Received: 25 March 2019 Revised: 6 May 2019 Accepted: 7 May 2019

DOI: 10.1111/jep.13190

ORIGINAL PAPER

Operationalization of the new Pain and Disability Drivers

Management model: A modified Delphi survey of
multidisciplinary pain management experts

Yannick Tousignant‐Laflamme PhD, PT1 | Chad E. Cook PhD, PT2 |

Annie Mathieu PhD, Scientific Professional3 | Florian Naye M. Sc, PT1,4 |

Frédéric Wellens B.Sc, PT4 | Timothy Wideman PhD, PT5,6 |

Marc‐Olivier Martel PhD, Assistant Professor7 | Olivier Tri‐Trinh Lam M.Sc, PT4

1
School of Rehabilitation, Faculty of Medicine
and Health Sciences, Université de Abstract
Sherbrooke, Sherbrooke, Quebec, Canada
Background: We recently proposed the Pain and Disability Drivers Management
2
Physical Therapy Division, Duke University,
Durham, North Carolina
(PDDM) model, which was designed to outline comprehensive factors driving pain
3
Institut de recherche Robert‐Sauvé en santé and disability in low back pain (LBP). Although we have hypothesized and proposed
et en sécurité du travail (IRSST), Montreal, 41 elements, which make up the model's five domains, we have yet to assess the
Quebec, Canada
4
external validity of the PDDM's elements by expert consensus.
Faculty of Medicine and Health Sciences,
Université de Sherbrooke, Sherbrooke, Research objectives: This study aimed to reach consensus among experts regard-
Quebec, Canada
5
ing the different elements that should be included in each domain of the PDDM
Physio Axis, Prévost, Quebec, Canada
6 model.
School of Physical and Occupational Therapy,
McGill University, Montreal, Quebec, Canada Relevance: The PDDM may assist clinicians and researchers in the delivery of
7
Faculties of Dentistry & Medicine, McGill targeted care and ultimately enhance treatment outcomes in LBP.
University, Montreal, Quebec, Canada
Methods: Using a modified Delphi survey, a two‐round online questionnaire was
Correspondence
administered to a group of experts in musculoskeletal pain management. Participants
Yannick Tousignant‐Laflamme, PT, PhD,
School of Rehabilitation, Faculty of Medicine were asked to rate the relevance of each element proposed within the model.
and Health Sciences, Université de
Participants were also invited to add and rate new elements. Consensus was defined
Sherbrooke, 3001 12e Avenue Nord,
Sherbrooke, J1H 5N4 QC, Canada. by a greater than or equal to 75% level of agreement.
Email: yannick.tousignant‐
laflamme@usherbrooke.ca Results: A total of 47 (round 1) and 33 (round 2) participants completed the survey.
Following the first round, 38 of 41 of the former model elements reached consensus,
Funding information
Canadian Musculoskeletal Rehabilitation
and 10 new elements were proposed and later rated in the second round. Following
Research Network, Grant/Award Number: this second round, consensus was reached for all elements (10 new + 3 from first
CIHR CF1‐148081
round), generating a final model composed of 51 elements.
Conclusion: This expert consensus–derived list of clinical elements related to the
management of LBP represents a first step in the validation of the PDDM model.

