The STarT Back Screening Tool and Individual
Psychological Measures: Evaluation of Prognostic
Capabilities for Low Back Pain Clinical Outcomes in
Outpatient Physical Therapy Settings
Jason M. Beneciuk, Mark D. Bishop, Julie M. Fritz,
Michael E. Robinson, Nabih R. Asal, Anne N. Nisenzon
and Steven Z. George
PHYS THER. 2013; 93:321-333.
Originally published online November 2, 2012
doi: 10.2522/ptj.20120207
The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/93/3/321
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Research Report
The STarT Back Screening Tool and
Individual Psychological Measures:
Evaluation of Prognostic Capabilities
for Low Back Pain Clinical Outcomes in
Outpatient Physical Therapy Settings
Jason M. Beneciuk, Mark D. Bishop, Julie M. Fritz, Michael E. Robinson,
Nabih R. Asal, Anne N. Nisenzon, Steven Z. George
Background. Psychologically informed practice emphasizes routine identification of modifiable psychological risk factors being highlighted.
Objective. The purpose of this study was to test the predictive validity of the
STarT Back Screening Tool (SBT) in comparison with single-construct psychological
measures for 6-month clinical outcomes.
Design. This was an observational, prospective cohort study.
Methods. Patients (n⫽146) receiving physical therapy for low back pain were
administered the SBT and a battery of psychological measures (Fear-Avoidance Beliefs
Questionnaire physical activity scale and work scale [FABQ-PA and FABQ-W, respectively], Pain Catastrophizing Scale [PCS], 11-item version of the Tampa Scale of
Kinesiophobia [TSK-11], and 9-item Patient Health Questionnaire [PHQ-9]) at initial
evaluation and 4 weeks later. Treatment was at the physical therapist’s discretion.
Clinical outcomes consisted of pain intensity and self-reported disability. Prediction
of 6-month clinical outcomes was assessed for intake SBT and psychological measure
scores using multiple regression models while controlling for other prognostic
variables. In addition, the predictive capabilities of intake to 4-week changes in SBT
and psychological measure scores for 6-month clinical outcomes were assessed.
Results. Intake pain intensity scores (␤⫽.39 to .45) and disability scores (␤⫽.47 to
.60) were the strongest predictors in all final regression models, explaining 22% and
24% and 43% and 48% of the variance for the respective clinical outcome at 6 months.
Neither SBT nor psychological measure scores improved prediction of 6-month pain
intensity. The SBT overall scores (␤⫽.22) and SBT psychosocial scores (␤⫽.25) added
to the prediction of disability at 6 months. Four-week changes in TSK-11 scores
(␤⫽⫺.18) were predictive of pain intensity at 6 months. Four-week changes in
FABQ-PA scores (␤⫽⫺.21), TSK-11 scores (␤⫽⫺.20) and SBT overall scores
(␤⫽⫺.18) were predictive of disability at 6 months.
Limitations. Physical therapy treatment was not standardized or accounted for in
the analysis.
Conclusions. Prediction of clinical outcomes by psychology-based measures was
dependent upon the clinical outcome domain of interest. Similar to studies from the
primary care setting, initial screening with the SBT provided additional prognostic
information for 6-month disability and changes in SBT overall scores may provide
important clinical decision-making information for treatment monitoring.
J.M. Beneciuk, PT, PhD, MPH,
FAAOMPT, Department of Physical Therapy, University of Florida,
Gainesville, Florida, and Clinical
Research Center, Brooks Rehabilitation, Jacksonville, Florida. Mailing address: Department of Physical Therapy, College of Public
Health & Health Professions, University of Florida Health Science
Center, Box 100154, Gainesville,
FL 32610-0154 (USA). Address all
correspondence to Dr Beneciuk at:
beneciuk@phhp.ufl.edu.
M.D. Bishop, PT, PhD, Department of Physical Therapy and
Center for Pain Research and
Behavioral Health, University of
Florida.
J.M. Fritz, PT, PhD, Department of
Physical Therapy, University of
Utah, and Intermountain Healthcare, Salt Lake City, Utah.
M.E. Robinson, PhD, Department
of Clinical and Health Psychology
and Center for Pain Research and
Behavioral Health, University of
Florida.
N.R. Asal, PhD, FACE, Department
of Epidemiology, University of
Florida.
A.N. Nisenzon, PhD, Department
of Clinical and Health Psychology,
University of Florida.
Author information continues on
next page.
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321
The STarT Back Screening Tool and Individual Psychological Measures
S.Z. George, PT, PhD, Department of Physical Therapy and Center for Pain Research
and Behavioral Health, University of Florida.
Mailing address: Department of Physical
Therapy, College of Public Health & Health
Professions, University of Florida Health
Science Center, Box 100154, Gainesville, FL
32610-0154 (USA). Address all correspondence to Dr George at: szgeorge@
phhp.ufl.edu.
[Beneciuk JM, Bishop MD, Fritz JM, 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. Phys Ther. 2013;93:321–333.]
© 2013 American Physical Therapy Association
Published Ahead of Print:
November 2, 2012
Accepted: October 19, 2012
Submitted: May 23, 2012
I
n the United States, low back pain
(LBP) point prevalence estimates
range from 17% to 26%, with
chronic LBP estimated at approximately 10%.1–3 Recent North Carolina data indicate that the prevalence
of acute and chronic LBP has
increased 44% and 162%, respectively, over a 14-year period.4 Furthermore, approximately 25% of the
caseload in outpatient physical therapist practice is LBP related.5–7
Direct costs associated with health
care services for LBP are enormous,
with physical therapy services
accounting for a large portion of
these costs.8,9 However, only a small
percentage of patients with chronic
LBP may account for a large fraction
of associated costs.10,11
Early risk factor screening has been
implicated as one strategy to identify
patients who may be at risk for poor
clinical outcomes and as a potential
method to improve the efficiency
and effectiveness of care.12–14 In
physical therapy, “psychologically
informed practice” has been presented as a secondary prevention
approach for chronic LBP that integrates both biomedical (focused on
pathology or physical impairments)
and cognitive-behavioral (focused on
psychological distress or behavior)
principles.15 The primary goal of a
psychologically informed approach
is to prevent future LBP-associated
disability, with routine identification
of modifiable psychological risk factors being emphasized. Specific to
this current study, determining the
validity and clinical utility of commonly used psychological screening
measures has been indicated as a top
future research priority for psychologically informed practice.15
There are unresolved issues relevant
to psychologically informed practice
involving the value of information
obtained during the assessment of
modifiable psychological factors.
