The prediction of return to the workplace after Multidisciplinary Pain Center treatment

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.

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.

Delayed recovery in patients with whiplash-associated disorders

BACKGROUND

Prognosis of whiplash injury has been found to be related to a number of sociodemographic, treatment and clinical factors. In the current study, we attempt to identify several novel prognostic factors for delayed recovery in whiplash-associated disorders (WADs), using a validated and reliable measure of recovery.

PATIENTS AND METHODS

Retrospective review of a large database of a national network of physiotherapy and rehabilitation service providers in Canada yielded 5581 individuals injured in motor vehicle collisions. Cases were grouped into 3 cohorts based on time lapsed between injury date and initial presentation. Acute (n=3075), early chronic (n=958) and chronic (n=1548) patient cohorts were compared regarding treatment outcome and relative distribution of 29 prognostic factors. Outcome was defined by a minimally important clinical change (10%) on a previously validated disability questionnaire between initial and discharge rehabilitation visits.

RESULTS

Analysis demonstrated positive outcomes to be proportionally fewer in the chronic cohort (52.1%) relative to the early chronic (61.4%), which was in turn lower than the acute cohort (72.3%). Furthermore, individuals presenting with chronic pain were more likely to: (1) be female; (2) present with lower limb pain or nonorganic signs; (3) have returned to work; (4) have retained a lawyer; or (5) have undergone previous spinal surgery, and were less likely to: (1) present with neck or midback pain; (2) live in Ontario or Nova Scotia; or (3) have modified duties upon return to work. Acute, early chronic and chronic cohorts were also found to differ in the distribution of several other prognostic factors at initial clinical visit.

CONCLUSIONS

Recovery in whiplash-associated disorder appears to be multifactorial with both medical and non-injury related factors influencing outcome. Further characterisation of these factors may prove invaluable in guiding future clinical treatment and referral practices.

Readiness for change predicts outcomes of functional rehabilitation following motor vehicle accident

INTRODUCTION

Previous research has found pre-treatment motivational readiness to engage in pain self-management to be associated with completion of a rehabilitation program. This preliminary study examined this relationship, as well as the ability of pre-treatment readiness to change to predict clinical decisions of post-treatment functional work capacity.

METHODS

The sample consisted of 106 individuals involved in a tertiary functional rehabilitation program for motor vehicle accident (MVA) survivors. The Multidimensional Pain Inventory (MPI) and Pain Stages of Change Questionnaire (PSOCQ) were completed prior to treatment.

RESULTS

Hierarchical logistic regression analyses revealed that PSOCQ profile scores (P = 0.008), including higher individual PSOCQ contemplation (OR = 5.30; P = 0.017) and action (OR = 5.16; P = 0.049) scores, significantly increased the likelihood of completing the functional rehabilitation program. Clinical decisions about functional work capacity were predicted by MPI profile scores (P = 0.001), and this model was significantly improved by the addition of PSOCQ scores (P = 0.037). Lower MPI interference (OR = 5.41; P = 0.002), and higher MPI affective distress (OR = 2.81; P = 0.010), MPI support (OR = 1.72; P = 0.027), and PSOCQ action (OR = 5.35; P = 0.038) scores were significant predictors of clinicians' decisions regarding functional work capacity in the final model that identified 88% of those judged capable of returning to work and 63% of those who were judged not capable of returning to work.

CONCLUSIONS

This preliminary study suggests that readiness to self-manage pain is an important predictor of both completion of functional rehabilitation program and clinicians' decisions regarding functional work capacity after an MVA. The latter outcome appears to be more complex, influenced both by motivational readiness to engage in pain self-management and cognitive-behavioral adaptation to pain.

Predicting work status following interdisciplinary treatment for chronic pain

The effectiveness of interdisciplinary treatments for chronic pain is well established. In general, these treatments decrease psychosocial distress and increase physical abilities. Further, return to work rates following interdisciplinary treatment tend to be quite high. Previous studies have highlighted a number of factors that individually influence return to work rates; however, there is a need for more comprehensive and unified models that allow an evaluation of the inter-relations among these factors. The present investigation examined how demographic and treatment outcome variables interacted to influence post-treatment return to work rates in a sample of individuals with chronic pain following interdisciplinary treatment. Results indicated that patient age, lifting ability, pain duration, depression level, and reported disability were individually related to return to work; however, when these variables were evaluated relative to one another, level of depression and patient age had the best ability to predict post-treatment work status. These results add to the literature by specifically highlighting post-treatment factors that best discriminate patients who had returned to work from those that had not. Furthermore, they provide evidence that general emotional distress is perhaps the most important predictor of work status following treatment.

Risk for five forms of suicidality in acute pain patients and chronic pain patients vs pain-free community controls

OBJECTIVES

. The objective of this study was to determine the risk for five forms of suicidality in rehabilitation acute pain patients (APPs) and rehabilitation chronic pain patients (CPPs) vs pain-free community controls.

DESIGN

The Battery for Health Improvement 2 was developed utilizing a healthy (pain-free) community sample (N = 1,478), a community patient sample (N = 158), and a rehabilitation patient sample (N = 777). These groups were asked five suicidality questions relating to history of wanting to die, wanting to die because of pain, recent frequent suicide ideation, having a suicide plan, and history of suicide attempt. Of the rehabilitation patients, 326 were identified as being APPs, 341 as being CPPs, and 110 as having no pain. The risk for affirming each of the five suicidality questions was calculated for rehabilitation APPs, rehabilitation CPPs, and rehabilitation patients without pain utilizing the healthy pain-free community sample as the reference group. In addition, risk was calculated for various subgroups of rehabilitation patients: those with worker's compensation status, with litigation status, and with personal injury status.

SETTING

There are a variety of settings.

RESULTS

In rehabilitation CPPs the risk for suicidality was greater than community pain-free controls for three suicidality questions: history of wanting to die, recent frequent suicide ideation, and having a suicide plan. Worker's compensation status, litigation status, and personal injury status appeared to increase risk for affirmation of some types of suicidality in CPPs. Rehabilitation APPs were at greater risk for all five suicidality items than the community pain-free controls.

CONCLUSION

Rehabilitation CPPs are at greater risk for some forms of suicidality than community pain-free controls. This risk is increased by variables such as worker's compensation status, litigation status, and personal injury status. However, it is yet unclear if these variables actually predict suicidality as this requires further analysis.

Pain locus of control predicts return to work among Spanish fibromyalgia patients after completion of a multidisciplinary pain program

OBJECTIVE

To assess the influence of the pain locus of control on return to work in fibromyalgia patients.