K E Y W OR D S

chronic pain, Delphi survey, disability, low back pain, pain

J Eval Clin Pract. 2019;1–10. wileyonlinelibrary.com/journal/jep © 2019 John Wiley & Sons, Ltd. 1
2 TOUSIGNANT‐LAFLAMME
1 | I N T RO D U CT I O N
Nonspecific low back pain (LBP) is defined as “low back pain not
1
attributable to a recognizable, known specific pathology.” This painful
musculoskeletal problem is highly prevalent and recurrent.2 The life-
time prevalence is estimated at 84%, and approximately 55% of
patients will have at least 10 episodes in their lifetime.3 LBP can also
persist over time—with a point prevalence of approximately 25%,
chronic LBP is a major health burden and is ranked as the most
disabling pathology with respect to global burden of disease and is
the leading cause of years lived with disability in developed countries.4
This costly and socially burdensome condition prevails, despite the
presence of 15 international multidisciplinary guidelines for treatment
of LBP,5,6 numerous systematic reviews/meta‐analyses on LBP,2,7-9
and multiple mono‐disciplinary classification tools that are designed
to guide clinicians in identifying an optimal diagnosis and treatment
10-12
approach. Unfortunately, disability reported by persons with
LBP has largely remained unchanged over the past decade,13 suggest-
ing existing guidelines and frameworks have yet to capture the
complexities associated with LBP and its management.
Studies have shown that development and persistence of LBP are
influenced by psychological, biological, sociocultural, and environmen-
tal factors.14-16 These multidimensional mechanisms are well repre-
sented in the World Health Organization's International Classification
of Functioning, Disability and Health (ICF) model, 17
a model chosen by
many rehabilitation professionals as the framework to inform assess-
ment and management of different health problems. Choosing the most
appropriate treatment options, informed by a framework that integrates
deficits in body functions and structures, along with a full consideration
of personal and environmental factors, may provide additional benefits.
Evidence shows that the influence of personal and environmental
factors tends to receive less focus by physical rehabilitation providers,
thus potentially limiting the outcomes of a more comprehensive
18
management approach. As a holistic framework for health and well‐
being, the ICF should serve as the foundational model underpinning a
comprehensive framework to better guide the management of LBP.
In this context, we recently proposed the Pain and Disability Drivers
Management (PDDM) model for LBP.19 This model, which encompasses
the multidimensional elements included within the ICF framework and
19
which is explained in detail elsewhere, is distinct from previous
models in this field as it does not propose a new classification system.
Rather, it aims to identify the domains influencing pain and disability
in order to create an ICF‐based profile or clinical/social phenotype to
19
guide clinical decisions. The PDDM model is composed of five
domains, each requiring evaluation when determining appropriateness
of care and application of treatment. Guided by the PDDM model, the
management of LBP can then be individualized and guided by the
relative contribution of each domain, or combination of domains,
influencing the experience of pain and disability for a particular patient.
To provide evidence of the model's content validity and to ensure
the face validity of the model and its contextual elements, we aimed to
achieve consensus among experts in pain management on the differ-
ent elements that should be included in each domain of the PDDM.
ET AL.
A Delphi method is used to systematically explore consensus among
experts and is particularly useful in early phases of concept develop-
ment.20,21 This anonymous and iterative process, where the experts
are asked to rank or agree upon items with the goal of achieving con-
sensus on those items,22,23 has previously been used in the context of
musculoskeletal rehabilitation.20,21 On the basis of the consensus‐
based conclusion of the Delphi results, we aimed to propose a revised
version of the PDDM model, where each component of the model
conveys elements that are comprehensive of each domain.
2 | METHODS
2.1 | Study design
2.1.1 | Delphi method
We used a modified Delphi survey technique, a methodology
commonly used to obtain group consensus on the opinions of
“experts” through a series of structured questionnaires.23-25 This
design is particularly appropriate since other forms of evidence
regarding the specific elements to be included within each
subdomain/domain of the PDDM model is lacking. Ethics approval
was granted by the Ethics Review Board of the Clinical Research
Center of the CHUS (project # 2018‐2486).
2.2 | Participants
We aimed to recruit health professionals deemed experts in musculo-
skeletal pain management. For this, we purposely invited health
professionals who completed a graduate certificate in pain manage-
ment from two Canadian universities, namely McGill University26
and Université de Sherbrooke.27
To enhance the diversity of the panellists' expertise, we also
targeted professionals who resided/practised in Canada or the United
States with recognized expertise in the fields of musculoskeletal pain,
pain science, and/or pain management (not limited to LBP) within the
scope of physical therapy, occupational therapy, psychology, and
medicine (including anesthesiology). The expertise of this subgroup
