What do clinicians consider when assessing chronic low back pain? A content analysis of multidisciplinary pain centre team assessments of functioning, disability, and health

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Bagraith, Karl S.a,b,c,d,*; Strong, Jennyb,d; Meredith, Pamela J.d,e; McPhail, Steven M.f,g PAIN: October 2018 - Volume 159 - Issue 10 - p 2128–2136 doi: 10.1097/j.pain.0000000000001285 Clinical Note aInterdisciplinary Persistent Pain Centre, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia bOccupational Therapy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia cProfessor Tess Cramond Multidisciplinary Pain Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia dOccupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia eOccupational Therapy, School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia fCentre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia gInstitute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia Corresponding author. Address: Interdisciplinary Persistent Pain Centre, 2 Investigator Dr, Robina, Gold Coast, Queensland 4226, Australia. Tel.: +61756686825; fax: +61756809539. E-mail address: Karl.Bagraith@gmail.com (K.S. Bagraith). Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.painjournalonline.com). Received January 26, 2018 Received in revised form May 10, 2018 Accepted May 13, 2018 PAIN: October 2018 - Volume 159 - Issue 10 - p 2128–2136 doi: 10.1097/j.pain.0000000000001285 Clinical Note Global Year 2018 Abstract In Brief Author Information Beyond expert suggestions as to the appropriate subject matter for chronic pain assessments, little is known about the actual content of multidisciplinary pain centre (MPC) clinical assessments. The International Classification of Functioning, Disability and Health Low Back Pain Core Set (ICF LBP-CS) provides a universal language to support the consistent description of LBP-related assessments across disciplines within multidisciplinary teams (MDTs). This study sought to map the content of MPC clinical assessments to the ICF to: (1) identify and compare the content of clinical MDT assessments using a cross-disciplinary framework and (2) examine the content validity of the LBP-CS. A qualitative examination of MPC team clinical assessments of chronic low back pain was undertaken. Multidisciplinary team (pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology) assessments were audio-recorded and transcribed. Concepts were extracted from transcripts using a meaning condensation procedure and then linked to the ICF. Across 7 MDT assessments, comprised 42 discipline-specific assessments and 241,209 transcribed words, 8596 concepts were extracted. Contextual factors (ie, the person and environment), except for physiotherapy, accounted for almost half of each discipline's assessments (range: 49%-58%). Concepts spanned 113 second-level ICF categories, including 73/78 LBP-CS categories. Overall, the findings revealed novel insights into the content of MPC clinical assessments that can be used to improve health care delivery. International Classification of Functioning, Disability and Health–based assessment profiles demonstrated unique contributions from each discipline to chronic low back pain assessment. Finally, users of the LBP-CS can be confident that the tool exhibits sound content validity from the perceptive of MDT assessments of functioning, disability, and health. Back to Top | Article Outline 1. Introduction Chronic low back pain (CLBP) affects approximately 1 in 5 people34 and is the most frequently reported condition in patients attending Multidisciplinary Pain Centers (MPCs).42 On entering MPCs, patients commonly undergo a multidisciplinary team (MDT) assessment to ascertain their functioning problems and guide treatment planning; an approach originally championed by Bonica.41 Multidisciplinary pain centre assessments typically entail input from multiple professionals, including pain medicine physicians, psychiatrists, nurses, psychologists, occupational therapists, and physiotherapists.28 Generally, each professional conducts their assessments independently, with findings integrated at a case conference.54 Beyond expert suggestions as to the appropriate subject matter for chronic pain assessments,22,32,59 little is known about the actual content and focus of MPC clinical assessments. Multidisciplinary pain centre professionals use differing frames of reference to guide and document their assessments,37 which often hampers interdisciplinary collaboration.31 Similarly, understanding each team member's contribution to MDT assessments remains a challenge because of discipline-specific terminology.52 The International Classification of Functioning, Disability and Health (ICF) provides a universal language and standard framework for functioning and health.60 This ICF is considered to be a Rosetta Stone,53 crossing