STarT Back Screening Tool

Abstract

The STarT Back Screening Tool (SBT), developed by researchers at Keele University (Hill et al., 2008), is a brief, validated prognostic screening instrument designed for primary care management of patients presenting with low back pain (LBP). Created to facilitate subgroup-targeted treatment, the tool identifies modifiable physical and psychosocial risk factors that predict chronicity, functional disability, and long-term healthcare utilization. The instrument comprises 9 self-report items evaluated through a dichotomous and categorical response structure. Items 1 through 4 assess physical functional limitations and referred symptoms (radicular pain, comorbid musculoskeletal pain, walking restriction, and dressing difficulty), whereas items 5 through 9 constitute a dedicated psychosocial subscale measuring kinesiophobia (fear of movement), catastrophic worry, pain-related hopelessness/catastrophizing, depressive symptoms (anhedonia), and overall pain bothersomeness. The scoring architecture categorizes individuals into three prognostic risk groups: low risk (total score 0–3), medium risk (total score 4–9 with psychosocial subscale ≤ 3), and high risk (psychosocial subscale score ≥ 4). This stratification directly informs matched clinical care pathways, pairing low-risk patients with self-management support to avoid over-medicalization, medium-risk patients with evidence-based physical rehabilitation, and high-risk patients with psychologically informed physiotherapy (combining cognitive-behavioral techniques with physical reactivation). Extensive psychometric evaluations demonstrate robust concurrent validity with legacy instruments (such as the Roland-Morris Disability Questionnaire, Tampa Scale for Kinesiophobia, and Pain Catastrophizing Scale), strong discriminative capacity (area under the receiver operating characteristic curve [AUC] ranging from 0.70 to 0.82 for predicting 6- to 12-month persistent disability), and adequate test-retest reliability (quadratic weighted kappa between 0.70 and 0.83). Subsequent randomized controlled trials, notably the landmark STarT Back trial published in The Lancet (Hill et al., 2011), confirmed that stratified care guided by the SBT achieves superior clinical outcomes at reduced socioeconomic costs compared to standard, non-stratified primary care.

Keywords

STarT Back Screening Tool, Low Back Pain, Risk Stratification, Psychosocial Screening, Prognostic Assessment, Musculoskeletal Rehabilitation, Biopsychosocial Model, Fear Avoidance, Pain Catastrophizing, Primary Care Triage

Authors

The STarT Back Screening Tool was primarily developed and validated by a multidisciplinary research consortium based at the Arthritis Research UK Primary Care Centre (now the Primary Care Centre Versus Arthritis, School of Medicine) at Keele University, United Kingdom:

• Jonathan C. Hill, PhD, PT: Professor of Musculoskeletal Physiotherapy, School of Medicine, Keele University, Staffordshire, UK. Lead investigator in the conceptualization, validation, and implementation of the STarT Back prognostic approach.
• Elaine M. Hay, MD, FRCP: Professor of Community Rheumatology, Keele University, Staffordshire, UK. Senior clinical investigator in stratified care models for musculoskeletal disorders.
• Daniele A. van der Windt, PhD: Professor of Primary Care Epidemiology, Keele University, Staffordshire, UK. Methodological lead in prognostic research and clinical prediction modeling.
• Krysia Dziedzic, PhD, PT: Professor of Musculoskeletal Therapies, Keele University, Staffordshire, UK.
• Nadine E. Foster, DPhil, PT: Professor of Musculoskeletal Health, Keele University (subsequently Academic Director of the Surgical Treatment and Rehabilitation Service, University of Queensland, Australia). Co-principal investigator of the randomized evaluation trials.

The standard Dutch validation and transcultural adaptation was established by a research group comprising:

• Maurits W. van Hooff, PhD: Sint Maartenskliniek, Nijmegen, The Netherlands.
• Wendy van Lankveld, PhD: HAN University of Applied Sciences, Nijmegen, The Netherlands.
• P. Anderson, MSc: Sint Maartenskliniek, Nijmegen, The Netherlands.
• F. van Hartingsveld, MSc: Sint Maartenskliniek, Nijmegen, The Netherlands.
• Raymond W. J. G. Ostelo, PhD: Professor of Evidence-Based Physiotherapy, Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute, The Netherlands.

