STarT Back Tool has limited prognostic value in older patients with low back pain in chiropractic practice

The study concludes that the STarT Back Tool is not suitable for predicting the prognosis of pain and disability in older patients with low back pain in chiropractic practice.

For chiropractors, this means:

• The STarT Back Tool should not be used as the sole guide for treatment choices or prognostic assessments in older patients.
• Other factors – including comorbidity, pain duration, previous episodes, and the patient’s own expectations of recovery – appear to be more relevant indicators of prognosis.
• There is a need to develop and validate more targeted tools, such as models from the BACE-D studies, which have shown promising results.

Although SBT has previously shown potential in certain primary care contexts, this study emphasizes that its usefulness is context- and population-dependent. For chiropractors treating many older patients, the focus should be on individualized assessment rather than standardized risk stratification via SBT.

Background

Low back pain represents a major challenge in older populations, where both prevalence and burden increase with age. About 16% of chiropractic patients are over 65 years old, and for more than half of them, back pain is the primary reason for seeking care.

The STarT Back Screening Tool was originally developed in primary care to identify patients at high risk of persistent disability and to support stratified treatment. Previous studies have shown mixed results – some with positive effects, others without clinical or economic benefit. Until now, no studies have specifically focused on the tool’s prognostic value in a chiropractic context for older patients.

Method

This study is a secondary analysis of the BACE-C cohort (Back Complaints in Elders – Chiropractic), which followed 738 patients (mean age 66 years, 51% women) over 12 months. At baseline, patients completed questionnaires including the SBT, and at follow-up (3, 6, and 12 months), disability (Roland Morris Disability Questionnaire, RMDQ) and pain intensity (NRS) were measured.

The primary outcome was “no improvement,” defined as <30% reduction in RMDQ or NRS scores. Analyses included logistic regression models and AUC (area under the curve) as a measure of discriminatory ability.

Results

• SBT showed poor prognostic ability: All AUC values were below 0.60, regardless of whether risk groups (low, medium, high) or sum scores were used.
• Subgroup analyses (country, sex, pain duration) did not change the results.
• Sensitivity analyses with alternative definitions of “no improvement” also showed insufficient precision.
• High specificity but very low sensitivity in identifying high-risk patients – meaning many patients with poor outcomes were not detected by the tool.

Yanyan Fu, Alan D. Jenks, Sidney M. Rubinstein, Katie de Luca, Iben Axen, Bart W. Koes, Alessandro Chiarotto. Prognostic ability of the sTarT back screening tool for disability and pain intensity outcomes in older adults with low back pain seeking chiropractic care: a multi-national external validation study. Chiropractic & Manual Therapies 2025.