disciplinary, contextual, and geographic boundaries, harmonising the description of patient functioning.10 The ICF has been recommended as a basis for pain practice55 and is guiding the Initiative on Methods Measurement and Pain Assessment in Clinical Trials (IMMPACT).51 With over 1400 categories, the ICF is exhaustive and impractical for use in its entirety.53 To operationalise the ICF in daily pain practice, salient selections of categories have been compiled for various conditions, the so-called ICF Core Sets.19 The 78-category Low Back Pain Core Set (LBP-CS) includes “as few categories as possible to be practical, but as many as necessary to be sufficiently comprehensive to describe in a comprehensive multidisciplinary assessment the typical spectrum of problems in functioning of patients (with CLBP)” [19(p9); 21]. The LBP-CS has been put forth as a practical tool to permit consistent description of patient functioning across disciplines, facilitating more effective interdisciplinary communication and better integrated care.49 The LBP-CS was compiled by experts through a formal decision-making and consensus process19,21 that considered evidence from preparatory studies.12,25,56 Despite the potential benefits afforded by use of the LBP-CS, it has been suggested that clinical practice uptake is less than ideal.1,15,50,58 One potential reason for limited utilisation may be inadequate evidence regarding the LBP-CS's content validity.36 Whether the LBP-CS is sufficiently comprehensive to cover diverse health professional's perspectives, or more importantly, the content of multidisciplinary clinical assessments, remains unanswered. Bagraith and Strong5 provided proof-of-concept that the content of clinical MPC assessments can be mapped to the ICF, with each discipline's assessment described using the same ICF-based yardstick. This study sought to map the content of MPC clinical assessments to the ICF to: (1) identify the content and focus of clinical MDT assessments using a cross-disciplinary framework and (2) examine the content validity of the LBP-CS from the perspective of clinical MDT assessments of functioning, disability, and health. Back to Top | Article Outline 2. Methods 2.1. Overview This study entailed a qualitative examination of the routine MDT assessments undertaken by patients attending a tertiary-referral MPC at a metropolitan hospital in Australia. As part of routine practice, patients attending the MPC for a rehabilitation program underwent an MDT assessment on day 1 of the program. The MDT consisted of pain medicine (in Australia, Pain Medicine is recognised as a medical speciality in its own right [http://www.fpm.anzca.edu.au/]. A career in pain medicine is generally obtained by qualifying as a Fellow of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Fellowship of this multidisciplinary medical academy is an “add-on” specialist degree. Fellows also have a specialist qualification in one of the participating specialties [eg, anaesthesia or rheumatology]), psychiatry, nursing, physiotherapy, occupational therapy, and psychology disciplines. Each discipline was allocated up to 50 minutes to assess patients, with patients undergoing 6 separate successive assessments (1 for each discipline) as part of their MDT assessment. For the purposes of this study, clinicians audio-recorded their assessments using a small MP3 device. As a complementary data collection strategy, the chart notes for the pain medicine and physiotherapy assessments were reviewed to further capture the physical examinations of these 2 disciplines' assessments (eg, palpation of structures, reflex tests, and assessment of gait pattern). The study was approved by the Royal Brisbane and Women's Hospital and The University of Queensland human research ethics committees. Back to Top | Article Outline 2.2. Participants 2.2.1. Patients Patients who met the following criteria were eligible to participate: (1) nonspecific LBP16 of >3-month duration as the primary reason for attendance, (2) aged 18 years or older, (3) able to read and write English, and (4) no known cognitive deficits. Patients meeting these eligibility criteria were invited to participate in the study on arriving at the MPC and before commencement of their MDT assessment. Consenting patients provided written informed consent and their background details. Participant's diagnosis was available before MDT assessment through their medical practitioner referral and affirmed, to be in line with Chou et al.'s16 criteria for chronic nonspecific LBP, by reviewing the ensuing MDT assessment, inclusive of physical examinations. Participants were recruited to maximize variation in sex, age, marital status, and employment status, according to the principals of maximum variation sampling,43 to enhance the diversity of findings that were likely to arise from MDT assessments. Back to Top | Article Outline 