Jason M. Beneciuk, Steven Z. George, Mark A. Jones
Assessment, Reasoning and Management of Psychological Factors in Musculoskeletal Practice
Pain and associated disability are an overall experience and not simply isolated sensory, emotional or physiological responses (Institute of Medicine, 2011; Sim and Smith, 2004). Pain and disability occur in both a psychological and sociocultural context. As reflected in the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization (2001) biopsychosocial framework depicted in Chapters 1 and 3, biological and psychosocial factors interact reciprocally in determining patients’ pain and disability experiences that are both individual and complex (Borrell-Carrio et al., 2004). Within the literature, the term ‘psychosocial’ is commonly used as a single construct capturing both psychological and social influences. However, although psychological and social factors are intimately associated with each other, and in turn with pain and disability, they are individually comprised of specific characteristics that need to be understood and considered in musculoskeletal clinicians’ patient assessment and management. Although the ‘psychosocial’ construct is used within this chapter because it is more broadly linked to the literature, this chapter focuses on psychological factors, with Chapter 3 focussing more explicitly on the influences of stress, coping and the interaction of social factors.
An important point to establish at the outset of this chapter is that psychological factors should not all be construed as negative. As an example, as discussed in Chapter 3, high self-efficacy related to pain-provoking tasks has been identified as a positive prognostic indicator for musculoskeletal pain clinical outcomes (Foster et al., 2010; Sarda et al., 2009). Building on the clinical reasoning theory in Chapter 1 and the theoretical foundations for the interaction between psychological and social factors covered in Chapter 3, this chapter discusses clinical reasoning associated with the identification and management of psychological factors that have been described as complications associated with recovery because they provide modifiable treatment targets.
There is increasing evidence that negative psychosocial factors are adversely influential in the transition from acute to chronic pain conditions (Burton et al., 1995; Linton, 2000; Linton, 2005; Nicholas et al., 2011; Chou et al., 2007; Chou and Shekelle, 2010). For example, a systematic review involving psychological factors as prognostic indicators for persistent pain and disability suggests there can be consistent relationships between depression, pain catastrophizing, pain intensity and beliefs about pain with future clinical or occupational outcomes in patients with acute or subacute low back pain (LBP) (Nicholas et al., 2011). A similar, yet separate systematic review involving predictors of poor clinical outcomes indicated that nonorganic signs, elevated maladaptive pain coping behaviors, elevated baseline LBP-related disability, the presence of psychiatric comorbidities and low general health status were the strongest predictors of poor clinical outcomes at 1-year follow-up (Chou and Shekelle, 2010). The theoretical foundations of coping beliefs and behaviours, pain, disability and general health status are covered in Chapter 3. Although most of the previous research in this area has explored the influence negative psychological factors have on LBP outcomes, it seems plausible (from a theoretical perspective) that similar relationships may be relevant for musculoskeletal pain complaints in other body regions (Nicholas et al., 2008; Hunt et al., 2013; Sullivan et al., 2006, 2009; George et al., 2007, 2011; Hartigan et al., 2013). Similarly, although not the focus of research, psychological factors can impact positively and negatively on any patient, and negative factors can contribute to attitudes, beliefs and behaviours that underpin the slow recovery and recurrence of any problem, thus supporting their screening in all patients.
