J Pain 0000000000001285

PAIN Publish Ahead of Print
DOI: 10.1097/j.pain.0000000000001285
Clinical Note
What Do Clinicians Consider when Assessing Chronic Low
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Back Pain? A Content Analysis of Multidisciplinary Pain
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Centre Team Assessments of Functioning, Disability, and
Health
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Karl S Bagraitha,b,c,d*, Jenny Strongb,d, Pamela J Meredithd,e and Steven M McPhailf,g
a
Interdisciplinary Persistent Pain Centre, Gold Coast Hospital and Health Service, Gold Coast,
Queensland, Australia.
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b
Occupational Therapy Department, Royal Brisbane and Women’s Hospital, Brisbane, Queensland,
Australia.
c
Professor Tess Cramond Multidisciplinary Pain Centre, Royal Brisbane and Women’s Hospital,
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Brisbane, Queensland, Australia.

d
Occupational Therapy, School of Health and Rehabilitation Sciences, The University of
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Queensland, Brisbane, Queensland, Australia.

e
Occupational Therapy, School of Health, Medical and Applied Sciences, Central Queensland
University, Rockhampton, Queensland, Australia.
f
Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia
g
Institute of Health and Biomedical Innovation and School of Public Health & Social Work,
Queensland University of Technology, Brisbane, Queensland, Australia.
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8 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
*Corresponding author: Karl S Bagraith
Interdisciplinary Persistent Pain Centre, 2 Investigator Drive, Robina, Gold
Coast, Queensland, 4226, Australia.
t: +61756686825; f: +61756809539; e: [email protected]
Conflicts of Interest: None.
Number of main text words: 3473(excluding abstract, references, figures and tables)
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Number of pages: 31 (including figures and tables)
Number of tables: 4
Number of figures: 1
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Supplementary Digital Content: 2 Supplementary Tables
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1 Abstract
2 Beyond expert suggestions as to the appropriate subject matter for chronic pain assessments,
3 little is known about the actual content of multidisciplinary pain centre (MPC) clinical assessments.
4 The International Classification of Functioning, Disability and Health Low Back Pain Core Set (ICF
5 LBP-CS) provides a universal language to support the consistent description of LBP-related
6 assessments across disciplines within multidisciplinary teams (MDT). This study sought to map the
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7 content of MPC clinical assessments to the ICF to: 1) identify and compare the content of clinical
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8 MDT assessments using a cross-disciplinary framework and, 2) examine the content validity of the
9 LBP-CS. A qualitative examination of MPC team clinical assessments of CLBP was undertaken. MDT
10 (pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology)
11 assessments were audio-recorded and transcribed. Concepts were extracted from transcripts
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12 using a meaning condensation procedure and then linked to the ICF. Across seven MDT
13 assessments, comprised of 42 discipline-specific assessments and 241,209 transcribed words,
14 8596 concepts were extracted. Contextual factors (i.e., the person and environment), except for
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15 physiotherapy, accounted for almost half of each discipline’s assessments (range: 49% – 58%)
16 Concepts spanned 113 second-level ICF categories, including 73/78 LBP-CS categories. Overall, the
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17 findings revealed novel insights into the content of MPC clinical assessments that can be used to
18 improve healthcare delivery. ICF-based assessment profiles demonstrated unique contributions

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19 from each discipline to CLBP assessment. Finally, users of the LBP-CS can be confident that the tool
20 exhibits sound content validity from the perceptive of MDT assessments of functioning, disability,
21 and health.
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23 Keywords: low back pain; multidisciplinary team; core set; LBP; content validity; International
24 Classification of Functioning, Disability and Health; ICF.
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25 1 Introduction
26 Chronic low back pain (CLBP) affects approximately one in five people [34] and is the most
27 frequently reported condition in patients attending Multidisciplinary Pain Centers (MPCs) [42].
28 Upon entering MPCs patients commonly undergo a multidisciplinary team (MDT) assessment to
29 ascertain their functioning problems and guide treatment planning; an approach originally
30 championed by Bonica [41]. MPC assessments typically entail input from multiple professionals,
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31 including pain medicine physicians, psychiatrists, nurses, psychologists, occupational therapists,
32 and physiotherapists [28]. Generally, each professional conducts their assessments independently,
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with findings integrated at a case conference [54]. Beyond expert suggestions as to the
appropriate subject matter for chronic pain assessments [22; 32; 59], little is known about the
actual content and focus of MPC clinical assessments.

