Background & Aims
There is a complex bidirectional relationship between low back pain (LBP)
and psychological factors [1]. A biopsychosocial assessment of a person with LBP should
include the detection of psychological risk factors [2]. When people with LBP seek healthcare, it is often with musculoskeletal (MSK) clinicians (e.g., physiotherapists) or spinal clinicians (e.g., orthopaedic surgeons) who are not specially trained in psychopathology.
Pragmatically, clinicians often use their clinical impression rather than questionnaires to screen for psychological risk factors. This review will summarise the available evidence on how accurately depression, anxiety, and psychological distress can be identified by MSK or spinal clinicians using their clinical impression compared to reference standard questionnaires.
Methods
The scoping review was conducted following the Joanna Briggs Institute updated methodological guidance for scoping reviews [3] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) checklist[4].
A comprehensive search strategy using five databases (MEDLINE, CINAHL, Academic Search Complete, APA PsycInfo, APA PsycArticles) was conducted on June 13th 2023 relating to three domains; (i) LBP, (ii) MSK and spinal clinicians, and (iii) depression, anxiety and
psychological distress as outlined in the pre-registered OSF protocol https://osf.io/pt3a6. All relevant primary quantitative research studies published in English were included, without date restriction.
Two reviewers independently carried out the database searches, assessed titles and abstracts for relevance based on eligibility criteria, and reviewed the full texts of the studies initially selected for potential inclusion.
Results
The initial search returned 7, 125 articles. Following removal of duplicates and screening of titles and abstracts there were 12 potentially eligible studies. Sensitivity and specificity values were available across seven of the eight included studies [5-12], and analyses were determined using a threshold of ‘high’ clinician impression compared to ‘high’ reference standard scores.
Overall MSK and spinal clinicians were not accurate at identifying depression, anxiety or
psychological distress in adults with LBP. The tendency of the clinicians was to underestimate the presence of psychopathology, in particular when the higher threshold for more severe states was analysed.
-Clinicians failed to identify at least half the cases of moderate and higher depression (sensitivity 18.0% to 50.0%), and were especially poor at recognising high depression accurately (sensitivity 9.0% to 33.3%).
-Clinicians failed to identify moderate and higher anxiety (sensitivity 33.3% to 43.0%), and were especially poor at recognising high anxiety accurately (sensitivity 0.0% to 24.0%).
-Mean sensitivity for how accurately clinicians correctly identified patients with moderate or higher distress was 54.1%, with lower mean sensitivity of 40.0% for those in the higher categories of distress.
Conclusions
This review adds to data that overall MSK and spinal clinicians cannot accurately judge the presence of depression, anxiety, and psychological distress well using clinical impression alone in adults with LBP. Overall, clinicians tend to underestimate the presence of depression, anxiety, and psychological distress; in particular the more severe or extreme states. Accurate recognition of distress seems to be somewhat better than that of depression and anxiety.
Further research, cumulating in specific guidance on screening of psychopathology and implementation of this guidance, is required. Screening alone without appropriate follow up care for diagnosis and management is not worthwhile, and this reality must also be incorporated into future research.
References
This review adds to data that overall MSK and spinal clinicians cannot accurately judge the presence of depression, anxiety, and psychological distress well using clinical impression alone in adults with LBP. Overall, clinicians tend to underestimate the presence of depression, anxiety, and psychological distress; in particular the more severe or extreme states. Accurate recognition of distress seems to be somewhat better than that of depression and anxiety.
Further research, cumulating in specific guidance on screening of psychopathology and implementation of this guidance, is required. Screening alone without appropriate follow up care for diagnosis and management is not worthwhile, and this reality must also be incorporated into future research.9(7): p. E455.
Presenting Author
Julie Sugrue
Poster Authors
Topics
- Specific Pain Conditions/Pain in Specific Populations: Low Back Pain