METHODS

Ninety-eight fibromyalgia patients on sick leave were enrolled in a multidisciplinary treatment program and were followed up for 12 months post-discharge. Treatment was considered successful at discharge in the case of patients who returned to work and unsuccessful in patients who remained sick listed. Treatment was considered successful during follow-up in patients who remained at work for at least the last 6 months of follow-up. Patients who took sick leave again and those lost to follow-up were considered failures. Logistic regression methods were used to define the best predictive models of treatment failure.

RESULTS

Fifty-eight patients were considered treatment successes at discharge and 50 at 12-month follow-up. The subscale Fate from the Multidimensional Health Locus of Control-Pain Scale and the Health Assessment Questionnaire predicted treatment failure at discharge (-2lnR=57.79; chi-square=74.74; df=2; P<.001). The predictive model of treatment failure at 12-month follow-up was unspecific.

CONCLUSION

Fibromyalgia patients undergoing a multidisciplinary treatment who were least likely to return to work at discharge were those with a pain locus of control characterized by more negative expectations about pain progression and a high perceived functional disability.

Does smoking status affect multidisciplinary pain facility treatment outcome?

OBJECTIVES

Smoking may be a major problem in chronic low back pain (LBP) patients. The goal of this study was to determine whether smoking status affected multidisciplinary pain facility treatment outcome.

DESIGN

As part of a grant study, chronic LBP patients identified themselves as either current smokers (N = 81) or current nonsmokers (N = 140), and were compared by chi-square for employment status at 1, 6, 12, and 24 months after multidisciplinary pain facility treatment. Smokers who were unemployed at each time interval were then compared with employed smokers for a large number of assessment scales and clinical variables of interest by chi-square or Student's t-test. The significant independent variables from these analyses were then utilized in a logistic regression to determine predictors for smoker nonemployment.

SETTING

Pain facility.

RESULTS

Current smokers were less likely to be employed at each follow-up time point. Pain levels over the previous 24 hours predicted employment status for current smokers at 1-, 12-, and 24-month follow-up, while worker compensation status predicted employment status at 6 months.

CONCLUSIONS

Current smoking status appears to be associated with poorer treatment outcome after multidisciplinary pain facility treatment. Return to work within smokers is predicted by pain and worker compensation status. Pain facilities should target current smokers with significant perceived pain for close treatment monitoring in an attempt to improve treatment outcome.

The influence of the grade of chronicity on the outcome of multidisciplinary therapy for chronic low back pain

STUDY DESIGN

Prospective longitudinal clinical study.

OBJECTIVE

The objective of the study was to analyze the outcome of different stages of chronicity in patients with chronic low back pain treated with a multidisciplinary therapy.

SUMMARY OF BACKGROUND DATA

Results of studies comparing different grades of chronicity in therapy for chronic low back pain have not been published so far.

METHODS

A total of 387 patients with chronic low back pain for 3 months or longer and a corresponding sick leave for longer than 6 weeks underwent a 3-week standardized multidisciplinary therapy. At baseline (T0), patients were assigned into 3 groups of chronicity grades according to the classification of von Korff et al (Group A, Grades I and II; Group B, Grade III; Group C, Grade IV) and were prospectively followed. At the the 6-month follow-up (T1), 5 different therapy outcomes were analyzed and compared in the 3 groups: back-to-work status, generic health status (SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy.

RESULTS

At T0, patients in Group C had a higher pain level, a longer history of pain, and more general and more psychosomatic comorbidities than patients with lower levels of chronicity. All 3 treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up, there were significantly better results in terms of functional capacity and pain level in patients with lower grades of chronicity but mostly due also to worse initial baseline values. Back-to-work rate, satisfaction with therapy, and the Mental Component Summary of the SF-36 did not show a significant difference at T1 between the groups analyzed.

CONCLUSION

According to the results of this study, patients with chronic low back pain also derive significant benefit from a multidisciplinary treatment strategy in higher stages of chronicity. Therefore, therapy should not be limited to the patients in lower stages of chronicity.

The INTERMED questionnaire for predicting return to work after a multidisciplinary rehabilitation program for chronic low back pain

OBJECTIVES

To evaluate the performance of the INTERMED questionnaire score, alone or combined with other criteria, in predicting return to work after a multidisciplinary rehabilitation program in patients with non-specific chronic low back pain.

METHODS

The INTERMED questionnaire is a biopsychosocial assessment and clinical classification tool that separates heterogeneous populations into subgroups according to case complexity. We studied 88 patients with chronic low back pain who followed an intensive multidisciplinary rehabilitation program on an outpatient basis. Before the program, we recorded the INTERMED score, radiological abnormalities, subjective pain severity, and sick leave duration. Associations between these variables and return to full-time work within 3 months after the end of the program were evaluated using one-sided Fisher tests and univariate logistic regression followed by multivariate logistic regression.

RESULTS

The univariate analysis showed a significant association between the INTERMED score and return to work (P<0.001; odds ratio, 0.90; 95% confidence interval, 0.86-0.96). In the multivariate analysis, prediction was best when the INTERMED score and sick leave duration were used in combination (P=0.03; odds ratio, 0.48; 95% confidence interval, 0.25-0.93).

CONCLUSION

The INTERMED questionnaire is useful for evaluating patients with chronic low back pain. It could be used to improve the selection of patients for intensive multidisciplinary programs, thereby improving the quality of care, while reducing healthcare costs.

Age as a predicting factor in the therapy outcome of multidisciplinary treatment of patients with chronic low back pain—a prospective longitudinal clinical study in 405 patients

This prospective longitudinal clinical study evaluates the prognostic value of age in the therapy outcome of patients with chronic low back pain treated with a multidisciplinary therapy. Four hundred five patients with chronic low back pain for 3 months or longer and a corresponding sick leave for longer than 6 weeks underwent a 3-week standardized multidisciplinary therapy. Patients were assigned into three groups of age with comparable baseline values at T0. At the 6-month follow-up (T1) five different therapy outcomes were analysed and compared in the three groups: back-to-work status, generic health status (SF36), pain intensity, functional capacity, and satisfaction with the therapy. All three treatment groups improved significantly in all outcome criteria between T0 and T1 except of functional capacity, which did not improve in the older patients. In the total group, the back-to-work rate was 61.7%. At the final follow-up, there were significantly better results in terms of functional capacity and pain level in younger patients, whereas back-to-work rate and satisfaction with therapy did not show a significant difference between the groups analysed. According to the results of this study, older patients with chronic low back pain also derive significant benefit from a multidisciplinary treatment strategy, although in some outcome criteria results were inferior to those obtained in younger patients.

Lidocaine 5% Patch: An Open-Label Naturalistic Chronic Pain Treatment Trial and Prediction of Response: Table 1

OBJECTIVE

There have been a few open-label nonplacebo reports on the successful use of lidocaine 5% patch (L5P) for other types of pain besides postherpetic neuralgia, such as chronic low back pain. With the these reports, we began to utilize L5P routinely for chronic pain patients (CPPs) with various pain diagnoses. The purpose of this report was to describe the results of a retrospective review of this open-label naturalistic L5P chronic pain treatment trial and to attempt to delineate predictors of perceived clinical response.