2.2.2. Clinicians This study took place within the context of routine service delivery to enhance generalisability; ie, MPC clinical procedures and processes were not altered for the research study. Hence, all the MPC's clinicians were eligible and invited to participate. To be included in the study, each clinician was required to provide written informed consent and details regarding their experience and expertise. Back to Top | Article Outline 2.3. Procedure for extracting and linking concepts to the International Classification of Functioning, Disability and Health Audio-recordings were transcribed verbatim. The concept extraction and linking process reported by Bagraith and Strong5 was implemented. In brief, the meaning condensation procedure described by Kvale40 was applied. Transcripts were read and divided into meaning units. Meaning units comprised discrete segments of text, not necessarily related to grammatical conventions, that were discerned to be related to a common theme.38 From each meaning unit, identified concepts, one or more, were extracted and documented. The ICF-Linking Rules18,20 were then applied to link-extracted concepts to the ICF, and where possible to second-level ICF categories. Each concept could be linked to more than one ICF category if necessary to suitably represent the concept. The concept extraction and linking process was also applied to the objective physical examination information extracted from the pain medicine and physiotherapy chart notes (eg, from the meaning unit “obj/gait Ax—moderately antalgic,” the concept of “objective assessment of gait pattern” was identified, which was linked to b770 gait pattern functions). A senior pain occupational therapist (K.S.B.) independently undertook the concept extraction and linking procedure with additional reference to a guideline developed by the ICF Research Branch. K.S.B. had previously undertaken training in the ICF and the procedure for linking health information to the ICF. In addition, K.S.B. had previous experience with linking clinical assessments to the ICF.5,11 A research diary was used throughout analyses to enhance methodological rigour by providing context for decisions on application of the ICF linking rules.48 To assess methodological rigour, a peer-review process was undertaken, whereby a second investigator (J.S., who had experience with qualitative analysis2 and the linking of MDT assessments to the ICF5) independently extracted concepts from 2 of the MDT assessments and linked them to the ICF. To further examine the validity of the findings, clinician member checking was undertaken following the concept extraction and linking procedures.23 Clinicians were asked to rate the extent to which: (1) the extracted concepts represented their assessment focus, (2) the linked ICF categories represented the extracted concepts, and (3) the linked ICF categories represented their typical assessments. Clinicians undertook the member checking process for one of their recorded assessments. Back to Top | Article Outline 2.4. Sample size The number of patients recruited to the study was determined by data saturation, which refers to the point where no additional information is obtained from the data.46 Data saturation is the most frequently used criterion for determining sample size in ICF-linking studies.26,61 For the purpose of this study, data saturation was considered to be achieved when no new second-level ICF categories were identified from 2 consecutive MDT assessments. After each participant's MDT assessment was linked to the ICF, data saturation was assessed. If data saturation was not achieved, a further participant was sampled, as detailed in section 2.2.1, and their MDT assessment was linked to the ICF. This process was repeated until data saturation was achieved. Because of the use of maximum variation sampling and the time required to perform the linking process outlined in section 2.3, participants were not necessarily consecutive patients being assessed by the MPC MDT. Back to Top | Article Outline 2.5. Data analysis The relative distribution of ICF-linking outcomes for extracted concepts was examined in relation to: (1) the total number of concepts extracted from each MDT assessment and (2) the total number of concepts extracted from all MDT assessments. The linking outcomes were: not covered in the ICF (eg, assessment of a patient's knowledge regarding an assessor's role in pain management), not defined in the ICF (ie, encompassed within the framework but not able to be linked to a specific component; eg, assessment of general functioning), and linked to an ICF component or category (eg, assessment of driving limitations, which was linked to d475 driving). The absolute frequency of linkage of each ICF category was also calculated. Comparisons between disciplines were made in terms of the components and categories that accounted for