Physical Therapy information to answer your questions.
When did you realize that this was serious?
I’m not an early adapter or a late adapter.
I thought my profession was recession proof.
When the St. Paddy’s day parade and dying of the river was canceled, I realized that this was going to be big.
I never realized that this was going to be something to shut down the country until the following week.
When was your tipping point?
We have a professional responsibility to spread the word of PT.
Not everyone has the chutzpah to our themselves in front of a group of kids prepping for college to discuss the pros and cons of this profession.
There are other ways.
Start a blog
Write a letter to the editor
Make videos on FB or YT.
Start a podcast
Go volunteer with a group or organization and wear a shirt that promotes PT.
The point is that we have to be the ones to promote the good and make the public aware of the bad.
No one else will do it for us.
“For example, individuals at a low risk of persistent disabled problems can be reassured and discouraged from receiving unnecessary treatments and investigations, while those at high risk can matched to treatment which combines physical and psychological approaches”
For those of you that haven’t read my previous posts on the Start Back Screening Tool, then this first post may not make sense. It is recommended to read those posts before reading this post.
In short, some patients improve without treatment, with simple advice to stay active.
“In addition, an implementation study testing risk stratification for patients with low back pain in routine general practice demonstrated significant improvements in physical function and time off work, sickness certification rates and reductions in healthcare costs compared to usual non-stratified care.”
Who knew? 🤷♂️
If we start classifying patients, we tend to get better results.
This should be a no-brained. Two different patients with similar pains may respond completely different to treatments. We need to be able to determine which type of intervention/or lack of intervention is best paired with each type of patient.
Until we get better at understanding the patient and both the patient’s response to movement and belief systems, we will continue to fail a percentage of these patients when they come into the clinic. Some patients will improve regardless of the intervention/treatment.
“GPs are not alone in wanting information about patients’ likely prognosis over time, as >80% of musculoskeletal patients also want prognostic information from their GO, although less than a third actually receive this information”
The fact that almost 1/3 of patients receive information from their physician is surprising to me. With shortened face time with physicians and the incentive to refer within the system in which the GPs operate, I’m surprised that there is enough time to spend educating even 1/3 of patients.
We know that patients want information. What is bothersome to me is that some practitioners, throughout healthcare as a whole, give patients flippant answers without substance. These patients then hang on to that information and allow it to dictate how they live or avoid living life.
To tell a patient with osteoporosis that they will fracture their spine when flexing can produce fear of a movement and greatly impact the patients quality of life. Giving the patient statistics about fracturing, not just with bending but also with staying neutral, allows the patient to have a more active role in decision-making.
The last thing we want to do is to label a patient, or cause a patient to label themself, as having “big bones”, slipped discs, degenerative spines, or as many of my patients say “Uncle Arthur”.
“The distribution of primary pain regions was reported by clinicians as: lower limb 31.1%, Back 28.7%, upper limb 23.5%, neck 11.8%, and multisite pain 4.8%”
The modified STarT Back tool is a version explores more options than back pain only.
“…a modified STarT Back Tool is similarly predictive of 6-month physical health across different musculoskeletal pain regions.”
This type of prognostic data is important for healthcare providers to obtain in order to build a long-term plan for patients beyond simply 3 times per week for 6 weeks of therapy.
What happens to patients after this six weeks?
If we have not educated and empowered the patient, they will become a patient again.
“This implies that the existing STarT Back Tool score cut-point (4 or more out of 9) used to allocate patients with low back pain to the medium-risk/high-risk subgroups cannot simply became applied to patients with other musculoskeletal pain presentations or in different clinical services”
This is pretty self-explanatory. We can’t use a back tool to help us make decisions about a knee pain, neck pain, headache, etc.
“It is found that regardless of body region of pain, higher modified STarT Back Tool scores were associated with higher levels of kinesiophobia, catastrophising, fear avoidance, anxiety and depressive symptoms.”
