Construct and discriminant validity of STarT Back Screening Tool - Brazilian version

Stratified health care for low back pain using the STarT Back approach: Holy Grail or doomed to fail?

ABSTRACT

There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes.

Instruments for assessing back pain in athletes: A systematic review

Back pain in athletes varies with sport, age, and sex, which can impair athletic performance, thereby contributing to retirement. Studies on back pain in this population use questionnaires to assess components, such as pain intensity and location and factors associated with pain, among others. This study aimed to review validated questionnaires that have assessed back pain in athletes. This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) by searching the databases Embase, MEDLINE, SPORTDiscus, CINAHL, and Scopus. The articles were selected regardless of language and date of publication. Titles and abstracts were independently selected by two reviewers; disagreements were resolved by a third reviewer. All the steps were conducted using the software Rayyan. The methodological quality of the questionnaire validation articles was assessed using a critical appraisal tool checklist proposed by Brink and Louw. The search returned 4748 articles, of which 60 were selected for this review, including 5 questionnaire validation studies. These articles were published between 2004 and 2022, which were performed in more than 20 countries, particularly Germany (14) and Sweden (5). Thirteen different instruments were identified, of which 46.1% were developed in Europe. The most commonly used questionnaires were the Oswestry Disability Index and Nordic Standardized Questionnaire. In addition, five questionnaire validation studies were selected for methodological quality assessment, with only two studies demonstrating high methodological quality. The following three instruments were identified for assessing back pain specifically in athletes: Micheli Functional Scale, Persian Functional Rating Index, and Athlete Disability Index. This review confirmed that all three instruments were specifically designed to assess this condition.

Risk Stratification in a Tertiary Care Spine Centre: Comparison Between STarTBack and OSPRO-YF Screening Tools

Purpose

STarT Back Screening Tool and OSPRO-YF scales have been reported to be accurate tools for estimating risk for the development of persistent pain or prolonged disability in primary care settings. We performed a comparison of construct convergent and known-group validity and ceiling floor effect (CFE) of these tools using a common sample of patients seen at a tertiary care spine centre.

Methods

This was a cross-sectional study of patients with and without a work-related back injury. The Hospital Anxiety and Depression Scale (HADS) was used as the reference outcome measure for convergent validity. For known-group validity, we examined the ability of the scales to differentiate between different levels of compensation, presence of non-organic signs, and work status. The CFE values were calculated.

Results

Fifty consecutive injured workers were included along with 50 patients without an active compensation claim related to their low back pain. STarTBack and OSPRO-YF had moderate to high associations with the depression component of the HADS (0.69 to 0.77 respectively) with a statistically significant difference in favour of the OSPRO-YF. STarTBack's risk stratification categories were able to differentiate patients with a compensable injury, non-organic signs, and inability to work (p values ranging from 0.002 to < 0.001). The physical activity and work fear-avoidance beliefs constructs of the OSPRO-YF consistently outperformed other yellow flag constructs (p values ranging from 0.008 to < 0.001). The psychological sub-score of STarTBack showed a ceiling effect. There was a floor effect for the negative affect domain of OSPRO-YF. Neither total score had a floor or ceiling effect.

Conclusions

STarTBack and OSPRO-YF are short screening tools with acceptable convergent and known-group construct validity and no floor or ceiling effect of their total score. Both tools could assist with the identification, evaluation, and management of psychological distress in patients presenting to tertiary care spine centres.

Convergent and Discriminative Validity of the PROMIS Physical Function 4 Questionnaire for Assessing Pain-related Disability in Low Back Pain Patients Seeking Chiropractic Care

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

To investigate construct validity by examining the convergent and discriminative validity of the Patient-Reported Outcomes Measurement Information System Physical Function 4a (PROMIS-PF4) questionnaire in low back pain (LBP) patients seeking care from Danish chiropractors.

SUMMARY OF BACKGROUND DATA

The Roland-Morris Disability Questionnaire (RMDQ) is often used to assess physical functioning in LBP. However, it consists of 24 items, which is time consuming to complete in clinical practice. The PROMIS-PF4 questionnaire has only four items and may be more applicable for clinical use.

MATERIALS AND METHODS

Patients with LBP seeking care from chiropractors in Denmark completed the PROMIS-PF4, RMDQ, Subgroups for Targeted Treatment (STarT) Back screening tool, and Numeric Pain Rating Scale (NPRS) in advance of their first appointment with the chiropractor. Convergent validity was assessed using Spearman correlation coefficients between the PROMIS-PF4 and RMDQ and NPRS, respectively. Discriminative validity of the PROMIS-PF4 was assessed by calculating the area under the receiver operating characteristic curve (AUC) when plotting the PROMIS-PF4 t score against a reference case for RMDQ; NPRS; and high and low risk groups using the STarT Back screening tool.