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37 MPC professionals employ differing frames of reference to guide and document their assessments
38 [37], which often hampers interdisciplinary collaboration [31]. Similarly understanding each team
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39 member’s contribution to MDT assessments remains a challenge due to discipline-specific
40 terminology [52]. The International Classification of Functioning, Disability and Health (ICF)
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41 provides a universal language and standard framework for functioning and health [60]. This ICF is
42 considered to be a Rosetta Stone [53], crossing disciplinary, contextual, and geographic

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43 boundaries; harmonising the description of patient functioning [10]. The ICF has been
44 recommended as a basis for pain practice [55] and is guiding the Initiative on Methods
45 Measurement and Pain Assessment in Clinical Trials (IMMPACT) [51].
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48 With over 1400 categories the ICF is exhaustive and impractical for use in its entirety [53]. To
49 operationalise the ICF in daily pain practice, salient selections of categories have been compiled
50 for various conditions, the so-called ICF Core Sets [19]. The 78-category Low Back Pain Core Set
51 (LBP-CS) includes “as few categories as possible to be practical, but as many as necessary to be
52 sufficiently comprehensive to describe in a comprehensive multidisciplinary assessment the typical
53 spectrum of problems in functioning of patients (with CLBP)” [19(p9); 21]. The LBP-CS has been
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54 put forth as a practical tool to permit consistent description of patient functioning across
55 disciplines, facilitating more effective inter-disciplinary communication and better integrated care
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56 [49]. The LBP-CS was compiled by experts via a formal decision-making and consensus process [19;
57 21] that considered evidence from preparatory studies [12; 25; 56]. Despite the potential benefits
58 afforded by use of the LBP-CS, it has been suggested that clinical practice uptake is less than ideal
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59 [1; 15; 50; 58]. One potential reason for limited utilisation may be inadequate evidence regarding
60 the LBP-CS’s content validity [36].
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62 Whether the LBP-CS is sufficiently comprehensive to cover diverse health professional’s

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63 perspectives, or more importantly the content of multidisciplinary clinical assessments, remains
64 unanswered. Bagraith and Strong [5] provided proof-of-concept that the content of clinical MPC
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65 assessments can be mapped to the ICF; with each discipline’s assessment described using the
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66 same ICF-based yardstick. This study sought to map the content of MPC clinical assessments to the
67 ICF to: 1) identify the content and focus of clinical MDT assessments using a cross-disciplinary
68 framework and, 2) examine the content validity of the LBP-CS from the perspective of clinical MDT
69 assessments of functioning, disability, and health.
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72 2 Methods
73 2.1 Overview
74 This study entailed a qualitative examination of the routine MDT assessments undertaken by
75 patients attending a tertiary-referral MPC at a metropolitan hospital in Australia. As part of routine
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76 practice, patients attending the MPC for a rehabilitation program underwent an MDT assessment
77 on day one of the program. The MDT consisted of pain medicine1, psychiatry, nursing,
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physiotherapy, occupational therapy, and psychology disciplines. Each discipline was allocated up
to 50 minutes to assess patients, with patients undergoing six separate successive assessments
(one for each discipline) as part of their MDT assessment. For the purposes of this study, clinicians
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81 audio-recorded their assessments using a small MP3 device. As a complementary data collection
82 strategy, the chart notes for the pain medicine and physiotherapy assessments were reviewed to
83 further capture the physical examinations of these two disciplines’ assessments (e.g., palpation of
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84 structures, reflex tests, and assessment of gait pattern). The study was approved by the Royal
85 Brisbane and Women’s Hospital and The University of Queensland human research ethics
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86 committees.
87
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88 2.2 Participants
89 2.2.1 Patients
90 Patients who met the following criteria were eligible to participate: 1) non-specific LBP [16] of >3
91 months duration as the primary reason for attendance, 2) ≥18 years of age, 3) able to read and
1
In Australia Pain Medicine is recognised as a medical speciality in its own right (http://www.fpm.anzca.edu.au/). A career in pain medicine is generally obtained by qualifying as a Fellow of the
Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Fellowship of this multidisciplinary medical academy is an "add-on" specialist degree. Fellows also have a specialist
qualification in one of the participating specialties (e.g., anaesthesia or rheumatology).

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92 write English, and 4) no known cognitive deficits. Patients meeting these eligibility criteria were
93 invited to participate in the study upon arriving at the MPC and prior to commencement of their
94 MDT assessment. Consenting patients provided written informed consent and their background
95 details. Participant’s diagnosis was available prior to MDT assessment via their medical
96 practitioner referral and affirmed, to be in line with Chou et al’s [16] criteria for chronic non-
97 specific LBP, by reviewing the ensuing MDT assessment, inclusive of physical examinations.
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98 Participants were recruited to maximize variation in gender, age, marital status, and employment
99 status, according to the principals of maximum variation sampling [43], to enhance the diversity of
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100 findings that were likely to arise from MDT assessments.
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102 2.2.2 Clinicians

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103 This study took place within the context of routine service delivery to enhance generalisability;
104 that is, MPC clinical procedures and processes were not altered for the research study. Hence, all
105 of the MPC’s clinicians were eligible and invited to participate. To be included in the study, each
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106 clinician was required to provide written informed consent and details regarding their experience
107 and expertise.

