A male incumbent worker industrial database. Part II: Cervical spinal physical capacity

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.

Comparison of chronic occupational upper extremity versus lumbar disorders for differential disability-related outcomes and predictor variables

OBJECTIVE

To systematically evaluate if an interdisciplinary functional restoration program (FRP), shown to be a viable treatment option for patients with chronic disabling occupational lumbar disorders, is as effective in treating chronic disabling occupational upper extremity disorders.

METHODS

Participants were 2484 consecutive patients with either arm or lumbar disorders admitted to an FRP. Analyses compared demographic, psychosocial, and work-related factors, and 1-year post-rehabilitation socioeconomic outcomes.

RESULTS

Socioeconomic outcomes showed that work-return and work-retention rates after successful completion of the FRP did not differ between the two groups, or among the upper extremity subgroups.

CONCLUSIONS

FRP is equally effective for patients with chronic upper extremity or lumbar spine disorders, regardless of the injury type, site in the upper extremity, or the disparity in injury-specific and psychosocial factors identified before treatment.

The lack of association between changes in functional outcomes and work retention in a chronic disabling occupational spinal disorder population: implications for the minimum clinical important difference

STUDY DESIGN

A prospective study in a chronic pain/ disability population, relating changes in the Oswestry Disability Index (ODI), as well as the Mental Component Summary (MCS) and Physical Component Summary (PCS) of the Short Form-36 (SF-36), to work retention (WR) status at 1-year postrehabilitation.

OBJECTIVE

To explore the relationship between WR status and change in ODI, and the MCS and PCS of the SF-36, and determine if an MCID can be identified using WR as an external criterion for the group of patients under consideration.

SUMMARY OF BACKGROUND DATA

Clinically meaningful change may be defined through self-report, physician- based, or objective criteria of improvement, although most assessments have been based on self-report assessment of improvement. The disability occurring after work-related spinal disorders lends itself to anchoring self-report measures to objective work status outcomes 1-year post-treatment. Additional research is needed to evaluate the relationship between change and objective markers of improvement.

METHODS

A consecutive cohort of patients (n = 2024) with chronic disabling occupational spinal disorders completed an interdisciplinary functional restoration program, and underwent a structured clinical interview for objective, socioeconomic outcomes at 1-year post-treatment. The average percent change in the ODI, as well as the MCS and PCS of the SF-36, were calculated for patients who successfully retained work and those who had not after completing a functional restoration program. Predictive ability of the percent change scores were evaluated through logistic regression analysis.

RESULTS

No percent difference variables were strong predictors of WR status 1-year following treatment.

CONCLUSION

The current analyses suggest that the ODI and SF-36 MCS and PCS measures are not responsive at the individual patient level when WR data are used as the external criterion using an anchor-based approach. This finding contrasts to reports of responsiveness based on distributional methods, or methods using self-report anchors of change.

Muscle specificity in tests of cervical flexor muscle performance

The deep cervical flexor (DCF) muscles are considered to be of substantial clinical importance in the management of neck pain. While conventional cervical flexion (CF) dynamometry methods have been used frequently to assess the capacity of the cervical flexor muscles, it has been suggested that cranio-cervical flexion (CCF) methods may provide a more specific test of DCF muscle performance. This study compared the activation of the deep and superficial cervical flexor muscles between tests of isometric cranio-cervical flexion (CCF) and conventional cervical flexion (CF) dynamometry. Normalised root-mean-square values were recorded for the deep cervical flexor (DCF), sternocleidomastoid (SCM), anterior scalene (AS), and sternohyoid (SH) muscles during isometric CCF and CF tests at maximal voluntary contraction (MVC), 50% MVC, and 20% MVC in ten healthy volunteers. The results demonstrated significantly greater electromyography (EMG) amplitude for the SCM (P<.001-.002) and AS (P<.001-.001) muscles in the CF test conditions (MVC, 20%MVC, and 50%MVC) compared to CCF test conditions. Moreover, the SH muscle demonstrated significantly greater EMG amplitude during CF compared to CCF but only in the 50% MVC and 20% MVC conditions (P=.007 and .02 respectively). These results demonstrate that dynamometry tests of CF result in greater activity of the superficial cervical flexor muscles compared to tests of CCF. As a result, CCF dynamometry may provide a more specific method to assess and retrain DCF muscle performance, compared to conventional CF in which superficial muscle activity may mask impaired performance of the DCF muscles.

