Sensitivity and Specificity of Reliable Digit Span in Malingered Pain-Related Disability

The reliable digit span (RDS) performance of chronic pain patients with unambiguous spinal injuries and no evidence of exaggeration or response bias (n = 53) was compared to that of chronic pain patients meeting criteria for definite malingered neurocognitive dysfunction (n = 35), and a group of nonmalingering moderate-severe traumatic brain injury (TBI) patients (n = 69). The results demonstrated that scores of 7 or lower were associated with high specificity (> .90) and sensitivity (up to .60) even when moderate to severe TBI are included. Multiple studies have demonstrated that RDS scores of 7 or lower rarely occur in TBI and pain patients who are not intentionally performing poorly on cognitive testing. This study supports the use of the RDS in detecting response bias in neuropsychological patients complaining of pain as well as in the assessment of pain-related cognitive impairment in patients whose primary complaint is pain.

Don't look at my wheelchair! The plasticity of longlasting prejudice

CONTEXT

Scientific research has consistently shown that prejudicial behaviour may contribute to discrimination and disparities in social groups. However, little is known about whether and how implicit assumptions and direct contact modulate the interaction and quality of professional interventions in education and health contexts.

OBJECTIVES

This study was designed to examine implicit and explicit attitudes towards wheelchair users.

METHODS

We investigated implicit and explicit attitudes towards wheelchair users in three different groups: patients with traumatic spinal cord injury (SCI); health professionals with intense contact with wheelchair users, and healthy participants without personal contact with wheelchair users. To assess the short-term plasticity of prejudices, we used a valid intervention that aims to change implicit attitudes through brief direct contact with a patient who uses a wheelchair in an ecologically valid real-life interaction.

RESULTS

We found that: (i) wheelchair users with SCI held positive explicit but negative implicit attitudes towards their novel in-group; (ii) the amount of experience with wheelchair users affected implicit attitudes among health professionals, and (iii) interacting with a patient with SCI who contradicts prejudices modulated implicit negative bias towards wheelchair users in healthy participants.

CONCLUSIONS

The use of a wheelchair immediately and profoundly affects how a person is perceived. However, our findings highlight the dynamic nature of perceptions of social identity, which are not only sensitive to personal beliefs, but also highly permeable to intergroup interactions. Having direct contact with people with disabilities might foster positive attitudes in multidisciplinary health care teams. Such interventions could be integrated into medical education programmes to successfully prevent or reduce hidden biases in a new generation of health professionals and to increase the general acceptance of disability in patients.

Factors determining health awareness in persons after spinal injury with neurological complications. Pilot study

BACKGROUND

Dedicated health education is a core intervention in comprehensive rehabilitation programmes. Health awareness of those disabled as a result of a spinal injury with neurological complications (SINC) has rarely been the subject of scientific analyses despite its importance for designing dedicated educational programs.

PURPOSE

To evaluate factors determining the health awareness of persons after SINC.

MATERIAL AND METHODS

133 SINC patients (32 women) between 0.5 and 31 years after injury. An ad hoc questionnaire designed by the authors consisting of 150 detailed questions about the diagnosis, prophylaxis and management of typical health consequences of SINC.

RESULTS

The mean test score (TS) was 56.6 points. TS correlated inversely with age in a statistically significant manner (correlation coefficient (CC) = -0.31). TS increased with the time elapsed since injury, with distinct increments at 1 year and 10 years after the event. Significantly higher TSs were noted in persons with university (64.6) and secondary education (65.7) compared with the rest of the group (37.9). Those unable to walk but able to use the wheelchair for independent locomotion had a higher TS (59.7) compared to wheelchair-bound persons unable to drive the wheelchair (47.5) and to persons with preserved walking ability (46.2). Significantly higher scores were achieved by inhabitants of towns above 100,000 population, those employed, members of an association for disabled persons, and respondents capable of independent self-care. There was an inverse correlation between TS and Beck's depression score (CC=-0.36). TS did not depend on gender. Interaction with other persons with SINC is perceived as the most important source of health related knowledge.

