Psychosocial Assessment The emergence of a new fashion, or a new toolin physiotherapy for musculoskeletal pain?

Physiotherapy October 1999/vol 85/no 10

by Paul J WatsonMSc BSc MCSP

Research Fellow, University of Manchester, and Manchesterand Salford Pain Centre

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The last decade and a half have seen an international increase in healthcare, litigation and social costsassociated with common musculoskeletal pain such as low back pain and whiplash. In the UK it hasbeen estimated that less than 10% of those with back pain account for 90% of the social costs for thecondition (Mason, 1994). In one large-scale study 3% of newly registered cases of back pain, thosewho remained off work for up to one year accounted for 33% of the all wages replacement benefitspaid for back pain during that period (Watson et al, 1998). Furthermore, almost 11% of the totalwages replacement costs in one year were paid to people suffering from back pain.

The increase in chronic incapacity in the absence of anyincrease in the prevalence of the conditions has quiterightly prompted those who pay for health care toquestion the validity of the current treatments offered(Waddell, 1998). Physiotherapists are likely to comeunder close scrutiny as purchasers seek to find the bestand most cost-effective care for people withmusculoskeletal pain.

Physiotherapy as a primary point of contact for thosewith painful problems has often focused on the relief ofpain using a predominantly biomedical or tissue basedapproach. Research into the development of chronic painand disability is forcing physiotherapists to broaden theirmodel of care and the assessment and management of psychosocial factors is the suggested approach. The last Annual Congress of the Chartered Society ofPhysiotherapy heard research evidence on the predictionof outcome from the management of musculoskeletalpain and questioned if we could do better. ThePhysiotherapy Pain Association (PPA) will publish its1999/2000 yearbook on new approaches to theassessment and management of these conditions. Recentargument in this journal demonstrates the currentinterest in the subject. Are physiotherapists ready andwilling to take on this challenge?

Progression from Acute to ChronicHow many people who develop musculoskeletal pain goon to develop chronic pain problems? In the case ofchronic low back pain it had been the received wisdomthat about 70% to 90% of people recover within the firstfour to eight weeks following an attack of back pain, andonly around 3% go on to suffer chronic incapacity. Mostof these data are based on return to work and continuedconsultations with practitioners for an individual episode.Studies based on patients’ report of pain or subsequentwork loss within the following year demonstrate thatbetween 15% and 26% of people continue to have eitherpain-related work loss, continuing symptoms, orfunctional limitation up to one year after the initialepisode (Croft et al, 1998).

The increase in healthcare and social care funding paidto those who go on to develop prolonged work loss due topain and who use health services has promptedgovernments to initiate reviews and produce guidelineson the way in which these people should be managed.Major reviews were carried out around the world andguidelines were drawn up for the management of the twomost problematic conditions: low back pain (Bigos et al,1994; CSAG, 1994; Kendall et al, 1997) and whiplashassociated disorder (Spitzer et al, 1995).

These focused on the identification of those whorequire prompt medical attention; those with so called‘red flags’ -- and factors which predict the development ofcostly chronic disability. These reports found psychosocialrather than physical factors most predictive of chronicdisability. The latter have become known as ‘yellow flags’after the report carrying that name (Kendall et al, 1997).

These reports recommended conducting a psychosocialassessment of those who fail to respond to routinetherapy. It is suggested that it be conducted between fourand 12 weeks after onset if the individual does notrespond to routine reassurance, symptom management(eg analgesia and manipulation) and advice to remainactive.

It is important to note here that at no time have thesereports ever suggested that the presence of psychosocialfactors question the reality of these patients’ condition.The presence of such factors is an indication that recoveryis likely to be prolonged or outcome poor if steps are nottaken to address them.

Whose Responsibility is Psychosocial Assessment and Management?It is difficult to gain accurate data, but in the case of back pain, most patients presenting to a physiotherapistwill have had previous episodes of back pain and will havehad their current pain for many weeks (Waddell, 1998; Muncey and Watson, 1999). It is this group that the

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above reports suggest requires a psychosocial assessment.Spitzer et al (1995) recommended that anyone who has

not returned to normal activities within six weeks of awhiplash injury should be assessed by a multidisciplinaryteam. This is unrealistic in the UK, where less than 1% ofthose with chronic pain are ever referred to such a clinic(Smith et al, 1996). Although some may say this is themost appropriate place to manage these individuals,realistically we must admit it is highly unlikely to happen.The CSAG on low back pain said that such an assessmentcould ‘be carried out by the doctor or therapist’ (CSAG,1994, page 61). The ‘yellow flags’ document also says thatthe responsibility for management of psychosocial factorsshould lie, in most cases, with the practitioner consultedby the patient (physiotherapist or GP).

