Screening to Make a Better Prognosis

As Physical Therapists (in the United States), we have the ability to see patient via direct access, or without a Physicians referral.  But with this professional privilege, comes responsibility, and determining if a patient is appropriate for our services is necessary.  In addition, once determining appropriateness, screening for prognosis (when applicable) allows us to not only determine who is appropriate for our services, but who will ultimately benefit from them.   In this post, I want to highlight several variables that we should be screening for (or with), because of their potential prognostic value over outcomes.
Pain Catastrophizing and Depression
A 2011 article, published in Physical Therapy, investigated the relationships between pain catastrophizing and depressed mood in patients seeking care for musculoskeletal pain.   The investigators of this study collected data on 297 patients and found that elevated pain catastrophizing or depressed moods at baseline was related to an absence of improvement and elevated levels of disability following Physical Therapy care.  When both variables were elevated, the level of disability was the highest.   The authors state,

“Early identification of key differences could help clinicians make decisions about which patients should receive normally effective treatments. Moreover, combinations of modifiable prognostic factors could help identify which patients need another treatment approach and what this treatment approach should be.”

So if this article is correct, what do we do if patient presents with these variables?  I suspect we should always consider the utilization of practitioners who can best address Psychological issues.  Reaching out for assistance or referring to specialized practitioners (Physicians, Clinical Psychologists), such as those with PCH treatment (, is likely necessary.  Two quick and easy ways to screen for Depression and Pain Catastrophizing have been provided below:
Screening for Depression via PHQ-2
Screening for Pain Catastrophizing via Pain Catastrophizing Scale
Kinesiophobia, also known as a fear of movement, has demonstrated its ability to be prognostic over outcomes.  This is generally measured on the Tampa Scale for Kinesiophobia (TSK) (one study did demonstrate that simply asking a patient “You visited your general practitioner because of complaints in your back or leg.  How much ‘fear’ do you have that these complaints would be increased by physical activity (0= no fear to 10= very much fear” is just as, if not more, prognostic than the TSK).   A recent article published in Manual Therapy demonstrated Kinesiophobia to be prognostic over short and long-term outcomes in those with sub-acute neck pain.
 Clinical Prediction Rules (CPRs)
While I am not a huge fan (or believer) of allowing a CPR to guide a clinical decision making process, I do suspect they allow us to make better diagnoses and establish more accurate prognoses.   This stated, we must be cautious in our interpretation of CPRs, because most have limited research behind them (lacking validation studies and impact analyses).
Now for my question of the day:  
What tools or variables do you use to give a clinical prognosis?
Bergbom S, Boersma K, Overmeer T, et al.  Relationship among pain catastrophizing, depressed mood, and outcomes across Physical Therapy Treatments.  Physical Therapy 2011: 91; 754-764.
Verwoerd AJH, Luijsterburg PAJ, Timman R, et al. A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study. Australian Journal of Physiotherapy 2012: 58; 249-254.
Pool JJM, Ostelo RWJG, Knol D. Are psychological factors prognostic indicators of outcome in patients with subacute neck pain. Manual Therapy 2010: 15; 111-116.

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  • The short form Orebro Musculoskeletal Pain Screening Questionnaire is something I tend to use often, not all the time due to time constraints at the institution that I work in, to predict and explain to patients where they score worse, and inform them why they can influence prognosis. I know of the DASS (depression, anxiety and stress scale) and FABQ, TSK for fear avoidance behaviors but tend not to use them because they tend to measure just fear of movement, unless its for data collection purposes.

    Lian Guojie September 9, 2013 7:24 pm Reply
  • Hi Joe, Once again, good job on this wonderful blog of yours! I use many tools (FABQ, ODI, NDI, TSK, IES-R,… and a series of questions on neuropathic pain) as clusters and put them in relation with my clinical exam to help form my opinion on the prognostic. Always keeping in mind that these tools are there to give a general probability about the direction in which the diagnostic may be going. Regardless of these tools the direction can still be in the opposite direction. Thus, I use caution when disclosing the results to the patient to avoid causing negative expectations and risking a self realizing prophecy.

    Frédéric Wellens, pht September 9, 2013 7:52 pm Reply

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