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2012; 92:58-68.PHYS THER. Timothy H. Wideman and Michael J.L. SullivanWork-Related Musculoskeletal InjuriesIndex for Problematic Recovery Following Development of a Cumulative Psychosocial Factor

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Development of a CumulativePsychosocial Factor Index forProblematic Recovery FollowingWork-Related Musculoskeletal InjuriesTimothy H. Wideman, Michael J.L. Sullivan

Background. Psychosocial variables such as fear of movement, depression, andpain catastrophizing have been shown to be important prognostic factors for a widerange of pain-related outcomes. The potential for a cumulative relationship betweendifferent elevated psychosocial factors and problematic recovery following physicaltherapy has not been fully explored.

Objective. The purpose of this study was to determine whether the level of riskfor problematic recovery following work-related injuries is associated with the num-ber of elevated psychosocial factors.

Design. This was a prospective cohort study.

Methods. Two hundred two individuals with subacute, work-related musculo-skeletal injuries completed a 7-week physical therapy intervention and participatedin testing at treatment onset and 1 year later. An index of psychosocial risk wascreated from measures of fear of movement, depression, and pain catastrophizing.This index was used to predict the likelihood of experiencing problematic recoveryin reference to pain intensity and return-to-work status at the 1-year follow-up.

Results. Logistic regression analysis revealed that the number of prognostic fac-tors was a significant predictor of persistent pain and work disability at the 1-yearfollow-up. Chi-square analysis revealed that the risk for problematic recoveryincreased for patients with elevated levels on at least 1 psychosocial factor and washighest when patients had elevated scores on all 3 psychosocial factors.

Limitations. The physical therapy interventions used in this study were notstandardized. This study did not include a specific measure for physical function.

Conclusions. The number of elevated psychosocial factors present in the sub-acute phase of recovery has a cumulative effect on the level of risk for problematicrecovery 1 year later. This research suggests that a cumulative prognostic factor indexcould be used in clinical settings to improve prognostic accuracy and to facilitateclinical decision making.

T.H. Wideman, Department ofPsychology, McGill University,Montreal, Quebec, Canada.

M.J.L. Sullivan, Department ofPsychology, McGill University,1205 Docteur Penfield, Mont-real, Quebec, Canada H3A 1B1.Address all correspondence toDr Sullivan at: [email protected].

[Wideman TH, Sullivan MJL.Development of a cumulative psy-chosocial factor index for prob-lematic recovery following work-related musculoskeletal injuries.Phys Ther. 2012;92:58–68.]

© 2012 American Physical TherapyAssociation

Published Ahead of Print: October27, 2011

Accepted: September 5, 2011Submitted: March 5, 2011

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Work-related musculoskeletalinjuries are a leading causeof prolonged pain and

occupational disability. Clinical prac-tice guidelines commonly recom-mend activity-based interventions,such as physical therapy, for individ-uals with subacute musculoskeletalpain conditions.1–4 Although mostindividuals with these conditionsmake a full recovery, an estimated10% to 20% will go on to developchronic pain and disability.5 This rel-atively small but significant groupaccounts for the large majority ofthe workers’ compensation expendi-tures that are associated with theseconditions.5 Previous research sug-gests that psychosocial factors mea-sured in the early stages of recoverycan help predict patients’ prognosesfor long-term rehabilitation.6–9

Factors such as fear of movement,depression, and pain catastrophiz-ing have been shown to be impor-tant predictors of a wide range ofrehabilitation and work-related out-comes. For example, previousresearch has shown that these psy-chosocial factors prospectively pre-dict measures of pain severity, phys-ical function, and return-to-workstatus, even after controlling forbaseline levels of pain.10–13 Relatedresearch has shown that these prog-nostic factors are modifiable andthat their treatment-related reduc-tion is associated with improvedrehabilitation outcomes.14–18 Inresponse to these findings, therehave been calls in the literature toaddress psychosocial factors in phys-ical therapist practice.9,16,19–21

Despite the established clinicalimportance of different psychosocialfactors, there is a lack of researchthat facilitates the clinical inter-pretation of these measures by phys-ical therapists. One challenge is thatprevious research exploring theclinical implications of psychosocialfactors has typically reported results

in the form of regression coeffici-ents. Although high in statisticaland theoretical utility, regressioncoefficients are relatively low inclinical utility. For instance, previousstudies that have used regressioncoefficients alone have not providedadequate information about the clin-ical implications of patients with avarying number of elevated scoreson different psychosocial factors.For the practicing clinician, there-fore, it remains a challenge to under-stand the prognostic implications ofpatients who have elevated scoreson more than one psychosocialfactor.