(researchers, practice leaders, etc) was mainly based on publication
history (first or last author). These potential participants were identi-
fied through the Quebec Pain Research Network website,28 the Pain
Science Division of the Canadian Physiotherapy Association,29 and
keynote speakers from previous conventions of the American Physical
Therapy Association.
Overall, these two subgroups of participants constituted a high‐
expertise group, as required for a successful Delphi study.24,30
Eligibility criteria (beyond expertise) were to (a) be able to complete
two to three rounds of the Delphi survey within a 3‐month timeframe,
(b) be proficient in the use of written English or French, (c) be compe-
tent in using a computer, and (d) have access to Internet and emails. It
is worth noting that there is no predefined number of experts neces-
sary for a Delphi survey.31
TOUSIGNANT‐LAFLAMME ET AL.
2.3 | Recruitment
Invitations to participate to the survey were individually sent by email
to recent graduates of pain management programmes (current and
past students) by the pain management certificate programmes
coordinators. For the other subgroup of participants, we also sent
personal invitations by email to 56 other potential participants.
To compensate for their time to complete the survey, all partici-
pants received a $20 gift card after the completion of all rounds of
the survey.
2.4 | Delphi method procedures
After giving their consent, sociodemographic information was
gathered from the participants. Participants were first asked to
acquaint themselves with the PDDM model, where they had to watch
a narrated PowerPoint presentation, an 18‐minute audio‐visual devel-
oped by the first author detailing the model (available at https://
vimeo.com/225138614 using the password: pddm2017). The audio‐
visual did not allow individuals to skip or fast forward any content
and was designed to assure that each individual watched the complete
PowerPoint presentation. Participants were then shown an online
document summarizing the 41 elements initially proposed in the
PDDM model. This list was generated by the co‐investigators in
accordance with our previous work.19 A total of 41 elements were
included in this list—specifically, three elements for “nociceptive pain
drivers” domain, 10 elements for the “nervous system dysfunction
drivers” domain, four elements for the “comorbidity drivers” domain,
15 elements for the “cognitive‐emotional drivers” domain, and nine
elements for the “contextual drivers” domain.
After completing these preliminary steps, the participants were
allowed to initiate the survey through the SurveyMonkey platform
(surveymonkey.com). The online surveys for each round were
available for 6 weeks, and a weekly reminder and a reminder 1 day
prior to closing were sent to all participants in order to maximize
response rate.
2.4.1 | Round 1
The aim of this round was to collect consensus for each item within
the five domains of the model (nociceptive, nervous system dysfunc-
tions, comorbidities, cognitive‐emotional, and contextual drivers).
Accordingly, domain by domain, participants were asked to
score/rank the relevance of each proposed element using a 4‐point
Likert‐type scale (strongly relevant, relevant, not relevant, or strongly
irrelevant); a neutral middle point was not included to force
participants to choose a valence (see Table 1 for an example of the
nociceptive domain). Participants were invited to add additional
elements to the proposed list that, in their own opinion, would con-
tribute to a particular domain. The first round of the survey required
about 45 to 60 minutes to complete.
3
TABLE 1 Example question asked to the participant to assess the
relevance of each element in a particular domain
Domain 1: Nociceptive Pain Drivers
Elements Relevance
Nociceptive pain with a specific Strongly irrelevant 1 2 3 4
mechanical pattern of pain Strongly relevant
Low back pain without any s Strongly irrelevant 1 2 3 4
pecific mechanical pattern Strongly relevant
Nociceptive pain related to Strongly irrelevant 1 2 3 4
identifiable structural stability Strongly relevant
deficits (ie, postfracture,
postsurgery)
In your opinion, for this domain, would there be any other element
(treatment modifier) that could be included within this domain? If so,
please explain why/how.
2.4.2 | Round 2
Prior to the second round, we identified elements (themes) reaching
consensus as either relevant or irrelevant.32 Consensus was arbitrarily
defined at a greater than or equal to 75% level of agreement (the sum
of the percentages of participants who rated an element as strongly rel-
evant or relevant or who rated an item not relevant or strongly irrelevant).
Results with greater than 25% and less than 75% level of agreement
were re‐assessed during this second round, whereas elements with less
than or equal to 25% level of agreement (the sum of the percentages of
participants who rated an element as strongly irrelevant or irrelevant)
were rejected. The remaining elements, as well as the newly added ele-
ments (elements added by the participants), were presented and again
rated by the participants during the second round, which required about
20 minutes to complete. If elements had still not reached consensus
(agreement level remained between 25% and 75%) after the second
round, a third and final round could occur.
2.5 | Data analysis
2.5.1 | Open‐ended responses after round 1
Responses from each participant were extracted to an Excel database,