their assessments. The content validity of a LBP-CS category was considered confirmed if it was linked in at least one MDT assessment. Categories that were linked, and are not included in the LBP-CS, were considered potentially relevant if they were linked in at least 2 MDT assessments. Cohen's nominal kappa was used to quantify the interrater reliability of the multiple linking that occurred as part of the peer-review process. Bootstrap resampling (1000 replications) was used to generate 95% confidence intervals for kappa. All analyses were performed with Microsoft Excel 2010 and IBM SPSS v23.0. Back to Top | Article Outline 3. Results Saturation was achieved with MDT assessments of 7 patients (3 females and 4 males; see Table 1 for patient's background details). Table 2 outlines the characteristics of the MDT assessments, which were inclusive of 42 separate assessments (ie, each of the 7 patients underwent pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology assessments). In total, the multidisciplinary assessments were between 3:18 and 5:31 hours in duration, with 241,206 words recorded across all assessments. The pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology assessments were undertaken by 6, 3, 4, 2, 4, and 4 different clinicians, respectively. Each of the 23 clinicians (19 females) had experience in chronic pain management (0.5-16 years of practice) and rated their expertise 3 or higher (median: 4) on a 5-point scale (that ranged from 1 = low and 5 = excellent).39 They were all familiar with their role in the team, having been members of this particular MPC for at least 3 months (range: 0.25-12 years). Table 1 Table 1 Table 2 Table 2 Across all the MDT assessments, a total of 8596 concepts were extracted (Table 2). Of these, 334 (3.9%) were not covered within the ICF and 270 (3.1%) were designated as “not definable.” The remaining 7992 (93.0%) concepts were linked to the ICF. International Classification of Functioning, Disability and Health–linkable concepts spanned 113 second-level categories, inclusive of 31 body function, 5 body structure, 38 activity and participation, and 39 environmental factor categories. Table 3 details the distribution of linked concepts in relation to the LBP-CS. Inspection of Table 3 reveals that 73/78 comprehensive LBP-CS categories were assessed, including 19/19 body function, 5/5 body structure, 26/29 activity and participation, and 23/25 environmental factor categories. The most frequently linked categories within the body functions, body structures, activity and participation, and environmental factor components were b280 (sensation of pain), s760 (structure of trunk), d920 (recreation and leisure), and e310 (immediate family), respectively. Table 4 provides a list of 35 second-level categories that were assessed in at least 2 MDT assessments and are not contained in the LBP-CS. Carrying out daily routine (d230) accounted for the highest proportion of concepts linked to non–LBP-CS categories (16.6%). Table 3-a Table 3-a Table 3-b Table 3-b Table 4 Table 4 Figure 1 illustrates the focus of each discipline, as well as the collective MDT, in terms of the ICF components. Contextual factors (ie, the person and environment), except for physiotherapy, accounted for almost half of each discipline's assessments across the 7 patients (range: 49%-58%). Further details regarding the assessment of specific personal factor aspects are provided in supplementary Table S1 (available online at http://links.lww.com/PAIN/A589). Notably, assessment of body structures was limited; accounting for 4% of physiotherapy, 2% of pain medicine, and 1% of the collective MDT assessments. Figure 1 Figure 1 Good interrater reliability17 (kappa = 0.72; 95% confidence interval: 0.67-0.76) was observed for the assessments that were subjected to the peer-review multiple rating procedure. The clinician member checking analyses (see supplementary Table 2, available online at http://links.lww.com/PAIN/A589) supported the internal and external validity of the findings. Back to Top | Article Outline 4. Discussion This study sought to identify the content of MDT assessments using the ICF and to examine the content validity of the LBP-CS from the perspective of MDT assessments. Almost all the concepts extracted from the MDT assessments were ICF-linkable, facilitating description and comparison of assessments using the cross-disciplinary language and universal framework provided by the ICF. The findings provide novel insights into the content of MPC MDT assessments of patients with CLBP and reveal the unique contribution of each discipline to such assessments. The LBP-CS was shown to exhibit sound content validity from the perceptive of MDT assessments, with 73/78 LBP-CS categories confirmed. The present work demonstrated the utility of the ICF as a Rosetta Stone53 for describing MDT assessments of CLBP. Traditionally, aggregating