Lower Back Pain
Azimi et al (2014) (Mean age was 58.6 years (Range = 29-84). Female = 56.5% )
- A total of 269 patients with lumbar central canal stenosis at a large teaching hospital in Tehran, Iran.
Beneciuk et al (2013) (Mean age 41.1 (13.5) and 61% Female. 128 patients (88%) completed 4-week follow-up and 111 patients (76%) completed 6-month follow-up)
- 146 patients receiving treatment at 6 Florida outpatient physical therapy clinics.
Bruyère et al (2012) (59% female, with a mean age of 48 (13.1) within an age range of 18 to 78 years old)
- 44 patients with low back pain (LBP) randomly selected from a Spine Unit at the Liège University Hospital Centre, a private physiotherapy clinic, and a fitness center
Bruyère et al (2014)
- 108 patients with LBP: 60 females and 48 males with a mean age of 49.5 years within an age range of 34-59. 75.9% of the patient population had LBP for greater than 6 months.
Hill et al (2008)
- UK Citizens from 8 different practices; initial sample size of 200 people recruited over a 5 week period
Hill et al (2010)
- 12 primary care back pain patients, selected from a sample of 131 total individuals, mean age of 45.2 (ranging from 29-58 years)
Hill et al (2011)
- 851 individuals from ten general practices within the Keele General Practice Research Partnership, England, who consulted with their doctor about back pain from June 2007 to November 2008, with or without radiculopathy and excluded patients with any serious disorders or who had back surgery in the last 6 months, with a mean age of 50 (ranging from 18-87 years old)
- 0 to 3 = Low risk
- 4 to 9 = Medium risk
- High risk is determined using the distress subscale (the last five items), The distress scale ranges from 0 to 5, with scores of 4 or 5 classified as high risk.
Hill et al (2008)
- 0-3 on overall tool scores: low risk
- >3 on overall tool scores but <4 on psychosocial subscale: medium risk
- >3 on overall tool scores but 4-5 on psychosocial subscale: high risk
Hill et al (2010)
- The tool uses validated cut-off thresholds based on average group effects (see values posted above), which do not always ensure appropriate subgroup allocation for individual patients.
- In practice clinicians are, therefore, advised to use the instrument as an adjunct to their own decision-making rather than a replacement to their considered clinical acumen.
- Patients in the low risk category have significantly lower baseline numerical pain rating scale and disability questionnaire scores than high or medium risk patients (p < .001)
- Patients in the high risk category have higher baseline numeric pain rating and disability questionnaire scores than medium or low risk patients (p < .001)
(Hill et al, 2011: n = 851; mean age = 50 with 59% women; SBST categories. High risk – 28%, Medium risk = 46%, Low risk = 26%)
- Patient's classified as low risk had significantly lower baseline RMDQ disability scores, back pain intensity, PCS catastrophizing score, HADS anxiety and depression subscale than high or medium risk patients
- Patient's classified as high risk had significant higher baseline RMDQ disability scores, back pain intensity, PCS catastrophizing score, HADS anxiety and depression subscales than medium or low risk patients.
- Adequate test-retest reliability (quadratic weighted kappa) = 0.73
- Adequate test-retest reliability psychosocial subscale (quadratic weighted kappa)= .69
Bruyère et al (2014)
- 60 patients were asked to fill in the questionnaire two weeks after baseline. The test was only performed among those who reported no change during the past 2 weeks (n=35). ICC assessed 2-way random effects model was used to test reliability between baseline and retest scores, which was .90 (Excellent) (95% CI, 0.81–0.95)
Hill et al (2010)
- Twelve primary care back pain patients underwent a video recorded clinical assessment. The SBST was completed on the same day. Clinical experts (3 general practitioners, 3 physiotherapists, and 3 pain management specialists) individually reviewed the patient videos (4 each), blind to SBST allocation. Their task was to subgroup patients into low, medium, or high-risk groups.
- Agreement between clinicians and the tool was poor (k=0.22). There was observed agreement with the SBST in 17 of 36 cases (47%)
- Cohen's weighted K for interrater agreement was 0.28 (poor)
- Adequate internal consistency (alpha = 0.79)
- Adequate internal consistency for the 5 psychosocial items (alpha= 0.74)
Buryère et al (2014)
- Internal coherence was examined using the Cronbach's alpha, which was estimated for the Psychosocial subscale of the questionnaire
- Adequate: Cronbach's Alpha= 0.74
Beneciuk et al (2013)
- The STarT Back Screening Tool might provide valuable prognostic information for 6-month self-report disability.
- 4-week changes in full-length specific psychological measures (ie, Fear-Avoidance Beliefs Questionnaire physical activity scale and 11-item version of the Tampa Scale of Kinesiophobia) predicted 6-month self-report disability and, therefore, may be more appropriate for treatment monitoring purposes.
- Neither the STarT Back Screening Tool nor psychological measure scores improved prediction of 6-month pain intensity.
