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Does a modified STarT Back Tool predict outcome with a broader group of musculoskeletal patients than back pain? A secondary analysis of cohort data
  1. J C Hill,
  2. E K Afolabi,
  3. M Lewis,
  4. K M Dunn,
  5. E Roddy,
  6. D A van der Windt,
  7. N E Foster
  1. Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
  1. Correspondence to Dr J C Hill; j.hill{at}


Objectives The STarT Back Tool has good predictive performance for non-specific low back pain in primary care. We therefore aimed to investigate whether a modified STarT Back Tool predicted outcome with a broader group of musculoskeletal patients, and assessed the consequences of using existing risk-group cut-points across different pain regions.

Setting Secondary analysis of prospective data from 2 cohorts: (1) outpatient musculoskeletal physiotherapy services (PhysioDirect trial n=1887) and (2) musculoskeletal primary–secondary care interface services (SAMBA study n=1082).

Participants Patients with back, neck, upper limb, lower limb or multisite pain with a completed modified STarT Back Tool (baseline) and 6-month physical health outcome (Short Form 36 (SF-36)).

Outcomes Area under the receiving operator curve (AUCs) tested discriminative abilities of the tool's baseline score for identifying poor 6-month outcome (SF-36 lower tertile Physical Component Score). Risk-group cut-points were tested using sensitivity and specificity for identifying poor outcome using (1) Youden's J statistic and (2) a clinically determined rule that specificity should not fall below 0.7 (false-positive rate <30%).

Results In PhysioDirect and SAMBA, poor 6-month physical health was 18.5% and 28.2%, respectively. Modified STarT Back Tool score AUCs for predicting outcome in back pain were 0.72 and 0.79, neck 0.82 and 0.88, upper limb 0.79 and 0.86, lower limb 0.77 and 0.83, and multisite pain 0.83 and 0.82 in PhysioDirect and SAMBA, respectively. Differences between pain region AUCs were non-significant. Optimal cut-points to discriminate low-risk and medium-risk/high-risk groups depended on pain region and clinical services.

Conclusions A modified STarT Back Tool similarly predicts 6-month physical health outcome across 5 musculoskeletal pain regions. However, the use of consistent risk-group cut-points was not possible and resulted in poor sensitivity (too many with long-term disability being missed) or specificity (too many with good outcome inaccurately classified as ‘at risk’) for some pain regions. The draft tool is now being refined and validated within a new programme of research for a broader musculoskeletal population.

Trial registration number ISRCTN55666618; Post results.

  • prognosis
  • prospective cohort
  • STarT Back Tool
  • Risk stratification

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  • Contributors JCH, DAvdW, NEF, ER and KMD conceived and designed the research; NEF and ER were responsible for the modified STarT Back Tool being embedded within the PhysioDirect and SAMBA data sets; JCH, EKA and ML analysed the data and all authors were involved in the interpretation of the data analysis; JCH, ER, EKA, ML, DAvdW, KMD and NEF were involved in the drafting of the manuscript and its revision for important intellectual content, and gave final approval for the manuscript submission.

  • Funding This paper presents independent research (part) funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (Grant reference number: RP-PG-1211-20010), the NIHR Primary Care Career Scientist Award to NEF (CSA 04/03) and Arthritis Research UK (13413). DAvdW received funding from an MRC Partnership Grant for the PROGnosis RESearch Strategy (PROGRESS) group (grant reference number: G0902393). The SAMBA study was supported by an Arthritis Research UK Integrated Clinical Arthritis Centre Grant (17684), the Arthritis Research UK Primary Care Centre Grant (18139), funding secured from Stoke-on-Trent Primary Care Trust (PCT) and service support through the West Midlands North CLRN. NEF holds an NIHR Research Professorship (NIHR-RP-2011-015) which also supports JCH.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The views and opinions expressed within this manuscript do not necessarily reflect those of DH/NIHR. The funding bodies were not involved in the design of the study outlined within this protocol, and had no involvement in the writing and revision of this manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval This was secondary data analysis of two studies which both obtained ethical approval through written informed consent. For PhysioDirect approval came from Southmead NHS Research Ethics Committee, reference 08/H0102/95 and for the SAMBA study from the South Staffordshire NHS Research Ethics Committee reference 07/H1203/86.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data can be accessed via the Keele data repository at

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