Kinesiophobia is fear of movement. Catastrophising is making a bigger deal out of a situation than it actually is. Fear avoidance is actively avoiding an activity for fear of making oneself worse.
None of these descriptors are good, but you know what…we work with them in physical therapy.
Let me say this differently…a good physical therapist will work on these issues, but not all address these issues.
For more information on projects that I am working on, please visit my podcast
“affecting 60% to 80% of individuals during their lifetime”
This statistic gets thrown around so much that all PTs should know this without thinking about it.
LBP is such a common occurrence that many non-healthcare professionals are giving advice about how to fix it.
I was at a fundraiser recently and I heard people talking about back pain as part of the conversations had between laypeople. This is how prevalent that it has become, discussions of back pain have made their way into everyday conversation. Everyone and their mother has a remedy for it.
I heard about cutting out sugars, rolling on tennis balls and soaking in Epsom salt. It wasn’t until someone in the group turned to me (they had a previous knowledge of the website) that people stopped giving advice and started asking for information.
The public wants information. On that note, if you’ve found any information from this website helpful…please share it so others can learn.
“total annual direct healthcare costs in the United States incurred by patients with LBP were estimated at $90 billion in 1998, 60% higher than individuals without LBP.”
🤔
Sounds like we can start to create a change in total costs if we could just be better at treating this issue.
Back pain is top 5 reasons a person seeks out a healthcare provider.
We are spending so much money on this problem…you’d think we’d be making a dent in the number of people with back pain, and the expenses incurred for this ailment.
Nope!
Reading the rest of this post will start to shed light on why our system, as a whole, has a lot of sucky (scientific term 👍) parts.
“Recent reports suggest that the use of physical therapy for patients with LBP is increasing.”
This makes so many people tho I that our profession (as a PT) is booming. Yes, there is a bigger pool of patients daily, but insurance payments have been decreasing for decades.
This is a different conversation, but it also plays a role in why clinicians may choose on intervention over another.
Soapbox
***For instance, if there are 3 people in the clinic at the same time (which could be considered fraudulent if this is occurring for patients using Medicare as insurance), the therapist has to make the patient perform some activities independently (which also should not be billed for patients with Medicare) or they would have to place the patient on a non-effective piece of equipment in order to be paid, while the PT works with another patient. ***
It then makes sense that the use of PT is increasing if we are performing ineffective techniques in order to maximize reimbursement. Not all PTs operate in this fashion, but if the above scenario sounds familiar…go get a second, third or fourth opinion.
“…Consistent in recommending an active approach to pair with emphasis on maintaining and promoting activity, while avoiding passive interventions such as bed rest or physical methods (heat/cold, ultrasound, etc.)”
Look folks, doing nothing gets you nothing. We know this in many aspects of life. Don’t work, don’t get paid. This is no different.
If the patient doesn’t play an active role in the process of rehabilitation, the results tend to be no better than doing nothing…because that’s exactly what the patient is doing in many cases.
For instance, if a patient goes to physical therapy and the patient lays there while “therapy” is performed on the patient, then the patient has little active role aside from showing up and paying.
This has become such a problem in our profession that our national organization had to come up with a short read to help patients understand what generic therapy look like during an episode of care.
“…Adherence to this recommendation for an active approach was associated with better clinical outcomes of physical therapy, with fewer visits in lower charges for care.”
If a patient learns a home program that has been shown, in the clinic, to be effective at reducing that specific patient’s complaint, why should that patient go to a physical therapy session to get unproven passive treatment or to simply repeat the same exercises over and over?
I’ll wait for your response…because I don’t know the answer to this question aside from the fact that increasing a patient’s frequency in therapy also increases the total profits of the company benefitting from the therapy.
“… it is now understood that the natural history of LBP includes subsequent periods of exacerbation and recurrence for most individuals.”
A high percentage of patients, anywhere from 25% up to 80%, experience multiple periods of low back pain during the lifespan.