Reliability of a clinical test for deep cervical flexor endurance

OBJECTIVE

Endurance deficiencies of the deep cervical flexors are associated with pain, increased lordosis, and headache. A need exists for reliable clinical tests of flexor endurance. This study determined intrarater and interrater reliability of such a test in persons without neck pain.

METHODS

Twenty-seven subjects (aged 20-35 years) without a history of neck pain or injury were tested. Supine subjects were timed in maintaining a position involving two components: (1) craniovertebral flexion (chin tuck) and (2) lower cervical flexion (holding the occiput at a fixed height). Each subject was examined twice by 3 different examiners with 1 to 2 days between trials.

RESULTS

When two values were averaged, interrater reliability for the 3 testers was 0.83, 0.85, and 0.88. Intrarater reliability values were 0.78 and 0.85 for tests 1 and 2, respectively.

CONCLUSIONS

The flexor endurance test showed good intertester and intratester reliability when two values were averaged and, thus, may represent a useful clinical tool for practitioners involved in treating and preventing neck pain.

Isometric strength of the cervical flexor, extensor, and rotator muscles in 220 healthy females aged 20 to 59 years

STUDY DESIGN

Cross-sectional descriptive study.

OBJECTIVES

To determine the maximal isometric strength of the flexor, extensor, and rotator muscles of the cervical spine in healthy females of working age to document reference values for diagnostic and rehabilitation purposes.

BACKGROUND

Reference values for the isometric strength of the cervical muscles have often been based on small samples. To date, reference values for rotator muscles of the cervical spine have not been published.

METHODS AND MEASURES

The group consisted of 220 volunteer healthy females in 4 age groups (20-29 years, n = 57; 30-39 years, n = 51; 40-49 years, n = 51; 50-59 years, n = 61) from Jyadskyla, Finland. Isometric cervical muscle strength in flexion, extension, and rotation was evaluated with a specially designed measurement system.

RESULTS

Across all age groups, mean (+/-SD) maximal isometric neck strength was 73.8 +/- 20.0 N in flexion and 190.8 +/- 31.3 N in extension. Mean (+/-SD) rotation strength was 8.1 +/- 2.3 Nm to the right and 7.9 +/- 2.3 Nm to the left. Absolute strength values did not differ among the age groups. A weak but significant correlation between body mass and neck flexion (r = 0.31, P<.01) and extension (r = 0.25, P<.01) strength was found. Intratester reliability varied from 0.87 to 0.96.

CONCLUSIONS

Women aged 20 to 59 years appear to have similar absolute isometric neck muscle strength levels. Thus these values can be used as reference for the working-age female population.

The pain disability questionnaire: relationship to one-year functional and psychosocial rehabilitation outcomes

OBJECTIVE

The Pain Disability Questionnaire (PDQ) is a new functional assessment instrument designed for evaluating chronic disabling musculoskeletal disorders. It is useful for assessing function/disability as affected by pain. This is the first study to assess the predictive validity of the PDQ in its relationship to 1-year post-treatment work- and health-related outcomes in a chronic disabling occupational musculoskeletal disorder (CDOMD) population.

DESIGN

A prospective cohort of CDOMD patients (n=150) completed a prescribed functional restoration rehabilitation program, with PDQ and other psychosocial measures evaluated before and immediately after treatment. A structured telephonic interview for objective work- and health-related outcomes took place 1-year following treatment.

RESULTS

Lower rates of work retention were associated with more severe pre-treatment PDQ scores. Higher post-treatment PDQ were associated with decreased return-to-work rates, decreased work retention and a greater percentage seeking health care from a new provider. In addition, PDQ scores were also associated with psychosocial measures such as depression and perceived pain intensity, as well as alternative measures of disability.

CONCLUSIONS

Results demonstrated the ability of this simple and psychometrically-sound disability rating scale for systematic functional assessment in predicting treatment outcomes in patients with CDOMD. Results support the further use of the PDQ as a standard treatment outcomes measure in this area of musculoskeletal disorders.

