Predicting work status following interdisciplinary treatment for chronic pain

Influence of pain-related psychological factors on therapeutic outcomes in patients with chronic low back pain after oxygen-ozone treatment: a case-series

The aim of the study was to identify the variables related to therapeutic success of intramuscular oxygen-ozone (O2O3) in patients with chronic low back pain (LBP). Twenty-one patients underwent an eight-session intramuscular-paravertebral O2O3 treatment with a weekly frequency. Numeric Rating Score for pain (NRSp), anxiety (NRSa), mood (NRSm), Oswestry Disability Index (ODI) and Physical and Mental Component Summary scores (PCS and MCS) of Short Form 12 (SF-12) were assessed baseline, after the treatment and at six-months follow-up. The ODI and NRSp scores showed significant improvement at the end of the treatment: the improvement in pain was maintained also at 6 months’ follow-up. A significant correlation between baseline NRSa and the variation of the NRSp and ODI was observed. There was a correlation between NRSm at baseline and the variation of the ODI. A moderate correlation between MCS-12 at baseline and the variation of the NRSp score was found. Surprisingly, patients with a more compromised psychological well-being due to LBP had better results after oxygen-ozone therapy. Therefore, NRSa, NRSm and MCS-12 scores could be useful predictors of good therapeutic outcome.

The Relationship Between Level of Catastrophizing and Mental Health Comorbidity in Individuals With Whiplash Injuries

OBJECTIVES

Pain catastrophizing has been shown to be correlated with measures of mental health problems such as depression and post-traumatic stress disorder (PTSD). However, the clinical implications of findings reported to date remain unclear. To date, no study has been conducted to determine meaningful cut-scores on measures of catastrophizing indicative of the heightened risk of mental health comorbidity. One objective of the present study was to identify the cut-score on the Pain Catastrophizing Scale (PCS) indicative of the heightened risk of the comorbidity of depression and PTSD. A second objective was to determine whether mental health comorbidity mediated the relationship between catastrophizing and occupational disability.

MATERIALS AND METHODS

The sample consisted of 143 individuals with whiplash injuries. Pain severity, pain catastrophizing, depression, and post-traumatic stress symptoms were assessed after admission to a rehabilitation program. Mental health comorbidity was operationally defined as obtaining a score above the clinical threshold on measures of depressive and/or post-traumatic stress symptom severity.

RESULTS

A receiver operating characteristic curve analysis revealed that a PCS score of 22 best distinguished between participants with and without mental health comorbidity. Results also revealed that mental health comorbidity mediated the relationship between catastrophizing and occupational disability.

DISCUSSION

The findings suggest that a score of ≥22 on the PCS should alert clinicians to the possibility that patients might also be experiencing clinically significant symptoms of depression or PTSD. Greater attention to the detection and treatment of mental health conditions associated with whiplash injury might contribute to more positive recovery outcomes.

Endogenous Pain Modulation Profiles Among Individuals With Chronic Pain: Relation to Opioid Use

It is generally assumed that individuals exhibiting high pain inhibition also tend to exhibit low pain facilitation, but little research has examined this association in individuals with pain. The aims of this cross-sectional study were 1) to examine the association between measures of conditioned pain modulation (CPM) and temporal summation (TS) in individuals with chronic pain, and 2) to examine whether this association was moderated by demographic (age, sex), psychological (depression, catastrophizing), or medication-related (opioid use) variables. Individuals (N= 190) with back or neck pain completed questionnaires and underwent a series of quantitative sensory testing procedures assessing CPM and TS. Results indicated that individuals with higher levels of CPM showed lower levels of TS, r = -.20, P < .01. Analyses, however, revealed that the magnitude of this association was substantially weaker among opioid users (r= -.08, NS) than nonusers (r= -.34, P < .01). None of the demographic or psychological variables included in our study influenced the association between CPM and TS. The magnitude of CPM was lower for opioid users than nonusers, suggesting that opioid use might dampen the functioning of endogenous pain-inhibitory systems and possibly contribute to a discordance between measures of pain inhibition and pain facilitation. PERSPECTIVE: Results of the present study indicated that greater endogenous pain-inhibitory capacity is associated with lower levels of pain facilitation. This association, however, was not significant among opioid users, suggesting that opioids might compromise the functioning and interrelationship between endogenous pain modulatory systems.

Internet delivered transdiagnostic treatment with telephone support for pain patients with emotional comorbidity: a replicated single case study

In pain patients, comorbid emotional problems have been linked to negative outcomes, including suboptimal treatment gains. Developing parsimonious and accessible treatment options is therefore important. The overarching aim of this study was to test an internet delivered therapist guided transdiagnostic treatment with telephone support. An adapted version of the Unified Protocol for Transdiagnostic Treatments of Emotional Disorders was used as an intervention for pain patients with residual pain problems and comorbid emotional problems after having received a multimodal pain rehabilitation. The study used a replicated AB single case experimental design (N = 5; 3 females). Outcome measures were depressive and general anxiety symptoms, pain intensity, pain coping problems, and diagnostic status. Feasibility measures (completion and compliance) and patient satisfaction were also assessed. Scores on Nonoverlap of All Pairs (NAP) indicate a decrease of anxiety for three participants and a decrease of depression for four participants. Decreases were small and did not always reach statistical significance. Also, Tau-U scores could only confirm a reliable trend for one participant. Two out of four patients who were diagnosed with psychiatric disorders before treatment did no longer fulfill diagnostic criteria posttreatment. No improvements could be seen on pain problems. The treatment was feasible and patient satisfaction was high. Hence, while an internet delivered transdiagnostic treatment with telephone support may be a feasible and accepted secondary intervention for pain patients with comorbid emotional problems, the effects are unclear. The gap between high patient satisfaction and small changes in symptomatology should be explored further.

Return to work after vocational rehabilitation for sick-listed workers with long-term back, neck and shoulder problems: A follow-up study of factors involved

BACKGROUND

Absence from work due to musculoskeletal disorders is a significant problem from a number of perspectives, and there is a great need to identify factors that facilitate return to work (RTW).

OBJECTIVE

To identify factors related to RTW after vocational rehabilitation for sick-listed workers with long-term back, neck and/or shoulder problems, and to compare the results with those from a previous literature review based on studies from 1980 to 2000.

METHODS

A literature review based on studies published 2001-2014 in PubMed, CINAHL, EMBASE, ERIC and the Cochrane Library.

RESULTS

Major risk factors for not returning to work are: higher age, factors related to pain such as higher levels of pain and pain related fear, avoidance of activity, high distress and depression. Facilitating factors for RTW are: lower functional disability, gaining control over one's own condition, believing in RTW and work-related factors such as occupational training, and having a job coach or an RTW coordinator. Compared with the results from the previous review, the present review shows less of a focus on sociodemographic factors and more on psychological factors. Both studies highlight risk factors such as older age, higher levels of pain, depression and less internal locus of control.

