Physiotherapy - The Journal of Indian Association of Physiotherapists

: 2018  |  Volume : 12  |  Issue : 2  |  Page : 63--72

Comparative effects of Stratified Back care approaches in individuals with nonspecific low back pain

Bashir Bello1, Muhyiddeen Suleiman Bichi2,  
1 Department of Physiotherapy, Faculty of Allied Health Sciences, Bayero University Kano, Kano, Nigeria
2 Department of Physiotherapy, General Hospital Dawakin-Tofa, Kano, Nigeria

Correspondence Address:
Dr. Bashir Bello
Department of Physiotherapy, Faculty of Allied Health Sciences, Bayero University Kano, Kano


BACKGROUND: Stratified Back care is a recently developed method for treating low back pain. PURPOSE: This study compared the effects of two stratified care approaches (sub-grouping for targeted treatment [STarT] and specific treatment of the problems of the spine [STOPS] in patients with nonspecific low back pain [NSLBP]). MATERIALS AND METHODS: Forty-six individuals, with NSLBP, participated in this single-blinded, randomized clinical trial. Participants were randomly assigned into one of the two groups: STarT Back Group (n = 23) or STOPS group (n = 23). Treatment was applied twice weekly for 8 weeks. Outcomes assessed pre- and post-interventions were pain intensity (PI) using numeric pain rating scale and functional disability (FD) using the Oswestry Disability Index. Participants in both groups were comparable in age (44.65 ± 9.03 vs. 46.40 ± 7.39) years. At baseline, PI, FD, and anthropometric values were comparable in both groups. RESULTS: The Results showed a significant difference in PI between the STarT and STOPS with a mean difference of −1.24 and 95% confidence interval (−0.86 to −0.04), P < 0.05, with no significant difference in FD, P > 0.05 between the groups. However, there was a significant difference within each group in pain and FD with P < 0.05. CONCLUSION: It was concluded that STarT Back approach was more effective in reducing PI only than STOPS approach in individuals with NSLBP.

How to cite this article:
Bello B, Bichi MS. Comparative effects of Stratified Back care approaches in individuals with nonspecific low back pain.Physiother - J Indian Assoc Physiother 2018;12:63-72

How to cite this URL:
Bello B, Bichi MS. Comparative effects of Stratified Back care approaches in individuals with nonspecific low back pain. Physiother - J Indian Assoc Physiother [serial online] 2018 [cited 2019 Feb 16 ];12:63-72
Available from:

Full Text


Low back pain (LBP) is the most prevalent musculoskeletal condition in orthopedic practice, ranked as the sixth highest overall morbidity and the leading cause of disability across the world.[1] Maluf et al.[2] reported back pain as the most commonly treated disorder in outpatient physiotherapy clinics worldwide and considered as the most common health problem, with about 60% to 90% of the population experiencing it at some point in their lives.[3] It is classified based on duration as acute, subacute or chronic, and classified based on causal mechanism as either specific or nonspecific.

Stratified Back care has been recently advocated as an appropriate method to manage patients with LBP as it merges patient's symptom to their treatment. The approach (Stratified Back care) involves matching specific treatments to subgroups of patients with similar characteristics, with the aim of improving patient's outcomes, reducing the inefficient variability of treatment associated with usual physiotherapy care, and provide a helpful communication tool for managing patients with LBP.[4]

Foster and Hill[5] identified three different stratified care approaches that can be used to subgroup and treat patients with LBP. They include (a) subgrouping for targeted treatment (STarT Back Approach), which is based on patients prognosis, i.e., matching treatment to patients' risk of poor outcome (likelihood of persistent pain and disability). The approach allows early decision-making about amount and broad direction of therapy a patient should receive, (b) STOPS which is based on responsiveness to treatment, i.e., matching specific treatment to patients who are likely to respond to it, and (c) IMpacT Back which is also a stratified care method that is most appropriate for chronic conditions.

Despite evidence that the treatment of patients based on subgrouping (Stratified care) results in better outcomes than the usual care,[6] it has not been established whether one approach is superior to the other regarding effectiveness in improving clinical variables, and currently, there is no clear consensus as to which classification system to use.[6] Kerayanis[7] reported the low use of these classification systems among physiotherapist, although, that was attributed to unfamiliarity with the classification system, inability to choose between the classifications systems or a preference for other assessment methods, and therefore suggested that further studies should be conducted to ascertain the effect of Stratified Back care in the management of LBP. Previous researchers have suggested STarT Back approach and treatment-based approach (STOPS) as most appropriate for acute/subacute nonspecific LBP while the cognitive functional therapy approach is more suitable for chronic condition.[5] This study, therefore, compared the effects of STarT and STOPS approaches on pain and functional disability (FD) in patients with nonspecific LBP (NSLBP).

