The usefulness of the STarT back screening tool and single-item general health measures when predicting future disability in patients with low back pain treated in Danish primary care physiotherapy

Highlights

• Baseline pain and disability is important predictors of future disability.

• The STarT Back Screening Tools predictive ability was small.

• The GH-1 had similarly small predictive ability.

• The results question the clinical utility of adding such measures.

Abstract

Introduction

The extent to which disease specific screening tools or other health measures add to the predictive value of common clinical factors (pain, disability and socio-demographics) has been sparsely investigated. The aim of this study was to investigate whether a disease specific screening tool and a single-item general health measure adds predictive value to basic information collected in primary physiotherapy care when predicting future disability in patients with low back pain.

Material and methods

This longitudinal cohort study included 354 patients with low back pain from Danish primary care physiotherapy. Information was collected on socio-demographics, common clinical factors, The STarT Back Screening Tool (SBT) and general health perceptions measured as a single item from the SF-36 (GH-1). Disability at 6-month follow-up, measured by the Roland-Morris Disability Questionnaire, was predicted using multiple linear regression models.

Results

Clinical factors and baseline disability level explained 28.3% of the variance in 6-month disability scores. With SBT and GH-1 added separately to the baseline model, the explained variance increased by 2.1% (p = 0.01) and 3.6% (p < 0.001), respectively.

Conclusion

The added value of the disease specific screening tools or the single-item general measure when predicting disability in patients with low back pain was generally small. Moreover, the predictive value of the single-item general measure seems comparable to and slightly better than the disease specific screening tool. Overall these findings may question the clinical utility of such measures.

Introduction

Low back pain (LBP) is the leading cause of disability worldwide (Hoy et al., 2014; Policies OEOoHSa, 2019) and is a major contributor to direct and indirect healthcare costs (Flachs, 2015; Maher et al., 2017). It is estimated that 880,000 Danes are currently affected by LBP (Flachs, 2015). In Denmark, most LBP patients receive treatment in primary care which includes physiotherapy treatment, with approximately 30% of all physiotherapy visits being due to LBP (Flachs, 2015; Jørgensen et al., 2001).

Physiotherapists often include basic components such as information on pain (e.g. duration and intensity), function and socio-demographic factors in the clinical assessment of the patient (Delitto et al., 2012). Studies have found many of these factors to have predictive value of poor outcomes and thus utility in the clinical decision-making (Artus et al., 2017; Burgess et al., 2020; Chou and Shekelle, 2010; Hayden et al., 2009). To further support clinical decision-making, several tools based on patient-reported risk factors have been developed to assess the prognosis for patients with LBP. One such tool is the STarT Back Screening Tool (SBT). The SBT is a brief questionnaire consisting of nine questions related to modifiable risk factors in the biological domains (e.g., pain and function) and psychosocial domains (e.g., fear avoidance and depression). The SBT is used to stratify patient care by subgrouping patients as being at low-, medium- or high-risk of developing persistent LBP (Hill et al., 2008; Sowden et al., 2018). With psychological factors being viewed as drivers of a high risk of prolonged disability, this raises the question of whether the SBT has additional predictive value to the basic components in the assessment in primary physiotherapy care.

Furthermore, several studies have found poor self-rated general health perceptions to be related to negative outcomes such as poor recovery from chronic LBP (Nordstoga et al., 2017) and disability (Hartvigsen et al., 2020; Dunn et al., 2011), increased healthcare costs and reduced quality of life (Kigozi et al., 2019). The term ‘general health perception’ refers to an individual's self-evaluation of their own health status with respect to physical, mental and social wellbeing (Fayers and Sprangers, 2002; Jylhä, 2009). General health perceptions can be measured in various ways, and one such way is a single question from the SF-36 questionnaire, namely the General Health question (GH-1) (Bjorner et al., 1998). So far, most studies on LBP prognosis have only included general health perceptions as a secondary measure when predicting future outcomes (Fayers and Sprangers, 2002; Jylhä, 2009; Nielsen et al., 2008). To our knowledge, few previous studies have evaluated the extent to which disease specific screening tools, such as the SBT, or general health perceptions, measured by the GH-1, provide additional prognostic information about LBP outcomes when used in combination with the basic components of assessment in primary physiotherapy care (Beneciuk et al., 2013; Wideman et al., 2012).

The aim of this study was to investigate whether a disease specific screening tool and a single-item general health measure adds value to basic information collected in primary physiotherapy care when predicting future disability in patients with low back pain.

We hypothesized that the disease specific screening tool would add greater predictive value to commonly assessed clinical factors than a single-item general health measure due to its LBP specific nature.