First, the design of self-report psy-
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chological questionnaires ranges
from those focusing on a single construct that measure a specific psychological factor to those that utilize
a multiple-construct approach and
measure overall psychological distress. Each of these approaches is
associated with strengths and weaknesses. For example, a potential
weakness in using single-construct
questionnaires is that they do not
provide information beyond the targeted psychological factors of interest. Although more feasible for use in
clinical settings, multiple-construct
questionnaires are frequently used as
prognostic indicators for future outcomes based on overall psychological distress, which is a potential
strength; however, they do not provide detailed information on specific
psychological factors that may serve
as behavioral treatment targets.
Second, information obtained during
psychological assessment has potential to vary based on the timing (eg,
pretreatment, over an episode of
care, posttreatment) and number of
repeated assessments,16 –21 with
some studies indicating that changes
in psychological risk factors may
improve the prediction of clinical
outcomes compared with pretreatment assessments.18 –21 The clinical
relevance of these findings is that
changes in psychological risk factors
have potential not only for use as
prognostic indicators administered
at initial patient encounter, but also
for treatment monitoring during a
patient encounter, specifically associated with psychologically oriented
interventions.22,23 Although potentially appealing, using a single measure for multiple purposes (eg, prognostic screening and treatment
monitoring) is not always appropriate, as many screening measures
were developed to be used only as
brief triage instruments.
Finally, the prediction of clinical outcomes by psychologically based
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The STarT Back Screening Tool and Individual Psychological Measures
measures is likely to be dependent
on the clinical outcome domain of
interest.24,25 Combined, these are
important issues because information about specific psychological factors may be needed to implement
psychologically oriented interventions that have potential to reduce
the likelihood of developing chronic
LBP. However, assessing psychological factors may increase the burden
on clinicians, staff, and patients. An
optimal clinical scenario, therefore,
would consist of early screening
with a brief multiple-construct risk
prediction instrument to determine
which patients require further detailed
assessment via individual singleconstruct questionnaires.13,15,23
Hill et al26 developed the STarT Back
Screening Tool (SBT), a 9-item
screening measure used to identify
subgroups of patients with LBP in
primary care settings based on the
presence of physical or modifiable
psychosocial prognostic factors (or
both), which may be useful in matching patients with targeted interventions. The SBT has demonstrated predictive validity for long-term
disability outcomes for patients with
LBP in primary care settings.26 Furthermore, recent findings from a
clinical trial have indicated that a
stratified primary care management
approach for LBP based on SBT subgroup allocation was associated with
improved clinical and economic outcomes compared with current best
practice.27 The SBT was developed
and intended for use in primary care
settings, so information about utilizing the SBT in outpatient physical
therapy settings is limited.28 Moreover, the SBT was designed as a
screening tool and has previously
been implemented in primary care26
and outpatient physical therapy28
settings. Its usefulness for treatment
monitoring, however, has only
recently been evaluated in primary
care settings.29 Therefore, the specific purpose of our study were: (1)
March 2013
to test the predictive validity of the
SBT in comparison with commonly
used single-construct psychological
screening measures for 6-month clinical outcomes and (2) to test the
value of psychological information
measured at different points in time
(ie, intake or 4-week changes) in predicting 6-month clinical outcomes.
Investigation of these purposes will
allow us to make recommendations
about optimal screening methods
for identifying psychological distress in patients with LBP seeking
treatment in outpatient physical
therapy settings.
Method
Data for this observational, prospective cohort study were collected
between December 14, 2009, and
February 5, 2012, from 4 outpatient
physical therapy clinics of Brooks
Rehabilitation located in Jacksonville, Florida, and 2 outpatient physical therapy clinics of Shands Rehabilitation located in Gainesville,
Florida.
The Bottom Line
What do we already know about this topic?
Screening for psychological risk factors for poor clinical outcomes is an
important component in the physical therapist management of individuals
with low back pain. Identification of elevated psychological distress has
been strongly linked to poor clinical outcomes in a variety of health care
settings. The optimal method of screening for psychological factors is the
subject of debate. Screening methods range from using full-length specific
psychological measures to using brief risk prediction instruments such as
the 9-item STarT Back Screening Tool, which has not been thoroughly
evaluated in physical therapy settings.
What new information does this study offer?
This is the first study to thoroughly assess the STarT Back Screening Tool
in the outpatient physical therapy setting. Findings from this study indicate that the STarT Back Screening Tool might provide valuable prognostic information for 6-month self-report disability. Furthermore, 4-week
changes in full-length specific psychological measures (ie, Fear-Avoidance
Beliefs Questionnaire physical activity scale and 11-item version of the
Tampa Scale of Kinesiophobia) predicted 6-month self-report disability
and, therefore, may be more appropriate for treatment monitoring purposes. Interestingly, neither the STarT Back Screening Tool nor psychological measure scores improved prediction of 6-month pain intensity.
If you’re a patient or a caregiver, what might these
findings mean to you?
The findings from this study indicate that although it is important to assess
psychological distress in patients seeking physical therapy care for low
back pain, it may be unnecessary to complete multiple questionnaires to
make this assessment. A simple, straightforward assessment may be all
that is required.
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The STarT Back Screening Tool and Individual Psychological Measures
Participants
Consecutive patients seeking treatment for LBP at 6 participating outpatient physical therapy clinics were
screened for study eligibility by a
physical therapist. Potential study
participants met both of the following criteria before being enrolled
into this study: (1) adults between
the ages of 18 and 65 years seeking
physical therapy for LBP (defined as
having symptoms at T12 or lower,
including radiating pain into the buttocks and lower extremity) and (2)
the ability to read and speak the English language. These broad inclusion
criteria were chosen to allow for a
cohort that was applicable to clinical
practice. Potential study participants
were ineligible to participate in this
study if any of the following criteria
were met: (1) the presence of systemic involvement related to metastatic or visceral disease, (2) recent
spinal fracture, (3) osteoporosis, or
(4) pregnancy. Physical therapists
provided all patients who met study
eligibility criteria with a brief explanation of the study and a study advertisement with primary investigator
contact
information.
