STarT Back Approach

Original Editor - Rachael Lowe

Top Contributors - Tarina van der Stockt, Claire Knott and Kim Jackson  


The STarT Back approach uses a simple tool to match patients to treatment packages appropriate for them based on prognosis. This has been shown to:

  1. Significantly decrease disability from back pain
  2. Reduce time off work
  3. Save money by making better use of health resources

Taking the concept further it has been shown in the IMPaCT study that this approach can be successfully embedded into normal primary care[1]. The STarT Back approach is used widely in the UK and and continues to be adopted internationally.

The STarT Back Screening Tool

The Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability.  The resulting score stratifies patients into low, medium or high risk categories.  For each category there is a matched treatment package.

There are now several different versions of the Keele STarT Back screening tool:

9-item tool: for all clinicians including GPs

The SBST 9 item tool has 9 questions about predictors for persistent disabling back pain. They include radiating leg pain, pain elsewhere, disability (2 items), fear, anxiety, pessimistic patient expectations, and low mood and how much the patient is bothered by their pain. All 9-items use a response format of ‘agree' or ‘disagree', with exception to the bothersomeness item, which uses a Likert scale. The Keele SBST produces two scores: overall and distress (psych) subscale. These are used to stratify patients into low, medium and high risk groups which have their respective matched treatment packages.

The patient is asked to think about the last 2 weeks and tick "disagree" or "agree" for questions 1-8 and then give a scale for question 9.

  1. Back pain spread down the leg(s)
  2. Pain in the shoulder or neck at some time
  3. Only walked short distances due to back pain
  4. Dressed more slowly due to back pain
  5. "It is not safe for a person with a condition like mine to be physically active"
  6. "Worrying thoughts have been going through my mind a lot of the time"
  7. "I feel that my back pain is terrible and it's never going to get any better"
  8. "In general I have not enjoyed all the things I used to enjoy"
  9. How bothersome has your back pain been?
Start scoring system.jpg

Clinical measurement tool: monitor change

The 9-item SBST Clinical Measurement Tool is designed to help clinicians objectively measure the severity of the domains screened by the 9-item tool. When repeated measures are used this enables an objective marker of change over time to be made for individual items.
Cut-offs have been established for each item - to enable those using this tool to subgroup patients in the same way as the 9-item screening tool. The cut-off points that equate to an agree/positive score on the clinical measurement tool for subgrouping are:

  • Leg pain - 'moderately' or more
  • Shoulder/neck - slightly or more
  • Dressing - 5 or more
  • Walking - 5 or more
  • Fear - 7 or more
  • Worry - 3 or more
  • Catastrophising - 6 or more
  • Mood - 7 or more
  • Bothersomeness - 'very' or more

Its very easy to produce an acetate using these cut-offs that you place over the questionnaire to quickly enable you to score the clinical measurement tool for subgrouping purposes.

Matched Treatments

The STarT Back approach uses the STarT Back tool to stratify patients with back pain into low, medium and high risk groups for ongoing disability. For each group there is a different treatment package matched to their level of risk.

Low Risk

The patients in the low risk category are very likely to improve. The aims of this package are to support and enable self-management. The key factors are to address patient concerns and to provide information.

  • One-off consultation with clinician (doctor, physiotherapist or nurse) sufficient for most patients
  • Assessment to include medical issues but also patient worries, concerns and social impact
  • Brief physical assessment as appropriate. Examination helps with patient confidence
  • Medication review and advice
  • Address specific patient issues from the assessment
  • Seek to encourage activity and self-management
  • Avoid unhelpful labels and medicalisation
  • Provide oral and written information
  • Explain outlook is good but can re-consult if necessary

Medium Risk

This builds on the assessment from the low risk package. The main aims are to restore function (including work), minimise disability even if pain is unchanged and to support appropriate self-management.  This is the risk group that we are most likely to use usual physiotherapy treatments with as directed by guidelines.

  • Similar to low risk, elicit concerns and adequate physical examination
  • Tailored treatment according to physical findings and specific needs / worries of the individual patient
  • Course of physiotherapy, which for some patients may only be brief
  • Specific physiotherapy interventions when clear specific findings from physical assessment (i.e. manual therapy, specific exercises).
  • General functional activities when no strong relationship between physical findings and back pain complaint
  • Treatment objectives should be specific and have an end time point. All specific treatment effects should ‘translate’ into functional improvements and reduced disability
  • Some patients will need onward referral to specialist services (i.e. secondary care spinal services, ortho, pain clinic)

High Risk

This again builds on the low and medium risk packages. The aims are to reduce pain, reduce disability and improve psychological functioning. The physiotherapists delivering the high risk package have additional training, mentorship and ongoing professional support to enable them to elicit and address more complex issues in patients who often have additional psycho-social barriers to recovery. It is important to emphasis that the physiotherapists also provided physical treatments to these patients as required.