If most patients attending physiotherapy have had theirpain problem for more than a few weeks and they havenot responded to analgesia and advice given by the GP,then if we accept the recommendations of the abovereports, most require a psychosocial assessment and thiswould most appropriately be carried out by aphysiotherapist.

What Is Important to Assess?The list of factors predictive of poor outcome grows witheach new piece of research. However, there are somewhich repeatedly demonstrate a negative influence onoutcome. It is not the purpose of this editorial to reviewall the data – for this, further reading is required.

The psychological factors most commonly identified aredepressed mood, negative or passive coping, fear of painand reinjury and consequent avoidance of activity(fear/avoidance beliefs), preoccupation with bodilysymptoms (somatic anxiety), high self-report of stress oranxiety and misunderstandings about the nature of thecondition (see Main and Watson, 1995; Turk, 1997;Watson (in press) for review).

The social and economic influences includedissatisfaction with current work, worries about safety atwork, solicitous behaviour of family to pain, participationin medico-legal compensation claims, high level of wagesreplacement benefits, low educational level and substanceabuse (see Main and Watson, 1995; Turk, 1997; Watson(in press) for review).

Should Physiotherapists Become Involved inPsychosocial Assessment?There is good evidence that introducing cognitivebehavioural skills into the management ofmusculoskeletal pain has a beneficial effect on outcome(Linton, 1999). These can range from a physiotherapist-led intervention to a full pain management programme.Providing intensive interventions for all patients wouldnot be cost-effective, hence the need for appropriatescreening.

Psychosocial assessment presents physiotherapists withnew problems. Are there measures that can currently beused in physiotherapy practice? Once these factors havebeen identified, what is the physiotherapist expected to

do about them? How can the results of such a screeninform clinical decision-making? Can physiotherapistsrecognise when they are out of their depth? When do theyrefer on to a specialist practitioner or interdisciplinaryteam? What additional training is required? What are thecompetencies required for practice in this area?

It would be remarkably convenient if there were a one-size-fits-all questionnaire that would serve physiotherapistsinvolved in the management of musculoskeletal pain inall situations. Current knowledge indicates that therelative influence of each risk factor may change withtime; factors predictive of outcome in the acute stage maybe less predictive in the sub-acute stage (Burton et al,1995; Main and Burton, 1995). The predictive value of ameasure may vary according to the outcome measured,for example some factors may predict return to work butnot report of pain (Main and Burton, 1995; Linton andHallden, 1998). Another consideration is the treatmentgiven; the predictive value of a fear avoidancequestionnaire may vary if one group is given manipulativetreatment only and another a programme of gradedactivity.

Psychosocial screening questionnaires have beendeveloped on specific pain populations (eg low backpain) and in specific settings (orthopaedic clinics (Mainet al, 1992) occupational health settings (Linton andHallden, 1998; Hazard et al, 1996). Few of these measureshave been used in a wide range of conditions and indifferent settings and there is currently limited evidencefor the predictive value of these measures in physio-therapy clinics in the UK.

Physiotherapists must not get too hung up on thesearch for the perfect screening tool. They can do muchto facilitate the disclosure of potential barriers toimprovement by asking simple questions during theclinical interview, such as ‘What do you think is the causeof your pain?’ ‘When do you think you will be able toreturn to your normal activities?’ (Kendall et al, 1997). Aformal screen is required only if the patient fails torespond to treatment.

There is support for the view that some patients are toodistressed to respond to physiotherapy (Williams et al,1995) and would be managed more appropriately in amultidisciplinary or interdisciplinary setting (Flor et al,1992; Williams et al, 1995). However, Main and Watson (inpress) have suggested that managing the distress that isprimarily related to a patient’s pain and physicalincapacity has to be part of the physiotherapist’sresponsibility to the patient. In contrast, it is not thephysiotherapist’s obligation to directly manage distressthat is primarily due to other factors which, although theymay be related to the incapacity and will affect thepatients’ response to their condition, are not directlyattributable to the pain condition (eg marriagebreakdown, financial worries). Physiotherapists do nothave the experience or training to manage the latter andneed to refer on to specialist practitioners or develop aworking relationship with mental health practitioners tofacilitate joint management of these patients.