Clinicians
emphasized to patients that participating in this study would not dictate
the treatment they received for their
LBP and that if they elected not to
participate, they would receive the
same treatment. Informed consent
was obtained in compliance with the
University of Florida’s Institutional
Review Board.
Demographic and Historical
Information
Study participants were asked to
complete a standardized self-report
questionnaire consisting of questions related to age, sex, race, ethnicity,
education,
household
income, and marital and employment status. Additionally, information involving LBP clinical characteristics (ie, prior surgery, symptom
duration, symptom onset, symptom
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location, work-related LBP) was
obtained.
Psychological Measures
Data for psychological measures
were collected at baseline, at 4
weeks, and at 6 months. These measures are described in more detail
below.
SBT. The primary measure of interest for this study was the SBT. The
SBT contains items related to physical and psychosocial factors that
have been identified as strong independent predictors for persistent disabling LBP. The SBT overall scores
(ranging from 0 to 9) are determined
by summing all positive responses,
and the SBT psychosocial subscale
scores (ranging from 0 to 5) are
determined by summing items
related to bothersomeness, fear,
catastrophizing, anxiety, and depression. Based on overall and psychosocial subscale scoring, the SBT categorizes patients as “high risk”
(psychosocial subscale scores ⱖ4),
in which high levels of psychosocial
prognostic factors are present with
or without physical factors present;
“medium risk” (overall score ⬎3,
psychosocial subscale score ⬍4), in
which physical and psychosocial factors are present but not a high level
of psychosocial factors; or “low risk”
(overall score 0 –3), in which few
prognostic factors are present.30
Utilization of SBT overall and psychosocial subscale scoring has demonstrated acceptable test-retest reliability and internal consistency.26 The
SBT subgroup cutoff scores have
demonstrated good predictive validity for dichotomized 6-month disability outcomes in low-risk (16.7%),
medium-risk (53.2%), and high-risk
(78.4%) subgroups in primary care
settings.26 The SBT overall scores
have demonstrated acceptable to
outstanding discriminant validity for
physical reference standards (eg, disability, referred leg pain), and the
SBT psychosocial subscale scores
best discriminated psychosocial reference standards (eg, catastrophizing, fear, depression).26 The SBT has
demonstrated concurrent validity in
comparison with the Örebro Musculoskeletal Pain Screening Questionnaire, in which both multipleconstruct instruments displayed
similar subgroup characteristics and
the ability to discriminate for disability, catastrophizing, fear, comorbid
pain, and time off work reference
standards.31
Fear-Avoidance Beliefs Questionnaire
(FABQ). Fear-avoidance
beliefs specific to LBP were assessed
with the FABQ.32 The FABQ consists
of a 4-item FABQ physical activity
scale (FABQ-PA, scores potentially
ranging from 0 to 24) and a 7-item
FABQ work scale (FABQ-W, scores
potentially ranging from 0 to 42),
with higher scores indicating higher
levels of fear-avoidance beliefs for
both FABQ scales. Both FABQ scales
have been found to have acceptable
reliability32–35 and demonstrated
internal consistency.32,35–38 The
FABQ-W has demonstrated predictive validity for disability and work
loss in patients with LBP.35,39 – 41
Pain Catastrophizing Scale (PCS).
The PCS was used to assess the
degree of catastrophic cognitions
due to LBP.42 Pain catastrophizing
has been broadly defined as an exaggerated negative orientation toward
actual or anticipated pain experiences.42 The PCS is a 13-item questionnaire with a potential range of
scores from 0 to 52, with higher
scores indicating higher levels of
pain catastrophizing. The PCS has
been found to have good test-retest
reliability42 and internal consistency.43– 45 The PCS also has been found
to demonstrate several different
types of validity.42– 45
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The STarT Back Screening Tool and Individual Psychological Measures
11-Item Version of the Tampa
Scale of Kinesiophobia (TSK-11).
The TSK-11 was used to assess the
degree of fear of movement and
injury or reinjury in individuals with
LBP.46 The TSK-11 is an 11-item questionnaire with a potential range of
scores from 11 to 44, with higher
scores indicating greater fear of
movement and injury or reinjury due
to pain. The TSK-11 has been found
to have good test-retest reliability
and internal consistency.46 Predictive and concurrent validity also
have been reported for the TSK-11.46
9-Item Patient Health Questionnaire (PHQ-9). The PHQ-9 was
used to assess the degree to which
depressive symptoms have on
patients with LBP. The PHQ-9 is a
9-item questionnaire with a potential
range of scores from 0 to 27, with
higher scores indicating elevated
depressive symptoms. The PHQ-9
has demonstrated various types of
validity in different health care settings47,48 and has been used in studies involving patients with LBP.49
Outcome Measures
Data for outcome measures were collected at baseline, at 4 weeks, and at
6 months. These measures are
described in more detail below:
Numerical pain rating scale
(NPRS). Pain intensity was rated
using an NPRS, ranging from “0” (no
pain) to “10” (worst pain imaginable).50 –52 Participants were asked to
rate their current pain intensity, as
well as their best and worst levels of
pain intensity over the past 24 hours.
These 3 pain ratings were averaged
and used as the NPRS variable in this
study.53
Revised Oswestry Disability
Questionnaire (ODQ). Disability
related to LBP was assessed with a
revised version of the ODQ, which
has 10 items that assess how LBP
affects common daily activities.54,55
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The ODQ has a range of 0% (“no
disability due to LBP”) to 100%
(“completely disabled due to LBP”),
with higher scores indicating
higher disability from LBP. The
ODQ has been found to have high
levels of test-retest reliability, internal consistency, validity, and
responsiveness.55–57
Data Analysis
All data analyses were performed
using SPSS version 20.0 (SPSS Inc,
Chicago, Illinois). Means and standard deviations were calculated for
all baseline continuous variables, and
frequency counts with percentages
were calculated for categorical variables. These descriptive statistics are
presented for the entire study sample at each assessment time point
(ie, intake, 4 weeks, and 6 months).
