Current Evidence: STarT Back Screening Tool Jacqueline Zak, SPT July 14, 2017

The STarT Back Screening Tool for Prediction of 6-Month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings

Purpose and “filling the gap” Background: Predicting outcomes for LBP is not straightforward Initial assessment info used for long-term outcomes but does not account for changes that occur during treatment to better tailor the treatment plan Purpose: Describe SBT change following 4 weeks of outpatient PT and test predictive ability of SBT categorization using baseline, 4-week and change patterns for 6-month pain intensity and disability outcomes

Methods Observational, prospective cohort study (n= 123) All participants screened for eligibility by a PT, referred for PT by a physician Criteria: 18-65 years old, LBP (symptoms at T12 or lower, including radiating pain into the buttocks and LE), able to read and speak English *applicable to practice Exclusion criteria: systemic involvement related to metastatic or visceral disease, recent spinal fracture, osteoporosis, pregnancy Treatment not standardized SBT: intake and at 4 weeks Classified in SBT change categories: -improved: medium to low, high to low or high to medium -stable: remain at medium or low risk -worsened: low to medium, low to high, medium to high or remained high

Outcome Measures Numeric Pain Rating Scale (NPRS) Intake and 6 months Current pain, best and worst levels (average) MCID: 2 points Oswestry Disability Index (ODI) MCID: 10 points STarT Back Screening Tool Intake and 4 weeks *6 separate multiple regression models

Results and Implications Initially SBT used as a screening tool, now measure for treatment monitoring based on changes in SBT categorization 6-month pain intensity scores did not consistently improve with SBT categorization (high risk), while 6-month disability scores did consistently improve Changes in psychosocial risk factors throughout course of treatment provides more important information regarding long-term prognosis (management of LBP) Solely relying on SBT as a screening tool at initial assessment can be misleading; suggest administering 4 weeks following initial assessment to identify patients at an increased risk for poor disability outcomes at 6 months (esp. high risk)

Chronic Low Back Pain Clinical Outcomes Present Higher Associations with the STarT Back Screening Tool than with Physiologic Measures: a 12-Month Cohort Study

Purpose and “filling” the gap Background: LBP 85% non specific More recent approach deals with targeting treatment to patient subgroups based on patient prognosis Purpose: Assess associations between short (less than 6 months) and long (12 months) terms clinical status both physiological measures and SBT and discriminate between participants with or without higher levels of disability, pain, fear of movement and patient’s impression of change

Method Cohort study, n= 53 with chronic non-specific LBP (between 12th rib and inferior gluteal fold, 12 weeks or more) Exclusion: LBP of specific orgin, spine surgery or trauma, scoliosis, neuro disease, uncontrolled HTN, pregnancy, recent lumbar injection, pain irradiating below knee Eligibility criteria: 18-60 years old, read and understand English Physiologic measures: maximal voluntary contraction, maximal endurance and muscle activity during prone and lateral isometric tasks (EMG) SBT, ODI, NPRS, TSK, PGIC

Outcome Measures Physiologic measures: MVC and endurance tasks Measured at baseline SBT Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS), Tampa Scale of Kinesiophobia (TSK), Patient’s Global Impression of Change (PGIC) Measured at baseline, 2, 4, 6 and 12 month follow up

Results and Implications Physiological measures are only moderately associated with clinical outcomes over a 12 month period, the SBT demonstrates excellent ability to identify patients presenting with higher levels of disability, pain or fear of moving short and long term Importance of psychological factors affecting treatment for LBP

Other findings: SBT psychosocial subscale demonstrates a greater prognostic significance when compared with the overall score³ Changes in SBT overall scores provide important clinical decision making for treatment monitoring⁴

References 1. Beneciuk JM, Fritz JM & George SZ. The STarT Back Screening Tool for Prediction of 6-Month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. Journal of Orthopaedic & Sports Physical Therapy, 2014; 44(9): 656-664. 2. Page I, Abboud J, O’Shaughnessy J, Laurencelle L, Descarreaux M. Chronic Low Back Pain Clinical Outcomes Present Higher Associations with the STarT Back Screening Tool than With Physiologic Measures: a 12 Month Cohort Study. Musculoskeletal Disorder, 2015; 1-10. 3. Toh I, Hwei-Chi C, Suet-Ching Liaw J & Yong-Hao P. Evaluation of the STarT Back Screening Tool for Prediction of Low Back Pain Intensity in an Outpatient Physical Therapy Setting. Journal of Orthopedic & Sports Physical Therapy, 2017; 47(4): 261-267. 4. Benecuik et al. The STarT Back Screening Tool and Individual Psychological Measures: Evaluation of Prognostic Capabilities for Low Back Pain Clinical Outcomes in Outpatient Physical Therapy Settings. Journal of Physical Therapy, 2013; 93(3): 321-333.