DESIGN

Consecutive CPPs were selected for this clinical trial according to the following inclusion criteria: the CPPs with pain greater than 6-month duration and either a hyperalgesic pain area or trigger point, which could be covered by one L5P, were offered a 3-day L5P naturalistic treatment trial. The purpose of this trial was to determine which CPPs would perceive improvement and continue using L5P. CPPs entering the trial completed the neuropathic pain scale (NPS) at entrance and completion of the trial. The senior author also completed a baseline information tool on each CPP entering this naturalistic trial. At the completion of the 3-day trial, the CPPs were asked if they perceived pain improvement with the use of L5P. In the retrospective review, the CPPs were thus segregated into two groups, those with and without perceived clinical improvement, and were statistically compared for available clinical variables. Logistic regression was then utilized to determine which significant independent variables contributed to the correct prediction of perceived improvement.

SETTING

Multidisciplinary pain facility.

PATIENTS

Patients with chronic pain.

RESULTS

Of 362 consecutive CPPs, 114 or 31.5% were deemed candidates for this naturalistic trial. None of the CPPs refused or fulfilled exclusion criteria eliminating them from the trial. The total sample (N = 114) showed statistical improvement on all 10 NPS scales (except scales 4 and 6) plus the NPS 4, NPS nonallodynic 8, and NPS 10. The perceived clinically improved group (N = 87, 76.3% of those entering the trial), also showed perceived improvement on all preceding scales except 4 and 6. The perceived clinically nonimproved group (N = 27, 23.7% of those entering the trial) showed statistical improvement on scales B and NPS 10. Perceived improvement was predicted by the following variables: pain wakes patient up, patch placement not low back, and not in litigation. These variables explained 9.8%, 20%, and 14% of the variance, respectively. Overall, 44.5% of the variance was explained.

CONCLUSIONS

A significant percentage of CPPs exposed to an L5P 3-day naturalistic trial perceived clinical improvement. However, this can only be concluded as an initial effect, and whether or not this effect is attributable to L5P cannot be derived from our data as the effect could have been nonspecific. The apparent CPP perceived clinical improvement was not associated with any particular useful clinical indicator. As such, at present, no variable can be recommended for use in selecting CPPs for such a naturalistic L5P clinical treatment trial. However, this study indicates that such a trial can be useful in selecting CPPs who may perceive benefit from L5P.

Influence of workers’ compensation eligibility upon functional recovery 10 to 28 years after polytrauma

BACKGROUND

Previous studies have shown that work-related injuries are often associated with inferior outcomes. The aim of the current study was to compare the long-term functional outcome after polytrauma between work-related and non-work-related injuries at a minimum follow-up of 10 years.

METHODS

Six hundred thirty-seven polytrauma patients were evaluated using a patient questionnaire and a physical examination. The average follow-up was 17.5 years (range 10-28 years); the average Injury Severity Score (ISS) was 20.7 (range 4 to 54).

RESULTS

A multivariate analysis, with adjustments for age, sex, injury severity, and injury pattern, demonstrated that work-related injuries resulted in significantly inferior outcomes measured by the Hannove Score for Polytrauma Outcome (HASPOC), 12-Item Short-Form Health Survey (SF-12), requirement for medical aids and devices, length of rehabilitation, and retirement status (P < .05).

CONCLUSIONS

Polytrauma patients receiving workers' compensation achieve significantly inferior long-term outcomes than other patients. The obtained results demonstrate that psychosocial variables such as insurance status have a significant impact on the functional recovery following polytrauma.

Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering?

This is a structured evidence based review of all available studies addressing the concept of nonorganic findings (Waddell signs) and their potential relationship to secondary gain and malingering. The objective of this review is to determine what evidence, if any, exists for a relationship between Waddell signs and secondary gain and malingering. Waddell signs are a group of 8 physical findings divided into 5 categories, the presence of which has been alleged at times to indicate the presence of secondary gain and malingering. A computer and manual literature search produced 16 studies relating to Waddell signs and secondary gain or malingering. These references were reviewed in detail, sorted, and placed into tabular form according to topic areas, which historically have been linked with the alleged possibility of secondary gain and malingering: 1) Waddell sign correlation with worker compensation and medicolegal status; 2) Waddell sign improvement with treatment; 3) Waddell sign correlation with Minnesota Multiphasic Personality Inventory validity scores; and 4) Waddell sign correlation with physician dishonesty perception. Each report in each topic area was categorized for scientific quality according to guidelines developed by the Agency for Health Care Policy and Research. The strength and consistency of this evidence in each subject area was then also categorized according to Agency for Health Care Policy and Research guidelines. Conclusions of this review were based on these results. There was inconsistent evidence that Waddell signs were not associated with worker's compensation and medicolegal status; there was consistent evidence that Waddell signs improved with treatment; there was consistent evidence that Waddell signs were not associated with invalid paper-pencil test; and there was inconsistent evidence that Waddell signs were not associated with physician perception of effort exaggeration. Overall, 75% of these reports reported no association between Waddell signs and the 4 possible methods of identifying patients with secondary gain and/or malingering. Based on the above results, it was concluded that there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association.

Palliative pharmaceutical care: a randomized, prospective study of telephone-based prescription and medication counseling services for treating chronic pain

OBJECTIVE

To evaluate the effects of providing a unique telephone-based pharmaceutical care program to a sample of patients enrolled at a university pain clinic in Philadelphia, Pa. We hypothesized that in comparison to routine pharmaceutical care, the telephone-based pharmaceutical care program would have a positive impact on delivery of medication, quality of life, and overall satisfaction with the pain clinic program.

PATIENTS

One hundred seven pain clinic patients were randomly assigned to the control and intervention groups. Seventy-four patients (control group, n = 36; intervention group, n = 38) met inclusion criteria.

METHOD

The control group continued to receive care and prescription services through the same means as prior to the study. There were 2 components to the pharmaceutical care program offered to the intervention group. The first component consisted of a palliative care pharmacy company, PainRxperts, providing specialized prescription services tailored to the needs of a pain medicine clinical practice. The second component involved the palliative-trained pharmacist's proactive monitoring of patient pharmacotherapy for potential or actual drug related problems (DRPs).

RESULTS

Intervention patients perceived that they had better access to medication, more efficient processing of prescriptions, and fewer stigmatizing experiences. They also endorsed pharmacists' behavioral interventions such as medication counseling, availability to answer medication-related questions, and non-judgmental attitudes when managing opioid prescriptions.

