Back pain screening
|
Back pain Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Lecture |
|
Case Studies |
|
Back pain screening On the Web |
|
American Roentgen Ray Society Images of Back pain screening |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Routine population screening for mechanical or nonspecific low back pain in asymptomatic individuals is not recommended. In patients presenting with low back pain, prognostic questionnaires and structured psychosocial assessment estimate the risk of persistent disability and may inform care planning.[1][2]
Prognostic questionnaires do not replace assessment for serious underlying pathology. A low prognostic-risk score does not exclude serious disease. Red-flag assessment is addressed in the differential diagnosis microchapter.[3]
Screening
Population and timing
- Asymptomatic individuals: routine questionnaire, imaging, or laboratory screening for mechanical low back pain has no established role.[1] Indications for imaging and laboratory testing in symptomatic patients are addressed in the diagnostic microchapters.
- Patients presenting with low back pain: consider a validated prognostic questionnaire during the initial assessment, particularly for acute or subacute presentations. The VA/DoD 2022 guideline provides a Weak for recommendation for assessment of psychosocial factors and use of predictive screening instruments.[2]
- UK guidance: NICE NG59 recommends considering risk stratification, such as the STarT Back tool, at first contact for each new episode of low back pain to inform shared decisions about management.[4]
- Very early presentations: interpret STarT Back scores cautiously during the first 0–2 weeks of an episode, when discrimination between prognostic groups is reduced.[5]
- Care setting: prognostic performance varies with setting and timing. In an emergency department cohort, medium- or high-risk STarT Back classification at 6 weeks, but not at presentation, together with baseline disability, predicted persistent disability at 3 months. This does not establish a universal requirement to delay assessment.[6]
- Reassessment: consider reassessment when recovery is slower than expected, recognizing that prognostic performance varies with episode duration.[5] No fixed repeat-screening interval has been established.
Prognostic screening instruments
| Instrument | Structure and purpose | Predictive performance and limitations |
|---|---|---|
| STarT Back Screening Tool | Nine-item self-completed questionnaire; total score 0–9, with five items forming a psychosocial subscale.[7] | Acceptable discrimination for future disability (pooled area under the receiver operating characteristic curve [AUC] 0.74), with substantial heterogeneity; non-informative discrimination for pain outcomes (pooled AUC 0.59).[8] |
| Örebro Musculoskeletal Pain Screening Questionnaire | Full 25-item questionnaire and a 10-item short form are available. Evaluates psychosocial and occupational risk; apply scoring instructions for the specific version used.[9][10] | Discrimination for work absence was higher at 6 months (pooled AUC 0.83) than at 12 months (0.71). Pooled discrimination was acceptable for disability (AUC 0.75) and poor for pain (AUC 0.69). These estimates should not be assumed to apply equally to every version or population.[8] |
AUC describes discrimination between patients with and without the predicted outcome; it is not the percentage of patients classified correctly. Performance depends on the outcome, follow-up interval, and clinical population.[8]
STarT Back and Örebro classifications are not interchangeable. Agreement varies by population, and their suitability in non-care-seeking population samples remains unclear.[11]
For predicting chronic pain itself, the Predicting the Inception of Chronic Pain (PICKUP) tool is a validated five-item model assessing disability compensation, leg pain, pain intensity, depressive symptoms, and perceived risk of persistence after an initial presentation with low back pain.[12]
STarT Back risk categories
| Risk category | Score | Implication for care planning |
|---|---|---|
| Low | Total score ≤3. | Lower-intensity support emphasizing advice and self-management. |
| Medium | Total score ≥4 and psychosocial subscale ≤3. | Consider structured physical rehabilitation. |
| High | Psychosocial subscale ≥4. | Consider psychologically informed physical therapy or a coordinated biopsychosocial approach. |
These categories and care pathways reflect the STarT Back stratified-care model. High-risk classification depends on the psychosocial subscale; pain severity alone does not establish high risk. Detailed treatment selection is addressed in the treatment microchapter.[7][13]
Evidence for stratified care
Prognostic discrimination does not establish that screening-based care improves outcomes. In the original UK STarT Back randomized trial of 851 patients, stratified care modestly improved disability compared with current best practice. Between-group differences favored stratified care by approximately 1.8 Roland-Morris Disability Questionnaire points at 4 months and 1.1 points at 12 months; work absence was also reduced.[13]