RESULTS

Among 356 patients the PROMIS-PF4 questionnaire had strong convergent validity with the RMDQ ( r =-0.76) and moderate convergent validity with the NPRS ( r =-0.42). The PROMIS-PF4 had good and acceptable discriminative validity for disability (AUC=0.88) and high risk of persisting disability (AUC=0.72), and poor or no discriminative validity for pain intensity (AUC=0.66) and low-risk of persisting disability (AUC=0.26), respectively.

CONCLUSION

As hypothesized, for convergent validity the PROMIS-PF4 has stronger correlation with the RMDQ than the NPRS and good discriminative validity for identifying patients with pain-related disability and at high risk of persisting disability but not for identifying pain intensity or low-risk of persisting disability. Consequently, the PROMIS-PF4 has adequate construct validity for measuring pain-related disability in an LBP population in chiropractic care.

Stratifying workers on sick leave due to musculoskeletal pain: translation, cross-cultural adaptation and construct validity of the Norwegian Keele STarT MSK tool

OBJECTIVES

Stratified care using prognostic models to estimate the risk profiles of patients has been increasing. A refined version of the popular STarT Back tool, the Keele STarT MSK tool, is a newly developed model for matched treatment across a wide range of musculoskeletal pain presentations. The aim of this study was to translate and culturally adapt the Keele STarT MSK tool into Norwegian, examine its construct validity and assess the representativeness of the included sample.

METHODS

The Keele STarT MSK tool was formally translated into Norwegian following a multistep approach of forward and backward translation. A pre-final version was tested in 42 patients. Minor changes were implemented. To assess its construct validity, an online survey was conducted among workers aged 18-67 years who were on sick leave (>4 weeks) due to musculoskeletal disorders. Construct validity was evaluated in terms of convergent and discriminant validity using Pearson's correlation coefficient, and known-group validity by comparing risk subgroups as suggested by the COSMIN checklist. The representativeness of the sample was assessed by comparing demographic and sick leave information of participants to eligible non-participants (n=168,137).

RESULTS

A representative sample of 549 workers participated in the validity assessment; 74 participants (13.5%) were categorised as low risk, 314 (57.2%) as medium risk and 161 (29.3%) as high risk. The construct validity was found sufficient, with 90.9% and 75.0% of the pre-defined hypotheses confirmed for convergent and discriminant validity, and known-group validity, respectively. Floor or ceiling effects were not found.

CONCLUSIONS

The Keele STarT MSK tool was successfully translated into Norwegian. The construct validity of the tool was acceptable in a representative cohort of workers on sick leave as a result of musculoskeletal pain. However, the analyses raised concerns as to whether one of the questions captures the construct it is intended to measure.

Convergent and known group validity of the STarT Back Tool in a Nigerian population with chronic low back pain

Background The STarT Back Tool (SBT) was developed to aid the stratification of patients with low-back pain (LBP), based on future risks for physical disability.

Objective Investigation of the convergent and known group validity of the SBT in a Nigerian population with chronic LBP using disability-related psychosocial outcomes.

Method Cross-sectional study involved 30 consenting patients with chronic LBP in an outpatient physiotherapy clinic of a tertiary health institution in Nigeria. Future risk of disability was assessed using the SBT. Psychosocial variables of pain catastrophizing, fear-avoidance beliefs (FAB), and kinesiophobia were assessed using the Pain Catastrophizing Scale, the Fear-Avoidance Beliefs Questionnaire and the Tampa Scale of Kinesiophobia, respectively. Data was analysed using percentages and Spearman correlation.

Results Based on the SBT, there were rates of 43.3 % and 23.3 % for low and high future risks of physical disability. The median score of pain catastrophizing was 13.5, that of FAB came in at 16.5 related to physical activity and 14.0 related to work, and the score for kinesiophobia amounted to 39. The SBT total scores moderately correlated with the FAB related to work (rho = 0.45 (95 % CI 0.09–0.700). FAB related to physical activity (p = 0.040) significantly differed across the SBT subgroups.

Conclusion The SBT and the other psychosocial instruments used in this study did not correlate to a sufficient degree. In addition, patients exhibiting catastrophizing, fear-avoidance beliefs, or kinesiophobia could not be differentiated based on SBT risk groups. The results should be interpreted with caution until findings from additional studies with sufficient sample sizes are at hand.