How one defines recurrence has a huge role in how this number is determined. It used to be that researchers would look at a group of patients with low back pain and then see how many of them had back pain one year later. The problem with this approach is that for many of the patients, the pain never went away from the first episode.
How can this be classified as a recurrence if it never went away?!
Better questions were then asked and about 25% of patients experience at least a period of one month of relief before having a recurrence.
Because of this, it is prudent for the PT (physical therapist, not personal trainer) to teach the patient how to self-manage and to reduce as many risk factors that one particular patient has for developing back pain in the future.
“The ratio of active: passive codes had to be at least 3:1 for each phase, and every visit had to have at least one active code for the patient care to be considered inherent to guideline recommendations.”
I think that this is very conservative.
This means that for each hour a patient is seen, anywhere from 8-22 minutes are spent on manual (hands on) therapy, ultrasound, electrical stimulation, heat, ice.
The other 38-52 minutes are spent working on balance, exercise, returning to a functional activity.
This type of scenario would allow for 3 units of an active charge (75% of the session) and 1 unit of a passive charge (25% of the session).
Keep in mind, a clinician doesn’t have to follow this type of ratio, but a higher ratio of passive treatment is not consistent with the guidelines of treating patients with back pain.
“Consistent with previous studies, a successful outcome was defined as achieving at least 50% improvement on the 0SW – disability score.”
I’ve seen many patients that have gone through an episode of care without any relief before coming to see me in the clinic. For patients to get a 50% improvement in symptoms and ability to live the life they want, many would be happy with that outcome. In the research, we see as little as a 2-3 point change being considered significant when using the (pain scale). A 50% improvement is considered significant.
“471 patients with LBP met the criteria for inclusion. (18-60y, at least 3 visits of PT, duration of PT at least 10 days, initial OSW >10%, and no surgery recorded)”
This simply shows that there were a large number of patients that could be studied.
The inclusion criteria is important because it’s hard to take a study and apply it to a patient that doesn’t fit the inclusion criteria. For instance, this study included people from age 18-60. The results of the study may not apply to those under the age of 18 or over the age of 60.
Also, the study may not be applicable to those that experienced a back surgery.
“132 patients (28.0%) received adherent care and 339 (72.0%) received non-adherent care.”
Less than 1/3 received care that was consistent adherent to an active plan of care. This is disturbing!
This means that many patients going to therapy are having treatment DONE TO THEM instead of DONE WITH THEM!
There are many treatments that can be billed without the therapist directly treating the patient one-one. For instance, mechanical traction can be performed while the therapist is treating another patient. Other treatments that can be performed while the PT is treating another patient is “electrical stimulation”, moist heat and cold packs.
“Patient receiving adherent care experience greater improvement in disability, and pain intensity, and were more likely to experience a successful physical therapy outcome than patient receiving nonadherent care.”
This literally means that when patients are doing more for themselves, they get more from PT. It doesn’t have to be hard.
The PT should act as the guide in order to introduce the patient into a more pain-free, more functional and self-sustaining state. If the PT is acting as the “hero” of your story and not the “guide” in your story, it may be time to find another PT.
“Patient receiving adherent care also attended fewer physical therapy visits, had a shorter length of stay, and lower charges for physical therapy care.”
Fewer therapy visits = less money!
Is it getting easier to see why some clinics are more than happy to perform traction and electrical stimulation to patients?
💵💸💰
In the end, the patients are rarely at the center of care. Physical therapy is also is a business. Businesses function based on profit.
When you find a PT that treats you as a patient and not a $$$, then you have found the right person.
“296 patients (62.8%) had billed charges for additional healthcare related to the management of LBP in the 1-year period After completion of the physical therapy episode of care.”
It is common for patients with back pain to go to multiple providers, such as pain management, orthopedic surgeons, chiropractors and other PTs in order to seek treatment throughout the year.