Musculoskeletal Clinicians’ Lack of Knowledge and Ability to Assess and Manage Psychological Factors
Although musculoskeletal clinicians are generally well educated to assess and manage the physical and many environmental dimensions of the patient’s health condition, formal education and experience assessing, evaluating and managing psychological and social factors contributing to both acute and chronic pain are often less developed and less structured (Barlow, 2012; Bishop and Foster, 2005; Foster and Delitto, 2011; Main and George, 2011; Overmeer et al., 2005; Sanders et al., 2013; Singla et al., 2015). This was evident in survey responses from Australian primary care clinicians (n = 651), including musculoskeletal specialists (n = 255; 39.2%), that indicated formal psychosocial screening is not common (Kent et al., 2009). These results are alarming when one considers that formal screening has been shown to be more accurate than informal judgement (Spitzer et al., 1994; Haggman et al., 2004). Therefore, it seems apparent that embedding attention to psychological factors into musculoskeletal clinicians’ management strategies is faced with several challenges, including inconsistency in breadth and depth of psychosocial education during entry-level study, competency in application of theory to practice (which is difficult to measure) and clinician culture (Foster and Delitto, 2011; Main and George, 2011). Most notably, biomedical or impairment-based perspectives are predominantly emphasized during the formal education and ongoing professional development of many musculoskeletal clinicians, with little, if any, content being provided from a biopsychosocial perspective (Foster and Delitto, 2011; Main and George, 2011; Smart and Doody, 2007; Daykin and Richardson, 2004; Bishop and Foster, 2005; Simmonds et al., 2012). Further complicating this issue is that collectively and traditionally, there has been a lack of clear knowledge regarding musculoskeletal clinicians’ psychosocial assessment, reasoning and management best practice (Linton and Shaw, 2011; Nicholas et al., 2011; Foster and Delitto, 2011). However, suggestions have been put forward (Jones and Edwards, 2008), and a growing body of literature is now available informing musculoskeletal clinicians’ psychosocial assessment and management, as well as underpinning reasoning (French and Sim, 2004; Hasenbring et al., 2012; Jones and Edwards, 2008; Keefe et al., 2006; Main et al., 2008).
The ‘Flag’ System of Screening for Psychosocial-Related Risk Factors
The ‘flag’ system has been suggested as a framework to classify patients and assist in clinical decision-making processes based on colours representing different types of risk factors (Nicholas et al., 2011; Main and George, 2011):
- • Red flags – serious pathology (e.g. fracture)
- • Orange flags – psychopathology (e.g. clinical depression)
- • Yellow flags – psychological reactions to symptoms (e.g. fear-avoidance beliefs about physical activity)
- • Blue flags – perceptions about work and health relationships (e.g. belief that increased work will lead to further injury)
- • Black flags – healthcare system influence on clinical decisions and contextual factors (e.g. insurance restrictions, socioeconomic status)
- • Orange flags – psychopathology (e.g. clinical depression)
Although sociocultural influences outside the workplace and healthcare system (e.g. family, community, government, etc.) are not represented in the flag classifications, they are equally important to consider, as discussed in Chapter 3.
An important component to incorporating the flag system into musculoskeletal practice is the ability to distinguish between different types of clinical decisions (Nicholas et al., 2011). ‘Psychologically informed practice’ has been presented as a secondary prevention approach for chronic musculoskeletal pain that integrates both biomedical (focused on pathology or physical impairments) and cognitive-behavioural (focused on psychological distress or behaviour) principles (Main and George, 2011). Psychologically informed practice also underpins cognitive-behavioural approaches used for patients who may be experiencing recurrent symptoms or have already progressed to chronicity. The primary goal of psychologically informed musculoskeletal practice is minimization of current and future disability related to musculoskeletal pain by emphasizing (1) identification of individuals who are at high risk for developing chronic or recurrent symptoms based on the presence of psychological factors and (2) targeted treatment aimed at psychological factors in conjunction with traditional, impairment-based therapy (Main and George, 2011). Therefore, although screening for ‘red flags’ as indicators of serious pathology is an important component of routine clinical practice, psychologically informed practice is predominantly characterized by screening for elevated and functionally maladaptive ‘yellow flags’ to identify patients at risk for poor outcomes primarily based on psychological factors that potentially can be targeted through direct therapeutic intervention.