The distributions of baseline continuous variables were examined by
visual inspection of histograms and
by calculating skewness and kurtosis
statistics. Nonparametric estimates
were used for variables with significant deviations from a normal distribution based on visual inspection
and skewness and kurtosis statistics.
Univariate relationships between
SBT (overall and psychosocial)
scores and single-construct psychological measures (using either intake
scores or 4-week change scores) are
presented as Pearson correlation
coefficients (r) for continuous
variables.
Predictive Validity Using Intake
Scores: SBT and Single-Construct
Psychological Measures for
6-Month Clinical Outcomes
Univariate analyses consisted of separate simple linear regression models
that were used to evaluate the independent contribution of intake SBT
(overall or psychosocial) and individual single-construct psychological
measure (FABQ-PA, FABQ-W, PCS,
TSK-11, or PHQ-9) scores as predictors of NPRS and ODQ scores at 6
months. Then separate multiple
regression models were used to evaluate the relative contributions of
intake SBT and individual singleconstruct psychological measures as
predictors of NPRS and ODQ scores
at 6 months. Three separate models
were created for each SBT and individual single-construct psychological
measure. Model 1 accounted for
intake NPRS or ODQ scores depending upon the outcome of interest,
model 2 added demographic and
clinical variables (age, sex, symptom
duration, and surgery for current
condition) to model 1, and model 3
added either SBT (overall or psychosocial score) or individual singleconstruct psychological measure
(FABQ-PA, FABQ-W, PCS, TSK-11, or
PHQ-9) scores to model 2. Regression diagnostics were performed to
assess for multicollinearity between
predictor variables in all multiple
regression analyses.
Predictive Validity Using 4-Week
Change Scores: SBT and SingleConstruct Psychological
Measures for 6-Month Clinical
Outcomes
For these analyses, we used similar
regression models as previously
described, with the only exception
being that we used intake to 4-week
change scores for SBT and individual
single-construct psychological measures instead of their respective
intake scores alone. Specifically, for
multiple regression analyses, model
3 added either SBT (overall or psychosocial) or individual singleconstruct psychological measure
(FABQ-PA, FABQ-W, PCS, TSK-11, or
PHQ-9) intake to 4-week change
scores to model 2. These exploratory
models would allow us to provide
more information on the value of
timing of assessment for SBT and
single-construct psychological measures so that we could speculate on
the usefulness of the SBT and singleconstruct psychological measures
for treatment monitoring.
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The STarT Back Screening Tool and Individual Psychological Measures
Patients with low back pain screened for eligibility
during this study period (n=275)
Patients enrolled in study after obtaining informed consent
(n=152)
Patients screened and not eligible due to:
• >65 years of age (n=47)
• language barrier or illiterate (n=2)
• cancer (n=3)
• pregnant (n=2)
Patients screened and eligible but not enrolled due to:
• refusal to participate (n=19)
• never completed informed consent process (n=24)
• never returned to physical therapy (n=26)
Patients dropped from study due to personal reasons
(n=6)
Patients included in intake analysis
(n=146)
Patients included in analysis of 4-week outcomes
(n=128)
• in-person (n=107)
• mail (n=21)
Patients included in analysis of 6-month outcomes
(n=111)
• in-person (n=61)
• mail (n=50)
Figure.
Flow diagram of patients through the study.
Results
During the study period, 275
patients were screened for eligibility
criteria (Figure). Of these patients,
123 were excluded from study participation, with the most common
reason being that they were greater
than 65 years of age (n⫽47). The
remaining 152 patients provided
informed consent and were enrolled
into the study. Of these patients, 6
were not able to complete the study
due to personal reasons. Therefore,
baseline data was obtained from 146
patients, 4-week follow-up data were
obtained from 128 patients (88%)
either in person (n⫽107) or through
mail (n⫽21), and 6-month follow-up
data were obtained from 111
patients (76%) either in person
(n⫽61) or through mail (n⫽50).
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Baseline demographic data for entire
sample are presented in Table 1.
Approximate normal distribution for
initial pain intensity, disability, and
individual single-construct psychological measures was suggested
based on visual inspection of histograms and normality plots.
The average number of physical therapy visits at 4 weeks was 6.91
(SD⫽2.64, range⫽1–13) where 102
participants (79.7%) were still
receiving physical therapy, 16
(12.5%) completed physical therapy
and were discharged, and 10 (7.8%)
elected not to continue with physical therapy. Independent-samples t
tests were used to compare participants who completed the 4-week
follow-up assessment (n⫽128) with
those who did not (n⫽18) on demographic, clinical, and psychological
characteristics at initial evaluation.
Results indicated that completers
were older (mean difference⫽9.4
years, standard error⫽3.3) and
reported higher PHQ-9 scores (mean
difference⫽2.9, standard error⫽1.1)
compared with noncompleters
(P⬍.05). The average number of
physical therapy visits at 6 months
was 11.40 (SD⫽6.51, range⫽2–35)
where no participants were still
receiving physical therapy, 72
(66.7%) completed physical therapy
and were discharged, and 36 (33.3%)
elected not to continue with physical therapy. Independent-samples t
tests also were used to compare participants that completed the
6-month
follow-up
assessment
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The STarT Back Screening Tool and Individual Psychological Measures
Table 1.