Evaluation Instruments for Assessing Back Pain in Athletes: A Systematic Review Protocol

Back pain is a public health problem that affects adolescents and adults worldwide. However, studies on back pain present inconsistent findings in part due to the use of different instruments, especially for athletes. Therefore, the objective of this systematic review protocol was to map the existing evidence on such tools. The systematic review will be conducted according to PRISMA guidelines. Five electronic databases, Embase, MEDLINE, SPORTDiscus, CINAHL, and Scopus will be searched. This review includes studies that investigated prevalence, incidence, and other variables. Titles and abstracts will be selected. Two independent reviewers will read the articles carefully and discrepancies, if any, will be dealt with by a third reviewer. All steps will be completed with Rayyan for systematic reviews and the methodological quality will be analyzed with a COSMIN checklist. Discussion: This systematic review will gather evidence on tools that assess back pain in athletes. The findings may indicate the most appropriate tools for assessing back pain. They will contribute to better reliability, safe measurements, and help to standardize a comparison tool between different studies. They will also assist in the development of specific tools for athletes. Registration: This review was submitted and registered under CRD42020201299 in PROSPERO.

Clustering of patients with chronic low back pain in terms of physical and psychological factors: A cross-sectional study based on the STarT Back Screening Tool

BACKGROUND

The STarT Back Screening Tool (SBT) is a multidimensional questionnaire consisting of physical and psychological factors which categorizes the patients in the low, medium or high risk subgroups.

OBJECTIVE

To investigate the relationship between SBT-based subgrouping and clustering of patients with LBP using uni-dimensional psychological, clinical and physical examination measures.

METHODS

One hundred and fifty-seven patients with chronic LBP completed the SBT and uni-dimensional psychological, disability and pain questionnaires. Physical impairments were evaluated through the Physical Impairment Index (PII). Hierarchical and K-means methods were used for cluster analysis. Between-clusters differences and the association between the clusters and SBT-based subgrouping were investigated.

RESULTS

Three clusters were identified. The derived clusters were labeled severe, moderate and mild physical-psychological-distress clusters, because pain intensity, disability, psychological and physical factors were relatively high, moderate or low, respectively. Most of the patients in moderate and mild physical-psychological distress clusters were categorized as medium risk based on SBT. The mean difference for the PII was higher than that of psychological factors between moderate and mild physical-psychological-distress clusters.

CONCLUSIONS

Patients in low and high risk subgroups of SBT were sufficiently differentiated, but patients in a medium risk subgroup had a different profile based on PII. Including additional physical factors in the SBT may be required to better differentiate among patients.

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.

Baseline characteristics did not identify people with low back pain who respond best to a Movement System Impairment-Based classification treatment

STUDY DESIGN

Secondary analysis of data from a randomized controlled trial.

BACKGROUND

Treatment based on the Movement System Impairment-Based classification for chronic low back pain results in the same benefit when compared to other forms of exercise. It is possible that participant's characteristics measured at baseline can identify people with chronic low back pain who would respond best to a treatment based on the Movement System Impairment model.

OBJECTIVES

To assess if specific characteristics of people with chronic low back pain measured at baseline can modify the effects of a treatment based on the Movement System Impairment model on pain and disability.

METHODS

Four variables assessed at baseline that could potentially modify the treatment effects of the treatment based on the Movement System Impairment model were selected (age, educational status, physical activity status and STarT back tool classification). Separate univariate models were used to investigate a possible modifier treatment effect of baseline participant's characteristics on pain and disability after the treatment. Findings of interaction values above 1 point for the outcome mean pain intensity or above 3 points for disability (Roland Morris questionnaire) were considered clinically relevant.

RESULTS

Linear regression analyses for the outcomes of pain and disability did not show interaction values considered clinically relevant for age, educational status, physical activity status and STarT back tool classification.

CONCLUSION

Age, educational status, physical activity status and STarT back tool classification did not modify the effects of an 8-week treatment based on the Movement System Impairment model in patients with chronic low back pain. Registered at www.clinicaltrials.gov: NCT02221609 (https://clinicaltrials.gov/ct2/show/NCT02221609).

