Whatever happened to STarT Back?

If you didn’t know, Low Back Pain (LBP) is a condition that is crippling the current healthcare system. I have written extensively about this, and if a regular reader, you definitely already know.

LBP is the most burdensome musculoskeletal condition and consistently appears near the top of any health burden studies you may care to view. Surprising? Take a look and see.

Australian data:

Global data: “in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs).”

If you think your approach to LBP doesn’t really matter in the grand scheme of things, think again. Every single interaction with these patients contributes – in a positive or negative way – to this burden.

Although you may not be guilty of nocebo language and over-treatment, you can bet your bottom dollar (the accuracy of this statement will become clear later) that a lot of other physios and allied health practitioners are.

And so, to the crux of this instalment. I have also previously written about an approach to LBP, which is different. The Keele STarT back approach is one that, yes admittedly, have been indoctrinated into since very early on in my career, but for me makes perfect sense to attend for this immense health burden.

I don’t think it alters the whole picture, as I’ve said before, I think that will take a very widespread public health approach, which starts with thinking about pain differently. But it goes a long way to improve the care of people with new back pain now and who currently contribute to this burden. It doesn’t seem to be all that valid in those people with long-term back pain, so for this reason and more it doesn’t seem to be all that it is cracked up to be; let’s delve in!

What is the STarT Back screening tool?

The  Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disabilityThe resulting score stratifies patients into low, medium or high risk categoriesFor each category there is a matched treatment package.This approach has been shown to reduce back pain related disability and be cost-effective.


So, the STarT Back Screening Tool (SBT) makes it easy to identify those people with high levels of well-established psychosocial factors relating to poor clinical outcomes. In my opinion, any good practitioner should be able to identify these people any way, without using a tool. These people should be given the appropriate management and their ‘yellow flags’ should be up front and centre to that management. What this tool does do, however, is ‘filter’ people that will improve with little more than advice and put some metrics around those people that will require more intensive input.

This is where I think the SBT has its strengths; giving the clinician some objective data relating specifically to psychosocial cues and ensuring management is reduced to the bare minimum. Yes there’s a cost-effective element to this, but more important for me is the public health consequences. Less time with clinicians means less potential for nocebo and inappropriate treatment, less dependant patients, a minimally ‘curative’ and reactive system. These patients do not associate a resolution in back pain to the ‘treatment’ they have received, it empowers them to deal with another bout independently; heck, if you provide the right advice, they may even start to exercise and losing weight to reduce the risk of another bout returning!

Does it work?

In the UK, in its original effectiveness study, the tool was put to work in a huge population. It is a great read. A large cohort (n=851) RCT; including what I would say is a very representative sample of patients with LBP. My only issue with their chosen sample is the that they excluded people undergoing treatment for Axis-1 mental health disorders, because the incredibly prevalent mental health conditions we deal with on a day to day basis both adds to and complicates the overall LBP burden.

Through ensuring their approach to LBP management is based on a structured pathway, dictated by an initial risk stratification, they found a statistically significant difference between their intervention group and control group in disability, measured by the Roland-Morris Disability Questionnaire (RMDQ). The intervention group was also shown to have greater health benefit for a lower cost than the control group. They also found the intervention group had fewer days off work, which was most significant in the medium-risk group.

Their ‘intervention’ consisted of an initial appointment that included some specific advice about appropriate activity and return to work, shown a video called Get Back Active and given the Back Book. Low risk patients were only given this one session and told to go on their merry way. The medium and high risk groups were first given this initial session and then provided with care dictated by physiotherapists who were aware of their ‘risk group’.

Digging deeper, it is clear that both groups improved over time; you’d expect this in LBP as most cases improve with no other intervention other than the passage of old father time. But it seems stratification of care results in a measurable improvement in disability, overall. I’m a natural skeptic and this threw some questions for me; if it seems too good to be true, the chances are it is. So, in low risk groups there is no significant change in RMDQ scores at any follow-up; when someone is given nothing but advice and a couple of pamphlets, their improvement is on par with normal physiotherapy treatment. At the other end of scale, it seems knowing someone is of higher ‘risk’ may involve a more intensive approach by the physiotherapist and definitely does result in less disability.

Is this equation just self-serving? In so far as does it just reflect what happens in normal practice?

Certainly, in the public sector it is crucially important to ensure that resources are not wasted and the appropriate intervention is applied to a cost-effective end. Time is not wasted on those that will just get better anyway and those people needing most care receive it. So in the ‘ideal’ world, yes this is most definitely self-serving to demonstrate the best approach to utilisation of governmental dollars. But still, structuring this approach through the SBT isn’t such a bad thing.

It’s all in the context

Primary care settings have understandably become very interested in the tool and the approach. Adequate use of resources is of utmost importance.

The problems arise when time with patients equates to money in the bank as is the case in the private sector. And, in Australia, private sector clinicians are very much primary care clinicians for musculoskeletal disorders. Is this tool feasible in the private sector? Why haven’t we seen this researched in this setting?

Primary care physiotherapists in Germany are skeptical about the utility of this tool in different sectors precisely due to the inherent financial disincentives. Unfortunately, like my fantastic window-making German counterparts, I share this skepticism.

Is it reliable?

The tool has been applied in different countries across the globe. From Norway, Brasil and The (good old) United States.

study of 52 participants attending a primary care physiotherapy setting in Norway, found the SBT had good internal consistency and the stratification into higher risk groups correlated with higher levels of pain and disability. Pretty poor description of follow-up, and honestly, a pretty average study; generally I expect more of those Norwegians….

In the US a study of 1109 adults with acute non-specific LBP (non-work related), demonstrated that applying the SBT significantly predicted pain and disability levels.

Similar results have been found in Dutch and Danish populations.

In Brasil, they found applying the tool had most effect when applied after 6 weeks. This was in an Emergency Department setting.

So a lot of people are talking about it. For a reason.

The challenge

Can you do nothing? If in the private sector, this is the challenge. I don’t necessarily think this tool is the be all and end all, as stated above, it pretty much fulfils and structures the gold-standard approach. Do little in the patients that need little and do more about the important things in the patients that need a lot. The approach is the important point.

Can you do nothing?

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