CONCLUSIONS

Predictors of better health awareness in SINC persons include a young age, at least secondary education, more than 10 years since injury, participation in community rehabilitation organised by an association of persons with disability, being employed, being unable to walk, effective self-care, and absence of depression.

[Chronic right-sided pain-associated nondermatomal somatosensory deficit following an accident]

We present the case of a 48-year old man who, eight years after an industrial accident, presents with chronic right-sided nondermatomal pain and hypaesthesia to heat and touch. During symmetric peripheral touch functional magnetic resonance imaging revealed hypometabolism in the left thalamus, somatosensory cortex, and anterior cingulate cortex. Pain-associated nondermatomal somatosensory deficits (NDSDs) localizing to one side of the body are a frequent clinical entity, which are often triggered by an accident. The tendency of NDSDs to extend to adjunct ipsilateral body parts and to become chronic points to maladaptive adjustment of pain-processing areas in the central nervous system. Psychological stress prior to or around the triggering event seems an important risk factor for NDSDs.

[Using music in work therapy complex in able-bodied patients with spinal injury]

The authors analyzed results of using music in work therapy rehabilitation complex in able-bodied patients with spinal injury. Efficiency of the therapy was demonstrated. Findings are that the patients demonstrate positive change in views, interests, desires, attitude to the personal condition and surroundings, tendency to overcome the disease, to realize compensatory resources of the body, more motivation to work--that serves as a good basis for further work rehabilitation of the patients.

[Trauma of the spine and intervertebral disk. A challenge for the expert in compensation claims after sustained "trifle trauma"]

In the literature, the association between chronic pain syndromes of the spine and sustained "trifle trauma" is a matter of controversy. "Trifle trauma" is identified as a contusion, compression and/or sprain without a definite, acute imaging sign of injury to the bone, the disk or the ligaments of the spine. Most of the time, striking isolated changes to the intervertebral disks are interpreted as preexisting without relevance to an acute injury. However, complex chronic pain syndromes causing permanent and significant functional limitations in daily life and work may occur. Besides the diagnostic and therapeutic challenge for the treating physician, the expert confronted with compensation claims very often has to answer questions as to whether "trifle trauma" of the spine may lead to significant and permanent functional limitations or loss with chronic pain syndromes, and what the importance of possible isolated changes in intervertebral disks is. The data from literature dealing with this topic is contradictory and deficient. In this article, we critically examine the causality between "trifle trauma" to the spine and possible permanent chronic complaints based on currently available data from the literature in order to support the process of decision making in questions of litigation and controversial compensation claims.

Impaired Awareness of Deficits and Treatment Adherence Among People With Traumatic Brain Injury or Spinal Cord Injury

OBJECTIVE

To examine the relation between impaired awareness of deficits (IAD) and treatment adherence and to verify previous findings regarding the types of disabilities that people with traumatic brain injury (TBI) tend to underestimate.

DESIGN

Cross-sectional study.

PARTICIPANTS

Twenty-four persons with moderate to severe TBI and 16 persons with traumatic spinal cord injury (SCI) admitted to an inpatient neurorehabilitation program.

MAIN OUTCOME MEASURES

IAD assessed using the short version of the Problem Checklist of the Head Injury Family Interview and treatment adherence using the Medical Regimen Adherence Scale.

RESULTS

Presence of IAD is linked with poor adherence. Patients with TBI significantly underestimate their emotional/behavioural and cognitive disabilities, but accurately assess their physical disabilities, whereas patients with SCI accurately assess all spheres. Patients with TBI are significantly less aware of their disabilities compared with the patients with SCI as expected.

CONCLUSIONS

These results confirm IAD's link to treatment adherence, and support the observation that IAD is a common clinical feature of brain injury that should be carefully considered when making prognoses and developing and applying interventions with this population.

