Validity and reliability of the Dutch STarT MSK tool in patients with musculoskeletal pain in primary care physiotherapy

A Reliability Study of the Load Distribution Percentage While Walking Using Curalgia Feet Sx Smart Insoles

Background Gait analysis has evolved through many years of research. Many methods are used to analyze the gait of a subject. Recent times have shown a high demand for wearable sensor-based insoles integrated with smartphone-based devices used for gait analysis due to ease of use. This study utilized Curalgia Feet Sx Smart Insoles and its software toolset, Gait Analysis+, designed and manufactured in India making it an accessible and cost-effective option. The Curalgia Feet Sx Smart Insoles allow for a broad range of biofeedback-based rehabilitation and recovery training for several patients and have many applications, such as sports performance enhancement and neurological disorder rehab (e.g., brain stroke rehab). The system also significantly delays the onset of neurodegenerative illnesses by providing balance and proprioceptive training. The smart insole can help the athlete, the coach, and the sports medicine team get the on-field data in real-time, which will help them understand if any technical or biomechanical alterations are required. This may help in performance enhancement. This study aimed to determine the interrater reliability of the load distribution percentage parameter of the Curalgia Feet Sx Smart Insole for both feet while walking in a controlled setting. Methodology A total of 120 subjects were enrolled in the study. In total, 90 subjects were randomly selected using Research Randomizer which included male and female students and staff at Sardar Bhagwan Singh University. The subjects were asked to come to the research lab of the physiotherapy department wearing their sports shoes. Curalgia Feet Sx insoles were inserted into the shoe firmly to fit properly. Two assessors took two readings after the smart insole was connected to the smartphone-based application, GaitAnalysis+, via Bluetooth. The dynamic analysis option was selected, and each subject's analysis was done one after another with a desirable break in between. Each subject walked for three minutes at their normal speed after pressing "Start Analysis." At the three-minute mark, the subjects were asked to press "Stop Analysis" and the investigator downloaded the report on the smartphone. The data collected was compiled as the cumulative weight in kg (load distribution) borne and the % weight (load distribution %) borne by each foot for the duration of the walk. Statistical analysis was done using Karl Pearson's test and interclass correlation calculation. Results Assessor 1 and Assessor 2 collected readings for the left foot as "L" and the right foot as "R." Assessor 1 readings were L1-R1 for load distribution and L1% and R1% for load distribution %. Assessor 2 readings were L2-R2 for load distribution and L2% and R2% for load distribution %. The r value (correlation coefficient) was calculated using the load distribution. The mean value of L1 was 337.46 (SD=94.16). The mean L2 was 313.6 (SD=104.40). The R1 mean was 229.03 (SD=112.88), and the R2 mean was 233.011 (SD=79.84). The r was 0.7171 for the left foot and 0.7502 for the right foot, suggesting an excellent correlation. The ICC was calculated for load distribution %. The means of L1% was 55.94, L2% was 57.59, R1% was 44.06, and R2% was 42.41. The ICC was found to be 0.91 for both feet, suggesting high interrater reliability for the tested parameter. Conclusions The findings confirmed that the Curalgia Feet Sx Smart Insoles presented good interrater reliability for the load distribution % parameter.

Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings

The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35-.37) while moderate-to-good relationships (r = .51-.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PERSPECTIVE: This study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.

Does the Keele STarT MSK tool predict the risk of poor outcome in non-specific shoulder complaints in primary care in a Dutch population?

OBJECTIVES

The Keele STarT MSK tool is a questionnaire to identify the prognostic factors for musculoskeletal conditions, such as shoulder complaints, developed by Keele University, UK. This study assessed whether the Keele STarT MSK tool can predict the risk of poor outcome in non-specific shoulder complaints in a Dutch population.

DESIGN

Multicentre prospective cohort study.

SETTING

Fourteen primary care physiotherapy clinics in the Netherlands participated in this study.

