Development of a brief psychosocial screening instrument for people with low-back pain

• A psychosocial screening questionnaire for workers with low-back pain can be trimmed from 129 to 46 items and remain a reliable and valid tool for identifying what programs may help them most.
• This shortened tool, called the Pain Recovery Inventory of Concerns and Expectations (PRICE), estimates the overall likelihood of quickly recovering and returning to work within three months after injury.
• The PRICE tool also groups workers into four risk categories, allowing clinicians to target interventions.

The ability of individuals to recover from low-back pain and return to normal activities, including work, is influenced by psychological issues and their interaction with social factors. Current tools to screen for these “psychosocial issues” typically only indicate if patients are at high risk of not returning to work, and are generally unable to indicate what the specific problems are and the types of targeted interventions needed to help them recover and return to work sooner.

In a previous study, the researchers developed a 129-item screening tool to address this gap. This tool was successfully able to predict the likelihood of returning to work, and also able to group patients into four risk subgroups: those at minimal risk, those with emotional distress, those with activity limitations, and those with organizational concerns. The aim of the current study was to create a shorter psychosocial screening questionnaire to help triage return-to-work strategies among patients with low-back pain.

In the earlier study, 496 working adults in the U.S. completed a questionnaire of 129 items before an initial medical evaluation for work-related acute low-back pain. Researchers followed up with patients three months later to assess their level of pain, functional limitations and work status. In the current study, researchers analyzed results for each of the 129 items to isolate which items could be dropped from the initial screening test without significantly affecting the test outcomes. They also analyzed participant responses to see if the four risk groupings still applied.

The researchers were able to shorten the screening tool from 129 items to 46 items without affecting its ability to predict likelihood of recovering and returning to work, or its ability to group workers by risk category. The shorter version asks about depressive symptoms (12 items), pain catastrophizing (2), lack of organizational support (7), activity limitations (15), fear of movement (4), perceptions of grave life impacts (3), expectations of recovery (2) and pain intensity (1).

Among the four risk subgroups, those in the one scoring high for emotional distress (e.g. for depressive symptoms, pain intensity, pain catastrophizing, activity avoidance, functional limitations and life impact of pain) were seven times less likely than those in the low-risk group to be back at work within three months. Those in the other two subgroups—high physical limitations and workplace concerns—stood only a slightly higher chance than those in the low-risk group of not being back at work.

A shorter psychosocial screening tool such as the PRICE can be used to indicate the overall likelihood of patients making a quick recovery and returning to work. It can also group workers with low-back pain into risk groups that help indicate to clinicians the interventions needed to help prevent long-term disability, thus helping ensure scarce dollars are spent on interventions most likely to be effective. For example:

• for patients lacking organization support, interventions might include participatory ergonomics interventions, facilitated communication with supervisors or problem-solving to address workplace barriers;
• for patients with severe emotional distress, interventions might include group or individual sessions applying cognitive-behavioural strategies to address unhelpful pain beliefs, strengthen coping skills and learn pain self-management; and
• for patients with severe pain and activity limitations (but without emotional distress), interventions might focus on pain education, graded exercise and exposure to gradual activity.

One of the strengths of this study is that it builds on earlier studies indicating the important influence of psychosocial factors. Among its weaknesses are its narrowly defined study population (mostly younger, blue-collar workers) and its focus on the acute phase of low-back pain when many workers are able to resume normal work activities with little or no support.