Translation, Cross-cultural Adaptation and Reliability of Brazilian portuguese version of the DRAM Questionnaire for Psychometric Evaluation in Low Back Pain

Objective  Based on studies regarding pain physiology and its relation to emotional distress conditions, psychological evaluation became essential to determine the most favorable patient profiles to distinct therapeutic approaches. The Distress Risk Assessment Method (DRAM) has been developed as a screening instrument for patients with lumbar pain, classifying them in subgroups as normal, at risk, distressed somatic and distressed depressive, based on the two components of DRAM scores (Modified Somatic Perception Questionnaire [MSPQ] and Zung questionnaires). The objective of the present study is to translate and culturally adapt the DRAM to the Brazilian Portuguese language, and to determine the reliability of the final version.

Methods  As proposed by the International Quality of Life Assessment (IQOLA) method, a Brazilian Portuguese version of the DRAM has been applied to a sample of 85 individuals from 3 participant centers.

Results  The results confirmed the reliability and reproducibility of the DRAM in its Brazilian Portuguese final version: Cronbach alpha of 0.815 (MSPQ) and 0.794 (Zung) and intraclass correlation coefficient (ICC) of 0.688 (MSPQ) and 0.659 (Zung).

Conclusion  The presented DRAM version in Brazilian Portuguese is reliable and is available to clinical practice use.

Comparison of Hip and Lumbopelvic Performance Between Chronic Low Back Pain Patients Suited for the Functional Optimization Approach and Healthy Controls

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

We explored the differences between chronic low back pain (CLBP) patients suited for the functional optimization approach and healthy controls in isometric hip-strength and lumbar-endurance tests and determined classificatory cutoff values for strength and endurance tests and ratios.

SUMMARY OF BACKGROUND DATA

To optimize the treatment effect for CLBP, some approaches have classified patients into homogeneous subgroups matched to specific treatments. We evaluated CLBP patients suited for the functional optimization approach, who seek care because they experience symptoms during activities with high physical demands, although they are relatively asymptomatic.

METHODS

Three hundred fifty subjects (healthy controls, 170; CLBP patients, 180) were stratified by age (18-40 and 41-65 yrs), sex, and physical activity level. The CLBP patients had an Oswestry Disability Index score < 20% and a Numeric Pain Rating Scale score < 3. The subjects underwent hip abductor, extensor, and flexor isometric strength tests; a deep abdominal function test; and lateral/frontal bridge and lumbar flexor/extensor endurance tests.

RESULTS

Relative to the healthy controls, the CLBP patients showed significantly (P > 0.05) higher strength scores in the hip flexor and deep abdominal function tests but lower endurance in the lateral and frontal bridge and lumbar flexor and extensor tests. The cutoff values of the lumbar flexor test and the lumbar flexor/extensor, lateral bridge/lumbar flexor, frontal bridge/lumbar flexor, and hip extensor/flexor test ratios showed acceptable accuracy (AUC = 0.84, 0.82, 0.79, 0.75, and 0.73, respectively).

CONCLUSION

In lumbopelvic and hip-performance tests, CLBP patients suited for the functional optimization approach showed differences from healthy controls. These patients could be discriminated from healthy controls on the basis of accurate cutoff values for strength and endurance tests and ratios, which should be considered in treatment decision-making when patients need to return to activities with higher physical demands.

LEVEL OF EVIDENCE

2.

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.

'It's very complicated': Perspectives and beliefs of newly graduated physiotherapists about the biopsychosocial model for treating people experiencing non-specific low back pain in Brazil

Non-specific low back pain is a common complaint frequently presented by patients and this complex clinical condition has challenged the biomedical model. The Biopsychosocial (BPS) model is recognized as an option for better guidance and patient management. However, physiotherapy training is based on the biomedical perspective, added to which, in clinical practice the applicability of the BPS model is a challenge for many professionals. In this article, we explore the feelings, beliefs, and attitudes of newly trained physiotherapists about using the BPS model to treat people with non-specific low back pain. It also aims to understand to what extent these physiotherapists are willing and prepared to use this model. Method: A qualitative phenomenological research was carried out in the Brazilian federal capital. A set of criteria was used to select 10 physiotherapists. The data were collected through semi-structured interviews and analyzed using five steps: familiarization, identification, indexation, mapping, and interpretation. Results: We identified one theme and three categories. The theme 'a practitioner physiotherapist can consider BPS aspects, but it is not necessary in his/her role to approach them' explains a shared belief about the use of BPS. The theme is better understood when looking at the three categories that explore and exemplify key elements of the theme: (i) understanding the BPS model and its relation to non-specific low back pain; (ii) the role of practitioner physiotherapists regarding the BPS model; and (iii) barriers: from undergraduate training to clinical settings.

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 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.