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How to use the STarT Back Screening tool for low back pain

by Ryan Sharkey, PT, DPT


Low back pain has such a broad scope of symptoms and stigmas attached to it, that it can become confusing to any therapist trying to determine what the patient's prognosis might be. When you first walk into an evaluation for a patient with “low back pain”, how are you to know whether this is something mild or severe before you walk in the door?

It sounds mundane, but getting the most information out of that initial paperwork can really set the stage for a more effective evaluation. It can help you maximize your precious in-clinic time and get to the treatment part of your evaluation faster.

Outcome measures like the Modified Oswestry are great for assessing progress from one visit to the next based on level of function, so they are measures of progress, not prognosis.

For patients with low back pain, there is a quick screening tool that I’d like to introduce to you if you aren’t already using it. The STarT Back Screening Tool is a fantastic risk stratification tool that will give you a quick snapshot of where the patient falls in relation to how serious they perceive their back pain and their level of risk of developing chronic symptoms from it.

STarT Back can be used by any clinician as a way to enhance clinical decision-making for patients with low back pain. It can help you understand how the patient actually feels vs. just what hurts. That can be a powerful driver of great patient care.

What is the STarT Back Screening Tool?

Originally developed by Keele University in 2007, the STarT Back Screening Tool is a 9 point questionnaire that was designed to help primary care providers direct care for patients suffering from low back pain. The tool helps separate patients into various categories for treatment.

STarT Back looks at a combination of physical symptoms and psycho-emotional factors to give you a more complete understanding of where the patient is coming from. It then groups the patient into one of 3 distinct areas to better drive your treatment and prognosis based on how at risk the patient is for developing chronic low back pain. Here are the categories:

  • Low Risk – The patient has minimal risk for developing chronic low back pain and may benefit from basic home exercises, reassurance that the nature of their pain should resolve in time.
  • Medium Risk – The patient has a moderate risk for developing chronic low back pain, and will most likely benefit from physical therapy to address biomechanical deficits and pain-neuroscience education.
  • High Risk – Pt demonstrates tendencies that indicate they have a higher risk for developing low back pain. In this instance, a bio-psychosocial approach would be most effective vs. addressing musculoskeletal issues only. This means a team-centered approach involving multiple care providers would be in the patient's best interest.

How is it used?

Take a quick look at the overall scoring metrics below (photo on the right):

STarT Back Screening Tool


What you should notice is the STarT Back Screening Tool is broken up into 2 distinct parts.

1. The first is the total score marked down on the tool. If it is a 3 or below, the patient is at low risk for developing chronic low back pain.

2. The second is the subscore, which is comprised mostly of questions related to the patient's overall psychology and beliefs regarding their low back pain. Again, this can be a great driver for your clinical intervention. This is how you might look at the 3 groups:

  • Mild Risk: The patient is going to need a HEP that is simple and effective. Your first visit with them may be the only visit they need to feel improved. Additional therapy could be helpful to help the patient to prevent further injury or reduce the risk of recurrence of low back pain.
  • Moderate Risk: This would fall in the “6 weeks of PT” bucket. The patient would benefit from a consistent regimen of PT, a comprehensive HEP that builds on itself, and great pain-neuroscience education. I don’t think I need to go into much detail about this, since you're already doing it!
  • High Risk: You may not be the only person (or even the best person) that should see this patient. Consider a whole bio-psychosocial approach involving their primary care, yourself, a behavioral health expert, or any other tools at your care teams’ disposal. The primary focus of your intervention isn’t going to be addressing a biomechanical issue as much as it’s going to be adjusting the patient's fear, anxiety, and beliefs regarding their current state of pain. Remember, not only are you a master of movement but you are also an incredible educator on how the brain affects pain!

Implications of the STarT Back Screening Tool

As we move towards more and more patients seeking physical therapy through direct access, PTs are taking on bigger roles as gatekeepers for musculoskeletal disorders. With this comes more responsibility to help a wider range of patients, from the one-time evaluation and HEP types to patients who may need services beyond our scope.

Here are a few things to think about related to learning and using this tool:

1. The STarT Back Screening Tool is a valid measure that can help drive your clinical decision-making when you first see a patient, just by having them fill out a small questionnaire.

2. A good tool needs to be shared. Are physicians in your area using this? If so, great. You can now be sure that you are both speaking the same language when it comes to patient prognosis. This can help you build trust within a care team, leading to more productive conversations down the road.

What if a physician isn’t using this? It never hurts to send them a valid tool that was created for physicians to determine when they should send a patient to PT. Physicians are short on time, so every tool helps.

3. Finally, the STarT Back Screening Tool may have implications in the authorization and direction of care. In fact, Oregon Health and Science University(OHSU) recently published guidelines for acute low back pain, suggesting to physicians how many visits might be appropriate for each category using the STarT Back screening tool. Insurers have caught on to the effectiveness of PT for early intervention of high-risk populations, and are willing to pay to see these patients given great care. The STarT Back screening tool just might be beneficial in conjunction with traditional outcome measures to cement the need for physical therapy services in your clinic to insurers.

So tell me, have you used STarT Back before? Let us know in the comments below.

The StarT Back tool is great for gaining a deeper understanding of your patient, the person vs. your patient, the back issue. You will also be able to walk into that evaluation with a better idea of how that patient might progress, and some of their barriers to success. Doing this can help drive your intervention with this patient and make you look, sound, and feel more like the expert you are! For a low-risk category patient, it may well be a one to two visit scenario and they feel like they’re capable of continuing on by themselves. For a high-risk patient, you may need to dive deeper into your pain-neuroscience education tool kit to help limit fear from taking over the equation.

Reliability and screening ability of the StarT Back screening tool


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  1. Hill et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet. 2011;378. 1560. Published October 29,2011.
  2. Robinson HS, Dagfinrud H. Reliability and screening ability of the StarT Back screening tool in patients with low back pain in physiotherapy practice, a cohort study. BMC Musculoskelet Disord. 2017;18(1):232. Published 2017 May 31. doi:10.1186/s12891-017-1553-x


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