STarT Back (Screening) Tool

Abstract

The STarT Back (Screening) Tool (SBT) is a concise, 9-item screening instrument developed for use in patients presenting with non-specific low back pain (LBP) within the primary care setting. Its primary function is to assess the level of risk associated with developing persistent, disabling LBP. By evaluating the psychosocial factors contributing to the patient’s pain experience, the SBT facilitates clinical decision-making. The resulting classification of patients into specific risk sub-groups (low, medium, or high risk) provides clear direction for implementing stratified treatment strategies tailored to individual patient needs.

Keywords

STarT Back Tool, Low Back Pain, LBP, Risk Stratification, Primary Care, Psychosocial Factors, Screening Instrument, Musculoskeletal Pain, Stratified Care.

Authors

The original scale was authored by Hill JC (2007). The development and validation of the official Dutch version were conducted by van Hooff M, van Lankveld W, Anderson P, van Hartingsveld F, and Ostelo R (2011).

Purpose

The core purpose of the STarT Back Tool is to enable clinicians, particularly in physiotherapy and general practice, to rapidly and accurately stratify patients presenting with LBP based on their prognosis and the key obstacles to recovery. This stratification moves beyond traditional pathoanatomical diagnoses to focus on prognostic indicators.

The tool is designed to identify individuals who are most likely to benefit from simple, minimal intervention (low risk) versus those who require more complex, psychologically informed treatments (medium or high risk). By directing resources efficiently, the SBT aims to improve clinical outcomes and reduce the societal burden associated with chronic disability stemming from LBP.

Construct

The SBT measures prognostic factors, focusing heavily on the psychosocial dimension of pain, often referred to as ‘yellow flags.’ The scale is inherently multidimensional, divided into two main sections: a physical subscale (the first question) and a psychosocial subscale (the remaining eight questions).

Key constructs assessed include:

1. Pain Catastrophizing: Excessive negative focus on pain.
2. Fear-Avoidance Beliefs: Beliefs that activity will cause harm or re-injury.
3. Anxiety and Depression: Mood disorders that can significantly impede recovery from LBP.
4. Self-Efficacy: The patient’s belief in their ability to cope with pain and return to function.

Validity

The SBT demonstrates strong predictive validity, which is its ability to accurately forecast future outcomes, specifically the patient’s risk of developing persistent, disabling pain and their likelihood of responding favorably to stratified treatment. Studies consistently show that the SBT effectively identifies patients who will experience poor outcomes if only provided with generic care.

Content validity is established as the 9 items cover the most commonly recognized prognostic factors for LBP chronicity. Construct validity is supported by its correlation with established measures of disability, fear, and catastrophizing, confirming that the scale measures the intended underlying physical and psychosocial constructs.

Reliability

The scale exhibits high internal consistency, particularly within the psychosocial subscale, indicating that the items measuring psychosocial factors are strongly correlated. Test-retest reliability is generally good, suggesting that the tool provides stable scores when administered to patients whose clinical status has not changed significantly between assessments. This ensures that the risk classification is dependable across different administrations.

Factor Analysis

Factor analysis of the SBT typically supports a two-factor structure. The first factor usually relates to generalized pain and physical function (represented primarily by the first item), while the second, and more dominant, factor captures the cluster of psychosocial risk factors (fear, anxiety, catastrophizing, and depression). This factor structure confirms the scale’s ability to separate LBP patients based on the relative importance of these physical versus psychosocial barriers to recovery.

Instrument

Test Type: Screening Questionnaire / Risk Stratification Tool

Format: Self-report Questionnaire (9 items)

Language Available: English (Original), Dutch, and numerous other validated translations globally.

Population Group: Patients presenting with non-specific low back pain.

Age Group: Adults and Elderly (Volwassenen, Ouderen).

Population Details: Individuals with pain affecting the Wervelkolom (Spine) associated with Bewegingsapparaat (Musculoskeletal system) conditions, particularly those seeking care in primary care settings.

Test Methodology: Patients answer 9 dichotomous (Yes/No) questions. Scores are summed, and patients are categorized into three groups: Low Risk (0-3 points), Medium Risk (4 points overall score, but low psychosocial score), or High Risk (4+ points overall score, high psychosocial score). The original PDF of the explanatory form (Toelichtingsformulier) can be downloaded here: SBST-form.pdf. The original PDF of the measurement instrument (Meetinstrument) can be downloaded here: SBST-meetinstr.pdf.

Keywords

Fear-Avoidance, Catastrophizing, Disability Prediction, Stratified Care, Musculoskeletal, Spine, LBP, Prognostic Indicator, Psychosocial Risk.

Authors

Author ORCID Identifier: [Not provided in source content; requires external search for primary author Hill JC]

Affiliation Email addresses: [Not provided in source content]

Correspondence Address: [Not provided in source content]

Permissions & Fee and Test Year

The STarT Back Tool is generally considered freely available for use in clinical practice and non-commercial research, although formal registration or permission may be required depending on the version and country of use. The original English version was developed in 2007 (Hill JC), and the validated Dutch version was published in 2011 (van Hooff M et al.).

Reference’s

• Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Grotle M, Wodehouse R, Hay EM. (2011). Efficacy and cost-effectiveness of a stratified primary care treatment approach for low back pain: results of the randomized controlled STarT Back trial. The Lancet, 378(9802), 1515-1525.
• Hill JC, Vohora K, Dunn KM, Main CJ, Mason E, Foster NE. (2007). The STarT Back Tool: development and validation of a new screening tool to identify patient subgroups for risk-stratified treatment. Pain, 131(1-2), 90-103.
• van Hooff M, van Lankveld W, Anderson P, van Hartingsveld F, Ostelo R. (2011). Dutch translation and psychometric properties of the STarT Back Screening Tool. European Spine Journal, 20(11), 1957-1961.

Items of the STarT Back (Screening) Tool

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The source content provided for this entry did not include the specific 9 items of the STarT Back (Screening) Tool. However, the items typically cover the following domains (answered Yes/No):

1. Referred leg pain (Physical item)
2. Comorbid pain (Physical item)
3. Disability/Function
4. Worry/Anxiety (Psychosocial item)
5. Pain catastrophizing (Psychosocial item)
6. Fear-avoidance (Psychosocial item)
7. Low mood/Depression (Psychosocial item)
8. Beliefs about work (Psychosocial item)
9. Beliefs about pain persistence (Psychosocial item)