Health-related quality of life (HRQOL) in Japanese osteoporotic patients and its improvement by elcatonin treatment

Health-related quality of life (HRQOL; "QOL" hereafter) was evaluated in Japanese osteoporotic patients using three questionnaires; the SF-36 (MOS 36-Item Short-Form Health Survey; generic, profile-type), the EQ-5D (Euro Qol-5 Dimensions; generic, preference-based), and the JOQOL (Japanese Osteoporosis Quality of Life 1999; disease-targeted). The eight subscales and two summary scores of the SF-36 were impaired in these patients even after correction for age and sex. The scores on the EQ-5D and JOQOL correlated well with the subscales of the SF-36 that represent the physical aspects of physical function and bodily pain, which suggests that physical aspects are important determinants of overall QOL status in osteoporotic patients. Although the QOL scores did not correlate with bone mineral density, they were markedly influenced by the presence of vertebral fractures. In particular, the presence of two or more vertebral fractures greatly decreased the QOL scores. We then evaluated the QOL scores before and after treatment. The patients were either given calcium supplementation alone or calcium plus once-weekly elcatonin (Elcitonin, Asahi Kasei Pharma, Tokyo, Japan) injection. Elcatonin treatment markedly improved diverse aspects of the QOL, whereas calcium alone did not. The current data suggest that osteoporosis, especially in the presence of vertebral fracture, is associated with compromised QOL, and therapeutic intervention for osteoporosis should be evaluated in terms of QOL, as well as in terms of increases in bone mineral density and fracture prevention.

Familial disability patterns in individuals with chronic work-related spine injury/illness

STUDY DESIGN

A case control study of familial disability patterns and other potential risk factors identified in a group of individuals with work-related spine injury/illness.

OBJECTIVES

The objective of the present study is to provide information on the relationship between a disabled family member and work-related spine injuries or illnesses leading to disability among another family member.

SUMMARY OF BACKGROUND DATA

Extensive studies have been conducted to identify the medical and nonmedical factors associated with prolonged disability after work-related spine injury/illness. Many of the relevant nonmedical factors are psychosocial and are dependent to some degree on family of origin environment and experience. Although similar recurring pain behaviors have been described in certain families, no recent study has been conducted of coexisting family disabilities in individuals with work-related spine injury/illness.

METHODS

A case-control investigation examining nine potential risk factors, including familial disability patterns, for the development of disability following work-related spine injury/illness was conducted. The case group (n = 88) consisted of individuals disabled from any and all gainful employment, whereas the controlled group (n = 40) continued working in spite of their spine complaints.

RESULTS

In this study, gender, number of spinal areas involved, current injury considerations/severity, and having a primary family member or spouse similarly disabled were found to be significant predictors of disability following work-related spine injury/illness. However, further analysis revealed that having an associated family disability was the greatest predictor of disability in the study group.

CONCLUSIONS

These data suggest that the presence of a primary family member or spouse with a work-related spine disability may be a risk factor for the development of disability in individuals sustaining a work-related spine injury.

Gender-related differences in treatment outcomes for patients with musculoskeletal disorders

BACKGROUND CONTEXT

Clinicians have long hypothesized that gender may be a risk factor in treatment outcomes of patients with chronic disability associated with musculoskeletal disorders. Although the scientific literature shows a higher prevalence of occupational low back injury in men, and a higher rate of repetitive motion and neck injuries in women, few studies have comprehensively investigated the role of gender regarding cost-related outcome variables of significance after work-related injuries.

PURPOSE

This study was designed to examine the relationship between gender and biopsychosocial treatment outcomes in a predominately chronically disabled spinal disorder (CDSD) workers' compensation cohort undergoing a tertiary functional restoration program.

STUDY DESIGN

A prospective comparison cohort study investigating the effect of gender on biopsychosocial treatment outcomes as risk factors for rehabilitation failure.

PATIENT SAMPLE

A cohort of 1,827 consecutively treated patients with CDSD were placed into two gender-based groups: men (n=1,158, average age 40.7+/-10 years) and women (n=669, average age 42.5+/-10 years).

OUTCOME MEASURES

Before the start of the program, and again upon completion of the program, all patients received a standard psychosocial assessment and were assessed on a variety of physical factors (leading to a cumulative score, calculated on the basis of the aggregates and averages of these physical measures). A structured clinical interview examining socioeconomic outcomes was conducted at 1 year after program completion, and at least partial information was obtained from this interview on all patients in the present study.

METHODS

All patients underwent a medically directed functional restoration program combining quantitatively guided exercise progression with a multimodal disability management approach using psychological and case management techniques.