Descriptive Characteristics of the Study Samplea
Intake
(nⴝ146)
Variable
4 Weeks
(nⴝ128)
6 Months
(nⴝ111)
2.6 (2.3)
2.4 (2.5)
Demographic and clinical
Age (y)
41.1 (13.5)
Sex, female, n (%)
89 (61.0%)
Employment
Employed
94 (65.7%)
Unemployed
39 (27.3%)
Retired
10 (7.0%)
Previous low back surgery (yes)
26 (17.9%)
Symptom duration (d) (SD⫽1,157.7, median⫽90.0,
interquartile range⫽30–365)
Acute (ⱕ14 d)
17 (11.8%)
Subacute (15–90 d)
56 (39.2%)
Chronic (ⱖ91 d)
70 (49.0%)
Symptom location
LBP only
49 (33.6)
LBP and buttock or thigh
72 (49.3%)
LBP and lower leg
25 (17.1%)
Work-related LBP (yes)
19 (13.0%)
SBT measures
SBT overall score (range⫽0–9)
SBT psychosocial score (range⫽0–5)
4.5 (2.5)
2.3 (1.6)
1.1 (1.3)
1.1 (1.5)
SBT low risk
53 (36.3%)
90 (73.2%)
77 (69.4%)
SBT medium risk
55 (37.7%)
25 (20.3%)
23 (20.7%)
SBT high risk
38 (26.0%)
8 (6.5%)
11 (9.9%)
Individual psychological measures
FABQ-PA (range⫽0–24)
14.5 (5.7)
11.7 (6.3)
11.5 (7.0)
FABQ-W (range⫽0–42)
12.5 (10.9)
11.7 (11.1)
11.4 (12.7)
PCS (range⫽0–52)
16.8 (12.1)
11.1 (11.0)
10.9 (11.5)
TSK-11 (range⫽11–44)
25.1 (6.8)
23.2 (6.9)
22.7 (7.7)
7.2 (6.1)
4.7 (4.7)
4.2 (4.7)
5.3 (2.0)
3.5 (2.3)
3.3 (2.4)
32.4 (16.7)
24.6 (17.6)
20.8 (17.4)
PHQ-9 (range⫽0–27)
Clinical outcome measures
NPRS (range⫽0–10)
ODQ (range⫽0%–100%)
a
Values are mean (SD) unless otherwise indicated. LBP⫽low back pain, SBT⫽STarT Back Screening Tool, FABQ-PA⫽Fear-Avoidance Beliefs Questionnaire
physical activity scale, FABQ-W⫽Fear-Avoidance Beliefs Questionnaire work scale, PCS⫽Pain Catastrophizing Scale, TSK-11⫽11-item version of the Tampa
Scale for Kinesiophobia, PHQ-9⫽9-item Patient Health Questionnaire, NPRS⫽numerical pain rating scale, ODQ⫽Oswestry Disability Questionnaire.
(n⫽111) with those who did not
(n⫽35) on demographic, clinical,
and psychological characteristics at
initial evaluation. Results indicated
that completers were older (mean
difference⫽8.9
years,
standard
error⫽2.7) compared with noncomMarch 2013
pleters (P⬍.05). Based on initial
SBT risk category status, there were
no differences in number of visits,
follow-up rates, methods of followup, or current physical therapy status at 4 weeks or 6 months (P⬎.05).
Predictive Validity Using Intake
Scores: SBT and Single-Construct
Psychological Measures for
6-Month Clinical Outcomes
Intake univariate associations.
As expected, initial single-construct
psychological measures were signifi-
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The STarT Back Screening Tool and Individual Psychological Measures
Table 2.
Prediction of 6-Month Pain Intensity (NPRS) Scores: Multiple Regression Modelsa
Model 2
Change From
Model 1 to
Model 2
Intake
NPRS Scores
Model 1 ⴙ
Demographic
and LBP
Clinical
Variables
Additional
Variance
Explained by
Demographic
and LBP
Clinical
Variables
FABQ-PA
% R2⫽18.2
Adjusted %
R2⫽17.4
% R2⫽22.3
Adjusted %
R2⫽18.4
% R2⫽4.0
P⬎.05
% R2⫽22.3
Adjusted % R2⫽17.6
␤⫽⫺.01
% R2⫽0.0
P⬎.05
FABQ-W
% R2⫽18.2
Adjusted %
R2⫽17.4
% R2⫽22.3
Adjusted %
R2⫽18.4
% R2⫽4.0
P⬎.05
% R2⫽23.5
Adjusted % R2⫽18.9
␤⫽.12
% R2⫽1.2
P⬎.05
PCS
% R2⫽18.2
Adjusted %
R2⫽17.4
% R2⫽22.3
Adjusted %
R2⫽18.4
% R2⫽4.0
P⬎.05
% R2⫽22.3
Adjusted % R2⫽17.7
␤⫽.02
% R2⫽0.0
P⬎.05
TSK-11
% R2⫽18.2
Adjusted %
R2⫽17.4
% R2⫽22.3
Adjusted %
R2⫽18.4
% R2⫽4.0
P⬎.05
% R2⫽22.5
Adjusted % R2⫽17.8
␤⫽⫺.04
% R2⫽0.2
P⬎.05
PHQ-9
% R2⫽19.1
Adjusted %
R2⫽18.3
% R2⫽22.7
Adjusted %
R2⫽18.8
% R2⫽3.6
P⬎.05
% R2⫽23.3
Adjusted % R2⫽18.6
␤⫽.09
% R2⫽0.6
P⬎.05
SBT overall score
% R2⫽18.2
Adjusted %
R2⫽17.4
% R2⫽22.3
Adjusted %
R2⫽18.4
% R2⫽4.0
P⬎.05
% R2⫽22.4
Adjusted % R2⫽17.7
␤⫽.03
% R2⫽0.1
P⬎.05
SBT psychosocial
score
% R2⫽18.2
Adjusted %
R2⫽17.4
% R2⫽22.3
Adjusted %
R2⫽18.4
% R2⫽4.0
P⬎.05
% R2⫽22.8
Adjusted % R2⫽ 8.2
␤⫽.08
% R2⫽0.5
P⬎.05
Model 1
Psychological
Variable
(Intake Score)
Model 3
Change From
Model 2 to
Model 3
Model 2 ⴙ Intake
Psychological
Measure
Additional
Variance
Explained by
Intake
Psychological
Measure
a
NPRS⫽numerical pain rating scale, LBP⫽low back pain, FABQ-PA⫽Fear-Avoidance Beliefs Questionnaire physical activity scale, FABQ-W⫽Fear-Avoidance
Beliefs Questionnaire work scale, PCS⫽Pain Catastrophizing Scale, TSK-11⫽11-item version of the Tampa Scale for Kinesiophobia, PHQ-9⫽9-item Patient
Health Questionnaire, SBT⫽STarT Back Screening Tool.
cantly correlated with each other
(r⫽.28 to .57, P⬍.01) and with initial SBT overall (r⫽.28 to .63, P⬍.01)
and SBT psychosocial (r⫽.20 to .62,
P⬍.01) scores. Initial singleconstruct psychological measure
scores that were most strongly correlated with intake SBT scores were
obtained for the PCS, TSK-11, and
PHQ-9.
