Publish in this journal
Journal Information
Vol. 22. Issue 4.
Pages 255-264 (01 July 2018)
Download PDF
More article options
Vol. 22. Issue 4.
Pages 255-264 (01 July 2018)
DOI: 10.1016/j.bjpt.2018.06.003
Advancing practice for back pain through stratified care (STarT Back)
Gail Sowdena,b,
Corresponding author

Corresponding author at: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
, Jonathan Charles Hilla, Lars Morsoc, Quninette Louwd, Nadine Elizabeth Fostera
a Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
b Interdisciplinary Musculoskeletal Pain Assessment and Community Treatment Service, Haywood Hospital, High Lane, Burslem, Stoke-On-Trent ST6 7AG, UK
c Centre for Quality, Department of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 3 Odense C DK 5000, Denmark
d Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

  • The STarT Back stratified care approach involves the use of a prognostic screening tool and matched treatments.

  • Two UK studies have demonstrated improved clinical outcomes and cost savings in the National Health Service.

  • Studies testing this approach in other countries are needed to adapt the approach to their own healthcare system.

  • A number of potential obstacles to implementing stratified care in high- and low-and-middle-income settings are emerging.

  • Evidence based innovations and strategies to overcome these obstacles and support successful implementation are discussed.

This item has received
Article information
Full Text
Download PDF

Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care.


The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care.


The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.

Stratified care
Back pain
STarT Back


These are the options to access the full texts of the publication Brazilian Journal of Physical Therapy

If you already have your login data, please click here .

If you have forgotten your password you can you can recover it by clicking here and selecting the option “I have forgotten my password”
Phone for subscriptions and reporting of errors
From Monday to Friday from 9 a.m. to 6 p.m. (GMT + 1) except for the months of July and August which will be from 9 a.m. to 3 p.m.
Calls from Spain
932 415 960
Calls from outside Spain
+34 932 415 960
Brazilian Journal of Physical Therapy

Subscribe to our newsletter

Article options
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.