“Receiving adherent care was associated with decreased use of prescription medication…also associated with a decreased likelihood of receiving diagnostic imaging procedures…associated with decrease use of MRI”
This is simply saying that when patients do more activity in physical therapy (PT), that the patient is less likely to seek out imaging.
There could be many reasons for this outside of just being active in therapy. This is purely conjecture, but if the therapist is able to educate the patient on when imaging is needed and the patient buys in, then it may have a rom in future imaging.
If the therapist demonstrates to the patient that they are strong and robust through the exercises or movements performed in therapy, then the patient may believe that the injury is less severe than initially believed.
If the therapist can change the patients belief system in order to understand that what is seen in imaging may not give them the answer they are looking for, the patient may be less likely to get imaging.
The one constant in all of this is the patient-PT relationship. It may be harder to foster that patient in an environment where multiple patients are being seen at the same time compared to when a patient is seen one-one.
These are great questions to ask when calling a PT clinic to inquire about treatment prior to actually signing up
1. How comfortable are your PTs at treating LBP
2. Do I need to use electrical stimulation and how many patients is this used on in your clinic?
3. Will the therapist be treating more than one patient at a time?
You have the right to this information prior to signing up. If you don’t care about this information, then don’t bother. If it is important to you that you have the individual attention you are paying for…ask away.
“Similar to other healthcare providers, it appears that physical therapy care for patients with LBP is characterized by widespread and unwarranted variations in practice”
We see PTs using craniosacral therapy , dry needling, MDT and other methods/interventions to treat back pain. Because of the variability, it is imperative that the PT ask about previous treatments because there is no common standard with physical therapy.
“…it may be surprising that adherence to an active approach has been reported to be low in studies of both primary care physicians and physical therapists”
Nope! ❌🙅♂️
When determining what interventions have the least amount of friction in order to get paid, the passive interventions win every time.
It’s unfortunate, but until insurance based physical therapy is linked to total costs for the treatment issued to a patient (such as a large lump sum issued to the clinic at the beginning of the year in order to manage a patients physical therapy needs and complaints), we will continue to see passive treatments as they reimburse with little time spent with patients.
Excerpts from:
Fritz JM, Cleland JA, Speckman M et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine. 2008;33:1800-1805.

Bill Curtis reminded me recently of advice he told me when I was a student and then worked for him.
“What you do the first two to three years in practice will shape the clinician you become for the rest of your career”
This is a quote that I still use when mentoring students and new grads.
Taking this quote a step further, this is also sad for our profession.
Not many students are able to get the job that fosters clinical growth and patient-centered care over profitability, productivity and bonus-centered care.
When looking at the quote through this lens, many Physical Therapists (PTs) then become engrained in this as the norm for our profession.
This is what I believe is a threat to not only our profession, but healthcare in general.
We are seeing independent private practices (both in PT and medicine) selling to the larger corporate or hospital practices. This changes the culture of the clinic from one of owner beliefs to one of corporate beliefs.
When we see Medicare giving PT an 8% cut in reimbursement, leading to an average cost of session at about $94, there is less money to go around for salaries, rent, insurance, EMR, benefits, and profit.
From the corporate position, the profit can not be the variable to take a loss. The structural costs (rent/utilities) stay relatively stable, but also goes up with time.
This means that benefits and salaries are what takes a hit. We’ve seen company matches for retirement go down over the years. We’ve seen salaries stagnate and in some areas reduce with time.
This forces corporations to demand higher productivity (I call it widget making). The problem with increasing the number of widgets we produce is…WE WORK WITH PEOPLE AND PEOPLE AREN’T WIDGETS!
I’m not sure if the solution is universal healthcare, getting rid of EMRs, going back to the old cash/bartering days, eliminating Insurance companies trickery on charges, etc, but something will need to change.
Patients have trouble…hell healthcare professionals have trouble…understanding what is actually being charged to patients.
Some hospital systems are charging over $1,000 per visit of physical therapy (PT), only to show an adjustment (a discount that was agreed upon with the insurance company) in order to show the patient how much money they saved by using their insurance.
