Screening for the risk of chronic disability

While not quite a Philosopher’s Stone, finding a method to identify ‘at risk’ people has been something clinicians have been searching for over a long time. It has to be brief, easy to use, accurate and acceptable to the people using it.

We have known in the field of chronic pain that some of the most important risk factors are not biophysical (ie reduced range of movement, changes on X-ray), but are psychosocial – but of the myriad factors out there, which ones?!

The Orebro Musculoskeletal Screening Tool is a brief, 25-item self report questionnaire originally developed as a tool for screening ‘at risk’ patients. It has been used widely in New Zealand since the first publication of the Acute Low Back Pain guidelines and screening for ‘yellow flags’ in 1997. It’s also been used in several studies looking at the predictive validity of the questionnaire for work loss and ongoing disability (e.g. Hurley, Dusoir, McDonough, Moore, Baxter,2001).

The study referred to in this post is a further examination of the measure over a longer term than the Hurley et al study – this one is over 3 years. I won’t go through all the methodology of this study, apart from mentioning that the inclusion criteria were people aged between ’18 and 65 years old, sick listed 28 days – 180 days and/or had consulted the doctor about the same problem 3 times the last 12 months The participants either had permanent employment or were at the disposal of the labour market. Patients requiring orthopaedic surgery and patients with a psychiatric disorder or a substance abuse problem were excluded. Furthermore, participants had to be able to speak Swedish sufficiently well in order to describe their symptoms and understand the information given.’ Participants were recruited from a primary care treatment setting.

The questionnaire is simple to administer and score – the authors quote a previous study indicating that when using a cut-off score of 105 (the maximum being 210), the specificity was found to be 0.75 and the sensitivity 0.88. At the same cut-off point the chance of accurately classifying someone as ‘‘at risk” for future sick leave would be 88%.
In this study, again the total score was found to be most predictive of future sick leave ‘The prediction of future sick leave with the OMPSQ is based on the total score. As in earlier studies the
results showed that the total score of the screening questionnaire was related to future sick leave and functional ability; the higher the score, the higher the risk for long term sick leave and developing of chronic problems.’
The higher functional limitation scores the greater disability in the long term, which is slightly different from previous studies which have suggested psychosocial distress and avoidance were more predictive.

Again, this study shows that using this screening tool early in the course of an episode of low back pain (whether the first episode or subsequent episodes) is a good way to identify those who are at risk of developing disability in the longer term. It seems to me that one way to help target high-impact interventions to those who really need it would be for every person reporting a new episode of low back pain lasting more than a week to complete this questionnaire. Those with scores above 105 or so should then receive focused input looking at psychosocial factors and, more importantly, starting to rigorously address reduced function by setting goals and developing a plan to address the issues the person is identifying at that time.

This approach doesn’t need a huge investment in more psychologists – simply for primary care clinicians such as physiotherapists, occupational therapists, occupational health nurses, general practitioners and so on to start using the OMPSQ as matter of routine for all patients with more than a couple of weeks functional limitations from back pain.

Boersma K, Linton SJ. Early assessment of Psychological factors: the
Orebro Screening Questionnaire for Pain. In: Linton SJ, editor.
New avenues for the prevention of chronic musculoskeletal pain
and disability. Amsterdam: Elsevier Science B.V.; 2002. p. 205–13

Hurley DA, Dusoir TE, McDonough SM, Moore AP, Linton SJ,
Baxter GD. Biopsychosocial screening questionnaire for patients
with low back pain: preliminary report of utility in physiotherapy
practice in Northern Ireland. Clin J Pain 2000;16:214–28.

Hurley DA, Dusoir TE, McDonough SM, Moore AP, Baxter GD.
How effective is the acute low back pain screening questionnaire for
predicting 1-year follow-up in patients with low back pain? Clin J
Pain 2001;17:256–63.
A WESTMAN, S LINTON, J OHRVIK, P WAHLEN, J LEPPERT (2008). Do psychosocial factors predict disability and health at a 3-year follow-up for patients with non-acute musculoskeletal pain?A validation of the Örebro Musculoskeletal Pain Screening Questionnaire European Journal of Pain, 12 (5), 641-649 DOI: 10.1016/j.ejpain.2007.10.007

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