Purpose

Low back pain is the leading contributor to years lived with disability globally, placing an enormous economic strain on healthcare systems and workforce productivity. In non-specific low back pain, clinical presentations are notoriously heterogeneous: whereas most acute episodes resolve favorably within weeks, a substantial subset of patients (approximately 10% to 20%) transitions to persistent, disabling chronic conditions. Historically, routine clinical practice has struggled to identify which patients will spontaneously recover and which are vulnerable to chronicity, leading simultaneously to the overtreatment of low-risk individuals (e.g., unnecessary imaging, inappropriate opioid prescription, unwarranted spinal injections, and bed rest) and the undertreatment of complex, high-risk individuals (e.g., standard physical therapy devoid of psychological interventions).

The primary purpose of the STarT Back Screening Tool is to solve this clinical dilemma through prognostic stratification at the point of primary care consultation. Rather than functioning purely as an epidemiological survey or a broad diagnostic inventory, the SBT was engineered as a rapid, pragmatic, actionable clinical decision-support tool. It measures modifiable prognostic determinants—encompassing both somatic/biomechanical symptoms and cognitive-affective psychosocial barriers—to classify patients into one of three risk tiers, each linked to a distinct, evidence-based treatment pathway:

• Low-Risk Subgroup: Patients in this cohort have a favorable natural history and minimal psychosocial distress. The clinical objective is reassurance, promotion of self-management, provision of evidence-based educational resources (such as The Back Book), advice to maintain normal daily activities, and the deliberate avoidance of invasive or costly biomedical investigations.
• Medium-Risk Subgroup: Patients exhibit marked functional physical disability and pain symptoms, but without overwhelming cognitive-affective overlay. The clinical objective is referral to outpatient physiotherapy directed toward restoring spinal mobility, improving neuromuscular control, optimizing strength, and addressing biomechanical dysfunctions without extensive psychological restructuring.
• High-Risk Subgroup: Patients present with high levels of maladaptive cognitive-affective beliefs, including fear-avoidance behaviors, severe pain-related worry, helplessness, and depressed affect, regardless of structural physical presentation. The clinical objective is targeted psychologically informed physiotherapy (PiP) or multidisciplinary rehabilitation combining physical reactivation with cognitive-behavioral therapies (CBT) to alter dysfunctional pain perceptions and dismantle catastrophic interpretations of somatic sensations.

In research contexts, the SBT provides a standardized methodology for baseline risk stratification in clinical trials. It ensures that randomized experimental interventions are tested within homogeneous prognostic strata, resolving the longstanding dilution effects observed in classical low back pain rehabilitation trials where heterogenous cohorts obscured intervention efficacy.

Psychological Construct

The STarT Back Screening Tool measures a multidimensional prognostic construct defined by the interaction between physical symptom severity/impairment and psychosocial vulnerability. The latent architecture reflects contemporary multidimensional perspectives on chronic pain, recognizing that chronicity is rarely driven by peripheral tissue pathology alone, but by reciprocal relationships among sensory inputs, cognitive appraisals, emotional states, and behavioral selections. The construct is operationalized across nine distinct symptomatic indicators mapped onto two integrated domains:

1. Physical Symptom and Functional Disability Indicators (Items 1 to 4)

The first four items capture neuro-mechanical and behavioral expressions of back dysfunction:

• Referred Radicular Symptoms (Item 1): Inquires whether back pain has radiated below the knee or into the lower extremity during the prior 14 days. Leg pain radiation serves as an indicator of neural irritation or radiculopathy, historically associated with delayed functional recovery, heightened pain intensity, and elevated risk of surgical intervention.
• Widespread / Comorbid Musculoskeletal Pain (Item 2): Identifies co-occurring axial or peripheral symptoms in the shoulder or neck region. The presence of multi-site or widespread pain reflects generalized central sensitization, altered descending pain modulation, or systemic pain vulnerability, marking a departure from localized, uncomplicated biomechanical back symptoms.
• Locomotor Restriction (Item 3): Measures ambulation intolerance (only walking short distances). Severe reduction in basic walking capacity reflects acute functional impairment and heightened disability, signaling significant activity limitation according to the International Classification of Functioning, Disability and Health (ICF) framework.
• Self-Care and Dressing Impairment (Item 4): Assesses whether dressing velocity and independence have been constrained. Self-care deceleration indicates interference with basic activities of daily living (ADLs), capturing movement-evoked mechanical pain and biomechanical spinal guarding.