CONCLUSION

Psychosocial and work-related factors are important and should be included in interventions for the RTW of people with long-term back, neck and/or shoulder problems.

Rates and Correlates of Unemployment Across Four Common Chronic Pain Diagnostic Categories

PURPOSE

To examine rates and correlates of unemployment across distinct common chronic pain diagnoses.

METHODS

Data were analyzed from a sample of 2,382 patients with chronic pain in the Quebec Pain Registry (QPR). Patients were grouped into the following diagnostic categories based on their primary pain diagnosis recorded in the QPR: musculoskeletal pain; myofascial pain; neuropathic pain, and visceral pain. Analyses were performed to examine the associations between pain diagnosis, patient demographics, pain intensity, depressive symptoms, and unemployment status.

RESULTS

Pain diagnosis, age, marital status, education, pain intensity, and depressive symptoms were each significant unique predictors of unemployment status in a hierarchical logistic regression analysis; the addition of depressive symptoms in this model contributed to the greatest increment of model fit.

CONCLUSIONS

Depressive symptoms are associated with unemployment across a number of common chronic pain conditions, even when controlling for other factors that are associated with unemployment in these patients. Depressive symptoms, as a modifiable factor, may thus be an important target of intervention for unemployed patients with chronic pain.

Working and Living in Northern vs Southern Ontario Is Associated with the Duration of Compensated Time off Work: A Retrospective Cohort Study

Background:

Northern Ontario, Canada has a larger elder population, more resource-based employment, and limited access to physicians and specialists compared to southern Ontario. Given these important differences, it is possible that work disability rates will vary between the two Ontario jurisdictions.

Objective:

To determine the association between time lost due to workplace injuries and illnesses occurring in northern vs southern Ontario and work disability duration from 2006– 2011.

Methods:

The study base included all lost-time claims approved by the Workplace Safety and Insurance Board in Ontario, Canada for workplace injury or illness compensation occurring between January 1, 2006 and December 31, 2011. All eligible participants had to be 18 years of age or older at the time of making the claim and participants were excluded if one of the three variables used to determine location (claimant home postal code, workplace geographical code, and WSIB firm location) were missing. Multivariable proportional hazards regression models were used to estimate hazard ratios and 95% confidence intervals adjusted for sex, age, occupation, part of body, and nature of injury relating Ontario geographical location to compensated time off work.

Results:

A total of 156 453 lost-time claims were approved over the study period. Injured and ill workers from northern Ontario were 16% less likely to return to work than those from southern Ontario. Adjustment for potential confounding factors had no effect.

Conclusion:

The disability duration in northern Ontario is longer than that in southern Ontario. Future research should focus on assessing the relevant factors associated with this observation to identify opportunities for intervention.

Several submaximal exercise tests are reliable, valid and acceptable in people with chronic pain, fibromyalgia or chronic fatigue: a systematic review

QUESTION

Are submaximal and maximal exercise tests reliable, valid and acceptable in people with chronic pain, fibromyalgia and fatigue disorders?

DESIGN

Systematic review of studies of the psychometric properties of exercise tests.

PARTICIPANTS

People older than 18 years with chronic pain, fibromyalgia and chronic fatigue disorders.

INTERVENTION

Studies of the measurement properties of tests of physical capacity in people with chronic pain, fibromyalgia or chronic fatigue disorders were included.

OUTCOME MEASURES

Studies were required to report: reliability coefficients (intraclass correlation coefficient, alpha reliability coefficient, limits of agreements and Bland-Altman plots); validity coefficients (intraclass correlation coefficient, Spearman's correlation, Kendal T coefficient, Pearson's correlation); or dropout rates.

RESULTS

Fourteen studies were eligible: none had low risk of bias, 10 had unclear risk of bias and four had high risk of bias. The included studies evaluated: Åstrand test; modified Åstrand test; Lean body mass-based Åstrand test; submaximal bicycle ergometer test following another protocol other than Åstrand test; 2-km walk test; 5-minute, 6-minute and 10-minute walk tests; shuttle walk test; and modified symptom-limited Bruce treadmill test. None of the studies assessed maximal exercise tests. Where they had been tested, reliability and validity were generally high. Dropout rates were generally acceptable. The 2-km walk test was not recommended in fibromyalgia.

CONCLUSION

Moderate evidence was found for reliability, validity and acceptability of submaximal exercise tests in patients with chronic pain, fibromyalgia or chronic fatigue. There is no evidence about maximal exercise tests in patients with chronic pain, fibromyalgia and chronic fatigue.

The association between catastrophizing and craving in patients with chronic pain prescribed opioid therapy: a preliminary analysis

BACKGROUND

A growing number of studies have shown that opioid craving (i.e., the perceived need or desire to consume opioids) is one of the strongest determinants of prescription opioid misuse in patients with chronic pain prescribed opioid therapy. To date, however, the factors that are associated with craving in patients with pain remain largely unexplored. Based on previous research, there is reason to believe that catastrophizing might be associated with heightened opioid craving.

OBJECTIVES

To test the hypothesis that catastrophizing would be associated with heightened craving in patients with chronic pain prescribed long-term opioid therapy.

DESIGN AND SUBJECTS, AND METHODS

In this cross-sectional study, 109 patients with chronic pain were asked to provide self-reports of catastrophizing and craving. Patients also provided self-reports of pain intensity and depressive symptoms.

RESULTS

We found that higher levels of catastrophizing were associated with higher levels of craving. Importantly, results of a regression analysis revealed that the association between catastrophizing and craving remained significant even after controlling for a host of demographic (i.e., age, sex), psychological (i.e., depressive symptoms), medical (i.e., pain intensity, pain duration), and medication regimen (i.e., opioid doses) variables.

CONCLUSIONS

Our preliminary findings provide valuable new insights into the determinants of craving in patients with pain. The finding that catastrophizing was associated with craving even after controlling for a host of demographic, psychological, medical, and medication regimen variables is particularly striking, and raises questions concerning the factors that underlie the association between catastrophizing and craving in patients prescribed opioid therapy.

Physical functioning after occupational rehabilitation and returning to work among employees with chronic musculoskeletal pain and comorbid depressive symptoms

Background

The aim of this investigation was to assess whether measures of physical functioning after multidisciplinary rehabilitation are associated with return to work among individuals with chronic musculoskeletal pain conditions and comorbid depressive symptoms.

Methods

Included were 92 employees with chronic musculoskeletal disorders who had participated in a 57- week multidisciplinary rehabilitation program. Their ages ranged from 25–59 years. The Hospital Anxiety and Depression Scale was used to assess depressive symptoms. Different aspects of physical functioning (muscle strength, mobility, endurance capacity, and balance) were measured with single-item visual analog scales, and physical fitness was measured with the validated COOP/WONCA charts. Being on “active work strategies,” such as receiving rehabilitation benefit/vocational rehabilitation or being reported partly or completely fit, was defined as “on their way into/in work”. Cross-sectional associations were measured using logistic regression models, estimating odds ratio with 95% confidence intervals.

