Improving the Predictive Validity of the Dutch STarT Back Tool

Objective The purpose of this study was to evaluate whether the predictive validity of the Dutch version of the STarT Back Tool (SBT) can be improved by (1) using other cut-off values, (2) changing the items, or (3) adding prognostic factors to the SBT. Design Secondary analysis of a prospective cohort study (PRINS study: Prevalence of Risk groups in Neck- and back pain patients according to the STarT back screening tool) in patients with low back or neck pain. Methods The predictive validity was calculated with a relative risk ratio (RR) and a Spearman correlation. The new cut-off values were calculated with receiver operating characteristic (ROC) curves. Replacing items of the SBT and adding new items were assessed with logistic regression analyses. Results A total of 150 patients were included; 51% were categorized as having low risk, 39% as having moderate risk, and 11% as having high risk. Changing the cut-off total score to ≤2 and of the subscore to ≥5 led to an improvement of the Spearman correlation and RR. Adding the item “duration of the complaints” improved the RR for moderate risk (3.6) (95% CI = 1.6–7.9) and for high risk (9.0) (95% CI = 4.2–19.1) compared with low risk. The new Spearman correlation was improved to rs = 0.37. Conclusions The predictive validity was improved by adding the item “duration of the complaints” and changing the cut-off values.

The perspectives and experiences of physiotherapists and general practitioners in the use of the STarT Back Tool Tool: A review and meta-synthesis.

Background: Chronic low back pain is associated with disability and work absence. Stratified primary care management of acute low back pain using a prognostic screening tool (STarT Back Tool, SBT) triages people with LBP into targeted treatment groups, matched to their level of risk of chronicity. The SBT was designed for use in the health service in the United Kingdom where it has been shown to improve clinical outcomes, patient satisfaction, and reduce treatment costs and time off work. Successful implementation of the SBT outside the UK is dependent on the health practitioners who will use it and the healthcare system in which they work. Gaining health practitioners’ perspectives on the SBT is an important step in implementation. Methods: A computerised search of qualitative literature was conducted across seven databases in March 2021 using keywords to identify studies investigating the perspectives of physiotherapists and general practitionners on the use of the SBT in primary health care. Study quality was assessed using the CASP tool. Data were coded and analysed using reflexive thematic analysis. Results: Eight articles met inclusion criteria and included the views of general practitionners and physiotherapists from primary health care settings from four countries. Three themes were created from the data, the first ‘making it work’, identifies factors that may influence implementation and continued use of the SBT in clinical practice. The second ‘will I do it?’, captured potential consequences of adopting the SBT and the third, ‘it’s all about the patient’ emphasised how the SBT may affect patients and their potential reactions. Conclusions: Physiotherapists and general practitionners found using the SBT frequently enhanced their practice. General practitioners expressed concerns about time constraints and potential for the SBT to undermine their clinical experience. Findings from this study will inform modifications to contextualise the tool to each healthcare environment.

The perspectives and experiences of physiotherapists and general practitioners in the use of the STarT Back Tool Tool: A review and meta- synthesis

Background: Chronic low back pain is associated with disability and work absence. Stratified primary care management of acute low back pain using a prognostic screening tool (STarT Back Tool, SBT) triages people with LBP into targeted treatment groups, matched to their level of risk of chronicity. The SBT was designed for use in the health service in the United Kingdom (UK) where it has been shown to improve clinical outcomes, patient satisfaction, and reduce treatment costs and time off work. Successful implementation of the SBT in health care outside the UK is dependent on the health practitioners who will use it and the healthcare system in which they work. Gaining health practitioners’ perspectives on the SBT is an important step in effective implementation. Methods: A computerised search of qualitative literature was conducted across seven databases in March 2021 using keywords to identify studies that investigate the perspectives of physiotherapists and general practitionners on the use of the SBT in primary health care. Study quality was assessed using the CASP tool. Data were coded and analysed using reflexive thematic analysis. Results: Eight articles met the inclusion criteria and included the views of general practitioners and physiotherapists from primary health care settings from four countries. Three overarching themes were created from the data, the first ‘making it work’, identifies factors that may influence implementation and continued use of the SBT in clinical practice. The second ‘will I do it?’, captured potential consequences of adopting the SBT and the third ‘it’s all about the patient’ emphasised how the SBT may affect patients and their potential reactions to risk stratification and matched treatments.Conclusions: Physiotherapists and general practitioners found using the SBT frequently enhanced their practice. General practitioners did express concerns about time constraints and the potential for the SBT to undermine their clinical experience. Findings from this study will inform modifications to contextualise the tool to each healthcare environment.

Validity of the STarT Back Tool in Patients with Low-Back Pain Using Spinal Flexibility Measures

Background: Correlation between prediction tools of disability and traditional physical performance tests in ascertaining disability risks remains unexplored. Objectives: The present study aimed to assess the convergent validity of the STarT back tool (SBT) for predicting disability risk using the spinal range of motion (ROM). Methods: Thirty patients with low-back pain (LBP) volunteered for this study. We used the SBT and Dual inclinometers to assess the future risk for disability and spinal ROM, as well as Anthropometric factors and pain intensity. Results: Poor and moderate spinal ROM for forward (93.3%, 6.7%), left lateral (63.30%, 36.70%) and right lateral (80.00%, 20.00%) flexion respectively were common among the participants. Backward extension ROM (36.70%, 46.70%) was mostly good and very good. There was a 60% medium risk for future physical disability based on SBT. There was no significant association between spinal ROM and SBT future disability prediction (χ2 = 3.367, P > 0.05). Conclusions: The SBT and spinal ROM assessment are independent measures of functional disability. They should complement one another in clinical assessment procedures for effective outcomes in the treatment of LBP.

Patients’ Views on the Implementation Potential of a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study

Stratified care for low back pain (LBP) has been shown to be clinically- and cost-effective in the UK, but its transferability to the German healthcare system is unknown. This study explores LBP patients’ perspectives regarding future implementation of stratified care, through in-depth interviews (n = 12). The STarT-Back-Tool was completed by participants prior to interviews. Interview data were analysed using Grounded Theory. The overarching theme identified from the data was ‘treatment-success’, with subthemes of ‘assessment and treatment planning’, ‘acceptance of the questionnaire’ and ‘contextual factors’. Patients identified the underlying cause of pain as being of great importance (whereas STarT-Back allocates treatment based on prognosis). The integration of the STarT-Back-Tool in consultations was considered helpful as long as it does not disrupt the therapeutic relationship, and was acceptable if tool results are handled confidentially. Results indicate that for patients to find STarT-Back acceptable, the shift from a focus on identifying a cause of pain and subsequent diagnosis, to prediction-orientated treatment planning, must be made clear. Patient ‘buy in’ is important for successful uptake of clinical interventions, and findings can help to inform future strategies for implementing STarT-Back in the Germany, as well as having potential implications for transferability to other similar healthcare systems.