 Materials and Methods

This study was a single-blinded randomized controlled clinical trial design, registered with Pan Africa Clinical Trial Registry PACTR 201707002001797. Consecutive sampling technique was used to recruit participants for the study as they become available in the Outpatient Department of Physiotherapy department, Aminu Kano Teaching Hospital, Kano. The participants were screened to determine whether they met the inclusion criteria for the study. The participants for this study were patients with NSLBP, who were able to comprehend instruction in English or Hausa language, and were not involved in any other treatment during the study. Ethical approval was sought and obtained from the Research Ethics Committee Aminu Kano Teaching Hospital, Kano, Nigeria, (AKTH/MAC/SUB/12A/P-3/VI/1825) [Appendix I].[INLINE:1]

The following categories of patients were excluded from the study: Patients with a history of a prior surgery to the lumbosacral spine; patients with evidence of systemic disease, carcinoma or organ diseases; and patients with evidence of pregnancy and patients who are below 18 years. The consented participants were randomly allocated into two groups: STarT Back group (SBG) (n = 23) and STOPS group (SPG) ((n = 23). See [Figure 1] on flowchart of the participants' recruitment.{Figure 1}


Eligible participants were randomly allocated to either STarT Back or SPG using block randomization technique. Sealed envelope software was used to generate the block sequence which was then selected at random. A block size of two was used to achieve an equal number of participants in each group. In addition, ordering of blocks and block size used were blinded to further avoid selection bias.

Data collection instruments

Oswestry Disability Index (ODI) questionnaire: This questionnaire was used to assess the level of disability of patients in both groups at baseline and postintervention periodsNumerical Pain rating scale: Numerical rating scale is a scale of 0–10 that assesses the intensity of pain due to various conditions. It was used to assess the intensity of low back painThe Keele STarT Back Screening Tool: This is a (9-items questionnaire) that classifies the participants into subgroups. It was used to identify the risk level of the participants which determined specific treatment administered [Appendix II]Subjective complaints questionnaire: This questionnaire was used to get the subjective information of the patients relating to the history and pattern of back pain, especially those in SPG, and was also used to determine the type of treatment that SPG received [Appendix III].[INLINE:2][INLINE:3]

Data collection procedure

Preintervention assessment

Participants were assessed to rule out any red flags. Outcomes measured before intervention were pain intensity (PI) using numerical pain rating scale and FD through ODI. Participants' sociodemographic variables, such as age, gender, occupation and marital status, were also recorded using personal information sheet.

Postintervention assessment

Participants in both groups were reassessed for clinical outcomes (pain and FD), at 4 and 8 weeks postintervention. The outcomes were measured by an independent assessor (physiotherapist) who was blinded of the patient's group and treatment received.


Participants in both groups received allocated treatment which is determined by the results of the screening tools (STarT Back tool or STOPS tool), the tools categorized patients into subgroups based on their risk level/characteristics and then subjected to a specific treatment. Treatment in both groups was administered twice per week, for 8 weeks with each treatment session lasting 30 min as further explained below.

Subgrouping for targeted treatment back approach

Low risk: Because patients in the low-risk category are very likely to improve, the aims of this package are to support and to the enable self-management. The key factors are to address patient concerns and to provide informationMedium risk: This builds on the assessment from the low-risk package. The main aims are to restore function (including work), minimize disability even if pain is unchanged and to support appropriate self-management coupled with specific exercises, for example, back stabilization exercisesHigh risk: This builds on the low- and medium risk packages. The aims are to reduce pain, reduce disability and improve psychological functioning. It also emphasizes on providing adequate combined physical and cognitive-behavioral approach.

Specific treatment of the problems of the spine approach

Participants in this group were further classified into sub-groups using decision rule algorism coupled with physical examination [Appendix III]. The decision rule contain characteristics that qualify patients to be in one of the five predefined subgroups, and there exist, a specific treatment package for each of the five subgroups as seen in [Appendix IV]. However, in this study, patients were only available for three of the five subgroups, namely, (i) reducible discogenic pain (ii) multifactorial persistent pain, and (iii) nonreducible discogenic pain. This is probably because only patients with NSLBP were considered in the study, as such they might have not presented additional characteristics that would qualify them to be in the other subgroups. Treatment received is further explained below:[INLINE:4]

Reducible discogenic pain: Treatment in this subgroup involves McKenzie method comprising up of; identification of direction of repeated movements or sustained positions that leads to improvement or centralization of patients pain, advice on postural strategies and exercise to promote movements and positions corresponding with the directional preferenceNonreducible discogenic pain: Treatment for this subgroup involves a graded functional exercise program that focuses on specific motor control training targeting the local stabilizing muscles (transverse abdominis, lumber multifidus and pelvic floor muscles), with initial exercise taught in nonweight-bearing positions and then progressed to functional exercises, postural self-management, and education regarding realistic recovery time framesMultifactorial persistent pain: Treatment in this subgroup involves graded functional exercise to restore patients normal functional levels of activity with more emphasis on; cognitive restructuring and behavioral strategies targeting key psychosocial barriers to recovery, detailed education in relation to the neurophysiology of pain, and central sensitization identified through Orebro Musculoskeletal Questionnaire.