Results

There were no differences between the “on their way into/in work” group (n=70) and the “on their way out/out of work” group (n=22) regarding age, sex, or levels of anxiety or pain. Surprisingly, regression analyses showed that those with higher levels of physical functioning had significantly lower odds of returning to work.

Conclusion

The findings of an inverse relationship between self-reported physical function and returning to work in this sample illustrate that the return-to-work process among employees with chronic musculoskeletal pain and comorbid depressive symptoms is multifactorial and influenced by factors other than physical functioning at the individual level. Further research, especially longitudinal studies, is needed to assess the occupational trajectories among employees with chronic musculoskeletal pain and comorbid depressive symptoms after participation in a multidisciplinary rehabilitation program.

Factors promoting a successful return to work: from an employer and employee perspective

OBJECTIVE

Efforts have been made to explain the inability to return to work (RTW) due to employees' chronic musculoskeletal pain. Knowledge of factors facilitating the RTW process is however still limited. Based on the experiences of employees and employers, this study aims to identify factors promoting a successful return process for persons with chronic musculoskeletal pain.

METHODS

The findings from interviews, involving six employees with musculoskeletal pain, and five employers with various work experience, were analysed by Giorgi's phenomenological analysis through four stages.

RESULTS

The major themes underlying the employees' comments for a successful RTW were identifying and mobilizing their personal resources, adapting a balanced daily life, and requiring a positive dialogue with family and their employer, while the employers underlined the need for a helpful adjustment at work and how they wanted to become more involved in the rehabilitation process.

CONCLUSIONS

In conclusion our findings underline the need for extended collaboration between the employees, employer, and rehabilitation staff, and should encourage occupational therapists to direct even more of their expertise towards the situation at the workplace.

Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain

BACKGROUND

As a consequence of the substantial rise in the prescription of opioids for the treatment of chronic noncancer pain, greater attention has been paid to the factors that may be associated with an increased risk for prescription opioid misuse. Recently, a growing number of studies have shown that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse.

OBJECTIVE

The primary objective of this study was to examine the variables that might underlie the association between catastrophizing and risk for prescription opioid misuse in patients with chronic pain.

METHODS

Patients with chronic musculoskeletal pain (n=115) were asked to complete the SOAPP-R, a validated self-report questionnaire designed to identify patients at risk for prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, catastrophizing, anxiety, and depression.

RESULTS

Consistent with previous research, we found that catastrophizing was associated with an increased risk for prescription opioid misuse. Results also revealed that the association between catastrophizing and risk for opioid misuse was partially mediated by patients' levels of anxiety. Follow-up analyses, however, indicated that catastrophizing remained a significant 'unique' predictor of risk for opioid misuse even when controlling for patients' levels of pain severity, anxiety and depressive symptoms.

DISCUSSION

Discussion addresses the factors that might place patients with high levels of catastrophizing at increased risk for prescription opioid misuse. The implications of our findings for the management of patients considered for opioid therapy are also discussed.

Predicting return to work following treatment of chronic pain disorder

BACKGROUND

The care of injured workers with chronic pain remains an important public health issue given its increasing prevalence. The consequences often include loss of self-esteem and stress in family relationships.

AIMS

To report our interdisciplinary approach to the care of chronic pain disorder (CPD) and describe the predictors associated with a successful return to work (RTW).

METHODS

Relevant covariates, including demographic data, time from injury, and functional scores were recorded for clients injured at work in Ontario, Canada. Our primary outcome, RTW, was assessed at 3 months post-discharge. Descriptive statistics and logistic regression were used to identify those factors predicting a successful RTW.

RESULTS

Of the injured workers who participated in the interdisciplinary CPD treatment programme, 1002 clients met our inclusion criteria and were included in the study. Fifty-five per cent were male with a mean age of 46 years. Median time from injury to treatment was 720 days. At 3 months post-treatment, 136 (14%) of the participants were working. Multivariable logistic regression revealed that earlier time since injury (OR = 0.71, 95% CI 0.55-0.92) and presence of an RTW coordinator (RTWC) (OR = 3.42, 95% CI 2.08-5.63) were significant predictors of successful RTW. There was also a significant interaction between RTWC involvement and time since injury. The latter did not appear to influence the likelihood of RTW when an RTWC was present.

CONCLUSIONS

Workers compensation boards should refer injured workers with CPD to treatment programmes as early as possible to achieve a successful RTW. Additionally, RTWCs play an important role in improving work outcomes.

Workers who stay at work despite chronic nonspecific musculoskeletal pain: do they differ from workers with sick leave?

PURPOSE

Most workers with chronic nonspecific musculoskeletal pain (CMP) do not take sick leave, nor consult a health care professional or search vocational rehabilitation. Yet, the knowledge of many researchers, clinicians and policy makers is largely based on people with CMP who discontinue work. The aim of this study was to explore characteristics of workers who stay at work despite CMP, and to compare these with sick-listed workers with CMP following vocational rehabilitation.

METHODS

The clinical characteristics of workers who stay at work despite CMP (n = 119) and sick-listed workers who follow vocational rehabilitation (n = 122) were described and the differences between these groups were assessed. Logistic regression analysis was used to assess differences between the groups and to determine which variables predicted group status.

RESULTS

Workers who stayed at work despite CMP reported significantly lower levels of fear avoidance (OR = 0.94), pain catastrophizing (OR = 0.93), perceived workload (OR = 0.93), and higher pain acceptance (OR = 1.11), life control (OR = 1.62) and pain self-efficacy (OR = 1.09) compared to sick-listed workers following rehabilitation, even after controlling for confounders. The groups did not differ on physical activity level, active coping and work satisfaction. Group status was predicted best by pain intensity, duration of pain, pain acceptance, perceived workload, mental health, and psychological distress (area under the receiver operating characteristic curve = 0.91, 95% CI = 0.87-0.95).

CONCLUSIONS

A wide range of characteristics of workers who stay at work despite CMP were explored. Relevant differences from sick-listed workers with CMP were observed in all domains of the bio-psycho-social model. Six main predictors were identified that best discriminate between both groups.

Multidisciplinary pain treatment - Which patients do benefit?