It is also important to distinguish between modifiable and non-modifiable psychosocial risk factors from a musculoskeletal intervention perspective because both may be strong predictors of future outcomes and can be identified through screening. Some psychosocial risk factors are non-modifiable through musculoskeletal clinical intervention. For example, social class has been identified as a predictor of poor outcome in patients with neck pain treated by physical therapists (Hill et al., 2007); however, it is non-modifiable through musculoskeletal clinical intervention. From a psychological perspective, Main and George (2011) have suggested that the ability to distinguish between modifiable and non-modifiable risk factors based on the flag system is a critical component of psychologically informed practice because musculoskeletal clinicians are not trained to address all psychological risk factors. For instance, properly trained musculoskeletal clinicians are equipped to identify and provide interventions tailored to addressing yellow flags (e.g. maladaptive pain coping), which are considered modifiable psychological risk factors. However, it is not within the scope of musculoskeletal practice to provide direct treatment interventions that target orange flags (e.g. clinical depression), which are considered non-modifiable psychological risk factors, through direct musculoskeletal treatment interventions alone. Therefore, orange flag screening combined with frequent and early re-assessment is a vitally important role for musculoskeletal clinicians during the ongoing clinical reasoning process to determine if referral to other healthcare professionals (e.g. clinical psychologist) is warranted. Similar to screening for visceral disease masquerading as a musculoskeletal disorder, the appropriately trained musculoskeletal clinician’s role in orange flag screening is, for example, to screen for symptoms of clinical depression and other psychological disorders (e.g. anxiety) and not to diagnose psychological or psychiatric disorders. Just as every clinical feature listed as a potential red flag does not necessitate immediate referral, not every patient with elevated depressive symptoms will need to be referred to a psychologist or back to the referring practitioner. This is an area requiring more attention in musculoskeletal education to assist clinicians to be able to recognize indicators warranting immediate referral or consultation (e.g. suicidal tendencies, features of post-traumatic stress syndrome). Musculoskeletal clinicians are advised to add this screening to their current patient assessment, to monitor any overt symptoms linked to orange flags and to consult with the referring practitioner or a psychologist when uncertain about the significance of such symptoms.
Psychosocial yellow flags are probably the most manageable from a musculoskeletal clinical perspective; therefore, increased emphasis should be placed on clinical reasoning associated with information obtained from yellow flag assessments to identify individuals who may benefit from psychologically based interventions (Nicholas and George, 2011). Expert musculoskeletal clinicians have been shown to employ a range of ‘clinical reasoning strategies’ incorporating different foci of reasoning, including psychosocially oriented reasoning (i.e. ‘narrative reasoning’) (Edwards et al., 2004) as discussed in Chapter 1. Expanding your knowledge of theoretical constructs that characterize pain coping behaviours, as covered in Chapter 3, combined with an understanding of narrative reasoning, will facilitate clinical assessment, analysis and management of yellow flags for patients experiencing musculoskeletal pain.
Psychosocial ‘Yellow Flag’ Screening and Assessment Process
The intent of primary prevention is the protection of health by personal and community-wide efforts. As a potential component of primary prevention, screening can provide valuable information regarding risk factors for future disease among healthy individuals in the general population (e.g. demographics or lifestyle) (Straus et al., 2005). However, screening is also commonly associated with secondary prevention processes where the intent is early identification of individuals with the potential for poor future outcomes (e.g. disability related to musculoskeletal pain). Early risk factor screening has been advocated as one strategy to identify patients who may be at risk of poor clinical outcomes and as a potential method to improve the efficiency and effectiveness of care (Pransky et al., 2011; Hill and Fritz, 2011; Chou et al., 2007). Risk factor screening can be achieved by questionnaire and by patient interview. Validated questionnaires provide quantitative measurement of psychological factors while also opening the door to important areas of assessment patients may not spontaneously volunteer. Information provided via questionnaire can then be explored further through the patient interview for a fuller understanding of the patient and psychological factors that may be contributing to the patient’s pain and disability. Although psychosocial factor screening to inform psychologically informed management has mostly been investigated and discussed in the area of LBP, the overarching premise of routine screening may have applicability to many if not all musculoskeletal conditions (Nicholas et al., 2008, 2011).