where each response was set up as a separate variable. Qualitative
content analysis was performed on answers to open‐ended questions
(only for new items proposed by the participants) using a process
called thematic coding. In short, thematic coding involves recording
or identifying passages of text that are linked by a common theme
or idea allowing one to index the text into dedicated categories.33
As an example, each text offering (eg, perceived injustice) was set up
and sorted out in its own dedicated category by identifying and
interpreting unique themes within each response. The process began
with the identification of text suggestions that were provided by mul-
tiple responders that were very close in terms of idea/concept
(different wording, same concept). These concepts were then themat-
ically grouped by the first author (YTL) until an exhaustive list was
created and no new themes were present. Upon completion, the
4 TOUSIGNANT‐LAFLAMME
researchers decided on the uniqueness of each for inclusion as new
elements to be rated in round 2. Since not many new elements were
suggested and the concepts were quite convergent, we had no
disagreements in the interpretation and classification of the responses.
2.5.2 | Both rounds
Descriptive statistics (frequencies and proportions) were conducted in
order to determine the levels of agreement with each element. The
sum of the strongly relevant and relevant responses and the sum of
the strongly irrelevant and irrelevant responses for each element were
transformed to a percentage of total participants providing any
response for a single item. Only those items of which at least 75%
of respondents endorsed as relevant or strongly relevant were retained
in the final model.
3 | RESULTS
3.1 | Participants—Expert panel
We sent out a total of 257 invitations to potential participants. Of
these, 76 potential participants accessed the initial page of the survey,
70 (92%) participants gave their consent to participate, and 47 (62%)
completed the full survey (see Figure 1 for the flow chart). The charac-
teristics of the final sample (n = 47) are presented in Table 2. The mean
age of the panel of experts was 42.7 years (range from 28 to 64 years).
Thirty‐one participants (66%) were female. Forty‐two (89%) were
from Canada and five from the United States. The average years of
experience was 17 years (range from 2 to 40 years). The panel was
constituted of experts from various health‐related professions, with
a majority being physical therapists (45%) and occupational therapists
(13%). Among participants with an academic background, 58% mainly
worked in clinical care, 25% exclusively worked in research activities,
FIGURE 1 Flow chart
ET AL.
and 13% had both appointments, while 4% exclusively had teaching
activities. Forty‐nine percent of participants had completed a pain
management certificate programme, and 94% had underwent pain‐
specific professional development in the last 5 years. Also, 28% of
the panel had more than 15 peer‐reviewed publications, and 53%
had actively participated in the field of pain management research in
the previous 5 years.
3.2 | Results of round 1
For the nociceptive pain drivers domain, consensus was reached for
two out of three elements (no consensus for Low back pain without
any specific mechanical pattern), and a new element was suggested
(Presence of signs/symptoms of an active inflammatory process). For
the nervous system dysfunction drivers domain, consensus was
reached for eight out of 10 elements (no consensus for Evidence of
disproportionate pain intensity in relation to injury and Hypersensitivity
of senses unrelated to the MSK system), and three new elements were
suggested (Evidence of sympathetic nervous system dysfunction (ie,
sweating/dryness, skin temperature changes), Symptoms of dysesthesia,
and Sleep disturbances secondary to painful symptoms). For the comor-
bidity drivers domain, consensus was reached for all four elements,
and one new element was suggested (Posttraumatic stress disorder).
For the cognitive‐emotional drivers domain, consensus was reached
for all 15 elements, and four new elements were suggested (Poor
knowledge related to pain science, Perceived injustice, Perception that
medical treatments are still needed or incomplete, and Discordance
between reported behaviours (by the patient) and observed behaviours
(by the therapist)). Finally, for the contextual drivers domain, consensus
was reached for all nine elements, and one new element was
suggested (Communication barriers). Thus, following the first round,
38 of 41 elements of the original model reached consensus, and 10
new elements were proposed. It is relevant to highlight that none of
the initially proposed elements were rejected (less than or equal to
25% level of agreement) during round 1.
3.3 | Results of round 2
Thirty‐eight participants (81% of the participants who completed the
first round) accessed the second‐round survey, and 33 answered all
questions. Round 2 was composed of the three elements that had
yet to reach consensus after round 1 and 10 new elements proposed
by the participants during round 1. After summing the strongly relevant
and relevant ratings, consensus was reached for all of the 13 elements.
Thus, the final version of the model consists of 51 elements (see
Table 3).
4 | DISCUSSION
The PDDM is a theoretical model composed of five domains linked to
the ICF model.17 The PDDM model is proposed to enhance and better
structure the pain management of LBP by rehabilitation professionals.
TOUSIGNANT‐LAFLAMME ET AL. 5