Background The prevalence of chronic non-malignant pain in developed countries is high, ranging from 14% to 50%. Patients with chronic pain are active users of health-care services and they report impaired health-related quality of life (HRQoL) when compared with the general population. Psychological distress has been identified as one of the risk factors for pain chronicity. Depression, anxiety and negative beliefs are associated with pain interference and perceived disability. Multidisciplinary pain management (MPM) aims to rehabilitating chronic pain patients by addressing both physical, psychological, social and occupational factors related to the pain problem. MPM programmes have been shown to be effective in reducing pain and improving function in patients with diverse chronic pain states. However, MPM programmes are often heterogeneous and predicting MPM treatment results in different patients groups may be difficult. Methods The present study examined changes in HRQoL after MPM in 439 patients treated at a multidisciplinary pain clinic using the 15D HRQoL questionnaire. The characteristics of the 100 patients with the greatest improvement and the 100 patients with the largest decrease in HRQoL were examined more closely (demographics, characteristics of pain, pain interference, psychiatric comorbidity, employment status, details of MPM) after answering a follow-up 15D questionnaire at three years after their MPM had ended. Result During MPM, HRQoL was significantly improved in 45.6% of the 439 patients, decreased in 30.7% of the patients and did not change in 23.7% of the patients. Patient-related factors that predicted a better HRQoL among the 100 patients with good MPM outcome compared with the 100 patients with poor MPM outcome were higher education and better employment status. Age, gender, marital status, duration of pain, number of pain sites, pain intensity or pain interference at baseline did not differ between the patient groups. Patient expectations regarding MPM were similar. A tendency towards more psychiatric comorbidity in the non-responder group was seen. The duration of MPM in the two patient groups was similar, as well as the number of medications started, the variety of specialists seen and psychiatric counselling with supportive therapy included. More non-responder than responder patients had died during the three-year follow-up period, some of the deaths were related to substance abuse. Conclusions and Implications HRQoL in chronic pain patients was significantly improved during MPM compared with the baseline. Pain duration of several years, multiple pain sites and neuropathic pain were not discerning factors between the responders and non-responders of the present study, implying that a positive change in HRQoL may be achieved by MPM even in these pain patients. In agreement with previous studies, factors predicting poor treatment outcome in the non-responder group of chronic pain patients were not treatment related. To further improve MPM outcome even in pain patients with risk factors for less benefit of treatment such as low education and poor general health, more individualized MPM approaches with emphasis on analysis and treatment of psychological symptoms and patient beliefs is essential.

Functional disability among chronic pain patients receiving long-term opioid treatment

This study of 2,163 adult chronic, non-cancer-pain, long-term opioid therapy patients examines the relationship of depression to functional disability by measuring average pain interference, activity limitation days, and employment status. Those with more depression symptoms compared to those with fewer were more likely to have worse disability on all 3 measures (average pain interference score >5, OR = 5.36, p < .0001; activity limitation days ≥ 30, OR = 4.05, p < .0001; unemployed due to health reasons, OR = 4.06, p < .0001). Depression might play a crucial role in the lives of these patients; identifying and treating depression symptoms in chronic pain patients should be a priority.

Barriers to rehabilitation and return to work for unemployed chronic pain patients: A qualitative study

This paper explores the perceived barriers to return to work presented by unemployed patients with chronic musculoskeletal pain. The findings are based on one to one in depth semi-structured interviews conducted with patients from four sites in the UK. Interview data were recorded from 38 patients (15 male, 23 female) aged between 29 and 62 years the sample included patients who had participated in a vocational rehabilitation scheme, those who had refused to participate and a nai ve group. Patients were in receipt of long-term social welfare benefits (incapacity benefits) and recruited via local Job Centres. The mean duration of work absence was over 5 years. The data was transcribed and analysed by means of thematic analysis. Several themes were identified as barriers to return to work from the data including pain related issues, uncertainty (both financial and physical), the healthcare system, interaction with benefits providers, perceptions of employers and personal limitations. The uncertainty and the pain condition itself were the overarching barriers from which other obstacles stemmed. This is the first qualitative study of long term unemployed benefit recipients with chronic pain. Others authors have reported psychosocial factors as barriers to work among disabled populations however, this qualitative study has identified barriers specific to unemployed chronic pain patients. The themes identified will help with the planning and development of future initiatives for returning chronic pain patients to employment.

Catastrophizers with chronic pain display more pain behaviour when in a relationship with a low catastrophizing spouse

The present study examined the relationship between couple concordance of catastrophizing and adverse pain outcomes. Possible mechanisms underlying the relationship between couple concordance of catastrophizing and pain outcomes were also explored. Fifty-eight couples were recruited for the study. The chronic pain patients were filmed while lifting a series of weighted canisters. The spouse was later invited to view the video and answer questions about the pain experience of their partner. Median splits on Pain Catastrophizing Scale scores were used to create four 'catastrophizing concordance' groups: low catastrophizing patient-low catastrophizing spouse; low catastrophizing patient-high catastrophizing spouse; high catastrophizing patient-low catastrophizing spouse; and high catastrophizing patient-high catastrophizing spouse. Analyses revealed that high catastrophizing pain patients who were in a relationship with a low catastrophizing spouse displayed more pain behaviours than patients in all other groups. These findings suggest that high catastrophizing chronic pain patients may need to increase the 'volume' of pain communication to compensate for low catastrophizing spouses' tendency to underestimate the severity of their pain experience. Patients' perceived solicitousness and punitive response from the spouse could not explain the group differences in pain behaviour. Theoretical and clinical implications of the findings are discussed.

Factors promoting staying at work in people with chronic nonspecific musculoskeletal pain: a systematic review

PURPOSE

To identify determinants for staying at work (SAW) in workers with chronic musculoskeletal pain (CMP).

METHOD

A systematic review of factors that promote SAW in workers with CMP. We searched the databases of PubMed, EMBASE, PsycInfo, CINAHL and the Cochrane Library. We included studies reporting on working subjects without present CMP-related sick leave. A quality assessment of GRADE criteria and evidence synthesis was performed.

RESULTS

We identified five cross-sectional studies and two qualitative studies reporting on factors associated with SAW in workers with CMP. Consistent association with SAW was found for low perceived physical disability and low emotional distress (low-level evidence). Duration of pain, catastrophizing, self-esteem and marital status were not associated with SAW (low-level evidence). Qualitative studies indicated that personal adjustments and workplace interventions are important determinants for SAW (evidence not graded).

CONCLUSIONS

No high-level evidence for SAW determinants for workers with CMP was identified. Future interventions aimed at promoting SAW could consider reducing perceived physical disability and emotional distress, and promoting adjustment latitude at work, support from supervisors, and the workers' motivation and self-management skills. Further research is required because knowledge of SAW in workers with CMP is scarce, and the relevance of the subject is high.

Are performance-based measures predictive of work participation in patients with musculoskeletal disorders? A systematic review

Objective

Assessments of whether patients with musculoskeletal disorders (MSDs) can participate in work mainly consist of case history, physical examinations, and self-reports. Performance-based measures might add value in these assessments. This study answers the question: how well do performance-based measures predict work participation in patients with MSDs?