EMG power spectra of cervical muscles in lateral flexion and comparison with sagittal and oblique plane activities

The purpose of this study was to calculate electromyographic (EMG) power spectra of the sternocleidomastoid (SCM), the splenius capitis (SPL) and the trapezius (TRP) muscles from both sides of the body in bilateral lateral flexion and compare them with the EMG spectral characteristics of the same muscles in the sagittal and oblique planes recorded from the same subjects in the same experimental session but reported elsewhere in the literature. Forty normal and healthy young adults (21 males, 19 females) volunteered for the study. The subjects were prepared and positioned appropriately to exert linearly ramping isometric exertion aided by visual feedback against a rigid and load cell instrumental device. Exertions were carried out in a random order. The maximal voluntary contraction was reached within a 5-s test period. The torque and EMG from the SCM, SPL and TRP muscles were sampled bilaterally at a rate of 1 kHz. The EMG data were subjected to fast Fourier transform analysis. During lateral flexion, the torque generated by females was significantly lower than males ( P<0.01) and represented at 75% of male torque. Contrary to flexion/extension and oblique plane activities, the ipsilateral SCM was most active with highest power and up to four dominant frequencies demonstrating four distinct peaks. The bandwidth of this muscle progressively increased with the grade of contraction up to 400 Hz, similar to flexion/extension with median frequency (MF) spread between 21 and 109 Hz for males and 78 and 99 Hz for females. The ipsilateral SPL was the second most active muscle, which maintained a narrow bandwidth (200 Hz) and one dominant frequency, rising in power with increasing grade of contraction. Flexion and extension caused symmetrical activity bilaterally. The results of MANOVA revealed a significant main effect of gender, activity direction, grade of contraction and individual muscles ( P<0.001). There was a significant interaction between muscle and activity direction ( P<0.001) implying significantly different MF and mean power frequency if the direction of exertion was changed. Male and female subjects responded to direction differently ( P<0.001).

Maximal isometric muscle strength of the cervical spine in healthy volunteers

OBJECTIVE

To describe the maximal isometric neck muscle strength in healthy Chinese volunteers, in six different directions, as measured by a Multi Cervical Rehabilitation Unit.

DESIGN

A standardized cross-sectional observational study.

SETTING

A university rehabilitation unit.

SUBJECTS

Ninety-one healthy volunteers aged 20-84.

METHODS

During the measurement the subject was instructed to do three consecutive steady contractions as hard as possible, with a 10-second rest in between each contraction and a 2-minute rest between different directions. The peak isometric strength for each of the six directions (flexion, extension, lateral flexions, protraction and retraction) was calculated.

RESULTS

No significant difference was found in muscle strength between different age groups. Isometric muscle strength in the direction of right lateral flexion was significantly greater than that to the left in men (p = 0.030), but no difference was found in women (p = 0.297). Isometric strength in all directions in men was 1.2-1.7 times that in women (all p < 0.028). Correlations between physical measurements (height and weight) and strength values were all insignificant in both genders.

CONCLUSION

Men have approximately 20-70% greater isometric neck muscle strength than women. Both men and women can maintain high levels of cervical muscle strength in six different directions up to their seventh decade. There is no significant correlation between physical measurements and isometric neck muscle strength.

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.

Normative database of isometric cervical strength in a healthy population

OBJECTIVES

This was a descriptive study involving maximal and average isometric strength measurements of the cervical musculature. The purpose of this study was 1) to determine the test-retest reliability of a computerized dynamometer for measuring muscular strength of the neck flexor and extensor muscles in a healthy population, and 2) to afford a normative database of the maximal and averaged isometric strength of the cervical flexors and extensors in a healthy population of 94 volunteers. The literature contains only a few descriptive studies pertaining to strength levels of the cervical musculature; none of these studies used a computerized dynamometer to determine cervical isometric strength. Only a few studies include cervical flexor and extensor isometric strength, evaluating its normal ratio as well as their correlation to body mass index.

METHODS

Testing was carried out using a computerized dynamometer to measure isometric cervical strength at 0 degrees (neutral), 5 degrees, and 10 degrees of flexion and extension of the neck.

RESULTS

Men show approximately 30 to 40% more strength than women both for flexion and extension at all angles and age groups. Neutral positioning showed the maximum strength values for both flexion and extension.

CONCLUSION

There was a significant negative correlation between age and cervical strength and a significant positive correlation between weight and strength and between height and strength. However, the flexor/extensor ratio was maintained around 0.6 in all ages.

Cervical strength of young adults in sagittal, coronal, and intermediate planes

OBJECTIVES

To measure the cervical isometric force generation capacity of men and women reliably while seated in upright neutral posture.

DESIGN

The cervical muscle isometric strength was determined in flexion, extension, lateral flexion, anterolateral flexion and posterolateral extensions in an upright seated neutral posture. For this measurement a device was designed, fabricated and its reliability established.