Data analysis

Descriptive statistic of frequency and percentage was used to describe the sociodemographic characteristics of the participants as shown in [Table 1]. Inferential statistics of paired and independent t-test were used to determine the statistical differences in clinical variables within and between groups. One-way ANOVA was used to determine the statistical differences in clinical variables (pain and FD) across phases (baseline and 8 weeks postintervention). All statistical analyses were performed with alpha levels set at 0.05, using Statistical Package for Social Sciences (SPSS) version 16.0 software (SPSS Inc. Chicago, Illinois, USA).{Table 1}


A total of 46 participants were recruited; however, only 41 participants completed the study, with (STarT; n = 19) and (STOPS; n = 22). Descriptive statistics of participants' demographic, clinical, and anthropometric variables at baseline are presented in [Table 1]. The result indicated no significant difference between the groups at baseline. The mean age of participants in the STarT and SPGs is 43.57 ± 9.64 and 40.57 ± 10.01 years respectively. The mean BMI of participants in the STarT and SPGs is 24.39 ± 3.73 and 29.08 ± 11.65 kg/m2 respectively. At baseline, the mean PI, FD score, and duration of pain of both groups are also shown in [Table 1], and no significant difference was observed between the groups. The mean PI and FD scores of the STarT group were 5.95 ± 1.80 and 38.29 ± 11.95, respectively while that of SPG was 6.19 ± 1.81 and 40.95 ± 11.96, respectively. No significant difference was observed in PI and FD scores of both groups at baseline.

With regard to occupation of the participants, 16 (34.78%) were civil servants, 11 (23.91%) were farmers while homemakers constituted the remaining percentage 16 (41.30%). In eneral, duration of symptoms of the participants ranges from 0 to 16 weeks. However, most participants (63.04%) fall within 0–8 weeks category while (36.96%) of the participants had a duration of 8 weeks and above. In addition, 14 (30.43%) had a previous history of low back pain while 32 (69.57%) had no previous history.

[Table 2] shows the comparison of pre- and post-treatment outcome scores within SBG after 8 weeks of treatment. The result indicated a significant difference in PI (P = 0.001; t = 9.51). Similarly, significant difference in FD within the group was noted (P = 0.001; t = 10.72), with reduced mean in PI and FD 8-weeks postintervention.{Table 2}

The comparison of pre and 8 weeks posttreatment outcome scores within SPG is presented in [Table 3] shows the result indicated significant difference in PI between pre- and post-treatment scores (P = 0.001; t = 8.09). However, there was a significant difference in FD (P = 0.001; t = 9.53), with marked reduction in mean scores of PI and FD posttreatment.{Table 3}

[Table 4] shows the result of independent t-test between the two groups (STarT and STOPS) which indicated a significant difference in PI between the two groups (P < 0.05) with no significant difference in FD between the groups (P = 0.25).{Table 4}


This study investigated the effects of Stratified Back care approaches (STarT and STOPS) in patients with NSLBP, attending Physiotherapy Clinics of Aminu Kano Teaching Hospital and Dawakin Tofa General Hospital, Kano. Back PI and FD were the clinical outcomes accessed. In addition, the baseline comparison of the clinical and anthropometric variables of the participants between the two groups was not statistically significant (P > 0.05), indicating that the two groups did not differ at baseline [Table 1]. Thus, any effect/change produced may not be by chance.

The main findings of this study were that STarT Back approach which involves subgrouping and targeting treatment to patients into low-, medium-, and high-risk subgroups were found to be more effective in reducing PI among individuals with NSLBP when compared to STOPS approach. However, there was no any significant difference in FD scores between the groups when the approaches were compared at 8-week postintervention [Table 4], signifying STarT Back approach is not superior to STOPS regarding reducing FD and vice versa. This maybe likely due to discrimination of the stratification approaches used. This is affirmed by the study of Rampersaud et al.[8] which concluded that most mechanical symptom stratification resulted in further discrimination of a large subgroup of LBP patients not identified by disability. Although this finding slightly differs from the review of Chou et al.[9] who reported that no existing evidence suggests that a particular stratified care approach is superior to the other regarding reducing PI or FD. This present study showed that there was a significant difference regarding PI only between the SBG and SPG. Another reason responsible for this difference would be due to the fact that the STOPS stratification is mainly base on the pathoanatomical affection of the intervertebral disc, which is not the common culprit in most affectation in individuals with NSLBP. Thus, treatment strategy would be only centered through reduction of the intervertebral disc prolapse.

