HPE Chronic pain – part two - Page 5

problem of not taking into account functionality and physical activity. In some situations, only a minority of patients receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. 19 Nevertheless, none of the currently available measures are sufficiently comprehensive in covering all of the key domains of physical functioning. Some questionnaires focus only on physical functioning, whereas others include multiple domains in which physical functioning is only one component of the assessment tool. Furthermore, some of the challenges that are encountered are not given adequate importance including: 12,14 1 Instruments developed for use in adults aged above 18 and under a certain age might not be appropriate for older adults, children and adolescents 2 Measures might not be transferrable to second language samples 3 Measures of work outcomes must be included, because different kinds of work will have different levels of functionality (any measures should not only look at work loss but also take into account absenteeism and productivity) 4 Cultural and ethnic factors can play a major role, and outcome measures might differ in certain cultural or ethnic groups 5 There is a possibility that functionality tests might have differences in patients whose pain has a neuropathic component and this must be accounted for. This was shown in a recent study in which the intensity, impairment of QoL and functionality were not necessarily reported in association: some patients’ QoL and functionality were highly impaired despite a moderate-to-low pain intensity, whereas others suffered from severe pain but their QoL or functionality were impaired to a lesser degree. 11 Which questionnaires should be used? From a practical point of view, which questionnaires can be used? There is no clear agreement on which instrument should be used, although an expert consensus reached the conclusion that physical functioning, pain intensity, and HRQoL should be core outcome domains. The use of the Oswestry Disability Index version 2.1a or 24-item Roland- Morris Disability Questionnaire for physical functioning and the Numeric Rating Scale (NRS) for pain intensity have been recommended. No consensus was achieved on any measure of HRQoL, although the Short Form 12 (SF12) or 10-item PROMIS Global Health form for HRQoL are the main options. 20 The six main questionnaires that can be used in clinical practice are discussed here. The first two questionnaires measure the quality of life globally with subsections for functionality: these are the 36-item Short Form Health Survey (SF-36) and the 12-item Short Form Survey (SF-12). Both can be used in clinical practice and they are described briefly below. The four remaining questionnaires measure functionality specifically in LBP. SF-36 First published in 1992, the SF-36 is a measure of HRQoL. It is a subset of questions from longer instruments that were used in the Medical Outcomes Study. 21 It is a patient-reported questionnaire with 36 items based on scores in eight subdomains: physical functioning (10 items), role-physical (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social functioning (2 items), role-emotional (3 items), and mental health (5 items); scored by patients on a scale from 0 to 100 (0 = “poor health” to 100 = “good health”) and two summary scales of physical and mental component summaries. 21 It is perhaps the most widely used instrument to assess perceived health status. 22 In a study carried out on more than 900 patients evaluating different outcomes in low back disease, regardless of the aetiology, the conclusion was that the general SF-36 may be a sufficient measure of health status and patient function, without the need for additional condition-specific instruments. Pain scales appear to be the most responsive measures in patients with LBP. 23 SF-12 This is a general health questionnaire that was first published in 1995 as part of the Medical Outcomes Study. The SF-12 was constructed using questions drawn from each of the eight dimensions of SF-36. It is designed to have similar performance to the SF-36, while taking less time to complete. Two summary scores are reported from the SF-12 – a mental component score (MCS-12) and a physical component score (PCS-12). The scores may be reported as Z-scores (difference compared with the population average, measured in standard deviations). 24,25 The SF-12 has the advantage of being easier and quicker to complete, thus minimising the costs for data collection and management. SF-12 was developed as an alternative to the SF-36 for use in large-scale studies to assess overall physical and mental health outcomes. 22 The Oswestry Disability Index This comprises 12 assessment items covering ten domains including pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and travelling. The scoring conventions allow the clinician to assess the level of associated disability or pain interference. It has been recommended for use in primary care, but clinician preference and ease of administration should guide tool selection. 26 The Roland-Morris Disability Questionnaire (RMQ) This is a 24-point, self-administered disability measure in which greater levels of disability are reflected by ascending numbers on the scale. The RMQ yields reliable measurements that are valid for inferring the level of disability, and which are sensitive to change over time for groups of patients with LBP. The score of the RMQ is the total number of items checked – that is, a minimum of 0 to a maximum of 24. The authors did not provide descriptions of the varying degrees of disability (for example, 40%–60% is severe disability). Clinical improvement over time can be graded based on the analysis of serial questionnaire scores. If, for example, at the beginning of treatment, a patient’s score was 12 and at the conclusion of treatment, their score was 2 (10 points of improvement), this represents an 83% (10/12 x 100) improvement. The questionnaire can be adapted for use online or by telephone. 27 The Hannover Functional Ability Questionnaire (FFbH-R) This is the least known of the three but has equivalent functionality. The FFbH-R comprises 12 questions about ability to perform activities such as lifting a heavy object, putting on socks, hospitalpharmacyeurope.com | 2020 | 5