Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study
Abstract Background Low back pain (LBP) is common among older adults, and it is a frequent reason for seeking chiropractic care. The STarT Back Screening Tool (SBT) was developed to stratify patients with LBP into low, medium, and high-risk treatment pathways, so that the treatment can be matched to...
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BMC
2025-07-01
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| Series: | Chiropractic & Manual Therapies |
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| Online Access: | https://doi.org/10.1186/s12998-025-00592-1 |
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| author | Yanyan Fu Alan D. Jenks Sidney M. Rubinstein Katie de Luca Iben Axen Bart W. Koes Alessandro Chiarotto |
| author_facet | Yanyan Fu Alan D. Jenks Sidney M. Rubinstein Katie de Luca Iben Axen Bart W. Koes Alessandro Chiarotto |
| author_sort | Yanyan Fu |
| collection | DOAJ |
| description | Abstract Background Low back pain (LBP) is common among older adults, and it is a frequent reason for seeking chiropractic care. The STarT Back Screening Tool (SBT) was developed to stratify patients with LBP into low, medium, and high-risk treatment pathways, so that the treatment can be matched to each participant’s risk profile. But its prognostic performance varies across settings and populations. No studies have focused on the SBT’s utility as a stratified-care tool in older adults with LBP in a chiropractic setting. Therefore, our aim was to evaluate the ability of the SBT to predict three-, six-, and 12-month disability and pain outcomes in older adults (≥55 years) with a new episode of LBP consulting chiropractors in the Netherlands, Sweden, and Australia. Methods This was a secondary analysis of the Back Complaints in Older Adults – Chiropractic (BACE-C) cohort. Participants visiting chiropractors with LBP completed baseline questionnaires for demographic and clinical characteristics, including the SBT. Follow-up questionnaires assessed disability (Roland Morris Disability Questionnaire (RMDQ)) and pain intensity (11-point Numerical Rating Scale (NRS)). “No improvement” on disability and pain intensity was defined as less than 30% reduction in baseline scores. We used logistic regression models to estimate discrimination metrics including the area under the receiver operating characteristic curve (AUC). Subgroup analyses were conducted by country, sex, and LBP duration; sensitivity analyses employed alternative “no improvement” definitions and linear regression on continuous outcome scores. Results A total of 738 participants were included. The mean age of the study sample was 66.2 ± 7.5 years and 50.9% of the participants were female. The SBT showed poor discrimination for predicting no improvement in disability and pain intensity. All AUC values were below 0.60 regardless of whether SBT risk subgroups (i.e. low/medium/high) or the SBT sum score were used. Subgroup and sensitivity analyses did not meaningfully improve discrimination. Conclusion The SBT presented limited prognostic ability to predict outcomes of disability and pain intensity in older adults with LBP in a chiropractic setting. These findings suggest insufficient evidence for the prognostic ability of the SBT risk stratification tool. Future research should explore reasons behind the limited prognostic accuracy and consider potential modifications or alternative tools. |
| format | Article |
| id | doaj-art-a377d61d9cf14e71b661853da839ec3a |
| institution | DOAJ |
| issn | 2045-709X |
| language | English |
| publishDate | 2025-07-01 |
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| series | Chiropractic & Manual Therapies |
| spelling | doaj-art-a377d61d9cf14e71b661853da839ec3a2025-08-20T03:05:07ZengBMCChiropractic & Manual Therapies2045-709X2025-07-0133111110.1186/s12998-025-00592-1Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation studyYanyan Fu0Alan D. Jenks1Sidney M. Rubinstein2Katie de Luca3Iben Axen4Bart W. Koes5Alessandro Chiarotto6Department of General Practice, Erasmus MC, University Medical CenterSchool of Kinesiology, Faculty of Global & Community Studies, Capilano UniversityDepartment of Health Sciences, Faculty of Science and Amsterdam Movement Sciences research institute, Vrije UniversiteitSchool of Health, Medical and Applied SciencesInstitute of Environmental Medicine, Unit of Intervention and Implementation Research for Worker health, Karolinska InstitutetDepartment of General Practice, Erasmus MC, University Medical CenterDepartment of General Practice, Erasmus MC, University Medical CenterAbstract Background Low back pain (LBP) is common among older adults, and it is a frequent reason for seeking chiropractic care. The STarT Back Screening Tool (SBT) was developed to stratify patients with LBP into low, medium, and high-risk treatment pathways, so that the treatment can be matched to each participant’s risk profile. But its prognostic performance varies across settings and populations. No studies have focused on the SBT’s utility as a stratified-care tool in older adults with LBP in a chiropractic setting. Therefore, our aim was to evaluate the ability of the SBT to predict three-, six-, and 12-month disability and pain outcomes in older adults (≥55 years) with a new episode of LBP consulting chiropractors in the Netherlands, Sweden, and Australia. Methods This was a secondary analysis of the Back Complaints in Older Adults – Chiropractic (BACE-C) cohort. Participants visiting chiropractors with LBP completed baseline questionnaires for demographic and clinical characteristics, including the SBT. Follow-up questionnaires assessed disability (Roland Morris Disability Questionnaire (RMDQ)) and pain intensity (11-point Numerical Rating Scale (NRS)). “No improvement” on disability and pain intensity was defined as less than 30% reduction in baseline scores. We used logistic regression models to estimate discrimination metrics including the area under the receiver operating characteristic curve (AUC). Subgroup analyses were conducted by country, sex, and LBP duration; sensitivity analyses employed alternative “no improvement” definitions and linear regression on continuous outcome scores. Results A total of 738 participants were included. The mean age of the study sample was 66.2 ± 7.5 years and 50.9% of the participants were female. The SBT showed poor discrimination for predicting no improvement in disability and pain intensity. All AUC values were below 0.60 regardless of whether SBT risk subgroups (i.e. low/medium/high) or the SBT sum score were used. Subgroup and sensitivity analyses did not meaningfully improve discrimination. Conclusion The SBT presented limited prognostic ability to predict outcomes of disability and pain intensity in older adults with LBP in a chiropractic setting. These findings suggest insufficient evidence for the prognostic ability of the SBT risk stratification tool. Future research should explore reasons behind the limited prognostic accuracy and consider potential modifications or alternative tools.https://doi.org/10.1186/s12998-025-00592-1Low back painSTarT back screening toolOlder adultsPrognostic ability |
| spellingShingle | Yanyan Fu Alan D. Jenks Sidney M. Rubinstein Katie de Luca Iben Axen Bart W. Koes Alessandro Chiarotto Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study Chiropractic & Manual Therapies Low back pain STarT back screening tool Older adults Prognostic ability |
| title | Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study |
| title_full | Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study |
| title_fullStr | Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study |
| title_full_unstemmed | Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study |
| title_short | Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study |
| title_sort | prognostic ability of the start back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care a multi national external validation study |
| topic | Low back pain STarT back screening tool Older adults Prognostic ability |
| url | https://doi.org/10.1186/s12998-025-00592-1 |
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