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108
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109 2.3 Procedure for extracting and linking concepts to the ICF
110 Audio-recordings were transcribed verbatim. The concept extraction and linking process reported
111 in Bagraith and Strong [5] was applied. In brief, the meaning condensation procedure described by
112 Kvale [40] was applied. Transcripts were read and divided into meaning units. Meaning units
113 comprised discrete segments of text, not necessary related to grammatical conventions, that were
114 discerned to be related to a common theme [38]. From each meaning unit, identified concepts,
115 one or more, were extracted and documented. The ICF Linking Rules [18; 20] were then applied to
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116 link extracted concepts to the ICF, and where possible to second-level ICF categories. Each concept
117 could be linked to more than one ICF category if necessary to suitably represent the concept. The
118 concept extraction and linking process was also applied to the objective physical examination
119 information extracted from the pain medicine and physiotherapy chart notes (e.g., from the
120 meaning unit ‘obj/ gait Ax - moderately antalgic’, the concept of ‘objective assessment of gait
121 pattern’ was identified, which was linked to b770 gait pattern functions).
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123 A senior pain occupational therapist (KB) independently undertook the concept extraction and
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124 linking procedure with additional reference to a guideline developed by the ICF Research Branch.
125 KB had previously undertaken training in the ICF and the procedure for linking health information
126 to the ICF. In addition, KB had prior experience with linking clinical assessments to the ICF [5; 11].
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128 A research diary was employed throughout analyses to enhance methodological rigour by
129 providing context for decisions on application of the ICF linking rules [48]. To assess
130 methodological rigour a peer-review process was undertaken, whereby a second investigator (JS,
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131 who had experience with qualitative analysis [2] and the linking of MDT assessments to the ICF [5])
132 independently extracted concepts from two of the MDT assessments and linked them to the ICF.
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133 To further examine the validity of the findings, clinician member checking was undertaken
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134 following the concept extraction and linking procedures [23]. Clinicians were asked to rate the
135 extent to which: 1) the extracted concepts represented their assessment focus, 2) the linked ICF
136 categories represented the extracted concepts, and 3) the linked ICF categories represented their
137 typical assessments. Clinicians undertook the member checking process for one of their recorded
138 assessments.
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140 2.4 Sample size
141 The number of patients recruited to the study was determined by data saturation, which refers to
142 the point where no additional information is obtained from the data [46]. Data saturation is the
143 most frequently used criterion for determining sample size in ICF linking studies [26; 61]. For the
144 purpose of this study, data saturation was considered to be achieved when no new second-level
145 ICF categories were identified from two consecutive MDT assessments. After each participant’s
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146 MDT assessment was linked to the ICF, data saturation was assessed. If data saturation was not
147 achieved, a further participant was sampled, as detailed in section 2.2.1, and their MDT
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148 assessment was linked to the ICF. This process was repeated until data saturation was achieved.
149 Due to the use of maximum variation sampling and the time required to perform the linking
150 process outlined in section 2.3, participants were not necessarily consecutive patients being
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151 assessed by the MPC MDT.
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153 2.5 Data analysis

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154 The relative distribution of ICF linking outcomes for extracted concepts was examined in relation
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155 to: a) the total number of concepts extracted from each MDT assessment, and b) the total number
156 of concepts extracted from all MDT assessments. The linking outcomes were: not covered in the
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157 ICF (e.g., assessment of a patient’s knowledge regarding a assessor’s role in pain management),
158 not defined in the ICF (i.e., encompassed within the framework but not able to be linked to a
159 specific component; e.g., assessment of general functioning), and linked to an ICF component or
160 category (e.g., assessment of driving limitations which was linked to d475 driving). The absolute
161 frequency of linkage of each ICF category was also calculated. Comparisons between disciplines
162 were made in terms of the components and categories that accounted for their assessments. The
163 content validity of a LBP-CS category was considered confirmed if it was linked in at least one MDT