CONCLUSION

This study suggests that the palliative-trained pharmacist can play an important collaborative role in managing chronic pain. Application of the pharmaceutical care model in pain medicine centers can improve satisfaction and remove some of the barriers to good pharmaceutical care facing patients with chronic pain disorders

Pain: psychiatric aspects of impairment and disability

Patients with chronic pain frequently experience a complex and convoluted journey through the health care system that often is unrewarding for all involved. As job satisfaction and financial security diminish during our economic recession, the impact of the disability epidemic becomes more profound. There often is no direct correlation between objective impairment and a patient's request for disability status. Injured workers maintained on workers' compensation may have an increased risk for developing chronic pain syndromes unresponsive to conventional treatments. These patients may have significant financial, psychosocial, and environmental reinforcement for maintenance of their disability and little incentive to return to work. Excessive pain behavior may lead to unnecessary diagnostic testing or invasive procedures and result in iatrogenic complications and prolonged disability. Patients with chronic pain syndrome who have not had psychosocial treatment may not be at maximum medical improvement. The purpose of this paper is to help the readership identify types of psychiatric, psychologic, and psychosocial issues that can coexist in patients with chronic pain who are applying for disability, and to help treating physicians avoid contributing to iatrogenic pain and disability by performing needless and potentially harmful procedures on patients who may be better served with an emphasis on psychiatric or psychologic care.

Vocational rehabilitation in patients with chronic rheumatic diseases: a systematic literature review

OBJECTIVE

To describe the effectiveness of vocational rehabilitation programs for patients with chronic rheumatic diseases by means of a systematic review of the literature.

METHODS

Data were obtained by a computer-aided and manual search of the literature from 1980 until May 2001. Vocational rehabilitation programs had to be clearly defined interventions specifically aimed at having patients with rheumatic diseases reenter or remain in the work force. The vocational rehabilitation programs had to be executed by one or more health professionals. Outcome of the intervention had to be described in terms of vocational status (work disability, sick leave, job modification, paid occupation, retraining).

RESULTS

Six studies were identified. All were uncontrolled studies. Follow-up periods ranged 2-84 months. Five of six vocational rehabilitation programs consisted of multidisciplinary intervention and 15% to 69% of the patients successfully returned to work.

CONCLUSIONS

Although 5 of 6 studies showed a marked positive effect of vocational rehabilitation on work status, proof of the benefit of these interventions is limited, mainly due to methodologic differences and shortcomings.

RELEVANCE

Work disability is a major consequence of the disease in patients with rheumatic conditions. More and more attention is being paid to preventing disability and promoting return to work. Knowledge regarding the effectiveness of vocational rehabilitation programs is insufficient. Semin Arthritis Rheum 32:196-203.

Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process

STUDY DESIGN

A literature review was conducted.

OBJECTIVE

To examine the outcome of behavioral (BT) and cognitive-behavioral treatment (CBT), collectively referred to as BT-CBT, for chronic pain, to identify the predictors of treatment outcome, and to investigate the change processes associated with these treatments.

SUMMARY OF BACKGROUND DATA

Numerous controlled clinical trials of BT-CBT for chronic pain, alone or more commonly in multidisciplinary treatment contexts, suggest that these treatments are effective. However, further study is needed to examine which outcome variables change, when, for whom, and how.

METHODS

Published literature was gathered from Medline, PsychLit, and searches of relevant journals.

RESULTS

Overall, BT-CBT for chronic pain reduces patients' pain, distress, and pain behavior, and improves their daily functioning. Differences across studies in sample characteristics, treatment features, and assessment methods seem to produce varied treatment results. Also, some patients benefit more than others. Highly distressed patients who see their pain as an uncontrollable and highly negative life event derive less benefit than other patients. Decreased negative emotional responses to pain, decreased perceptions of disability, and increased orientation toward self-management during the course of treatment predict favorable treatment outcome.

CONCLUSIONS

Current BT-CBT helps many patients with chronic pain. Continuing clinical research should improve the matching of treatments with patient characteristics and refine the focus of treatments on behavior changes most associated with positive outcome. Further study of fear, attention, readiness to adopt self-management strategies, acceptance of pain, and new combinations of interdisciplinary treatments may lead to improved interventions.

Impact of functional restoration after anterior cervical fusion on chronic disability in work-related neck pain

BACKGROUND CONTEXT

Spinal surgery in the workers compensation population shows evidence of less favorable outcomes than in general health cases. Although spine surgery has been alleged to be a cause of poor outcomes, such outcomes may be improved by appropriate postsurgical rehabilitation.

PURPOSE

To compare objective demographic, physical and psychological measurements and socioeconomic outcomes of treatment in work-related disabling cervical pain for the combination of anterior cervical fusion (ACF) plus functional restoration, compared with rehabilitation alone.

STUDY DESIGN/SETTING

A prospective study of patients undergoing ACF for degenerative disc disease before rehabilitation for work-related musculoskeletal disorders versus neck pain unoperated controls, with data collected in an outpatient tertiary interdisciplinary rehabilitation setting.

PATIENT SAMPLE

A group of 52 patients completed a functional restoration treatment program after undergoing ACF (Group S) at one or two levels for degenerative cervical disc disease. During the study period, 625 patients with work-related neck pain were identified from the same study population, from which a rehabilitation (Group R) comparison group (n=150) was identified who were stratified according to the number and location of other compensable body parts.

OUTCOME MEASURES

Socioeconomic outcomes relevant to chronic disabling work-related cervical spinal disorders are reported based on 1-year posttreatment interviews. Pre- to posttreatment assessment of pain intensity, disability, depression and cumulative physical capability were assessed prospectively.

METHODS

All patients were totally or partially disabled before completing an intensive, medically supervised, functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. Preprogram preparation included drug detoxification, psychotropic medication management and preparatory aerobic and mobility training. The intensive treatment phase involved strength and endurance training, with counseling geared to goals of work return and fitness maintenance. The 1-year structured clinical interview had a contact rate of 93% to 95%, and partial information acquisition on all patients.

RESULTS

Although Group S had lower work return and work retention outcomes, the differences were not significant. Group S patients had significantly more health utilization from a new provider in the year after completion of functional restoration (46% vs 24%; OR=2.7 [1.3, 5.3], p<.004). Group S patients were also more likely to be depressed, both at pre- and postrehabilitation. There were no significant differences in recurrent injury, additional surgery, physical measures or pain/disability self-report between the groups.

CONCLUSIONS

Workers compensation patients with chronic disabling work-related cervical spinal disorders who undergo a cervical fusion, combined with functional restoration, have socioeconomic outcomes after their surgery statistically similar to those for unoperated controls. Surgery patients had a higher rate of additional health-care-seeking behaviors from new providers and a greater likelihood of being clinically depressed before and after rehabilitation. This study suggests that cervical fusion for degenerative disc disease in workers compensation patients is not contraindicated, as long as interdisciplinary rehabilitation is available for complex cases after the surgical procedure.

