The predictive ability of the STarT Back Screening Tool in a Danish secondary care setting

Time course and correlates of psychological distress post spinal surgery: A longitudinal study

Background

Psychological distress post lumbar spine surgery is associated with poorer outcomes. There is a scarcity of studies devoted to analyzing the risk factors associated with psychological distress in patients who have undergone lumbar fusion surgery. The purpose of this study was to (1) describe the time course and severity of psychological distress using the STarT Back Tool (SBT) and (2) determine the demographic and clinical predictors of SBT score post lumbar spine fusion surgery.

Methods

This retrospective longitudinal study analyzed 227 subjects with 1- and 2-level lumbar fusion surgery who underwent standardized assessment preoperatively and at 4 and 12 weeks postoperatively. Preoperative variables collected were demographic, clinical, and psychological variables. Postoperative psychological distress was measured by self-reported SBT. Risk factors for SBT over time were identified using ordinal and mixed-effects modelling.

Results

Although the trajectory of SBT levels declined postoperatively over time, at week-12, 20% of patients had moderate to high SBT. Postoperative SBT scores at week-4 time point was significantly greater than SBT scores at week-8 (OR = 2.7, 95% credible interval [CrI]; 1.8-3.9). Greater SBT scores at week-4 were strongly associated with greater SBT scores throughout 12 weeks of follow-up (OR = 7.3, [95% CrI; 1.2-31.4]). Greater postoperative SBT levels over time were associated with being male (OR = 2.2, 95% CrI; 1.0-3.9), greater preoperative back or leg pain intensity (OR = 2.2; 95% CrI: 1.0-4.4), greater preoperative leg weakness (OR = 4.2, 95% CrI: 1.7-7.5) and higher preoperative depression levels (OR = 4.8; 95% CrI: 1.6-10.4).

Conclusion

Postoperative SBT levels declined nonlinearly over time. However, a sizable proportion of patients had moderate to high psychological distress at week-12 postsurgery. Greater preoperative back or leg pain intensity, leg weakness and depression levels, and male gender were risk factors of greater psychological distress postsurgery. Although requiring validation, our study has identified potential modifiable risk factors which may give an opportunity to provide early (preoperative) and targeted strategies to optimize postoperative psychosocial outcomes in patients undergoing lumbar fusion surgeries.

Predictive performance of the STarT Back tool for poor outcomes in patients with low back pain: protocol for a systematic review and meta-analysis

INTRODUCTION

Subgroups for Targeted Treatment Back Tool (SBT) is a brief multiple-construct risk prediction tool for patients with low back pain (LBP). Thus far, the predictive ability of this tool has been inconsistent. Therefore, we aim to conduct a literature review on the predictive ability of the SBT to determine the outcomes of patients with LBP. The results of this review should improve the ability of the SBT to predict poor outcomes in patients with LBP.

METHODS AND ANALYSIS

Databases including PubMed, EMBASE, Cochrane Central, Web of Science, Chinese National Knowledge Infrastructure Databases, Chinese Science and Technology Journal Database, and Wanfang will be searched for studies on SBT and LBP from their inception until 31 March 2023. Longitudinal studies investigating the association between SBT subgroups and LBP outcomes, including pain, disability and quality of life, will be included. The identified studies will be independently screened for eligibility by two reviewers. A standardised sheet will be used to extract data. The Newcastle-Ottawa Scale will be used to assess the methodological quality of the included studies. Heterogeneity will be evaluated by the χ2 test with Cochran's Q statistic and quantified by the I2 statistic. The results will be synthesised qualitatively and presented as pooled risk ratios or beta coefficients quantitatively. The results will also be presented using their 95% confidence limits. Publication bias will be assessed using the method proposed by Egger and by visual inspection of funnel plots.

ETHICS AND DISSEMINATION

This study is a secondary analysis of original studies that received ethics approval. Therefore, prior ethical approval is not required for this study. The findings will be submitted to relevant peer-reviewed journals for publication and presented at profession-specific conferences.

TRIAL REGISTRATION NUMBER

PROSPERO registration numberCRD42022309189.

Prospective observational study investigating the predictive validity of the STarT Back tool and the clinical effectiveness of stratified care in an emergency department setting

PURPOSE

To determine the predictive validity of the STarT Back tool (SBT) undertaken at baseline and 6 weeks to classify Emergency Department (ED) patients with LBP into groups at low, medium or high risk of persistent disability at 3 months. A secondary aim was to evaluate the clinical effectiveness of pragmatic risk-matched treatment in an ED cohort at 3 months.

METHODS

A prospective observational multi-centre study took place in the physiotherapy services linked to the ED in four teaching hospitals in Dublin, Ireland. Patients were stratified into low, medium and high-risk groups at their baseline assessment. Participants received stratified care, where the content of their treatment was matched to their risk profile. Outcomes completed at baseline and 3 months included pain and disability. Linear regression analyses assessed if baseline or 6-week SBT score were predictive of disability at 3 months. Changes in the primary outcome of disability were dichotomised into those who achieved/ did not achieve a 30% improvement in their RMDQ at 6 weeks and 3 months.