TABLE 2 Demographic characteristics of respondents (n = 47)

Language French 23
English 24
Age, years Mean 42.7
Range 28‐64
Sex Female 31
Male 16
Occupation (clinical/research/both) Physiotherapist 21 (13/4/2), only 2 professors
Researcher 7 (0/7/0)
Occupational therapist 6 (5/0/1)
Clinician nursing 2 (2/0/0)
Psychologist 2 (0/0/2)
Physiatrist 2 (1/0/1)
Kinesiologist 2 (2/0/0)
Social worker 1 (1/0/0)
Assistant researcher 1 (0/1/0)
Physical rehabilitation technician 1 (1/0/0)
Chiropractor 1 (1/0/0)
Clinical exercise physiologist 1 (1/0/0)
Country Canada 42
USA 5
Years of experience Mean 17
Range 2‐40
Background Completion of a pain management certificate programme
Yes 23
No 24
Pain‐specific professional development (over the last 5 years)
Yes 44
No 3
Research in pain management over the last 5 years
Yes 25
No 22
Peer‐reviewed publications
1‐5 9
6‐15 1
>15 13

Our goal was to establish the content validity of the model and its
elements through consensus of key expert stakeholders—healthcare
professionals involved in the management of chronic pain. Via a
modified Delphi survey, experts in different domains of pain manage-
ment agreed to a list of elements (previously vetted by the authors as
well as proposed elements from the participants themselves)
pertaining to the five domains of the PDDM model. After a two‐round
process, 51 elements reached consensus (greater than or equal to 75%
agreement), no initially proposed elements were rejected, and 10 new
elements were added.
4.1 | Domain 1: Nociceptive pain drivers
In clinical practice, the integration of classification systems or stratifi-
cation tools to guide diagnosis and management of LBP is an effective
means to personalized care and address the nociceptive components
driving painful symptoms.12,34 Although classification systems may
diverge in regards to the specific causes of pain,35 each mainly
addresses management of LBP by targeting motor control (ie,
enhanced core stability), specific techniques, and/or exercises to
positively modulate symptoms (ie, directional preference exercises)
or mobility (ie, manual techniques). Thus, it was not surprising to
observe very high levels of agreement (96%) for elements pertaining
to a specific mechanical pattern of pain. This observation is coherent
with the results of a recent study by Dewitt and colleagues,36 which
underlined a high level of agreement among clinicians regarding the
association between nociceptive dysfunction patterns and specific
patterns of pain as well as impaired neuromuscular control.
Yet, patients with LBP may present without any specific mechani-
cal patterns of pain, as often observed in highly deconditioned
patients or structural stability deficits. Although this element had
lower agreement rate (83% after round 2), participants judged that it
was still related to a nociceptive input. Interestingly, a new element
(presence of signs/symptoms of an active inflammatory process)
reached consensus (100% agreement) and was included in this

