|Year : 2017 | Volume
| Issue : 1 | Page : 23-30
Does the STarT Back screening tool correlate with the focus on therapeutic outcomes functional scale in patients with low back pain?
Alexander Harris, Stephen Kareha, Rett Holmes
Physical Therapy at St. Luke's, St. Luke's University Health Network, Bethlehem, PA, USA
|Date of Web Publication||7-Jul-2017|
77 Bates Street, Suite 201, Lewiston, ME 04240
Source of Support: None, Conflict of Interest: None
Study Design: Cross-sectional correlational.
Objectives: Examine the relationship between the STarT Back Screening Tool (SBST) and the Focus on Therapeutic Outcomes (FOTO) functional status questionnaire in patients with low back pain (LBP).
Background: LBP is one of the most common and costly orthopedic conditions in the health-care system, but the diagnosis, prognosis, and treatment are unclear and uncertain. Tools such as the SBST and FOTO have been developed as a way to subclassify individuals with LBP to determine prognosis and stratify care.
Methods: The SBST and FOTO questionnaires were administered during the initial consultation with a physical therapist for a chief complaint of LBP. Kendall's tau-c coefficient was calculated for correlation between the SBST risk stratification and FOTO functional staging. Kappa coefficient was calculated for correlation between the dichotomized SBST psychosocial subscale and the dichotomous fear avoidance level derived from the FOTO questionnaire.
Results: A total of 65 patients were included in the final analysis ranging in age from 18 to 89 years. The correlation between SBST risk level and FOTO functional staging was poor (Kendall's tau-c = 0.406, P < 0.001) and the correlation between elevated fear-avoidance and high psychosocial distress was also poor (K = 0.099, P = 0.335).
Conclusion: The poor inverse relationship between the SBST and FOTO demonstrates that both tools should be used concurrently to complement each other to effectively subclassify patients with LBP. Future efforts may want to focus on integrating constructs from the SBST into the FOTO computerized adaptive test to improve risk stratification.
The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement.
Keywords: Chronicity, classification, prognosis
|How to cite this article:|
Harris A, Kareha S, Holmes R. Does the STarT Back screening tool correlate with the focus on therapeutic outcomes functional scale in patients with low back pain?. Int J Acad Med 2017;3:23-30
|How to cite this URL:|
Harris A, Kareha S, Holmes R. Does the STarT Back screening tool correlate with the focus on therapeutic outcomes functional scale in patients with low back pain?. Int J Acad Med [serial online] 2017 [cited 2021 Jan 16];3:23-30. Available from: https://www.ijam-web.org/text.asp?2017/3/1/23/209842
| Introduction|| |
Musculoskeletal conditions account for nearly 15%–30% of encounters in family practice. Treatment of low back pain (LBP) cost $85 billion dollars in 2005 and is expected to continue to rise with an active but aging general population. Acute LBP resolves in 90% of cases within 6 weeks, however, 62% of people experiencing their first episode of LBP will go on to develop symptoms lasting longer than 1 year.
Over the past 20 years, the medical management of LBP has changed. The use of nonsteroidal anti-inflammatory drugs has decreased (−12.4%), while the use of narcotics (+9.8%), and computed tomography (CT) and magnetic resonance imaging (MRI) has increased (+4.1%)., Early MRI is associated with an 8-fold increased risk for surgery, and the iatrogenic effects of early MRI include worsened disability and increased medical costs, unrelated to severity. The management of spinal pathology is trending toward discordance with guideline recommendations for care and represents an area with the opportunity for both costs savings and improving patient outcomes.
The classification has routinely been shown to improve outcomes with patient care.,,,, For example, risk stratification has been shown to improve cost-effectiveness, patient disability outcomes, and halving time off work without increased health-care costs.,,
Numerous outcome measures and surveys have been developed to aid in predicting outcomes to direct appropriate care. The STarT Back Screening Tool (SBST) was developed as a screening tool to identify prognostic indicators that would effect initial treatment options for patients with back pain in primary care. Use of the SBST, when combined with matched treatment based off the prognostic score has been shown to be effective when used by primary care physicians including decreasing mean time off of work by 50%, decreased disability scores as well as health care cost savings. In the physical therapy setting, use of the SBST has been shown to improve patient care outcomes when timing and duration of treatment is selected based on SBST scores.