The funny thing is this…if we actually charged what we wanted to get paid and not what we want to bill the insurance company in order to get a discount, the public may be paying less for healthcare in total (monthly premiums, deductibles, copays, etc).
Just rambling, but if you made it this far…thanks for reading and I hope it inspires thought.
What are your thoughts on the direction healthcare is going?
Look everyone.
If you have a medical problem 💩
don’t go to Dr. Google. ❌
Don’t go to muscle and fitness. ❌
Don’t go to apple news ❌
Go find a licensed professional. 👍
Here’s where it gets really interesting 🤔
Not everyone that is able to treat your symptoms is good at treating your symptom 🤫
They will try to sell you a package, tell you to come in multiple times per week and on the same breath they will tell you to be patient and it takes time 😂
You know what happens while your waiting 💸💸💸
Everyone wants hope, but unfortunately some people will take advantage of this.
Too often people experiencing back pain become a number instead of a person.
It becomes about checking boxes and jumping through hoops laid out within the broken medical system.
I tell many of the people I come in contact with: “give me 2-3 weeks to see if we can help you”
That’s it…two to three weeks.
I hear about patients having seen multiple doctors, pain specialists, acupuncturist and having gone through 4 months (yes 4 months!) of PT only to be lighter in the wallet without any more answers or relief than prior to all of the medical treatments.
I average 7 visits for patients with back pain. Mind you, 7 visits may be spread out over months because patients get homework.
If a patient is doing the homework and not responding, then why come to therapy 3x per week for more of the same that didn’t work in the first place!? 🤷♂️
I understand that people want relief and many of them are willing to spend thousands on relief and hope that the professionals are right when they say “it just takes time”, but how much of your life are you willing to wait through in order to get relief?
Waiting for relief is not the only answer.
There is a bell curve for all professions, I’m sure yours also.
Not all professionals are rockstars at their job.
Don’t get me wrong, you can like their personality, the professional can be “nice” or a “good person”, but is that what you want to pay for?
Physical therapy services are performed by someone licensed in the physical therapy profession. This can either be a licensed physical therapist (either a Bachelor, Master, or Doctor of Physical Therapy) or a licensed Physical Therapist Assistant (Associate degree).
Aspects of our profession that are performed in the clinic are as follows:
therapeutic exercise: exercises performed in order to help a patient improve function, strength, endurance, range of motion and/or reduce pain
Neuromuscular re-education: training movement patterns, balance, coordination, kinesthetic sense (where the body is at in space during movement), posture, and proprioception (where the body is at during one moment in time)
Manual therapy: using ones hands or tools to perform massage, joint mobilization (moving individual or groups of joints), traction, passive ROM (using hands to move a joint through its range) in order to improve pain, range of motion, swelling or other restrictions
These are the most common interventions used in my clinic. Other interventions used are modalities (which may or may not have evidence to support the intervention and may or may not be covered by an insurance plan). Some are as follows:
Ultrasound
Electrical stimulation
Heat/cold
Mechanical Traction
Iontophoresis
Laser therapy/light therapy
This is still a grey area for many Physical Therapists (PTs). Although the rules are very straightforward, some clinicians never read the rules that insurance companies impose to the clinicians. When a clinician is treating a patient and is in-network with the insurance company, the PT is accepting the rules imposed by insurance companies. Medicare will pay for medically necessary services.
It is up to the PT to establish this necessity in the documentation. The PT the. Needs to have a physician or other allowable non-physician provider (think nurse practitioner) sign off on the initial documentation, which establishes the PTs plan of action/treatment/care. This plan of action must establish a few details and is valid for up to 90 days.
Let’s talk numbers. Our spending on outpatient therapy services (occupational therapy, speech therapy, physical therapy) is more than many countries spend to run the entire country. This is a very large number and insurance companies, both public and private, are trying to cut down on the total expenditures over time.