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164 assessment. Categories that were linked, and are not included in the LBP-CS, were considered
165 potentially relevant if they were linked in at least two MDT assessments. Cohen’s nominal kappa
166 was used to quantify the inter-rater reliability of the multiple linking that occurred as part of the
167 peer-review process. Bootstrap resampling (1000 replications) was used to generate 95%
168 confidence intervals for kappa. All analyses were performed with Microsoft Excel 2010 and IBM
169 SPSS v23.0.
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3 Results
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Saturation was achieved with MDT assessments of seven patients (three female and four male;
see Table 1 for patient’s background details). Table 2 outlines the characteristics of the MDT
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175 assessments, which were inclusive of 42 separate assessments (i.e., each of the seven patients
176 underwent pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and
177 psychology assessments). In total, the multidisciplinary assessments were between 3:18 and 5:31
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178 hours in duration, with 241,206 words recorded across all assessments. The pain medicine,
179 psychiatry, nursing, physiotherapy, occupational therapy, and psychology assessments were
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180 undertaken by six, three, four, two, four, and four different clinicians, respectively. Each of the 23
181 clinicians (19 female) had experience in chronic pain management (0.5 – 16 years practice) and
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182 rated their expertise three or higher (median: four) on a 5-point scale (that ranged from 1 = low
183 and 5 = excellent).[39] They were all familiar with their role in the team, having been members of
184 this particular MPC for at least 3 months (range: 0.25 – 12 years).
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187 Across all the MDT assessments, a total of 8596 concepts were extracted (see Table 2). Of these,
188 334 (3.9%) were not covered within the ICF and 270 (3.1%) were designated as ‘not definable’. The
189 remaining 7992 (93.0%) concepts were linked to the ICF. ICF linkable concepts spanned 113
190 second-level categories, inclusive of 31 body function, five body structure, 38 activity and
191 participation, and 39 environmental factor categories. Table 3 details the distribution of linked
192 concepts in relation to the LBP-CS. Inspection of Table 3 reveals that 73/78 comprehensive LBP-CS
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193 categories were assessed, including: 19/19 body function, 5/5 body structure, 26/29 activity and
194 participation, and 23/25 environmental factors categories. The most frequently linked categories
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195 within the body functions, body structures, activity and participation, and environmental factors
196 components were b280 (sensation of pain), s760 (structure of trunk), d920 (recreation and leisure),
197 and e310 (immediate family), respectively. Table 4 provides a list of 35 second-level categories
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198 that were assessed in at least two MDT assessments and are not contained in the LBP-CS. Carrying
199 out daily routine (d230) accounted for the highest proportion of concepts linked to non-LBP-CS
200 categories (16.6%).
201
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202 Figure 1 illustrates the focus of each discipline, as well as the collective MDT, in terms of the ICF
203 components. Contextual factors (i.e., the person and environment), except for physiotherapy,
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204 accounted for almost half of each discipline’s assessments across the seven patients (range: 49% –
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205 58%). Further details regarding the assessment of specific personal factors aspects are provided in
206 Supplementary Table S1 (available online at http://links.lww.com/PAIN/A589). Notably,
207 assessment of body structures was limited; accounting for 4% of physiotherapy, 2% of pain
208 medicine, and 1% of the collective MDT assessments.
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211 Good inter-rater reliability [17] (kappa = 0.72; 95%CI: 0.67 – 0.76) was observed for the
212 assessments that were subjected to the peer-review multiple rating procedure. The clinician
213 member checking analyses (see Supplementary Table 2, available online at
214 http://links.lww.com/PAIN/A589) supported the internal and external validity of the findings.
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216 4 Discussion
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217 This study sought to identify the content of MDT assessments using the ICF, and to examine the
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218 content validity of the LBP-CS from the perspective of MDT assessments. Almost all of the
219 concepts extracted from the MDT assessments were ICF-linkable, facilitating description and
220 comparison of assessments using the cross-disciplinary language and universal framework
221 provided by the ICF. The findings provide novel insights into content of MPC MDT assessments of
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222 patients with CLBP and reveal the unique contribution of each discipline to such assessments. The
223 LBP-CS was shown to exhibit sound content validity from the perceptive of MDT assessments, with
224 73/78 LBP-CS categories confirmed.

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225
226 The present work demonstrated the utility of the ICF as a Rosetta Stone [53] for describing MDT
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227 assessments of CLBP. Traditionally aggregating and comparing the assessment foci of different
228 disciplines has been challenging due to the dissimilar terminology and frameworks inherent across
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229 disciplines in MDTs [27; 30; 31; 33; 44]. Accordingly, beyond expert suggestions as to the
230 appropriate subject matter for chronic pain assessments [22; 32; 59], little is known about the
231 actual content and focus of MPC MDT clinical assessments. The present findings provide evidence
232 that different discipline’s clinical assessments of CLBP can be readily reconciled using the ICF’s
233 common language [5]. The present results are the first to combine and display MPC MDT
234 assessments using a common yardstick, and accordingly, considerably extend understanding

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235 regarding the content and focus of actual MPC clinical assessments of CLBP. Inspection of the ICF-
236 based profiles reveals numerous novel and important insights into MPC clinical practice. Of such
237 insights, two examples are particularly noteworthy. First, the results suggest that MPC MDTs
238 assess personal factors and body structures more and less, respectively, than other ICF domains.
239 Second, immediate family (e310), sensation of pain (b280), and products or substances for
240 personal consumption (e110), as the three most frequently assessed areas, appear particularly
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241 important for MPC MDT assessment of CLBP. Aspects of these findings are consistent with
242 established evidence regarding important contributors to CLBP-related functioning and provide
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243 reassurance that routine clinical practice assessments are aligned with the evidence base. For
244 example, the importance of coping styles/strategies in chronic pain has been established [45] and
245 the significant focus on coping strategies/styles revealed in the present findings (i.e., the second
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246 most frequently assessed personal factor category; linked 437 times) is reassuring. On the other
247 hand, future research is warranted to understand the perceived value of factors identified as
248 especially important in the present study, for example immediate family (e310), for which the
249 evidence base is still emerging [13; 14].