The SBST was developed for use in primary care, not physical therapy. Physical therapists (PTs) use other tools for patient subclassification and risk stratification, such as the Focus On Therapeutic Outcomes (FOTO) tool. The FOTO tool is a computerized adaptive test (CAT) used for tracking patient perception of functional ability over the course of care. FOTO also provides prognostic information through risk stratification utilizing multiple components including functional status. FOTO has been used for more than 3.4 million episodes by over 17,000 clinicians in 3800 clinics throughout all fifty states as well as internationally and has been shown to be a valid and reliable measurement system for outpatient orthopedic rehabilitation for patients with lumbar spine pain.,,,,
While there are numerous outcomes measures to aid in the management of LBP, in patients' and clinicians' interests for time efficiency, it is impractical to use all available tools. In addition, providers use different tools based on personal preference. The correlation and concurrent validity between measures has not been established for most of these tools. This poses a large burden to the patient and clinician and barrier to effective communication between providers in different practices utilizing different risk stratification tools.
To the best of our knowledge, no research has been performed to date correlating the FOTO tool's functional staging categories with SBST's risk stratification categories. The aim of this study was to examine for a potential relationship between the SBST risk stratification categories and the FOTO tool functional staging in patients with LBP. Evidence of a relationship could provide the ability to reduce the burden of questionnaires on the patient and the provider as well as provide utility in identifying cases that are at a higher risk for chronicity, guide interventions, improve communication between providers, and improve patient care outcomes.
| Methods|| |
PTs within a large regional hospital network were selected to be data collectors for this study. Criteria for PTs were: (1) Licensure in the Commonwealth of Pennsylvania, and (2) currently employed by the regional hospital network. A convenience sample of consecutive patients, of at least 18 years of age, presenting for outpatient PT consultation with a chief complaint of LBP were recruited from the regional hospital network's outpatient physical therapy clinics from May 2015 to August 2015. Subjects were required to be literate in the English language and complete the necessary questionnaires. Subjects found to have a need for referral to another medical professional were not included in the study and were referred to the appropriate medical provider. While completion of the FOTO questionnaire and the SBST questionnaire were considered part of standard care for the setting, patients who did not want to take one of the surveys were excluded from the study sample. Institutional Review Board approval was provided by the St. Luke's University Health Network.
We did not limit our sample population based on insurance type, referral source, surgical status, acuity, or age as we wanted to have the most representative sample of patients typically seen in outpatient physical therapy practice settings.
Each subject completed a FOTO survey which is a CAT and is given through iPad (iPad 2, Apple, Cupertino, CA, USA) and the SBST.
The FOTO lumbar functional scale was designed to efficiently evaluate each patient's function by selecting items that provided the maximum information related to the patient's functional status. In contrast to giving each patient fixed length questionnaires, a CAT administration selects items from the item bank one at a time based on an administrative algorithm. As patients select answers to each item, FOTO progressively estimates the patient's functional score until the standard error is as small as possible (stopping rule). The FOTO continues to administer additional items until a stopping rule is satisfied. The final FOTO score represents a point estimate of FOTO scores for each patient on a ratio scale of 0–100, with higher measures representing higher functioning.
The FOTO scale has been found to be a reliable and valid measurement system for outpatient orthopedic rehabilitation for patients with lumbar spine pain.,, The standard error of measure is four points.
In addition to the functional score derived through the CAT, the lumbar functional scale is divided into five distinct functional staging categories. The functional staging categories are nonuniformly distributed ranging in size from 14 to 23 points with higher levels of functional staging representing decreasing severity of symptoms. These functional staging categories are designed to provide an overview of the patient's general functional status in the relation of overall disability. In addition, these functional staging categories are theorized to predict effectiveness and utilization of physical therapy services. The functional staging levels are defined in [Table 1].
