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STarT Back Screening Tool

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Purpose

A back-pain screening tool designed to identify prognostic indicators relevant to general practitioner decision-making concerning initial treatment options in primary care.

Link to Instrument

Instrument Details

Acronym SBST

Area of Assessment

Activities of Daily Living
Depression
Functional Mobility
Gait
General Health
Life Participation
Mental Health
Pain
Quality of Life

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Populations

Back Pain

Key Descriptions

  • The SBST (full version) is composed of 9 items.
  • 8 items are dichotomously scored (agree or disagree) and one item is designed to assess distress (five response options, scores range from 0 to 1).
  • Covers 8 constructs:
    1) Bothersomeness
    2) Referred leg pain
    3) Comorbid pain
    4) Disability
    5) Catastrophizing
    6) Fear
    7) Anxiety
    8) Depression
  • Two disability (RMDQ) items were selected to achieve an appropriate level of sensitivity.
  • Scores are produced by summing positive items (items 1–9).
  • The psychosocial subscale score is a sum of bothersomeness, fear, catastrophizing, anxiety, and depression items (items 1, 4, 7, 8, and 9).

Number of Items

9
Short form: 6

Time to Administer

5-10 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad; updated byChloe Smith, SPT; Ted Zabel, SPT; Chris Green, SPT; Cristina Raiti, SPT; Justin Andrews, SPT; and Will Harrison, SPT.

Body Part

Neck
Back
Lower Extremity

ICF Domain

Body Function

Measurement Domain

Activities of Daily Living
Emotion
General Health
Sensory

Considerations

  • 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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Back Pain

back to Populations

Cut-Off Scores

Lower Back Pain

  • 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) UK Citizens from 8 different practices; initial sample size of 200 people recruited over a 5 week period

  •  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) 12 primary care back pain patients, selected from a sample of 131 total individuals, mean age of 45.2 (ranging from 29-58 years)

  • 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.

Normative Data

Lower Back Pain

(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)

  • 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.

Test/Retest Reliability

Low back pain:

(Hill, et al, 2008; n = 131, ages ranged from 18 to 59, patients diagnosed with non-specific lower back pain)

  • 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)

Interrater/Intrarater Reliability

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)

Internal Consistency

Low back pain

(Hill, et al, 2008; n = 131, ages ranged from 18 to 59, patients diagnosed with non-specific lower back pain) 

  • 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

 

Criterion Validity (Predictive/Concurrent)

Low back pain

(Field and Newell, 2012; n = 404 assessed prior to treatment then at 14, 30 and 90 days post intervention, participants drawn from six chiropractic clinics in the UK)

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 

Construct Validity

Low back Pain:

(Kongsted, Johannesen and Leboeuf-Yde, 2011, n = 475 primary care patients; mean age = 43 (range = 18 to 67) years; data collected at 19 chiropractic clinics; 59% SBST low risk, 29% medium risk and 11% high 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

 

 

Content Validity

Low back pain:

(Hill, et al, 2008; n = 131, ages ranged from 18 to 59, patients diagnosed with non-specific lower back pain)

  • 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.

Face Validity

Low back pain:

(Hill, et al, 2008) 

  • Assessed by a clinical panel, however, no statistical induces from the original validation study were reported.

Floor/Ceiling Effects

Low back pain:

(Hill, et al, 2008)

  • 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.”

Responsiveness

Lower Back Pain:

(Hill et al, 2008)

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

Bibliography

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. 

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. 

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. 

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. 

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. 

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