  • 6 individual (45-60 min) physiotherapy appointments over 3 months using a combined physical & cognitive-behavioural approach
  • Enable patients to manage on-going and/or future episodes of low back pain
  • Specific focus on cognitive, emotional and behavioural responses to pain and their impact on function
  • Identification of potential obstacles to rehabilitation (e.g. Yellow & Blue Flags)
  • Identification of possible targets for intervention

Recommendations for Practice


A brief examination of patients with back pain has two basic purposes.  Firstly it will help screen patients for possible serious spinal pathology even though taking a good history is much more important. Secondly it will improve patient satisfaction and effectiveness of the consultation. It is suggested that the following be performed as a bare minimum:

  • Inspect – general appearance, gross structural deformities
  • Active movements – flexion (significant limitation often pathological), extension, side flexion
  • Myotomes– rise from a knee squat (L3/4), walk on heels (L4/5) and walk on toes (S1/2).
  • SLR (if leg pain or if you feel is needed for reassurance) +/- slump test

Obviously if the history raises concerns that there may be non-spinal pain, structural deformity, widespread neurological disorder or serious spinal pathology it is appropriate to examine the patient more fully as per normal clinical practice

Screen for Red Flags

Red flags in spinal conditions

Explanation and management

Language and labels

  • Use functional explanations for pain (sprained back, non-serious back pain). Example: “Many people have back pain from time to time but it is rare for this to be caused by a specific problem. Mostly all that is needed is to get your back moving again and things will settle down.
  • ”Avoid “spondylitis, degeneration, crumbling” etc.
  • Can be more specific sometimes, for example sciatica, if this leads to specific management.
  • Avoid investigating in the first place unless it is specifically indicated (link CKS). However if you do so be aware that the technical terms used in reports often alarm patients. Translate appropriately, examples: “normal for your age ”, “ the changes seen on your scan are like getting grey hair or wrinkles as you get older”
  • Prognosis: low risk – excellent, medium risk – good but guarded, high risk – suggest hope for improved function but don’t promise cure pain.

Dealing with distress

  • Suspend pre-judgment
  • Listen carefully / summarize points
  • Plan to address points
  • Care with language and labels
  • Be honest and realistic
  • Do not criticize the opinions of other clinicians who have seen the patient.
  • Provide information

Activity promotion

  • Activity promotion: beneficial, hurt doesn’t equal harm, minimise bed rest
  • Pacing: short, frequent bouts of activity rather than overdoing things and then regretting it the next day, rests between activity, do less than maximal capabilities and increase as tolerated.
  • Return to work as soon as possible, prolonged absence likely to lead to loss of employment. Use fit notes to support return to work and communicate suggestions to the employer. Help the patient negotiate an early return to work if at all possible.
  • Medication usage to aid recovery link to Clinical Knowledge Summaries

Key Resources

STarT Back Trial

  • Hill J, D Whitehurst, Lewis M, Bryan S, Dunn K, Foster N, Konstantinou, Main C, Mason E, Somerville S, Sowden G, Vohora K, Hay E. A randomised controlled trial and economic evaluation of stratified primary care management for low back pain compared with current best practice: The STarT Back trial.The Lancet, Volume 378, Issue 9802, Pages 1560 - 1571, 29 October 2011 link
  • E Hay, K Dunn, J Hill, M Lewis, E Mason, K Konstantinou, G Sowden, S Somerville, K Vohora, D Whitehurst and C Main. A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care. The STarT Back Trial Study Protocol . BMC Musculoskeletal Disorders April 2008, 9:58 link
  • Whitehurst DG, Bryan S, Lewis M, Hill J, Hay EM. Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups. Ann Rheum Dis 2012; 71(11): 1796-802. link
  • Main C, Hill J, Sowden G and Watson P. Integrating physical and psychosocial approaches to treatment in low back pain. The development and content of the Keele STarT Back trial's "high risk" intervention (StarTBack; ISRCTN 37113406). Physiotherapy 2011 link

