Anna W. Stowell

Models of return to work for musculoskeletal disorders.

Background: Musculoskeletal pain disorders are the most prevalent, costly, disabling, and commonly researched conditions in the workplace, yet the development of overarching conceptual models of return to work (RTW) in these conditions has been lagging. Method: A critical review of the literature was performed using multiple medical and health search engines in order to provide an evaluation of the evolution and the state of the art of health and disability models with a focus on specific models of RTW. Results: The main tenets, implications for diagnosis, treatment, and disability compensation, are the key perspectives analyzed for the following specific models of RTW: biomedical, psychosocial, forensic, ecological/case management, biopsychosocial, and two more recent models developed by the Institute of Medicine and the World Health Organization, respectively. Conclusions: Future development of models that are truly transdisciplinary, and address temporal and multidimensional aspects of occupational disability, remains a goal.

An opioid screening instrument: Long-term evaluation of the utility of the pain medication questionnaire

Abstract:  The Pain Medication Questionnaire (PMQ) was designed to assess the risk for opioid medication misuse in chronic pain patients. A preliminary study showed a positive relationship between higher PMQ scores and concurrent measures of substance abuse, psychopathology, and physical/life‐functioning. Using a larger sample size, the present study sought to replicate these findings, and to expand upon them by examining the relationship between PMQ scores and various treatment outcomes. The PMQ was administered to 271 newly evaluated chronic pain patients who were subsequently re‐evaluated immediately post‐treatment, as well as six months following discharge. Subgroups were then formed according to the lowest (L‐PMQ), middle (M‐PMQ), and highest (H‐PMQ) one‐third of PMQ total scores. It was found that the H‐PMQ group was 2.6 times more likely to have a known substance‐abuse problem, 3.2 times more likely to request early refills of prescription medication, and 2.3 times more likely to drop out of treatment, as compared to the L‐PMQ group. They also had diminished biopsychosocial functioning. In addition, at six months following discharge, patients who completed the program experienced a significant decrease in PMQ scores over time relative to those patients who were unsuccessfully discharged from the program or who dropped out. This study represents the second stage in the development of a psychometrically sound screening tool for measuring risk for opioid medication misuse among chronic pain patients, and findings suggest the long‐term utility of the PMQ in identifying patients who are more likely to complete and benefit from a pain management program.

Psychosocial differences between high-risk acute vs. chronic low back pain patients

▪ Abstract:  The present study was designed to evaluate the relative degree and type of emotional distress in high‐risk acute low back pain (ALBP) subjects (defined as less than 3 months since initial injury) vs. high‐risk chronic low back pain (CLBP) subjects (defined as greater than 3 months since initial injury). It is an extension of earlier findings that demonstrated the significant role that such emotional distress may play in the development of CLBP disability if not appropriately treated in the acute phase. This work stems from a conceptual three‐stage model, which characterizes the progression from acute to chronic pain. Several psychosocial measures were administered that included information allowing for the classification of subjects as high‐risk based upon an earlier developed screening algorithm. The ancova procedure in SPSS was used to compare groups, controlling for gender, ethnicity, and age. Results revealed that CLBP subjects had higher rates of certain measures of emotional distress and depression relative to ALBP subjects. These findings further support the importance of effectively managing emotional distress factors early, when treating musculoskeletal disorders such as low back pain. ▪

A cost-utility analysis of chronic spinal pain treatment outcomes : Converting SF-36 data into quality-adjusted life years