To date, there is only limitedresearch exploring the cumulativerelationship among different psycho-social factors. Recent findings sug-gest that different psychosocial fac-tors might have an additive effect onpatients’ prognoses for problematicoutcomes.22 For instance, a recentstudy suggests that patients seen forphysical therapy with high scores

on measures of both pain catastroph-izing and depression are more likelyto have a problematic recovery thanindividuals with elevated scores onjust one measure.23 This researchsuggests that information regardingthe number of elevated psycho-social factors may help physicaltherapists better determine theirpatients’ prognoses for recovery.This line of research, however,remains in its infancy. For instance,previous research exploring thecumulative effect of different psy-chosocial factors among patientsseen for physical therapy has yetto consider the effects of fear ofmovement. There is a compellingbody of research in the field ofphysical therapy linking pain-relatedfear to a wide variety of clinical out-comes.24–27 Also, the fear-avoidancemodel (FAM) of pain suggests that,in addition to pain catastrophizingand depression, fear of movement isan important determinant of pro-longed pain and pain-related dis-ability.28 Further research exploring

The Bottom Line

What do we already know about this topic?

Previous research has shown that patients who have pain conditions andwho start physical therapy with elevated levels of fear of movement,depressive symptoms, or pain catastrophizing are more likely to experi-ence a problematic recovery.

What new information does this study offer?

Findings from this study suggest that elevated scores on multiple psycho-social factors have a negative, cumulative effect on long-term levels ofpain intensity and work disability.

If you’re a patient or a caregiver, what might thesefindings mean for you?

Patients who start physical therapy with elevated levels of fear of move-ment, depressive symptoms, and pain catastrophizing are at the greatestrisk of experiencing a problematic recovery. If you have elevated levels inall 3 of these areas, your physical therapist may take this into consider-ation when developing your plan of care.

Risk for Problematic Recovery Following Work-Related Musculoskeletal Injuries

January 2012 Volume 92 Number 1 Physical Therapy f 59 at McGill University on July 26, 2012http://ptjournal.apta.org/Downloaded from


the cumulative relationship amongthese 3 psychosocial factors mayhelp guide physical therapists in theclinical management of patients withpain conditions.23

The purpose of this study was todetermine whether the risk for prob-lematic recovery following work-related injuries varies as a function ofthe number of elevated psychosocialfactors. To address this question,we conducted a prospective cohortstudy using a sample of individualswith subacute, work-related muscu-loskeletal injuries. Study participantscompleted a 7-week physical ther-apy intervention and participated intesting at treatment onset and 1 yearlater. A Cumulative Prognostic Fac-tor Index (CPFI) was created frompreviously validated measures offear of movement, depression, andpain catastrophizing. This indexwas used to predict the likelihood ofexperiencing problematic recoveryin reference to patients’ pain inten-sity and return-to-work status at the1-year follow-up. We hypothesizedthat patients with greater numbersof elevated psychosocial factorswould be more likely to experienceproblematic outcomes at the 1-yearfollow-up.

MethodStudy DesignA prospective cohort study was con-ducted in which a convenience sam-ple of patients was recruited from 6physical therapy clinics across theprovince of Quebec, Canada.

Inclusion CriteriaPatients were eligible for the study ifthey were between the ages of 18and 65 years and had sustained awork-related soft tissue injury totheir backs or necks. At the time ofinitial consultation, all patients werein the subacute phase of recovery(ie, 3–12 weeks since injury) andwere receiving wage indemnity ben-efits from the provincial workers’

compensation board. Patients werenot eligible for the study if theyhad been diagnosed with a vertebralfracture, disk herniation, ankylosingspondylitis, infectious disease, or anymedical condition that did not per-mit a physical evaluation.

ProcedureInterested and eligible patients werefirst asked to sign an informed con-sent form. Self-report questionnaireswere administered at the onset ofphysical therapy and after complet-ing 7 weeks of treatment. Baselineand demographic information wasalso collected at treatment onset. Afollow-up telephone interview wasconducted 1 year following treat-ment onset.

Physical therapy interventions wereaimed at reducing pain and disabilityassociated with soft tissue injuries.Specific interventions varied at thediscretion of the treating therapist;however, treatments were consis-tent with clinical practice guide-lines for functional restoration aftera subacute musculoskeletal injuryand the reimbursement guidelinesof the provincial workers’ com-pensation board.2,29,30 Therefore,treatment focused on early mobiliza-tion and physical activity and primar-ily consisted of range of motion,joint manipulation, and progressivestrength exercises. Physical therapysessions were scheduled 3 days perweek.

