Cross-sectional differences of physical and psychosocial measures in low back pain according to pain chronification risk groups
DOI:
https://doi.org/10.2340/jrm.v57.42639Keywords:
low back pain, STarT back screening tool, physical and psychosocial measures, age, gender, BMIAbstract
Objective: To investigate whether low-back-pain patients classified based on the risk of pain chronification (low, medium, high) differ in psychosocial and physical function measures, and whether these subgroup differences are moderated by age, gender, and body mass index.
Methods: In this cross-sectional study, 595 Austrian patients with chronic low back pain (68% female; mean age: 53 ± 6.7 years) completed the STarT Back screening tool, visual analogue scale, Roland Morris Disability Questionnaire, Pain Disability Index, 5-level European Quality of Life Questionnaire, Hospital Anxiety and Depression Scale, and Avoidance–Endurance fast screen. Physical function tests assessed maximum trunk strength, trunk range of motion, and hand grip strength, while multivariate analyses of variance evaluated differences among the risk groups.
Results: The intensity of physical and psychosocial problems differed significantly among the pain chronification risk groups. Physical function also varied across subgroups, with the high-risk group exhibiting the weakest muscle strength and the greatest stiffness. Gender significantly moderated the association between pain risk group and trunk strength.
Conclusion: In people of working age with chronic low back pain, the STarT risk of pain chronification was correlated with physical and psychosocial variables. Moreover, this screening tool can be used irrespective of personal factors such as age, gender, and BMI.
Downloads
References
Buchbinder R, Blyth FM, March LM, Brooks P, Woolf AD, Hoy DG. Placing the global burden of low back pain in context. Best Pract Res Clin Rheumatol 2013; 27: 575–589. DOI: https://doi.org/10.1016/j.berh.2013.10.007
Global Burden of Disease 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2023; 5: e316–e329.
Fatoye F, Gebrye T, Mbada CE, Useh U. Clinical and economic burden of low back pain in low- and middle-income countries: a systematic review. BMJ Open 2023; 13: e064119. DOI: https://doi.org/10.1136/bmjopen-2022-064119
Ceulemans D, Moens M, Reneman M, Callens J, De Smedt A, Godderis L, et al. Biopsychosocial rehabilitation in the working population with chronic low back pain: a concept analysis. J Rehabil Med 2024; 56: jrm13454. DOI: https://doi.org/10.2340/jrm.v56.13454
Foster NE, Hill JC, O’Sullivan P, Hancock M. Stratified models of care. Best Pract Res Clin Rheumatol 2013; 27: 649–661. DOI: https://doi.org/10.1016/j.berh.2013.10.005
Hill JC, Dunn KM, Lewis M, Mulli R, Main CJ, Foster NE, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008; 59: 632–641. DOI: https://doi.org/10.1002/art.23563
Hill 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: 1560–1571. DOI: https://doi.org/10.1016/S0140-6736(11)60937-9
Al Zoubi FM, Eilayyan O, Mayo N, Bussières A. Evaluation of cross-cultural adaption and measurement properties of STarT Back screening tool: a systematic review. J Manipulative Physiol Ther 2017; 40: 558–572. DOI: https://doi.org/10.1016/j.jmpt.2017.07.005
Aebischer B, Hill JC, Hilfiker R, Karstens S. German translation and cross-cultural adaptation of the STarT Back screening tool. PLoS One 2015; 10: e0132068. DOI: https://doi.org/10.1371/journal.pone.0132068
Cieza A, Stucki G, Weigl M, Disler P, Jäckel W, van der Linden S, et al. ICF Core Sets for low back pain. J Rehabil Med 2004; suppl. 44: 69–74. DOI: https://doi.org/10.1080/16501960410016037
Sowden G, Hill JC, Morso L, Louw Q, Foster NE. Advancing practice for back pain through stratified care (STarT Back). BJPT 2018; 22: 255–264. DOI: https://doi.org/10.1016/j.bjpt.2018.06.003