(Hill et al, 2011: n=851, age range from 18-87, patient diagnosed with back pain with or without radiculopathy)
- For medium and high risk groups the adjusted between group mean difference in Roland and Morris Disability Questionnaire scores were significant at 4 months compared to the control group (p=0.0012, p=0.0024, respectively)
- The adjusted between group mean difference in RMDQ scores was only significant for the medium-risk group (p=0.0253) and not the high risk group (p=0.1547) for the 12 month follow up
(Fritz, Beneciuk and George, 2013; n = 214; mean age = 44.3 (15.8) with 56.5% women; SBST categories ; High risk = 19.2%, Medium risk = 47.7% and Low risk = 33.2%; patients assessed in a physical therapy setting)
- Greater improvement was associated with patients categorized as high risk, however, there was no difference in predicted improvement among patients categorized as medium risk.
- Patients categorized as high risk experienced longer median symptom duration than patients classified as medium risk
- Patients with high SBST risk scores experienced ten-fold increase for having a high score on at least one of the following questionnaires:
- The Major Depression Inventory
- The Fear-Avoidance Beliefs Questionnaire
- The Coping Strategies Questionnaire
(Wideman et al., 2012; n = 300; mean age = 54.32 (12.65) years; 59.3% female; mean SBST score = 6.06 (1.73); change assessed 4 months post-baseline)
| Changes Between the SBST and other psycho-social measures | ||
| Measure | Follow-up Change Scores | No Follow-up Change Score |
| Global Improvement (n = 113) | No Global Improvement (n = 187) | |
| SBST | 4.91 (1.73) | 2.50 (2.57) |
| RMDQ | 9.74 (4.49) | 3.86 (5.62) |
| PCS | 10.79 (10.24) | 4.94 (9.83) |
| TSK | 8.81 (6.75) | 3.55 (5.40) |
| HADS-Dep | 3.57 (3.51) | 1.36 (3.73) |
| | Improved pain severity (n = 183) | Not improved pain severity (n = 117) |
| SBST | 4.69 (1.96) | 1.39 (2.07) |
| RMDQ | 8.77 (5.18) | 1.86 (4.44) |
| PCS | 10.10 (10.03) | 2.52 (9.16) |
| TSK | 7.75 (6.37) | 2.06 (4.89) |
| HADS-Dep | 3.25 (3.43) | 0.54 (3.77) |
| Improved disability (n = 167) | Not improved disability (n = 133) | |
| SBST | 4.60 (2.12) | 1.90 (2.29) |
| PCS | 9.54 (9.89) | 4.14 (10.21) |
| TSK | 7.66 (6.69) | 2.85 (5.02) |
| HADS-Dep | 3.18 (3.57) | 0.95 (3.73) |
| SBST = STarT Back Screening Tool RMDQ = Roland Morris Disability Questionnaire PCS = Pain Catastrophizing Scale TSK = Tampa Scale of Kinesiophobia HADS-Dep = Hospital Anxiety and Depression Scale Depression Component | ||
- The tests used were researched in the existing literature about low back pain and then analyzed by their prognostic constructs. All items that were used were then reviewed by an advisory board panel.
- Assessed by a clinical panel, however, no statistical induces from the original validation study were reported.
- Floor and ceiling effects were not detected (defined as >15% reporting highest or lowest possible scores
- 10.8% had tool scores of 0: Adequate
- 5.4% had tool scores of 9: Adequate
Bruyère et al (2014)
- "The lowest and highest possible SBST scores were found only in 8 (7.4%) and in 3 patients (2.8%), respectively, both adequate. For the Psychological subscale, lowest and highest possible scores were found only in 24 (22.2%; poor) and in 12 patients (11.1%; adequate), respectively."
| SBST Sensitivity and Specificity | |||
| Stratification | Subgroup cutoffs* | Sensitivity % | Specificity % |
| <1 month duration | L vs. M/H | 78.0 | 65.0 |
| L/M vs. H | 31.3 | 91.8 | |
| 1–3 months' duration | L vs. M/H | 81.0 | 69.9 |
| L/M vs. H | 14.3 | 98.6 | |
| 4–6 months' duration | L vs. M/H | 80.0 | 73.2 |
| L/M vs. H | 35.0 | 98.1 | |
| 7 months' to 3 years' duration | L vs. M/H | 71.2 | 59.7 |
| L/M vs. H | 21.2 | 90.3 | |
| >3 years' duration | L vs. M/H | 86.8 | 54.5 |
| L/M vs. H | 36.8 | 93.2 | |
| *L/M vs. H = Low/Medium risk versus High risk patients; L vs. M/H = Low risk versus Medium / High risk patients | |||
Azimi et al (2014)
- The SBST was able to detect changes after intervention(surgery), indicating improvement in all subscales.