MeasuresParticipants completed self-reportmeasures of pain intensity, pain cata-strophizing, fear of movement, anddepressive symptoms. Participantsalso provided baseline informationrelating to their age, sex, preinjuryoccupation, highest level of educa-tion, location of injury, time sinceinjury, and use of medication fortheir pain condition. The 1-yearfollow-up interview evaluated par-

ticipants’ levels of pain intensity andreturn-to-work status.

Pain intensity. Numeric ratingscales were used to quantify partici-pants’ levels of pain severity. Par-ticipants were asked to rate theirpain intensity on an 11-point scalewith end-point anchors of 0 (“nopain”) and 10 (“excruciating pain”).Past research suggests that suchscales are reliable and valid measuresof pain intensity.31

Pain catastrophizing. The PainCatastrophizing Scale (PCS) wasused to quantify participants’ levelsof catastrophic thoughts. The PCSis a 13-item self-report question-naire that includes items to mea-sure each of the 3 subdimensionsof pain catastrophizing (rumina-tion, magnification, and helpless-ness). Higher scores on the PCS indi-cate greater levels of catastrophicthinking; past research has used acutoff score of 20 to identify patientswith elevated scores of pain catastro-phizing.14,32 Previous research hasshown that the PCS has good reliabil-ity and validity and that elevatedscores indicate risk for poor pain-related outcomes.33,34

Fear of movement. Fear of move-ment and reinjury was measuredusing the Tampa Scale of Kinesio-phobia (TSK).35 The TSK is a self-report questionnaire consisting of17 items that address beliefs relatingto pain, movement, and injury. Par-ticipants are asked to rate their levelof agreement for each of the items;higher scores indicate greater levelsof fear of movement. Past researchhas shown the TSK to have goodreliability and to be an importantpredictor of pain-related disability.28

Previous research has used a cutoffscore of 39 to identify individualswith elevated levels of fear ofmovement.14,32




Depression. The Beck DepressionInventory–II (BDI) was used tomeasure the severity of partici-pants’ depressive symptoms.36 Ele-vated BDI scores are an indicationof more severe depressive symp-toms and have been shown to bean important predictor of negativepain-related outcomes.37,38 Previousresearch has identified a cutoffscore of 13 to identify patients withclinically meaningful symptoms ofdepression.39 Past research in thefield of pain suggests that the BDI is areliable and valid measure of depres-sive symptoms.40

One-year follow-up interview.One year after the initial assessment,a telephone interview was used toassess participants’ levels of painintensity and return-to-work status.Pain intensity was measured using an11-point numeric rating scale thathad the same anchors as the pre-viously described measure (ie, 0�“no pain,” 10�“excruciating pain”).Return-to-work status was based onwhether patients had or had notreturned to full-time employment(yes/no).*

Data AnalysisScores on the PCS, TSK, and BDIwere split on previously establishedcutoff scores (ie, 20, 39, and 13,respectively), and participants werecoded as either having or not havingelevated scores on each scale.14,32,39

Using these data, a variable named“number of prognostic factors” wascreated; the term “prognostic factor”was used in this study to indicate anelevated score on a psychosocialmeasure. This variable ranged from 0(ie, below or equal to the cutoff for

* In the province in which testing was con-ducted, employers are required by law to pro-vide injured workers with the opportunity toreturn to their preinjury occupation. As aresult, return-to-work status in this study canbe construed as a measure of participants’ability to return to their previous employ-ment, rather than their ability to find newemployment.

Table 1.Characteristics of the Study Sample (N�202)a

Characteristicsn (%) orX (SD)

Education

Less than high school 35 (17.3%)

High school 58 (28.7%)

Trade school 40 (19.8%)

College 47 (23.3%)

University 22 (10.9%)

Occupation

Laborer 65 (32.2%)

Nursing 48 (23.8%)

Clerical 39 (19.3%)

Trade 21 (10.4%)

Driving 13 (6.4%)

Sales 13 (6.4%)

Other 3 (1.5%)

Injury site (categories are not mutually exclusive)

Back 187 (92.6%)

Neck 162 (80.2%)

Upper extremity 115 (56.9%)

Lower extremity 52 (25.7%)

Pretreatment medication use

OTC NSAIDs 96 (47.5%)

Opioids 36 (17.8%)

Anti-inflammatories 12 (5.9%)

Pretreatment assessment variables

Pain intensity 5.1 (1.8)

PCS 21.5 (10.7)

TSK 42.8 (8.1)

BDI 15.1 (9.4)

Pretreatment psychosocial prognostic factor index 1.7 (1.1)

No. of prognostic factors

0 34 (16.8%)

1 54 (26.7%)

2 53 (26.2%)

3 61 (30.2%)

1-year follow-up variables

Pain intensity 3.6 (2.3%)

Less than 30% reduction in pain intensity 106 (52.5%)

Did not return to work 63 (31.2%)

a OTC NSAID�over-the-counter nonsteroidal anti-inflammatory drugs, PCS�Pain CatastrophizingScale, TSK�Tampa Scale of Kinesiophobia, BDI�Beck Depression Inventory.




all scales) to 3 (ie, above the cutofffor all scales).

