Patient Rated Outcomes Measures in Chronic Pain

The use of patient-rated outcome measures (PROM), often in the form of questionnaires, is a key part of our evaluation and re-evaluation. They play an important role in documenting activity limitations, levels of disability, quality of life, response to interventions and they help provide a quantifiable measure of subjective complaints.

As our knowledge of chronic pain broadens, we are beginning to appreciate that there are modifiable risk factors that contribute to the development of long term pain and disability. For example, fear avoidance beliefs and behaviours, fear of movement, high levels of anxiety and depression, low satisfaction with work and catastrophization beliefs. Several outcome measures are currently available to clinicians to help guide their clinical reasoning by identifying these risk factors and dig deeper into how they play a part in the patient’s pain presentation. The purpose of this blog is to look specifically at outcome measures and explore how they guide our patient management.

• The STarT back questionnaire
• Neurophysiology of Pain Questionnaire
• Central sensitization inventory
• Tampa Scale for kinesiophobia
• Pain catastrophizing Scale
• Fear avoidance beliefs questionnaire

START BACK QUESTIONNAIRE

This is a tool used to match patients to treatment packages with the hope of reducing disability from back pain, reduced time off work and reduced medical usage costs. Originally designed in the UK for doctors to identify what treatment path patients may require. It has been adopted in Physiotherapy practice to identify risk factors for long term disability for low back pain and the need for additional input (pain psychology).

This questionnaire is easy to use, simple to complete and is a screening tool to identify risk factors associated with the development of long term disability due to back pain (biomedical, psychological, and social).

Each question assesses a different domain of pain:

• Question 1 & 2 are exploring physical pain, radicular pain and the presence of widespread pain - which might lead you to administer the central sensitizing inventory
• Question 3 & 4 look at level of disability in ADLs (activities of daily living)
• Question 5 Fear Avoidance - which might lead you to administer the Fear Avoidance Beliefs Questionnaire or Tampa Kinesiophobia Scale
• Question 6 Anxiety
• Question 7 Catastrophizing - which might lead you to administer the Pain Satastrophizing scale
• Question 8 Depression
• Question 9 Overall bothersomeness

It is a 9-item tool with each answer agree/disagree

• <3 low risk
• >4 look at scores 5-9
  • If <3 medium risk
  • If >4 high risk and would benefit from 6 x 1:1 60 minute PT sessions with cognitive behavioural therapy and pain neuroscience education

One of the downfalls of this screening tool is that it is not used to re-evaluate patient risk. It does however, have an extended form that has been created to give a scale from 0-10 for each answer. This extended form can provide a number for each question and a total, that can be used in reassessment. I did not learn of a meaningful significant difference suggested for this extended scale, but it does allow for some measure of change. The cut off points for high risk on this extended questionnaire are listed for each question below:

• Leg pain > moderate
• Shoulder/neck pain >slightly
• Dressing >5
• Walking >5
• Fear >7
• Worry >3
• Catastrophsing >6
• Mood >7
• Bothersomeness > Very

Prior to researching this questionnaire, I didn’t know that an extended form existed and always thought it was little silly to just administer the screening tool once so that a degree of risk could be associated with the case. I then learnt aside from selecting treatment packages, it was also intended to provide feedback to patients about their risk of long term disability (again something I had not done before and now do). For example, you might say to a patient “that even though they have pain, they are at low risk of developing long term disability”. Or, “based on the story you have told me and the score on this test, I might recommend a more comprehensive treatment approach”. After understanding the use and value of this questionnaire, I have been far more agreeable to use it to create helpful discussions with patients about the chronicity of their symptoms and the need for further assessment (fear avoidance, anxiety etc) or referral for additional help in treatment (pain psychology) and patients have been far more receptive to these ideas because it is not just “my impression” but what we can interpret from the information on a standardized measure.

NEUROPHYSIOLOGY OF PAIN QUESTIONNAIRE

This is a great questionnaire developed by Body in Mind to assess a patient’s current understanding about pain neurophysiology. It provides an overall score of true/false answers and can be approached to cover each question (relating to a key topic) as a starting point for educating patients about pain. Patients’ understanding of their pain will influence their experience of pain, especially in chronicity. The NPQ provides important information about patients’ understanding of their pain. You can choose to use this questionnaire to:

• To measure patients’ knowledge of pain
• To determine where patients require further pain education
• To evaluate effectiveness of pain education sessions
• To evaluate clinician understanding of current concepts in pain physiology

I was not able to find information about a cut-off score, significant change score, and believe that the goal is to educate your patient in all incorrect answers until they score 100%. Personally, I have always been daunted by the idea of educating patients about chronic pain. There are two fantastic resources that I commonly recommend to patients: Explain Pain and Why do I hurt, but when you look at these approaches, it often involves teaching someone all the content. So I ask myself, where should I start to really maximize patient engagement and learning? And this questionnaire is my answer. It tells me where to begin the conversation, where to direct the patient to further their understand and how to individualize a pain neuroscience education approach.

