1. Current Evidence: STarT Back Screening Tool
Jacqueline Zak, SPT
July 14, 2017

2. The STarT Back Screening Tool for Prediction of 6-Month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings

3. Purpose and “filling the gap”
Background:
Predicting outcomes for LBP is not straightforward
Initial assessment info used for long-term outcomes but does not account for changes that occur during treatment to better tailor the treatment plan
Purpose:
Describe SBT change following 4 weeks of outpatient PT and test predictive ability of SBT categorization using baseline, 4-week and change patterns for 6-month pain intensity and disability outcomes

4. Methods Observational, prospective cohort study (n= 123)
All participants screened for eligibility by a PT, referred for PT by a physician
Criteria: years old, LBP (symptoms at T12 or lower, including radiating pain into the buttocks and LE), able to read and speak English *applicable to practice
Exclusion criteria: systemic involvement related to metastatic or visceral disease, recent spinal fracture, osteoporosis, pregnancy
Treatment not standardized
SBT: intake and at 4 weeks
Classified in SBT change categories:
-improved: medium to low, high to low or high to medium
-stable: remain at medium or low risk
-worsened: low to medium, low to high, medium to high or remained high

5. Outcome Measures Numeric Pain Rating Scale (NPRS) Intake and 6 months
Current pain, best and worst levels (average)
MCID: 2 points
Oswestry Disability Index (ODI)
MCID: 10 points
STarT Back Screening Tool
Intake and 4 weeks
*6 separate multiple regression models

6. Results and Implications
Initially SBT used as a screening tool, now measure for treatment monitoring based on changes in SBT categorization
6-month pain intensity scores did not consistently improve with SBT categorization (high risk), while 6-month disability scores did consistently improve
Changes in psychosocial risk factors throughout course of treatment provides more important information regarding long-term prognosis (management of LBP)
Solely relying on SBT as a screening tool at initial assessment can be misleading; suggest administering 4 weeks following initial assessment to identify patients at an increased risk for poor disability outcomes at 6 months (esp. high risk)

7. Chronic Low Back Pain Clinical Outcomes Present Higher Associations with the STarT Back Screening Tool than with Physiologic Measures: a 12-Month Cohort Study

8. Purpose and “filling” the gap
Background:
LBP 85% non specific
More recent approach deals with targeting treatment to patient subgroups based on patient prognosis
Purpose:
Assess associations between short (less than 6 months) and long (12 months) terms clinical status both physiological measures and SBT and discriminate between participants with or without higher levels of disability, pain, fear of movement and patient’s impression of change

9. Method
Cohort study, n= 53 with chronic non-specific LBP (between 12th rib and inferior gluteal fold, 12 weeks or more)
Exclusion: LBP of specific orgin, spine surgery or trauma, scoliosis, neuro disease,
uncontrolled HTN, pregnancy, recent lumbar injection, pain irradiating below knee
Eligibility criteria: years old, read and understand English
Physiologic measures: maximal voluntary contraction, maximal endurance and muscle activity during prone and lateral isometric tasks (EMG)
SBT, ODI, NPRS, TSK, PGIC

10. Outcome Measures Physiologic measures: MVC and endurance tasks
Measured at baseline
SBT
Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS), Tampa Scale of Kinesiophobia (TSK), Patient’s Global Impression of Change (PGIC)
Measured at baseline, 2, 4, 6 and 12 month follow up

11. Results and Implications
Physiological measures are only moderately associated with clinical outcomes over a 12 month period, the SBT demonstrates excellent ability to identify patients presenting with higher levels of disability, pain or fear of moving short and long term
Importance of psychological factors affecting treatment for LBP

12. Other findings: SBT psychosocial subscale demonstrates a greater prognostic significance when compared with the overall score³ Changes in SBT overall scores provide important clinical decision making for treatment monitoring⁴

13. References
1. Beneciuk JM, Fritz JM & George SZ. The STarT Back Screening Tool for Prediction of 6-Month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. Journal of Orthopaedic & Sports Physical Therapy, 2014; 44(9):
2. Page I, Abboud J, O’Shaughnessy J, Laurencelle L, Descarreaux M. Chronic Low Back Pain Clinical Outcomes Present Higher Associations with the STarT Back Screening Tool than With Physiologic Measures: a 12 Month Cohort Study. Musculoskeletal Disorder, 2015; 1-10.
3. Toh I, Hwei-Chi C, Suet-Ching Liaw J & Yong-Hao P. Evaluation of the STarT Back Screening Tool for Prediction of Low Back Pain Intensity in an Outpatient Physical Therapy Setting. Journal of Orthopedic & Sports Physical Therapy, 2017; 47(4):
4. Benecuik 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. Journal of Physical Therapy, 2013; 93(3):