RESULTS

The study enrolled 118 patients with a primary complaint of LBP ± leg pain with 67 (56.7%) completing their 6-week and 3-month follow-up. Baseline RMDQ and being in medium or high risk SBT group at 6 weeks were predictive of persistent disability at 3 months. A total of 54 (80.6%) participants reported a > 30% improvement at 3 months.

CONCLUSION

Disability at baseline and SBT administered at 6 weeks more accurately predicted disability at 3 months than SBT at baseline in an ED population.

Translation, cross-cultural adaptation and psychometric validation of the Thai version of the STarT Back Screening Tool in patients with non-specific low back pain

BACKGROUND

Low back pain (LBP) is a top musculoskeletal problem and a substantial cause of socioeconomic burden internationally. The STarT Back Screening Tool (SBST) is a useful screening tool to manage patients with LBP but it is unavailable in Thai. Therefore, the aims of this study were to translate and cross-culturally adapt the SBST into a Thai version (SBST-TH) and validate its psychometric properties (e.g., factor analysis, internal consistency, test-retest reliability, agreement, convergent validity and discriminative validity).

METHODS

Translation and cross-cultural adaptation of the SBST into Thai version were conducted according to standard guidelines. A total of 200 participants with non-specific LBP were invited to complete the SBST, visual analogue scale for pain intensity, Roland-Morris disability questionnaire (RMDQ), fear-avoidance beliefs questionnaire, pain catastrophising scale, hospital anxiety and depression scale and the EuroQol five-dimensional questionnaire. Thirty participants completed the SBST-TH twice with an interval of 48 h to evaluate test-retest reliability.

RESULTS

Factor analysis demonstrated two (physical and psychological) components for the SBST-TH (39.38% of the total variance). The Cronbach's alpha (0.86 for total score and 0.76 for psychosocial subscore) represent satisfactory internal consistency. The acceptability of intraclass correlation coefficient was found in the total (0.73) and subscore (0.79). The areas under the curve (AUC) for the total score ranged 0.67-0.85 and 0.66-0.75 for subscore. The excellent discriminative validity was observed (AUC = 0.85, 95% confidence interval = 0.72, 0.97) between the total score of the SBST-TH and disability (RMDQ). Spearman's correlation coefficients represented moderate to strong correlation (0.32-0.56) between the SBST-TH and all questionnaires. The findings suggest a good relationship between the SBST-TH and disability and quality of life. Owing to the results from the convergent and discriminative validity, construct validity of the SBST-TH can be supported. The minimal detectable changes of the total score and subscore were 2.04 and 1.60, respectively. Significant floor and ceiling effects were not found in the SBST-TH.

CONCLUSION

The SBST-TH was successfully translated and adapted. It is a valid and reliable tool to classify Thai patients with non-specific LBP into low, moderate and high risks for chronicity.

TRIAL REGISTRATION

TCTR20191009005 #.

Predicting Persistent Disabling Low Back Pain in Veterans Affairs Primary Care Using the STarT Back Tool

BACKGROUND

The Subgrouping for Targeted Treatment (STarT Back) is a stratified care approach to low back pain (LBP) treatment. The predictive validity of STarT Back in Veterans Affairs (VA) primary care has not been demonstrated.

OBJECTIVE

To examine the validity of the STarT Back tool for predicting future persistent disabling LBP in VA primary care.

DESIGN

Cohort study.

SETTING

VA primary care in Washington State.

PARTICIPANTS

Veterans seeking care for LBP in VA primary care clinics.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The STarT Back tool was used to classify Veterans according to their baseline risk group (low vs medium vs high). The primary study outcome, persistent disabling LBP, was defined as a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 7 at 6-month follow-up. Analyses examined discrimination and calibration of the baseline STarT Back risk groups for prediction of persistent disabling LBP at 6-month follow-up.

RESULTS

Of the study sample, 9% were female and 80% reported longstanding LBP (>5 year duration). Among 538 participants, the baseline STarT Back risk groups were associated with future persistent disabling LBP at 6-month follow-up. Within each baseline STarT Back risk group, the proportions with future persistent disabling LBP at 6-month follow-up were 54% (low risk), 88% (medium risk), and 97% (high risk). The baseline STarT Back risk groups had useful discrimination (area under the curve [AUC] 0.79) for predicting future persistent disabling LBP, but the proportion of Veterans with persistent disabling LBP at 6-month follow-up was substantially higher than that observed in non-VA primary care settings.

CONCLUSIONS

The STarT Back risk groups had useful discrimination (AUC = 0.79) for future persistent disabling LBP, but calibration was poor, underestimating the risk of persistent disabling LBP. The STarT Back tool may require updating for use in VA primary care.

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

Supplemental Digital Content is Available in the Text.

Substantial overlap between interventions and models of care for osteoarthritis and low back pain suggests potential for one common model, which may facilitate implementation.

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.

Use of the STarT Back Screening Tool in patients with chronic low back pain receiving physical therapy interventions

BACKGROUND

The STarT Back Screening Tool (SBST) is used to stratify care. It is unclear if the SBST approach works as well for patients in low- and medium-income countries as for patients from high-income countries.