The Initiative on Methods, Measure-ment, and Pain Assessment in Clini-cal Trials (IMMPACT) advisory boardhas recommended a 30% reductionas the cutoff criterion for clinicallymeaningful change in pain inten-sity.41 Percent reductions in painintensity were calculated from initialassessment to the 1-year follow-up,and using a 30% reduction as a cut-off, participants were coded as expe-riencing either a reduction in pain orno reduction in pain.

Using SPSS version 18.0 (SPSS Inc,Chicago, Illinois), data analysis wasconducted in 3 steps. First, zero-order mean comparisons wereused to determine the relationshipsbetween pretreatment variables and1-year follow-up outcomes. Next,hierarchical logistic regression anal-ysis was used to determine whethernumber of prognostic factors wasa significant predictor of each out-come while controlling for all otherfactors that were significant inthe zero-order analysis. Finally, chi-square analysis was conducted todetermine the relationship betweenthe number of prognostic factorsand the rates of problematicrecovery.

Role of the Funding SourceThe primary author (T.H.W.) wassupported by funds from the Cana-dian Institutes for Health Research(CIHR), the Institut de RechercheRobert-Sauve en Sante et en Securitedu Travail (IRSST), and the Physio-therapy Foundation of Canadathrough the Dominion Physiother-apy Research Scholarship. The fund-ing sources of the authors had noinfluence on this study.

ResultsMissing DataTwo hundred thirty-five individualsagreed to participate in the study and

completed the pretreatment assess-ment. Of this group, however, 33individuals (14.0%) did not havecomplete follow-up data. Meancomparisons were conducted todetermine whether individuals withcomplete data and those with incom-plete data differed with respect tosex, age, pain duration, and pretreat-ment levels of medication use, painintensity, pain catastrophizing, fearof movement, or depression. Resultsshowed a significant between-groupdifference in pain duration; indi-viduals with complete data hadan average pain duration of 8.63(SD�3.35) weeks, whereas individu-als with incomplete data averaged6.64 (SD�3.02) weeks since theirinjury. Aside from this difference,the groups appeared homogenous.The 33 individuals with incompletedata, therefore, were not included inthe study sample.

Previous findings suggest that psy-chosocial prognostic factors are notstrongly related to self-reportedlocation of pain.20,42 To ensure thatthis was the case in our sample andthat patients with back or neck painwere homogenous, we conductedan analysis that compared baselineand pretreatment variables for indi-viduals with back pain (n�187)and those without back pain (n�15); all comparisons were nonsig-nificant (P�.05). The study sample(n�202), therefore, was consideredto be homogenous with respect toself-reported location of pain.

Sample CharacteristicsThe study sample consisted of202 individuals (79 men and 123women), with a mean age of 36.57(SD�10.34) years. Table 1 pre-sents participants’ level of educa-tion, preinjury occupation, locationof injury, and the distribution offindings of their pretreatment andfollow-up assessments. To summa-rize, the majority of participantscompleted some form of postsec-

ondary education and, prior to theirinjury, were working as either alaborer or nurse. The majority of theparticipants identified their back asthe primary location of pain. Oneyear following the initial assessment,106 participants (52.5%) did notexperience a meaningful reductionin their pain intensity, and 63 indi-viduals (31.2%) had not returned towork.

Correlation analyses between par-ticipants’ pretreatment scores on thepsychosocial factors are presentedin Table 2. Consistent with previousfindings,43–45 our results revealed sig-nificant correlations between psy-chosocial factors that were in themodest to moderate range (P�.001,Pearson r�.288–.570).

Mean comparisons between scoreson psychosocial prognostic factorsand the follow-up outcomes arepresented in Table 3. Pretreatmentlevels of pain catastrophizing anddepression were significantly relatedto both of the outcomes (P�.05),and relationships with levels offear of movement were marginallysignificant.

