Chronic low back pain (LBP) is the leading cause of disability worldwide, and carries a tremendous economic burden - we’ve known this for a long time! Evidence-based guidelines have recommended screening for poor prognostic indicators and stratifying LBP patients based on chronicity and disability risk. The STarT Back Tool (SBT) was created to enable primary care/first contact practitioners to dictate future LBP care pathways, based on the risk of future disability. A randomized trial demonstrated that a risk stratification approach based on the SBT resulted in better clinical outcomes and reduced costs compared to usual care in UK primary care consults (reference in the Review). Since, multiple studies have been conducted supporting the psychometric properties, and the predictive and discriminative ability of the SBT. However, the SBT risk subgroups have not been profiled, nor have the tool’s predictive and discriminative ability been adequately investigated in a chronic LBP population. As such, the authors sought to determine the predictive and discriminative validity of the SBT for pain intensity, self-reported LBP-disability and self-perceived change at 1-year follow-up. They also hoped to determine the profile of the SBT chronic LBP risk subgroups with respect to demographic variables, pain intensity, self-reported disability and psychological measures.  This paper was published in the Journal of Physiotherapy (2018).
 
STarT Back
 
What did they find?
 
The SBT was initially designed to risk-stratify patients with non-specific LBP into various chronicity and disability profiles and outcomes, with a matched care pathway for each subgroup. It has been shown to be predictive and discriminative of future disability due to LBP in primary care.
 
In this study, those with higher SBT risk category had significantly greater pain intensity and disability, higher scores on negative psychosocial outcomes, and lower scores on positive psychosocial constructs at baseline. This is consistent with past studies which have demonstrated that SBT risk subgroups are related to pain, disability, depression, fear avoidance beliefs, catastrophizing, kinesiophobia and anxiety. These results indicate that the SBT may be an acceptable surrogate measure for multiple full-length unidimensional measures. However, the SBT performed poorly with respect to pain intensity and subjective global perceived change at the 1-year follow-up mark. Therefore, using the SBT as a sole indicator of prognosis in chronic LBP is NOT recommended. However, the SBT should be used alongside the clinical examination and in conjunction with sound clinical reasoning when making care decisions for chronic LBP patients.
 

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