Spinord L, Stenberg G, Kassberg AC, Stålnacke BM. Sex and age group focus on outcomes after multimodal rehabilitation for patients with chronic pain in northern Sweden. J Rehabil Med 2022; 54: jrm00333. DOI: https://doi.org/10.2340/jrm.v54.2336
Fehrmann E, Kotulla S, Fischer L, Kienbacher T, Tuechler K, Mair P, et al. The impact of age and gender on the ICF-based assessment of chronic low back pain. Disabil Rehabil 2019; 41: 1190–1199. DOI: https://doi.org/10.1080/09638288.2018.1424950
Fehrmann E, Ebenbichler G, Tüchler K, Habenicht R, Mair P, Fischer-Grote L, et al. Do the WHO-ICF personal factors “age” and “sex” impact limited activity and restricted participation category profiles differently between younger and older women and men in multimodal chronic back pain rehabilitation? Disabil Rehabil 2022; 0: 1–10. DOI: https://doi.org/10.1080/09638288.2021.2023665
Zhang TT, Liu Z, Liu YL, Zhao JJ, Liu DW, Tian QB. Obesity as a risk factor for low back pain: a meta-analysis. Clin Spine Surg Spine Publ 2018; 31: 22–27. DOI: https://doi.org/10.1097/BSD.0000000000000468
Rabey M, Kendell M, Godden C, Liburd J, Netley H, O’Shaughnessy C, et al. STarT Back Tool risk stratification is associated with changes in movement profile and sensory discrimination in low back pain: a study of 290 patients. Eur J Pain 2019; 23: 823–834. DOI: https://doi.org/10.1002/ejp.1351
Ingemann-Molden S, Pessoto Hirata R, Bach Jensen M, Graven-Nielsen T, Riis A. Difference in postural stability between STarT Back Tool subgroups of patients with low back pain under conditions of sensory deprivation and cognitive load. J Int Med Res 2022; 50: 030006052211120. DOI: https://doi.org/10.1177/03000605221112046
Sindhu BS, Shechtman O, Tuckey L. Validity, reliability, and responsiveness of a digital version of the visual analog scale. J Hand Ther 2011; 24: 356–364. DOI: https://doi.org/10.1016/j.jht.2011.06.003
Zhang Z, Mai Y. WebPower: Basic and advanced statistical power analysis. 2023 [cited 2024 Aug 15]. Available from: https://CRAN.R-project.org/package=WebPower
Amatya B, Elmalik A, Song K, Lee SY, Galea MP, Khan F. Responsiveness of the International Classification of Functioning, Disability And Health (ICF) Clinical Functioning Information Tool (ClinFIT) in routine clinical practice in an Australian inpatient rehabilitation setting. J Rehabil Med 2022; 54: jrm00268. DOI: https://doi.org/10.2340/jrm.v54.159
Tuechler K, Fehrmann E, Kienbacher T, Mair P, Fischer-Grote L, Ebenbichler G. Mapping patient reported outcome measures for low back pain to the International Classification of Functioning, Disability and Health using random forests. Eur J Phys Rehabil Med 2020; 56: 286–296. DOI: https://doi.org/10.23736/S1973-9087.20.05465-9
Wiesinger GF, Nuhr M, Quittan M, Ebenbichler G, Wölfl G, Fialka-Moser V. Cross-cultural adaptation of the Roland-Morris questionnaire for German-speaking patients with low back pain. Spine 1999; 24: 1099–1103. DOI: https://doi.org/10.1097/00007632-199906010-00009
Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine 2000; 25: 3115–3124. DOI: https://doi.org/10.1097/00007632-200012150-00006
Chibnall JT, Tait RC. The Pain Disability Index: factor structure and normative data. Arch Phys Med Rehabil 1994; 75: 1082–1086. DOI: https://doi.org/10.1016/0003-9993(94)90082-5
Herdman M, Gudex C, Lloyd A, Janssen MF, Kind P, Parkin D, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011; 20: 1727–1736. DOI: https://doi.org/10.1007/s11136-011-9903-x
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–370. DOI: https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
James M, Banik A. ICF-based analysis of psychological and functional aspects of tinnitus. IJHSR 2018; 8: 226–237.
