A STarT Back score of 3 or less is considered to be low risk - discharge see exit/redirection and health improvement.

A STarT Back score of 4 or more - medium to high risk.

The Keele STarT Back Tool can be completed online or download a PDF (permission to use the tool is outlined on this entry from NHS Scotland Tools and Measures catalogue).

For advice and support on how to use the Keele StarT Back Tool in NHSGGC please watch the video below.

The main aims of the examination process are to assess the severity of the presenting complaint (in terms of pain, functional disability and psychological impact), formulate the diagnostic triage and to evaluate how and to what extent physiotherapy can be helpful. Diagnostic triage refers to the screening of patients into three priority groups (CSAG 1994):

Mechanical LBP (95% of cases). No identifiable cause can be found in 90% of these presentations.
Nerve root compression / irritation (Radiculopathy,< 5% of cases)
Serious spinal pathology (<1% of cases)
Informed consent should be sought and documented prior to commencing assessment.

The following information should be collected and documented through interviewing the patient:

• Symptom site/description using body chart and Numerical Pain Rating Scale (NPRS)
• Aggravating and easing factors
• History of present condition (HPC)
• Functional limitations
• Social history (employment status/nature of work/hobbies/family)
• Past Medical History (PMH)
• Medication/Drug history
• Previous treatment and outcomes/investigations and results
• Assessment of patient’s fears, attitudes and beliefs in relation to their impairment
• Identification of the patient’s agenda for consultation and their expectations of physiotherapy
• Evaluation of the patient's understanding of the current problem
• Formulation of the diagnostic triage: -
  • Mechanical LBP
  • Nerve root compression / irritation
  • Serious spinal pathology

NB: Diagnosis should be kept under review and not presumed definitive.

Refer to red flags and serious pathology guidance.

There is a general consensus that the most important predictor of determining outcome post an episode of LBP is the patient’s psychosocial status. Linton (2000) concluded that psychological factors are strongly associated with the transition from acute to persistent pain and disability, and that psychosocial factors generally have a greater impact on disability than biomedical and biomechanical factors. The following psychological dispositions are consistent predictors of poor outcomes (Waddell, 1996):

• A belief that back pain is harmful or potentially severely disabling
• Fear avoidance behaviour (avoiding a movement or activity due to a misplaced anticipation of pain) and reduced activity levels
• Tendency to low mood and withdrawal from social interaction
• Expectation of passive treatment(s) rather than a belief that active participation will help

It is therefore essential to screen for and document evidence of psychosocial barriers to recovery (yellow flags). These provide indicators on the risk of chronicity developing. An assessment of the psychosocial status of the patient should be made with regard to the following (Kendall et al., 2004):

A = Attitudes and beliefs about pain

B = Health behaviours

C = Compensation issues

D = Diagnoses and treatment issues

E = Emotions

F = Family

W = Work related issues (see blue and black flags)

If appropriate, screen for Blue flags. Blue flags are individually perceived occupational factors that impede recovery and return to work (RTW). Examples include low job satisfaction or inadequate support from supervisor.

Identify black flags. Black flags are actual (organisational) barriers to RTW. These relate to social security and healthcare systems. Examples may include adverse sickness policies or benefit systems.

A person is at risk of developing disability if there is a cluster of a few salient yellow flags or a group of less important factors that combine cumulatively.

The objective assessment should be tailored to the individual patient and their subjective history. In the majority of patients with NSLBP the evidence base suggest that diagnostic tests used by therapists demonstrate limited reliability and validity (Dutch Physiotherapy Guidelines, 2003). Diagnosis is hence made on the basis of sound clinical reasoning. The objective examination should therefore focus on the patient’s functional abilities, cultural sensitivities and their willingness to participate as opposed to finding a physical cause of their LBP.  Assessment may include:

• Examination of posture
• Identification of structural deformities
• Neurological examination
• Range of movement/ functional movements
• Assessment of neural mobility
• Palpation
• Repeated Movement testing
• Gait

Neurological examination should always be undertaken whenever signs or symptoms are present outside of the lumbar region or where neurological pathology is suspected. The lumbar region is defined as the area between the bottom of the rib cage and the buttock creases.  The neurological examination should incorporate an assessment of:

• Dermatomes
• Myotomes
• Reflexes (knee jerk, ankle jerk, Babinski and clonus)

Wikimedia commons. Depiction of dermatomes of the human body.

WikiMSK. Visceral pain.

Myotomal weakness should be recorded in relation to the Medical Research Council (MRC) grading system for muscle power (0 – 5).

On completion of the assessment the patient’s health problem in relation to their LBP or radiculopathy should be defined. The therapist should be able to:

• Confirm the diagnostic triage 
• Consider formulating a clinical impression that attempts to identify the dominant cause of the patient’s pain/symptoms e.g. are the symptoms predominantly from the muscular, articular or nervous system and is there a dominant pain mechanism e.g. nociceptive, peripheral neuropathic or central sensitisation. There is some evidence to support the reliability of making a diagnosis within a sub-classification system e.g. McKenzie MDT. Generating a clinical impression or diagnosis facilitates the clinical reasoning process and may provide some patients with a better understanding of their condition
• Summarise the patient’s main complaints in terms of physical, psychological and social factors
• Where possible identify the dominant pain mechanism (nocioceptive, peripheral neuropathic, central or sympathetic)
• Negotiate agreed goals and formulate a time directed treatment plan
• Identify and record appropriate outcome measures 

Tobin, D.  Keel STarT Back Screening Tool Presentation. Sept 2016.

Linton SJ. Psychological factors in neck and low back pain. In: Nachemson AN, Jonsson E, editors. Neck and back pain: the scientific evidence of causes, diagnosis and treatment New York: Lippincott/Williams & Wilkins; 2000

Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M. Low back pain evidence review. London: Royal College of General Practitioners; 1999
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Knowledge Network
Bekkering G, Hendriks H, Koes B, Oostendorp R, Ostelo R, Thomassen J, et al. Dutch Physiotherapy Guidelines for Low Back Pain. Physiotherapy 2003 2;89(2):82-96 (link here - link correct as at 14/2/22)

Clinical Standards Advisory Group. Back Pain. Report of a CSAG Committee on back pain. 1994

Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Wellington, New Zealand: Accident Compensation Corporation and the New Zealand Guidelines Group; 1997 (link here - link correct as at 14/2/22)