Is one screening tool enough to identify the diverse spectrum of behavioral factors that may influence a poor outcome in musculoskeletal pain?

Reference as:
Gibbons SGT (2019) Is one screening tool enough to identify the diverse spectrum of behavioral factors that may influence a poor outcome in musculoskeletal pain? Proceedings of: The 10th Interdisciplinary World Congress on Low Back Pain. October 28-31, 2019; Antwerp, Brussels

General Comment: A battery of ultra brief screens may be a way forward for screening the diverse array of behavioral presentations that present in chronic musculoskeletal pain. Current screens have limited diagnostic accuracy. This project was a feasibility study.

Introduction
Behavioral factors are known to predict a poor outcome from acute low back pain (LBP) and are associated with chronic LBP. The psychiatric and pain literature note many behavioral conditions that are associated with chronic pain. There are behavioral conditions that are not commonly recommended in screening since they are often co-morbid with other conditions that are screened. This screening approach has potential problems. First, the screening of only one behavioral condition will lower the accuracy of the screening since other relevant conditions may be missed. Second, it is not well understood how outcome is affected if multiple behavioral conditions are present. Third, the treatment for one behavioral condition is different from combinations of behavioral conditions.

Purpose/Aim
The purpose of this paper was to identify the percentage of patents that score above the cut off point on a battery of behavioral screening tools.

Materials and Methods
A clinical audit was performed on 485 patient charts: 223 LBP (85 acute/138 chronic); 118 whiplash associated disorders (WAD) (37 acute/ 81 chronic); 63 neck pain (11 acute/ 52 chronic); 81 peripheral regions. The following behavioral factors were assessed using a battery of previously validated short questionnaires with cut off points. Category 1 included: anxiety (2 items); kinesiophobia (1 item); catastrophication / recovery expectation (1 item); ); stress (2 items); post traumatic stress disorder (4 items). Category 2 included: depression (2 items); hopelessness (1 item). Category 3 included: self esteem (1 item); body appreciation (2 items). Category 4 included personality disorders (8 items). Category 5 included social factors (2 items). A category was considered positive if any one score for any condition was recorded above the suggested cut off score. Descriptive statistics were used. Standard practice was to assess outcome with a 7 point Global Rating of Change scale; Numerical Rating Scale for pain, function with the Patient Specific Functional Scale and a disability questionnaire related to the body region: Roland Morris Disability Questionnaire; Neck Disability Index.

Results
The questionnaire took under 10 minutes to complete. Missing values were under 2%. A poor outcome was considered not improving beyond the minimal clinically important change (MCIC) on any domain using evidence based interventions. A poor outcome was found in 68% (1 category positive; n=12); 82% (2 categories positive; n=17); 92% (3 categories positive; n=26); 100% (4 categories positive; n=23).

Conclusion(s)
This clinical audit suggests that a variety of behavioral factors present with musculoskeletal pain. As well, scores above the recommended cut off point suggested cut off values for multiple categories of behavioral factors may be more predictive of outcome than 1. There is a clear need to understand how the interaction of psychiatric conditions in different categories influences the response to different therapies. Using multiple short questionnaires appears to be feasible. Further research is needed to test the reliability of the items used as a whole and to control for subejct's co-treatments and exposures in a larger sample.

Keywords
Low back pain, whiplash associated disorders, psychosocial factors, outcome, screening, Sub-classification