TABLE 3 Final version of the elements deemed relevant for each domain of the model
Nociceptive Pain Drivers
Responders to LBP The patient shows/has
classification clinical characteristics of
system nociceptive pain (somatic
or inflammatory)
AND
• Specific mechanical
pattern of pain (96%)
Nonresponders to The patient shows/has
LBP classification clinical characteristics
system of nociceptive pain
(somatic or inflammatory)
AND
• Low back pain without
any specific mechanical
pattern (round 1: 66%;
round 2: 83%)
OR
• Nociceptive pain related
to identifiable structural
stability deficits
(postfracture, postsurgery)
(92%)
OR
• Presence of signs/symptoms
of an active inflammatory
process (new: 100%)
Nervous System Dysfunctions Drivers
Peripheral or central The patient shows/has clinical
sources of NSD evidence of neuropathic
pain such as:
• Radicular pain pattern (98%)
AND/OR
• Tingling/paresthesia or
burning/shooting pain (96%)
AND/OR
• Signs of radiculopathy (98%)
AND/OR
• Signs of myelopathy (89%)
Nervous system The patient may or may
hypersensitivity not have clinical evidence
of neuropathic pain but
shows:
• Evidence of increased neural
mechanosensitivity (92%)
AND/OR
• Evidence of hyperalgesia
• Low pain thresholds at distal
sites. (94%)
AND/OR
• Evidence of allodynia
• Provoked or spontaneous
(98%)
AND/OR
• Evidence of widespread
pain location:
○ Widespread pain outside
the anatomical relationship
to LBP (77%)
AND/OR
• Evidence of disproportionate
pain intensity in relation to
injury (round 1: 72%;
round 2: 100%)
AND/OR
• Hypersensitivity of senses
unrelated to the MSK system
(round 1: 62%; round 2: 94%)
Comorbidity Drivers (as a domain
influencing the effect of other drivers)
Physical The patient shows/has/
report:
• Identified/known co‐
occurring painful MSK
pathologies (98%)
○ OA, RA, Spondy‐
larthritis, etc
○ Any other painful MSK
pathology triggering pain
AND/OR
• Identified/known co‐
occurring disorders related
to pain sensitization, such
as: (96%)
○ Chronic fatigue, migraines,
IBS, fibromyalgia
Mental‐health The patient shows/has/
report:
• Mental health disorders
(within the DSM): (98%)
○ Depressive disorders
○ Anxiety disorders
○ Personality disorders
○ History of substance‐
use disorder
• Patient‐reported sleep
disorders (92%)
• PTSD (new: 97%)
Cognitive‐Emotional Drivers
Maladaptive cognitive‐ The patient shows/has
emotional factors any of the following:
• Pain catastrophizing (100%)
• Pain‐related anxiety (98%)
• Negative mood (96%)
• Fear of movement (100%)
• Pain‐related fears (100%)
• Poor self‐efficacy (100%)
• High illness perception 94%)
• Negative pain expectations
(94%)
• Negative/low expectation
of recovery (98%)
• Low pain coping (98%)
• Poor knowledge relating
to pain science (new: 79%)
Maladaptive pain The patient shows/has any
behaviours of the following:
• Facial expressions (eg,
grimacing or wincing) (75%)
• Verbal/paraverbal pain
expressions (eg, pain words,
grunts, sighs, and moans).
(77%)
• A guarded posture (eg,
keeping the back straight
while lifting). (87%)
• Bending/rubbing the back
after performing an
activity. (77%)
• Completely avoiding
performing a task (98%)
• Perceived injustice (new:
97%)
• Perception that medical
treatments are still needed
or incomplete (new: 91%)
• Discordance between
reported behaviours (by
the patient) and observed
behaviours (by the
therapist) (new: 91%)
6
Contextual Drivers
Occupational The patient shows/has any of
context the following:
• Low RTW expectations (94%)
• Low job satisfaction (92%)
• Perception of heavy work
(89%)
• High job stress (98%)
• High occupational demands
(98%)
• Low job flexibility (ie,
nonmodifiable work or
hours) (94%)
• Employer's policies regarding
RTW are limited or
restrictive (100%)
Social context The patient shows/has
any of the following:
• Poor attitudes of employer,
family or health care
professionals (100%)
•Low or non‐access to care
(100%)
• Communication barriers
(new: 91%)
TOUSIGNANT‐LAFLAMME
(Continues)
ET AL.
 TOUSIGNANT‐LAFLAMME ET AL. 7

domain, suggesting that the experts' representation of LBP nocicep-

a given element of a particular domain should DRIVE a relatively specific intervention, which targets the domain(s) influencing pain and/or disability for a particular patient. As for comorbidity drivers, each ele-
Note. The following was what was presented to participants: “These elements are moderators of treatment (versus cause of LBP) and should influence your decision making process. Accordingly, the presence of

Abbreviations: IBS, irritable bowel syndrome; LBP, low back pain; MSK, Musculoskeletal; NSD, nervous system dysfunctions; OA, osteoarthritis; PTSD, post‐traumatic stress disorder; RA, rheumatoid arthritis;
tive drivers is not only associated with deficits in specific structures
(or local articular dysfunctions) or deconditioning, but also with
“systemic” (or specific) conditions.
Contextual Drivers

4.2 | Domain 2: Nervous system dysfunction drivers

Most of the elements of this domain obtained very high consensus

levels (lowest was Widespread pain outside the anatomical relationship
to LBP at 77%), although two very specific elements related to cen-
tral sensitization (CS) needed two rounds to reach consensus (ie,
Evidence of disproportionate pain intensity in relation to injury and
Hypersensitivity of senses unrelated to the MSK system). We noted
that the following elements did not reach consensus after round 1:
Cognitive‐Emotional Drivers