and comparing the assessment foci of different disciplines has been challenging because of the dissimilar terminology and frameworks inherent across disciplines in MDTs.27,30,31,33,44 Accordingly, beyond expert suggestions as to the appropriate subject matter for chronic pain assessments,22,32,59 little was known about the actual content and focus of MPC MDT clinical assessments. The present findings provide evidence that different disciplines' clinical assessments of CLBP can be readily reconciled using the ICF's common language.5 The present results are the first to combine and display MPC MDT assessments using a common yardstick, and accordingly, considerably extend understanding regarding the content and focus of actual MPC clinical assessments of CLBP. Inspection of the ICF-based profiles reveals numerous novel and important insights into MPC clinical practice. Of such insights, 2 examples are particularly noteworthy. First, the results suggest that MPC MDTs assess personal factors and body structures more and less, respectively, than other ICF domains. Second, immediate family (e310), sensation of pain (b280), and products or substances for personal consumption (e110), as the 3 most frequently assessed areas, seem particularly important for MPC MDT assessment of CLBP. Aspects of these findings are consistent with established evidence regarding important contributors to CLBP-related functioning and provide reassurance that routine clinical practice assessments are aligned with the evidence base. For example, the importance of coping styles/strategies in chronic pain has been established,45 and the significant focus on coping strategies/styles revealed in the present findings (ie, the second most frequently assessed personal factor category; linked 437 times) is reassuring. On the other hand, future research is warranted to understand the perceived value of factors identified as especially important in this study, eg, immediate family (e310), for which the evidence base is still emerging.13,14 The potential of the ICF for clarifying team member roles has been posited52; however, the usefulness of the ICF for elucidating the actual contributions of team members to multidisciplinary assessments had yet to be substantiated before the present report. The present findings are the first to demonstrate that each discipline (ie, pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology) makes unique contributions to the MDT assessment of CLBP when considering their overall focus across the spectrum of functioning, disability, and health. However, assessment duplication was also observed across each ICF domain. Feedback from the team suggests that aspects of the assessment duplication may be attributable to rapport building (eg, assessment of areas, such as pain interference, that patients expect to be assessed by each discipline) and collection of collateral information to enhance discussion at MDT meetings. On the other hand, it was noted that overlap may also represent redundancy and opportunities to improve efficiency and reduce patient burden. To this end, 2 applications of ICF-based profiles of MPC MDT clinical assessments seem worthwhile. First, use of ICF-based profiles to compare the focus of each discipline to identify duplication in clinical assessments. Second, use of ICF-based profiles to identify disciplines most suited to assess segments of ICF Core Sets. For example, with respect to these 2 applications, the profiles from this study suggest that within MPCs, there may be duplication across pain medicine and physiotherapy when assessing motor reflex functions (b750). Based on a review of the assessment profiles and skill sets, MPCs may consider allocating the assessment and rating of b750 to physiotherapists, thereby, extricating pain medicine resourcing for redistribution to maximise value from their specialised skill set. Discipline-specific allocation of ICF Core Set categories may also enhance practice uptake of the ICF by minimising implementation burden and providing context for application of user guides.3,9 Extending the presented ICF-linking approach to generate profiles of other MPC input (eg, management decisions) is recommended to understand the broader utility of this method and potentially provide further insights to guide improvements in the efficiency and effectiveness of health care delivery. In previous studies, the LBP-CS has been shown to be inclusive of physicians'29 and physiotherapists'39 perspectives, sourced from Delphi studies, regarding important aspects of functioning as well as physicians' work capacity reports47 and physiotherapists' assessment templates.24 However, each of these previous LBP-CS valuation studies has important methodological limitations. Delphi methods rely on retrospective accounts and opinion-based judgements, while assessment templates and reports represent