Predicting Reductions in PainIntensity at 1-Year Follow-upZero-order analyses were conductedto determine whether age, sex, painduration, pretreatment medicationuse, pretreatment pain intensity,and number of prognostic factorswere significantly related to follow-up reductions in pain intensity.Results revealed that the number of

Table 2.Correlations Among PretreatmentPsychosocial Factors (N�202)a

Factor TSK BDI

PCS .570* .503*

TSK .288*

a PCS�Pain Catastrophizing Scale, TSK�TampaScale of Kinesiophobia, BDI�Beck DepressionInventory. Asterisk indicates P�.001.




prognostic factors (F�11.279, �2�0.053, P�.001) was the only variableto have a significant relationshipwith reduction in pain intensity. As aresult, no hierarchical testing wasrequired.

In order to ensure that our categori-zation of patients’ reduction in painintensity (ie, using a 30% reductioncutoff score) had not influenced thepredictive value of the number ofprognostic factors, we repeated thisanalysis using 2 continuous depen-dent variables: pain intensity at the1-year follow-up and the percentreduction in pain intensity from pre-treatment to 1-year follow-up. Simi-lar to our initial findings, both analy-ses showed that after controlling forother baseline factors, the number ofprognostic factors was a significant

predictor of pain-related measures atfollow-up (P�.05).

Next, chi-square analysis was con-ducted to determine whether thelikelihood of failing to achieve ameaningful reduction in pain inten-sity increased with the number ofprognostic factors; results confirmedthis relationship (�3

2�14.947, P�.002). The likelihood of failing toachieve a reduction in pain for par-ticipants with 0, 1, 2, and 3 prognos-tic factors was 23.5%, 55.6%, 54.7%,and 63.9%, respectively.

Table 4 presents a summary ofhow participants with differentnumbers of prognostic factors weredistributed across both outcomes; agraph of the data is presented inthe Figure. Contrast comparisons

revealed significant differences inthe likelihood of pain reductionbetween individuals with no prog-nostic factors and those with 1 prog-nostic factor (�1

2�8.722, P�.003,Phi statistic��0.315), between indi-viduals with no prognostic factorsand those with 2 prognostic factors(�1

2�8.243, P�.004, Phi statistic��0.308), and between individualswith no prognostic factors and thosewith 3 prognostic factors (�1

2�14.258, P�.001, Phi statistic��0.387). Results of contrast compar-isons for pain reduction and return-to-work status are presented inTable 5.

Predicting Return-to-WorkStatus at 1-Year Follow-upZero-order analysis revealed signifi-cant findings for pretreatment painintensity (F�4.532, �2�0.022, P�.034) and number of prognostic fac-tors (F�13.245, �2�0.062, P�.001).Hierarchical logistic regression anal-ysis revealed that the number ofprognostic factors predicted return-to-work status after controlling forlevel of pain intensity (Wald test�9.308, odds ratio�1.630, P�.034).Chi-square analysis showed thatthe likelihood of failing to returnto work increased with the numberof prognostic factors (�3

2�14.076,

Table 3.Means, Standard Deviations, and Effect Sizes of Pretreatment Psychosocial Factors for Participants Who Did and Did NotExperience a Meaningful Reduction in Pain Intensity and Return to Work at the 1-Year Follow-upa

Variable

PositiveOutcome

NegativeOutcome

F Statistic(�2) PX (SD) X (SD)

Meaningful reduction in pain n�96 n�106

PCS 19.25 (10.58) 23.61 (10.40) 8.720 (0.04) .004*

TSK 41.61 (8.69) 43.80 (7.48) 3.693 (0.02) .056

BDI 13.68 (9.30) 16.35 (9.30) 4.129 (0.02) .043*

Return to work n�139 n�63

PCS 19.88 (10.75) 25.21 (9.65) 11.33 (0.05) .001*

TSK 42.05 (8.32) 44.33 (7.52) 3.46 (0.02) .064

BDI 13.15 (7.53) 19.33 (11.57) 20.55 (0.09) �.00*

a PCS�Pain Catastrophizing Scale, TSK�Tampa Scale of Kinesiophobia, BDI�Beck Depression Inventory. Asterisk indicates P�.05.

Table 4.Distribution of Participants Across Cumulative Prognostic Factor Index (CPFI) ScoresWho Experienced a Problematic Outcome at the 1-Year Follow-up

CPFI Score

Participants WithoutMeaningful Reduction

in Pain Intensityn (%)

ParticipantsWho Did Not

Return to Workn (%)

0 (n�34) 8 (23.5) 4 (11.8)

1 (n�54) 30 (55.6) 15 (27.8)

2 (n�53) 29 (54.7) 15 (28.3)

3 (n�61) 39 (63.9) 29 (47.5)




P�.003). The rate of work dis-ability for participants with 0, 1,2, and 3 prognostic factors was11.8%, 27.8%, 28.3%, and 47.5%,respectively. Contrast comparisonsrevealed significant differencesbetween individuals with no prog-nostic factors and those with 3 prog-nostic factors (�1

2�12.326, P�.001,Phi statistic�0.360), between indi-viduals with 1 prognostic factorand those with 3 prognostic factors(�1

2�4.736, P�.030, Phi statis-tic�0.203), and between individ-uals with 2 prognostic factors andthose with 3 prognostic factors (�1

2�4.429, P�.035, Phi statistic�0.197).