OBJECTIVES

(1) To investigate whether patients with chronic low back pain (LBP) stratified by the SBST are different at baseline; (2) to describe the clinical course for each SBST subgroup; (3) to investigate the SBST utility to predict clinical outcomes; and (4) to determine which SBST subgroup show greater clinical improvement.

DESIGN

This is a secondary analysis of data derived from a previously published clinical trial.

METHODS

148 patients with chronic nonspecific LBP were included. Pain intensity, disability, global perceived effect, and the SBST were assessed at baseline and at 5, 12, and 24 weeks after baseline. Descriptive data were provided and ANOVA, unadjusted and adjusted regression models, and linear mixed models were used for data analysis.

RESULTS

Duration of symptoms, use of medication, pain, disability, and global perceived effect were different between SBST subgroups. Clinical improvements over a 6-month period were consistently greater in patients classified as high risk. The SBST was able to predict disability but this predictability decreased when the analysis was adjusted for possible confounders.

CONCLUSION

Clinical outcomes were different between SBST subgroups over 6 months. Adjusting for confounders influenced the predictability of SBST. Patients classified as high risk presented higher improvements in terms of disability.

Artificial intelligence to improve back pain outcomes and lessons learnt from clinical classification approaches: three systematic reviews

Artificial intelligence and machine learning (AI/ML) could enhance the ability to detect patterns of clinical characteristics in low-back pain (LBP) and guide treatment. We conducted three systematic reviews to address the following aims: (a) review the status of AI/ML research in LBP, (b) compare its status to that of two established LBP classification systems (STarT Back, McKenzie). AI/ML in LBP is in its infancy: 45 of 48 studies assessed sample sizes <1000 people, 19 of 48 studies used ≤5 parameters in models, 13 of 48 studies applied multiple models and attained high accuracy, 25 of 48 studies assessed the binary classification of LBP versus no-LBP only. Beyond the 48 studies using AI/ML for LBP classification, no studies examined use of AI/ML in prognosis prediction of specific sub-groups, and AI/ML techniques are yet to be implemented in guiding LBP treatment. In contrast, the STarT Back tool has been assessed for internal consistency, test-retest reliability, validity, pain and disability prognosis, and influence on pain and disability treatment outcomes. McKenzie has been assessed for inter- and intra-tester reliability, prognosis, and impact on pain and disability outcomes relative to other treatments. For AI/ML methods to contribute to the refinement of LBP (sub-)classification and guide treatment allocation, large data sets containing known and exploratory clinical features should be examined. There is also a need to establish reliability, validity, and prognostic capacity of AI/ML techniques in LBP as well as its ability to inform treatment allocation for improved patient outcomes and/or reduced healthcare costs.

The Adolescent Knee Pain (AK-Pain) prognostic tool: protocol for a prospective cohort study

Background: One in three children and adolescents experience knee pain. Approximately one in two adolescents with knee pain will continue to experience pain even five years later and have low quality of life. The general practitioner (GP) is the first point of contact for children and adolescents with knee pain in Denmark. There is a variety of treatments being delivered in general practice, despite similar symptoms and patients' characteristics. This suggests a need to support the GPs in identifying those at high risk of a poor outcome early on, in order to better allocate resources. The aim of this study is to develop a user-friendly prognostic tool to support GPs' management of children and adolescents' knee pain. Methods: A preliminary set of items in the prognostic tool were identified using systematic reviews and meta-analysis of individual participant data. Following feedback from GPs and children and adolescents on the content and understanding, the tool was piloted and implemented in general practice. A cohort of approximately 300 children and adolescents (age 8-19 years old) is being recruited from general practices (recruitment period, July 2019 - June 2020). Clinically meaningful risk groups (e.g. low/medium/high) for the recurrence/persistence of knee pain (at 3 and 6 months) will be identified. Discussion: If successful, this prognostic tool will allow GPs to gain insights into the likely prognosis of adolescents with knee pain and subsequently provide the first building blocks towards stratified care, where treatments will be matched to the patients' prognostic profile. This has the potential to improve the recovery of children and adolescents from knee pain, to improve the allocation of resources in primary care, and to avoid the decline in physical activity and potential associated health and social consequences due to adolescent knee pain. Registration: Registered with ClinicalTrials.gov on 24 June 2019 (ID NCT03995771).

Feasibility and long-term efficacy of a proactive health program in the treatment of chronic back pain: a randomized controlled trial

BACKGROUND

To facilitate access to evidence-based care for back pain, a German private medical insurance offered a health program proactively to their members. Feasibility and long-term efficacy of this approach were evaluated.

METHODS

Using Zelen's design, adult members of the health insurance with chronic back pain according to billing data were randomized to the intervention (IG) or the control group (CG). Participants allocated to the IG were invited to participate in the comprehensive health program comprising medical exercise therapy and life style coaching, and those allocated to the CG to a longitudinal back pain survey. Primary outcomes were back pain severity (Korff's Chronic Pain Grade Questionnaire) as well as health-related quality of life (SF-12) assessed by identical online questionnaires at baseline and 2-year follow-up in both study arms. In addition to analyses of covariance, a subgroup analysis explored the heterogeneity of treatment effects among different risks of back pain chronification (STarT Back Tool).