Refractory chronic pain

Refractory chronic pain is a significant public health problem and frustrating to everyone affected by it. All physicians can participate in the care of these patients, but psychiatrists should take a leading role in their care. A comprehensive approach offers hope and increases the opportunities for successful treatment. Each perspective of an interdisciplinary formulation has a unique logic that defines specific methods for designing treatment for the patient with refractory chronic pain. The patient does not have to fit into one theoretic approach or model to receive and accept treatment. The patient's diagnoses are based on the formulation, which then directs treatment along rational directions. The linkages and interactions of a patient's diagnoses can then be investigated within a framework that includes the entire person and not just his or her biochemistry. If a patient's suffering persists, other factors must be considered that may have been overlooked before the treatment plan is abandoned or modified. Usually these factors are within one of the perspectives initially thought to be less important. A new combination of approaches is then required to treat the patient successfully. The perspectives appreciate not only that the patient is struggling through important life events but also that he is a person composed of vulnerabilities and strengths, having made many choices and afflicted by diseases.

[Efficiency of multidisciplinary treatment of chronic pain with locomotor disability]

BACKGROUND AND OBJECTIVE

Disabling chronic pain is especially devastating among working population and, in many cases, it does not respond to conventional therapies. In chronic pain, the importance of psychosocial and occupational factors, in addition to biological ones, has prompted the development of successful multidisciplinary treatment programmes in various countries. We assessed the outcome of a multidisciplinary therapeutic program for work-disabled selected patients with chronic pain refractory to conventional treatment.

PATIENTS AND METHOD

The study included 70 patients (58 women, mean age [SD]: 42 [9]years) with chronic pain and sick leave (mean [SD]: 7 [4] months of work disability) diagnosed with fibromyalgia (51%), chronic low back pain (16%), regional myofascial pain (15%), cervicocraneal syndrome (3%), anquilosing spondylitis (3%), and other conditions(12%). All patients had received previous pharmacological treatment,physical therapy and/or other measures (surgery in 12% cases)without improvement. All patients underwent an intensive multidisciplinary treatment of 4 weeks' duration including medical techniques for pain control, cognitive-behavioural therapy, physical therapy,and occupational therapy. Average follow-up was 10 (4) months(1-24 months) post-discharge.

RESULTS

Significant improvements were observed with regard to all relevant variables, as reflected in pre and post-discharge measures: pain(Visual-Analogue Scale 1-10 cm): 7.4 (1.5) versus 3.2 (2) (p <0.01); anxiety (HARS), 19 (7) versus 14 (8) (p < 0.01); depression(BDI), 16 (8) versus 10 (8) (p < 0.01); functional ability(HAQ), 1.6 (0.4) versus 0.6 (0.5) (p < 0.001). At discharge,73% of patients returned to work. In addition, 69% of treated patients maintained the acquired improvement and their employment status at the end of follow-up.

CONCLUSION

Multidisciplinary treatment of chronic pain with special attention to work return is useful for selected patients with a disabling chronic pain syndrome refractory to conventional treatment.

Quality of life and chronic nonmalignant pain

Chronic nonmalignant pain is a prevalent and costly phenomenon. Chronic pain induces stressors that affect personal and work lives of sufferers. Because of this interference, quality of life is impacted. The purpose of this pilot study was to explore the impact of stressors on the quality of life of adult patients with chronic pain. The framework guiding this study was Neuman's Systems Model based on the concepts of stress and reaction to stress. A descriptive correlational research design was used to compare participants' quality of life according to their health and function; family, psychological, spiritual, and socioeconomic status; and the stressors of age, gender, income, marital and work status, occupation, monthly treatment costs, and type of insurance. Each participant was administered the Ferrans and Powers Quality-of-Life Index and a demographic survey. Results revealed that a higher quality of life was associated with participants who were older, female, and employed, whereas a lower quality of life was associated with participants with a low income, higher treatment costs, and a lack of workmen's compensation insurance. Based on Neuman's model, the implications of chronic pain sufferers' resistance to the negative impact of various stressors are discussed.

Outcomes of pain center treatment in Washington State workers' compensation

BACKGROUND

Injured workers with chronic pain who have failed conventional therapies often receive treatment at pain centers. This study evaluated the effect of pain center treatment on time loss status of Washington State injured workers. The primary hypothesis was that treatment at a pain center would lead to a reduction in the probability of a worker's receiving time loss benefits at a 2-year follow-up.

METHODS

A population-based retrospective cohort study was performed on 2,032 Washington State workers' compensation patients who underwent pain center evaluations. Subjects who received pain center treatment were compared to those who were evaluated but not treated with respect to time loss status at 2-year follow-up.

RESULTS

Univariate analysis revealed that at 2-year follow-up, 35% of treated subjects were receiving time loss payments vs. 40% of evaluated only subjects (P < 0.05). Subjects who were younger, female, and less chronic were more likely to undergo pain center treatment and were less likely to be on time loss at 2-year follow-up. In multivariate analyses, which statistically controlled baseline differences between the two groups, there was no difference between treated subjects and evaluated only subjects.

CONCLUSIONS

There was no evidence that pain center treatment alters 2-year time loss status of already disabled workers.

Prediction of return-to-work of low back pain patients sicklisted for 3-4 months

The purpose of this Dutch prospective population-based study was to identify prognostic factors for return-to-work of employees with 3-4 months sick leave due to low back pain (LBP). A cohort of 328 employees was formed and baseline data were collected. One year after the first day of the sick leave, 91% of the original cohort participated in a second interview (n=298). During the baseline measurement, information was collected about health status, history of LBP, occupational variables, job characteristics and social economic variables. At the second interview, 66% of the employees had returned to work (n=198). Return-to-work was independently predicted by having a better general health status (OR 1.53; 95% CI 1.30-1.80), having better job satisfaction (OR 1.26; 95% CI 1.11-1. 44), being a bread winner (OR 2.46; 95% CI 1.37-4.40), having a lower age (OR 0.70; 95% CI 0.52-0.93) and reporting less pain (OR 0. 85; 95% CI 0.73-0.99) all measured at cohort entry. This study shows that psycho-social aspects of health and work in combination with economic aspects have a significantly larger impact on return-to-work when compared to relatively more physical aspects of disability and physical requirements of the job. This suggests that interventions aimed at return-to-work of employees sicklisted with LBP should predominantly be focused on these psycho-social aspects such as health behavior and job satisfaction, and on the (lack of) economic incentives for return-to-work.