PARTICIPANTS

In total, 180 patients with non-specific shoulder complaints with complete data from the Keele STarT MSK tool (baseline), Short-Form 12 Health Survey (SF-12), Shoulder Pain and Disability Index (SPADI), Numeric Pain Rating Score (NPRS) and Global Perceived Effect (GPE) scale at week 6, week 12 or endpoint were included. Data were collected from January 2019 to January 2020. Of these, 180 patients were eligible for the study. Of these, 139 completed the study and were included in the analysis.

MAIN OUTCOME MEASURES

Poor outcome was defined as: SF-12 score ≤33 (physical health), SPADI score ≥30% (disability in activity), NPRS score ≥3 (pain intensity) and GPE scale score ≥3 (patient-reported recovery).

RESULTS

The area under the receiver operating characteristic curves for prediction of outcome were excellent for the SF-12, acceptable for the SPADI and NPRS, and showed no discrimination for the GPE scale. The optimal cut-off value for the Keele STarT MSK score to discriminate between low and medium/high risk groups was ≥5.

CONCLUSIONS

The Keele STarT MSK tool is able to predict the risk of poor outcome in patients with non-specific shoulder complaints in primary care physiotherapy clinics. Further research is needed to establish whether stratified care (subgrouping and targeted treatment) is more efficient. CONTRIBUTION OF PAPER.

Validity and reliability of the Persian version of the STarT musculoskeletal tool

BACKGROUND

The Subgrouping for Targeted Treatment (STarT) musculoskeletal (MSK) tool stratifies patients with MSK disorders (MSDs) into prognostic categories based on poor outcomes.

PURPOSE

This study aimed at investigating the validity and reliability of the Persian STarT MSK tool in people suffering from painful MSDs in Iran.

METHODS

A total of 593 subjects with painful MSDs including neck, shoulder, low back, knee, and multisite pain received and completed the STarT MSK tool, visual analog scale (VAS), EuroQol five-dimensions three-levels questionnaire (EQ-5D-3 L), short form-36 health survey questionnaire (SF-36), and Örebro musculoskeletal pain screening questionnaire (ÖMPSQ) in the first visit. To examine test-retest reliability, 234 patients completed the STarT MSK tool 2 days after the initial visit.

RESULTS

In this study, 139 (23.5%), 266 (44.9%), and 188 (31.7%) participants were classified as low-, medium-, and high-risk groupings for poor outcomes, respectively. Spearman's correlation coefficient showed a strong relationship among Persian STarT MSK tool and EQ-5D-3 L (-0.78), SF-36 (-0.76), and OMPSQ (0.70). The results of known-group validity indicated that this tool could distinguish among the participants in different risk subgroups based on the scores of the ÖMPSQ, VAS, SF36, and EQ-5D-5 L (p < .001). No ceiling and floor effects were observed. Cronbach's alpha and intra-class correlation coefficient (ICC2,1) were acceptable (0.71) and excellent (0.98), respectively.

CONCLUSION

The Persian version of STarT MSK tool has shown to be a valid and reliable instrument to stratify people with painful MSDs into low-, medium-, and high-risk subgroups based on persistent pain disability.

Predicting persisting disability in musculoskeletal pain patients with the STarT MSK screening tool: Results from a prospective cohort study

BACKGROUND

The STarT MSK screening tool aims to categorise musculoskeletal patients into three risk groups for treatment stratification. The tool has been translated and validated into Hebrew. However, its ability to predict persistent disability in patients has yet to be evaluated.

OBJECTIVE

The primary aim of this study was to assess the ability of the Hebrew version of the STarT MSK tool to predict persistent disability in patients experiencing musculoskeletal pain.

METHODS

A prospective observational cohort study was conducted, recruiting 135 patients with musculoskeletal pain in five common areas: back, neck, shoulder, knee, or multisite pain over the age of 21. At the first consultation, all patients completed demographic information, the Focus On Therapeutic Outcomes (FOTO) questionnaire (function, pain, and fear avoidance score), and the STarT MSK questionnaire. The patients completed the FOTO questionnaire again at the end of the physiotherapy treatments.