RESULTS

Out of 3462 persons selected, randomized and thereafter contacted, 552 agreed to participate. At the 24-month follow-up, data on 189 of 258 (73.3%) of the IG were available, in the CG on 255 of 294 (86.7%). Significant, small beneficial effects were seen in primary outcomes: Compared to the CG, the IG reported less disability (1.6 vs 2.0; p = 0.025; d = 0.24) and scored better at the SF-12 physical health scale (43.3 vs 41.0; p < 0.007; d = 0.26). No effect was seen in back pain intensity and in the SF-12 mental health scale. Persons with medium or high risk of back pain chronification at baseline responded better to the health program in all primary outcomes than the subgroup with low risk at baseline.

CONCLUSIONS

After 2 years, the proactive health program resulted in small positive long-term improvements. Using risk screening prior to inclusion in the health program might increase the percentage of participants deriving benefits from it.

TRIAL REGISTRATION

The trial was registered at the German Clinical Trials Register under DRKS00015463 retrospectively (dated 4 Sept 2018).

A Responsiveness Analysis of the Subgroups for Targeted Treatment (STarT) Back Screening Tool in Patients With Nonspecific Low Back Pain

BACKGROUND

The Subgroups for Targeted Treatment (STarT) Back Screening Tool (SBST) screens patients with low back pain and directs them to different levels of physical therapy treatment. The SBST is also used to monitor changes in a range of modifiable prognostic factors. However, the current evidence on the responsiveness of the SBST is limited.

OBJECTIVES

To test the responsiveness of the SBST at 6 weeks and 6 months.

METHODS

This measurement property study is a secondary analysis of data from 2 previous studies that included 348 participants with nonspecific low back pain. All participants were assessed at baseline, 6 weeks, and 6 months. To detect clinical changes, the SBST was compared to 3 one-dimensional constructs: global perceived effect, disability, and pain intensity. To assess responsiveness, we tested 15 specific predefined hypotheses based on correlation, effect size, and receiver operating characteristic curve analyses. If 75% or more of the hypotheses were accepted, then responsiveness was considered to be high.

RESULTS

Most of the hypotheses were accepted. Testing the SBST as a continuous score, 85.7% and 87.5% of the hypotheses were accepted at 6 weeks and 6 months, respectively. For medium- and high-risk subgroups, 85.7% and 87.5% of the hypotheses were accepted at 6 weeks and 6 months. The low-risk subgroup had 42.9% of the hypotheses accepted at 6 weeks and 100% of the hypotheses accepted at 6 months.

CONCLUSION

The SBST had high responsiveness at 6 weeks in subgroups of patients with a medium and high risk, and poor responsiveness in those with a low risk, of persistent disability. The SBST has high responsiveness in all SBST subgroups at 6 months. Clinicians can confidently use the SBST to measure changes over time in terms of subgroups.

LEVEL OF EVIDENCE

Longitudinal clinical measurement, level 1b. J Orthop Sports Phys Ther 2019;49(10):725-735. Epub 23 Aug 2019. doi:10.2519/jospt.2019.8776.

Multidimensional screening for predicting pain problems in adults: a systematic review of screening tools and validation studies

Screening tools allowing to predict poor pain outcomes are widely used. Often these screening tools contain psychosocial risk factors. This review (1) identifies multidimensional screening tools that include psychosocial risk factors for the development or maintenance of pain, pain-related distress, and pain-related disability across pain problems in adults, (2) evaluates the quality of the validation studies using Prediction model Risk Of Bias ASsessment Tool (PROBAST), and (3) synthesizes methodological concerns. We identified 32 articles, across 42 study samples, validating 7 screening tools. All tools were developed in the context of musculoskeletal pain, most often back pain, and aimed to predict the maintenance of pain or pain-related disability, not pain-related distress. Although more recent studies design, conduct, analyze, and report according to best practices in prognosis research, risk of bias was most often moderate. Common methodological concerns were identified, related to participant selection (eg, mixed populations), predictors (eg, predictors were administered differently to predictors in the development study), outcomes (eg, overlap between predictors and outcomes), sample size and participant flow (eg, unknown or inappropriate handling of missing data), and analysis (eg, wide variety of performance measures). Recommendations for future research are provided.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Advancing practice for back pain through stratified care (STarT Back)

BACKGROUND

Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care.

RESULTS

The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care.

CONCLUSIONS

The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.

The effectiveness of a stratified care model for non-specific low back pain in Danish primary care compared to current practice: study protocol of a randomised controlled trial

Background

Prior studies indicate that stratified care for low back pain results in better clinical outcome and reduced costs in healthcare compared to current practice. Stratified care may be associated with clinical benefits for patients with low back pain at a lower cost, but evidence is sparse. Hence this study aims to evaluate the clinical effects and cost-effectiveness of stratified care in patients with non-specific low back pain compared to current practice.