Evidence of widespread pain location, Disproportionate pain intensity

in relation to injury, and Hypersensitivity of senses unrelated to the
MSK system. This may reflect that even experts in pain management
have yet to fully integrate concepts of CS into their clinical practice.
Considering that this concept appeared in guidelines only very
ment of this domain should INTERACT with other drivers, thus mediating the effect of interventions targeted by other domains.”

recently,37 its large‐scale dissemination may be difficult because of

the limited number of clinical assessment tools available38 or the fact
influencing the effect of other drivers)

that there is more symptoms than clinical signs associated with this
Comorbidity Drivers (as a domain

problematic. Yet, incorporating elements pertaining to CS in the

PDDM model represents a good opportunity to better recognize
and integrate these important nervous system–related drivers of pain
into clinical care.
Our findings pertaining to the nervous system dysfunction drivers
domain are in line with the findings of DeWitt et al36 who reported
similar subjective and objective examination criteria regarding the
“neural” and “central dysfunctions” classification, further enhancing
• Sleep disturbances secondary
nervous system dysfunction
(ie, sweating/dryness, skin

• Symptoms of dyesthesia

the validity of elements within this domain.

• Evidence of sympathetic

temperature changes)

to painful symptoms
Nervous System Dysfunctions Drivers

(new: 100%)
(new: 100%)

(new: 82%)
AND/OR

AND/OR

AND/OR

4.3 | Domain 3: Comorbidity drivers

This domain reached high levels of consensus for both physical comor-
bidities (98% agreement for Identified/known co‐occurring painful MSK
pathologies and 96% agreement for Identified/known co‐occurring disor-
ders related to pain sensitization) and mental health comorbidities (92%
agreement for Patient‐reported sleep disturbances and 98% agreement
for Mental health disorders). The panel of experts recognized that the
impact of these factors on rehabilitation seems to be very important
for the success and the personalization of the care, as also highlighted
in previous research.39,40 The addition of the Posttraumatic stress
disorder (PTSD) element by participants, which reached a 98% level
(Continued)

Nociceptive Pain Drivers

RTW, return to work.

of agreement in round 2, is highly relevant as a recent systematic

review reported that PTSD, a recognized mental health disorder, is
an important mediator of pain ratings.41,42 Given that up to a third
of injured workers with chronic pain also report symptoms consistent
TABLE 3

