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Targeted treatment for back pain

A man holding his lower back in pain

Lower back pain is a major health problem in the UK, affecting four out of five people at some point in their lifetime.

For most people, back pain is caused by a simple muscle, tendon or ligament strain and they’ll recover within a few weeks. However, around three quarters of people continue to experience back pain and disability a year after first seeing their GP.

Ongoing severe back pain can impact on a person’s ability to work and carry out daily activities, as well as affecting relationships, sleep and mood.

Back pain is estimated to make up 20% of total health spend in the UK and was responsible for almost 10 million lost work days in 2014.

There are a range of treatments available for back pain – including painkillers and other drugs, physiotherapyoccupational therapy and surgery – but previously it was unclear which patients would benefit most from which treatment.

Developing the STarT Back Tool

We funded Professor Elaine Hay and her team at the Arthritis Research UK Primary Care Centre at Keele University to address this problem by developing a new way of grouping patients according to the treatment most likely to work best for them.

The team developed the STarT Back Tool, which is a short questionnaire that GPs can use to assess an individual’s physical, psychosocial and psychological risk factors for chronic back pain that can be improved with treatment.

The patient’s responses are then used to categorise them as being of either low, medium or high risk of experiencing chronic pain. 

Those considered to be at low risk can be given reassurance and advice to self-manage their condition, whereas those at medium or high risk of chronic back pain can be referred for further treatment.

Testing the effectiveness of targeted treatment

Using a randomised controlled trial, the research team compared the effectiveness of a targeted treatment approach using the STarT Back Tool with current best practice physiotherapy for patients with low back pain.

In the trial, 851 patients visiting their GP for low back pain were referred to community-based physiotherapy clinics, before being randomised to receive either targeted treatment or current best practice.

All patients attended a 30-minute session with a physiotherapist, which included:

  • reassurance
  • advice on pain relief and activity
  • self-help information.

Those in the targeted treatment group were then assigned further care depending on which risk category they were classified as:

  • Low risk – no further intervention.
  • Medium risk – physiotherapy using a physical approach.
  • High risk – physiotherapy using a combined physical and psychological approach.

This trial, along with a subsequent trial funded by the Health Foundation, identified significant improvements in symptoms when using the targeted treatment approach compared to usual care.

Specifically, a targeted treatment approach led to:

  • a reduction in patient-reported disability at 4 and 12 months
  • 50% fewer days off work
  • 30% fewer sickness certificates issued
  • cost savings to the NHS of £34 per patient 
  • wider societal cost savings of over £400 per patient due to reduced time off work.

Changes in practice

Use of the STarT Back Tool is now recommended by the Royal College of General Practitioners, the Department of Health National Spinal Taskforce, and the British Pain Society, among others.

Free access to the tool and information on how to implement the tool into clinical practice is provided at

The site has had 30,000 unique visits since 2009.

More than 20 healthcare organisations in the UK have adopted the tool. Further afield, over 85 clinical services worldwide are using the tool to stratify patients and inform them of the probable progression of their pain.

For more information, go to
Arthritis Research UK fund research into the cause, treatment and cure of arthritis. You can support Arthritis Research UK by volunteering, donating or visiting our shops.