Optimal spinal strength normalization factors among male railroad workers

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population

OBJECTIVES

To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure.

MATERIALS AND METHODS

In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge. Associations with objective lifting performance and other patient-reported psychosocial measures were determined at admission and discharge, and objective work outcomes for this predominantly disabled cohort, were assessed 1 year later.

RESULTS

Those patients in the severe and extreme FACS severity groups at admission were more likely to "drop out" of treatment than those in the lower severity groups (P=0.05). At both admission and discharge, the FACS severity groups were highly and inversely correlated with objective lifting performance and patient-reported fear-avoidance-related psychosocial variables, including kinesiophobia, pain intensity, depressive symptoms, perceived disability, perceived injustice, and insomnia (Ps<0.001). All variables showed improvement at FRP discharge. Patients in the extreme FACS severity group at discharge were less likely to return to, or retain, work 1 year later (P≤0.02). A factor analysis identified a 2-factor solution.

DISCUSSION

Strong associations were found among FACS scores and other patient-reported psychosocial and objective lifting performance variables at both admission and discharge. High discharge-FACS scores were associated with worse work outcomes 1 year after discharge. The FACS seems to be a valid and clinically useful measure for predicting attendance, physical performance, distress, and relevant work outcomes in FRP treatment of chronic musculoskeletal pain disorder patients.

Knee flexor strength and endurance profiles after ipsilateral hamstring tendons anterior cruciate ligament reconstruction

OBJECTIVES

To profile knee flexor strength and endurance responses to ipsilateral hamstring tendon autograft anterior cruciate ligament reconstruction in patients, and to describe knee flexor strength and endurance as predictors of subjective outcomes. The hypothesis was that the involved leg would demonstrate deficits compared with uninvolved and matched legs.

DESIGN

Retrospective cohort.

SETTING

Controlled laboratory.

PARTICIPANTS

Women (n=15; mean age, 20.47±1.96y; height, 1.69±.08m; weight, 68.51±12.64kg), who were a mean ± SD of 25.93±11.25 months postsurgery, were matched to 15 sex-matched controls (mean age, 20.93±1.22y; height, 1.65±.06m; weight, 66.52±10.69kg).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Concentric peak flexor moment over the entire isokinetic joint range of motion, peak flexor moment at 105° of joint flexion, and knee flexor total work, normalized to body mass, and subjective questionnaire scores for the involved leg.

RESULTS

Significantly lesser peak flexor moment over the entire isokinetic joint range of motion (P=.034) and total work (P=.048) existed for the involved leg (.959±.186Nm/kg; 21.933±5.881J/kg) compared with the matched leg (1.108±.134Nm/kg; 27.431±6.499J/kg). Significantly lesser peak flexor moment at 105° of joint flexion (P=.002) existed between the involved (.221±.116Nm/kg) and uninvolved (.40±.234Nm/kg) and matched (.475±.183Nm/kg) legs. Significantly greater strength deficits (P≤.001) existed at peak flexor moment at 105° of joint flexion compared with peak flexor moment over the entire isokinetic joint range of motion for side (53.83%±38.8%; 9.87%±10.77%) and group (77.61%±44.14%; 18.09%±11.73%) differences. Peak flexor moment at 105° of joint flexion was a significant predictor of subjective pain (P=.007), symptoms (P=.006), function (P=.011), and sports (P=.022) outcomes.

CONCLUSIONS

Knee flexor strength and endurance deficits suggest susceptibility to reinjury, and strength in a deep joint angle predicts subjective outcomes.

Is obesity overrated as a "risk factor" for poor outcomes in chronic occupational spinal disorders?

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To investigate whether obesity is a risk factor for poor socioeconomic outcomes in patients with chronic occupational spinal disorders beginning an interdisciplinary functional restoration program.

SUMMARY OF BACKGROUND DATA

Obesity is known as a risk factor for a multitude of physical and mental health disorders. A classification system can define obesity based on body mass index (BMI). Limited evidence is available on the effect of obesity on rehabilitation from chronic occupational spinal disorders.

METHODS

A large cohort of chronic occupational spinal disorder patients with extended disability (average 16 months) following work-related injuries (n = 2483) were divided into 5 groups based on BMI. Socioeconomic outcomes were identified through a 1-year post-rehabilitation structured telephone interview. Patients were also assessed before and after intervention with validated questionnaires measuring pain intensity, functional deficits, and depression. The interdisciplinary functional restoration program was individualized for length of disability and severity of physical and psychological deficits.

