The “psychosocial yellow flags” or risk factors for developing ongoing disability after a bout of acute low back pain have been promulgated in New Zealand since 1997. Introduced as part of the Acute Low Back Pain Guidelines, the yellow flags were lauded both locally and internationally and subsequently there have been many international guidelines which have adopted this kind of integration. But what exactly do we do with that information? How does it help if we find out that someone is really afraid their pain means something awful, or if they fear their life will never be the same again, or if they truly worry about doing movements that provoke their pain?
Truth to tell, although there have been a lot of studies examining the relevance of psychosocial risk factors, the uptake among clinicians has been fairly abysmal. This is particularly so among clinicians who work either mainly with acute musculoskeletal pain, or amongst those who are mainly involved in treated the body. One physio I know said she got the impression during her training that psychosocial factors “are the things we can blame when our treatments don’t work”.
I think part of the problem is the focus on assessment “technology”. There is a proliferation of questionnaires that can be used to help spot the person who’s likely to have difficulty recovering. We have STartBack, Orebro Musculoskeletal Questionnaire, Pain Catastrophising Scale, Tampa Scale of Kinesiophobia, Depression Anxiety Stress Scale, Pain Self Efficacy Scale – most of which are known by their abbreviations, so it’s like an alphabet soup! But despite knowing about these questionnaires, and perhaps even administering them to people we think might need assessment, once the results come in it’s pretty difficult to know what to do next.
So what if a person reports really high levels of catastrophising? Or that they’re very high on the Fear of Injury/Reinjury on the TSK? Or that they have the lowest ever score on the PSEQ? What on earth do you do to make an impact?
Some people are very actively engaged in “Pain Education”. It’s given to absolutely everyone because “the evidence says” it “works”. Pain reduces. People get engaged in their exercise. Life returns to normal.
Some people refer immediately on to a psychologist. Let them deal with the “difficult” patients.
Others just carry on as normal but in the back of their mind have the “out” that “Oh but they have yellow flags” – and drop their expectations accordingly.
To me that’s just not good enough, and it suggests to me that we need to learn more about what these measures mean – and what to do differently as a result.
There’s a couple of problems though:
- How do we choose who to give a questionnaire to? – do we rely on “intuition” or do we give them out to everyone?
- Which questionnaires do we use? There’s no “gold standard” – just a mix of various measures that tap into part of the picture…
- How much do we rely on strong RCT’s examining whole treatment packages, versus how much do we rely on principles of behaviour change and knowledge of the underlying theories relevant to pain and disability?
- What if our clinical reasoning models are completely silent on the work involved in supporting people who present with these risk factors – what if our clinical reasoning models suggest that this work is not all that important compared with the “real” work of tissues and muscles and movement?
Here are my thoughts on what we can do.
I think we should give screening questionnaires to everyone who comes in with an acute bout of musculoskeletal pain, and I think there are a couple that really work well – Orebro is clearly one of them, PCS or PASS are both useful, and I think it’s helpful to screen for mood problems. Why do I think everyone needs these? Well, it’s easier to give them to everyone than to rely on our terribly inaccurate intuition. The risk of failing to identify someone who needs more support is high (and the consequences of omitting this is serious). By routinely administering screening measures we can de-stigmatise the process (though there shouldn’t be any stigma associated with understanding that pain involves the whole person!). We can make the administration easy by integrating it within routine clinic entry process – and by using electronic forms of each questionnaire we can make entering and scoring them easy.
We then need to learn what the questionnaires actually measure – not just the total score, but the subscales as well. Then we need to use those subscale scores to understand what we need to ask the person when we see them face-to-face. This helps us begin to understand the person and how they came to develop these beliefs and attitudes, and in doing so we can develop greater empathy for their experience – and alter our treatments to reflect their needs.
For management, I think we have to, at this stage, step beyond the RCT for evidence. There’s a few reasons for this: one is that RCTs naturally omit individual responses to the treatment meaning we lost the detail as to who responds to which aspect of the treatment. Another is that RCTs often group patients together to ensure power is reached – but in doing this, omit important individual differences. And finally, each person we see is a unique individual with a unique interaction between the various factors influencing their presentation – and there are simply insufficient RCTs to account for these differences. Does this mean we stop using evidence? Oh no!! It just means we need to look at the principles behind many treatments – what are the guiding principles and why might they apply to this person at this time? Finally we need to monitor outcomes so we can establish whether our approach actually helped.
Finally, I think our clinical reasoning models need to include important aspects of treatment that we vary, often without being aware that we do.
For example, if we see someone who scores very high on the PCS and tends to ruminate or brood on the negative, we can’t go ahead and give that person the same set of exercises or activities we’d give someone who is quite confident. We’ll need to lower the physical demands, give really good explanations, take the time to explain and de-threaten various sensations the person may experience, we’ll probably need to move slowly through the progressions, and we’ll definitely need to take time to debrief and track progress.
These “invisible” aspects of treatment are, I think, often the most important parts – but they’re often not mentioned in clinical protocols, and perhaps our skill in titrating the challenges we give our patients is not well developed. These factors incorporate psychological techniques of behaviour change – things like reinforcement, motivational interviewing, problem solving, Socratic questioning, how to fade support, how to bolster confidence, how to vary the environment, and how to avoid pliance and tracking (or going along with things rather than truly integrating the learning). If we want to work with people and help them change their lives, we need to learn how people change behaviour. That means, I’m afraid, learning some psychology…!