Secondary Analysis toExplore Specific Combinationsof 2 Prognostic FactorsThe above analysis suggests thatparticipants’ likelihood of problem-atic recovery is related to their num-ber of prognostic factors (ie, 0, 1, 2,or 3). However, it also is possiblethat the specific combination ofprognostic factors contributed to therecovery of participants with 2 prog-nostic factors.22 To explore theserelationships within our sample, weconducted a secondary analysis todetermine whether elevated scoreson different combinations of 2 fac-tors related to problematic recov-ery. First, we created a subsampleof individuals with elevated scoreson 2 psychosocial factors (n�53).We then grouped these individualsinto 3 categories, which representedeach of the possible interactionsbetween prognostic factors, namely:(1) high catastrophizing and highfear, (2) high depression and highcatastrophizing, and (3) high fearand high depression. Next, chi-square analyses were conducted todetermine whether there were sig-nificant relationships between thedifferent combinations and prob-lematic recovery on the follow-upindexes. Results failed to reveal anysignificant differences (P�.05).

DiscussionThe purpose of this study was toexplore the relationship betweenthe number of elevated scoreson FAM-relevant factors and thelikelihood of problematic recoveryfollowing physical therapy. Ourresults suggest that elevated scoreson the CPFI were associated withan increased risk of problematicrecovery. These results build onprevious cumulative psychosocialresearch22,23 by showing a similar

phenomenon within a popula-tion with work disabilities and byaddressing the 3 primary psycho-social factors of the FAM. Our find-ings also suggest that use of the CPFIin the early stages of recovery mayhelp identify patients at risk for prob-lematic recovery and facilitate deci-sion making regarding clinicalmanagement.

Our results suggest that differentscores on the CPFI are associated

Table 5.Contrast Comparisons of the Likelihood of Outcome Among Elevated PsychosocialFactors

Prognostic FactorComparisons by

Outcome

�2 Value(Effect Size

[Phi Statistic]) P a

Reduction in pain

0 vs 1 prognostic factor 8.722 (�0.315) .003*

0 vs 2 prognostic factors 8.243 (�0.308) .004*

0 vs 3 prognostic factors 14.258 (�0.387) �.001*

1 vs 2 prognostic factors 0.008 (0.008) .931

1 vs 3 prognostic factors 0.838 (�0.085) .360

2 vs 3 prognostic factors 1.001 (�0.094) .317

Return to work

0 vs 1 prognostic factor 3.160 (0.190) .075


0 vs 3 prognostic factors 12.326 (0.360) �.001*


1 vs 3 prognostic factors 4.736 (0.203) .030*

2 vs 3 prognostic factors 4.429 (0.197) .035*

a Asterisk indicates P�.05.

Figure.Profiles of problematic outcomes at 1-year follow-up.




with different profiles of recovery.Profile of recovery, in this instance,refers to the participants’ perfor-mance at the 1-year follow-up on the2 dependent variables (pain reduc-tion and work disability). When con-sidered from this perspective, ascore of 0 on the CPFI representsthe most favorable profile of recov-ery following physical therapy. Ourresults suggest that the profile ofrecovery changes (in reference to aCPFI score of 0) with certain incre-mental increases on the index. Forinstance, when compared with aCPFI score of 0, a CPFI score of 1 or2 is associated with a significantincrease in the likelihood of experi-encing unimproved pain symptomsat 1-year follow-up. A CPFI score of3 further contributes to the likeli-hood of problematic recovery bybeing associated with both an ele-vated likelihood of experiencing pro-longed pain and an increased risk ofexperiencing long-term work disabil-ity. Our findings, therefore, suggestthat the risk associated with prob-lematic recovery increases with CPFIscores above 0 and that levels of riskare most elevated with a CPFI scoreof 3.