BACKGROUND

To-date only a few studies on cervical strength data have been published. Of these, validity of some data is suspected due to the use of unstandardized methodology. No studies were identified which reported cervical strengths in lateral and oblique planes.

METHODS

A testing device consisting of sturdy, stable and strong telescopic adjustable square metal tube was firmly bolted in the floor. Another rotating metal tube was pivoted and adjustably counterweighted and attached to an immovable object with a load cell in its path. Using a horizontal bar upholstered at the terminal end attached to the rotating tube 40 young subjects were tested. They exerted their maximal voluntary isometric contraction in flexion, extension, lateral flexion, anterolateral flexion, and posterolateral extension bilaterally.

RESULTS

Cervical muscle strength was maximum in extension and minimal in anterolateral flexion (which was very close to flexion strength). With progressive change in direction towards posterior region the strength progressively increased. There was a significant difference between male and female strengths (P < 0.01). The flexion/extension ratio of males was 1:1.37 and for females 1:1.79. There was a significant difference in strength values in different directions (P < 0.01).

CONCLUSIONS

The cervical strength is direction dependent. The extension generates maximum force and flexion close to minimum. A progressive change from anterior to posterior direction generates increasing force.

RELEVANCE

There is insufficient information regarding cervical strength, which may at least indirectly and in part, indicate the force bearing capacity of cervical musculature. The present study furnishes some data to this end.

Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful?

OBJECTIVES

To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises.

DESIGN

Preliminary 2-part study: (1) presentation of a technique for, identifying lumbar segmental rigidity based on physical observation of the spine's lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises.

SETTING

An outpatient tertiary rehabilitation facility providing interdisciplinary functional restoration for chronic disabling work-related spinal disorders.

PATIENTS

Chronically disabled patients with lumbar spinal disorder (n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2.

INTERVENTIONS

Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1-4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected.

MAIN OUTCOME MEASURES

Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically.

RESULTS

Patients' mobility improved significantly (p < .01-.0001) across all 4 motions. A large majority (71%-97%) of individuals improved on motion. According to self-reports made over the postinjection period, most patients improved their disability (83%) and pain intensity (63%) ratings.

CONCLUSIONS

A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improvements in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticosteroid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improvements cannot be determined from the present study, but warrants future investigation.

Interobserver reliability in physical examination of the cervical spine in patients with headache

OBJECTIVE

To assess interobserver reliability of two expert headache neurologists when examining the cervical spine of patients with headache.

BACKGROUND

The diagnosis of cervicogenic headache involves the physical examination of the cervical spine.

METHODS

Twenty-four patients diagnosed as having migraine, tension-type headache, or cervicogenic headache were included in the study. After interview, each patient's cervical spine was examined in a structured way. Reliability was assessed by Cohen's kappa.

RESULTS

Reduced range of motion in the cervical spine showed kappa scores indicating moderate agreement. Provocation of headache revealed moderate-to-substantial agreement. Assessment of zygapophyseal joint pressure pain showed slight-to-fair agreement. The kappa values of the circumscribed characteristic tender points showed agreement ranging from "not better than chance" to "substantial agreement."

CONCLUSIONS

Our study showed that the interobserver reliability of expert headache neurologists was satisfactory in the majority of the physical examination tests of the cervical spine in patients with different headache syndromes. However, standardization of the clinical tests in order to improve their reliability is recommended.

Meta-analysis of normative cervical motion

STUDY DESIGN

Meta-analysis of normative cervical range of motion literature performed by applying summary statistics to range of motion and reliability values reported among studies.

OBJECTIVES

To identify reliable and valid methods for measuring active and passive cervical range of motion and to estimate normative values.

SUMMARY OF BACKGROUND DATA

Range of motion studies use a variety of measuring instruments and statistical analyses, making it difficult to select the most suitable instruments, procedures, and normative values for clinical application. Reviews of the literature, being limited in scope, have not quantitatively synthesized the literature.

METHODS

Range of motion and reliability data were grouped by technology and types of motion, then summarized by deriving means and variabilities. Clinical validity was assessed by examining discrepancies, variabilities, and correlations. Change in range of motion as a function of age was determined by comparing range of motion ratios (fourth:third and seventh:third decades).