Methods/design

The study is a two-armed randomised controlled trial in primary care in the Regions of Southern and Central Denmark (2.5 million citizens). Patients with non-specific low back will be recruited by paticpating GPs. Patients are randomised to either (1) stratified care or (2) current practice at participating physiotherapy clinics. In the stratified care arm, the intervention is based on the patient’s STarT Back Tool classification and trained accordingly, whereas physiotherapists in the current pratice arm are blinded to the STarT score. Primary outcomes in the trial will be group differences in time off work, improvement in LBP disability measured by the Roland Morris Disability Questionnaire (RMDQ) and patient-reported global change. Secondary measures will be pain intensity, patient satisfaction, data on patient healthcare resource utilisation and quality-adjusted life year based on the EQ-5D-5L.

Discussion

Stratified care that effectively targets treatment to relevant sub-groups of patients has potentially great impact on the treatment pathways of low back pain. Thus, if effective, this could result in better patient outcomes and at the same time reduce the costs for treatment of low back pain.

Trial registration

ClinicalTrials.gov, NCT02612467. Registered on 16 November 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2685-5) contains supplementary material, which is available to authorized users.

Risk classification of patients referred to secondary care for low back pain

Background

Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories.

Methods

An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen’s Kappa coefficient, Pearson’s r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool.

Results

A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ.

Conclusion

The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

The use of STarT BACK Screening Tool in emergency departments for patients with acute low back pain: a prospective inception cohort study

PURPOSE

(1) To analyse the clinical utility of the STarT Back Screening Tool (SBST) in emergency departments by describing changes in classification over time and; (2) to identify what would be the best time to use the SBST to predict long-term clinical outcomes in patients with acute nonspecific low back pain (LBP) seeking emergency care.

METHODS

A 6 months prospective inception cohort study was conducted. 200 participants with LBP seeking emergency medical treatment were included. Pain intensity, disability and SBST were collected at baseline, 6 and 26 weeks. Categories of improvement, clinical worsening, and stability were created to calculate the changes in the SBST subgroups. Linear regression models were built to analyse the predictive ability of SBST when applied at baseline, 6 weeks as well as changes in the subgroup from baseline to 6 weeks. These models were adjusted for potential confounders.

RESULTS

45% of patients were classified as high risk of chronicity at baseline. Most patients classified as medium (86.7%) or high (52.4%) risk changed their risk subgroup after 6 weeks and most of them improved. The SBST improved the prediction for all outcomes when applied at 6 weeks (R² = 22.1% for disability and R² = 15.6% for pain intensity), but not at baseline.

CONCLUSION

Most of patients seeking care in emergency departments with a new episode of acute LBP improved after 6 weeks. The use of SBST to guide initial treatment and to predict clinical outcomes are most indicated when the instrument is applied after 6 weeks after presentation to emergency care. These slides can be retrieved under Electronic Supplementary material.

Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting

OBJECTIVE

To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.

DESIGN

Secondary analysis of data from participants receiving usual care in a randomized clinical trial.

SETTING

Primary care clinics.

PARTICIPANTS

Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.

RESULTS

The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.

CONCLUSIONS

The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.

The predictive ability of the STarT Back Tool was limited in people with chronic low back pain: a prospective cohort study

QUESTIONS

In people with chronic non-specific low back pain (LBP), what is the predictive and discriminative validity of the STarT Back Tool (SBT) for pain intensity, self-reported LBP-related disability, and global self-perceived change at 1-year follow-up? What is the profile of the SBT risk subgroups with respect to demographic variables, pain intensity, self-reported LBP-related disability, and psychological measures?

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 290 adults with dominant axial LBP of≥3months' duration recruited from the general community, and private physiotherapy, psychology, and pain-management clinics in Western Australia.

OUTCOME MEASURES

The 1-year follow-up measures were pain intensity, LBP-related disability, and global self-perceived change.

RESULTS

Outcomes were collected on 264 participants. The SBT categorised 82 participants (28%) as low risk, 116 (40%) as medium risk, and 92 (32%) as high risk. The risk subgroups differed significantly (p<0.05) on baseline pain, disability, and psychological scores. The SBT's predictive ability was strongest for disability: RR was 2.30 (95% CI 1.28 to 4.10) in the medium-risk group and 2.86 (95% CI 1.60 to 5.11) in the high-risk group. The SBT's predictive ability was weaker for pain: RR was 1.25 (95% CI 1.04 to 1.51) in the medium-risk group and 1.26 (95% CI 1.03 to 1.52) in the high-risk group. For the SBT total score, the AUC was 0.71 (95% CI 0.64 to 0.77) for disability and 0.63 (95% CI 0.55 to 0.71) for pain.

CONCLUSION

This was the first large study to investigate the SBT in a population exclusively with chronic LBP. The SBT provided an acceptable indication of 1-year disability, had poor predictive and discriminative ability for future pain, and was unable to predict or discriminate global perceived change. In this cohort with chronic non-specific LBP, the SBT's predictive and discriminative abilities were restricted to disability at 1year. [Kendell M, Beales D, O'Sullivan P, Rabey M, Hill J, Smith A (2018) The predictive ability of the STarT Back Tool was limited in people with chronic low back pain: a prospective cohort study. Journal of Physiotherapy 64: 107-113].