The manner by which risk for prob-lematic recovery increased in oursample suggests that reductions inpain intensity and return-to-workstatus have at least partially distinctrelationships with the number ofelevated psychosocial factors. Ourfindings suggest that individualswith elevated scores on 1 or 2 prog-nostic factors are significantly morelikely to report persistent pain at1-year follow-up (when comparedwith those with no elevated scores),but are not significantly more likelyto experience work disability at thesame time point; only patients with aCPFI score of 3 have an increasedrisk of experiencing work disability.These findings suggest that althoughlevels of pain intensity may be sen-sitive to the presence of just one

prognostic factor, measures of workdisability are more resilient, onlybeing influenced by elevated scoreson several psychosocial factors.

It is possible that rates of work dis-ability are only significantly increasedwhen patients’ psychosocial distresshas become sufficiently complex.Work disability is a behavioral/socialoutcome that is influenced by awide variety of different psychoso-cial mechanisms (eg, negative expec-tancies, avoidant behavior, motiva-tional deficits).46 It is possible thatpatients who are experiencing dis-tress in only a few psychosocialdomains (ie, patients with lowerCPFI scores) are able to success-fully overcome these return-to-workbarriers over the course of physicaltherapy, but patients experiencingdistress in a wider range of psycho-social domains are not. The relation-ship between different psychosocialfactors and levels of pain severity, onthe other hand, has been suggestedto occur through common physio-logical pathways (eg, descendingmodulation of pain).47,48 This over-lap may mean that more complexforms of psychosocial distress have aless dramatic impact on the severityof pain intensity. The reader isreminded, however, that this inter-pretation remains speculative andthat despite the reported statisticaldifferences between specific CPFIscores, both outcomes followed ageneral trend of increasing with thenumber of elevated prognostic fac-tors (as shown in the Figure).

Although the FAM proposes sequen-tial relationships among pain cata-strophizing, fear of movement, anddepressive symptoms, it does notprovide specific predictions regard-ing the potential cumulative rela-tionships among these factors.Recent findings have suggested theprognostic importance of specificcombinations of model-relevant fac-tors.22 Our findings, however, failed

to show any differences betweenindividuals with various combina-tions of 2 prognostic factors, but didshow significant differences amongindividuals with varying CPFI scores.Our results, therefore, suggest thatthe number, rather than specificcombinations, of elevated FAM fac-tors may be more closely related toprognosis. Readers should be cau-tioned in the interpretation of thesefindings, however, as it is possiblethat this secondary analysis wasunderpowered. Assuming that ourfindings are valid, one explanationfor the discrepancy with previousfindings is that related analyses hadmeasured 2, rather than 3, FAM-relevant factors; with only 2 factorsunder analysis, it is not possible toflush out the contributions betweenthe number of elevated factors ver-sus the contribution of their inter-action. Future research will needto use larger sample sizes to furtherexplore the cumulative relation-ships among FAM-relevant factors todetermine whether expansion of themodel is warranted.

Our findings also relate to recentclinical research exploring the useof brief psychosocial screeningtools. Previous research suggeststhat scores on The Orebro Musculo-skeletal Pain Screening Question-naire and the Subgroups for TargetedTreatment (STarT) Back ScreeningTool can predict pain-related recov-ery.49–53 These scales share sev-eral similarities with the CPFI. Forinstance, each of these tools aims toprovide a generalized measure of dif-ferent forms of pain-related psycho-social distress that can be used inclinical settings.

Despite their prognostic value andsimilarities, however, there may beimportant differences in the clinicalinformation that they can provide.One important difference may be theunderlying psychosocial constructsthat each of the scales were designed




to represent. As described above, theCPFI is not a new scale, but rather anovel index of scores on validated,FAM-relevant scales. As a result, therelatively large body of FAM litera-ture can be used to guide the clinicalinterpretation of CPFI scores. Forinstance, previous research suggeststhat the psychosocial factors in theFAM are modifiable by a wide rangeof clinical interventions.54–56 It alsohas been suggested that lighterFAM-based interventions suffice forindividuals with lower profiles ofpsychosocial risk, whereas moreintensive psychosocial treatmentsare required for those with higherprofiles of risk.57

Together, this research suggests thatthe CPFI may be useful in guidingthe use of different FAM-based inter-ventions. For example, it is possiblethat individuals with CPFI scores of1 or 2 may benefit from targeted psy-chosocial interventions that can beeasily integrated within traditionalphysical therapy; interventions suchas graded activity, graded exposure,and education have been used inthis manner.58–60 Although individu-als with a CPFI score of 3 mayrequire, in addition to traditionalphysical therapy, more intensivepsychosocial interventions or refer-ral to additional health care profes-sionals; standardized 10-week inter-ventions have been delivered byphysical therapists and psychologistsin this context.16,61,62

In comparison, the clinical infor-mation that physical therapists cangarner from streamlined screeningtools may be less clear. For exam-ple, the Orebro MusculoskeletalPain Screening Questionnaire wasoriginally constructed without refer-ence to a guiding theoretical frame-work,63 and the broad psychosocialconstructs that are addressed in thisquestionnaire have yet to be vali-dated in reference to established psy-chosocial scales. Previous research

also suggests ambiguity in the num-ber, and name, of factors underlyingthis scale.63–65 Without a clear senseof the psychosocial factors or theo-retical framework that are relevantto the Orebro Musculoskeletal PainScreening Questionnaire, it may bedifficult for physical therapists to usepatients’ scores on this scale to guidetheir clinical practice.