The disability benefit was not reproduced in four subsequent randomized trials: MATCH and TARGET in the United States, a Danish primary-care trial, and the US Military Health System trial (V-START MHS). Of these five trials testing the STarT Back stratified-care pathway or close adaptations of it, only the original UK trial demonstrated a disability advantage.[14][15][16][17]
In TARGET, a cluster randomized trial in 77 US primary-care clinics that enrolled only STarT Back high-risk patients and tested referral to psychologically informed physical therapy, progression to chronic low back pain occurred in 47% of the intervention group and 51% of the usual-care group (odds ratio 0.83; 95% confidence interval 0.64–1.09). Differences in progression, disability, opioid use, and imaging were not statistically significant.[15][18]
Implementation fidelity may help explain contrasting results. A review of at least seven trials across four countries identified incomplete stratification and failure to deliver risk-matched care as important explanations. In MATCH, clinicians used the tool for approximately half of patients but did not substantially change treatment recommendations. These findings do not establish that improved implementation will necessarily reproduce the original benefit; a questionnaire alone is not a therapeutic intervention.[19][14]
Modified approaches have shown benefit in some trials. In the SPINE CARE cluster randomized trial of adults with acute or subacute back or neck pain, a two-level STarT Back-stratified model (low versus medium/high risk) combining physical therapy, health coaching, and specialist e-consultation improved Oswestry Disability Index scores compared with usual care at 3 months (between-group difference −5.8; 95% confidence interval −7.7 to −3.9), with benefit maintained at 12 months.[20] Clinics were randomized without allocation concealment, and baseline imbalances were present, limiting interpretation.[20][21]
PACBACK evaluated treatment in a prognostically selected population rather than comparing a complete risk-stratified care pathway with usual care. Among 1000 adults with acute or subacute low back pain at STarT Back medium or high risk, clinician-supported biopsychosocial self-management produced a small improvement in disability at 1 year compared with guideline-based medical care (Roland-Morris mean difference −1.2; 95% confidence interval −1.9 to −0.5), without a significant effect on pain; spinal manipulation added no benefit.[22] Generalizability of research-clinic benefits to usual-care settings remains uncertain. Intervention details are addressed in the treatment microchapter.[23]
Guideline recommendations remain heterogeneous: a review of 28 guidelines found that 16 recommended risk-stratification tools, one recommended against their use, one was neutral, and ten did not address them.[1]
Psychosocial assessment
Yellow flags are psychosocial prognostic factors associated with persistent disability, including maladaptive coping, fear-avoidance beliefs, and emotional distress. Assess depressive symptoms, anxiety, pain catastrophizing, pain self-efficacy, and relevant occupational or contextual barriers.[3][24][2]
Additional instruments may include the Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and Tampa Scale for Kinesiophobia. These assessments characterize barriers to recovery; they do not establish that pain is psychological in origin.[2][9]
Related flag categories distinguish other barriers:
- Orange flags: psychiatric illness.
- Blue flags: beliefs and perceptions concerning the relationship between work and health.
- Black flags: system-level or contextual obstacles, including compensation systems, legislation, and work conditions.
These categories supplement psychosocial assessment and are distinct from red flags for serious underlying pathology.[3][25]
References
- ↑ 1.0 1.1 1.2 Oliveira CB, Koes BW, Pinto RZ, et al. Towards Global Clinical Practice Guidelines for the Management of Non-Specific Low Back Pain in Primary Care: A Review of Current Guideline Recommendations and How They Have Changed Over the Last 30 Years. The Lancet Rheumatology. 2026.
- ↑ 2.0 2.1 2.2 2.3 Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. 2022. Full guideline.
- ↑ 3.0 3.1 3.2 Vlaeyen JWS, Maher CG, Wiech K; et al. (2018). "Low back pain". Nature Reviews Disease Primers. 4 (1): 52. doi:10.1038/s41572-018-0052-1.
- ↑ National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59. 2016; updated 2020. NICE NG59.
- ↑ 5.0 5.1 Morso L, Kongsted A, Hestbaek L, Kent P (2016). "The prognostic ability of the STarT Back Tool was affected by episode duration". European Spine Journal. 25 (3): 936–944. doi:10.1007/s00586-015-3915-0.
- ↑ Treanor C, Brogan S, Burke Y; et al. (2022). "Prospective observational study investigating the predictive validity of the STarT Back tool and the clinical effectiveness of stratified care in an emergency department setting". European Spine Journal. 31 (11): 2866–2874. doi:10.1007/s00586-022-07264-1.
- ↑ 7.0 7.1 Haglund E, Bremander A, Bergman S (2019). "The StarT back screening tool and a pain mannequin improve triage in individuals with low back pain at risk of a worse prognosis – a population based cohort study". BMC Musculoskeletal Disorders. 20 (1): 460. doi:10.1186/s12891-019-2836-1.