A quasi-randomised, controlled, feasibility trial of GLITtER (Green Light Imaging Interpretation to Enhance Recovery)-a psychoeducational intervention for adults with low back pain attending secondary care

Background

Although it is broadly accepted that clinicians should endeavour to reassure patients with low back pain, to do so can present a significant clinical challenge. Guidance for how to provide effective reassurance is scarce and there may be a need to counter patient concerns arising from misinterpretation of spinal imaging findings. ‘GLITtER’ (Green Light Imaging Intervention to Enhance Recovery) was developed as a standardised method of communicating imaging findings in a manner that is reassuring and promotes engagement in an active recovery. This feasibility study is an important step towards definitive testing of its effect.

Methods

This feasibility study was a prospective, quasi-randomised, parallel trial with longitudinal follow-up, involving sampling of patients attending a spinal outpatient clinic at a metropolitan hospital. English speaking adults (18–75 years) presenting to the clinic with low back pain and prior spinal imaging were considered for inclusion. Eligible patients were allocated to receive a GLITtER consultation or a standard consultation (as determined by appointment scheduling and clinician availability), and were blinded to their allocation. Full details of the GLITtER intervention are described in accordance with the Tidier template.Follow-up data were collected after 1 and 3 months. The primary outcome of this study was the fulfillment of specific feasibility criteria which were established a priori. Determination of a sample size for a definitive randomised controlled trial was a secondary objective.

Results

Two hundred seventy-six patients underwent preliminary screening and 31 patients met the final eligibility criteria for study inclusion. Seventeen participants were allocated to the intervention group and 14 were allocated to the control group. Three month follow-up data were available from 42% of the 31 enrolled participants (N = 13, six intervention, seven control). Feasibility indicators for consent, resource burden and acceptability of the GLITtER intervention were met, however participant recruitment was slower than anticipated and an acceptable follow-up rate was not achieved.

Conclusions

Failure to achieve pre-specified recruitment and follow-up rates were important outcomes of this feasibility study. We attribute failure to issues that are likely to be relevant for other clinical trials with this population. It is realistic to consider that these challenges can be overcome through careful strategy, ample funding and continued partnership with health care providers.

Trial registration

The trial was registered on the Australian and New Zealand Clinical Trials Registry on 28/2/2017 (ACTRN12617000317392).

Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice

Background

Low back pain (LBP) is a common cause of contact with the primary healthcare sector. In some patients, symptoms quickly resolve, but others develop long-lasting pain and disability. To improve the care pathway for patients with LBP, the STarT Back Tool (STarT) questionnaire has been developed. It helps initial decision-making by subgrouping patients on the basis of their prognosis and helps to target treatment according to prognosis. An assumption behind the use of STarT is the ability to predict functional improvement. This assumption has never been tested in a population that consists exclusively of patients enrolled when consulting a Danish general practitioner for LBP. The aim of this study was to investigate STarT’s ability to predict a 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score.

Methods

This was an ancillary analysis using data from a Danish guideline implementation study (registered at ClinicalTrials.gov NCT01699256). An inclusion criterion was age 18 to 65 years of age. Exclusion criteria were pregnancy, fractures, and signs of underlying pathology. Patient-reported STarT score and the Roland Morris Disability Questionnaire were administered at baseline and again after 4, 8, and 52 weeks.

Results

Between January 2013 and July 2014, 475 patients from the original trial participated with questionnaires. From this subpopulation, 441 (92.8%) patients provided information regarding STarT. Baseline and eight-week RMDQ data were available for 304 (64.0%) patients. After 8 weeks, 61 (65.6%) in the low-risk group, 67 (54.9%) in the medium-risk group, and 33 (37.1%) in the high-risk group had achieved a 30% improvement in the RMDQ score. After 8 weeks, high-risk patients were at 61% (95% CI: 20–125%, P < 0.001) higher risk of not achieving a 30% improvement in the RMDQ score compared with patients in either the low-risk group or the medium-risk group.

Conclusion

STarT was predictive for functional improvement in patients from general practice with LBP.

Trial registration

ClinicalTrials.gov NCT01699256, Nov 29, 2016 (registered retrospectively).

Longitudinal Monitoring of Patients With Chronic Low Back Pain During Physical Therapy Treatment Using the STarT Back Screening Tool

Study Design Preplanned secondary analysis of a randomized clinical trial. Background The STarT Back Screening Tool (SBST) was developed to screen and to classify patients with low back pain into subgroups for the risk of having a poor prognosis. However, this classification at baseline does not take into account variables that can influence the prognosis during treatment or over time. Objectives (1) To investigate the changes in risk subgroup measured by the SBST over a period of 6 months, and (2) to assess the long-term predictive ability of the SBST when administered at different time points. Methods Patients with chronic nonspecific low back pain (n = 148) receiving physical therapy care as part of a randomized trial were analyzed. Pain intensity, disability, global perceived effect, and the SBST were collected at baseline, 5 weeks, 3 months, and 6 months. Changes in SBST risk classification were calculated. Hierarchical linear regression models adjusted for potential confounders were built to analyze the predictive capabilities of the SBST when administered at different time points. Results A large proportion of patients (60.8%) changed their risk subgroup after receiving physical therapy care. The SBST improved the prediction for all 6-month outcomes when using the 5-week risk subgroup and the difference between baseline and 5-week subgroup, after controlling for potential confounders. The SBST at baseline did not improve the predictive ability of the models after adjusting for confounders. Conclusion This study shows that many patients change SBST risk subgroup after receiving physical therapy care, and that the predictive ability of the SBST in patients with chronic low back pain increases when administered at different time points. Level of Evidence Prognosis, 2b. J Orthop Sports Phys Ther 2017;47(5):314-323. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7199.