The FOTO questionnaire also includes a measure of fear avoidance. The CAT utilizes a single item screen for fear avoidance derived from the Fear Avoidance Beliefs Questionnaire. The single item screen has been found to be a valid method to screen for depressive and somatization symptoms.
The SBST is a nine-item questionnaire that classifies patients into one of three categories on the basis of the presence of physical and psychosocial risk factors for persistent, disabling LBP symptoms. The nine items are divided into physical and psychosocial subscales. The physical subscale includes four items about referred leg pain, disability (two items), and comorbid shoulder or neck pain. The psychosocial subscale includes five items about bothersomeness, catastrophizing, fear, anxiety, and depression. Each item is scored as positive or negative, with the number of positive items being counted as the subscale score. Subscale scores are used to categorize the patient's risk level: Low risk if the total score from both subscales is 0–3, high risk if the psychosocial subscale score is 4 or 5, and medium risk if falling into neither the low-risk nor the high-risk category.,,
The SBST reliability for overall scores and psychosocial subscale scores has been found to be 0.73 (95% confidence interval [CI] 0.57–0.84) and 0.69 (95% CI 0.51–0.81), respectively. Furthermore, during implementation testing of the SBST, when stratified care was provided to patients with similar baseline characteristics according to the SBST, mean time off of work decreased by 50%, disability scores decreased, and health-care cost savings were observed.
PTs within the regional hospital network were recruited through E-mail for data collection training. Data collection training occurred during a single 1-hour session.
On presentation for consultation regarding a chief complaint of LBP, patients were provided with information regarding the study and consented by one of the study coinvestigators. All questionnaires were completed during the initial consultation in accordance with the institutional protocol.
In addition to the functional scale information, FOTO was also used to establish demographic values including duration of symptoms, age, insurance provider, gender, and number of comorbidities. The comorbidities each subject was asked to select from included arthritis, osteoporosis, asthma, chronic obstructive pulmonary disease, acquired respiratory distress syndrome, emphysema, angina, congestive heart failure, myocardial infarction, hypertension, neurological disease (such as multiple sclerosis or Parkinson's disease), cerebrovascular accident, peripheral vascular disease, headaches, diabetes mellitus, gastrointestinal disease, visual impairment, hearing impairment, urinary disorders, previous accidents, allergies, incontinence, anxiety disorders, depression, hepatitis, AIDS, prior surgery, prostheses or implants, sleep dysfunction, and cancer.
Following the administration of the questionnaires, usual patient consultation and care was provided in accordance with patient need.
A priori power analysis was calculated using PASS software version 11 (Hintze, J. (2011). PASS 11. NCSS, LLC. Kaysville, Utah, USA. http//www.ncss.com). The sample size required to attain a power of 90% was n = 61 with α =0.05. We increased this minimum sample size by 40% to help guard against missing or otherwise unusable data, for a total of 85 subjects. Data collection was stopped once there were 85 subjects.
Correlation between SBST risk stratification and FOTO functional staging was calculated by Kendall's tau-c as both variables are ordinal and have differing numbers of categories. In addition, the association between SBST psychosocial subscale (dichotomized to ≤3 or >3 based on the utilization of the subscale to differentiate medium risk from the high risk of developing chronic LBP) and the dichotomous fear avoidance level derived from the FOTO questionnaire was assessed with the Kappa statistic. α =0.05 was utilized for all statistical analysis.
| Results|| |
A total of 85 individuals were provided with the SBST as a part of the initial evaluation across 12 clinics in the network of clinics. A total of twenty subjects were excluded from analysis because (1) either screen was not fully completed or filled out incorrectly, (2) a nonlumbar functional survey was provided to the patient, (3) inclusion criteria were not met, or (4) indistinguishable and illegible writing of patient identifiers and/or coding.
Demographic data are provided in [Table 2] below. The mean age of subjects was 53.7 years with a range of 18–89 years. Most subjects were female (61.5%), and had four or more comorbidities (78.5%), were insured by a managed care program (26.2%) or Medicare (32.3%) and had elevated fear-avoidance (63.1%).