RESULTS

Men had a significantly higher rate of lumbar injury than women, whereas women had a significantly higher rate of cervical injury. Men returned to work and retained work at a 40 hours/week job at a higher rate at 1-year follow-up. Women evidenced a higher rate of health care-seeking behaviors from new providers. On physical testing immediately after treatment, men had a significantly higher cumulative physical score (gender normalized), both before and after treatment. On depression and disability questionnaires, men showed fewer pre- and posttreatment depressive symptoms with lower pretreatment disability scores.

CONCLUSIONS

The present study represents the first large-scale examination of the relationship between gender and treatment outcomes for a population with CDSD after work injuries. There was a pattern of moderately better 1-year posttreatment socioeconomic outcome for men. On psychosocial measures, men showed lower disability and depression scores than women, with higher levels of physical functioning both before and after treatment. Overall, male patients with CDSD appeared to show somewhat better biopsychosocial outcomes. This leaves the question of identifying gender-specific risk factors to explain these differences.

Effect of age on outcomes of tertiary rehabilitation for chronic disabling spinal disorders

STUDY DESIGN

A prospective cohort study evaluating age as a factor in treatment outcomes for chronic disabling work-related spinal disorders undergoing tertiary rehabilitation.

OBJECTIVE

To assess the association between age and objective psychosocioeconomic treatment outcomes for work-related spinal disorders undergoing functional restoration.

SUMMARY OF BACKGROUND DATA

As early as the 1950s, a link between age and low back symptoms has been identified in the literature. Several studies have demonstrated that the occurrence of low back pain is positively correlated with age up to about 50-60 years, after which prevalence declines. It has been argued that this pattern is stronger for more severe, chronic back pain cases. Little research attention has been given to age as a factor in treatment outcomes for work-related spinal disorders.

METHODS

A cohort of 1052 chronically disabled (none working full-time when starting the rehabilitation program) spinal disorder (CDSD) patients were placed into five groups based on age: Group 1, <25 years (22 +/- 2 years, n = 59); Group 2, 25-34 years (30 +/- 3 years, n = 301); Group 3, 35-44 years (39 +/- 3 years, n = 381); Group 4, 45-54 (49 +/- 3 years, n = 237); and Group 5, > or =55 years (59 +/- 4 years, n = 74). All patients completed a functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach using psychological and case management techniques. Before the start of the program, and again on completion of the program, all patients received a psychosocial evaluation and were also assessed on a variety of physical motion, strength, aerobic, and functional factors, and a cumulative score was calculated, which aggregates and averages these physical measures. A structured clinical interview examining socioeconomic outcomes (work return, health utilization, recurrent injury, and resolution of financial disputes) was conducted at 1 year after program completion, and at least partial information was obtained from this interview on all consecutive patients in the study.

RESULTS

The length of pretreatment disability increased with age (P < 0.001), as well as pretreatment surgery rates (P < 0.002). A Mantel-Haenzel chi2 test for linear trend across age groups revealed that the percentage of patients who returned to work declined progressively from 100% in Group 1 to 69% in Group 5 (P < 0.001). The same linear trend was revealed for the percentage of patients retaining work at the end of 1 year (98-62%, P < 0.001). Older workers returned to the same job and/or the same employer (P < 0.005). Younger workers found different jobs with new employers (48-11%, P < 0.0001). Analysis of variance for the disability questionnaire revealed that after treatment subjective disability progressively increased (while improvements decreased) from Group 1 to Group 5 (P < 0.01). The cumulative physical score variable, even normalized for age, was progressively lower from Group 1 to Group 5, both at pretreatment (P < 0.03) and post-treatment (P < 0.02).