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251 The potential of the ICF for clarifying team member roles has been posited [52]; however, the
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252 usefulness of the ICF for elucidating the actual contributions of team members to multidisciplinary
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253 assessments had yet to be substantiated prior to the present report. The present findings are the
254 first to demonstrate that each discipline (i.e., pain medicine, psychiatry, nursing, physiotherapy,
255 occupational therapy, and psychology) makes unique contributions to the MDT assessment of
256 CLBP when considering their overall focus across the spectrum of functioning, disability, and
257 health. However, assessment duplication was also observed across each ICF domain. Feedback
258 from the team suggests that aspects of the assessment duplication may be attributable to rapport
259 building (e.g., assessment of areas, such as pain interference, that patients expect to be assessed

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260 by each discipline) and collection of collateral information to enhance discussion at MDT meetings.
261 On the other hand, it was noted that overlap may also represent redundancy and opportunities to
262 improve efficiency and reduce patient burden. To this end, two applications of ICF-based profiles
263 of MPC MDT clinical assessments seem worthwhile. First, use of ICF-based profiles to compare the
264 focus of each discipline to identify duplication in clinical assessments. Second, use of ICF-based
265 profiles to identify disciplines most suited to assess segments of ICF Core Sets. For example, with
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266 respect to these two applications, the profiles from the present study suggest that within MPCs
267 there may be duplication across pain medicine and physiotherapy when assessing motor reflex
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268 functions (b750). Based on a review of the assessment profiles and skills sets, MPCs may consider
269 allocating the assessment and rating of b750 to physiotherapists, thereby, extricating pain
270 medicine resourcing for redistribution to maximise value from their specialised skill set. Discipline-
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271 specific allocation of ICF Core Set categories may also enhance practice uptake of the ICF by
272 minimising implementation burden and providing context for application of user guides [3; 9].
273 Extending the presented ICF-linking approach to generate profiles of other MPC input (e.g.,
274 management decisions) is recommended to understand the broader utility of this method and
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275 potentially provide further insights to guide improvements in the efficiency and effectiveness of
276 healthcare delivery.

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277
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278 In prior studies, the LBP-CS has been shown to be inclusive of physicians’ [29] and
279 physiotherapists’ [39] perspectives, sourced from Delphi studies, regarding important aspects of
280 functioning as well as physicians’ work capacity reports [47] and physiotherapists’ assessment
281 templates [24]. However, each of these prior LBP-CS valuation studies have important
282 methodological limitations. Delphi methods rely on retrospective accounts and opinion-based
283 judgements, while assessment templates and reports represent abbreviated or summarised
284 versions of assessments. The present findings extend understanding of the LBP-CS’s content

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285 validity, demonstrating that the LBP-CS is sufficiently comprehensive to describe in a
286 comprehensive multidisciplinary assessment the typical spectrum of problems in functioning of
287 CLBP patients. Of note, the present findings provide initial validation evidence for the LBP-CS from
288 the perspectives of disciplines that were not represented within the committee selecting LBP-Cs
289 categories (i.e., nursing, and psychology).
290
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291 Taken together with existing psychometric evidence [4; 6-8; 21; 39; 55], the present results
292 suggest that the LBP-CS is likely to have good utility for supporting MDTs to guide and document
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293 their assessments using the standard cross-disciplinary language provide by the ICF [35]. Whilst
294 generally supportive of the LBP-CS’s content validity, the present findings highlight opportunities
295 to improve the LBP-CS. For example, from the activity and participation component, 11 categories
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296 that are not contained in the LBP-CS were assessed in more than one patient. Of these, four (d230,
297 d520, d720, and d855) were linked over 15 times. Further research into the importance of
298 categories identified as potentially relevant in the present study is necessary to understand their
299 usefulness for consideration of inclusion in LBP-CS revisions.

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301 Two study limitations merit consideration when interpreting the present findings. First, the study
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302 was conducted within the context of routine clinical practice. Whilst this approach is advantageous
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303 with respect to external validity, not all the participating clinicians considered themselves to be
304 experts. The extent to which this may have influenced findings is unclear, and future comparisons
305 between expert clinician assessments and those undertaken in routine practice may be
306 worthwhile to understand any meaningful differences. Second, whilst the employed
307 methodological approach provides a comprehensive account of assessments, it cannot be
308 considered a complete account of the clinical assessment process. For instance, information
309 gathered by clinicians from pre-assessment chart reviews was not captured.

