub-grouping/individualised care is working? Based on her work with clinicians, she will talk about what skills and techniques may be useful for clinicians to be able to deliver targeted treatment to people with musculoskeletal pain conditions.

Jonathan Hill will focus on the learning from the original STarT Back trial and the more recent STarT MSK trial which has tested the use of a risk stratified approach designed for United Kingdom first contact clinicians for patients with common musculoskeletal disorders. He will present the findings from the Back-UP project (a large European Union funded project) which sought to implement evidence-based back and neck pain care online providing support for clinical decision making (including stratified care) across Europe, and describe the scalability and next steps for sub-grouping research.

Peter O’Sullivan has spent 25 years evolving his (and our) understanding of sub-grouping and individualised care for people seeking care for low back pain. This research/clinical journey has led to the development of a physiotherapy-led individualised approaches to managing disabling low back pain disorders. Underpinning this approach is a multidimensional clinical reasoning framework, that enables clinicians to identify and then target relevant modifiable biopsychosocial barriers to recovery for each individual. He will present the framework and application of Cognitive-Functional Therapy as an example of a patient centred, individualised behavioural approach for people with persistent and disabling low back pain disorders.

IMPLICATIONS/CONCLUSIONS
Efforts to reduce the global burden of musculoskeletal pain over a number of decades have been challenging. Evidence suggests the costs of managing this burden continue to rise without concomitant improvement in the level of burden for individuals or society. While far from perfected, evidence would suggest that sub-grouping and individualised care holds some promise, and further exploration of this is warranted. In this symposium, we provide guidance for clinicians to integrate the latest knowledge of sub-grouping into their clinical work, how this links to the provision of individualised-care and how this might fit at a health-care systems level.