Psychological Factor Screening by Questionnaire
Self-report psychological factor screening questionnaires are commonly used by clinicians as a component of the assessment process. The design of these questionnaires can range from unidimensional measures that provide an assessment of a specific psychological construct to multidimensional measures that provide an assessment of overall psychological distress. Each of these approaches is associated with strengths and weaknesses. For example, a potential weakness in using unidimensional questionnaires is that they do not provide information beyond the targeted psychological factor(s) of interest. In addition, it has been suggested that many commonly used unidimensional psychological screening instruments (e.g. Tampa Scale of Kinesiophobia) may be better suited for patients with persistent pain, rather than acute or sub-acute pain (Nicholas et al., 2011). On the other hand, there are potential benefits of using multidimensional instruments with a small number of items (e.g. STarT Back screening tool) for estimating patient risk of a poor outcome (based on assessment of modifiable risk factors), for example, with respect to disability, return to work and, to a lesser extent, pain (Nicholas et al., 2011; Hill and Fritz, 2011; Chou et al., 2007; Chou and Shekelle, 2010; Karran et al. 2017). Considering time is commonly indicated as a barrier to administering and interpreting questionnaires with patients in clinical settings, the use of brief multidimensional measures that have prognostic value while also highlighting for the clinician areas to explore further through the patient interview is potentially advantageous. However, although a potential strength of multidimensional questionnaires is their broader screening of psychological distress, they do not provide detailed information on specific psychological factors that may serve as behavioural treatment targets. Therefore, in later sections of this chapter, we describe a two-step screening approach that consists of using multidimensional measures to identify those patients at high risk for poor outcomes and then further screening those high-risk patients using unidimensional measures and the patient interview.
Disability and health screening questionnaires are often completed as part of an intake process. We suggest these include an initial multidimensional psychosocial screening tool. Although unidimensional psychosocial screening questionnaires can also be completed at that time, this would require prior review of the multidimensional screening scores and a judgment on which unidimensional measures to use. Also, the administering of excessive questionnaires at the one time can be overwhelming to patients. Therefore, completion of a multidimensional screening measure followed by the patient interview may be more feasible for clinical practice, and together both will assist in identifying the need for and selection of the more focused unidimensional psychosocial questionnaires to subsequently administer.
Examples of Multidimensional Measures
STarT Back Screening Tool (SBT)
The SBT is a nine-item measure used to identify subgroups of patients associated with different levels of risk for persistent LBP-related disability based on the presence of modifiable prognostic factors which may be useful in matching patients with targeted interventions (Hill et al., 2008). The SBT contains items related to physical and psychosocial factors that have been identified as strong independent predictors for persistent, disabling LBP. The SBT overall score (ranging from 0 to 9) is determined by summing all positive responses, and the SBT psychosocial subscale score (ranging from 0 to 5) is determined by summing items related to bothersomeness, fear, catastrophizing, anxiety and depression. Based on the patient’s responses, the SBT categorizes the patient as either ‘high risk’ (psychosocial subscale score ≥4), in which high levels of psychosocial prognostic factors are present with or without physical factors being present; ‘medium risk’ (overall score >3, psychosocial subscale score <4), in which physical and psychosocial factors are present, but not a high level of psychosocial factors; or ‘low risk’ (overall score 0–3), in which few prognostic factors are present (Hill et al., 2008). Other studies on the horizon should (and will) further evaluate the capabilities of these multidimensional tools and do so in different capacities (i.e. purely prognostic capabilities versus treatment that is provided based on stratification strategies) while also evaluating different screening instruments’ prognostic accuracy for specific outcome parameters. For example, Karran et al. (2016) demonstrated that the accuracy of the risk assessment classification via a range of prognostic screening instruments administered within the first 3 months of an episode of LBP is best for predicting return to work (>80% probability), somewhat less accurate for predicting persistent disability (70%–80% probability), and least accurate for predicting persistent pain (60%–70% probability), highlighting the importance of considering different outcome dimensions when seeking prognostic information. As with any new and evolving area of research, clinicians need caution in relying on a single measure, and hence the three-dimensional approach to psychosocial factor assessment recommended in this chapter incorporates multidimensional questionnaires, unidimensional questionnaires and the patient interview.