Wolff SV, Willburger R, Hallner D, Rusu AC, Rusche H, Schulte T, et al. Avoidance-endurance fast screening (AE-FS): content and predictive validity of a 9-item screening instrument for patients with unspecific subacute low back pain. Schmerz 2020; 34: 1–7. DOI: https://doi.org/10.1007/s00482-018-0323-5
R Core Team. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing. 2022 [cited 2024 Aug 15]. Available from: https://www.R-project.org
Fox J, Weisberg S. An R companion to applied regression, third edition. Thousand Oaks, CA: Sage; 2019 [cited 2024 Aug 15]. Available from: https://www.john-fox.ca/Companion/
Friendly M, Fox J, Monette G. Heplots: Visualizing hypothesis tests in multivariate linear models. The R Foundation (CRAN: Contributed Packages). 2007 [cited 2024 Sep 17]. Available from: https://CRAN.R-project.org/package=heplots DOI: https://doi.org/10.32614/CRAN.package.heplots
Wickham H. Ggplot2: elegant graphics for data analysis. New York: Springer-Verlag; 2016. DOI: https://doi.org/10.1007/978-3-319-24277-4_9
Lüdecke D (2023). sjPlot: data visualization for statistics in social science. R package version. 2023 [cited 2024 Aug 2]. Available from: https://CRAN.R-project.org/package=sjPlot
Lenth RV. emmeans: estimated marginal means, aka least-squares means. 2017 [cited 2024 Aug 29]. Available from: https://CRAN.R-project.org/package=emmeans DOI: https://doi.org/10.32614/CRAN.package.emmeans
Fehrmann E, Tuechler K, Kienbacher T, Mair P, Spreitzer J, Fischer L, et al. Comparisons in muscle function and training rehabilitation outcomes between avoidance-endurance model subgroups. Clin J Pain 2017; 33: 912–920. DOI: https://doi.org/10.1097/AJP.0000000000000479
Nieminen LK, Pyysalo LM, Kankaanpää MJ. Prognostic factors for pain chronicity in low back pain: a systematic review. Pain Rep 2021; 6: e919. DOI: https://doi.org/10.1097/PR9.0000000000000919
Al-Obaidi SM, Nelson RM, Al-Awadhi S, Al-Shuwaie N. The role of anticipation and fear of pain in the persistence of avoidance behavior in patients with chronic low back pain. Spine 2000; 25: 1126–1131. DOI: https://doi.org/10.1097/00007632-200005010-00014
Thomas JS, France CR, Sha D, Wiele NV. The influence of pain-related fear on peak muscle activity and force generation during maximal isometric trunk exertions. Spine 2008; 33: E342–348. DOI: https://doi.org/10.1097/BRS.0b013e3181719264
Bordoni B, Marelli F. Emotions in motion: myofascial interoception. Complement Med Res 2017; 24: 110–113. DOI: https://doi.org/10.1159/000464149
Abraham A, Franklin E, Stecco C, Schleip R. Integrating mental imagery and fascial tissue: a conceptualization for research into movement and cognition. Complement Ther Clin Pract 2020; 40: 101193. DOI: https://doi.org/10.1016/j.ctcp.2020.101193
Verhoeven JE, Han LK, Lever-van Milligen BA, Hu MX, Révész D, Hoogendoorn AW, et al. Antidepressants or running therapy: comparing effects on mental and physical health in patients with depression and anxiety disorders. J Affect Disord 2023; 15: 19–29. DOI: https://doi.org/10.1016/j.jad.2023.02.064
Kahl KG, Utanir F, Schweiger U, Krüger TH, Frieling H, Bleich S, et al. Reduced muscle mass in middle-aged depressed patients is associated with male gender and chronicity. Prog Neuropsychopharmacol Biol Psychiatry 2017; 76: 58–64. DOI: https://doi.org/10.1016/j.pnpbp.2017.01.009
Masaki M, Aoyama T, Murakami T, Yanase K, Ji X, Tateuchi H, et al. Association of low back pain with muscle stiffness and muscle mass of the lumbar back muscles, and sagittal spinal alignment in young and middle-aged medical workers. Clin Biomech 2017; 49: 128–133. DOI: https://doi.org/10.1016/j.clinbiomech.2017.09.008
Schanberg LE, Gil KM, Anthony KK, Yow E, Rochon J. Pain, stiffness, and fatigue in juvenile polyarticular arthritis: contemporaneous stressful events and mood as predictors. Arthritis Rheum 2005; 52: 1196–1204. DOI: https://doi.org/10.1002/art.20952
Additional Files
Published
How to Cite
License
Copyright (c) 2025 Elisabeth Fehrmann, Linda Fischer-Grote, Julian Dietl, Patrick Mair, Gerold Ebenbichler, Thomas Kienbacher

This work is licensed under a Creative Commons Attribution 4.0 International License.
All digitalized JRM contents is available freely online. The Foundation for Rehabilitation Medicine owns the copyright for all material published until volume 40 (2008), as from volume 41 (2009) authors retain copyright to their work and as from volume 49 (2017) the journal has been published Open Access, under CC-BY-NC licences (unless otherwise specified). The CC-BY-NC licenses allow third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
From 2024, articles are published under the CC-BY licence. This license permits sharing, adapting, and using the material for any purpose, including commercial use, with the condition of providing full attribution to the original publication.