Methods

A systematic literature search was performed to obtain longitudinal studies that used reliable performance-based measures to predict work participation in patients with MSDs. The following five sources of information were used to retrieve relevant studies: PubMed, Embase, AMA Guide to the Evaluation of Functional Ability, references of the included papers, and the expertise and personal file of the authors. A quality assessment specific for prognostic studies and an evidence synthesis were performed.

Results

Of the 1,230 retrieved studies, eighteen fulfilled the inclusion criteria. The studies included 4,113 patients, and the median follow-up period was 12 months. Twelve studies took possible confounders into account. Five studies were of good quality and thirteen of moderate quality. Two good-quality and all thirteen moderate-quality studies (83%) reported that performance-based measures were predictive of work participation. Two good-quality studies (11%) reported both an association and no association between performance-based measures and work participation. One good-quality study (6%) found no effect. A performance-based lifting test was used in fourteen studies and appeared to be predictive of work participation in thirteen studies.

Conclusions

Strong evidence exists that a number of performance-based measures are predictive of work participation in patients with MSDs, especially lifting tests. Overall, the explained variance was modest.

Impact of psychological factors in the experience of pain

This article reviews the role of psychological factors in the development of persistent pain and disability, with a focus on how basic psychological processes have been incorporated into theoretical models that have implications for physical therapy. To this end, the key psychological factors associated with the experience of pain are summarized, and an overview of how they have been integrated into the major models of pain and disability in the scientific literature is presented. Pain has clear emotional and behavioral consequences that influence the development of persistent problems and the outcome of treatment. Yet, these psychological factors are not routinely assessed in physical therapy clinics, nor are they sufficiently utilized to enhance treatment. Based on a review of the scientific evidence, a set of 10 principles that have likely implications for clinical practice is offered. Because psychological processes have an influence on both the experience of pain and the treatment outcome, the integration of psychological principles into physical therapy treatment would seem to have potential to enhance outcomes.

Understanding the link between depression and pain

Background and aims

Patients seeking care for a pain problem very often also report symptoms of depression.In fact, depression is associated with the development of chronic pain as well as poor treatment results. Yet, the mechanisms by which depression and pain impact upon one another are not clear. This paper provides a critical review of the literature with the aim of shedding light on the relationship between pain and depression. Further, we introduce the Örebro Behavioral Emotion Regulation Model which may stimulate understanding in addition to research.

Method

Data bases (MedLine and PsychINFO) were searched as well as reference lists to locate relevant articles, especially previous reviews, published since 2000. We located 244 articles including 6 reviews.

Results

We found that while depression is strongly linked to pain, there is little understanding of how this link works or how it might be utilized in clinical settings. It is not clear whether one of the symptoms precedes the other, but when both are present prognosis is significantly affected. Clinicians often fail to assess both depression and pain resulting in probable “under” treatment of one or both problems. There is little evidence that treating the pain will result in the disappearance of the depression. Indeed, early improvements in depression are associated with overall treatment gains for patients with musculoskeletal pain. Therefore, treatment outcomes might be substantially enhanced by addressing both the pain and the depression. Moreover, directly addressing the depression early in treatment may be especially valuable. While pharmacological treatments of depression are often pursued for pain patients, the results for depression, pain and function are not impressive. Although there are effective cognitive-behavioral techniques for depression, these have not been properly evaluated in patients with co-morbid pain and depression.

We found two likely mechanisms that can help to explain the link between depression and pain. First, catastrophizing plays a central role in models of both pain and depression and hence might form an important link between them. Second, emotion regulation is important in both depression and pain since they both can be viewed as significant emotional stressors. We offer a model which focuses on the recurrent nature of pain and depression. It hypothesizes that flare-ups trigger catastrophic worry which in turn strains the individual’s emotion regulation system. Successful behavioral emotion regulation is said to result in coping while negative behavioral emotion regulation results in spiraling negative affect, pain and mood related disability and, in the long term, a consequent relapse.

Implications

Since both pain and depression are closely linked and are both involved in the development of long-term problems, it is important for clinicians to assess them as early as possible. Moreover, both symptoms should be monitored and addressed in treatment to maximize outcome results. Because pharmacological treatment has limited effects, cognitive-behavioral therapy is an alternative. Behavioral emotion regulation may be an important mechanism linking depression and pain.

Conclusions

It is concluded that pain and depression impact on each other and play an important role in the development and maintenance of chronic problems. Future studies of treatments for co-morbid depression and pain are urgently required. The purposed Örebro Behavioral Emotion Regulation Model provides much needed guidance for investigating the psychological mechanisms involved.

Depression among injured workers receiving vocational rehabilitation: contributions of work values, pain, and stress

INTRODUCTION

Work-related injuries or disabilities result in significant negative consequences to physical, economic, social, and psychological well-being. Depression has been shown to increase post-injury and to contribute to poor return to work outcomes. The primary goals of the study were to test known correlates of depression in a sample of injured workers receiving vocational rehabilitation and to assess the unique contribution of work values in injured worker depression.

METHOD

Scores on depression, stress, pain, work values, and demographic information were obtained from an archived sample of 253 injured workers receiving vocational rehabilitation.

RESULTS

Hierarchical multiple linear regression was used for analyses, resulting in a final model with a "large" effect size (R (2) = 0.42). The accepting vs. investigative work value dimension accounted for variance in depression scores beyond that accounted for by covariates and other significant correlates. Of the study variables, significant regression coefficients were found for pain, psychosocial stress, an interaction between pain and stress, and having an accepting work value.

CONCLUSIONS

Injured workers experiencing higher levels of pain and stress and who prefer to avoid workplace challenges may be vulnerable to experiencing depression. Results suggest that the presence of pain, stress, and the accepting work value dimension should be monitored in injured workers, and that the role of work values in injured worker depression may be a fruitful area for further research.

Narrative slope as a predictor of work and other occupational participation

This study aims to determine the utility of the narrative slope in predicting the vocational/productive outcomes of participants. For 65 participants living in supportive facilities for adults with HIV/AIDS in the United States, narrative slopes, based on the Occupational Performance History Interview II, were constructed and classified as progressive, stable, or regressive. Information regarding participants' productive activities was collected at discharge from intervention programming, and at 3-month intervals, up to 9 months. Data were analyzed to examine the relationship between narrative slope and engagement in employment and other productive activity post-intervention. Demographic variables were also analyzed. None of the demographic factors significantly correlated to outcomes. It was found that a more positive narrative slope was predictive of a higher likelihood of being employed or engaged in other productive activity.

Characteristics of disability pensioners returning to work: An interview study among individuals with musculoskeletal disorders

PURPOSE

To explore adaptation patterns among disability pensioners with musculoskeletal disorders returning to work by means of the Swedish law on 'resting disability pension'.

METHOD

Qualitative analyses of interviews with 17 individuals going back to work.

RESULTS

Three adaptation patterns were identified: The Go-getter, the Realist and the Indifferent. These differed regarding influence factors, own expectations, motive, morals and mentality.