abbreviated or summarised versions of assessments. The present findings extend understanding of the LBP-CS's content validity, demonstrating that the LBP-CS is sufficiently comprehensive to describe the typical spectrum of problems in functioning considered in a comprehensive multidisciplinary assessment of CLBP. Of note, the present findings provide initial validation evidence for the LBP-CS from the perspectives of disciplines that were not represented within the committee selecting LBP-CS categories (ie, nursing and psychology). Taken together with existing psychometric evidence,4,6–8,21,39,55 the present results suggest that the LBP-CS is likely to have good utility for supporting MDTs to guide and document their assessments using the standard cross-disciplinary language provided by the ICF.35 Although generally supportive of the LBP-CS's content validity, the present findings highlight opportunities to improve the LBP-CS. For example, from the activity and participation component, 11 categories that are not contained in the LBP-CS were assessed in more than one patient. Of these, 4 (d230, d520, d720, and d855) were linked over 15 times. Further research into the importance of categories identified as potentially relevant in this study is necessary to understand their usefulness for consideration of inclusion in LBP-CS revisions. Two study limitations merit consideration when interpreting the present findings. First, the study was conducted within the context of routine clinical practice. Although this approach is advantageous with respect to external validity, not all the participating clinicians considered themselves to be experts. The extent to which this may have influenced findings is unclear, and future comparisons between expert clinician assessments and those undertaken in routine practice may be worthwhile to understand any meaningful differences. Second, although the used methodological approach provides a comprehensive account of assessments, it cannot be considered a complete account of the clinical assessment process. For instance, information gathered by clinicians from preassessment chart reviews was not captured. In conclusion, this study provided novel insights into the content of clinical MPC team assessments of CLBP and provided evidence to support the content validity of the LBP-CS from the perceptive of MDT assessments. The generated ICF-based profiles of MPC assessments identified new opportunities to improve health care delivery and demonstrated the unique contribution of each discipline to such assessments. The present findings also suggest that users of the LBP-CS can be more confident that the tool mostly represents the aspects of functioning and contextual factors that MDTs consider when assessing patients with CLBP. Future research into the assessment practices of MPCs from other contexts is warranted to expand on the present findings. Back to Top | Article Outline Conflict of interest statement The authors have no conflict of interest to declare. Supported by grants from the Royal Brisbane and Women's Hospital Foundation, Australian NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, and Allied Health Professions' Office of Queensland. S.M. McPhail was supported by a National Health and Medical Research Council (of Australia) fellowship. These agencies did not provide input on any aspect of the study, decision to publish, manuscript preparation, or submission. Back to Top | Article Outline Acknowledgements The authors are grateful to the patients and clinicians for their participation. They are also appreciative of the input provided by Dr Libby Gibson and Emeritus Professor Roland Sussex during the early phase of this study. The authors are thankful for the training materials provided by the ICF Research Branch in collaboration with the WHO-FIC CC in Germany (at DIMDI). The authors also acknowledge the support provided to K.S.B. for the conduct of this work as part of the RBWH Cramond Fellowship in Pain Management and Occupational Therapy. Back to Top | Article Outline Supplemental digital content Supplemental digital content associated with this article can be found online at http://links.lww.com/PAIN/A589. Back to Top | Article Outline References [1]. Alvarezz AS. The application of the International Classification of Functioning, Disability, and Health in Psychiatry: possible reasons for the lack of implementation. Am J Phys Med Rehabil 2012;91(13 suppl 1):S69–73. Cited Here... [2]. Andrews NE, Strong J, Meredith PJ, Gordon K, Bagraith KS. “It's very hard to change yourself”: an exploration of overactivity in people with chronic pain using interpretative phenomenological analysis. PAIN 2015;156:1215–31. Cited Here... [3]. Australian Institute of Health and Welfare (AIHW) 2003. ICF Australian User Guide. Version 1.0. Disability Series. AIHW Cat. 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