Short-Form Orebro (SFO) Use and Interpretation in Clinical Practice. Communication with Doctors.
Luke McManus Musculoskeletal Physiotherapist
Review: What is the SFO? • A selection of 10 questions from the original long form Orebro Questionnaire. • Was designed to be more clinically useful for practitioners • Time efficient • Valid and reliable questionnaire • A objective measure of relative risk; a patient will fall into either a ‘low risk’ or ‘high risk’ category:
**Prediction of long term work absence and pain related disability**
What is measured? • 10 questions were specifically selected to measure: • Pain (questions 1-2) • Self-perceived function (questions 3-4) • Distress (questions 5-6) • Return to work expectancy (questions 7-8) • Fear-avoidance beliefs (questions 9-10)
When should it be used? • Preferably in the acute stage (predictive ability). • Preferably upon initial consultation • Best filled out either with initial admin paperwork, or with the physiotherapist during the first session.
• As a reassessment at 2-3 month mark, to monitor change over time.
Review of the Questions PAIN QUESTIONS 1. How long have you had your current pain problem? • 0-1 week = (1) • 2-3 weeks = (2) • 3-4 weeks = (3) • 4-5 weeks = (4) • 6-8 weeks = (5) • 9-11 weeks = (6) • 3-6 months = (7) • 6-9 months = (8) • 9-12 months = (9) • Over 12 months = (10)
2. How would you rate the pain you have had over the past week? (circle one) Scale of 0 – 10.
SELF-PERCEIVED FUNCTION 3. I can do light work for an hour? 0 1 2 3 4 5
6
7
Can’t do it because of pain
4. I can sleep at night. 0 1 2 3 Can’t do it because of pain
8
9
10
Can do it no problem
4
5
6
7
8
9
Can do it no problem
10
DISTRESS 5. How tense of anxious have you felt in the past week? 0 1 2 3 4 5 6 7 8 9 Absolutely calm relaxed.
10
As tense and anxious as I’ve ever felt
6. How much have you been bothered by feeling depressed in the last week? 0 1 2 3 4 5 6 7 8 9 10 Not at all
Extremely
RETURN TO WORK EXPECTANCY 7. In your view, how large is the risk that your current pain may become persistent? 0 1 2 3 4 5 6 7 8 9 10 No risk
Very large risk
8. In your estimation, what are the chances you will be working your normal duties in 3 months? 0 1 2 3 4 5 6 7 8 9 10 No chance
Very large chance
FEAR-AVOIDANCE BELIEFS 9. An increase in pain is an indication that I should stop what I’m doing until the pain decreases. 0 1 2 3 4 5 6 7 8 9 10 Completely disagree
Completely agree
10. I should not do my normal work with my current pain. 0 1 2 3 4 5 6 7 8 9 Completely disagree
10
Completely agree
Risk Categories LOW RISK: < 50. • Continue with usual physiotherapy intervention. • The consideration for multi-disciplinary management is low*. *Screening Tools are not infallible.
Risk Categories HIGH RISK:
>50.
Considerations: • Consider the impact of the individual questions. • Further assess areas of concern • Can you manage these areas? • Is referral required? • Are additional questionnaires warranted?
Case Study 1: How to Communicate with Doctors • Patient A: • SFO score = • Risk category =
Worker’s Compensation (Knee Injury) 37/100 Low risk
• Closer look through each question: • • • • •
Acute injury: Question 1 = Pain intensity: Question 2= Anxiety: Question 5= Depression: Question 6= All other scores are low.
1/10 3/10 7/10 6/10
Areas for further questioning? • Patient A scores quite high for distress questions (anxiety and depression). • When asked further about this, the patient reports: “I have football finals coming up, and now I’m not sure if I’ll be fit to play”. He has never had an injury like this before, and is awaiting the result of his recent MRI.
State or trait? • Patient A’s high anxiety and depression scores would appear to be more of a transient state, given that: • He has no previous history of anxiety or depression. • He is awaiting the result of his MRI scan. • He is uncertain as to what is required if there is structural damage.
One week later… • Patient has discussed his MRI result with physio and doctor, and ACL is intact. • A Grd II MCL injury which will be managed conservatively. • Will not miss any upcoming finals football.
• His anxiety and depression has now returned to 0-1/10.