CONCLUSION

Several actors may support a return to work for individuals who received a disability pension due to musculoskeletal disorders. In order to succeed, however, it is essential that the disability pensioner is motivated for a reconstruction of his/her life.

Depression and occupational disability in five diagnostic groups: A review of recent research

PURPOSE

To compare the methodologies and results of research across five diagnostic groups in which there was expected to be a high prevalence of depression and occupational disability.

METHOD

A review of research published since 1994 was carried out concerning depression and occupational disability in five diagnostic groups: Major depressive disorder (MDD), spinal cord injuries (SCI), traumatic brain injuries (TBI), chronic back pain (CP) and myocardial infarction/coronary artery bypass grafting (MI/CABG).

RESULTS

Prospective longitudinal designs were mostly undertaken in MDD studies. Diagnostic interview schedules were utilized in most MDD studies whereas self-report inventories that tend to confound somatic and depressive symptoms were mostly used in CP, SCI, TBI and MI/CABG studies. In longitudinal MDD studies both depression and occupational disability were related to access to enhanced primary care treatment. On the other hand, CP research reported different results concerning the strength of depressive symptoms, cognitive and psychosocial factors in predicting occupational disability. Different trends across diagnostic groups were evident in relation to depression, occupational disability, co-morbidity, socio-demographic factors and psychosocial resources.

CONCLUSIONS

Co-morbid, socio-demographic and psychosocial factors provide a framework from which to identify those at greater risk of depression and occupational disability. However, more CP, SCI, TBI and MI/CABG studies with diagnostic schedules, prospective designs and longer follow-up are required.

A prospective sequential analysis of the fear-avoidance model of pain

The primary purpose of this study was to analyze the sequential relationships proposed by the fear-avoidance model of pain [Vlaeyen JWS et al. The role of fear of movement/(re)injury in pain disability. J Occup Rehab 1995;5:235-52]. Specifically, this study evaluated whether early change in catastrophizing predicted late change in fear of movement, and whether these factors influenced post-treatment return-to-work. Secondary analyses tested relationships between (1) early change in catastrophizing, late change in depression, and disability; and (2) early change in catastrophizing, late change in pain severity, and disability. Analyses were conducted on a sample of 121 individuals (82 men and 32 women) with a work-related musculoskeletal injury, and high baseline catastrophizing and fear of movement scores. Participants were enrolled in a 10-week community-based disability management intervention, and they completed measures of catastrophizing, fear of movement, depression and pain severity at pre-, mid- and post-treatment. Return-to-work was assessed 4 weeks following termination of the intervention. Contrary to predictions, results from correlational analyses revealed non-significant relationships among indices of early change in catastrophizing and late changes in fear of movement, depression and pain severity. Multiple logistic regression analyses revealed that early change in catastrophizing, late changes in fear of movement and late change in pain severity were significant predictors of return-to-work, while late changes in depression were not. These findings highlight the importance of reductions in psychosocial risk factors in augmenting return-to-work outcomes. Implications for the fear-avoidance model and future research are discussed.

Efficacy and treatment compliance of a home-based rehabilitation programme for chronic low back pain: a randomized, controlled study

OBJECTIVE

To assess the efficacy and treatment compliance of a home-based rehabilitation programme for chronic low back pain (CLBP).

POPULATION

CLBP outpatients treated in a Physical Medicine Rehabilitation or Rheumatology unit within a university hospital.

METHODS

We performed a prospective, comparative study. The participants were randomly assigned to either a home-based rehabilitation programme (Gp A) or a standard physical therapy (Gp B). The programme included four weekly sessions. In each group, we measured pain intensity (on a visual analogue scale, VAS), flexibility and muscle endurance (the Schöber MacRae test, finger-to-floor distance, thigh-leg angle, the Shirado and Sorensen test), functional and psychological repercussions (the Quebec functional index and the Hospital Anxiety and Depression scale) and handicap (on a VAS). Follow-up examinations took place at baseline and four weeks and three, six and 12 months later.

RESULTS

One hundred and seven patients (82 women) with a mean+/-standard deviation (S.D.) age of 35.7+/-0.8 years were included (with 54 patients in Gp A). At four weeks, a significant improvement (relative to baseline) was observed for all parameters in both study groups but with a significantly greater difference in Gp A, which was maintained at one year (despite an observed regression of the improvement at six months). At one year, compliance with the home-based rehabilitation programme was good (68.1%) and 59.5% of the patients regarded the programme as useful.

CONCLUSION

Our results suggest that a home-based rehabilitation programme is as effective as standard physical therapy. However, this type of programme requires patient motivation and regular follow-up.

Individual and relational correlates of pain-related empathic accuracy in spouses of chronic pain patients

OBJECTIVE

This study aims to investigate correlates of pain-related empathic accuracy in spouses of chronic pain patients. Specifically, analyses addressed: (1) the correlates of pain-related empathic accuracy, (2) the relation between pain-related empathic accuracy, and patient and spouse adaptational outcomes, and (3) the relation between pain-related empathic accuracy and relational outcomes.

METHODS

Fifty-eight chronic pain patients (28 women and 30 men) were filmed while participating in a simulated occupational lifting task. Patients were asked to report their level of pain while lifting canisters partially filled with sand. Spouses were later asked to view the video record of their partner's performance and to estimate their partner's level of pain. Empathic accuracy was defined in terms of the overall discrepancy between patients' pain ratings and spouses' pain estimates, and by the degree of covariation between patients' pain ratings and spouses' pain estimates across trials.

RESULTS

Analysis revealed that patients' pain severity, catastrophizing, fear of pain, and level of disability were significant correlates of empathic accuracy. Higher levels of pain-related empathic accuracy were associated to negative adaptational outcomes for chronic pain patients. With regard to the spouse, empathic accuracy was associated with the spouses' perceiving that they express less punitive responses when the patient is in pain. Empathic accuracy was not significantly related to relational outcomes.

DISCUSSION

The results of this study suggest that empathic accuracy is associated with negative outcomes for the patient, and might not be an important correlate of marital satisfaction in couples in which one of the partners is suffering from chronic pain.

Validation of a French-Canadian version of the Pain Disability Index

OBJECTIVE

To examine the psychometric properties of the Index de l'incapacité reliée à la douleur, a French-Canadian version of the Pain Disability Index (PDI).

METHODS

A total of 176 chronic pain patients (94 women, 82 men) completed the French-Canadian version of the PDI (PDI-CF), as well as other pain-related measures. A subset of 52 patients (27 women, 25 men) also completed a lifting task designed to assess physical tolerance and pain behaviour.

RESULTS

Confirmatory factor analysis of the PDI-CF supported the two-factor structure of the original PDI. Reliability analyses revealed that the PDI-CF total score had a high degree of internal consistency, comparable with the original PDI. The PDI-CF total score was significantly correlated with self-reported pain, pain catastrophizing, depressive symptoms, fear of movement or (re)injury, lift duration and pain behaviours.