Evidence-based data on pain relief with antidepressants

This structured review addresses the issue of whether antidepressants have an antinociceptive (analgesic) effect for chronic pain independent of their antidepressant effect. In order to answer this question, human acute pain studies, individual placebo-controlled studies for the treatment of specific chronic pain syndromes, and metaanalytic studies were reviewed and placed into table format. Analysis of this evidence led to the following conclusions: The evidence was consistent in indicating that overall antidepressants may have an antinociceptive effect in chronic pain, and that these drugs were effective for neuropathic pain. There was also some evidence that these drugs could be effective for psychogenic or somatoform disorder-associated pain. This evidence also strongly suggested that serotonergic-noradrenergic antidepressants may have a more consistent antinociceptive effect than the serotonergic antidepressants. Finally, this evidence indicated that antidepressants could be effective for pain associated with some specific pain syndromes, such as chronic low back pain, osteoarthritis or rheumatoid arthritis, fibrositis or fibromyalgia, and ulcer healing. Possible reasons for the conflicting results of studies in this area are presented, and problems that could limit the validity of the conclusions of this review are discussed.

Risk for Violent Behavior in Patients with Chronic Pain: Evaluation and Management in the Pain Facility Setting

OBJECTIVE

Recent evidence indicates that physicians are at high risk for patient-perpetrated violence. The objectives of this article, in association with case reports of patients with chronic pain (PWCP), are the following: to review the literature and determine if pain physicians could be at risk for PWCP-perpetrated violence; to review the current evaluation and management procedures for potentially violent patients; and to identify some situations specific to PWCPs that can heighten the risk of PWCP-perpetrated violence.

DESIGN

Previous literature on patient-perpetrated violence against physicians was reviewed. In addition, literature on the evaluation for risk of violent behavior and management of violent behavior was also reviewed. Seven potentially violent PWCPs are described, including some who had threatened pain physicians and institutions. PWCP-specific situations thought to be instrumental in increasing the risk of PWCP-associated violence were identified.

SETTING

Pain facility (multidisciplinary center). RESULTS OF REVIEW AND ANALYSIS OF CASE REPORTS: The literature on patient-perpetrated violence against physicians indicates that, statistically, pain physicians could be at risk for this type of violence. Seven PWCP cases of threatened or potentially violent behavior are described. These case report data indicate that PWCPs with the potential for violence against physicians or institutions do present for treatment at pain facilities. All seven PWCPs were in a number of situations specific to chronic pain that increased the possibility of violent behavior. These situations are described.

CONCLUSIONS

In the evaluation for risk of violence against physicians or institutions by PWCPs, one needs to understand PWCP-specific situations. Management of potential violent behavior cannot be effective without this understanding.

Using the “TOPS,” an Outcomes Instrument for Multidisciplinary Outpatient Pain Treatment

OBJECTIVE

To assess the reliability of an augmented SF-36 instrument, the Treatment Outcomes in Pain Survey ("TOPS"), in patients treated in two pain management programs, and present norms for initial values and treatment-related improvements.

DESIGN

Prospective case series at two sites with longitudinal follow-up.

SETTING

Multidisciplinary, comprehensive outpatient pain treatment centers in university hospitals in Salt Lake City and Boston.

PATIENTS

Nine hundred and forty seven adult outpatients with a range of socioeconomic, demographic, and ethnic characteristics, all referred for evaluation and treatment of chronic pain.

INTERVENTIONS

Usual practice multidisciplinary pain treatment.

OUTCOMES MEASURES

TOPS prior to pain treatment and 5-week nominal follow-up. Means and standard deviations of baseline and follow-up results. Psychometric results for reliability (Cronbach alpha), validity (item discriminant validity, validity coefficients), and related statistical precision measures for group and individual designs.

RESULTS

Several measures were precise enough to permit following individual patients in standard clinic treatment, of which the Total Pain Experience dimension was the most powerful. Similar psychometrics were observed in the Boston and Salt Lake City sites. The Pain Symptom, Objective Family/Social Disability, Objective Work Disability, and Upper Body Functional Limitations scales were validated.

DISCUSSION

The TOPS was designed to satisfy several models of clinical pain treatment. It successfully monitored treatment based on those models. Not all patients improve with treatment, but most do. The TOPS can be administered in a variety of ways, but we found paper and pencil administration with computer scanning of results quick and efficient for making the data available to clinicians as part of treatment.

CONCLUSIONS

The accuracy of the TOPS is sufficient to monitor the response of individual patients during multidisciplinary treatment of chronic pain. The TOPS provides needed documentation (e.g., to third-party payors) of the aggregate value of multidisciplinary outpatient treatment of chronic pain as well as its benefit for individual patients.

When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up

Managed care has been accused of ignoring the patient with pain. The challenge for a health maintenance organization (HMO) was not just how to deliver state-of-the-art care, but how to deliver it to the 40,000 members who experience chronic pain at a reasonable cost and with enduring outcomes. This article describes how one managed care organization set about improving the care of patients with chronic pain. The article includes the design process, the model implemented, and some suggestions for transfer of this technology to others who might want to explore developing a similar model.

Prognostic factors and treatment-related changes associated with return to work in the multimodal treatment of chronic back pain

The goals of the current study were to determine those preprogram (= prognostic) variables and treatment-related changes that predict return to work in the multimodal management of chronic back pain. The outcome measures for 143 patients at 6-month follow-up were analyzed. The program had a duration of 4 weeks, was based largely on the functional restoration approach (Mayer and Gatchel, 1998), and occurred within a workers' compensation framework. Some 87% of the patients successfully returned to work. Three sets of predictor variables were considered: demographic/socioeconomic data, physical measures, and psychological measures. Three prognostic variables proved to be significant negative predictors of return to work: time off work, previous spinal surgery, and a clinically elevated (preprogram) score on the MMPI-2 scale Lassitude-Malaise (Hy3). A repeated-measures MANOVA showed an incomplete return to work to be associated with only limited improvement in self-reported disability and pain report. However, patients who failed to return to work did not differ with regard to improvement in objective physical functioning or psychological distress. It is therefore hypothesized that a change in the perceived disability status is the key element necessary to return patients with chronic back pain to work, although ongoing reinforcement schemes operative in the home/work environment may lead to a relapse in the posttreatment phase.

Prediction of "intent", "discrepancy with intent", and "discrepancy with nonintent" for the patient with chronic pain to return to work after treatment at a pain facility

OBJECTIVE

We previously determined that "intent" to return to work post pain facility treatment is the strongest predictor for actual return to work. The purposes of the present study were the following: to identify variables predicting "intent"; to predict membership in the "discrepant with intent" group [those chronic pain patients (CPPs) who do intend to return to work but do not]; and to predict membership in the "discrepant with nonintent" group (those CPPs who do not intend to return to work but do).

DESIGN

A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job post-pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. Preinjury job perceptions and other demographic variables were utilized using stepwise discriminant analysis to identify variables predicting "intent" and predicting membership in the "discrepant with intent" and "discrepant with nonintent" groups.

