Welcome back to Spine IQ’s Back Blog! Last week, we tackled the evidence around the “WHY” of using reliable screening tools and patient reported outcome measures in your practice.  The “WHY” entails a host of considerations, not the least of which are the potential for liability protection, improving the clinical standard care in your office by following guideline recommendations, and using data to demonstrate (to yourself and others!) your competence as a clinician. This week, we will focus on “HOW” to implement screening tools into your practice!

Current guidelines recommend that every patient with a new low back pain episode completes a screening tool. (1) We recognize that this might not be possible in the real world. If that is the case in your practice, you might still consider the use of screening tools, in addition to your clinical judgement, in those instances when you are evaluating difficult cases where the outcome is uncertain, and arriving at a diagnosis is difficult. Keele’s STARTBack screening tool is the tool most often recommended by guidelines and has significant amount of research on its validity and reliability. (2) The form can be found here. We will breakdown how to interpret the screening tool below.

STarTBack Questions and interpretation:

1.      My back pain has spread down my leg(s) at some time in the last 2 weeks Agree or disagree
2.      I have had pain in the shoulder or neck at some time in the last 2 weeks Agree or disagree
3.      I have only walked short distances because of my back pain Agree or disagree
4.      In the last 2 weeks, I have dressed more slowly than usual because of back pain Agree or disagree
5.      It’s not really for a person with a condition like mine to be physically active Agree or disagree
6.      Worrying thoughts have been going through my mind a lot of the time Agree or disagree
7.      I feel that my back pain is terrible and it’s never going to get any better Agree or disagree
8.      In general I have not enjoyed all the things I used to enjoy Agree or disagree
9.      Overall, how bothersome has your back pain been in the last 2 weeks Not at all, slightly, moderately, very much, extremely

The tool incorporates 9 questions focused on disability and pain intensity that have been shown to accurately predict patient prognosis. (3) Scores are separated into 3 categories: low risk (usually ~35% of LBP patients), medium risk (usually ~40% of LBP patients), and high risk (usually ~25% of LBP patients). ‘Agree’ answers count as 1; ‘disagree’ count as 0 in questions 1-8. For question 9, ‘not at all’, ‘slightly’, moderately’ count as 0; ‘very much’ and ‘extremely’ count as 1. If the total score is 3 or less, then that patient is ‘low risk’. If the total score is 4 or more then you must look at the score specifically for questions 5-9. If the total score is 4 or more AND questions 5-9 score is 3 or less, then that patient is ‘medium risk’. If the total score is 4 or more AND questions 5-9 score is 4 or more then that patient is ‘high risk’. We provided a figure for more explanation:

Patients that fall into low risk category are more likely to recover from their back pain within a couple of weeks and their acute LBP is less likely to become chronic. Discussing results from the STarTBack tool with your patients, enhanced by your clinical experience, can lead to honest and candid conversations that are appreciated by patients and have the potential to lead to better patient outcomes.  Patients that fall into the low risk category should be reassured that they can expect a good prognosis and treatment plans should reflect this with minimum visit numbers and minimal treatment. Patients that fall into medium and high risk categories have an increased likelihood of transitioning into chronic low back pain, with a poorer prognosis that is between 1.59 (medium) and 2.45 (high) times worse, respectively. (4) Although these numbers seem low, they can make a really big difference to patients. If you are interested in learning more about how impactful this increased likelihood is, this blog does a wonderful job of explaining odds ratios in non-academic terms. For patients at higher risk, clinicians should consider using interventions that target psychosocial factors (e.g. Cognitive Behavioral Therapy), bringing in a colleague to help with treatment of the patient (e.g. psychologist) or referring out to a healthcare professional that has access to additional and/or more sophisticated diagnostic testing and treatment, if need be.

The STarTBack tool helps open up discussion between clinician and patient about the underlying severity of their condition and what treatments might be appropriate. Clinicians should consider adding STarTBack to their intake form for LBP patients to increase the amount of information they have about the patient and facilitate shared decision-making regarding the best course of action for the patient. The research shows us that adding screening tools can help reduce challenges to patient care and help target treatment towards a  patient’s individual needs.

Stay tuned for next week’s blog when we dive into how to incorporate patient reported outcome measures in your clinic!


  1. National Guideline Centre (UK). Low Back Pain and Sciatica in Over 16s: Assessment and Management [Internet]. London: National Institute for Health and Care Excellence (UK); 2016 [cited 2021 Jun 11]. (National Institute for Health and Care Excellence: Clinical Guidelines). Available from: http://www.ncbi.nlm.nih.gov/books/NBK401577/
  2. Katzan IL, Thompson NR, George SZ, Passek S, Frost F, Stilphen M. The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain. Spine J Off J North Am Spine Soc. 2019 Apr;19(4):645–54.
  3. Khan Y, Lawrence D, Vining R, Derby D. Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey. Chiropr Man Ther [Internet]. 2019 Jan 15 [cited 2021 Mar 27];27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6332914/
  4. Stevans JM, Delitto A, Khoja SS, Patterson CG, Smith CN, Schneider MJ, et al. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open. 2021 Feb 1;4(2):e2037371.