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310
311 In conclusion, this study provided novel insights into the content of clinical MPC team assessments
312 of CLBP and provided evidence to support the content validity of the LBP-CS from the perceptive
313 of MDT assessments. The generated ICF-based profiles of MPC assessments identified new
314 opportunities to improve healthcare delivery and demonstrated the unique contribution of each
315 discipline to such assessments. The present findings also suggest that users of the LBP-CS can be
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316 more confident that the tool mostly represents the aspects of functioning and contextual factors
317 that MDTs consider when assessing patients with CLBP. Future research in to the assessment
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318 practices of MPCs from other contexts is warranted to expanded on the present findings.
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320 Acknowledgements
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321 The authors are grateful to the patients and clinicians for their participation. They are also
322 appreciative of the input provided by Dr Libby Gibson and Emeritus Professor Roland Sussex
323 during the early phase of this study. The authors are thankful for the training materials provided
324 by the ICF Research Branch in collaboration with the WHO-FIC CC in Germany (at DIMDI). We also
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325 acknowledge the support provided to KB for the conduct of this work as part of the RBWH
326 Cramond Fellowship in Pain Management and Occupational Therapy.

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327
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328 Funding
329 This work was supported by grants from the Royal Brisbane and Women’s Hospital Foundation,
330 Australian NHMRC Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, and
331 Allied Health Professions’ Office of Queensland. SMM was supported by a National Health and
332 Medical Research Council (of Australia) fellowship. These agencies did not provide input on any
333 aspect of the study, decision to publish, manuscript preparation, or submission.
334

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335 Conflict of interest statement
336 The authors have no conflicts of interest to declare.
337
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497
498 Figure legend
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499
500 Figure 1. Proportional distribution of linked concepts across the ICF components for the combined
A
501 multidisciplinary team (MDT) and discipline-specific assessments (N = 7). As per Whiteneck and
502 Dijkers [57] recommendations, the categories contained in chapters 1 – 6 of the activity and
503 participation component of the ICF, with the exception of d660 (assisting others), were considered
504 to constitute activity, with the remainder of the component (including d660) considered to
505 represent participation.
506

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Table 1. Patient participant details (n = 7)
Gender Age, Pain duration, Marital status Educational Employment
yr. months status
Female 27 93 Married/De facto Junior high- Unemployed
school due to pain
Male 49 56 Married/De facto Tertiary Employed full-
D
university time
Male 72 180 Divorced/Separated Tertiary Retired
Female 44 240 Single

TE university
Junior high-
school
Unemployed
due to pain
EP
Male 57 33 Married/De facto Junior high- Carer
school
Male 56 56 Married/De facto Junior high- Employed part-
school time
C
Female 34 49 Married/De facto Senior high- Home duties
school
C
A
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Table 2. Characteristics of multidisciplinary team assessments (n = 7a) and allocation of identified
concepts
Sum Minb Maxb
Duration, hours 31:01 3:18 5:31
Length, words 241,206 26,919 42,657
Identified Concepts, n 8596 1043 1347
D
Not defined in ICF, (%) 3.1 2.6 3.5
Not covered in ICF, (%) 3.9 2.3 5.3
a
Linked to ICF, (%)
TE
93.0 91.5 94.9
Comprised of 42 individual assessments (i.e., each of the seven participants underwent separate
pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology

EP
assessments).
b
Not necessary relative to the same patient’s multidisciplinary assessment, but rather across the pool
of data.
C
C
A
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Table 3. Distribution of the multidisciplinary team assessments (n = 7) in relation to the Low Back Pain Core Set.
ICF ICF Brief LBP- Number of times linked Discipline-specific linkage
Code Category Label CS across MDT
PM Ψ N PT OT PY
Body Functions
b126 Temperament and personality functions 90 x x x x x x
b130 Energy and drive functions x 74 x x x x x x
b134 Sleep functions x 125 x x x x x x
b152 Emotional functions x 263 x x x x x x
D
b180 Experience of self and time functions 4 x x x
b260 Proprioceptive function 6 x x
b280 Sensation of pain x 394 x x x x x x
TE
b455 Exercise tolerance functions x 2 x x
b620 Urination functions 18 x x x x x
b640 Sexual functions 10 x x x x x
b710 Mobility of joint functions x 32 x x x x
b715 Stability of joint functions x 30 x x
EP
b720 Mobility of bone functions 5 x x x x
b730 Muscle power functions x 26 x x x x x
b735 Muscle tone functions x 3 x x
b740 Muscle endurance functions x 2 x x
b750 Motor reflex functions 32 x x
b770 Gait pattern functions 20 x x
b780 Sensations related to muscles and movement functions
Body Structures
s120 Spinal cord and related structures
C x
46
14
x
x
x x x
x
x x
x
C
s740 Structure of pelvic region 6 x x
s750 Structure of lower extremity 11 x x
s760 Structure of trunk x 22 x x x x
A
s770 Additional musculoskeletal structures related to movement x 1 x
Activities and Participation
d240 Handling stress and other psychological demands x 28 x x x x x
d410 Changing basic body position x 115 x x x x x x
d415 Maintaining a body position x 79 x x x x x x
d420 Transferring oneself 2 x
d430 Lifting and carrying objects x 45 x x x x x x
d445 Hand and arm use 0
d450 Walking x 72 x x x x x x
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d455 Moving around 16 x x x
d460 Moving around in different locations 12 x x x x x
d465 Moving around using equipment 16 x x x x
d470 Using transportation 2 x x
d475 Driving 54 x x x x x x
d510 Washing oneself 47 x x x x x x
d530 Toileting x 23 x x x x x x
d540 Dressing x 43 x x x x x x
D
d570 Looking after one's health 61 x x x x x
d620 Acquisition of goods and services 30 x x x x x
d630 Preparing meals 41 x x x x x x
TE
d640 Doing housework x 170 x x x x x x
d650 Caring for household objects 69 x x x x x x
d660 Assisting others 32 x x x x x x
d710 Basic interpersonal interactions 1 x
d760 Family relationships x 47 x x x x x
d770 Intimate relationships 62 x x x x x
EP
d845 Acquiring, keeping and terminating a job x 0
d850 Remunerative employment x 69 x x x x x x
d859 Work and employment, other specified and unspecified x 0
d910 Community life 23 x x x x
d920 Recreation and leisure 223 x x x x x x
Environmental Factors
e110
e120
e135
Products or substances for personal consumption C
Products and technology for personal indoor and outdoor mobility and transportation
Products and technology for employment
x
x
356
37
2
x
x
x
x
x
x
x
x
x
x
x
x
x
C
e150 Design, construction and building products and technology of buildings for public use 5 x x x
e155 Design, construction and building products and technology of buildings for private use x 169 x x x x x x
e225 Climate 17 x x x x x
A
e255 Vibration 3 x x x
e310 Immediate family x 587 x x x x x x
e325 Acquaintances, peers, colleagues, neighbours and community members 10 x x x x
e330 People in positions of authority 4 x x x
e355 Health professionals x 96 x x x x x x
e360 Other professionals 1 x
e410 Individual attitudes of immediate family members x 26 x x x x x
e425 Individual attitudes of acquaintances, peers, colleagues, neighbours and community 1 x
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members
e450 Individual attitudes of health professionals 3 x x
e455 Individual attitudes of other professionals 0
e460 Societal attitudes 2 x x
e465 Social norms, practices and ideologies 0
e540 Transportation services, systems and policies 12 x x x
e550 Legal services, systems and policies x 2 x x
e570 Social security services, systems and policies x 48 x x x x x x
D
e575 General social support services, systems and policies 23 x x x x x x
e580 Health services, systems and policies x 66 x x x x x x
e585 Education and training services, systems and policies 3 x
TE
e590 Labour and employment services, systems and policies 27 x x x x x
Personal Factorsa 2657 x x x x x x
Index Health Condition 747 x x x x x x
Abbreviations/Symbols: LBP-CS: low back pain core set; MDT: multidisciplinary team; PM: pain medicine; Ψ: psychiatry; N: nursing ; PT: physiotherapy; OT: occupational
therapy; and PY: psychology.
a
See Supplementary Table 1 for further details.
EP
C
C
A
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Table 4. Categories not included in the Low Back Pain Core Set that were assessed in at least two of the multidisciplinary team assessments (n = 7).
ICF ICF Number of times Discipline-specific linkage
Code Category Label linked across MDT PM Ψ N PT OT PY
Body Functions
D
b114 Orientation functions 5 x
b140 Attention functions 35 x x x x x x
TE
b144 Memory functions 40 x x x x x
b156 Perceptual functions 23 x x x x
b160 Thought functions 95 x x x x x
EP
b164 Higher-level cognitive functions 49 x x x x x x
b265 Touch function 33 x x x x x
b270 Sensory functions related to temperature and other stimuli 4 x
b435 Immunological system functions 28 x x x x
b525
b530
Defecation functions
Weight maintenance functions
C 23
29
x
x
x
x
x
x
x
x
x
x x
C
b760 Control of voluntary movement functions 2 x x
Activities and Participation
A
d166 Reading 7 x x x
d170 Writing 6 x x
d177 Making decisions 13 x x x
d230 Carrying out daily routine 167 x x x x x x
d360 Using communication devices and techniques 8 x x x
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d520 Caring for body parts 15 x x x x
d720 Complex interpersonal interactions 22 x x x x
d750 Informal social relationships 4 x x
d855 Non-remunerative employment 35 x x x x x
d870 Economic self-sufficiency 9 x x x x
D
d930 Religion and spirituality 7 x x
Environmental Factors
TE
e115 Products and technology for personal use in daily living 103 x x x x x x
e165 Assets 82 x x x x x x
e220 Flora and fauna 11 x x x x x
e315 Extended family 54 x x x x x x
EP
e320 Friends 38 x x x x
e350 Domesticated animals 17 x x x x x
e415 Individual attitudes of extended family members 6 x x
e430
e525 Housing services, systems and policies
C
Individual attitudes of people in positions of authority 2
2 x
x
x
C
e535 Communication services, systems and policies 4 x x
e555 Associations and organizational services, systems and policies 5 x x
A
e565 Economic services, systems and policies 23 x x x x