2. Psychosocial Distress and Cognitive-Affective Vulnerability Indicators (Items 5 to 9)

Items 5 through 9 constitute the instrument’s dedicated Psychosocial Subscale, reflecting psychological constructs known to mediate the transition from acute discomfort to chronic disabling pain:

• Fear-Avoidance Beliefs / Kinesiophobia (Item 5): Measures the cognitive conviction that physical activity is hazardous to spinal integrity (“It’s not really safe for a person with a condition like mine to be physically active”). Rooted in the fear-avoidance model, this item captures the misinterpretation of benign physiological sensations as signs of progressive anatomical harm, prompting avoidance behaviors that drive neuromuscular deconditioning and secondary disability.
• Anxiety and Cognitive Hypervigilance (Item 6): Evaluates recurring, intrusive, worry-laden thoughts (“Worrying thoughts have been going through my mind a lot of the time”). This item reflects generalized anxious anticipation and somatic hypervigilance, states that amplify nociceptive transmission via neuroendocrine and limbic system activation.
• Pain Catastrophizing and Helplessness (Item 7): Measures catastrophic appraisals characterized by magnification of threat and perceived helplessness (“I feel that my back pain is terrible and it’s never going to get any better”). Catastrophizing represents an exceptionally potent predictor of functional decline, poor surgical outcomes, and heightened analgesic dependence.
• Depressive Affect and Anhedonia (Item 8): Captures core affective blunting and loss of interest in rewarding activities (“In general I have not enjoyed all the things I used to enjoy”). Anhedonia signals depressive symptomatology, blunted central dopaminergic reward processing, and systemic vulnerability to behavioral withdrawal.
• Overall Pain Bothersomeness (Item 9): A summary evaluative measure capturing the subjective suffering and disruption caused by the symptom state over the past 14 days. Pain bothersomeness acts as a pragmatic global indicator integrating physical intensity, emotional intolerance, and perceived disruption to daily roles.

Theoretical Framework

The STarT Back Screening Tool is grounded in the convergence of two dominant contemporary paradigms in behavioral medicine: the Biopsychosocial Model of Illness (Engel, 1977) and the Cognitive-Behavioral Fear-Avoidance Model of Musculoskeletal Pain (Vlaeyen & Linton, 2000; 2012).

Under George Engel’s Biopsychosocial Model, illness cannot be reduced strictly to biological lesions or mechanical aberrations. Instead, pain experiences, functional limitations, and healthcare consumption emerge through a non-linear interaction between structural biological status, psychological dynamics (beliefs, coping mechanisms, mood), and sociocultural context. Historically, primary care for back pain overemphasized biomedical diagnostics (such as MRI and radiography), seeking structural pain generators that correlate poorly with clinical symptom severity. The SBT operationalizes the biopsychosocial model into routine clinical practice by assessing both physical impairments and psychological variables within a single 9-item algorithm.

The cognitive-behavioral foundation of the SBT draws heavily from the Fear-Avoidance Model formulated by Johan Vlaeyen and Steven Linton. According to this framework, an individual confronted with acute musculoskeletal injury initiates an evaluative pathway that bifurcates based on cognitive appraisal:

1. The Adaptive Pathway (Low Risk): Pain is appraised as an unpleasant, non-catastrophic physical event. The individual maintains a realistic perspective regarding healing timelines, engages in behavioral confrontation (resuming normal activities, walking, working), and achieves functional recovery.
2. The Maladaptive Pathway (High Risk): Pain is cognitively appraised through catastrophic lenses (“terrible and never going to get better”). This cognitive distortion fosters fear of movement (kinesiophobia), which activates safety-seeking behaviors, hypervigilance, avoidance of everyday physical activity, and social withdrawal. Over time, prolonged disuse induces physical deconditioning, central sensitization, depression, and sustained functional disability.