Table 2
Responsiveness to change for the STarT Back Screening Tool (SBST) as indicated for patient subgroups (n = 97)
| Risk group | Preoperative | Postoperative | P value* |
| Mean (SD) | Mean (SD) | ||
| High (n = 61) | 6.3 (1.9) | 1.7 (1.4) | <0.0001 |
| Median (n = 28) | 4.8 (1.5) | 1.6 (1.3) | <0.0001 |
| Low (n = 8) | 1.9 (1.5) | 0.8 (1.2) | 0.03 |
| Overall | 4.4 (1.6) | 1.6 (1.3) | <0.0001 |
- Both long (9 item) and short (6 item) versions are available
- Translated in more than 15 languages
- A pediatric version is in development
- The SBST accurately assessed pain at baseline, however the SBST was not able to demonstrate a differential risk of poor outcomes between SBST categories at 30 days (Field and Newell, 2012)
Azimi et al (2014)
- Authors suggest performing other tests to establish stronger psychometric indexes for the SBST. As thsdfdfe test recognized clinical measures for known groups, comparing items such as walking distance is recommended.
Beneciuk et al (2013)
- Based on the findings of this study, authors suggest a 2-phase psychological assessment process consisting of: (1) initial screening with the SBT to provide prognostic information for 6-month disability outcomes only and (2) treatment monitoring at 4 weeks with the TSK-11 and the FABQ-PA to allow for an indication of 6-month pain and disability outcomes, particularly for patients allocated to the SBT high-risk category at initial assessment.
Gusi et al (2011)
- Conclusion: "The Spanish version of the SBST questionnaire was obtained, which was shown to be comprehensible and adapted to the general population in Spain. Due to being short and easy to use, it is a potentially useful tool for use in primary care."
(Hill et al, 2011)
- There was a greater than anticipated loss to follow-up and a slight attrition between the individual groups
(Main et al, 2012)
- Treatment of low back pain patients that are categorized as high-risk should integrate management of psychosocial risk factors and evidence-based pain management into the treatment program
(Bruyère et al, 2012)
- The translation process provided useful insights into how a person interprets each questionnaire item, but it did not address construct validity, reliability, or item-response patterns necessary for a cross-cultural adaptation.
(Bruyère et al, 2014)
- The authors conclude that, "The next step will be to assess the effectiveness of this version to identify subgroups of patients at different risk of progression to chronicity in a French-speaking population."
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Azimi P, Shahzadi S, Azhari S, Montazeri A. A validation study of the Iranian version of STarT Back Screening Tool (SBST) in lumbar central canal stenosis patients. J Orthop Sci. 2014;19(2):213-7.
Beneciuk JM, Bishop MD, Fritz JM, et al. The STarT back screening tool and individual psychological measures: evaluation of prognostic capabilities for low back pain clinical outcomes in outpatient physical therapy settings. Phys Ther. 2013;93(3):321-33.
Bruyère et al. Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French. Archives of Public Health. 2012;70:12.
Bruyère et al. Validity and reliability of the French version of the STarT Back Screening Tool for patients with low back pain. Spine:39,2;E123-E128.
Field, J. and Newell, D. (2012). "Relationship between STarT Back Screening Tool and prognosis for low back pain patients receiving spinal manipulative therapy." Chiropr Man Therap 20(1): 17-17. Find it on PubMed
Fritz, J. M., Beneciuk, J. M., et al. (2011). "Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain." Phys Ther 91(5): 722-732. Find it on PubMed
Gusi N, del Pozo-Cruz B, Olivares P, Hernández-Mocholi M, Hill J. The spanish version of the ''STarT back screening tool'' (SBST) in different subgroups Aten Primaria. 2011;43(7):356-361.
Hill, J. C., Dunn, K. M., et al. (2008). "A primary care back pain screening tool: identifying patient subgroups for initial treatment." Arthritis Rheum 59(5): 632-641. Find it on PubMed
Hill J, Vohora K, Dunn K, Main C, Hay E. Comparing the STarT back screening tool's subgroup Allocation of individual patients with that of independent Clinical experts. Clin J Pain. 2010;26(9):783-787.
Hill JC, Whitehurst DGT, Lewis M, et al. Comparison to stratified primary care management for low back pain with current best practice (STarT Back): a randomized controlled trial. Lancet. 2011;378:1560-71.
Kongsted, A., Johannesen, E., et al. (2011). "Feasibility of the STarT back screening tool in chiropractic clinics: a cross-sectional study of patients with low back pain." Chiropr Man Therap 19: 10. Find it on PubMed
Main CJ, Sowden G, Hill JC, Watson PJ, Hay EM. Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's 'high-risk' intervention. Physiotherapy. 2012;98:110-116.
Wideman, T. H., Hill, J. C., et al. (2012). "Comparing the responsiveness of a brief, multidimensional risk screening tool for back pain to its unidimensional reference standards: the whole is greater than the sum of its parts." Pain 153(11): 2182-2191. Find it on PubMed
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