Research in Focus: Using the Keele StarTBack Tool in Physiotherapy Practice

  •   April 8, 2021
  •  Karin Eldred, PT, Jason Daoust, PT, Krista Shore, PT and Geoff Bostick, PhD

Inquiries can be sent to

In February 2019, our team wrote an article for Research in Focus sharing the impetus for, and our plan to conduct, a small-scale research study to look at the feasibility of implementing a psychosocial screening process for physiotherapy outpatients in Alberta Health Services’ (AHS) North Zone. The project was funded by the AHS Research Challenge, a “capacity building program” for frontline clinicians to conduct practice-based research.1 Our research objectives were to:

  1. Examine the feasibility of implementing a psychosocial screening process for physiotherapy outpatients with low back pain seen in AHS North Zone facilities.
  2. Identify barriers and facilitators for broader implementation from physiotherapist perspectives.

We recruited 11 physiotherapists from the North Zone of AHS to use the Keele StartBack Tool (SBT)2 for three months with new outpatients with low back pain (LBP). 47 patients participated. The physiotherapists were then interviewed using a list of standardized questions about their experience using the tool. These interviews were transcribed, anonymized, and analyzed using “Interpretive Description”.3

StartBack Tool results

The SBT is a simple, nine-item standardized prognostic questionnaire developed at Keele University in the United Kingdom. Questions 1-4 address pain location and disability level. Questions 5-9 make up the “psychosocial subscale” and include questions about fear avoidance, anxiety, catastrophizing, depression and overall impact of the pain. Patients are classified into low, medium, or high risk of developing chronic pain and/or disability based on their score. In the UK, patients are matched with different treatment options based on their risk category.4  Due to the small scale of our research project, we had our physiotherapist participants use the SBT to classify their patients into different risk categories, but did not ask them to provide stratified care based on patient score.

Quantitative analysis of our patient participants’ SBT scores resulted in the unexpected distribution of 76.6% high risk, 14.9% medium risk, and 8.5% low risk. As a comparator, Hill et al.’s 2011 Lancet publication yielded a distribution of 28% high risk, 46% medium risk, and 26% low risk in a sample of 851 patients (Figure 1).5


Results of the qualitative analysis

Theme 1: Barriers to using the screening tool

North Zone physiotherapist participants were confident in their ability to identify patients at high risk of disability without using a screening tool. It was a common belief that patients could be screened sufficiently with a good subjective interview. Comments included “you get a feel for people” (PT03) and “I don’t need a tool to tell me if this person’s going to have a delayed recovery… because I’m good at reading people” (PT04). This belief could undermine the perceived utility of incorporating a tool like the SBT.

Physiotherapist participants also expressed that more education would be needed about the SBT before broader implementation. Physiotherapist participants were divided about whether they would continue to use the SBT in their practice and stated thoughts such as “When you first try to implement change it’s hard” (PT03).

Theme 2: Facilitators to using the screening tool

Despite their perceived confidence in identifying risk of chronicity without using a standardized tool, our physiotherapist participants did acknowledge the potential utility of a tool such as the SBT. Some representative comments include “…it would have made my assessment easier and more efficient. I didn’t have to dig as much in my subjective interview” (PT04). They also reported that the SBT was easy to use, easy to administer, and that patients found it easy to complete. “Patients can just fill out when they register to see the physiotherapist” (PT02).

Theme 3: Physiotherapist participants were not surprised by the finding of 77% high risk

As researchers, we were astonished by the large number of patients who scored in the high-risk category on the SBT. However, when we asked our physiotherapist participants about this, not one participant was surprised by the results. When probed further, our physiotherapist participants identified a variety of reasons why they weren’t surprised by this outcome. Some participants described intrinsic factors such as patient knowledge and beliefs regarding low back pain, and psychosocial factors such as fear avoidance. As an example, one participant said:

 “There’s just been lots of fear around back pain, and around recovery. And I just think based on people’s background and their previous encounters with injuries… it doesn’t surprise me that it would be that high” (PT04).

Other factors identified by the physiotherapist participants were socioeconomic and demographic indicators. Example comments include:

“You have a demographic population that is very sedentary, has high rates of occupations that are known to be associated with back pain. Things like a lot of trucking; things like a lot of hours on the job – 80-hour work weeks. A lot of unemployed or under-employed people as well” (PT05).

“We’re in a pretty low socioeconomic area, so limited income, limited education, significant substance abuse – a lot of psychosocial and economic factors in the north” (PT10).

Further, there were identified factors related to accessing physiotherapy services in patients’ local community.

“One of the biggest challenges is travel… I have some people that travel over an hour to come and see me” (PT02).

“All around us the consistency and accessibility of physiotherapy is not so good. Often these patients are traveling to me from long distances and so there’s a transportation barrier there” (PT08).

And finally, physiotherapists identified factors related to waitlists or gatekeeping by other health-care practitioners. Comments included:

“One of the ways we identify high risk is how long they’ve been on the wait list” (PT02).

 “If they’ve had a problem for four months and either they haven’t seen the doctor about it, or the doctor has not referred them or sent them; often that will obviously cause a delay in their recovery if their referral isn’t made for services” (PT07).

“We have a system where you go to the doctor for years and never get access to physio so they often they come with delayed outcomes” (PT08).

Practice implications

The findings from our interviews led us to consider:

  • Implementation of standardized screening will require education and training to emphasize the purpose and value of this type of approach. What is the perceived value of using a standardized method of screening for psychosocial risk factors? How can this be modified to encourage uptake of this practice?
  • Are North Zone AHS physiotherapists prepared to manage psychosocial risk factors? There may be a need for professional development and support, as well as knowledge about community resources to aid in way-finding to local counselling services and/or social services.
  • AHS North Zone sites may need to rethink how physiotherapy for patients with LBP is delivered based on a large prevalence of high risk of disability. Is AHS providing the right type of services to this population?

Study limitations and conclusion

Our study was small in scope and conducted within publicly-funded physiotherapy departments in diverse communities across Northern Alberta. It would be challenging to generalize our findings to the larger population of our province. However, the results do stimulate important questions about the perceived value of screening for risk of disability/persistent pain and why high risk of disability related to low back pain is unsurprising to physiotherapists in our area. Furthermore, clinicians and their employers need to consider whether physiotherapists are prepared to address psychosocial factors when they arise.

  1. Alberta Health Services. We Pursue Excellence. Available at: Accessed March 22, 2021.
  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 and Rheumatism 2008; 59(5):632–641.
  3. Thorne S, Kirkham SR, MacDonald-Emes J. Interpretive description: A noncategorical qualitative alternative for developing nursing knowledge. Research in Nursing & Health 1997; 20(2):169–177.
  4. Keele University. STarTBack: Evidence Based Implementation of Stratified Care. Available at: Accessed March 22, 2021.
  5. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main C J, Mason E, Somerville S, Sowden G, Vohora K, & Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): A randomised controlled trial. Lancet 2011; 378(9802):1560–1571.