RESULTS

Nine technologies were identified. Overall, passive motion was greater than active motion, and range of motion decreased as age increased, with women exhibiting greater range of motion than men. Variations within each technology were as large as or larger than those between technologies, indicating that clinical procedures are as important as the accuracy and precision of the technology itself. Reliability has not been adequately tested for the majority of technologies.

CONCLUSIONS

Clinical procedures appear to be as important as accuracy and precision in determining the reported range of motion values. Further research is needed to establish a gold standard for normative values and to identify an instrument that is reliable for all motions.

Maximal isometric strength of the cervical musculature in 100 healthy volunteers

STUDY DESIGN

A descriptive study involving maximal isometric strength measurements of the cervical musculature.

OBJECTIVES

To determine the maximal isometric strength of the flexors and extensors and of the cervical musculature in 100 healthy volunteers (50 men and 50 women).

SUMMARY OF BACKGROUND DATA

The literature contains only a few descriptive studies pertaining to strength levels of the cervical musculature. These studies include small subject populations, and measurement methods have demonstrated weak reliability.

METHODS

Testing was carried out using strain-gauge technology on a neck muscle training apparatus.

RESULTS

A reliability study demonstrated acceptable intraday and day-to-day values. Maximal isometric strength was approximately 20% to 25% higher in male subjects than female subjects in both flexion and extension from the third to the sixth decades. In the seventh decade, the women's strength levels surpassed values for men in both flexion and extension. Extension-flexion ratios were approximately 1.7 to 1 in both the men and women participants. The men demonstrated a significant decrease in maximal isometric strength with increasing age in both flexion and extension, whereas the women were able to maintain strength values in the ages tested.

CONCLUSIONS

Men and women demonstrate impressive levels of muscular strength in the flexors and extensors of the cervical spine and can maintain these values until the seventh decade of life. Successful rehabilitation of the cervical musculature will require considerable resistance for sufficient stimulation of the cervical musculature.

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.

Socioeconomic outcomes of combined spine surgery and functional restoration in workers' compensation spinal disorders with matched controls

STUDY DESIGN

A longitudinal cohort study (n = 448) comparing functionally restored discectomy (n = 123) and fusion (n = 101) workers' compensation patients to matched, unoperated control patients (n = 123 and n = 101, respectively).

OBJECTIVES

To determine successful treatment outcomes uniquely important in a workers' compensation environment when spine surgery is combined with comprehensive tertiary rehabilitation, to optimize anatomic and social sequelae.

SUMMARY OF BACKGROUND DATA

Multiple recent studies confirm suboptimal socioeconomic outcomes for spinal surgery for degenerative conditions in a workers' compensation venue. In other musculoskeletal regions, there is a clear relationship between the quality of postsurgical rehabilitation and the impact on disability, recurrent injury, and future health care use. It is hypothesized that poor surgical outcomes in compensation injuries may result from outmoded postoperative methods, rather than failures of patient selection or surgical technique. No previous combination of surgery plus rehabilitation has been carefully evaluated with disabled workers undergoing spine surgery. Functional restoration is an individualized medically directed, interdisciplinary program using quantitatively directed exercise progression, psychotherapeutic interventions, and monitoring of specific socioeconomic outcomes for chronically disabled workers.

METHODS

This study prospectively evaluated a cohort of consecutive functional restoration program graduates (n = 1202). Two surgical groups, discectomy (n = 123) and fusion (n = 101) were matched to two groups of unoperated control patients, control/discectomy and control/fusion, selected from the same cohort of patients with chronic spinal disorders based on age, gender, race, length of disability, and workers' compensation jurisdiction. A structured clinical interview was administered 12 months after program completion, with a contact rate of 95% to 98%.

RESULTS

Socioeconomic outcomes for work return, health care use, and recurrent lost-time injury were assessed. All groups demonstrated a return-to-work incidence of more than 85%, but work retention at 1 year was higher for the fusion group than for the discectomy or control/fusion groups. Health care use was significantly higher for the discectomy group than the control/discectomy or fusion groups for reoperation (8% vs. 4%/ 2%), as well as other factors. All groups showed comparable recurrent lost-time injury rates (2-3.3%), and made comparable improvements in prospectively collected physical and psychological measures.