SETTING

Pain facility (multidisciplinary pain center).

PATIENTS

Consecutive low back pain CPPs, mean age 41.66+/-9.54 years, with the most frequent highest educational status being high school completion (54.7%) and 60.2% being worker compensation CPPs.

RESULTS

"Intent" was predicted by (in decreasing order of probability) postinjury job availability variables, job characteristic variables, and a litigation variable. "Discrepant with intent" was predicted by (in decreasing order of probability) for the 1-month follow-up time point, postinjury job availability variables, pain variables, a litigation variable, and a function perception variable, and for the final follow-up time point, pain variables only. "Discrepant with nonintent" was predicted by (in order of decreasing probability) for the 1-month follow-up time point, a job availability variable, a demographic variable, and a functional perception variable, and for the final follow-up time point a pain variable and a job availability variable. The percentage of CPPs correctly classified by each of these analyses was as follows: "intent" 81.25%, "discrepant with intent" 87.01% (at 1-month follow-up) and 74.03% (final follow-up), "discrepant with nonintent" 92.16% (at 1-month follow-up) and 75.00% (final follow-up).

CONCLUSIONS

CPPs intentions of returning to their preinjury jobs are mainly determined by job availability and job characteristic variables but surprisingly not by pain variables. However, the results with "discrepant with intent" and "discrepant with nonintent" groups indicate that actual return to work is determined by an interaction between job availability variables and pain variables with pain variables predominating for long-term outcome.

Validity of the dictionary of occupational titles residual functional capacity battery

BACKGROUND DATA

The Dictionary of Occupational Titles (DOT) is a U.S. government publication that defines each job in the United States according to 20 job factors. Fishbain et al. (Spine 1994;19:872-80) developed a DOT residual functional capacity (RFC) battery whose predictive validity for employment/unemployment had not been tested previously.

OBJECTIVES

The purposes of this study were as follows: (a) to determine whether results of a DOT-RFC battery performed at completion of pain facility treatment predicted employment status at 30 months' follow-up and (b) to determine whether the DOT-RFC battery predicted employment capacity as determined by the DOT employment levels of the chronic pain patients' (CPPs) jobs.

STUDY DESIGN

This is a prospective low back pain CPP pain facility treatment study using employment status and the DOT occupational levels as outcome measures.

METHODS

One hundred eighty-five consecutive CPPs who fitted the selection criteria completed a DOT-RFC battery at the completion of pain facility treatment and were contacted at 1, 3, 6, 12, 18, 24, and 30 months for determination of their employment status and DOT employment level. Eight DOT job factors plus pain and worker compensation status were found to be significantly different between employed and unemployed CPPs and between those employed in different DOT employment levels. For the 10 variables, stepwise discriminant analysis was used to select final predictor variables. Sensitivity and specificity were calculated along with pain level cutpoints that separated the groups.

RESULTS

The eight DOT job factors found to be statistically significant between groups were the following: stooping, climbing, balancing, crouching, feeling shapes, handling left and right, lifting, carrying, and pain and worker compensation status. In the discriminant analysis, these variables could discriminate between the employed and unemployed categories, with a sensitivity and specificity of approximately 75%. The pain level cutpoint between employed and unemployed was 5.4 on a 10-point scale.

CONCLUSIONS

We cannot as yet predict DOT-RFC employment levels. However, if a CPP can pass the above eight DOT job factors and has a pain level less than the 5.4 cutpoint, that CPP will have a 75% chance of being employed at 30 months after treatment at the pain facility. Therefore, some DOT-RFC battery job factors demonstrate a predictive validity in the "real work world."

Treatment planning in pain medicine. Integrating medical, physical, and behavioral therapies

This article addresses a systematic approach to the treatment of chronic pain. The first section presents a biopsychosocial model of pain. The second section presents an application of the biopsychosocial approach to the clinical assessment and management of clinical cases with chronic pain.

Low back pain. Evaluation and management in the primary care setting

The primary care physician plays a major role in the identification of low back pain and the entry of the patient into the health care system. Acute low back pain remits within a short period of time in most patients, and major diagnostic studies are not required. If the pain persists beyond the treatment parameters of the primary care physician, consultation is necessary. A basic component of the initial evaluation is the identification of myofascial syndromes that mimic so-called root syndromes. Further, low back pain in the population at large is not usually a surgical problem, and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected. When the initial attempts at treatment fail, the patient should be referred to a multidisciplinary comprehensive pain center so as to avoid or limit chronicity, the earlier, the better. Practitioners should feel comfortable in asking the centers to which they make a referral for outcome data. If these are not available, the choice should be made elsewhere. Low back pain per se is in the majority not a neurologic problem, an orthopedic problem, or a neurosurgical problem, so that consultation with these groups, unless there are strong suspicions otherwise, has limited value. The criteria for selection and referral of patients to multidisciplinary pain centers have been presented, including specific considerations for the geriatric age group. The overwhelming cost of low back pain to the economy can be decreased along with suffering and the adverse impact that pain has on all social strata.

Primary care and pain medicine. A community solution to the public health problem of chronic pain

The author emphasizes that pain is an important public health problem that demands attention. He discusses ineffective management and its causes, administrative and socioeconomic problems perpetuating poor care, problems in technology transfer, organizational models, specialists and subspecialists, and other topics.

Rehabilitation: what do we do with the chronic patient?

Neurologists are often called on to see patients who have low back pain presenting with significant chronicity and disabling pain. Even in situations of chronic low back pain, it has been estimated that a structural diagnosis is made only 60% of the time. Even when a physical diagnosis is made in these cases, it may be irrelevant to the primary causes of persistent pain and disability. This article is designed to point out that, when nonstructural factors are adequately rehabilitated, even in a worst-case occupational injury cohort, remarkable outcomes can be anticipated irrespective of the structural pathology, patient age, or postoperative impairment.

Outcomes of disabling cervical spine disorders in compensation injuries. A prospective comparison to tertiary rehabilitation response for chronic lumbar spinal disorders

STUDY DESIGN

A prospective, longitudinal cohort study assessing quantitative socioeconomic outcomes of tertiary rehabilitation for chronically disabled patients with cervical spinal disorders compared with those with more common chronic lumbar spinal disorders.

OBJECTIVES

To assess 1-year socioeconomic outcomes of a worst-case cohort of consecutive patients with chronic cervical spinal disorders compared with those of patients with lumbar spinal disorders and to assess differences in an array of variables between those patients who reported any period of work during the posttreatment year and those who did not.

SUMMARY OF BACKGROUND DATA

Few investigators have evaluated outcomes in patients with cervical spinal disorders. None have specifically studied distinctions in socioeconomic outcomes in patients with chronic cervical spinal disorders and in patients with other spinal disorders. Reports of pain are noted to persist in a high percentage of patients with whiplash receiving compensation even 10 years after injury, but the status of work, use of health care resources, financial disputes, or recurrent injury are unknown.

