What is the STarT Back Tool?
The STarT Back Tool is a validated 9-item screening questionnaire that stratifies patients with low back pain into low, medium, or high risk categories for developing persistent disabling pain, enabling clinicians to match treatment intensity to patient risk level and improve resource allocation. 1
Purpose and Clinical Application
The STarT Back Tool serves as a decision support tool that predicts whether someone is at low, medium, or high risk for developing persistent disabling pain, going beyond the traditional 'yellow flag' approach by providing actionable risk stratification. 1
The British Pain Society recommends using the STarT Back Tool early—at 2 weeks from pain onset—to guide structured, evidence-based referral decisions and optimize resource utilization. 1
Risk Categories and Treatment Pathways
The tool stratifies patients into three distinct management pathways:
Low-risk patients are encouraged to self-manage their pain with reassurance and advice, avoiding unnecessary medicalization and reducing treatment burden for those likely to recover naturally. 1
Medium-risk patients are referred to physiotherapy with development of a patient-centered management plan that addresses both physical symptoms and emerging psychosocial factors. 1
High-risk patients are referred to physiotherapy with skills to provide comprehensive biopsychosocial assessment and a patient-centered management plan, recognizing that psychosocial factors (anxiety, depression, catastrophizing, fear-avoidance beliefs) significantly contribute to disability. 1
Evidence Base and Performance
The STarT Back Tool has been highly researched and its cost-effectiveness is established, representing an innovative approach to stratified care that directs resources to the most needy patients while reducing unnecessary treatments for low-risk individuals. 1
Research demonstrates that:
The tool has adequate psychometric properties with a two-factor structure (physical and psychological subscales) and acceptable test-retest reliability (ICC = 0.84). 2
High-risk patients are at 61% higher risk of not achieving 30% functional improvement at 8 weeks compared to low or medium-risk patients, confirming its predictive validity. 3
Performance is 'acceptable' for discriminating disability outcomes (pooled AUC = 0.74) but 'non-informative' for pain outcomes alone (pooled AUC = 0.59), indicating it better predicts functional disability than pain intensity. 4
The tool performs similarly to the longer 24-item Orebro Musculoskeletal Pain Screening Questionnaire but is shorter (9 items) and easier to score, making it more practical for primary care settings. 5
Implementation Context
The British Pain Society consensus recognizes that the current approach of "physical therapy for all" is not working for people with low back pain, making stratified care using the STarT Back Tool essential for effective management. 1
The tool is best adopted by general practitioners in primary care settings, though trials suggest considerable resistance to implementation, requiring further work to overcome barriers to adoption. 1
Common Pitfalls
Do not delay using the tool beyond 2 weeks from pain onset, as early risk stratification is critical for preventing chronicity and optimizing outcomes. 1
Recognize that the tool predicts disability outcomes better than pain intensity, so clinical decisions should focus on functional improvement rather than pain scores alone. 4
Avoid treating all patients uniformly—the tool's value lies in matching treatment intensity to risk level, not simply identifying high-risk patients while continuing standard care for all. 1
Ensure high-risk patients receive true biopsychosocial assessment with psychological intervention, not just standard physiotherapy with a psychosocial label, as this is where the stratified care model demonstrates cost-effectiveness. 1