In the SPG, majority of the study participants (60.87%) were of nonreducible discogenic pain subgroup as compared to the (47.82%) moderate risk level in the SBG. There was also a discrepancy in the percentage of participants in the mild versus reducible discogenic pain subgroups in both groups. SBG had 39.13% while SPG had 17.39% as shown in [Table 5]. This may also be responsible for the better response seen in the SBG as stated by Keele tool[10] that individuals classified under the mild-risk group will recover with only back care education and maybe few sessions of therapy. In general, there were more patients with mild risk in SBG when compared to those in SPG, (39.13%) versus (17.39%) and relatively more patients with moderate- and high-risk level in SPG as seen in [Table 5]. As such, the aforementioned reason could be a contributing factor or potential reason why STarT Back approach was more responsive to change in PI than with STOPS approach and showed no difference for FD.{Table 5}

In addition, participants in SPG were only available to three of the 5 subgroups namely (i) reducible discogenic pain (ii) multifactorial persistent pain, and (iii) nonreducible discogenic pain. This is probably because only patients with NSLBP were considered in the study, as such they might have not presented additional characteristics that would qualify them to be in the other subgroups.

Furthermore, within-group comparison of the clinical outcomes (PI and FD) showed a statistically significant difference P < 0.05 [see [Table 2] and [Table 3] implying both approaches were equally effective in reducing pain and functional disability at 8 weeks of treatment. These have been elucidated by previous studies,[5],[11] which shows that Stratified Back care is effective in improving patient's condition. However, the higher pain reduction seen in the SBG as compared to the SPG within the group, [Table 2] and [Table 3], may be attributed to the higher percentage of participants in the SBG. It could also be explained by the fact that both Stratified Back care approaches specify a particular treatment to the patients at baseline, with initial treatment being guided by a valid and reliable tool(s) which helps reduce the variability of treatment and time waste with try and error interventions typical with usual care.

It is worth mentioning that both approaches were shown to improve the clinical outcomes studied, but few differences between the tools used in screening the patients were noted; STarT Back tool which is a 9-items' questionnaire was more user friendly, simpler, and easier to administer within short period of time as oppose to STOPS which uses subjective complaint questionnaire/decision rule algorism [Appendix III] with relatively more questions making it little bit more complex and time-consuming when compared to STarT Back tool.

Conclusively, anecdotal evidence revealed that studies on Stratified Back care are limited in Nigeria, and the approach has not been adopted by most clinicians despite the fact that it was reported to be clinically and cost-effective method to treat back pain.[11] It will greatly enhance the clinical practice and standard of back care management if back care specialist begins to adopt to the most appropriate Stratified Back care model that fit into the specific symptoms of the patient/client.


STarT Back approach was more effective in reducing PI among individuals with NSLBP. In addition, STarT Back tool was found to be easier to administer requiring shorter time when compared to STOPS approach. However, there was no difference in FD. It was, therefore, recommended that Stratified Back care should be in-cooperated in the management of patients with NSLBP.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. Asystematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64:2028-37.
2Maluf KS, Sahrmann SA, Van Dillen LR. Use of a classification system to guide nonsurgical management of a patient with chronic low back pain. Phys Ther 2000;80:1097-111.
3Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-81.
4Cherkin DC, Sherman KJ, Kahn J, Erro JH, Deyo RA, Haneuse SJ, et al. Effectiveness of focused structural massage and relaxation massage for chronic low back pain: Protocol for a randomized controlled trial. Trials 2009;10:96.
5Foster NE, Hill JC, Ozed controlled trial. Trials 2009;10:96.assage for chronic low back painn RheumatoPhysiotherapy 2015;101:e17-8.
6Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: A randomized clinical trial. Spine (Phila Pa 1976) 2003;28:1363-71.
7Karayannis NV, Jull GA, Hodges PW. Physiotherapy movement based classification approaches to low back pain: Comparison of subgroups through review and developer/expert survey. BMC Musculoskelet Disord 2012;13:24.
8Rampersaud YR, Bidos A, Fanti C, Perruccio AV. The need for multidimensional stratification of chronic low back pain (LBP). Spine (Phila Pa 1976) 2017;42:E1318-E1325.
9Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: A review of the evidence for an american pain society clinical practice guideline. Spine (Phila Pa 1976) 2009;34:1078-93.
10University K. STarT Back Tool, Keele University. Keele Univ. Available from: [Last accessed on 2018 February 25].
11Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT back): A randomised controlled trial. Lancet 2011;378:1560-71.