- ↑ 8.0 8.1 8.2 Karran EL, McAuley JH, Traeger AC; et al. (2017). "Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis". BMC Medicine. 15 (1): 13. doi:10.1186/s12916-016-0774-4.
- ↑ 9.0 9.1 Macedo F, Annaswamy T, Coller R; et al. (2024). "Diagnosis and Treatment of Low Back Pain: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline". American Journal of Physical Medicine & Rehabilitation. 103 (4): 350–355. doi:10.1097/PHM.0000000000002356.
- ↑ Maher C, Underwood M, Buchbinder R (2017). "Non-Specific Low Back Pain". Lancet. 389 (10070): 736–747. doi:10.1016/S0140-6736(16)30970-9.
- ↑ Simula AS, Ruokolainen O, Oura P; et al. (2020). "Association of STarT Back Tool and the short form of the Örebro Musculoskeletal Pain Screening Questionnaire with multidimensional risk factors". Scientific Reports. 10 (1): 290. doi:10.1038/s41598-019-57105-3.
- ↑ Chiarotto A, Koes BW (2022). "Nonspecific Low Back Pain". The New England Journal of Medicine. 386 (18): 1732–1740. doi:10.1056/NEJMcp2032396.
- ↑ 13.0 13.1 Hill JC, Whitehurst DG, Lewis M; et al. (2011). "Comparison of Stratified Primary Care Management for Low Back Pain With Current Best Practice (STarT Back): A Randomised Controlled Trial". Lancet. 378 (9802): 1560–1571. doi:10.1016/S0140-6736(11)60937-9.
- ↑ 14.0 14.1 Cherkin D, Balderson B, Wellman R; et al. (2018). "Effect of Low Back Pain Risk-Stratification Strategy on Patient Outcomes and Care Processes: The MATCH Randomized Trial in Primary Care". Journal of General Internal Medicine. 33 (8): 1324–1336. doi:10.1007/s11606-018-4468-9.
- ↑ 15.0 15.1 Delitto A, Patterson CG, Stevans JM; et al. (2021). "Stratified Care to Prevent Chronic Low Back Pain in High-Risk Patients: The TARGET Trial. A Multi-Site Pragmatic Cluster Randomized Trial". EClinicalMedicine. 34: 100795. doi:10.1016/j.eclinm.2021.100795.
- ↑ Morsø L, Olsen Rose K, Schiøttz-Christensen B; et al. (2021). "Effectiveness of Stratified Treatment for Back Pain in Danish Primary Care: A Randomized Controlled Trial". European Journal of Pain. 25 (9): 2020–2038. doi:10.1002/ejp.1818.
- ↑ Rhon DI, Greenlee TA, Poehlein E; et al. (2023). "Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System: A Randomized Clinical Trial". JAMA Network Open. 6 (7): e2321929. doi:10.1001/jamanetworkopen.2023.21929.
- ↑ Cashin AG, Chou R, Weimer MB, McAuley JH (2026). "Low Back Pain: A Review". JAMA. 336 (2): 144–158. doi:10.1001/jama.2026.9631.
- ↑ Croft P, Hill JC, Foster NE, Dunn KM, van der Windt DA (2024). "Stratified Health Care for Low Back Pain Using the STarT Back Approach: Holy Grail or Doomed to Fail?". Pain. 165 (12): 2679–2692. doi:10.1097/j.pain.0000000000003319.
- ↑ 20.0 20.1 Choudhry NK, Fifer S, Fontanet CP; et al. (2022). "Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial". JAMA. 328 (23): 2334–2344. doi:10.1001/jama.2022.22625.
- ↑ Krebs EE, Goldsmith ES (2022). "Conservative Therapy for Acute and Subacute Back or Neck Pain". JAMA. 328 (23): 2307–2309. doi:10.1001/jama.2022.21833.
- ↑ Bronfort G, Meier EN, Leininger B; et al. (2026). "Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial". JAMA. 335 (6): 497–510. doi:10.1001/jama.2025.21990.
- ↑ Atlas SJ (2026). "Can Implementing Guideline-Recommended Care Prevent Chronic Low Back Pain?". JAMA Internal Medicine. 186 (8): 963–964. doi:10.1001/jamainternmed.2026.1904.
- ↑ Chou R, Shekelle P (2010). "Will This Patient Develop Persistent Disabling Low Back Pain?". JAMA. 303 (13): 1295–1302. doi:10.1001/jama.2010.344.
- ↑ Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP (2021). "Low Back Pain". Lancet. 398 (10294): 78–92. doi:10.1016/S0140-6736(21)00733-9.