Evaluation of the STarT Back Screening Tool for Prediction of Low Back Pain Intensity in an Outpatient Physical Therapy Setting

Study Design Prospective cohort study. Background Optimal management of patients with low back pain (LBP) relies on accurate prognosis of future clinical outcomes. The STarT Back Screening Tool (SBT), a prognostic index developed and validated in the primary care setting, has 3 scoring measures: SBT overall, psychosocial, and categorical scores. Objective Our study aimed to compare the predictive validity of 3 SBT measures with future pain intensity in patients receiving physical therapy for LBP. Methods Two hundred seven patients with LBP receiving physical therapy completed the SBT at initial (baseline) evaluation and were evaluated 12 weeks later for their pain intensity. Multivariable proportional odds regression was used to evaluate the associations of the various SBT measures with pain intensity at follow-up. Results Adjusting for covariates, all SBT measures were positively and significantly associated with the odds of greater pain intensity at follow-up evaluation (P<.01). Adding SBT psychosocial scores to a covariate-only model improved its predictive accuracy (concordance statistic increase, 0.03; 95% confidence interval: 0.01, 0.09), while improvements in prediction were smaller or negligible with the SBT overall and categorical scores (concordance statistic increase, 0.02 and 0.007, respectively). In mutually adjusted analyses, SBT psychosocial scores added incremental predictive value over SBT overall scores in predicting future pain intensity (P = .03). Conclusion Among the 3 SBT measures, the SBT psychosocial subscale was a significant predictor of future pain intensity in patients with LBP and had comparable, if not better, prognostic significance compared with the SBT overall score. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2017;47(4):261-267. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7284.

Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis

BACKGROUND

Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration.

METHODS

Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure).

RESULTS

We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was 'non-informative' (pooled AUC = 0.59 (0.55-0.63), n = 1153) and 'acceptable' for discriminating disability outcomes (pooled AUC = 0.74 (0.66-0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was 'poor' for discriminating pain outcomes (pooled AUC = 0.69 (0.62-0.76), n = 360), 'acceptable' for disability outcomes (pooled AUC = 0.75 (0.69-0.82), n = 512), and 'excellent' for absenteeism outcomes (pooled AUC = 0.83 (0.75-0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only.

CONCLUSIONS

LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO international prospective register of systematic reviews registration number CRD42015015778 .

Descriptive analysis of a 1:1 physiotherapy outpatient intervention post primary lumbar discectomy: one arm of a small-scale parallel randomised controlled trial across two UK sites

OBJECTIVE

There is a lack of high-quality evidence for physiotherapy post lumbar discectomy. Substantial heterogeneity in treatment effects may be explained by variation in quality, administration and components of interventions. An optimised physiotherapy intervention may reduce heterogeneity and improve patient benefit. The objective was to describe, analyse and evaluate an optimised 1:1 physiotherapy outpatient intervention for patients following primary lumbar discectomy, to provide preliminary insights.

DESIGN

A descriptive analysis of the intervention embedded within an external pilot and feasibility trial.

SETTING

Two UK spinal centres.

PARTICIPANTS

Participants aged ≥18; post primary, single level, lumbar discectomy were recruited.

INTERVENTION

The intervention encompassed education, advice, mobility and core stability exercises, progressive exercise, and encouragement of early return to work/activity. Patients received ≤8 sessions for ≤8 weeks, starting 4 weeks post surgery (baseline).

OUTCOMES

Blinded outcome assessment at baseline and 12 weeks (post intervention) included the Roland Morris Disability Questionnaire. STarT Back data were collected at baseline. Statistical analyses summarised participant characteristics and preplanned descriptive analyses. Thematic analysis grouped related data.

FINDINGS

Twenty-two of 29 allocated participants received the intervention. STarT Back categorised n=16 (55%) participants 'not at low risk'. Physiotherapists identified reasons for caution for 8 (36%) participants, commonly risk of overdoing activity (n=4, 18%). There was no relationship between STarT Back and physiotherapists' evaluation of caution. Physiotherapists identified 154 problems (mean (SD) 5.36 (2.63)). Those 'not at low risk', and/or requiring caution presented with more problems, and required more sessions (mean (SD) 3.14 (1.16)).

CONCLUSIONS

Patients present differently and therefore require tailored interventions. These differences may be identified using clinical reasoning and outcome data.

TRIAL REGISTRATION NUMBER

ISRCTN33808269; post results.

Chronic low back pain clinical outcomes present higher associations with the STarT Back Screening Tool than with physiologic measures: a 12-month cohort study

BACKGROUND

Stratification strategies based on identifying patient's prognosis in order to guide patient care constitute one of the most prominent and recent approach in low back pain research. The STarT Back Screening Tool (SBST) although promising, has not been studied in patients with chronic low back pain (cLBP). Considering how challenging it is to translate research into practice, the value of integrating a new tool should be thoroughly assessed. The purpose was therefore to assess associations between the short- and long-terms clinical status and two types of variables, physiologic measures and the SBST, in participants with cLBP. The ability of both types of variables to discriminate between participants with and without higher levels of disability, pain, fear of movement and patient's global impression of change was also investigated.