CONCLUSIONS

The present study represents the first large-scale examination of the association between age and treatment outcomes for a work-related CDSD population. Age is significantly and linearly related to pretreatment duration of disability and frequency of pretreatment surgeries. After rehabilitation treatment there is a linear decrement in both work return and work retention, so that younger patients are far more likely to return and hold work after functional restoration. Older workers who go back to work are much more likely to return to the same employer and do the same job, or to become self-employed. Calculation of odds ratios revealed that patients >55 years are 5.68 times more likely to return to the same job and employer, relative to those <25 years; those >55 years were also approximately three times more likely than those <25 years to return to the same employer, compared with those <25 years. Younger workers are far more likely to take a different job and/or seek a new employer. Older patients are also somewhat more likely to seek a new health provider to deal with perceived residual pain/disability. This trend coincides with their higher post-treatment subjective disability levels, and their lower cumulative physical scores both prerehabilitation and postrehabilitation. However, age does not affect additional surgery rates, subsequent injuries, or delays in settling financial disputes.

Enabling young 'ventilator-dependent' people to express their views and experiences of their care in hospital

Discussion in this paper is drawn from a phenomenological study carried out in England describing the views and experiences of young 'ventilator-dependent' people aged 6-18 years, regarding their health and social care, education, and aspirations for the future. This study presented many methodological and ethical challenges in order to elicit and present their views in a meaningful way. Data were elicited through focused face-to-face interviews with 18 young people. Innovative methods of data collection were used with younger children and those who had a range of communication impairments. In addition, family members of 15 young people were interviewed. Presentation of findings is limited to views and experiences of the young people's care in hospitals. Findings reveal that a significant number of Articles in the United Nations (UN) Convention on the Rights of the Child were not respected or upheld. Young 'ventilator-dependent' people were discriminated against when trying to access health services because of their need for assisted ventilation. They were particularly excluded from making important decisions about their lives and were not always offered the full protection of the Children Act 1989 (England). Some young people were not able to maintain adequate contact with their families, first language, culture, nationality and religion. Almost all spent prolonged periods of time (in some cases years) in hospital when they no longer wanted or needed to be there. All those interviewed wanted to be discharged home far sooner. The generalizability of findings is unknown; however, important questions are posed in relation to nursing practice and research regarding the overall management of this group of young people. Issues include: respecting and upholding human rights; and challenging the boundaries of current nursing practice in order to move towards child-centred, appropriate and effective models of care.

Coping effectiveness training for people with spinal cord injury: preliminary results of a controlled trial

OBJECTIVES

To develop and evaluate a brief group-based psychological intervention for improving psychological adjustment and enhancing adaptive coping following spinal cord injury. The Coping Effectiveness Training (CET) programme is grounded on the cognitive theory of stress and coping of Lazarus & Folkman (1984), and represents an original adaptation of the theory to the needs of this client group.

DESIGN

A controlled trial comparing patients receiving the CET intervention to matched controls in measures of psychological adjustment and coping was used.

METHODS

Nineteen intervention group participants and 19 matched controls were selected from in-patients at a hospital-based spinal injury rehabilitation centre. Outcome measures of depression, anxiety and coping were collected before, immediately after and six weeks after the intervention.

RESULTS

Intervention group participants showed significantly greater reductions in levels of depression (p < .01) and anxiety (p < .05) compared to matched controls immediately after the intervention and at six weeks follow-up. There was no evidence of a significantly greater change in the coping strategies used by the intervention group. Participants highlighted their interactions with other group members as the most helpful aspect of the intervention.

CONCLUSIONS

This evidence suggests that the CET intervention facilitated a significant improvement, in psychological adjustment to spinal cord injury. It is proposed this may be understood in terms of changes in participants' appraisal of the implications of spinal cord injury and of the coping skills needed to continue living meaningful and satisfying lives.

Psychosocial job factors, physical workload, and incidence of work-related spinal injury: a 5-year prospective study of urban transit operators

STUDY DESIGN

Five-year prospective cohort study of 1449 transit operators.

OBJECTIVES

To investigate psychosocial job factors as predictors of work-related spinal injuries, controlling for current and past physical workload.

SUMMARY OF BACKGROUND DATA

The association between psychosocial job factors and spinal disorders may be confounded by physical workload. A 1991 prospective study of Boeing workers found psychosocial but not physical factors to be associated with spinal injuries. However, data on physical workload were limited. Recent cross-sectional studies of transit drivers showed both physical and psychosocial factors to be independently associated with back and neck pain. This study was designed to test these findings prospectively.

