Prognostic ability of the German version of the STarT Back tool: analysis of 12-month follow-up data from a randomized controlled trial

Abstract

Background Stratified care is an up-to-date treatment approach suggested for patients with back pain in several guidelines. A comprehensively studied stratification instrument is the STarT Back Tool (SBT). It was developed to stratify patients with back pain into three subgroups, according to their risk of persistent disabling symptoms. The primary aim was to analyse the disability differences in patients with back pain 12 months after inclusion according to the subgroups determined at baseline using the German version of the SBT (STarT-G). Moreover, the potential to improve prognosis for disability by adding further predictor variables, an analysis for differences in pain intensity according to the STarT-Classification, and discriminative ability were investigated. Methods Data from the control group of a randomized controlled trial were analysed. Trial participants were members of a private medical insurance with a minimum age of 18 and indicated as having persistent back pain. Measurements were made for the risk of back pain chronification using the STarT-G, disability (as primary outcome) and back pain intensity with the Chronic Pain Grade Scale (CPGS), health-related quality of life with the SF-12, psychological distress with the Patient Health Questionnaire-4 (PHQ-4) and physical activity. Analysis of variance (ANOVA), multiple linear regression, and area under the curve (AUC) analysis were conducted. Results The mean age of the 294 participants was 53.5 (SD 8.7) years, and 38% were female. The ANOVA for disability and pain showed significant differences ( p < 0.01) among the risk groups at 12 months. Post hoc Tukey tests revealed significant differences among all three risk groups for every comparison for both outcomes. AUC for STarT-G’s ability to discriminate reference standard ‘cases’ for chronic pain status at 12 months was 0.79. A prognostic model including the STarT-Classification, the variables global health, and disability at baseline explained 45% of the variance in disability at 12 months. Conclusions Disability differences in patients with back pain after a period of 12 months are in accordance with the subgroups determined using the STarT-G at baseline. Results should be confirmed in a study developed with the primary aim to investigate those differences.

Artificial intelligence to improve back pain outcomes and lessons learnt from clinical classification approaches: three systematic reviews

“…Of these, 17 studies assessed pain and disability prognosis with univariate models 70 , 74 , 77 , 80 , 81 , 84 – 86 , 89 , 94 , 96 , 97 , 104 – 108 . Of the univariate analyses, eight showed significant prognostic benefits for pain intensity 74 , 83 , 85 , 89 , 93 , 97 , 106 , 107 , 13 showed significant prognostic benefits for disability 74 , 83 – 86 , 89 , 93 , 94 , 96 , 97 , 102 , 105 , 108 , while two showed significant prognostic benefits on mixed pain intensity and disability analyses 80 , 81 . Of the multivariate models, two studies showed the STarT Back to predict prognosis for pain intensity adjusted for baseline pain 90 , 91 , while four showed no significant association 71 , 72 , 78 , 93 .…”

“…the trajectory of a condition based on certain subgroup factors) of people with LBP, it is critical to account for the patients' pain and disability when they are first assessed, as these factors are the strongest and most consistent predictors of pain and disability in the months after LBP incidence [147][148][149][150] . The STarT Back tool was typically (in six 71,72,83,90,93,102 of eight 78,91 studies and 2080 of 2634 patients) able to predict future disability, but this was less consistent for pain intensity (two 90,91 of six 71,72,78,93 studies and 348 of 1899 patients). For the McKenzie method, no studies assessed the effectiveness of the classification method on future pain intensity while accounting for baseline values.…”

“…Jiang et al 31 for disability 74,[83][84][85][86]89,93,94,96,97,102,105,108 , while two showed significant prognostic benefits on mixed pain intensity and disability analyses 80,81 . Of the multivariate models, two studies showed the STarT Back to predict prognosis for pain intensity adjusted for baseline pain 90,91 , while four showed no significant association 71,72,78,93 .…”

“…Of these, 17 studies assessed pain and disability prognosis with univariate models 70,74,77,80,81,[84][85][86]89,94,96,97,[104][105][106][107][108] . Of the univariate analyses, eight showed significant prognostic benefits for pain intensity 74,83,85,89,93,97,106,107 , 13 showed significant prognostic benefits Azimi et al 22 1 1 1 1 0 0 0 1 0 5 / 9 Barons et al 52 1 1…”

“…Of the multivariate models, two studies showed the STarT Back to predict prognosis for pain intensity adjusted for baseline pain 90,91 , while four showed no significant association 71,72,78,93 . Eight studies assessed prognosis for disability in multivariate models adjusted for baseline levels of disability with, six studies in favour 71,72,83,90,93,102 and two against 78,91 a significant association. Four clinical trials assessed the STarT Back for classification and treatment allocation-compared outcomes to standard care (Supplementary Table 5) 15,76,95,110 .…”