Refinement and validation of a tool for stratifying patients with musculoskeletal pain

Abstract

Background Patients with musculoskeletal pain in different body sites share common prognostic factors. Using prognosis to stratify and treatment match can be clinically and cost‐effective. We aimed to refine and validate the Keele STarT MSK Tool for prognostic stratification of musculoskeletal pain patients. Methods Tool refinement and validity was tested in a prospective cohort study, and external validity examined in a pilot cluster randomized controlled trial (RCT). Study population comprised 2,414 adults visiting U.K. primary care with back, neck, knee, shoulder or multisite pain returning postal questionnaires (cohort: 1,890 [40% response]; trial: 524). Cohort baseline questionnaires included a draft tool plus refinement items. Trial baseline questionnaires included the Keele STarT MSK Tool. Physical health (SF‐36 Physical Component Score [PCS]) and pain intensity were assessed at 2‐ and 6‐month cohort follow‐up; pain intensity was measured at 6‐month trial follow‐up. Results The tool was refined by replacing (3), adding (3) and removing (2) items, resulting in a 10‐item tool. Model fit (R2) was 0.422 and 0.430 and discrimination (c statistic) 0.839 and 0.822 for predicting 6‐month cohort PCS and pain (respectively). The tool classified 24.9% of cohort participants at low, 41.7% medium and 33.4% high risk, clearly discriminating between subgroups. The tool demonstrated model fit of 0.224 and discrimination 0.73 in trial participants. Multiple imputation confirmed robustness of findings. Conclusions The Keele STarT MSK Tool demonstrates good validity and acceptable predictive performance and clearly identifies groups of musculoskeletal pain patients with different characteristics and prognosis. Using prognostic information for stratification and treatment matching may be clinically/cost‐effective. Significance The paper presents the first musculoskeletal pain prognostic stratification tool specifically for use among all primary care patients with the five most common musculoskeletal pain presentations (back, neck, knee, shoulder or multisite pain). The Keele STarT MSK Tool identifies groups of musculoskeletal pain patients with clearly different characteristics and prognosis. Using this tool for stratification and treatment matching may be clinically and cost‐effective.

Validation of the German version of the STarT-MSK-Tool: A cohort study with patients from physiotherapy clinics

“…To test for construct validity several reference instruments were added. Based on a formative model, both, the STarT-MSK like the OMPQ assess the risk for future pain and disability, using a set of items of known biopsychosocial risk factors [15,35,36]. Moreover, depending on the patients' complaints one of the following instruments were used to determine disability: German version of the Neck Disability Index (NDI) [37], Shoulder Pain and Disability Index (subscale disability, SPADI DIS ) [38], Roland Morris Disability Questionnaire (RMDQ) [39] or Western Ontario and McMaster Universities Osteoarthritis Index (subscale disability, WOMAC DIS ) [40].…”

“…The final score is calculated by summarizing the point for all 10 items, with a possible total score ranging from 0 to 12. Based on cut-off points established for the original version, a total score of �4 points indicates low risk, a total score between 5-8 points medium risk, and �9 points high risk for persisting pain disability [15].…”

“…Through a programme of research the STarT-Back-Tool has therefore been adapted and validated to produce the Keele STarT-MSK risk stratification tool (STarT-MSK) for use in a broader musculskeletal patient population [15]. This approach has been supported by a recent umbrella review indicating that there are a number of common prognostic factors among patients with MSK-complaints including: worse baseline function, higher symptom/pain severity, worse mental well-being, more comorbidities, older age and higher body mass index [16].…”

Quantifying the population burden of musculoskeletal disorders, including impact on sickness absence: analysis of national Scottish data

“…Although STarT Back has been well validated and widely used, this modified tool has not been validated. However, colleagues at the University of Keele have recently developed and validated the Keele STarT MSK tool, with 10 questions aiming to rate risk of poor outcomes in three categories (low, medium and high), creating a valid tool similar to that used here [ 20 ]. There were some missing data from the helpline.…”

Risk-based stratified primary care for common musculoskeletal pain presentations: qualitative findings from the STarT MSK cluster randomised controlled trial

“…Building on this evidence, a new risk-strati cation tool was developed and validated for use with patients with the ve most common MSK pain presentations (the 10-item Keele STarT MSK risk-strati cation tool) [13]; and 16 risk-matched treatment options for low, medium and high risk subgroups agreed through stakeholder consensus [14]. Using both the new tool and risk-matched treatment options, this new model of risk-based strati ed care was rst tested in a feasibility and pilot trial in UK general practice [15,16] prior to the main STarT MSK trial [17] (Trial registration: ISRCTN15366334; 26/04/2016).…”