RESULTS

25 patients (18.5%) were classified into the low-risk group, 68 patients (50.3%) into the medium-risk group, and 42 (31.1%) into the high-risk group. The baseline STarT MSK tool score demonstrated an excellent ability to identify patients at high risk of developing persistent disability (AUC = 0.795, 95% CI 0.716-0.873).

CONCLUSIONS

The Hebrew version of the STarT MSK tool can differentiate between three chronic risk groups and has high predictive validity for chronicity. This may provide a tool to assist clinicians in identifying patients who require more intensive care, and thus, potentially prevent the transition to chronic disabling pain.

The Swedish version of the STarT MSK Tool: cross-cultural adaption, test-retest reliability, and aspects of validity

BACKGROUND

Musculoskeletal disorders (MSDs) are a common reason for seeking primary health care. The STarT Musculoskeletal (MSK) tool is designed to stratify patients suffering from MSDs to risk groups, based on prognostic factors.

AIM

The aim was to translate and cross-culturally adapt the STarT MSK tool in a Swedish primary health care context through testing of reliability and construct validity.

METHODS

We included consecutive patients with MSDs seeking primary care (n = 99). The STarT MSK was translated using international recommendations. Construct validity was investigated by correlation analysis (Spearmans Rho) with the following reference instruments: the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ), the EuroQol 5-dimension (EQ-5D) and the Musculoskeletal Health Questionnaire (MSKHQ). Reliability was tested using test-retest (Intra Class Correlation, ICC2.1) (n = 31). Known-groups validity was calculated with a difference of 10% between risk groups based on how the participants had answered.

RESULTS

The STarT MSK was successfully translated into Swedish. The participants were grouped into low risk (n = 28), medium risk (n = 60) and high risk (n = 11). The construct validity showed a moderate to high correlation with the ÖMPQ (r = .61), EQ-5D (r = .59) and MSK-HQ (r = .56). All separate items except item 2 and 9 correlated according to predefined hypotheses. Test-retest demonstrated an excellent reliability for the total score (ICC2.1 0.85) (n = 31). The STarT MSK tool was able to differentiate by 10% between the risk groups, based on how the participants had answered.

CONCLUSION

The STarT MSK has been successfully translated and adapted into Swedish and shows acceptable measurement properties regarding test-retest reliability and aspects of validity and seems to be able to discriminate between the proposed risk groups. The tool can therefore be useful in a Swedish primary health care context. A future study needs to determine the tools predictive validity and to investigate if stratification to risk groups leads to a faster recovery and to lower health care costs.

Development and feasibility of stratified primary care physiotherapy integrated with eHealth in patients with neck and/or shoulder complaints: results of a mixed methods study

BACKGROUND

Providing individualized care based on the context and preferences of the patient is important. Knowledge on both prognostic risk stratification and blended eHealth care in musculoskeletal conditions is increasing and seems promising. Stratification can be used to match patients to the most optimal content and intensity of treatment as well as mode of treatment delivery (i.e. face-to-face or blended with eHealth). However, research on the integration of stratified and blended eHealth care with corresponding matched treatment options for patients with neck and/or shoulder complaints is lacking.

METHODS

This study was a mixed methods study comprising the development of matched treatment options, followed by an evaluation of the feasibility of the developed Stratified Blended Physiotherapy approach. In the first phase, three focus groups with physiotherapists and physiotherapy experts were conducted. The second phase investigated the feasibility (i.e. satisfaction, usability and experiences) of the Stratified Blended Physiotherapy approach for both physiotherapists and patients in a multicenter single-arm convergent parallel mixed methods feasibility study.