Pain intensity. In the univariate
analysis, initial SBT (overall and psychosocial) and single-construct psychological measure scores accounted
for between 4.5% and 8.4% of the
variance in 6-month NPRS scores
(P⬍.05), with the exception of
FABQ-PA and TSK-11 scores (P⬎.05)
(results not shown). In the multiple
328
f
Physical Therapy
regression analysis, for each linear
regression model, intake NPRS
scores explained a large amount of
variability in 6-month NPRS scores
(range⫽18.2%–19.1%)
(Tab.
2,
model 1). The addition of demographic and clinical variables did not
significantly explain any additional
variability in 6-month NPRS scores
(Tab. 2, change from model 1 to
model 2). The addition of intake SBT
or single-construct psychological
measure scores also did not significantly explain any additional variability in 6-month NPRS scores
(Tab. 2, change from model 2 to
model 3).
Disability. In the univariate analysis, initial SBT (overall and psychos-
ocial) and single-construct psychological measure scores accounted for
between 5.5% and 26.6% of the variance in 6-month ODQ scores
(P⬍.05) (results not shown). In the
multiple regression analysis, for each
linear regression model, intake ODQ
scores explained a large amount of
variability in 6-month ODQ scores
(range⫽38.3%–38.5%)
(Tab.
3,
model 1). The addition of demographic and clinical variables did not
significantly explain any additional
variability in 6-month ODQ scores
(Tab. 3, change from model 1 to
model 2). Only the addition of intake
SBT overall (2.5%) or psychosocial
(4.5%) scores explained an additional amount of variability in
6-month ODQ scores (Tab. 3, change
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The STarT Back Screening Tool and Individual Psychological Measures
Table 3.
Prediction of 6-Month Disability (ODQ) Scores: Multiple Regression Modelsa
Model 2
Change From
Model 1 to
Model 2
Intake ODQ
Scores
Model 1 ⴙ
Demographic and
LBP Clinical
Variables
Additional
Variance
Explained by
Demographic
and LBP
Clinical
Variables
FABQ-PA
% R2⫽38.3
Adjusted % R2⫽37.7
% R2⫽43.0
Adjusted % R2⫽40.2
% R2⫽4.7
P⬎.05
% R2⫽43.0
Adjusted % R2⫽39.6
␤⫽.02
% R2⫽0.0
P⬎.05
FABQ-W
% R2⫽38.3
Adjusted % R2⫽37.7
% R2⫽43.0
Adjusted % R2⫽40.2
% R2⫽4.7
P⬎.05
% R2⫽44.8
Adjusted % R2⫽41.4
␤⫽.15
% R2⫽1.7
P⬎.05
PCS
% R2⫽38.3
Adjusted % R2⫽37.7
% R2⫽43.0
Adjusted % R2⫽40.2
% R2⫽4.7
P⬎.05
% R2⫽44.6
Adjusted % R2⫽41.2
␤⫽.15
% R2⫽1.6
P⬎.05
TSK-11
% R2⫽38.3
Adjusted % R2⫽37.7
% R2⫽43.0
Adjusted % R2⫽40.2
% R2⫽4.7
P⬎.05
% R2⫽43.8
Adjusted % R2⫽40.4
␤⫽.10
% R2⫽0.8
P⬎.05
PHQ-9
% R2⫽38.5
Adjusted % R2⫽37.9
% R2⫽43.3
Adjusted % R2⫽40.4
% R2⫽4.8
P⬎.05
% R2⫽44.6
Adjusted % R2⫽41.2
␤⫽.13
% R2⫽1.3
P⬎.05
SBT overall score
% R2⫽38.3
Adjusted % R2⫽37.7
% R2⫽43.0
Adjusted % R2⫽40.2
% R2⫽4.7
P⬎.05
% R2⫽45.6
Adjusted % R2⫽42.3
␤⫽.22
% R2⫽2.5
P⬍.05
SBT psychosocial
score
% R2⫽38.3
Adjusted % R2⫽37.7
% R2⫽43.0
Adjusted % R2⫽40.2
% R2⫽4.7
P⬎.05
% R2⫽47.5
Adjusted % R2⫽44.3
␤⫽.25
% R2⫽4.5
P⬍.01
Model 1
Psychological
Variable
(Intake Score)
Model 3
Change From
Model 2 to
Model 3
Model 2 ⴙ Intake
Psychological
Measure
Additional
Variance
Explained By
Intake
Psychological
Measure
a
ODQ⫽Oswestry Disability Questionnaire, LBP⫽low back pain, FABQ-PA⫽Fear-Avoidance Beliefs Questionnaire physical activity scale, FABQ-W⫽FearAvoidance Beliefs Questionnaire work scale, PCS⫽Pain Catastrophizing Scale, TSK-11⫽11-item version of the Tampa Scale for Kinesiophobia, PHQ-9⫽9-item
Patient Health Questionnaire, SBT⫽STarT Back Screening Tool.
from model 2 to model 3). None of
the intake single-construct psychological measure scores significantly
explained any additional variability
in 6-month ODQ scores.
Predictive Validity Using 4-Week
Change Scores: SBT and SingleConstruct Psychological Measures
for 6-Month Clinical Outcomes
Four-week univariate associations. Four-week
changes
in
single-construct psychological measures were significantly correlated
with each other (r⫽.26 to .43,
P⬍.01), with the exceptions being
that FABQ-PA changes were not
related to FABQ-W, PCS, or PHQ-9
changes and FABQ-W changes were
not related to PCS or PHQ-9 changes
March 2013
(P⬎.05). Four-week changes in
single-construct psychological measures also were significantly correlated with 4-week changes in SBT
overall (r⫽.23 to .49, P⬍.01) and
SBT psychosocial (r⫽.39 to .50,
P⬍.01) scores, with the only exception being that FABQ-W changes
were not related to either SBT overall (r⫽.03, P⬎.05) or psychosocial
(r⫽⫺.02, P⬎.05) change scores.