METHODS

Spinal injuries were ascertained from workers' compensation records, employment history from company records, and psychosocial factors from questionnaires. Logistic regression models adjusted for age, gender, height, weight, vehicle type, and current and past physical workload.

RESULTS

During follow-up, 320 drivers reported a first spinal injury. Spinal injury was predicted by psychological job demands (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.33-1.95); job dissatisfaction (OR, 1.56; 95% CI, 1.09-2.23); and the frequency of job problems (OR, 1.52; 95% CI, 1.02-2.26). Marginally significant associations were found for low supervisor support (OR, 1.30; 95% CI, 0.99-1.72) and female gender (OR, 1.49; 95% CI, 0.95-2.32). Compared with full-time work, part-time work was associated with a 2.7-fold reduced risk for spinal injury (OR, 0.37; 95% CI, 0.15-0.93). Cable car crews performing the heaviest physical labor had a threefold increased risk of spinal injury compared with bus drivers (OR, 3.04; 95% CI, 1.85-5.00).

CONCLUSIONS

Physical workload and psychosocial job factors both independently predict spinal injury in transit vehicle operators.

Carol's story

It was all so sudden, such a dramatic life change. I had really expected to work for a further ten years, not this! All my life I had fought for my career. I was involved, I studied, I did many new and exciting things. I bathed in the joys of success, suffered frustrations and anger on occasions, and I challenged the exhaustion and long hours of following a career in nursing. A profession that I loved, and still love, and which gave me so much.

Social adjustment and rehabilitation in international competitors with spinal injuries sustained in military service

One hundred and eighteen competitors, with spinal injuries, attending the First International Ex-Service Wheelchair Games, held in July 1993, were interviewed. Athletes from 17 countries attended. Sixteen competitors were tetraplegic and 102 paraplegic, their injuries are detailed below. The injuries had occurred on average 14.0 years previously: 35 injuries were war injuries a further 10 due to combat training. The paraplegic athletes had spent 9.6 months and the tetraplegic 12.3 months in hospital. Fifty-five spinal stabilizations had been performed, and this was associated with a reduced inpatient stay for the paraplegic athletes (7.7 months vs 11.3 months). Spinal fixation did not affect later employment. Thirty-one athletes worked, and the amount of pension had no significant bearing on the numbers working. There was a mean delay of 38.3 months from injury until return to sport, and only 11.8% of competitors took up sport in the initial rehabilitation period. The differences between operative treatment, inpatient stay and numbers working from the different countries are compared. Financing of attendance and training seemed to be informal, with just over half of the athletes financed by their governments. The role of sport in rehabilitation of those patients with spinal injuries, and specifically those injured whilst serving in the armed forces, is discussed.

Self-directed patient education in soft-tissue rehabilitation: rationale and analysis of a pilot project

OBJECTIVES

To determine the compliance level and topic choice selection frequency of rehabilitation patients in a self-directed education program offered in conjunction with a rehabilitation exercise program.

DESIGN

Descriptive study.

SETTING

Soft-tissue injury rehabilitation clinic located within a chiropractic college.

SUBJECTS

Twenty-four rehabilitation patients with injured spines who were enrolled in a daily in-clinic program.

OUTCOME MEASURES

Data was collected from patient log-book pages, which recorded frequency of use, topic, medium and personal satisfaction for each selected resource. Clinic attendance data was collected by the clinical staff.

RESULTS

Eighty-one percent (81%) of the patient group voluntarily used the learning center. Average frequency of use was approximately one visit per patient per week. Of the 13 subject areas included in the resource center collection, back injury care (30), nutrition (22) and fitness/exercise (14) received the most use. Patient satisfaction with the resources' value/interest averaged 78.4%.

CONCLUSIONS

Most (81%) patients in this group were willing to spend some of their own time learning information that they thought was important. The results may allow for patient education program designs that put more responsibility for learning with the patient and allow for more efficient clinician time allocation.