METHODS

Fifty-three volunteers with cLBP participated in an initial evaluation and follow-ups at 2-, 4-, 6- and 12-month. Physiologic measures (maximal voluntary contraction, maximal endurance and muscle activity evaluated during prone and lateral isometric tasks) and the SBST were assessed at baseline. Disability (Oswestry Disability Index, ODI), pain intensity (101-point Numerical Rating Scale, NRS), fear of movement (Tampa Scale for Kinesiophobia, TSK) and patient's global impression of change (7-point scale, PGIC) were evaluated at baseline and at each follow-up. Aside the use of correlation analyses to assess potential associations; ROC curves were performed to evaluate the discriminative ability of physiologic measures and the SBST.

RESULTS

The SBST allowed for the identification of participants presenting higher levels of disability (ODI ≥24 %), pain (NRS ≥37 %) or fear of movement (TSK ≥41/68) over a 12-month period (AUC = 0.71 to 0.84, ps < 0.05). The SBST score was also correlated with disability at each follow-up (τ = 0.22 to 0.33, ps < 0.05) and with pain intensity and fear of movement at follow-ups. Among physiologic measures, only maximal voluntary contraction was correlated to disability, pain intensity or fear of movement during the follow-up (|τ| = 0.26 to 0.32, ps < 0.05) and none was able to identify participants presenting higher levels of outcomes (AUC ps > 0.05).

CONCLUSION

Physiologic measures obtained during prone and lateral tests have limited associations with the clinical status over a 12-month period in patients with nonspecific chronic low back pain. On the other hand, the STarT Back Screening Tool is useful for the identification of patients who will present higher levels of disability, pain intensity and fear of movement over a year.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02226692.

SpineData - a Danish clinical registry of people with chronic back pain

Background

Large-scale clinical registries are increasingly recognized as important resources for quality assurance and research to inform clinical decision-making and health policy. We established a clinical registry (SpineData) in a conservative care setting where more than 10,000 new cases of spinal pain are assessed each year. This paper describes the SpineData registry, summarizes the characteristics of its clinical population and data, and signals the availability of these data as a resource for collaborative research projects.

Methods

The SpineData registry is an Internet-based system that captures patient data electronically at the point of clinical contact. The setting is the government-funded Medical Department of the Spine Centre of Southern Denmark, Hospital Lillebaelt, where patients receive a multidisciplinary assessment of their chronic spinal pain.

Results

Started in 2011, the database by early 2015 contained information on more than 36,300 baseline episodes of patient care, plus the available 6-month and 12-month follow-up data for these episodes. The baseline questionnaire completion rate has been 93%; 79% of people were presenting with low back pain as their main complaint, 6% with mid-back pain, and 15% with neck pain. Collectively, across the body regions and measurement time points, there are approximately 1,980 patient-related variables in the database across a broad range of biopsychosocial factors. To date, 36 research projects have used data from the SpineData registry, including collaborations with researchers from Denmark, Australia, the United Kingdom, and Brazil.

Conclusion

We described the aims, development, structure, and content of the SpineData registry, and what is known about any attrition bias and cluster effects in the data. For epidemiology research, these data can be linked, at an individual patient level, to the Danish population-based registries and the national spinal surgery registry. SpineData also has potential for the conduct of cohort multiple randomized controlled trials. Collaborations with other researchers are welcome.

The prognostic ability of the STarT Back Tool was affected by episode duration

PURPOSE

The prognostic ability of the STarT Back Tool (SBT) reportedly varies, but the factors affecting this are unclear. This study investigated the influences of care setting (chiropractic, GP, physiotherapy, spine centre), episode duration (0-2, 3-4, 4-12, >12 weeks), and outcome time period (3, 6, 12 months) on SBT prognostic ability.

METHODS

This was a secondary analysis of data from three primary care cohorts [chiropractic (n = 416), GP (n = 265), and physiotherapy (n = 200) practices] and one cohort from a secondary care outpatient spine centre (n = 974) in Denmark. Care pathways were not systematically affected by SBT risk subgroup (non-stratified care). Using generalised estimating equations, we investigated statistical interactions between SBT risk subgroups and potentially influential factors on the prognostic ability of the SBT subgroups, when Roland Morris Disability Questionnaire scores were the outcome.

RESULTS

SBT risk subgroup, age, care setting, and episode duration were all independent prognostic factors. The only investigated factor that modified the prognostic ability of the SBT subgroups was episode duration.

CONCLUSIONS

These results indicate that the prognostic ability of the SBT in these non-stratified care settings was unaffected by care setting on its own. However, the prognosis of patients is affected by diverse clinical characteristics that differ between patient populations, many of which are not assessed by the SBT. When controlling for some of those factors and testing potential interactions, the results showed that only episode duration affected the SBT prognostic ability and, specifically, that the SBT was less predictive in very acute patients (<2 weeks duration).