Pain intensity. In the univariate
analysis, among psychological measures, only TSK-11 change scores
explained variance (5.9%, P⫽.01) in
6-month NPRS scores (results not
shown). In the multiple regression
analysis, for each linear regression
model, intake NPRS scores explained
a large amount of variability in 6month NPRS scores (range⫽18.8%–
20.2%). The addition of demographic and clinical variables did
not significantly explain any additional variability in 6-month NPRS
scores. Among psychological measure change scores, only TSK-11
change scores significantly explained
additional variability (2.9%, P⫽.05)
in 6-month NPRS scores (results not
shown).
Disability. In the univariate analysis, among psychological measures,
only TSK-11 change scores explained
variance (7.7%, P⫽.01) in 6-month
ODQ scores (results not shown). In
the multiple regression analysis, for
each linear regression model, intake
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The STarT Back Screening Tool and Individual Psychological Measures
ODQ scores explained a large
amount of variability in 6-month
ODQ scores (range⫽41.9%– 44.4%).
The addition of demographic and
clinical variables did not significantly
explain any additional variability in
6-month ODQ scores. Among psychological measure change scores,
only SBT overall (2.8%, P⬍.05),
FABQ-PA (4.0%, P⬍.01), and TSK-11
(3.8%, P⬍.01) change scores significantly explained additional variability in 6-month ODQ scores (results
not shown).
Exploratory Analyses and Results
To be consistent with previous studies assessing the SBT, we ran additional analyses where SBT was
entered as a categorical variable (ie,
low, medium, and high SBT risk).
The results from those analyses indicated similar results (not shown).
Therefore, we elected to keep SBT
scores as a continuous measure
because it was a better fit for the
regression modeling techniques
used in this study and it allowed for
direct comparisons with other psychological measures that do not have
established risk categories.
Discussion
The primary aim of this study was to
determine whether using the SBT or
individual psychological measure
scores provided more valuable prognostic information for 6-month clinical outcomes. Our results from multiple regression analyses suggested
that: (1) intake SBT scores were valuable in predicting 6-month ODQ
scores, but not NPRS scores; (2) SBT
change scores following 4 weeks of
physical therapy were valuable in
predicting 6-month ODQ scores; (3)
TSK-11 change scores were valuable
in predicting 6-month NPRS and
ODQ scores; and (4) FABQ-PA
change scores were valuable in predicting 6-month ODQ scores.
Although the SBT and individual psychological factors appeared to add
predictive value for outcome deter330
f
Physical Therapy
mination, intake NPRS and ODQ
scores were the strongest predictors
for all respective 6-month clinical
outcome regression models. This
finding was not unexpected and is
consistent with previous reviews23,58
and empirical studies.59,60 An unexpected finding was that neither SBT
nor individual psychological measures were predictive of 6-month
NPRS scores. This specific finding
highlights 2 main concepts: (1) psychological distress is not always predictive of pain intensity and (2) the
prediction of clinical outcomes by
psychology-based measures varies,
which is why multiple outcome
domains should be assessed.
SBT
Previous studies have indicated that
multiconstruct prediction instrument intake scores are useful in predicting long-term clinical outcomes
based on dichotomized recovery criteria.26,29,61 However, previous suggestions indicate that although using
dichotomized cutoff scores with
continuous data may improve interpretation of results, they also may be
associated with potential clinical limitations.15,62,63 For example, using
dichotomized cutoff scores may lead
to unrealistic results, with some individuals close to but on opposite sides
of the cutpoint characterized as having very different rather than very
similar outcomes.62 In this study, we
used clinical outcomes that were
measured on a continuous scale and
arrived at similar results for initial
SBT scores as prognostic indicators
for 6-month ODQ scores. To our
knowledge, there is one previous
study that has evaluated relationships between changes in SBT scores
and 4-month clinical outcomes. In a
primary care setting, Wideman et
al29 found that 4-month changes in
SBT scores were associated with
4-month changes in treatmentrelated outcomes and, therefore,
suggested that the SBT has potential
for use as a treatment monitoring
measure. The results of our analyses
in a physical therapy setting showed
that 4-week changes in SBT overall
scores were predictive of 6-month
ODQ scores. Collectively, these studies suggest that the SBT also may
have potential use as a treatment
monitoring measure for LBP
disability-related outcomes in outpatient physical therapy settings.
Potential strengths of this study in
comparison with a previous study28
that incorporated the SBT in outpatient physical therapy settings
include comparisons with several
individual single-construct psychological measures. Specifically, this
study is an extension of our previous
work28 because we were able to provide additional information about
the prognostic capabilities of the
SBT for 6-month clinical outcomes
and make comparisons with several
individual single-construct psychological measures via multiple regression analyses. Furthermore, we compared the value SBT scores at initial
evaluation in our primary analyses
with changes in SBT scores following 4 weeks of physical therapy in
our exploratory analyses so that we
could further speculate on the SBT’s
clinical importance as a prognostic
indicator and speculate on its potential usefulness as a treatment monitoring measure in outpatient physical therapy settings. Therefore, the
results of this study have potentially
important clinical implications for
physical therapists in outpatient settings relevant to initial and follow-up
screening procedures based on the
prognostic value of the SBT.
Single-Construct Psychological
Measures
Following 4 weeks of physical therapy, changes in single-construct psychological measures were more valuable in predicting 6-month clinical
outcomes in comparison with values
obtained at initial evaluation. Interestingly, initial single-construct psy-
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The STarT Back Screening Tool and Individual Psychological Measures
chological measures were not predictive of 6-month NPRS scores
when administered at intake, which
was unexpected considering our
previous analyses linking PCS and
FABQ-PA scores to LBP-related pain
intensity outcomes in outpatient
physical therapy settings.64,65 However, changes in TSK-11 scores were
predictive of 6-month NPRS and
ODQ scores and changes in
FABQ-PA scores were predictive of
6-month ODQ scores. These findings
are interesting because specific studies comparing the prognostic value
of intake and changes in pain-related
fear and fear-avoidance beliefs during an episode of physical therapy
care for clinical outcomes are limited
in the LBP literature. Previous studies have indicated that repeated psychological assessments provide
more valuable prognostic information for clinical outcomes when
compared with only relying on initial
assessments.16 –18,20 Therefore, clinically there appears to be potential
value in using the TSK-11 and
FABQ-PA as treatment monitoring
measures for self-report LBP-related
pain intensity and disability.
Strengths and Limitations
This study has several strengths.