ObjectivesThe present retrospective case review study sought to analyze the cost-utility, expressed in cost/quality-adjusted life years (QALY), of current chronic spinal pain treatments. In addition, it expands upon previously published data evaluating the efficacy of interdisciplinary pain management in relation to medication management. MethodsA recently developed algorithm was used to calculate QALYs using SF-36, v. 1 responses for 121 patients receiving treatment for chronic spinal pain at a pain rehabilitation center. Treatment groups evaluated were: (1) interdisciplinary program completers who received medication management and supplementary anesthetic procedures; (2) interdisciplinary program completers receiving medication management but not anesthetic procedures; (3) patients receiving medication management alone; and (4) patients receiving medication management with supplemental anesthetic procedures. Assessments were conducted at pretreatment and 6 months after the initiation of treatment. ResultsOne-way analyses of covariance indicated that patients who participated in an interdisciplinary pain management program, which included medication management, psychotherapy, group education, and physical therapy, reported significantly less impairment in daily activities of living, less subjective experience of pain, and a higher quality of life and more preferred health state at the completion of their treatment phase, relative to patients receiving medication with or without anesthetic procedures. In addition, improvements in all outcome measures between pretreatment and posttreatment were significantly greater for those patients completing the interdisciplinary component of treatment. Cost-utility analyses revealed that the interdisciplinary treatment alone group was cost-saving, relative to the medication and procedures alternative, suggesting the former modality was both less costly and more effective than the latter. DiscussionAverage cost-utility ratios for both interdisciplinary treatment groups, ranging from

Interdisciplinary treatment of failed back surgery syndrome (FBSS): a comparison of FBSS and non-FBSS patients.

57,627/QALY to

Presurgical Behavioral Medicine Evaluation (PBME) for Implantable Devices for Pain Management: A 1-Year Prospective Study

75,885/QALY, were within established cost-effective parameters (

Emotional Distress and Medication Use in Two Acute Pain Populations: Jaw and Low Back

20,000 to

A DEMONSTRATION OF A PRESURGICAL BEHAVIORAL MEDICINE EVALUATION FOR CATEGORIZING PATIENTS FOR IMPLANTABLE THERAPIES: A PRELIMINARY STUDY.

100,000/QALY, generally considered a good value), whereas cost-utility ratios for the standard care treatment groups were not interpretable because of a decrease in QALYs from pretreatment to posttreatment.

Psychotherapy with chronic pain patients

Abstract:  Many patients enrolled in chronic pain centers suffer from failed back surgery syndrome (FBSS). However, there has been a paucity of research concerning how these patients differ from other chronic pain patients, and how to most effectively address their complex problems within an interdisciplinary chronic pain treatment environment. The current study represents the first large‐scale examination of these issues, with two major aims: (1) to elucidate the differences between FBSS patients and other chronic lumbar pain patients; and (2) to clarify the role of injections in interdisciplinary treatment, particularly with FBSS patients. A total of 128 chronic lumbar pain patients who presented for treatment at an interdisciplinary center were included in the study. Patients completed various measures at pre‐, mid‐, and post‐treatment intervals, including physical, functional, and psychosocial measures. Overall, both FBSS and Non‐FBSS patients reported significantly decreased pain and disability, and significant improvements in physical and psychosocial functioning after interdisciplinary treatment. However, Non‐FBSS patients were associated with greater reductions in self‐reported pain and disability than FBSS patients. On the other hand, FBSS patients were significantly more improved on physical therapy measures, including Activities of Daily Living, Strength, and Fear of Exercise. Statistical comparisons of Injection (INJ) and No‐Injection (No‐INJ) groups yielded few significant findings.

Erratum: Models of return to work for musculoskeletal disorders (Journal of Occupational Rehabilitation DOI: 10.1007/s10926-007-9071-6)

Abstract:  To reduce poor surgical outcomes, presurgical psychological evaluations are used to better predict prognosis. The current study investigated the utility of a revised Presurgical Behavioral Medicine Evaluation (PBME) algorithm, developed specifically for patients who were candidates for implantable devices. Patients were categorized into a Green, Yellow I, Yellow II, or Red prognosis group, with Green having the best, and Red having the worst, prognosis for good surgical outcomes. Variables, including gender, disability payment status, and involvement in pending litigation, were found to be significantly different among the groups in a sample of 95 consecutive patients. Analysis of data at the initial evaluation indicated that patients within the Red group endorsed significantly more physical/functional limitations, depressive symptomatology, and psychosocial distress than the Green group. In a 12‐month follow‐up analysis, significant differences among the four groups on various psychosocial measures were found. In addition, post‐hoc tests revealed specific significant differences among the groups. A repeated measures analysis of the initial evaluation, 6‐month, and 12‐month follow‐up data revealed that these measures were also significantly affected by the prognostic group. Lastly, nonparametric analysis indicated that there were significant differences among the groups on total risk factor scores as determined by the PBME algorithm.