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After a review of the evidence, Watson and Kendall (inpress) have suggested guidelines for the use of ‘yellowflag’ screening with suggestions for further research anddevelopment in this area. They advocate a combinedapproach using both simple screening tools and a clinicalinterview. They advise caution in the use of screeningtools until there is sufficient evidence available to haveconfidence in cut-off scores for decision making andallocation to different interventions. They advocate anapproach for a clinical interview where screening toolsare used only to identify areas of concern such asirrational beliefs about reinjury, passive attitudesconcerning treatment, or developing beliefs about aninevitable poor outcome (catastrophising). The purposeof the clinical interview is to focus on these potentialbarriers to recovery and develop an interventionprogramme to address them. The programme must betailored to the needs of the individual.

Biopsychosocial IntegrationWe are moving towards the recognition ofmusculoskeletal pain as having biomedical andpsychosocial components which must be managed byphysiotherapists in a biopsychosocial framework(Waddell, 1992; Linton, 1999). It would be very worrying,and highly inappropriate, if physiotherapists were to relyexclusively on the results of a psychosocial questionnaireover physical assessment in patients with symptoms oflong duration. Psychosocial assessments cannot tell uswhich specific physiotherapy treatment to give a patient,they can only indicate the barriers to improvement.Psychosocial assessment must be integrated intophysiotherapy practice, not separated from it.

If during a biomedical assessment a physiotherapistidentifies a particular problem that, by the evidenceavailable, is likely to respond to a specific intervention (egmanipulation) then that should be given. Failure to do sowould be illogical and probably unethical. The difficultyfor the profession currently is demonstrating a specificcause and effect for many interventions because ofinadequate research.

The psychosocial assessment informs a physiotherapistof the framework in which treatment should be set. Forexample, if the patient is highly fearful of engaging inactivity, the focus of treatment is on reducing those fearsand increasing activity. If manipulation is indicated, it ispurely a symptomatic treatment to assist the process; inthe same way a GP prescribes an analgesic to help theprocess of rehabilitation. Symptomatic treatment andrehabilitation are not the same thing.

Implications for Education and TrainingWatson and Kendall (in press) suggest that currenteducation in physiotherapy does not equipphysiotherapists with the skills to conduct a goodpsychosocial assessment. They recommend:

� Knowledge of psychosocial assessment should beincluded in the undergraduate curriculum.

� All postgraduate physiotherapists managing peoplewith musculoskeletal pain should receive training inthis area.

� Those in a senior capacity and especially those insupervisory and training roles require specialisttraining in psychosocial assessment and management.

The key competencies for practice in this area are yet tobe established, although the Physiotherapy PainAssociation has gone some way through the developmentof standards for practice in pain managementprogrammes (PPA, 1997). Educationists, researchers andclinicians must collaborate to address this situation.

Personal ConclusionI believe that most physiotherapists try to assess andmanage their patients within a biopsychosocial frameworkalthough they may call it ‘good patient handling skills’which are developed over years of patient contact. Thedevelopment of a structured psychosocial assessment willhelp to formalise the process so that it can be evaluated,assessed, improved and taught to others.

The pressure on physiotherapists to become involved inpsychosocial screening to identify the best clinicalpathway for their patients is likely to increase. The currentstate of the knowledge allows only a blunt instrument forassessment and it most certainly should not be used todeny treatment without very good evidence. The oldcliché that ‘further research is still required’ stronglyapplies in this case.

Physiotherapists have extended their role in other areasin response to the needs of their patients, mainly in thearea of physical interventions. Psychosocial assessmentand management is an exciting opportunity to developfurther skills to the benefit of patients which we mustaccept. As with all innovations, we must proceed withevidence and develop it as a tool for improving patientcare; we must not allow it to become another of theunderdeveloped ‘latest fashions’ which plague ourprofession.

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Address for Correspondence

Paul J Watson, Rheumatic Diseases Centre, Clinical SciencesBuilding, Hope Hospital, Salford M6 8HD.