CONCLUSIONS

Discectomy patients had work, health care utilization, and recurrent injury outcomes comparable with those for unoperated control patients. Fusion patients had better outcomes of work retention, reoperation, and health care use compared with the unoperated control patients and even with discectomy patients, in spite of more cases of previous surgery and greater duration of disability. The discectomy and fusion cohorts of operated chronic spinal disorder compensation patients with subsequent functional restoration had the best documented outcomes found in the literature for this population. In spite of the common presumption that spine surgery patients fare poorly in a workers' compensation environment, these results demonstrate that such patients can show remarkably successful objective outcomes if accompanied by effective rehabilitation, documenting efficacy and clinical utility. A new clinical approach is required to evaluate prospectively the combination of surgery and rehabilitation in chronic pain/disability workers' compensation patients, in which the surgical role is to correct an anatomic lesion, but the socioeconomic outcomes either occur spontaneously or are effected through some form of rehabilitation.

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.

Relationship between subjective neck disorders and cervical spine mobility and motion-related pain in male machine operators

STUDY DESIGN

In a single blinded procedure, quantified cervical clinical tests were performed on machine operators with and without subjective reports of neck pain.

OBJECTIVES

To evaluate whether subjective reports of neck pain are associated with limited and painful cervical spine mobility.

SUMMARY OF BACKGROUND DATA

Spinal motion evaluation and pain rating are commonly used for assessing impairment in patients with spinal disorders. However, it is still unclear how cervical spinal motion and corresponding pain rating are affected by subjective reports of neck pain.

METHODS

Forty-nine male forest machine operators completed the Standardized Nordic questionnaire on musculoskeletal symptoms. Maximal voluntary cervical spinal flexion-extension, bilateral axial rotation, and lateral flexion were measured with a goniometer ad modum Myrin, while corresponding pain was rated on Borg's scale.

RESULTS

Nineteen men (38.8%) reported no neck pain within the past 12 months, nine men (18.4%) reported pain during the past 12 months (but not during the past 7 days), and 21 men (42.8%) had experienced neck pain during the past 7 days. The results of two of the range-of-motion tests (flexion and left axial rotation) and three of the pain ratings (during flexion, extension, and left axial rotation) differed significantly between men who reported pain the past 7 days and those with no pain, and they correlated significantly with the severity of pain as reported in the questionnaire.

CONCLUSIONS

Many forest machine operators reporting neck pain in the Nordic questionnaire did have limited and painful cervical spine mobility. Range-of-motion tests may be useful tools to describe impairment and constitute a basis for assessment for therapeutic interventions.

Cervical sagittal range-of-motion analysis using three methods. Cervical range-of-motion device, 3space, and radiography

STUDY DESIGN

Cervical flexion, extension, protrusion, and retraction were comparatively measured in volunteers using a cervical range-of-motion device (Performance Attainment Associates, Roseville, MN), a 3space system (Polhemus, Colchester, VT), and lateral radiographs.

OBJECTIVES

To compare the outcomes of three methods of measurement of cervical flexion, extension, protrusion, and retraction.

SUMMARY OF BACKGROUND DATA

Few studies compare cervical range-of-motion measurement devices with radiographic measurements, and no studies have compared methods of measurement for cervical protrusion and retraction measurement.

METHODS

In 20 asymptomatic volunteers, four end-range sagittal cervical positions (flexion, extension, protrusion, and retraction) were measured simultaneously using a cervical range-of-motion device, a 3Space and lateral cervical radiographs. Measurements were compared, and differences were analyzed.

RESULTS

There were no significant differences for flexion and extension measurements between the cervical range-of-motion device and that radiographic angle determined by an occipital line and the vertical, nor were there any between the 3Space and that radiographic angle between this same occipital line and C7. The cervical range-of-motion device and the 3Space measurements for flexion and extension, however, differed significantly from one another (P < 0.05). For protrusion and retraction, there was no significant difference between the 3Space and radiographic measurements, but these two both differed significantly from the cervical range-of-motion device (P < 0.05).

CONCLUSIONS

Available methods of measurement differ as to whether the cervical spine is isolated or includes upper thoracic motion. Protrusion and retraction can be measured reliably with all three methods studied, but without measurement consistency between devices. Because end-range cervical flexion and extension-cannot occur in isolation from upper thoracic motion, true cervical motion can be measured only with an internally referenced, or landmark-based, methodology such as the 3Space. Even though the cervical range-of-motion device cannot measure isolated cervical flexion and extension, it is nevertheless a reliable clinical tool in measuring flexion and extension as well as protrusion and retraction as long as patient thoracic positioning is standardized to minimize the upper thoracic contribution.

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.