Sports Medicine Research: In the Lab & In the Field: Risk Stratification is a STarT to Predicting Back Pain (Sports Med Res)


Wednesday, May 30, 2018

Risk Stratification is a STarT to Predicting Back Pain

Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S Primary Care Setting

Suri P, Delaney K, Rundell SD, & Cherkin DC. Archives of Physical Medicine and Rehabilitation. 2018; Online ahead of print:  
Take Home Message: Risk stratification seems to be an interesting and efficient approach to understanding who will have persistent disabling low back pain after 6 months.
Persistent disabling low back pain affects millions of people and costs the healthcare industry nearly $90 billion, yet it remains a relative challenge to identify people at risk and effective treatments.  A group in United Kingdom developed an instrument for Subgrouping for Targeted Treatment (STarT) in efforts to help with this challenge.  It consists of a risk categorization based on a 9-item questionnaire as well as a second portion involving possible best treatment options. It has shown positive outcomes in Europe, therefore these authors aimed to assess the validity of risk-level categorizations among Americans with low back pain visiting a primary care clinic.  Researchers assessed 1218 patients (who were enrolled in another research study) and stratified them into risk groups (42% low; 37% medium; 21% high risk) based on their STarT responses. 1109 patients reported their disability outcomes through a modified Roland-Morris Disability Questionnaire 6 months later at follow-up.  The authors defined persistent disabling back pain as anyone with a Roland-Morris Disability Questionnaire score of 7 or more at follow-up. Risk groups were associated with persistent disability from back pain. The results were similar to the European study and the cutoffs reported relatively good sensitivity, specificity, and likelihood ratios.  Persistent disabling back pain was present in 22% of people classified as low risk, 62% classified as medium risk, and 80% with high risk.  Additionally, a sub-analysis of patients > 65 years of age showed the risk categories were valid based on a relationship with persistent disabling back pain; however, for this population it may be reasonable to combine medium and high risk groups.

The authors showed that the risk stratification by the STarT 9-item questionnaire is a predictor of persistent disabling back pain among Americans visiting a primary care clinic.  This tool may help clinicians make clinical care decisions (e.g., rehabilitation referral), which may help mitigate the high costs associated with back pain care.  Now that risk categories have been shown to be associated with outcomes, it is important to start to investigate the effects of treatments on patients within each of these risk categories.  This study also showed that risk categories may be useful in patients > 65 years of age in the United States; but, it may be more valuable to look at the low risk category versus the medium- and high-risk groups together based on the relatively poor functional outcomes in these two groups within this aged cohort.  It would seem that age is a risk factor that needs to be considered when making risk stratifications.  It would be interesting to see if this classification tool performs well among younger physically active patients.  These findings are important for a primary care patient group, however, the generalizability to the physically active and/or athletic populations remains to be seen.  There are some other disability questionnaires that may be more valuable to use within a younger and more active population.  Overall, this is a great start to understanding risk, treatment options, and trying to optimize outcomes for patients. Clinicians working in a primary care setting may find this short 9-item questionnaire valuable for triaging and educating patients.

Questions for Discussion:  What risk factors do you see being linked with persistent low back pain?  Do you currently use any risk stratification systems or patient reported outcomes specific to back pain?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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