RESULTS

The prevalence of obesity in this population was high. Only 22% of patients were "normal" (BMI <25), while 43% were obese (BMI >30). There was a significant linear trend for males to be progressively less represented as obesity increased. There was also a significant trend for hypertension to be associated with greater levels of obesity. However, there were no significant differences in site of injury, disability duration, or attorney representation among the groups. Most importantly, there were no statistically significant differences in all but 1 of the socioeconomic outcomes among any of the obese groups and the normal weight patients. There was a trend toward higher pretreatment and posttreatment functional assessment scores (i.e., greater perception of disability), and a linear trend for higher pretreatment depression ratings across BMI groups, although they all improved at comparable rates after treatment.

CONCLUSIONS

Obesity is more prevalent and severe in chronic occupational spinal disorders when entering a functional restoration program as the final step in a prolonged treatment regimen. We conclude that obesity, even gross obesity, has no significant impact on outcomes of an interdisciplinary functional restoration program for patients disabled an average of 16 months.

Short-term outcomes of a back school program for chronic low back pain

OBJECTIVE

To assess the short-term outcome of a back school program for patients suffering from chronic, nonspecific low back pain (LBP).

DESIGN

Quasi-experimental cohort study with a waiting list control group.

SETTING

Dutch rehabilitation department.

PARTICIPANTS

Experimental group (n = 14) participating in the back school program and a waiting list control group (n = 10).

INTERVENTION

A back school program aimed to achieve optimal functional capacity and functional health status by teaching participants to react appropriately to overload signals.

MAIN OUTCOME MEASURES

Functional capacity assessed by the RAND-36 instrument; functional health status assessed by the Roland-Morris Disability Questionnaire; and static and dynamic lifting capacity, endurance, and range of motion assessed by objective measures.

RESULTS

The experimental group significantly improved in functional capacity and functional health status, with a large power, likely attributable to adequate reactions to signals of overload. Significant differences existed between the 2 groups, with large powers for the main outcomes.

CONCLUSION

The back school program improved the functional capacity and functional health status of patients with chronic, nonspecific LBP.

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.

Recurrent or new injury outcomes after return to work in chronic disabling spinal disorders. Tertiary prevention efficacy of functional restoration treatment

STUDY DESIGN

A large prospective longitudinal cohort study (n = 1204) to identify prevalence of new or recurrent injury and risk factors in a rehabilitated chronic disabling spinal disorder patient group with matched control subjects.

OBJECTIVES

To evaluate prevalence and risk factors for new or recurrent injury on a chronic disabling spinal disorder population.

SUMMARY OF BACKGROUND DATA

The rate of symptom recurrence after acute low back pain, like the rate of initial back pain episodes, is extremely high (40-70%). However, although the incidence of recurrent back pain after chronic disabling spinal disorder represents a small subcomponent of these cases, there is a large socioeconomic impact. An individual attempting to return to work after a chronic disabling spinal disorder episode usually bears a stigma of "high risk" for recurrent injury and related work disability that may result in barriers to reemployment or work retention. Before the present research, no large scale studies had been conducted to evaluate whether recurrent spine injuries or new injuries to other musculoskeletal areas could be prevented by medical treatment. In addition, no studies had emerged to evaluate physical and psychologic risk factors of injury recurrence in this context to facilitate design of prevention programs.

METHODS

The present study assessed the incidence of claimed recurrent spinal and new musculoskeletal injuries in a population of 1204 workers. A subgroup of 5.3% (n = 64) of treated patients with a new injury claim in the ensuing 12 months was matched for gender, age, race, length of disability, workers' compensation venue, previous surgery, and litigation status to an identically sized control group who did not report new or recurrent injuries. Demographic, physical, and psychologic measures were obtained prospectively on all patients, before and after treatment, to be analyzed as risk factors.

RESULTS

During the year after treatment, 1.3% (n = 16) of patients reported another injury to the same spinal area, with only a 0.9% (n = 11) recurrent disability rate. A new injury to a different musculoskeletal area was reported by 4.0% (n = 48) of patients. Only 3.4% of the whole cohort, or 64.1% (n = 41) of the sample reporting reinjuries after returning to work, experienced lost work time (i.e., disability) after the reinjury. Only a modest predictive association was found between risk for new or recurrent injury and two self-report indices.

CONCLUSIONS

The present study suggests that even a sample of the most severe chronic disabling spinal disorder workers' compensation patients who complete a tertiary functional restoration program are at relatively low risk for either a recurrent spinal disorder or new musculoskeletal injury claim (with or without disability). No major physical or psychologic risk factors for recurrent injury could be identified in this large cohort. These findings argue powerfully against employer bias in not rehiring employees with previous chronic disabling spinal disorder or discriminating in pre- or reemployment on the basis of putative reinjury risk factors after an appropriate rehabilitation program. Literature review documents a surprising paucity of quality studies examining variables predictive of this important socioeconomic outcome variable.