Have you thought about using the STaRT back tool?

The STaRT back tool is for risk stratisfication of back pain patients.  The recently produced NICE guidelines for low back pain recommended the use of a risk stratification tool as quoted below:

Risk assessment and risk stratification tools

1.1.2 Consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact with a healthcare professional for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management.

1.1.3 Based on risk stratification, consider:

  • simpler and less intensive support for people with low back pain with or without sciatica likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active and guidance on self-management)
  • more complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programmes with or without manual therapy or using a psychological approach).

As far as I am aware not many osteopath practices use risk stratification tools but is it something that would help us to provide better care for patients?

What is the STarT back tool?

This simple tool has been developed at the University of Keele.  It has been developed to give practitioners a consistent tool to help in making decisions about the right treatment for the patient.  In the NHS the tool is used to streamline patient management, identifying which patients need minimal intervention and which need more intensive treatment.  Patient’s are identified as Low, Medium or High risk.  When patients are coming to visit an osteopath they may have pre-conceived ideas about what treatment they want.  For some patients though, they have come because they want someone to look at them and tell them what is wrong with them.  They will be happy to receive advice and reassurance and return to normal activities.

The tool uses 9 simple questions to categorise the patient into the risk group.  It is available as an online tool, an app or as a download for you to print off.  The patient is scored into one of the risk groups and then there is a recommended protocol for treatment.  This can be discussed and agreed with your patient.

What treatments are recommended in the different risk categories:

  Low Risk
Aim Self-management
Protocol One visit to a practitioner

Include patient worries, concerns and social impact in the assessment physical examination

Medication review and advice

Address patient’s particular issues, encourage activity and self-management

Avoid unhelpful labels and medicalisation

Provide oral and written information

Explain outlook is good but can re-consult if necessary


  Medium Risk
Aim Restore function, minimise disability, support appropriate self-management
Protocol Understanding patient’s concerns and adequate physical examination Treatment as appropriate to physical examination and patient’s needs/worries

A course of manual therapy – which may be very few sessions Encouragement to resume functional activities where there is no strong relationship between physical findings and the back pain complaint

Specific treatment objectives with an end-time point – focussed on functional improvements and reduced disability

Possible onward referral to specialist services.

  High Risk
Aim Reduce pain, reduce disability, improve psychological functioning
Protocol Psycho-social treatment and physical treatment

6 individual (45-60 minute) physiotherapy appointments over 3 months using a combined physical and cognitive behavioural approach

Enabling patients to manage on-going and/or future episodes of low back pain

Focus on cognitive, emotional and behavioural responses to pain and their impact on function

Identification of potential obstacles to rehabilitation

Risk Stratification in Osteopathy

Most of these treatment recommendations are very easily transferred into Osteopathic practice.  I think one of the most helpful aspects of the tool is that it helps us to identify the high risk patients – those who may not respond well to simple physical treatment and would benefit from additional interventions.  It helps to give patients realistic expectations of treatment.

In a future blog post I would like to look in more detail at these treatment protocols and consider how they can be really applied to Osteopathic practice.

It’s a very simple tool to use and I plan to introduce it into my practice.  It would be really helpful if osteopaths would like to share their experience of using the tool and how it has influenced their practice.


Source:  These treatment protocols and information about the STaRT back tool are taken directly from the Keele University website.  It has lots of useful information for practitioners and all the resources to implement the tool.  Find it here:  https://www.keele.ac.uk/sbst/

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