CONCLUSIONS

The results suggest that the PDI-CF is a reliable and valid measure of self-reported disability that is psychometrically similar to the original scale.

Depression augments activity-related pain in women but not in men with chronic musculoskeletal conditions

OBJECTIVES

The primary objective of the present study was to examine the role of sex as a moderator of the relation between depression and activity-related pain.

METHODS

The study sample consisted of 83 participants (42 women, 41 men) with musculoskeletal conditions. Participants were asked to lift a series of 18 canisters that varied in weight (2.9 kg, 3.4 kg and 3.9 kg) and distance from the body. Participants were asked to rate their pain while they lifted each canister and estimate the weight of the canisters.

RESULTS

Consistent with previous research, the relations among depression, pain intensity and disability were stronger for women than for men. ANOVA revealed that depression was associated with more intense activity-related pain in women only. For both women and men, the intensity of pain increased with each trial, although the weight of the objects lifted remained constant. Neither sex nor depression had an effect on participants' weight estimates.

CONCLUSIONS

The present discussion addresses the mechanisms through which depression may differentially affect pain in women and men. It also addresses the potential clinical implications of pain-augmenting effects of depression in women.

Pain profiles and psychosocial distress symptoms in workers with low back pain

PURPOSE

The current study investigated the pain profiles of patients with subacute non-specific low back pain attending an outpatient return-to-work rehabilitation programme. Differences in symptoms of distress (depression and anxiety) and return to work between the pain-profile groups were assessed.

METHODS

Sixty-five volunteers who met the eligibility criteria and had complete follow-up data were included in the analysis. The mean age was 38.8 years (minimum 18, maximum 64); 38 (58.5%) were men. The median time since onset of low back pain was 30 days. Cluster analysis was used to categorize patients into groups according to pain severity scores (VAS).

RESULTS

Two distinct clusters-severe pain and moderate pain-emerged. There were significant differences in depressive and anxiety symptoms between the pain profiles. Further, return-to-work rates varied significantly between the two groups (31% in the severe pain cluster compared to 90% in the moderate pain cluster).

CONCLUSION

Although both groups showed significant improvements in depression and anxiety symptoms over time, the severe pain cluster scored higher at discharge (higher scores indicating worse outcomes). These results highlight the importance of early identification of sub-groups at risk so that rehabilitation interventions can be focused with the goal of minimizing long-term disability.

The role of perceived injustice in the experience of chronic pain and disability: scale development and validation

INTRODUCTION

The primary objective of this research was to evaluate the psychometric properties of a questionnaire designed to assess perceive injustice associated with injury.

METHODS

In Study 1, the 12-item Injustice Experience Questionnaire (IEQ) was administered to 226 individuals with musculoskeletal conditions. A subsample of 85 individuals were interviewed 1-year later about their ongoing symptoms and return to work status. In Study 2, the IEQ and other pain-related measures were administered on two separate occasions to 70 pain patients participating in a functional restoration rehabilitation program.

RESULTS

-Study 1 Principal components analysis yielded a two-component solution with eigenvalues greater 1. Item content of the two components reflected elements of blame and irreparability of loss. In cross sectional analyses, the IEQ was significantly correlated with measures of catastrophic thinking, r = .75, P < .01, fear of movement/re-injury, r = .58, P < .01, depression, r = .66, P < .01, and pain severity, r = .54, P < .01. Cross-sectional regression analyses revealed that the IEQ, beta = .44, P < .01, and the PCS, beta = .18, P < .05, each contributed significant unique variance to the prediction of pain severity. The IEQ prospectively predicted return to work status, OR = .75, 95% CI = .58-.99, but not pain severity.

RESULTS

-Study 2 Analyses supported the test re-test reliability of the IEQ, r = .90, P < .01. Treatment-related changes in the IEQ were significantly correlated with an objective index of improved physical function, r = .51, P < .01.

CONCLUSIONS

The findings of these two studies support the construct validity of the IEQ and suggest that this measure might be a useful complement to psychosocial assessment of individuals with persistent pain conditions. Discussion addresses the processes through which perceived injustice might impact on disability and rehabilitation outcomes.

Employment outcomes of persons with a mental disorder and comorbid chronic pain

OBJECTIVE

This study examined the independent and interactive effects of common mental disorders and chronic pain conditions on employment and work outcomes among individuals under 65 years old.

METHODS

Cross-sectional data were analyzed from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000-2001 (N=5,328). Common mental disorders were assessed by using the short-form version of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and employment outcomes were identified by self-report. Logistic and linear regression analyses were used to provide estimates for work impairment on the basis of the presence of a mental disorder or a chronic pain condition or both.

RESULTS

The interaction between presence of a mental disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (odds ratio=2.3, 95% confidence interval=1.2-4.2) and number of days of work missed in the past month because of health (regression coefficient=1.47, SE=.59). In stratified analyses this effect persisted for women but not for men. The presence of a mental disorder and the presence of a chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days because of health, although the interaction was not significant.

CONCLUSIONS

Mental disorders and chronic pain are each associated with work disability. Mental disorders are more strongly associated with some work disability outcomes when they are accompanied by chronic pain, especially among women.

Employment outcomes of persons with a mental disorder and comorbid chronic pain

OBJECTIVE

This study examined the independent and interactive effects of common mental disorders and chronic pain conditions on employment and work outcomes among individuals under 65 years old.

METHODS

Cross-sectional data were analyzed from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000-2001 (N=5,328). Common mental disorders were assessed by using the short-form version of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and employment outcomes were identified by self-report. Logistic and linear regression analyses were used to provide estimates for work impairment on the basis of the presence of a mental disorder or a chronic pain condition or both.

RESULTS

The interaction between presence of a mental disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (odds ratio=2.3, 95% confidence interval=1.2-4.2) and number of days of work missed in the past month because of health (regression coefficient=1.47, SE=.59). In stratified analyses this effect persisted for women but not for men. The presence of a mental disorder and the presence of a chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days because of health, although the interaction was not significant.

CONCLUSIONS

Mental disorders and chronic pain are each associated with work disability. Mental disorders are more strongly associated with some work disability outcomes when they are accompanied by chronic pain, especially among women.

