New Risk Score May Predict Pain Outcomes Effectively

A new biopsychosocial risk score that may help clinicians predict whether people are likely to develop persistent widespread or high impact pain, or suffer from current pain and then recover has been identified. Chronic pain affects how most people with the condition are able to live their lives, can affect sleep and mood and have a significant impact on work. Importantly, chronic pain is rarely the direct result of the initial injury and may follow a complex pain trajectory. The new score uses a small number of clinical predictors to estimate the future pain burden of individual patients. This could help to facilitate earlier intervention and enable planning of support for people with persistent pain within health services.

Why It Matters

Chronic pain is complex because it incorporates factors from biology, psychology, and the social environment in which a person lives. This means that two individuals diagnosed with the same condition may have vastly different experiences of pain and how it impinges on their lives. Some individuals will experience a quicker recovery with appropriate nonsurgical interventions, while others will have chronic persistent pain that worsens over time and is associated with decreasing function. Using a risk score allows clinicians to understand a patient’s prognosis early on and direct their treatment accordingly.

Rather than focusing on where people with pain say they experience pain, it is also useful to have a risk score that captures other factors that might influence their pain experiences and outcomes. For pain patients, sleep problems, low mood, anxiety, stress and social disadvantage all make people’s experience of pain worse and predict poorer outcomes. In addition, for patients who have chronic pain, a range of other variables such as obesity, deconditioning, medical comorbidities and baseline pain levels predict a variety of pain-related outcomes. Clinicians report that they identify these influential factors but currently do not routinely measure them in their pain consultations. Having a single score that could facilitate identification and monitoring of these several key predictors would be useful.

The score also captures pain burden (both extent and duration) as well as current pain location/s. Pain typically starts in one location (the low back) and then spreads to other parts (the knees) of the body, impacting daily activity and quality of life. Multi-site pain is associated with greater disability, greater healthcare utilization, and longer duration of opioid medication. The pain score can inform clinicians about future pain spread and aid in assessing risk for pain spread. This can guide decisions regarding dose and modality of care as well as whether the patient could benefit from greater emphasis on nonpharmacologic pain strategies as well as care from a multidisciplinary pain team.

Using predictive tools in clinical practice can enhance shared decision making and anticipate patient’s frustrations when pain-rated severity does not correspond with reported symptoms (e.g., pain not visible on imaging), or when the treatment plan selected does not lead to the relief patients have expected. A risk score helps to inform both the understanding of pain in an individual patient and the conversation about what to expect from specific treatments. In turn, clinicians can steer patients and families away from preoccupation with pain numbers and focus on a functional plan, that includes increased activity, sleep promotion, stress reduction and mental health treatment.

It can prevent avoidable harm by indicating the need for further intervention (e.g., pharmacological or psychological treatment) to prevent increasing pain and disability and exposure of patients and families to unnecessary risk. It can also prevent undertreatment of pain, including unsafe opioid prescribing. Stratification can prevent unnecessary use of medical imaging, inappropriate use of injections and surgery, and ensure that patients receive the most effective type and amount of care, including rehabilitation and other psychosocial interventions in addition to pain-focused interventions. Finally, it can identify individuals early in the course of chronic pain who are at risk for persistent pain and guide a closer monitoring and safer prescribing strategy to prevent opioid misuse.

Scoring health systems can help planning and assess the optimal use of resources. Chronic pain frequently co-exists with, or predicts, depression, anxiety, sleep problems and medication-related risk. Integrated healthcare pathways are required for effective treatment of chronic pain. Risk scores can inform the development of tiered pain pathways with those at lowest risk offered education or self management and early referral to multidisciplinary pain care for those at higher risk.

Prediction is worthless if it does not generalise to reality. Thus, any tool must be validated on a large dataset, and then tested on patients for whom the prediction is intended. Ideally it should also provide an assessment of whether or not the tool is good at predicting those patients who will actually develop symptoms, in addition to identifying those at highest risk. Of greater importance, however, is for the tool to provide clear explanation of how the patient’s modifiable risks contributed to their individual predicted risk, and for the tool to be transparent in its methodology, utilizing clinically meaningful variables. With such information, clinicians will be able to provide clear explanations to patients of their predicted risk, as well as rationale for any resulting treatment recommendations.

Since most clinicians will only use a score that can quickly be integrated into their workflow, a brief form is available for the Screen for Risk of Self-Harm Ideation (SROSI). The brief version uses everyday indicators like sleep, fatigue, stress, mood, body weight, and pain that is distributed across the body. The brief form is also very useful for retesting over time to see if risk is decreasing as sleep, activity, and mental health improves.

It is helpful to remember that Risk Scores do NOT replace history, physical exam, and clinical judgment. Risk Scores do not provide any information about the patient’s underlying reason for pain. What they do is look at patterns of multiple patients with similar presentations, and provide an estimate of the likelihood of certain outcomes for YOUR PATIENT. They are meant to assist in facilitating timely intervention and uniform follow-up of patients, and should NOT be used to stigmatize patients or to deny them appropriate care.

Who it affects

The target group for this innovation are all patients suffering from chronic pain (and their families and carers) who are at risk of worsening of pain, spread of pain, or disability. Chronic pain can be nociceptive (injury caused by external factors such as illness, injury, surgery), neuropathic (related to nerve damage or dysfunction), or of mixed quality (nociplastic) such as osteoarthritis, diabetic neuropathy, fibromyalgia, chronic widespread pain.

A risk score can introduce structure in follow up of patients over time and may help them to understand their situation and their risks for further pain.