The rise and fall of Erichsen's disease (railroad spine)

The railroad represented one of the major technologic achievements of the 19th century. Sadly, railroad collisions, which resulted in major injuries and loss of life, began to tarnish the image of this popular mode of transportation. Public alarm about rail travel intensified in 1866, when noted British surgeon John Eric Erichsen described a peculiar progressive spinal disorder, similar to spinal concussion, that was a sequela to railroad accident or injury. The history of this disorder, which came to be known as "railroad spine" or "Erichsen's disease", represents a little known yet important chapter in the evolution of the modern comprehension of functional illness that can complicate or even replace an initial substrate of organic disease.

Are occupational drivers at an increased risk for developing musculoskeletal disorders?

STUDY DESIGN

This study analyzed the role of exposure to driving and other covariates in reports of back, neck, and shoulder pain and resultant disability. Cohorts in Sweden and the United States were compared.

OBJECTIVES

To establish the effect of mechanical and psychosocial factors in reporting back, neck, and shoulder pain and work loss.

SUMMARY OF BACKGROUND DATA

There are numerous reports of a positive relationship between back pain and driving. However, exposure data are minimal. The influence of job satisfaction has not been assessed.

METHODS

The physical factors affecting reports of back, neck, and shoulder pain were investigated in a two-country cohort study of bus and truck drivers and sedentary workers. Vibration exposure was obtained by directly measuring the vibration imposed on the driver during a typical work day. Lifting exposure was attained by questionnaire. Cumulative exposure was computed based on work history. Musculoskeletal health information was based on a modified nordic questionnaire, and other questionnaires recorded the physical and psychosocial aspects of the work environment.

RESULTS

Of the sample, 50% reported low back pain, with no difference between countries. The highest risk factors (odds ratios) for back and neck pain were long-term vibration exposure, heavy lifting, and frequent lifting. A combination of long-term vibration exposure and frequent lifting carried the highest risk of low back pain. Work loss from low back pain was influenced by perceived job stress.

CONCLUSIONS

Vibration (resulting from driving) and lifting cause back, neck, and shoulder pain, whereas inability to work seems affected by stress at work.

The dominant role of psychosocial risk factors in the development of chronic low back pain disability

STUDY DESIGN

An inception cohort design was used in which 421 patients were evaluated systematically with a standard battery of psychosocial assessment tests (Structured Interview for DSM-III-R Diagnosis, Minnesota Multiphasic Personality Inventory, and Million Visual Pain Analog Scale) within 6 weeks of acute back pain onset.

OBJECTIVES

The present study evaluated the predictive power of a comprehensive assessment of psychosocial and personality factors in identifying acute low back pain patients who subsequently develop chronic pain disability problems (as measured by job-work status at 1-year follow-up evaluation).

SUMMARY OF BACKGROUND DATA

There has been a relative paucity of prospective research in the United States comprehensively evaluating potential psychosocial risk factors that are associated with those injured workers who subsequently fail to return to work and productivity after 1 year because of low back pain disability. Such research has been quite limited because of the time and cost involved in conducting prospective studies.

METHODS

All study patients were symptomatic with lumbar pain syndrome for no more than 6 weeks. These acute patients were tracked every 3 months, culminating in a structured telephone interview being conducted 1 year after the initial evaluation to document return-to-work status.

RESULTS

Logistic regression analyses, conducted to differentiate between patients who were back at work after 1 year versus patients who were not because of the original back injury, revealed the importance of three psychosocial measures: self-reported pain and disability, scores on Scale 3 of the Minnesota Multiphasic Personality Inventory, and workers' compensation and personal injury insurance status. The model generated correctly classified 90.7% of the cases. Results revealed that major psychopathology, such as depression and substance abuse, did not precede or cause the development chronic pain disability.

CONCLUSIONS

These results show the presence of a robust "psychosocial disability factor" that is associated with those injured workers who are likely to develop chronic low back pain disability problems. Based on these data, a statistical algorithm has been generated that can identify those acute patients who will require early intervention to prevent the development of chronic disability. The second major result is that preinjury or concomitant psychopathology does not appear to predispose patients to chronic pain disability, although high rates of psychopathology have been shown in chronic low back pain. Future research should be directed at emotional vulnerability and psychosocial events in the period after the injury that may lead to chronicity.