When categorized into risk stratification groups, the SBST denoted 32.3% of subjects (n = 21) in the high risk of developing chronic LBP category, 47.7% (n = 31) in the medium-risk category, and 20.0% (n = 13) in the low-risk category [Figure 1]. In contrast, the FOTO functional staging categories revealed 3.1% (n = 2) in the high disability category, 32.3% (n = 21) in the high-moderate disability category, 50.8% (n = 33) in the moderate disability category, and 13.8% (n = 9) in the low-moderate disability category. No subjects scored in the low disability category [Figure 2].
|Figure 1: Distribution of STarT Back Screening Tool risk stratification levels|
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|Figure 2: Focus on Therapeutic Outcomes functional stage distribution. FOTO: Focus on Therapeutic Outcomes|
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The correlation between SBST risk level and FOTO functional staging was poor with strong statistical significance with Kendall's tau-c of 0.369 (P < 0.001) [Table 3]. In addition, the correlation between elevated fear-avoidance and high psychosocial distress was also poor with a Kappa of 0.099 (P = 0.335). However, the statistical significance of the Kappa was poor, indicating that while the study was a priori powered for statistical significance of the main correlation, a larger sample size would be necessary to determine if elevated fear-avoidance is truly correlated with high psychosocial distress [Table 4].
|Table 3: Correlation of Focus on Therapeutic Outcomes functional stage and STarT Back Screening Tool risk level|
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|Table 4: Correlation between fear avoidance and STarT Back Screening Tool psychosocial subscale|
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| Discussion|| |
Acute LBP resolves in 90% of cases within 6 weeks, however, 62% of people experiencing their first episode of LBP will go on to develop symptoms lasting longer than 1 year. The SBST is a risk stratification assessment tool used by primary care physicians to aid care planning;,, the FOTO tool is used by PTs that also utilizes risk stratification for care planning., Understanding the relationship between these two different outcome tools may be useful in identifying cases that are at a higher risk for chronicity, guide interventions, improve communication between providers, and improve patient care outcomes.
We found that a statistically significant, poor relationship exists between the FOTO functional staging and the SBST risk stratification in patients with LBP. Although both tools are used to predict the risk of chronicity and used to stratify patients, we found that they cannot be used interchangeably. The SBST is intended to measure psychosocial distress as it relates to LBP whereas the FOTO is a measure of patient function. Both factors can be considered in risk stratification, but they do not appear to be directly dependent on each other given our findings. One may have a very high psychosocial distress finding through the SBST for example but have very little functional impairment. This individual would be in the high-risk category as measured by the SBST but present as a low-risk patient with the FOTO tool. The reverse situation is also possible as these variables are related but independent of each other. Both tools can be used independent of each other as appropriate management of LBP should be considered multifactorial and patient specific.
In 2011, Fritz et al. found the SBST categorized 33.2% of the patients as being at low risk, 47.7% as being at medium risk, and 19.2% as being at high risk. Our sample varied across the three categories: Low-risk category 21%, medium-risk category 67%, and high-risk category 12%. Our population was older (X̄ =44.3 versus 54), we did not exclude for postsurgical status, and the majority of our cases had symptoms lasting longer than 6 months compared to a mean of 46 days (18.5–147 days) from the sample Fritz et al. studied. Our sample was intended to be representative of the typical clinical presentation for LBP in the physical therapy setting. A different result may have been found had we excluded for surgical status or chronicity but excluding those groups may also have not been representative of a typical patient population for the setting either and provide less useful clinical information.