In addition to the Fear-Avoidance Model, the SBT incorporates principles from Howard Leventhal’s Common-Sense Model of Self-Regulation. Leventhal posits that patients construct dynamic illness representations encompassing identity (symptoms), timeline (acute vs. chronic expectations), cause, and consequences. Item 7 directly queries the timeline/consequence belief by testing expectations of chronicity (“never going to get better”). Patients holding negative timeline and consequence beliefs demonstrate markedly poorer recovery trajectories, making this a pivotal target for cognitive restructuring.

Validity

The STarT Back Screening Tool has undergone extensive psychometric evaluation across diverse primary care, physical therapy, and hospital settings internationally. Validation research has established its construct, concurrent, predictive, and discriminant validity.

1. Construct and Concurrent Validity

During initial validation by Hill et al. (2008), the SBT’s items and subscales were correlated with well-established legacy questionnaires. The total score correlated strongly with the Roland-Morris Disability Questionnaire (RMDQ; Pearson’s $r = 0.73$), demonstrating construct alignment with functional disability. The psychosocial subscale demonstrated strong convergent correlations with dedicated psychological instruments:

• Tampa Scale for Kinesiophobia (TSK): $r = 0.53$ to $0.62$
• Pain Catastrophizing Scale (PCS): $r = 0.60$ to $0.68$
• Hospital Anxiety and Depression Scale (HADS) Anxiety subscale: $r = 0.57$
• HADS Depression subscale: $r = 0.59$ to $0.64$

In the Dutch validation study conducted by van Hooff et al. (2011), the Dutch SBT exhibited similarly strong convergent validity with the RMDQ ($r = 0.68$), the TSK ($r = 0.52$), and the EuroQol 5D (EQ-5D) index ($r = -0.58$), confirming that the theoretical properties of the items translate reliably across language variants.

2. Predictive Validity

Predictive validity is the cornerstone of the SBT’s utility. The primary prognostic target is persistent functional disability at 6 and 12 months follow-up. In the developmental cohort (Hill et al., 2008), the area under the receiver operating characteristic curve (AUC-ROC) for predicting severe 6-month functional disability (defined as RMDQ score ≥ 7) was 0.80 (95% CI: 0.74–0.85) for the total score and 0.82 for the psychosocial subscale. When evaluating the tool’s ability to identify individuals with high psychological distress, the psychosocial subscale achieved an AUC of 0.84 against the TSK and 0.88 against the PCS.

Across independent validation cohorts, such as the US primary care study by Beneciuk et al. (2013) and European cohorts (Danish, French, and German validations), the SBT consistently demonstrates moderate-to-strong predictive validity for 6-month disability outcomes, with AUCs typically stabilizing between 0.70 and 0.81.

3. Discriminant and Stratified Predictive Validity

The SBT effectively discriminates between risk strata. In longitudinal clinical cohorts, patients classified as high-risk exhibit significantly higher healthcare utilization, longer sick leave duration, and lower rates of spontaneous recovery compared to low-risk patients. In the landmark STarT Back trial (Hill et al., 2011), patients stratified into the low-risk group achieved rapid symptom resolution with minimal intervention, showing an average RMDQ improvement of 2.4 points at 12 months with low medical consumption, whereas the high-risk cohort receiving standard, non-stratified care experienced sustained disability, high rates of specialist referral, and extensive work absence.

Reliability

The reliability of the STarT Back Screening Tool has been evaluated across internal consistency metrics, test-retest stability paradigms, and standard error of measurement calculations.

1. Internal Consistency

Because the SBT is an index composed of physical functional items and cognitive-affective indicators designed to capture distinct clinical domains, standard Cronbach’s alpha values for the overall 9-item scale reflect moderate heterogeneity. In the original development study by Hill et al. (2008), Cronbach’s alpha for the entire 9-item instrument was 0.79, indicating acceptable internal consistency. The 5-item psychosocial subscale demonstrated a Cronbach’s alpha of 0.74, reflecting moderate-to-high homogeneity among the cognitive-affective items without redundancy.

In subsequent transcultural evaluations, internal consistency parameters have demonstrated stability:

• Dutch version (van Hooff et al., 2011): Total scale $\alpha = 0.70$; Psychosocial subscale $\alpha = 0.65$.
• German version (Karstens et al., 2013): Total scale $\alpha = 0.74$; Psychosocial subscale $\alpha = 0.69$.
• Spanish version (Gusi et al., 2011): Total scale $\alpha = 0.76$.