A personal perspective: the psychological needs of spine-injured patients

1. The immediate needs of spine-injured patients, families and friends is for answers, advice, support and counselling. 2. Newly injured patents and their families and friends need continuous support and information throughout long-term rehabilitation. 3. Consideration must be given to the injured patient as a whole person because physical and psychological rehabilitation are dependent on each other.

[Occupational diseases of the "spine"--guidelines for expert assessment]

Until now there has been no definition of a typical job-related back injury. During the examination the only possibility was to separate all recognizable non-job-influenced injuries from the diagnosis, through which a step-by-step, logically organized progression was proven in practice. If the professional hypothetical claims are fulfilled, then the remaining disability is the outcome of job stress and can so be evaluated. The clinical-functional and neurological evidence delivers a conclusive evaluation in percentages that can be attuned without difficulty to verified standards of traumatic spinal assessment.

[Possibilities for rehabilitation in spinal injuries with or without neurological deficit]

Generally spine injured persons without neurological deficits can--as long as the principles of industrial medicine are observed--be occupationally integrated without any particular rehabilitation measures within the limits of their remaining capacity. Spine injured persons, however, with remaining instabilities, serious static deficiencies and/or neurological deficits need further rehabilitation after their in-patient and immediate posthospital treatment. Spinal cord injured patients usually have to accept serious changes and limitation in all spheres of life. Rehabilitation measure in work, school and the social field are vital. Despite all efforts at rehabilitation limitations do remain among other things in work, mobility and social contacts. The preceding paper presents the tasks and results of rehabilitation of spinal cord injured persons, special consideration being given to spinal cord injured persons with supporting facts from long term studies.

The Katz Adjustment Scale: modification for use with victims of traumatic brain and spinal injury

Although the assessment of the social, emotional and personality sequelae of traumatic injury is of central clinical and medico-legal importance, no satisfactory standard assessment device for this purpose has yet been developed. A multicentered study of a mixed group of head and spinally injured patients is reported. Factor analysis of a modified version of the relatives' form of the Katz Social Adjustment Scale (KAS-R) yielded 30 first-order factors under three main domains of emotional/psychosocial, physical/intellectual and psychiatric changes, together with seven second-order factors which were readily identifiable in terms of syndromes accompanying traumatic injury. Discriminant function analyses indicated that prediction of patient group using KAS-R data was most accurate using the current study's first-order factors as compared with the original factor structure proposed by Katz and Lyerly or the second-order factors from the current analyses. The modified KAS-R shows considerable promise as an instrument for measuring the complex social, emotional and personality changes following traumatic injury, with special significance for assessing brain-injury victims. The representativeness of the current patient sample and implications for future development of the method are discussed.

A follow-up study of accident neurosis

Thirty five claimants with accident neurosis, in which there were gross perplexing somatic symptoms without demonstrable organic pathology were traced and followed-up in their homes, from one to seven years after compensation was received. Few claimants recovered and such recovery as did take place was unrelated to the time of compensation. Family processes leading to over-protection by relatives were examined and appeared to be vitally important in the prolongation of symptoms. The legal process and the delays involved caused great distress.

Pain in patients with spinal cord injury

For this study of intractable pain after spinal cord injury (SCI), a questionnaire was developed, pilot-tested and mailed to 356 previously hospitalized SCI patients, 200 (56%) of whom returned the completed questionnaire. Of the respondents, 160 (80%) reported abnormal sensation and 96 (48%) called the discomfort painful. Abnormal sensations were first noted within 6 months of injury by 105 patients, from 7 months to 4 years after injury by 39, and longer than 4 years after injury or unknown by 16. Pain locations varied and were unrelated to the level of lesion. In 30% of those reporting abnormal sensation the location of pain remained stationary, whereas in 17% it changed over time. The intensity of pain was described as severe to extreme by 25%; 44% indicated that it interfered with daily activities. Increase of pain over time was noted by 41%. Activity, inactivity, weather change and overexertion were not frequently identified as aggravating circumstances. Rest and medication were cited as alleviating factors. Approximately 38% of those experiencing pain used medications but only 22% obtained consistent relief from their use. Patients with low level lesions were more willing to exchange a hypothetical chance of recovery and/or loss of reacquired physiologic functions for pain relief than were patients with higher lesions.