IMPaCT study

  • Foster N, Mullis R, Hill J, Lewis M, Whitehurst D, Doyle C, Konstantinou K, Main C, Somerville S, Sowden G, Wathall S, Young J, Hay E. Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison. Ann Fam Med March/April 2014 vol. 12 no. 2 102-111 link
  • Sowden G, Hill JC, Konstantinou K, Khanna M, Main C, Salmon P, Somerville S, Wathall S, Foster N. Subgrouping for targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281) Family Practice 2011 link
  • Foster NE, Mullis R, Young J, Doyle C, Lewis M, Whitehurst D, Hay EM; IMPaCT Back Study team. IMPaCT Back study protocol. Implementation of subgrouping for targeted treatment systems for low back pain patients in primary care: a prospective population-based sequential comparison. BMC Musculoskelet Disord 2010; 20(11): 186. link

STarT Back Tool

  • Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632–41 
  • Jonathan C. Hill *, Kate M. Dunn, Chris J. Main, Elaine M. Hay. Subgrouping low back pain: A comparison of the STarT Back Tool with the Örebro Musculoskeletal Pain Screening Questionnaire. Eur J. Pain 2009; doi:10.1016/j.ejpain.2009.01.003 
  • Gusi N, Del Pozo-Cruz B, Olivares PR, Hernandez-Mocholi M, Hill JC. The Spanish version of the “STarT Back Screening Tool” (SBST) in different subgroups. Aten Primaria 2010 
  • Hill et al. Comparing the STarT Back Screening Tool's Subgroup Allocation of Individual Patients With That of Independent Clinical Experts.Clinical Journal of Pain: 2010 - Volume 26 - Issue 9 - pp 783-787 
  • Morsø L, Albert H, Kent P, Manniche C, Hill J. Translation and discriminative validation of the STarT Back Screening Tool into Danish. Eur Spine J. 2011 Dec;20(12):2166-73. Epub 2011 Jul 19. 
  • Olivier Bruyere, Maryline Demoulin, Clara Brereton, Fabienne Humblet, Daniel Flynn, Jonathan C Hill, Didier Maquet, Julien Van Beveren, Jean-Yves Reginster, Jean-Michel Crielaard and Christophe Demoulin.Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French Archives of Public Health, 70:12 (07 Jun 2012) 

Stratified Care

  • Hill JC. The early identification of patients with complex back pain problems. The Back Care Journal. Spring 2010. 
  • Hill JC, Fritz JM. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011;91:712–721 
  • Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther. 2011;91:722–732
  • Alice Kongsted, Else Johannesen and Charlotte Leboeuf-Yde. Feasibility of the STarT back screening tool in chiropractic clinics: a cross-sectional study of patients with low back pain. Chiropractic & Manual Therapies 2011, 19:10 doi:10.1186/2045-709X-19-10 
  • Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther 2011;91:722–732. 
    del Pozo-Cruz B, Parraca JA, del Pozo-Cruz J, Adsuar JC, Hill JC, Gusi N. 2012. An occupational, internet-based intervention to prevent chronicity in sub-acute lower back pain: A randomized controlled trial. Journal of Rehabilitation Medicine. vol. 44(7), 581-587.
  • Hill JC, Foster NE, Hay EM. 2010. Cognitive behavioural therapy shown to be an effective and low cost treatment for subacute and chronic low-back pain, improving pain and disability scores in a pragmatic RCT. Evid Based Med, vol. 15(4), 118-119. l
  • Field J, Newell D. Relationship between STarT Back Screening Tool and prognosis for low back pain patients receiving spinal manipulative therapy. Chiropr Man Therap. 2012 Jun 12;20(1):17. 
  • Beneciuk JM, Bishop MD, Fritz JM, Robinson ME, Asal NR, Nisenzon AN, George SZ. 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. 2012 Nov 2.
  • Wideman TH, Hill JC, Main CJ, Lewis M, Sullivan MJ, Hay EM. Comparing the responsiveness of a brief, multidimensional risk screening tool for back pain to its unidimensional reference standards: The whole is greater than the sum of its parts. Pain. 2012 Nov;153(11):2182-91. 
  • N Foster & A Delitto. Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain: Integration of Psychosocial Informed Management Principles into Physical Therapist Practice - Challenges and Opportunities. Physical Therapy 2011. 


  1. Nadine E. Foster, Ricky Mullis, Jonathan C. Hill, Martyn Lewis, David G. T. Whitehurst, Carol Doyle, Kika Konstantinou, Chris Main, Simon Somerville, Gail Sowden, Simon Wathall, Julie Young, Elaine M. Hay. Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison. Ann Fam Med. 2014 March; 12(2): 102–111. doi: 10.1370/afm.1625