Stage of chronicity and treatment response in patients with musculoskeletal injuries and concurrent symptoms of depression ☆

The present study examined the relation between stage of chronicity and treatment response in patients with work-related musculoskeletal conditions and concurrent depressive symptoms. Also of interest was the role of reductions in pain severity, catastrophic thinking and fear of movement/re-injury as mediators of the relation between chronicity and treatment response. A sample of 80 individuals (38 women, 42 men) with a disabling musculoskeletal pain condition and concurrent depressive symptoms participated in the research. Individuals with work absence of less than 6 months (range 12-26 weeks) were classified as early chronic (N=40), and individuals with work absence greater than 6 months (range 27-52 weeks) were classified as chronic. Both groups were matched on sex, age (+/-2 years) and severity of depressive symptoms. All participants were enrolled in a 10-week community-based disability management intervention. The early chronic group showed significantly greater reduction in depressive symptoms, and pain symptoms, than the chronic group. Regression analyses revealed that pain reduction, but not catastrophic thinking or fear of movement/re-injury, mediated the relation between chronicity and improvement in depressive symptoms. The results highlight the importance of early detection and treatment of depressive symptoms, given that treatment response decreases over time. The results also suggest that reductions in depressive symptoms might be a precondition to the effective reduction of pain symptoms in this population. Discussion addresses the factors that might contribute to treatment resistance as the period of disability extends over time.

Chronic nonmalignant pain: a challenge for patients and clinicians

Chronic pain is widely regarded as a condition that is triggered by various factors, including physical, socio-cultural and psychological deficiencies (that is, maladaptive beliefs). These factors are important in the development and maintenance of this unpleasant experience, which consequently requires a biopsychosocial treatment approach. Pain is a multifaceted sense, the perception of which is personal. Pain also depends on various circumstances, and therefore represents a challenge for the patient, as well for the treating physicians. Patients who suffer from long-lasting pain with a predominantly psychosocial component should be referred to specialized pain clinics for further diagnostic assessment and possible allocation to multidisciplinary pain programs. High-quality randomized controlled trials indicate that multidisciplinary pain programs represent the best therapeutic option for the management of patients with complaints associated with complex chronic pain. The prevalence and the costs--both direct and indirect--that are attributed to chronic pain are increasing; however, not enough is being done to sufficiently and effectively treat chronic pain. There is, therefore, a need for well-designed, interdisciplinary, internationally comparable, and widely distributed pain programs, both in outpatient and inpatient settings, to contribute to the prevention of some future pain diseases.

Subjective quality of life according to work status following interdisciplinary work rehabilitation consequent to musculoskeletal disability

INTRODUCTION

Individualized subjective quality of life (ISQoL) is the appraisal of quality of life according to personal values, desired goal attainment and life priorities. "Gap" is a way to operationalize ISQoL. ISQoL is rarely measured by interdisciplinary work rehabilitation (IWR) programs attended by the musculoskeletal disorder (MSD) population. These programs commonly measure pain intensity, physical capacity, perceived disability, distress and return to work.

OBJECTIVES

The aims of this study were to compare ISQoL according to work status and reference values and to explore the relationships between ISQoL and common IWR measures.

METHODS

Six months after completing an IWR program, 40 working and 31 not-working participants completed questionnaires documenting work status, pain, ISQoL gap, health-related quality of life (SF-36, PCS and MCS), perceived disability and distress.

RESULTS

No significant difference in global ISQoL gap was found between working and not-working participants. When compared to reference values considerable variability exists but globally, for both groups, ISQoL gap scores were below average. The following clinical variables were related to global ISQoL (P < 0.05): pain (r = -0.42), PCS (r = -0.37), MCS (r = -0.56), perceived disability (r = 0.37) and distress (r = 0.61). High distress, present in both groups, explains 38% of the global ISQoL gap variance and PCS adds 4%.

CONCLUSION

Following IWR programs for the chronic MSD population, global ISQoL gap is not related to work status. The use of a client-centered interactive computerized measure of ISQoL reveals that domains related to emotional well-being are likely the most problematic for the persistently disabled MSD population.

Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial

OBJECTIVE

To compare the short-term outcomes of active individual therapy (AIT) with those of a functional restoration program (FRP).

DESIGN

Prospective randomized controlled study.

SETTING

Two rehabilitation centers and private ambulatory physiotherapy facilities.

PARTICIPANTS

One hundred thirty-two adults with chronic low back pain. Fifty-one percent of patients on sick leave or out of work (mean duration, 180d in the 2y before treatment).

INTERVENTIONS

For 5 weeks, FRP (at 25h/wk) or AIT (at 3h/wk).

MAIN OUTCOME MEASURES

Trunk flexibility, back flexor, and extensor endurance (Ito and Sorensen tests), general endurance, pain intensity, Dallas Pain Questionnaire (DPQ) scores, daily activities, anxiety depression, social interest, and work and leisure activities, and self-reported improvement (work ability, resumption of sport and leisure activities).

RESULTS

All outcome measures improved after treatment except endurance in AIT. There was no between-group difference for pain intensity or DPQ daily activities or work and leisure activities scores. Better results were observed in FRP for all other outcome measures. There was a significant effect of treatment and the initial value for the gain of the Sorensen score with a treatment or initial value interaction; a significant effect of treatment and initial value on the gains of Ito, endurance, and DPQ social interest and anxiety depression scores, with no treatment or initial value interaction; and a significant effect of initial value but not treatment for the gains of DPQ daily activities and work and leisure activities scores.

CONCLUSIONS

Low-cost ambulatory AIT is effective. The main advantage of FRP is improved endurance. We speculate that this may be linked to better self-reported work ability and more frequent resumption of sports and leisure activities.

Prediction of function in daily life following multidisciplinary rehabilitation for individuals with chronic musculoskeletal pain; a prospective study

BACKGROUND

The prevalence of chronic musculoskeletal pain is high, with widespread negative economic, psychological, and social consequences for the individual. It is therefore important to find ways to predict the outcome of rehabilitation programmes in terms of function in daily life. The aims of this study were to investigate the improvements over time from multidisciplinary rehabilitation in terms of pain and function, and analyse the relative impact of individual and psychosocial factors as predictors of function in daily life in individuals with chronic musculoskeletal pain.

METHODS

A prospective study was conducted among one hundred and forty three (N = 143) musculoskeletal pain patients. Measures of pain, function, and functional health status were obtained at baseline, after 5 weeks of intensive training, at the end of the 57-week rehabilitation programme, and at a 1 year follow-up, using validated self-administrated measures. Linear regression analysis was applied to investigate the relative impact of musculoskeletal pain, individual-, and psychosocial factors in function.

RESULTS

The participants studied showed a significant increase in function during the 57 weeks rehabilitation period. There was also a significant increase in function from the end of the rehabilitation period (57th week) to the one year follow-up measures. Pain intensity associated significantly with pain experience over all measurement periods. High levels of pain intensity (beta = .42**) and pain experience (beta = .37*), and poor psychological capacity (beta = -.68*) at baseline, as well as poor physiological capacity (beta = -.44**) and high levels of anxiety (beta = .48**) and depression (beta = .58***) at the end of the rehabilitation program were the most important prognostic factors of variance in functioning over the 4 measurement periods.

CONCLUSION

The data suggest that physical capacity, emotional distress and coping skills should be priority areas in rehabilitation programmes to improve functioning in daily life.