It makes sense, because expenses have increased by 6% year to year for the previous years.
It may come as a shock to many patients, but “outpatient” benefits can be used in an inpatient setting 🤫.
If you were in a nursing home, they may have used your outpatient benefits to pay for part of your rehab. This may not be the best use of your funds as seen Here and Here.
Surprisingly hospital outpatients use fewer funds than I suspected. It has been documented that many physicians are pressured to keep a patient “in-house”. This means that physicians are not “supposed to” refer a patient out of the hospital network. This keeps all of the money within the hospital to find profits. This was highlighted in a previous news Article
In a way, I’m not surprised that private practices see such a large amount of the Medicare pie, as it’s been noted how many are abusing the system for large payouts. Such as this company that settled for $7M for performing abusive practices. These practices are very common to see in the field of PT.
Patients with Medicare are only to be billed for non-group services (which by the way pay at a much lower rate), when they are actually seen one-one.
Also, patients are only to be seen by licensed professionals. This means that technicians (techs) or aides are not allowed to guide a patient through their exercise program, at least if the company plans to bill for these services. Don’t believe me…here’s another Example.
So I guess that I am not surprised by how much money is spent in outpatient settings.
Many patients don’t understand that sessions are typically billed by the “15 minute rule”. This essentially means that for every 15 minutes, or at times the better half of 15 minutes (8 minutes), that the patient will see a charge on their explanation of benefits or receipt for services.
For example, a patient may see 3 separate charges for a session if the patient was seen in the clinic for 45 minutes. It can get messy if this is not explained to the patient.
The amount of money that Medicare reimbursed is different for different areas of the country. This is based on how much the cost of performing business is within a certain locale.
Those that have Medicare have to pay 20% of accepted/fee schedule amount.
This is where things can get confusing. For instance, I’ve seen an average visit (1 hr) be charged from $360-$1200 to the insurance company. This is a huge range in charges, which is also a problem with our healthcare system because it makes it difficult for patients to understand the actual charge.
Out of the charge for an hour, Medicare will allow close to $100 depending on how that hour was broken up into charges. The other $260-1100 is written off as an “adjusted” amount based off of insurance “savings”. (This savings number is also arbitrary to make it look like you get a great deal from having insurance).
Of the $100 that is allowable, the patient is responsible for 20% of that charge. The patient can choose to have another entity, a Medicare supplement or secondary, pay the other 20%. Of course the patient has to pay a monthly premium, unless on state aid, for that other 20%.
This is a way for business to start gaming the system. They will start to shorten session lengths so that they don’t lose as much money per session. There are three separate components that go into what is allowable by Medicare. They cut one of the three components by 50%.
Companies are then shortening sessions to the least allowable to maximize charges, such as shortening sessions to 25 or 40 minutes in order to maximize their reimbursement per session. They will then keep the patient coming in for more sessions per week in order to maximize payment.
Sometimes it’s what’s best for the patient, but many times it’s only what’s best for the company.
Those companies that charge more, or are in the upper tier of chargers in our profession. For instance, in our state their was a company that was audited and asked to pay back over $600K to Medicare due to inappropriate charges.
The article can be found Here
“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”
These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?
It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.
The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.
“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”
If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).
Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.
Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.
This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.
“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”
This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.
Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.
With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with
“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”
There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.
The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.
“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”
For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.
“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).
I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.
I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.
It’s a small sample size, but it seems to match the research.
To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient
1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).
2. Requires PT/Rehab only
3. Requires a more psychologically intensive approach to care.
Click here for original research article.

“…changes in psychosocial risk factors during the course of treatment may provide important information for a patient’s long-term prognosis”
As professionals, we should be performing repeated assessments of patients during the plan of care (POC) and not waiting until the patient is ready for discharge (either because their benefits have been exhausted, the insurance company dictates that an assessment needs to be performed or the patient self-discharged). Performing repeated assessments throughout the POC allows us, as professionals, to understand if the patient is improving, worsening or remaining unchanged with care and to assist us in modifying the POC.