Örebro Musculoskeletal Pain Screening Questionnaire (OMPSQ)
The OMPSQ was originally developed to assist primary care practitioners in identifying psychosocial ‘yellow flags’ and patients at risk for future work disability due to pain. The OMPSQ is a 25-item screening questionnaire (of which 21 are scored) that consists of items involving pain location (item 4), work absence due to pain (item 5), pain duration (item 6), pain intensity (items 8 and 9), control over pain (item 11), frequency of pain episodes (item 10), functional ability (items 20–24), mood (items 12 and 13), perceptions of work (items 7 and 16), patient’s estimate of prognosis (items 14 and 15) and fear avoidance (items 17–19) (Linton and Hallden, 1997). The scored items are summed to provide a total score potentially ranging from 0 to 210, with higher scores indicating a higher risk of poor outcome. The ability of the OMPSQ to predict long-term pain, disability and sick leave has been supported in previous studies (Maher and Grotle, 2009), including a notable systematic review (Hockings et al., 2008). Karran et al. (2016) similarly found the OMPSQ was ‘excellent’ for discriminating workers at risk of prolonged absenteeism, and they reported that this was regardless of country and across varied clinical settings, supporting its wider utility for return-to-work risk assessment. A 10-item short-form OMPSQ (Linton et al., 2012) has been shown to have similar properties to the long version.
Examples of Unidimensional Measures
Fear Avoidance Beliefs Questionnaire (FABQ)
The FABQ assesses the degree of fear-avoidance beliefs specific to LBP (Waddell et al., 1993); however, modified versions have been used for other body regions (Piva et al., 2009; Hart et al., 2009; Cleland et al., 2008; Simon et al., 2011). The FABQ consists of a 4-item FABQ physical activity scale (FABQ-PA; score potentially ranging from 0 to 24) and a 7-item FABQ work scale (FABQ-W; score potentially ranging from 0 to 42), with higher scores indicating higher levels of fear avoidance for both FABQ scales.
Pain Catastrophizing Scale (PCS)
The PCS assesses the degree of exaggerated negative orientation toward actual or anticipated pain experiences and catastrophic cognitions due to musculoskeletal pain (Sullivan et al., 1995). The PCS consists of 13 items with a potential score range from 0 to 52, with higher scores indicating higher levels of pain catastrophizing (Sullivan et al., 1995).
Tampa Scale of Kinesiophobia (TSK-11)
The TSK-11 assesses the degree of fear of movement and injury or re-injury (Woby et al., 2005). The TSK-11 consists of 11 items with a potential score range from 11 to 44, with higher scores indicating greater fear of movement and increased injury or re-injury due to painful symptoms.
Pain Anxiety Symptoms Scale (PASS-20)
The PASS-20 assesses the degree of pain-related anxiety symptoms for individuals with pain disorders (McCracken and Dhingra, 2002). The PASS-20 consists of 20 items with a potential score range from 0 to 100, with higher scores indicating elevated symptoms of pain-related anxiety.
Patient Health Questionnaire (PHQ-9)
The PHQ-9 assesses the degree of depressive symptoms (Kroenke et al., 2001). The PHQ-9 consists of nine items with a potential score range from 0 to 27, with higher scores indicating elevated depressive symptoms.
Pain Self-Efficacy Questionnaire (PSEQ)
The PSEQ assesses the degree of self-efficacy beliefs in the context of pain that can be either low or high (Nicholas, 2007). The PSEQ consists of 10 items with a potential score range from 0 to 60, with higher scores indicating elevated levels of pain-related self-efficacy, which is a positive prognostic indicator.
Chronic Pain Acceptance Questionnaire (CPAQ)
The CPAQ assesses the degree of pain acceptance from a functional perspective by focusing on behavioural aspects (McCracken et al., 2004). The CPAQ consists of 20 items with a potential score range from 0 to 120, with higher scores indicating an increased level of pain acceptance, also a positive prognostic indicator.
Brief Illness Perception Questionnaire (Brief IPQ)
The Brief IPQ assesses cognitive and emotional representations of illness (Broadbent et al., 2006). The Brief IPQ consists of nine items rated using a 0–10 scale, except for the causal question. Five of the items assess cognitive illness representations: consequences (item 1), timeline (item 2), personal control (item 3), treatment control (item 4) and identity (item 5). Two of the items assess emotional representations: concern (item 6) and emotions (item 8). One item assesses illness comprehensibility (item 7). An open-ended response is provided so that patients are able to list the three most important causal factors of their illness (item 9).
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