Identifying risk early in the course of treatment is critical for patients with early or subacute pain as this is the time when there is the best opportunity to intervene to prevent the development of chronic pain. While some patients experience improvement in pain and function within weeks or months following an injury, surgery or flare up of a musculoskeletal condition, others will gradually progress from having short-term pain to having persistent pain that interferes with their quality of life. Risk screening at the first presentation of persistent pain allows for the earlier escalation of evidence-based nonpharmacologic interventions for those patients at highest risk, while avoiding unnecessary and potentially ineffective treatment for those at lowest risk.

Researchers are also interested in how individuals with medical or chronic conditions manage their levels of pain on a daily basis, as well as those recovering from surgery or traumatic injury experiencing persistent postsurgical pain or long-lasting pain after trauma. A patient may be healed from the physical effects of injury or illness, but left lying awake at night, unable to participate in activities they love, or unable to return to work. Research is developing prediction tools for use by perioperative and rehabilitation teams to identify individuals at risk of persistent pain early in their treatment and provide early multimodal pain interventions, closer follow-up, and more appropriate rehabilitation for return to function to prevent transition to chronic pain.

Our greatest focus is on treating those with sleep problems, depression, anxiety, stress and/or multiple pain sites. These problems often co-occur and have been shown to cause decreased function and increased health care use. A risk score allows us to give a number to the score to help triage and make initial and ongoing treatment decisions for patients. This might include physical therapy, behavioral health, sleep treatment all at the same time with the medical management of pain. This approach will help to reduce wait time for appointments and decrease the number of referrals to and from other specialties.

As a clinician, it may be particularly important to recognize the diverse experiences of patients from various backgrounds facing a variety of socioeconomic challenges. Patients experiencing stressors such as lack of transportation, unstable or precarious employment, inability to access psychotherapy, food insecurity, and/or unpredictable housing may require different models of pain management. Incorporating the social determinants of health into risk stratification tools can prompt clinicians to focus not on pharmacotherapy but on care navigation and community resources.

This risk assessment and prediction tool can be useful to a variety of clinicians from many different disciplines. While it is most clearly useful to pain specialists who see patients with chronic and persistent pain on a regular basis, it is also useful to primary care providers who are often the first to identify that a patient is developing chronic pain and are seeing the patient for ongoing management of treatment. In addition to pain management specialists, providers from a variety of disciplines, including orthopedics, rheumatology, neurology, rehabilitation, anesthesiology, and mental health, see patients with persistent pain. A shared risk framework can help providers from different disciplines to be on the same page in communicating to the patient their risk for improvement in functioning, decrease in disability, decrease or increase in use of treatments, and to guide decisions about next steps for a patient’s care.

Health professionals such as nurses, physiotherapists (e.g. for gradual exercise) and exercise scientists, psychologists and pharmacists may all be involved in the health management of individuals with many modifiable risk factors for weight-related problems and be required to monitor patients over an extended period. Coaching sessions, and multiple attempts to promote healthy sleep and positive mood, as well as healthy weight gain through gradual increases in exercise and dietary intake. Review of current medications and consideration of medication management as part of an inter-professional team. A risk score can help health professionals to target further attempts on those most likely to benefit.

• Clinical workflows may shift toward routine risk assessment when pain becomes persistent, rather than waiting until multiple treatments fail. A practical approach is to administer a short risk questionnaire during intake or before a visit, similar to other preventive screenings. The score can guide the depth of assessment and the initial plan. Lower-risk patients may receive education, reassurance, and a structured activity program with planned follow-up. Higher-risk patients may receive earlier multidisciplinary input.
• Treatment personalization becomes easier when the score points to modifiable targets. If the score highlights sleep disturbance, low mood, high stress, or low confidence in movement, clinicians can start there. Options include sleep hygiene coaching, brief cognitive behavioral strategies, mindfulness-based approaches, graded activity and strengthening, weight management support, and referral to behavioral health. Targeted care can improve engagement because patients can see that the plan addresses their specific barriers.
• Communication with patients can improve because the score offers a structured way to discuss prognosis and goals. Many patients want to know what to expect and what they can do to improve. Clinicians can explain that risk is not destiny and that many factors are changeable. This supports a hopeful but honest message with clear next steps, including how progress will be measured in function, sleep, and daily activities.
• Care pathways may become more tiered, with earlier referral for those most likely to develop high-impact pain. Higher-risk patients may benefit from integrated programs that combine physical reconditioning, behavioral therapy, and medication review. Some systems may use digital care programs for education, coaching, and exercise, with escalation to in-person services when needed. For rural or underserved areas, these approaches can improve access if follow-up and referral networks are reliable.
• Health systems may use the score for quality improvement, not just individual care. Aggregate results can show where a clinic is seeing many high-risk patients and whether those patients are receiving timely referrals, follow-up after flares, and access to nonpharmacologic options. Over time, teams can track whether risk-guided pathways reduce emergency visits, shorten delays to rehabilitation, and improve functional outcomes.
• Teams will need simple implementation rules so the score improves care rather than adding burden. Successful adoption depends on fitting the tool into routine workflows and linking score ranges to actions. Training should emphasize that the tool is supportive, not punitive, and that high-risk results should trigger added support, not reduced access.
• The biggest change is a shift from reacting to chronic pain to anticipating it. Predictive tools encourage earlier action on sleep, mood, stress, activity, and social needs. When combined with evidence-based multimodal care, a risk score can help clinicians prevent escalation, reduce disability, and support long-term recovery.

What changes

References:

https://experts.umn.edu/en/publications/a-prognostic-risk-score-for-development-and-spread-of-chronic-pai/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12367528/