The STarT Back Screening Tool,on the other hand, was designedto address specific psychosocialfactors that have been shown to bemodifiable. STarT Back ScreeningTool scores are intended to helpprimary care physicians decidewhether their patients with acuteback pain should be referred foradditional health care services (eg,physical therapy, psychology); useof the CPFI in clinical settings mayprove complementary to this screen-ing tool. For example, the concisenature of the STarT Back Screen-ing Tool may be ideal for a briefphysician consultation, whereas theCPFI, based on more comprehen-sive psychosocial scales, may be bet-ter suited for rehabilitation settings,particularly for patients who havebeen screened into the high-riskcategory in the initial consultation.Although psychosocial screeningtools have clear advantages withrespect to responder burden, it isnot clear whether additional clini-cally meaningful information canbe gained by using more compre-hensive measures of psychosocialfactors. Recent findings showingthat the STarT Back Screening Tooldid not perform as expected whenadministered in physical therapysettings50 suggest that more infor-mation may be required. Futureresearch is needed to determinethe most appropriate clinical con-texts for using streamlined screeningtools versus their more comprehen-sive counterparts.

Several limitations influence theapplication of our findings. Forinstance, our study did not includea specific measure of physical func-tion. Although successful return towork may infer a certain level ofphysical performance (eg, toleratinga regular work schedule), it doesnot address participants’ specificphysical impairments or abilities. Aspecific measure of physical func-tion would have provided a morecomprehensive profile of recovery.Also, although physical therapytreatment followed practice guide-lines, we did not have any informa-tion on the specific interventionsthat were administered. It is possiblethat variance in the treatment inter-ventions may have contributed topatients’ outcomes. Furthermore, noinformation was collected regardingtreatment attendance or participa-tion. Finally, the manner in whichwe created the CPFI was based onthe a priori assumption that the 3psychosocial factors had equal prog-nostic weights. It is possible that theCPFI would have had greater prog-nostic accuracy if a prediction modelhad been created in which exactweights for each factor were used.Although our simplified approachmay facilitate the integration of theCPFI into clinical practice, there islikely a loss of information regard-ing the specificity between differentfactors and problematic recovery.As the integration of psychosocialfactors into physical therapist prac-tice becomes more prevalent (andnuanced), research that exploresthe use of more sophisticated clini-cal prediction models will likely bewarranted.

Despite these limitations, thisresearch sheds light on the relativelynovel area of cumulative psycho-social risk. Our results suggest thatpatients’ prognoses for problematicrecovery are related to the numberof elevated psychosocial factors.More precisely, our findings suggest




that the risk associated with prob-lematic recovery increases withCPFI scores above 0 and that levelsof risk are most severe with elevatedscores on all 3 psychosocial factors.This research suggests that the CPFIcould be used in clinical settings tobetter evaluate prognosis and tofacilitate decisions regarding clinicalmanagement.

Both authors provided concept/idea/researchdesign, writing, and data analysis. Dr Sulli-van provided data collection, fund procure-ment, facilities/equipment, institutional liai-sons, and consultation (including review ofmanuscript before submission).

The research program was approved bythe ethics review boards of the Centre deRecherche Interdisciplinaire en Readaptationdu Montreal Metropolitain and the Univer-sity of Montreal.

The primary author (T.H.W.) was sup-ported by funds from the Canadian Insti-tutes for Health Research (CIHR), the Insti-tut de Recherche Robert-Sauve en Santeet en Securite du Travail (IRSST), andthe Physiotherapy Foundation of Canadathrough the Dominion PhysiotherapyResearch Scholarship.

DOI: 10.2522/ptj.20110071

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doi: 10.2522/ptj.20110071Originally published online October 27, 2011

2012; 92:58-68.PHYS THER. Timothy H. Wideman and Michael J.L. SullivanWork-Related Musculoskeletal InjuriesIndex for Problematic Recovery Following Development of a Cumulative Psychosocial Factor

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