METHODS

A cohort of consecutive chronically disabled patients with spinal disorders (N = 1198) was assessed for prospectively collected demographic, self-report, and physical performance data. A subset of patients (n = 421) with work-related cervical spinal disorders was compared with a group with various lumbar spinal disorders (n = 777). A structured clinical interview was administered 1 year after patients entered an interdisciplinary functional restoration program.

RESULTS

High rates of return to work and continuation of work were recorded in the cervical and lumbar spinal disorder groups, with low rates of recurrent injury, new surgery in the injured area, and use of health care resources. There were no statistically significant differences between the groups. Multivariate analyses showed several variables that differentiated between those patients who had any reported period of work during the post-treatment year versus those who did not in the cervical and the lumbar spinal disorder groups.

CONCLUSIONS

This first large cohort study of outcomes in chronically disabled patients with work-related cervical spinal disorder produced results similar to those found in tertiary functional restoration rehabilitation in chronic lumbar spinal disorders. In spite of poor outcomes reported in the literature for similar cervical and lumbar spinal disorders in patients receiving workers' compensation for disability, successful outcomes can be anticipated after effective rehabilitation, regardless of response to prerehabilitation treatment.

The meeting of pain and depression: comorbidity in women

The higher prevalence of depression in women is coupled with a higher prevalence of pain complaints. Growing evidence suggests that the comorbidity of these conditions is also proportionately higher in women than men. This paper critically reviews the empirical findings relating to gender differences in comorbid pain and depression as well as findings in support of hypothesized etiologic factors that could explain why women may be more susceptible than men to comorbidity. The empirical evidence for biogenic, psychogenic, and sociogenic explanatory models is presented, and an integration of these models is proposed as a guideline to both research and clinical practice. In conclusion, it is argued that gender-differentiated treatment strategies are not clinically indicated at this time.

Perceived efficacy of pain clinics in the rehabilitation of injured workers

OBJECTIVE

To assess the perceived efficacy of pain clinics in the rehabilitation of injured workers among four groups of professionals.

DESIGN

A questionnaire was given to 351 subjects representing four professional groups: physicians, vocational rehabilitation counselors, staff at pain clinics, and employees of a workers compensation program. Subjects rated the effectiveness of pain clinics in eight specific functions, estimated the percentage of workers who return to work after pain clinic treatment, and indicated how soon after injury a worker should be referred to a pain clinic.

RESULTS

Pain clinic staff consistently gave the most favorable ratings and workers compensation employees the least favorable ones. There was good agreement across professional groups regarding the need for early referral of injured workers to pain clinics and the specific functions that pain clinics carry out relatively well. Clinics were ranked as most effective in reducing workers' use of opiates, and as least effective in reducing workers' pain. Return-to-work estimates varied significantly across professional groups. Within professional groups, subjects with high estimates gave more favorable overall ratings to pain clinics.

CONCLUSIONS

The results provide a profile of the perceived effectiveness of pain clinics in various functions and highlight the importance of getting accurate information about return to work rates following pain clinic treatment. They suggest that workers are not referred to pain clinics early enough.

Relations of employment status to emotional distress among chronic pain patients: a path analysis

OBJECTIVE

This cross-sectional study evaluated the extent to which relations between employment status and emotional distress are mediated by pain-related and psychosocial measures among employed and unemployed persons with chronic pain.

DESIGN

A total of 40 unemployed and 43 employed persons reporting chronic pain were recruited from pain services at a tertiary-care hospital and community-based organizations. Volunteers completed self-report measures of pain severity, subjective financial stress, time structure, emotional distress, and background data.

RESULTS

A path analysis indicated that pain severity had direct associations with both emotional distress and employment status. In addition, employment status was only indirectly related to emotional distress; this relation was mediated by levels of reported financial strain and structured purposeful time use.

CONCLUSIONS

Findings suggest that pain severity and the quality of specific experiences related to being employed or unemployed as opposed to employment status per se correspond directly to levels of emotional distress reported by some persons with chronic pain.

Impact of chronic pain patients' job perception variables on actual return to work

OBJECTIVE

To examine the impact of preinjury job perceptions on chronic pain patients (CPPs) return to work after pain facility treatment.

DESIGN

A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job following pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months after treatment. The preinjury job perceptions and other demographic variables were used to predict return to work. Stepwise discriminant analysis was used to predict return to work at the 1-month and final time points utilizing the above variables. Stepwise regression analysis was used to predict mean employment status (at all time points) also using the above variables.

SETTING

Multidisciplinary Pain Center.

PATIENTS

Consecutive CPPs.

RESULTS

For the 1-month time point, employment status was predicted by "intent," educational status, work dangerous perception complaint, job stress, job physical demands, job liking, and job role conflicts. Here, 79.49% of the CPPs were correctly classified. For the final time point, employment status was predicted by the first three predictors for the 1-month time point (in the same order) and age, job stress, and gender. Here, 74.58% of the CPPs were correctly classified. Mean employment status was predicted by "intent" and educational status.

CONCLUSIONS

There is a relationship between preinjury job perceptions and actual return to work after pain facility treatment. Voiced "intent" not to return to the preinjury type of job is highly predictive of not returning to work after pain facility treatment.

Objectification of functional improvement after nonoperative care

STUDY DESIGN

In this article, the authors review the three broad categories of measures that have been used to objectify functional improvement after nonoperative care of painful spinal disorder patients-physical, psychological, and socioeconomic. For each of the three categories, the major measures used are discussed, as well as research relating to the efficacy of the measures.

OBJECTIVE

To point out the many differences that still exist among research studies regarding which functional outcome measures to use and when to use them.

SUMMARY OF BACKGROUND DATA

During the past few decades, it has been made abundantly clear that painful spinal disorders, particularly when associated with work disability and/or financial benefits, result from a complex interaction of medical, psychological, and social factors. This has resulted in frequent confusion regarding what constitutes the primary roots of the disabling process. Currently, a more comprehensive biopsychosocial perspective of chronic pain and disability has emerged that has significant implications for diagnostic and treatment philosophies of practitioners.

METHODS

Identifying the measures frequently used to address the important biopsychosocial factors, and evaluating their relative benefits and drawbacks.

RESULTS AND CONCLUSIONS

It is demonstrated that there has been an overall trend in recent years toward using more objective, quantifiable instruments, encompassing the physical, psychological, and socioeconomic parameters of outcomes research in painful spinal disorders. These changes will certainly improve the ability of researchers to tease out which factors tap more directly into such tissue as physical impairment, as well as create greater uniformity of measures that will permit direct comparisons between studies.