Background & Aims
Psychological characteristics are known to contribute to the development and maintenance of chronic musculoskeletal pain. As a result, psychological screening is a critical component of effective musculoskeletal pain care. The Screening for Pain Vulnerability and Resilience (SPARE) measures were developed as efficient assessments to guide decision-making on psychologically-focused education, treatment and referral. The 4-item SPARE short forms measure negative mood, fear avoidance, and negative pain coping domains. SPARE measures were derived through item response theory methods using the T-score metric. Numerous large health care systems have adopted the SPARE measures in practice. However, lack of guidance on SPARE score interpretation remains a major challenge for widespread implementation. The goal of this project is to provide guidance on interpretation of SPARE measure scores that will help clinicians with decisions on psychologically-focused pain care.
Methods
Retrospective data were extracted from the Focus on Therapeutic Outcomes (FOTO) Patient Outcomes system. All data were collected at initial evaluation by physical therapy providers in the United States working in 618 outpatient orthopedic clinics across 22 states. Patients with a musculoskeletal condition were categorized by body region of primary impairment. For each of the three psychologic domains, we established “yellow flag indicators” using cut-off scores suggesting the presence of high psychologic distress. To derive these scores, we used distribution-based and anchor-based methods and triangulated results to guide domain score interpretation. The anchor-based method used a criterion of top quartile baseline pain intensity score plus bottom quartile function score, then employed receiver operating curve (ROC) analysis to determine threshold scores. We derived separate group cutoffs if SPARE standardized mean differences (SMD) between sexes and by surgical status were > 0.2.
Results
Complete data were available for 299,978 patients (244,896 non-surgical, 55,082 postsurgical). Totals by body region (% postsurgical) were: lumbar spine, 61,592 (5.3%); cervical spine, 24,320 (4.3%); elbow-wrist-hand (EWH) 26,481 (21.3%); shoulder 55,872 (21.6%); and lower extremity (LE) 124,934 (26.3%). SMD was > 0.2 only for SPARE negative coping by surgical status. Negative mood, cutoff scores were (mean plus 0.5 standard deviation (SD), mean plus 1 SD, and anchor-based): lumbar and cervical spine (53, 57, 54); EWH, shoulder, and LE (51, 55, 51). Fear avoidance cutoffs were: lumbar and cervical spine (61, 64, 60); EWH (56, 60, 56); shoulder and LE (57, 61, 56). For pain coping in non-surgical patients, cutoffs were: lumbar spine (62, 66, 62), cervical spine (61, 66, 60); EWH (59, 64, 59); shoulder and LE (58, 63, 58). For pain coping after surgery, cutoffs were: lumbar spine (63, 68, 63), cervical spine (62, 67, 60); EWH (61, 66, 64); shoulder (63, 68, 63) and LE (62, 66, 62).
Conclusions
Cut-off scores derived in this analysis for lumbar and cervical spine conditions were similar, and generally higher than cut-offs for extremity conditions. Cut-off scores varied considerably across the three domains, suggesting the need to consider different cut-off criteria when interpreting measures of negative mood, fear avoidance, and negative pain coping. Score distributions for negative pain coping were different based on surgical status, and cut-off scores for this domain were higher among those after surgery, likely reflecting the higher prevalence of characteristics like low self-efficacy for managing pain and participating in activities after surgery. Future work should determine the prognostic value of these cut-off scores for pain-related outcomes in longitudinal studies.
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