The SBST is used for predicting risk of chronicity and disability at 6 months , and FOTO is a measure of patient perception of functional ability. While functional limitation and pain have been found to be dependent variables in predicting chronicity in patients with LBP  and “fear-avoidance beliefs” have been found to be one of the strongest predictors of functional limitation, the results of this study do not support a strong correlation between those constructs. Given this statistically significant, poor correlation found in both aspects of this study, it is our recommendation that the SBST and FOTO cannot be used interchangeably as a predictor for chronicity in patients with LBP. Both tools are useful in making a clinical decision that will best identify risk factors for chronicity and allow the clinician to act to address modifiable predictors for chronicity.,,, Thus, to minimize the burden on patients, it would be beneficial to investigate how to integrate the SBST into the FOTO CAT and utilize the SBST in prognostic modeling in addition to the current risk stratification factors utilized by FOTO.
As the FOTO fear avoidance screen was designed to screen for fear avoidance, which is a component of psychosocial distress, it would be logical that it would be correlated with the SBST psychosocial distress subscale. However, our findings of poor correlation between the two scores demonstrate that fear avoidance alone cannot predict the combined psychosocial distress from fear, worry, catastrophizing, depression, and bothersomeness. Implications for practice and future research include examining cutoff scores and including additional questioning in the FOTO CAT to capture these additional constructs.
This information is useful for future researchers trying to stratify care to most efficiently and cost-effectively manage patients with LBP. In addition, comparing the SBST and FOTO to other validated outcome measures such as the Oswestry Disability Index, Roland–Morris disability questionnaire, or the Quebec back pain disability scale  may further help decrease patient and provider burden and improve communication and understanding between primary care providers and PTs when managing patients with LBP.
FOTO is intended to be given periodically during care to measure progress. Fritz et al. suggested that the SBST could also be used to track progress. Future research should examine the relationship between changes in FOTO functional stage and SBST risk category over time to see if the correlation changes as the patient progress through care.
The study is limited to a sample of convenience of participants living in Eastern Pennsylvania and located within the authors' clinical network of physical therapy practice. We also did not control for the order of the SBST and FOTO questionnaires were completed or if they were performed immediately before or immediately after the consultation.
Newell et al. found that over one-third of patients swapped SBST risk groups in the 2 days period between initial stratification and postinitial visit, although there was little difference in eventual improvement at follow-up. This variation in stratification may have influenced our findings as we did not control for chronicity of symptoms when measuring patients at intake with the SBST or FOTO. Because we provided the FOTO and the SBST at the same time and the initial evaluation, this variance likely did not affect our findings but should be noted when considering using the SBST. The SBST is used mostly in the primary care setting with an individual with an acute episode of LBP; we did not exclude based on chronicity. At this present time, the authors are not aware of any efforts to examine the validity of the SBST in patients with chronic LBP compared to those with acute LBP. The SBST simply may not be valid in a chronic pain population. We wanted to examine the general relationship between the SBST and the FOTO tool; however, our results may have been different had we only included individuals with acute nonoperative LBP who have been seen by primary care or who are direct access patients.
In addition, some scores were not used in the final analysis because of patient and provider error using FOTO and/or the SBST. This may reflect the utility of the tool in practice. Therefore, more training may be required before using the tools in practice to improve the accuracy of risk stratification.
Finally, as the power analysis was targeted at the main variables of FOTO functional staging and SBST risk stratification, the analysis of FOTO fear avoidance screen and SBST psychosocial subscale may have been underpowered. This is evident by the high statistical significance of the main comparison and the poor statistical significance of the FOTO fear avoidance screen and SBST psychosocial subscale correlation. Therefore, future studies would benefit from a larger sample size needed to determine if elevated fear-avoidance is truly correlated with high psychosocial distress.
| Conclusion|| |
There is a poor correlation between the SBST risk category and the FOTO functional stage in patients being seen for LBP in the physical therapy setting. Each tool has a separate purpose to aid in clinical decision making with the SBST to be used as a predictor of chronicity and the FOTO as a measure of patient-perceived functional ability. Future research should investigate integrating the SBST into the FOTO CAT, compare the SBST and FOTO in acute versus chronic individuals with LBP, compare other outcome measures to the SBST and FOTO, and examine if the relationship between the SBST and FOTO changes during care.
The authors would like to thank Jill Stoltzfus, St. Luke's University Health Network.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]