Patient-reported outcome measure

STarT Back

STarT Back Screening Tool

The STarT Back Screening Tool stratifies patients with low back pain into low, medium and high risk of persistent disabling pain using nine items, of which five form a psychosocial subscale, so that treatment can be matched to risk rather than given uniformly.

Licensed instrument9 items~2 min0–9, lower is better

This instrument is not reproduced here

The STarT Back Screening Tool is copyrighted by Keele University, which operates a licensing programme covering its use, translation and incorporation into software. Licences are commonly granted without charge for non-commercial clinical and research use, but they must be applied for, and commercial or web-based use is treated separately. That is why the items are not reproduced here.

Obtain a licence from the rights holder

What the STarT Back score means

STarT Back scores run from 0 to 9, where a lower score is better. The bands below are conventional reporting categories, not diagnostic cut-offs.

Low risk0–3
Total score of 3 or less. Good prognosis. The recommended response is reassurance, advice to stay active and minimal intervention — additional treatment adds cost without improving outcome in this group.
Medium or high risk — determined by the subscale4–4
A total of 4 or more is medium risk unless the psychosocial subscale is also 4 or more, in which case the patient is high risk. The subscale is what separates the two.
Medium or high risk — determined by the subscale5–9
A total of 4 or more with a psychosocial subscale of 4 or more is high risk, warranting psychologically informed physiotherapy. With a subscale of 3 or less it is medium risk, warranting standard physiotherapy.

Published criteria and reliability

The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.

Type	Value	Subscale	Population	Follow-up	Source
Criterion	Total ≤ 3 — low risk	—	Primary care low back pain	—	Hill JC 2008
Criterion	Total ≥ 4 and subscale ≤ 3 — medium risk	—	Primary care low back pain	—	Hill JC 2008
Criterion	Total ≥ 4 and subscale ≥ 4 — high risk	—	Primary care low back pain	—	Hill JC 2008
Criterion	Stratified care improved disability and was cost-saving versus usual care	—	Primary care randomised controlled trial	—	Hill JC 2011

Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.

How the score is calculated

Stated in full so the calculation can be independently checked, and reproduced by hand if needed.

Nine items are scored. Eight are answered agree or disagree, with agree scoring 1 and disagree scoring 0. The ninth asks how bothersome the back pain has been over the last two weeks, and scores 1 if the answer is "very much" or "extremely" and 0 otherwise. The total score runs from 0 to 9. Items 5 to 9 form a psychosocial distress subscale scoring 0 to 5. Risk is then assigned by a two-step rule: a total of 3 or less is low risk; a total of 4 or more with a subscale of 3 or less is medium risk; and a total of 4 or more with a subscale of 4 or more is high risk. The subscale is only consulted once the total reaches 4, which is why the total alone cannot determine the group.

Missing data

All nine items are required. The two-step algorithm depends on both the total and the subscale, so a missing item can change the risk group and no substitution rule is published.

Instrument profile

Developer: Jonathan C. Hill and colleagues
Institution: Keele University, United Kingdom
First published: 2008
Custodian: Keele University
Items: 9
Response format: Nine items — eight agree/disagree, one 5-point bothersomeness item
Score range: 0 to 9
Direction: Lower score = better
Recall period: The last 2 weeks
Completion time: About 2 minutes
Age range: Adults aged 18 and over presenting in primary care
Regions: Spine
Conditions: Low back pain, Acute low back pain, Chronic low back pain
Procedures: Stratified primary care management, Physiotherapy, Psychologically informed physiotherapy
Languages: English, Danish, Dutch, German, French, Spanish, Persian, 20+ validated translations
Test–retest (ICC): Weighted kappa around 0.79 for the risk group allocation
Internal consistency: Cronbach's alpha 0.79 for the total score
Validity: Discriminates prognosis effectively in primary care, and the stratified care model built on it demonstrated better disability outcomes and lower costs than usual care in a randomised trial — one of the few risk-stratification tools in musculoskeletal medicine with trial evidence for the intervention it triggers, not merely for its prediction.
Responsiveness: It is a prognostic screening tool rather than an outcome measure, and is not designed to be repeated to track change. Performance is weaker outside primary care: in secondary care and in populations with long symptom duration, the distribution shifts and the thresholds discriminate less well.

Normative values

Reference values from published cohorts, for comparison against the score you calculated.

Population	Age	Mean	SD
UK primary care low back pain consultations	—	Approximately 25–35% low, 40–50% medium, 20–30% high risk	—

When to use the STarT Back

Well suited to

At first presentation of low back pain in primary care, to match treatment intensity to prognostic risk.
Services implementing stratified care pathways, where it is the tool the trial evidence was built on.

Limitations and poor fits

Without a licence from Keele University.
As an outcome measure — it is prognostic, and repeating it to measure change is a misuse. Use the Roland-Morris or Oswestry for that.
In secondary care, in patients with long-standing pain, or outside low back pain, where it was not validated.
Where serious pathology has not been excluded — it is a prognostic tool, not a screen for red flags.

STarT Back compared with other instruments

Instruments measuring a related construct, with the practical difference between them.

Instrument	Items	Range	What it adds
PSEQ	10	0–60	The Pain Self-Efficacy Questionnaire measures how confident a person is in carrying out activities despite their pain, scoring ten statements from 0 to 6 for a total of 0 to 60, where higher scores indicate stronger self-efficacy and 40 or more is the commonly cited threshold for a good functional prognosis.
RMDQ	24	0–24	The Roland-Morris Disability Questionnaire measures physical disability from low back pain by counting how many of 24 statements a patient agrees with, giving a score from 0 (no disability) to 24 (maximum disability).
ODI	10	0–100	The Oswestry Disability Index measures how far low back pain restricts ten everyday activities, scoring each section from 0 to 5 and expressing the total as a percentage from 0% (no disability) to 100% (maximum disability).

Copyright and permitted use

Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.

Licensed instrumentRights holder: Keele University

Rights holder’s own page

References

Hill JC, Dunn KM, Lewis M, et al.. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis & Rheumatism. 2008.PMID 18438893
Hill JC, Whitehurst DG, Lewis M, et al.. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet. 2011.PMID 21963002
Hill JC, Dunn KM, Main CJ, Hay EM. Subgrouping low back pain: a comparison of the STarT Back Tool with the Örebro Musculoskeletal Pain Screening Questionnaire. European Journal of Pain. 2010.PMID 19740684

Editorial status

Not yet reviewedQueued for clinical review by Sam Tuffun, PT, DPT. Sign-off has not taken place — this is a placeholder assignment, not a completed review.