STarT Back Screening Tool

Original Editor - Alistair James

Top Contributors - Alistair James, Tony Lowe, Elaine Lonnemann and Tarina van der Stockt  

Images (9-item tool)

STarT Back Screening Tool

Objective (9-item tool)

The Keele STarT Back Screening Tool (SBST) (9-item version) is a brief validated tool, designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making [1].

Intended Population (9-item tool)

Primary care patients with low back pain [1].

Method of Use (9-item tool)

The STarT Back Screening Tool helps primary care clinicians (GPs, physiotherapists etc) to group patients into three categories of risk of poor outcome (persistent disabling symptoms) - low, medium, and high-risk. By being able to categorise patients into these 3 groups, clinicians are then able to target interventions to each sub-group of patients to help outcome [1].

The STarT Back Screening Tool is available in a number of languages including: English, Dutch, French, Spanish, Danish and Welsh (Keele University n.d). The tool produces two scores: overall scores and distress subscale scores [2].

  • The distress subscale score is used to identify the high-risk subgroup. To score this subscale add the last 5 items; fear, anxiety, catastrophising, depression and bothersomeness (bothersomeness responses are positive for 'very much' or 'extremely' bothersome back pain). Subscale scores range from 0 to 5 with patients scoring 4 or 5 being classified into the high-risk subgroup [1].
  • The overall score is used to separate the low risk patients from the medium-risk subgroups. Scores range from 0-9 and are produced by adding all positive items; patients who achieve a score of 0-3 are classified into the low-risk subgroup and those with scores of 4-9 into the medium-risk subgroup [1].

Evidence (9-item tool)

The STarT Back trial [3] compared the clinical and cost effectiveness of stratified management approach; allocating patients to different treatment pathways based on their prognosis (low, medium, or high risk of poor outcome); with that of current best practice. The trial demonstrated that this new model results in greater health benefits, achieved at a lower average health-care cost, with an average saving to health services of £34.39 per patient and societal savings of £675 per patient [1].

The Keele SBST 6-Item Version

The Keele SBST 6-item version includes 6 of the same items as the original 9-item version, with 3 items excluded (fear, anxiety and pain elsewhere), making it quicker it use. However, [1] have reported that their research (unpublished) shows that the 6-item version is only able to allocate patients to one of two subgroups (low risk or high risk). Patients who score 3 or more items positively have a high-risk of persistent disabling low back pain.

The Keele SBST 9-Item Clinical Measurement Tool

The Keele SBST 9-item clinical measurement version has been designed to help physiotherapists objectively measure the severity of the domains screened by the original 9-item version. When repeated measures are used this enables an objective marker of change over time to be made for individual items; essentially this version can be used as an outcome measure in addition to being used to subgroup patients in the same way as the original 9-item version. In order to be able to use this version to subgroup patients in the same way as the original 9-item version, cut-offs have been established for each item. The cut-off points that equate to an agree/positive score on this version 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 [1]

The authors[1] suggest it is very easy to produce an acetate using these cut-off that you place over the questionnaire to quickly enable you to score the clinical measurement tool for subgrouping purposes.

The Keele SBST 5-Item Generic Condition Tool

The Keele SBST 5-item generic condition version is the 9-item psychosocial subscale adapted to screen/identify distress in other conditions. Scores range from 0-5 with patients scoring 4 or 5 being classified as a high psychosocial risk [1].

[1] have stated that for now they are unable to recommend the use of a modified version of the SBST (including the 5-item generic condition version) for conditions other than low back pain.


Keele STarT Back Screening Tool website:

Related Research

  • Beneciuk, J. M., Bishop, M. D., Fritz, J. M., Robinson, M. E., Asal, N. R., Nisenzon, A. N. and George, S. Z. (2012) 'The STarT Back Screning Tool and individual psychological measures: evaluation of prognostic capabilities for low back pain clinical outcomes in outpatient physical therapy settings' Physical Therapy 
  • Bruyere, O., Demoulin, M., Brereton, C., Humblet, F., Flynn, D., Hill, J. C., Maquet, D., Beveren, J. V., Reginster, J., Crielaard, J. and Demoulin, C. (2012) 'Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French' Archives of Public Health [online] 70, (12). Availalbe form <> [29 July 2013]
  • del Pozo-Cruz, B., Parraca, J. A., del Pozo-Cruz, J., Adsuar, J. C., Hill, J. C. and Gusi, N. (2012) 'An occupational, internet-based intervnetion to prevent chronicity in subacute lower back pain: a randomized controlled trial' Journal of Rehabilitation Medcine 44, (7) 581-587 
  • Field, J. and Newell, D. (2012) 'Relationship between STarT Back Screening Tool and prognosis for low back pain patients recieving spinal manipulative therapy' Chiropractic & Manual Therapies 20, (1) 17.
  • Foster, N. E., Mullis, R., Young, J., Doyle, C., Lewis, M., Whitehurst, D. and Hay, E. M. (2010) 'Implementation of subgrouping for targeted treatment systems for low back pain patients in primary care: a prospective popualtion-based sequential comparison' BMC Musculoskeletal Disorder 20, (11) 186.
  • Fritz, J. M., Beneciuk, J. M. and George, S. Z. (2011) 'Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain' Physical Therapy [online] 91, (5) 722-732. Availalbe from <
  • Foster, N. E. and Delitto, A. (2011) 'Embedding psychological perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice-challenges and opportuities' Physical Therapy [online] 91, (5) 790-803. Availalbe from <> [29 July 2013]
  • Hay, E., Dunn, K., Hill, J., Lewis, M., Mason, E., Konstantinou, K., Sowden, G., Somerville, S., Vohora, K., Whitehurst, D. and Main, C. (2008) 'A randomised clinical trial of subgrouping and targeted for low back pain compared with best current care. The STarT Back Trail Study Protocol' BMJ Musculoskeletal Disorders [online] 9 58-66. Availalble from <> [24 July 2013]
  • Hill, J. C., Dunn, K. M., Lewis, M., Mullis, R., Main, C. J., Foster, N. E. and Hay, E. M. (2008) 'A primary care back pain screening tool: identifying patient subgroups for initial treatment' Arthritis Care & Research [online] 59, (5) 632-641. Availalbe from <> [23 July 2013]
  • Hill, J. C., Dunn, K. M., Main, C. J. and Hay, E. M. (2012) 'Subgrouping low back pain: a comparison of the STarT Back Tool with the Orebro Musculoskeletal Pain Screening Questionnaire' European Journal of Pain [online] 14, (1) 83-89. Availalbe from <> [23 July 2013]
  • Hill, J. C., Foster, N. E. and Hay, E. M. (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' Evidence Based Medicine 15, (4) 118-119.
  • Hill, J. C. and Fritz, J. M. (2011) 'Pschosocial influences on low back pain, disability, and response to treatment'Physical Therapy [online] 91 712-721. Availalbe from <> [24 July 2013]
  • Hill, J. C. (2010) 'The early identification of patients with complex back pain problems' The Back Care Journal [online] Spring Availalbe from <> [24 July 2013]
  • Hill, J. C., Vohora, K., Dunn, K. M., Main, C. J. and Hay, E. M. (2010) 'Comparing the STarT Back Screening Tool's subgroup allocation of individual patients with that of independent clinical experts' Clinical Journal of Pain [online] 26, (9) 783-787. Availalbe from <> [29 July 2013]
  • Hill, J. C., Whitehurst, D. G., Lewis, M., Bryan, S., Dunn, K. M., Foster, N. E., Konstantinou, K., Main, C. J., Mason, E., Somerville, S., Sowden, G., Vohora, K. and Hay, E. M. (2011) 'Comparison of stratified primary care management for low back pain with curent best ractice (STarT Back): a randomised controlled trial' Lancet [online] 378, (9802) 1560-1571. Availalbe from <> [29 July 2013]
  • Kongsted, A., Johannesen, E. and Leboeuf-Yde, C. (2011) 'Feasibility of the STarT Back Screening Tool in chiropractic clinics: a cross-sectional study of patients with low back pain' Chiropractic & Manual Therapies 19, (1) 10.
  • Main, C. and George, S. (2011) 'Psychologically informed practice for management of low back pain: future directions in practice and research' Physical Therapy [online] 91, (5) 820-824. Availalbe from <> [29 Juy 2013]
  • Main, C. J., Sowden, G., Hill, J. C., Watson, P. J. and Hay, E. M. (2012) 'Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's 'high risk' intervention (StarT Back; ISRCTN 37113406)' Physiotherapy [online] 98, (2) 110-116. Availalbe from <> [29 July 2013]
  • Morso, L., Albert, H., Kent, P., Manniche, C. and Hill, J. (2011) 'Translation and discriminative validation of the STarT Back Screening Tool into Danish' European Spine Journal [online] 20, (12) 2166-2173. Availalbe from <> [29 July 2013]
  • Sowden, G., Hill, J. C., Konstantinou, K., Khanna, M., Main, C. J., Salmon, P., Somerville, S., Wathall, S. and Foster, N. E. (2011) '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 [online] 0 1-13. Availalbe from <> [29 July 2013]
  • Whitehurst, D. G., Bryan, S., Lewis, M., Hill, J. and Hay, E. M. (2012) 'Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups' Annals of the Rheumatic Diseases 71, (11) 1796-1802.
  • Widerman, T. H., Hill, J. C., Main, C. J., Lewis, M., Sullivan, M. J. and Hay, E. M. (2012) '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 152 (11) 2182-2191

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  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Keele University. STarT Back Screening Tool Website. (accessed 23 July 2013).
  2. Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Care & Research 2008;59:632-41. fckLR (accessed 29 July 2013).
  3. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best bractice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71. fckLR (accessed 29 July 2013).