Communication • Dear Dr _________ • *Fill in usual summary of the presentation, with important assessment findings*. I would also include: • Patient A has scored 37/100 on his Short-Form Orebro pain questionnaire. This validated screening tool puts Patient A in a low risk category for long term work absence and disability. • Patient A has scored moderately high on questions related to distress (anxiety and depression), however in light of his clinical presentation, this appears to be a reflection of his short-term uncertainty with work and sporting commitments. Once his MRI results are available, we will discuss together the options available. • Developing a clear rehabilitation plan for Patient A will likely ease his distress and uncertainty about his injury.
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Case Study 2: How to Communicate with Doctors • Patient B: • SFO score = • Risk category =
Worker’s Compensation (Low Back Pain) 61/100 High Risk
• Closer look through each question: • • • • •
Chronic/Recurrent: Pain intensity: Anxiety: Depression: Sleep:
Question 1 = Question 2= Question 5= Question 6= Question 4=
10/10 8/10 1/10 2/10 9/10
Further thoughts on Patient B • Patient B scores very low on questions related to distress (anxiety and depression). • He scores high on scores related to pain (duration and intensity). • He scores poorly on sleep evaluation. • On further discussion, Patient B takes several hours to get to sleep, but once he is asleep he does not wake for 3-4 hours. • He scores quite low on fear-avoidance beliefs. • His attitude is to adapt and get things done despite the pain, but suffers afterwards.
Communication Patient B • Dear Dr _________ • *Fill in usual summary of the presentation, with important assessment findings*. I would also include: • Patient A has scored 61/100 on his Short-Form Orebro pain questionnaire. This validated screening tool puts Patient A in a high risk category for long term work absence and disability. • This questionnaire has importantly identified that this injury has been a long standing pain problem (chronic recurrent). Positive prognostic indicators include no presence of psychosocial variables (eg anxiety or depression) and minimal fear avoidance. • Negative prognostic indicators include the persistence and intensity of his pain, as well a poor sleep hygiene. • I feel that Patient B may benefit with the additional help of an occupational therapist to help with education regarding activity pacing, flare up management as well as assessing his workplace to minimise pain aggravation.
Doctors like summaries! Posi&ve Prognos&c Factors
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Case Study 3: How to Communicate with Doctors • Patient C: • SFO score = • Risk category =
Worker’s Compensation (Low Back Pain) 83/100 High Risk
• Closer look through each question: • • • • •
Pain intensity: Anxiety: Depression: Sleep: Fear-Avoidance:
Question 2= Question 5= Question 6= Question 4= Question 10=
8/10 9/10 8/10 10/10 10/10
Further thoughts on Patient C • Patient C scores very high on questions related to distress (anxiety and depression). • Further questioning reveals that this has been an underlying condition for many years.
• He scores poorly on sleep evaluation. • Patient C finds it both difficult to get to sleep, and describes broken sleep ~3-4 hours per night. • He scores high on fear-avoidance beliefs. • He is highly fearful regarding forward bending, and has described a fear of his spine breaking with any exertion.
• Patient C feels very unsupported by his work, and has minimal family support locally.
Communication Patient C • Dear Dr _________ • *Fill in usual summary of the presentation, with important assessment findings*. I would also include: • Patient C has scored 83/100 on his Short-Form Orebro pain questionnaire. This validated screening tool puts Patient C in a high risk category for long term work absence and disability. • This questionnaire has importantly identified that presence of multiple significant contributing factors to his ongoing pain. Negative prognostic indicators include high levels of distress (anxiety and depression) which have been a long standing problem preceding the injury. This distress, however, is likely to significantly contribute to ongoing nervous system sensitivity and pain aggravation. Patient C describes, importantly, the emotional impact that this injury is taking, particularly with his close family overseas at this time. • Positive prognostic indicators include a willingness to learn and be an active participant in his rehabilitation.
• My clinical opinion is that Patient C would likely benefit from a multi-disciplinary review, in light of the various factors contributing to his pain. • Physiotherapy will play an important role in educating Patient C as to his current pain situation, as well as developing a safe and appropriate plan for movement and exercise. • I feel that a review with a clinical psychologist with experience in persistent pain would be helpful in addressing the high levels of distress that Patient C is experiencing.
Doctors like summaries! Posi&ve Prognos&c Factors
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Final Thoughts • The Short-Form Orebro is best used as part of your complete subjective and objective examination. • Screening tools are not infallible. • SFO only gives a broad indication of which category of risk the patient comes under. • The SFO can be used to test and retest over time, to measure any change (0-3 months). • Individual patient scores will vary, so the skill lies in making a clinical decision as to the importance of each individual question. *What are the dominant features in this patients presentation, and are there any features that warrant the help of other allied health practitioners.
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