Clinical StudyThe use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain
Introduction
Back pain is one of the most common health problems with more than two-thirds of the population reporting back pain at least once during life [1], [2]. Low back problems are the second and third leading complaint in outpatient visits and hospital admissions respectively [1], [3] and carry an annual prevalence of as high as 45% [4]. The high incidence and prevalence of back pain equates to substantial health care utilization and spending. In 2005 in the US, the direct health care costs of back pain were estimated at 85 billion dollars [5], [6]. More concerning is that these cost has increased by 65% since 1995 at a rate far outpacing overall healthcare spending [5], [6], [7].
At least 25% of outpatient physical therapy practice is related to low back pain (LBP) [8], [9], [10]. The American College of Physicians practice guidelines recommend many nonpharmacologic interventions used by physical therapists as front line LBP treatments [11]. However, 45% of patients receiving physical therapy fail to have significant improvement in pain and disability [12]. Early identification of those with favorable and nonfavorable prognoses could have a significant impact on future care models for LBP. In particular, emotional dimensions are important contributors to outcomes of patients with LBP. The STarT Back Screening Tool (SBST) [13] is one well-established clinical tool used to determine risk of future disability based on psychosocial factors. It was originally designed for use in primary care [14], where providing risk-stratified treatment improved disability outcomes while lowering healthcare utilization when compared to usual care [15]. The SBST has also been used to successfully predict disability outcomes for patients seeking outpatient physical therapy [16], [17].
There are still areas to explore for gaining a better understanding of the SBSTs predictive capabilities, in order to improve their utility in clinical practice. Previous studies have focused on differences in clinical outcomes between the three risk groups, because they lacked adequate statistical power to refine predictive accuracy within an individual risk group. Prior investigations were recruited as part of clinical trials or cohort studies, and may not reflect ethnic and socioeconomic diversity occurring in real practice settings. Future investigation of these factors is needed as highlighted by a recent analysis indicating individuals with greater psychosocial distress and lower socioeconomic status (SES) had decreased benefit of receiving risk stratified care [18]. Therefore, the overall purpose of this study to further refine SBST risk categorization for predicting improvements in disability in a multivariable model with attention toward patient level factors that might guide SBST use in routine outpatient physical therapy practice. First, we determined the association of SBST categorization with meeting a clinically meaningful improvement threshold for functional disability, as determined by the patient-reported modified low back pain disability questionnaire (MDQ). Second, we investigated whether there was an interaction between SBST risk category and baseline functional disability to provide better context in predicting improvement. Information from this analysis will optimize the use of SBST within clinical practice.
Section snippets
Study design
This was a retrospective cohort study of patients with LBP who presented for outpatient physical therapy at Cleveland Clinic Health System facilities in northeastern Ohio. In this system, patient-reported outcomes are systematically collected at the point of care on tablets at all physical therapy sites through the Knowledge Program data collection system [19]. Results are immediately available within the electronic health record (Epic, Epic Corporation, Verona, WI, USA). SBST and MDQ were both
Patient characteristics
A total of 10,329 patients had a PT episode of care between June 1, 2014 and May 31, 2015 with a primary ICD-9-CM diagnosis code for a LBP and were 18 years of age or older at their first visit. We removed 287 patients who were missing documentation indicating their episode of care was complete and an additional 6,130 patients who did not complete the SBST. Finally, we removed 2,743 patients who did not have an MDQ at baseline and follow-up. Thus, our final sample consisted of 1,169 patients (
Discussion
Our analyses demonstrated a potentially complex relationship between SBST category, disability score, and improvement. The interaction between SBST category and baseline MDQ score is a novel finding with clinical relevance, as our findings indicated that the relationship between SBST category and meaningful improvement in disability varied according to baseline MDQ scores. Among patients with lower baseline disability (MDQ scores <20), those categorized as low psychosocial risk had lower
Conclusion
This analysis has shown that SBST tool predicts outcomes of PT in a real world cohort of patients receiving outpatient physical therapy for LBP. We identified nuances that may refine future SBST use. First, there was an interaction indicating that odds of improvement varied according to baseline disability and SBST risk status. Second, we identified race, insurance type, and history of previous PT as variables that improved prediction independent of SBST risk status. Incorporating these
Acknowledgment
Dr. George acknowledges funding from the National Institutes of Health/National Center for Complementary and Integrative Health (UG3AT009790) in preparation of this manuscript.
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Treatment monitoring as a component of psychologically informed physical therapy: A case series of patients at high risk for persistent low back pain related disability
2019, Musculoskeletal Science and PracticeCitation Excerpt :Future research could compare these composite measures with unidimensional measures to determine which are most appropriate for treatment monitoring in high-risk patients. Finally, future research should consider how other non-psychological measures such as socioeconomic status (Beneciuk et al., 2017) and race (Katzan et al., 2018) impact treatment monitoring to provide further insight to the unexplained variance in pain and disability outcomes. In this case series, we included an index consisting of 8 different components including lumbar flexion, extension, pelvic flexion, lateral flexion, straight leg raising, spinal tenderness, bilateral active straight leg raise, and sit-up.
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FDA device/drug status: Not applicable.
Author disclosures: IK: Nothing to disclose. NT: Nothing to disclose. SG: Nothing to disclose. SP: Nothing to disclose. FF: Nothing to disclose. MS: Nothing to disclose.