2. Test-Retest Reliability

Given the fluctuating nature of acute musculoskeletal symptoms, establishing temporal stability requires retesting intervals short enough to prevent clinical shifting while long enough to avoid recall bias (typically 24 hours to 7 days). In the initial evaluation using a 24- to 48-hour retest interval, the overall risk categorization showed substantial agreement, with a quadratic weighted Cohen’s kappa ($kappa$) of 0.73 (95% CI: 0.57–0.89). For individual items, percentage agreement ranged from 71% to 88%, with simple kappa values ranging from 0.44 to 0.70.

In the Dutch validation by van Hooff et al. (2011), the intraclass correlation coefficient (ICC) for the total score over a 1- to 2-week interval was 0.78 (95% CI: 0.66–0.86), while the psychosocial subscale achieved an ICC of 0.74, confirming good temporal reproducibility in ambulant primary care populations.

Factor Analysis

The underlying factor structure of the STarT Back Screening Tool has been investigated via exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and Rasch measurement models to clarify whether the instrument functions as a single unified construct or a multidimensional matrix.

1. Exploratory and Confirmatory Factor Analyses

In early factor analytic explorations, principal component analysis (PCA) with varimax or oblimin rotation consistently extracted two distinct, intercorrelated factors explaining approximately 45% to 54% of the total variance:

• Factor 1: Psychosocial Distress / Cognitive-Affective Vulnerability — Consistently loaded heavily by items 5 (fear of activity), 6 (worry), 7 (catastrophizing/hopelessness), 8 (anhedonia), and 9 (bothersomeness). Factor loadings for these items typically range from 0.54 to 0.78.
• Factor 2: Physical Functional Disability / Symptom Distribution — Dominated by items 1 (referred leg pain), 3 (walking limitations), and 4 (slow dressing), with factor loadings ranging from 0.51 to 0.76. Item 2 (comorbid shoulder/neck pain) often exhibits moderate, cross-loading tendencies or lower communality, reflecting its role as a marker of systemic musculoskeletal complaints rather than localized lumbar biomechanics.

Confirmatory factor analytic investigations (e.g., Wideman et al., 2012; Hill et al., 2011) confirmed that a two-factor oblique model provides superior fit compared to a strict unidimensional model. Typical fit indices from structural equation modeling evaluations report:

• Comparative Fit Index (CFI) > 0.94
• Tucker-Lewis Index (TLI) > 0.92
• Root Mean Square Error of Approximation (RMSEA) between 0.045 and 0.062
• Standardized Root Mean Square Residual (SRMR) < 0.05

2. Item Response Theory and Rasch Analyses

Modern psychometric evaluations using Rasch modeling and Item Response Theory (IRT) have clarified item difficulty hierarchies. On the physical dimension, Item 4 (dressing slowly) represents an intermediate threshold of functional limitation, whereas Item 3 (walking short distances) captures more severe physical limitation. On the psychosocial dimension, Item 6 (worrying thoughts) represents a lower-threshold, highly sensitive marker of psychological distress, whereas Item 7 (catastrophizing/hopelessness) functions as a high-threshold indicator identifying patients with entrenched cognitive vulnerability. The differential item functioning (DIF) across age and gender cohorts has been found to be clinically negligible.

Instrument / Measurement Tool

The STarT Back Screening Tool is structured as a brief paper-and-pencil or digitally administered clinical questionnaire that can be completed by the patient in approximately 2 minutes.

