“…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.
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.