RESULTS

In the first phase, matched treatment options were developed for six patient subgroups. Recommendations for content and intensity of physiotherapy were matched to the patient's risk of persistent disabling pain (using the Keele STarT MSK Tool: low/medium/high risk). In addition, selection of mode of treatment delivery was matched to the patient's suitability for blended care (using the Dutch Blended Physiotherapy Checklist: yes/no). A paper-based workbook and e-Exercise app modules were developed as two different mode of treatment delivery options, to support physiotherapists. Feasibility was evaluated in the second phase. Physiotherapists and patients were mildly satisfied with the new approach. Usability of the physiotherapist dashboard to set up the e-Exercise app was considered 'OK' by physiotherapists. Patients considered the e-Exercise app to be of 'best imaginable' usability. The paper-based workbook was not used.

CONCLUSION

Results of the focus groups led to the development of matched treatment options. Results of the feasibility study showed experiences with integrating stratified and blended eHealth care and have informed amendments to the Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints ready to use within a future cluster randomized trial.

Validation of the German version of the STarT-MSK-Tool: A cohort study with patients from physiotherapy clinics

BACKGROUND

The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations.

OBJECTIVE

To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity.

METHODS

A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models.

RESULTS

The participants' (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%.

CONCLUSIONS

The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.

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.

STarT MSK tool: Translation, adaptation and validation in Hebrew

BACKGROUND

The Keele STarT MSK Tool divides musculoskeletal patients into three prognostic groups for risk-stratified care. It has shown good predictive and discriminative ability in development and validation samples.

OBJECTIVES

This study aimed to translate and validate the STarT MSK in a Hebrew version, among Israeli people living with musculoskeletal (MSK) pain.

METHOD

A cross-sectional study, with nested prospective sub-sample. The STarT MSK was translated into Hebrew using published guidelines. A total of 153 adults (18+) who reported living with MSK pain were administered the STarT MSK. Clinical measures included for validity testing included the 12-Item Short-Form Health Survey (SF-12), the Hospital Anxiety and Depression Scale (HADS), the Fear-Avoidance Beliefs Questionnaire (FABQ) and a numerical pain rating scale (NPRS).

RESULTS

The STarT MSK was forward and backward translated, with minor changes to ensure cultural adaptation. The test-retest reliability of the STarT MSK total score was excellent (intraclass correlation coefficient 0.92). Internal consistency for the MSK scale was (α = 0.612). The Spearman's correlation coefficients between STarT MSK total score and the validation measures confirmed the hypotheses and were significant.

CONCLUSION

The Israeli translation and validation of the STarT MSK suggest that it is a valid and reliable instrument. The STarT MSK discriminated low-, medium- and high-risk groups.

An eCoach-Pain for Patients with Chronic Musculoskeletal Pain in Interdisciplinary Primary Care: A Feasibility Study

eHealth could support cost-effective interdisciplinary primary care for patients with chronic musculoskeletal pain. This study aims to explore the feasibility of the eCoach-Pain, comprising a tool measuring pain complexity, diaries, pain education sessions, monitoring options, and chat function. Feasibility was evaluated (June–December 2020) by assessing learnability, usability, desirability, adherence to the application, and experiences from patients and general practitioners, practice nurses mental health, and physiotherapists. Six primary healthcare professionals (PHCPs) from two settings participated in the study and recruited 29 patients (72% female, median age 50.0 years (IQR = 24.0)). PHCPs participated in a focus group. Patient data was collected by evaluation questionnaires, individual interviews, and eCoach-Pain-use registration. Patients used the eCoach during the entire treatment phase (on average 107.0 days (IQR = 46.0); 23 patients completed the pain complexity tool and used the educational sessions, and 12 patients the chat function. Patients were satisfied with the eCoach-Pain (median grade 7.0 (IQR = 2.8) on a 0–10 scale) and made some recommendations for better fit with patient-specific complaints. According to PHCPs, the eCoach-Pain is of added value to their treatment, and patients also see treatment benefits. However, the implementation strategy is important for successful use of the eCoach-Pain. It is recommended to improve this strategy and involve a case-manager per patient.