CENTRAL SENSITIZATION INVENTORY

The CSI is a self-reported outcome measure designed to identify patients with symptoms of central sensitization or central sensitisation syndromes (CSS). If you find it complicated in the clinical setting to differentiate pain symptoms and interpret the findings of your subjective and objective examination, perhaps consider using this questionnaire to confirm/refute your clinical impressions. Another way to approach this questionnaire is that if you suspect your patient has signs of central sensitisation and wish to communicate these findings with external providers, it helps to give a degree of severity that others can relate more easily to.

Part A: 25 Q’s – each question is scored 0-4 with a total score of 100

Part B: Diagnosis of CSS

• 0-29 subclinical
• 30-39 mild CS
• 40-49 moderate CS - Score >40 indicates the presence of central sensitisation
• 50-59 severe CS
• 60-100 extreme CS

TAMPA SCALE FOR KINESIOPHOBIA

The Tampa Scale for Kinesiophobia (TSK) was designed by Miller and colleagues in 1991, in an attempt to quantify the extent of kinesiophobia in individuals.

• The questionnaire has 17 questions, with a short form of 11 also available.
• The therapist must then invert the scores of question 4, 8, 12 and 16, for example if the patient scores 1 on question 4, this must be counted as a score of 4.
• Total score of 68
• Most authors agree that a score greater than 37 shows high levels of kinesiophobia (Vlaeyen et al., 2016).

PAIN CATASTROPHIZING SCALE

Catastrophization is currently defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” (Sullivan et al, 2001). The PCS was developed in 1995. Attention to pain symptoms is one mechanism that leads to catastrophizing and the development of chronic hyperalgesic state. Catastrophizing directly impacts endogenous pain modulation mechanisms. The PCS was developed to identify patients with these beliefs in the hope of recognizing psychosocial contributors to chronic pain and delayed recovery.

• Rumination – Q 8,9,10,11
• Magnification – Q 6,7,13
• Helplessness – Q 1,2,3,4,5,12

It takes 5 minutes to complete and score with a total of 13 items.
Internal consistency of 0.87.
Scores range from 0-52 with the cut off as 30 (representing the 75%).

If score >30

• >70% remain unemployed >1 year
• >70% described themselves as totally disabled for work duties
• 66% also score with moderate depression.

FEAR AVOIDANCE BELIEFS QUESTIONNAIRE

There is little evidence to support that pain severity is related to level of disability. But, fear avoidance beliefs are correlated with levels of disability. Increased FAB = reduced RTW. Therefore FABQ measures how FAB contributes to LBP and resulting disability (identifying prolonged disability). I also find it very helpful to understand the breakdown between daily activities and work-related activities as it might help direct treatment approaches for functional re-training and activity modification.

There are two subsets

• Fear avoidance beliefs about work Q 6,7,9,10,11,12,15
  • High score 42, cut of >34
• Fear avoidance beliefs about physical activity Q 2,3,4,5
  • High score 24, cut off >15
• Therefore you do not score question 1,8,13,14,16
• Even though there are 16 questions, the total score is 66.

CONCLUSION

It is common for patients to develop survey-fatigue and frustration towards the continued implementation of questionnaires and as clinicians we might contribute to this by not taking the time really evaluate the outcome of the questionnaires. Beyond the cut off score for high risk, are you discussing the answers to the questions with patients, seeking clarification in our understanding of the answers, and providing further information about how these answers can help develop a more thorough and individualized treatment plan?

I would urge you to change your perspective, these are not a waste of time, they are valuable ways to measure different domains of the biopsychosocial contributions to pain. Ask yourselves, what does this questionnaire tell me about the patient that I didn’t previously know? In answering this question, you may discover a treatment pathway that is beyond your scope of practice or resources within your practice. Ultimately it will likely lead to improved patient outcomes and satisfaction with care.

Sian - via Rayner and Smale

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 

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