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

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?

by: Nicole Cattano
by: Jeffrey Driban