Abbreviations/Symbols: MDT: multidisciplinary team; PM: pain medicine; Ψ: psychiatry; N: nursing; PT: physiotherapy; OT: occupational therapy;
and PY: psychology.
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D
TE
EP
C
C
A
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PAIN Publish Ahead of Print

What Do Clinicians Consider when Assessing Chronic Low

Brisbane, Queensland, Australia.

Queensland, Brisbane, Queensland, Australia.

Conflicts of Interest: None.

5 LBP-CS) provides a universal language to support the consistent description of LBP-related

10 (pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology)

13 assessments, comprised of 42 discipline-specific assessments and 241,209 transcribed words,

18 improve healthcare delivery. ICF-based assessment profiles demonstrated unique contributions

24 Classification of Functioning, Disability and Health; ICF.

PAIN - Clinical Note Page 1 of 21

actual content and focus of MPC clinical assessments.

39 member’s contribution to MDT assessments remains a challenge due to discipline-specific

42 considered to be a Rosetta Stone [53], crossing disciplinary, contextual, and geographic

45 Measurement and Pain Assessment in Clinical Trials (IMMPACT) [51].

PAIN - Clinical Note Page 2 of 21

52 sufficiently comprehensive to describe in a comprehensive multidisciplinary assessment the typical

60 the LBP-CS’s content validity [36].

62 Whether the LBP-CS is sufficiently comprehensive to cover diverse health professional’s

63 perspectives, or more importantly the content of multidisciplinary clinical assessments, remains

69 assessments of functioning, disability, and health.

PAIN - Clinical Note Page 3 of 21

75 patients attending a tertiary-referral MPC at a metropolitan hospital in Australia. As part of routine

PAIN - Clinical Note Page 4 of 21

102 2.2.2 Clinicians

107 and expertise.

PAIN - Clinical Note Page 6 of 21

153 2.5 Data analysis

PAIN - Clinical Note Page 7 of 21

169 SPSS v23.0.

PAIN - Clinical Note Page 8 of 21

200 categories (16.6%).

206 Supplementary Table S1 (available online at http://links.lww.com/PAIN/A589). Notably,

208 medicine, and 1% of the collective MDT assessments.

PAIN - Clinical Note Page 9 of 21

213 member checking analyses (see Supplementary Table 2, available online at

224 73/78 LBP-CS categories confirmed.

PAIN - Clinical Note Page 10 of 21

249 evidence base is still emerging [13; 14].

PAIN - Clinical Note Page 11 of 21

276 healthcare delivery.

PAIN - Clinical Note Page 12 of 21

286 comprehensive multidisciplinary assessment the typical spectrum of problems in functioning of

289 categories (i.e., nursing, and psychology).

299 usefulness for consideration of inclusion in LBP-CS revisions.

307 methodological approach provides a comprehensive account of assessments, it cannot be

PAIN - Clinical Note Page 13 of 21

326 Cramond Fellowship in Pain Management and Occupational Therapy.

333 aspect of the study, decision to publish, manuscript preparation, or submission.

PAIN - Clinical Note Page 14 of 21

336 The authors have no conflicts of interest to declare.

344 an exploration of overactivity in people with chronic pain using interpretative

345 phenomenological analysis. Pain 2015;156(7):1215-1231.

349 core sets. J Rehabil Med 2013;45(5):481-487.

352 musculoskeletal conditions. Clin Rheumatol 2013;32(3):383-389.

355 low back pain core set. J Clin Epidemiol 2017;84:161-172.

358 pain core set. Disabil Health J 2017;10(4):621-626.

PAIN - Clinical Note Page 15 of 21

360 pain interference alone. Clin J Pain 2012;28(3):273-274.