• Target Population: Adults (aged 18 and older) and older adults presenting in primary care, occupational healthcare, physical therapy, or ambulatory orthopedic settings with non-specific low back pain (with or without associated lower limb radiation).
• Administration Format: Self-administered (paper, tablet, web-based portal) or clinician-administered interview.
• Item Count: 9 items.
• Response Scale Architecture:
  • Items 1 to 8: Dichotomous response format: Disagree (0) or Agree (1).
  • Item 9: 5-point ordinal bothersomeness scale: Not at all (0), Slightly (0), Moderately (0), Very much (1), or Extremely (1).
• Scoring Rules:
  • Each endorsed response contributing to risk receives 1 point; unendorsed responses receive 0 points.
  • Total Score: Sum of all 9 items (Range: 0 to 9).
  • Psychosocial Subscale Score: Sum of Items 5, 6, 7, 8, and 9 (Range: 0 to 5).
• Prognostic Stratification Algorithm:
  • Low Risk: Total score of 0, 1, 2, or 3 (regardless of psychosocial score).
  • Medium Risk: Total score of 4, 5, 6, 7, 8, or 9 AND a Psychosocial Subscale score of 3 or lower.
  • High Risk: Psychosocial Subscale score of 4 or 5 (regardless of total score; mathematically, total score will be ≥ 4).
• Associated Clinical Decision Pathways:
  • Low Risk: Prognosis is good. Management focuses on reassurance, self-care guidance, keeping active, avoiding bed rest, and avoiding unnecessary advanced imaging or immediate multidisciplinary referrals.
  • Medium Risk: Prognosis is intermediate. Management focuses on evidence-based conservative physical therapy targeting mobility, strength, and function, with physical reconditioning.
  • High Risk: Prognosis indicates high risk of chronicity and disability. Management requires psychologically informed physical therapy (PiP) combining active functional restoration with cognitive-behavioral techniques to address catastrophizing, kinesiophobia, hypervigilance, and depression.

Permissions, Fee, and Test Year

The original STarT Back Screening Tool was published in 2008 by Jonathan C. Hill and colleagues at Keele University (with preliminary cohort development tracing to 2007, and primary care implementation trials culminating in 2011). The standard Dutch translation was published in 2011 by Maurits W. van Hooff and co-authors.

Licensing and Availability: The STarT Back Screening Tool is copyrighted by Keele University. However, Keele University has dedicated the tool to public health dissemination: it is made freely available for clinical practice, non-commercial healthcare delivery, and academic research without fee. Clinicians and researchers may download authorized paper and digital versions directly from the Keele University website. Commercial vendors integrating the tool into proprietary electronic health record (EHR) systems or software platforms intended for commercial licensing are required to obtain formal written permission and licensing agreements from the Keele University Impact and Licensing Office.

References

• Beneciuk, J. M., Robinson, M. E., & George, S. Z. (2013). Subgrouping for targeted treatment in primary care for low back pain: Comparison of the STarT Back Screening Tool and the STarT Back stratified care approach. The Journal of Orthopaedic and Sports Physical Therapy, 43(5), 291–304. https://doi.org/10.2519/jospt.2013.4475
• Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460
• Foster, N. E., Mullis, R., Hill, J. C., Lewis, M., Whitehurst, D. G., Doyle, C., Best, P. R., Baxter, G. D., & Hay, E. M. (2014). Effect of stratified care for low back pain in family practice (IMPaCT Back): A cluster randomized trial. Annals of Family Medicine, 12(2), 102–111. https://doi.org/10.1370/afm.1594
• Gusi, N., del Pozo-Cruz, B., Olivares, P. R., & Hernandez-Mocholí, M. (2011). The Spanish version of the STarT Back Screening Tool: Psychometric properties in primary care back pain patients. Medicina Clínica, 137(12), 536–543. https://doi.org/10.1016/j.medcli.2010.11.031
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• Karstens, S., Kuithan, F., Joos, S., Hill, J. C., Steinhauser, J., & Szecsenyi, J. (2013). Cross-cultural adaptation and validation of the German version of the STarT Back Tool for low back pain patients. Der Schmerz, 27(4), 380–388. https://doi.org/10.1007/s00482-013-1335-5
• van Hooff, M. W., van Lankveld, W., Anderson, P., van Hartingsveld, F., & Ostelo, R. W. (2011). Validatie en betrouwbaarheid van de Nederlandse versie van de STarT Back Screening Tool (SBT). Fysiopraxis, 20(9), 24–27.
• Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85(3), 317–332. https://doi.org/10.1016/S0304-3959(99)00242-0
• Wideman, T. H., Hill, J. C., Main, C. J., Lewis, M., Sullivan, M. J., & Hay, E. M. (2012). Comparing the responsiveness of a brief, multidimensional risk screening tool for back pain to its unidimensional reference standards: The STarT Back assessment study. Pain, 153(11), 2182–2191. https://doi.org/10.1016/j.pain.2012.06.010

Items of the Scale