First, this was only the second study,
to our knowledge, that has incorporated SBT data from outpatient physical therapy settings in the United
States. Second, in an attempt to
meet previous research priorities,12,15,23,25,66 the SBT was compared with individual single-construct
psychological measures using a
study design with standardized timing of follow-up assessments and
measurement of multiple outcome
domains. Finally, this study focused
on modifiable psychological risk factors, many of which can be
addressed through direct physical
therapy intervention, which may
have important implications for
future studies involving matched
March 2013
treatment approaches in outpatient
physical therapy settings.
This study also had several limitations. First, our psychological questionnaires were largely aligned with
fear-avoidance models,67 and we did
not measure the influence that other
potentially important psychological
factors (eg, self-efficacy, preference,
expectation) have on LBP outcomes.59,68 Second, physical therapy
treatment was not standardized in
this study. Specifically, clinicians participating in this study (n⫽16) were
not required to review or tailor treatment based on SBT categorization or
individual single-construct psychological measure scores, which may
have influenced our results because
psychological factors were not targeted with treatment if indicated.
Although specific types of treatment
were not tracked during this study,
many of the participating physical
therapists were graduates of orthopedic residency programs where the
Treatment-Based Classification System69 is highlighted as an initial management approach for patients experiencing LBP during didactic and
clinical training. However, adherence to this system or any other system was not measured as part of this
study. Finally, the use of self-report
outcome measures may have biased
our results. Therefore, future studies
should incorporate both quantitative
and self-report outcome measures.
Future Research
This was an observational study;
therefore, participating clinicians
were not educated on SBT scoring
method and associated stratified
management
approaches
for
LBP.27,30 Furthermore, clinicians
were not required to interpret or
supplement treatment based on individual single-construct measures.
Recent clinical trial findings have
indicated that a stratified management care approach (ie, STarT Back
approach) for LBP was associated
with significantly greater beneficial
changes in disability at 4 and 12
months compared with current best
practice in primary care settings,
with similar findings also reported
for generic health benefit and costsavings at 12 months.27 Although the
findings of that study have potential
implications for primary care settings, further testing is needed
before the findings can be translated
to physical therapy settings. Furthermore, there is the important question of when psychological distress
warrants referral to another health
care provider (eg, clinical psychologist). That specific question was
beyond the purpose of the current
study, but we speculate that patients
who remain in the SBT high-risk category at 4-week reassessment may
be those who warrant referral, and
this hypothesis could be tested in
future clinical studies. Finally, the
lack of prediction for 6-month NPRS
scores using intake psychologically
based measures indicates that those
interested in predicting future pain
intensity may need to consider other
measures. For example, future studies can test using proxy measures of
central sensitization that are feasible
for use in clinical settings as predictors of future pain intensity.
Conclusions and Clinical
Implications
The American Pain Society and the
American College of Physicians have
recommended routine assessment of
psychological risk factors for
patients with LBP.14 However, a previous review has indicated that this
type of assessment may be lacking
from many physical therapy clinical
decision tools.70 In this study, we
aimed to provide direction for an
optimal psychological assessment
process specific to physical therapists in outpatient settings while
considering the burden placed on
clinicians, staff, and patients. These
data provide an important reminder
that prediction of clinical outcomes
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The STarT Back Screening Tool and Individual Psychological Measures
by psychology-based measures is
dependent upon the clinical outcome domain of interest.24,25 Therefore, based on the findings of this
study, we suggest a 2-phase psychological assessment process consisting of: (1) initial screening with the
SBT to provide prognostic information for 6-month disability outcomes
only and (2) treatment monitoring at
4 weeks with the TSK-11 and the
FABQ-PA to allow for an indication
of 6-month pain and disability outcomes, particularly for patients allocated to the SBT high-risk category at
initial assessment.
Dr Beneciuk, Dr Fritz, Dr Robinson, Dr Asal,
Dr Nisenzon, and Dr George provided concept/idea/research design. Dr Beneciuk, Dr
Bishop, Dr Robinson, Dr Asal, and Dr George
provided writing. Dr Beneciuk and Dr Nisenzon provided data collection. Dr Beneciuk,
Dr Bishop, Dr Robinson, and Dr Nisenzon
provided data analysis. Dr Beneciuk provided project management. Dr Beneciuk, Dr
Robinson, and Dr George provided fund
procurement. Dr Bishop, Dr Fritz, Dr Robinson, Dr Asal, Dr Nisenzon, and Dr George
provided consultation (including review of
manuscript before submission).
The authors acknowledge the following clinicians and personnel from Brooks Rehabilitation in Jacksonville, Florida (Ryan Reed, M.
Brian Hagist, Tim Shreve, Jason Kral, Matthew Stafford, Michael Spigel, Holly Morris,
Flo Singletary, Amanda Osborne, and Robert
Rowe), and the University of Florida Orthopaedics and Sports Medicine Institute and
Shands Rehabilitation Center at Magnolia
Parke in Gainesville, Florida (Giorgio Zeppieri, Josh Barabas, Debi Jones, Derek Miles,
Zack Sutton, Dalton Reed, Michael Hodges,
Shannon Long, Tim Shay, Amy Borut, and
Yvette Silvey). Dr Robinson’s laboratory
(Calia Torres and Laura Wandner) assisted
with data collection and management.
This study was approved by the University of
Florida’s Institutional Review Board.
This study was funded by a 2009 award from
the Brooks Health System to the University of
Florida Foundation (Dr Beneciuk and Dr
George). Dr Beneciuk was supported by a
National Institutes of Health T32 Neuromuscular Plasticity Research Training Fellowship
Grant (T32 HD043730).
DOI: 10.2522/ptj.20120207
332
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Physical Therapy
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Physical Therapy f
333
The STarT Back Screening Tool and Individual
Psychological Measures: Evaluation of Prognostic
Capabilities for Low Back Pain Clinical Outcomes in
Outpatient Physical Therapy Settings
Jason M. Beneciuk, Mark D. Bishop, Julie M. Fritz,
Michael E. Robinson, Nabih R. Asal, Anne N. Nisenzon
and Steven Z. George
PHYS THER. 2013; 93:321-333.
Originally published online November 2, 2012
doi: 10.2522/ptj.20120207
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