with PTSD,43,44 it certainly represents an important comorbidity

element to consider and address.
8 TOUSIGNANT‐LAFLAMME
4.4 | Domain 4: Cognitive‐emotional drivers
All 10 maladaptive cognitive‐emotional factors elements initially
proposed by the authors reached a very high level of agreement (low-
est levels of agreement were High illness perception and Negative pain
expectations at 94%), and the panel of experts suggested one new
element: Poor knowledge related to pain science. Interestingly, past
research has shown that poor knowledge of pain science can
negatively influence maladaptive pain‐related cognitions, which can
in turn drive emotional responses such as fear and anxiety and even-
tually lead to maladaptive behaviours.45-47
The five initially proposed elements for maladaptive pain behav-
iours also all reached consensus in round 1 (agreement levels
between 75% and 98%). Participants further proposed three new
elements that reached high levels of agreement in round 2 (between
91% and 97% agreement). Avoidance behaviours (Completely
avoiding performing a task) was the element that reached the highest
level of consensus (98%). This result is not surprising since past
research has shown that maladaptive pain behaviours such as fear
avoidance were associated with worst outcomes and chronicity of
pain.14,48,49 This phenomenon is best explained by the Avoidance‐
Endurance model, which suggests that the avoidance of movements
and activities due to fear is a central mechanism involved in long‐
term back pain because of the role it plays in physical
deconditioning.50,51 Yet, the same authors also showed that
deconditioning is certainly not the dominant factor explaining the
persistence of LBP.52
4.5 | Domain 5: Contextual drivers
The seven work context elements as well as the two social context
elements initially proposed reached high levels of agreement in round
1 (lowest level of agreement for Job satisfaction at 92%). Participants
suggested one additional social context element (Communication
barriers), which reached a level of agreement in round 2 of 91%. This
unanimity regarding the importance of contextual drivers suggests,
as proposed by the PDDM model, that environmental factors play a
substantial role in the LBP problematic. Elements surrounding return
to work such as expectations about returning to work, job satisfaction,
job stress, job demands, and flexibility are especially crucial as it has
been argued that resuming regular activities is important for decreas-
ing chronic pain and disability.53 While most individuals with LBP
return to work within 6 months, an estimated 7% of workers with
LBP will experience a long‐term absence from work.54 Thus, the
importance of work‐related contextual factors further highlights the
necessity of using a multidisciplinary or interdisciplinary approach to
care and rehabilitation.
This domain has one important limitation as it mostly focuses on
work and medical factors. Only one social context element includes
the familial context of patients, and it is bundled with work and health
care professionals: Attitudes of employer, family, or health care profes-
sionals. There are no specific elements about support from family
ET AL.
and friends as well as about social and leisure activities. Social support
is a well‐known influential factor for pain experience and pain behav-
iours.55,56 A better understanding of the social context thus appears to
be an important element guiding the management of patients.57
4.6 | Methodological limitations
The present research has some strengths and limitations. The results
from a Delphi survey represent the solution with the largest agree-
ment among all the opinions of the panel of experts. This consensus
process can eliminate divergent opinions that could potentially be
important to some experts. Thus, Delphi survey results are not neces-
sarily optimal solutions or truth on the topic, and final consensus can
be influenced by how the questions are presented in the first place.30
However, one nonnegligible advantage of the present research meth-
odology is the use of a web‐based Delphi survey, which enabled
access to a larger panel of experts58 as well as the option for partici-
pants to suggest additional elements.
The present study also presents some limitations pertaining to
questionnaire length and response rate, which might partly explain
the attrition we observed. Specifically, in the present study, 257 par-
ticipants were solicited, 76 (30%) accessed the survey, 70 (27%) gave
their consent, and, finally, only 47 (18%) completed the full survey at
round 1. At round 2, almost all participants from the first round
(n = 38; 15%) accessed the survey, and 33 (13%) completed it in full.
One potential explanation for the low response rate might be related
to the fact that the participants had to watch an 18‐minute video,
thus further lengthening the duration of the questionnaire for round
1, which has been found to have an important influence on response
level.59 The questionnaire for round 1 contained 41 elements to eval-
uate, demographics data questions, and open‐ended questions. For
round 2, the burden was much less, as the first‐round elements that
reached consensus were removed from the questionnaire for round
2, which considerably reduced its length and potentially maximized
response rates. However, this process affected data analysis as
answer stability between round 1 and round 2 could not be deter-
mined. Finally, only healthcare professionals (experts) from Canada
and the United States were invited to participate; our panellist of
experts was not international, therefore maybe limiting the
viewpoints.
5 | CO NC LUSIO N
The present study using a modified Delphi survey permitted to vali-
date the content of the PDDM model designed to outline compre-
hensive factors driving pain and disability in LBP. The process
resulted in a total of 51 elements divided into five domains. The
present study was the first step in determining the validity of this
theoretical framework, which could eventually help clinicians provide
more targeted care and optimize treatment outcomes. The next step
will be to gather consensus towards the specific tools (question-
naires, clinical procedures, etc) to be used to document the
TOUSIGNANT‐LAFLAMME ET AL.
presence/absence of a given element. This will allow us to develop
the most appropriate and rigorous set of core evaluation tools facil-
itating the operationalization of the PDDM model into future clinical
trials and translation into practice.
ACKNOWLEDGEMEN TS
The authors would like to thank Ms Geneviève Lavigne for her
insightful comments and help in the review of the manuscript. This
project was financially supported by the Canadian Musculoskeletal
Rehabilitation Research Network, a network of the Canadian Institute
of Health Research (grant CIHR CF1‐148081).
CONF LICT OF INT E RE ST
The authors declare no conflict of interest.
ORCID
Yannick Tousignant‐Laflamme https://orcid.org/0000-0002-1133-
8707
Annie Mathieu https://orcid.org/0000-0002-7024-9069
Timothy Wideman https://orcid.org/0000-0003-1574-6967
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How to cite this article: Tousignant‐Laflamme Y, Cook CE,
Mathieu A, et al. Operationalization of the new Pain and Dis-
ability Drivers Management model: A modified Delphi survey
of multidisciplinary pain management experts. J Eval Clin Pract.
2019;1–10. https://doi.org/10.1111/jep.13190