The STarT Back Screening Tool is one method of assessing psychosocial factors that may impede rehab potential.
“… repeated assessments during an episode of care can also provide valuable information about changes in a given variable that can be used for treatment monitoring”
Utilizing a standardized approach to assessing a patient will enable the professional (PT in my case) to determine if a patient is catastrophizing, losing hope, or requires the assistance of a more psychologically focused treatment approach.
“The STarT Back Tool (SBT) is a Screening questionnaire consisting of nine items related to physical and psychosocial statements that are used to categorize patients based on risk (low, medium, or high) for persistent LBP-related disability.”
Here is a copy of the tool in question.
“Wideman et al found that early changes in SBT scores were predictive of four month treatment related changes in several relevant psychological and clinical outcome measures.”
This is a little different than what is expected from an outcome tool. For instance, many tools are utilized to tell the clinician where the patient is at currently and if this patient Hs a risk of developing chronic pain.
When we utilize multiple scores instead of a standalone score, this is indicative of how a patient will progress over the course of time.
“all patients (in this study) were referred for physical therapy by a physician and did not seek physical therapy services through direct access… this setting was considered secondary care.”
This is an important topic. For instance, the previous blog post indicated that the tool gives us information when read minister over a 4-week time period. This indicates that there are changes that occur over the course of 4 weeks.
Many complaints of low back pain improve independently over the course of 6 weeks. If a patient is issued this test at the first visit and classified as low, medium or high, this may lead to an inaccurate classification. Seeing as this study issued the tool to patients in a secondary care (meaning that the patients were referred by a physician) indicates that the patient is not being seen within the first few days of injury.
“1. Aged 18-65 years,
2. Seeking physical therapy for LBP (symptoms are T12 or lower, including radiating pain into the buttocks and lower extremity), and
3. Able to read and speak English”
“treatment was not standardized or tracked in this study and was provided at the discretion of the physical therapist.”
This may also be an issue, as there is a newer study that indicates the treatment interventions may have a role in the patient’s scoring.
Please see the previous post about how to utilize this tool.
“…123 patients (84.2% of the entire sample) who completed the SBT at intake and 4 weeks…The percent of patients for each SBT risk category who were classified differently at intake and four weeks was 81.8% for SBT high risk, 76.0% for SPT medium risk and 11.3% for SBT low risk.”
This indicates that a patient’s initial score should be interpreted with caution because there is a high probability that it will change over the course of 4 weeks.
“most patients either improved (48.8%) or remained stable (40.6%) based on changes in SBT categorization.”
“Thirteen (10.6%) patients were categorized as worsened based on changes in SBT categorization, with six of those patients categorized as SB team high-risk at intake and four weeks later.”
This is interesting to me. Typically, in PT, a therapist will cite regression to the mean. This essentially states that given time the patient will transition from an extreme score towards a more moderate score. This doesn’t account for those that transition from a moderate score towards a more extreme score. To me, this indicates that the episode of care had an effect, albeit a negative effect, on this patient encounter.
Primary findings of this present study were as follows:
1. At over 4 weeks, approximately 11% of patients worsened SBT risk;
2. Clinicians should be less confident in the stability of an intake SBT categorization of high risk than that of medium and low risk;
3. Prediction of 6-month pain intensity scores was not improved when considering intake or 4-week change for SBT categorization; and
4. Prediction of 6-month disability scores was improved when considering intake, 4-week, and 4-week-change SBT categorization”
This indicates that the first measurement may not be a good indication of what will take place with the patient regarding disability over time and some patients can be made worse with therapy. We already knew the second part from previous blog posts.

Excerpts from:
Beneciuk JM, Fritz J, George SZ. The STarT Back Screening Tool for Prediction of 6-month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. J Orthop Sports Phys Ther. 2014;44(9):656-664.