Brian R. Theodore

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.

Role of gender norms and group identification on hypothetical and experimental pain tolerance.

Abstract Previous research indicates that men typically tolerate more pain in experimental settings than women. One likely explanation for these group differences in pain tolerance is conformity to traditional, gender group social norms (i.e., the ideal man is masculine and tolerates more pain; the ideal woman is feminine and tolerates less pain). According to self‐categorization theory, norms guide behavior to the degree that group members adopt the group identity. Therefore, high‐identifying men are expected to conform to gender norms and tolerate more pain than high‐identifying women who conform to different gender norms as a guide for their behavior. We conducted two studies to investigate whether gender group identification moderates individuals’ conformity to pain tolerance and reporting norms. In the first study, participants indicated their gender identification and expected tolerance of a hypothetical painful stimulus. As anticipated, high‐identifying men reported significantly greater pain tolerance than high‐identifying women. No differences existed between low‐identifying men and women. To determine if self‐reported pain tolerance in a role‐playing scenario corresponds to actual pain tolerance in an experimental setting, the second study examined pain tolerance to a noxious stimulus induced by electrical stimulation of the index finger. The experimental outcome revealed that high‐identifying men tolerated more painful stimulation than high‐identifying women. Further, high‐identifying men tolerated more pain than low‐identifying men. These results highlight the influence of social norms on behavior and suggest the need to further explore the role of norms in pain reporting behaviors.

Intrathecal Opioid Therapy for Chronic Nonmalignant Pain: A Retrospective Cohort Study with 3‐Year Follow‐Up

OBJECTIVE The objective of this study was the analysis of outcomes after intrathecal opioid treatment. Design. Retrospective chart review cohort study. Setting. Tertiary care university hospital and clinic. Patients. Adults of both sexes were included. Interventions. The intervention consisted of the implantation of intrathecal catheter and subcutaneous programmable pump to deliver opioids. OUTCOME MEASURES These included intrathecal and oral opioid consumption, self-reported pain levels, and complications. RESULTS We observed reduction of visual analog scale scores, decrease in oral opioid consumption. Stable long-term (3 year) pain reports. We also noted gradual increases in intrathecal opioid consumption. Pre-implant opioid consumption was inversely correlated with treatment success. The complication rate was approximately 20%. CONCLUSIONS We conclude that intrathecal opioids without adjunctive intrathecal medications have a favorable outcome. Some patients are able to eliminate oral opioids. Results seem stable for prolonged periods, although some increase in intrathecal opioids dosing may be required.

Reliability of a visual analog version of the QuickDASH

BACKGROUND The QuickDASH, an abbreviated form of the Disabilities of the Arm, Shoulder and Hand Questionnaire, uses a graded-adjectives ordinal measurement response scale. In order to improve the sensitivity of the measure and to make it compatible with widely used measures of pain and disability, a visual analog scale version was developed. The present study investigated the reliability of the new version over time when used for the evaluation of patients undergoing treatment. METHODS A test-retest model with a two-day interval was used to evaluate a sample of thirty-eight consecutive patients in an interdisciplinary tertiary rehabilitation setting who were identified as having an upper extremity disorder. RESULTS The intraclass correlation coefficient indicating test-retest reliability was 0.90 for the eleven-item QuickDASH visual analog scale questionnaire (without the work component) and 0.94 for the fifteen-item questionnaire (with the work component), neither of which was significantly different from the results reported for the original questionnaire. CONCLUSIONS The QuickDASH visual analog scale questionnaire has acceptable reliability over time, and it can be used as an alternative to the original QuickDASH.

Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders

Study Design. An epidemiologic prevalence study. Objectives. To clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSDs). Summary of Background Data. Few empirical data are available regarding the “chicken-or-egg” question of which occurs first: the injury or incident culminating in the painful CDOSD or the psychiatric disturbance. Methods. Subjects attended a tertiary interdisciplinary rehabilitation program. Psychiatric disorders were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID-DSM-IV). Psychiatric disorders were characterized as preexisting if they manifested themselves before the work-related injury claim (whether or not they resolved, continued, or reoccurred after injury). They were determined postinjury diagnoses only if they manifested for the first time after the injury claim. Results. A total of 38.7% of the present cohort had at least one preexisting major psychiatric disorder, while 98.9% developed one or more psychiatric disorders for the first time after injury onset (57.9% when pain disorder was excluded). The percentage of patients with preexisting psychiatric disorders was lower than general population base rates (48%). The first onset of certain psychiatric disorders was found to be elevated in patients only after the work-related injury; these included Pain Disorder (95.7%), Major Depressive Disorder (49.7%), and Opioid Dependence (15%). Moreover, 5 times as many patients with MDD, and 10 times as many with opioid dependence, developed these disorders for the first time after the injury. Conclusions. In general, psychiatric disturbance is not a risk factor for developing a CDOSD. Psychiatric disorders are much more likely to develop after the onset of the work injury, indicating that such injuries and accompanying stressors are likely to be precipitants, rather than consequences, of psychopathology.

Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders.

Study Design. Prospective outcomes study involving patients with chronic disabling occupational spinal disorders (CDOSD) diagnosed with (n = 199) or without (n = 1124) postinjury opioid-dependence disorder (ODD), based on the Diagnostic and Statistical Manual of Mental Disorders–fourth edition cirteria. Objective. To determine whether prescription opioid dependence, assessed at the beginning of rehabilitation treatment, is associated with poorer treatment outcomes in patients with CDOSDs attending an interdisciplinary rehabilitation program. Summary of Background Data. Controversy exists regarding the risk of iatrogenic ODD and treatment outcomes when long-term opioid therapy is used in the treatment of chronic nonmalignant pain conditions. Methods. A consecutive sample of patients with CDOSDs [n = 1323; mean (SD) length of disability = 18.8 (20.7) months] attending a tertiary referral center received intensive physical reactivation and pain/disability management interventions, based on a functional restoration model, including detoxification from opioids. One-year outcomes included return to work, work retention, healthcare utilization, new surgeries, recurrent injuries, and disability claim settlement. Results. Prevalence of ODD in this CDOSD population on entering the rehabilitation program was 15%. Even after adjusting for relevant demographic factors and comorbid psychiatric disorders, opioid-dependent patients were 1.7 times [95% confidence interval (CI): 1.0, 2.7] less likely to return to work, 2 times (95% CI: 1.3, 3.0) less likely to retain work at the 1-year interview, and 1.7 times (95% CI: 1.2, 2.5) more likely to engage in healthcare utilization from new providers, compared with nonopioid-dependent patients. Conclusions. Iatrogenic prescription opioid dependence may be a risk factor for less successful long-term work and health outcomes, even after detoxification from opioids as part of an interdisciplinary functional rehabilitation program. Chronic prescription opioid dependence in this patient population is also associated with a significantly higher prevalence of comorbid psychiatric conditions, both axis I and II.

Chronic Widespread Pain in Patients With Occupational Spinal Disorders : Prevalence, Psychiatric Comorbidity, and Association With Outcomes

Study Design. A prospective study assessing chronic widespread pain (CWP) and psychiatric comorbidities in patients with chronic disabling occupational spinal disorders (CDOSDs). Objective. To assess the prevalence of CWP, demographic characteristics, and associated psychiatric comorbidity among CDOSD patients, as well as determine if CWP is a risk factor for less successful one-year postrehabilitation socioeconomic outcomes. Summary of Background Data. CWP is an essential criterion for diagnosing fibromyalgia. CWP is estimated to affect between 4.1% to 13.5% of the general population and it is associated with higher rates of psychiatric disorders and growing rates of disability. The prevalence of CWP, or its associations as a comorbidity, in patients with CDOSDs are unknown. Methods. The socioeconomic outcomes, demographic characteristics, and psychiatric comorbidity of CDOSD patients with CWP were compared to non-CWP patients within a cohort of consecutive CDOSD patients (n = 2730), treated in an interdisciplinary functional restoration program. CWP was determined according to American College of Rheumatology criteria. Psychiatric comorbidity was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders—fourth Edition at the beginning of the rehabilitation program. Results. In the CDOSD cohort, 32% of the patients (N = 878) met American College of Rheumatology criteria for CWP, relative to 4.1% to 13.5% within the general population. CWP patients (82%) were much more likely than non-CWP patients (16%) to have multisite pain complaints, leading to the finding that CDOSD patients with multisite pain showed a CWP prevalence of 70%. CWP patients were 1.5 times more likely to be female, more likely to have multiple compensable injuries, and had slightly elevated rates of pre- and postinjury Axis I psychopathology. Nevertheless, CWP was not associated with less successful 1-year socioeconomic outcomes. Conclusion. A surprisingly high frequency of CDOSD patients participating in interdisciplinary rehabilitation met criteria for CWP, though the diagnosis was generally unknown to the patient. In this large workers’ compensation cohort, CWP was not associated with longer periods of disability, more prerehabilitation surgery or higher pain self-report. With appropriate rehabilitation, CWP patients can have equally successful work return and health utilization outcomes compared to non-CWP patients, despite having significantly higher rates of certain psychiatric disorders.

Pulsed Radiofrequency of Suprascapular Nerve for Chronic Shoulder Pain: A Randomized Double‐Blind Active Placebo‐Controlled Study

Background:  The suprascapular nerve block is frequently implemented to treat chronic shoulder pain. Although effective the nerve blockade provides only a short‐term relief, and more compelling apaproaches have been investigated. Pulsed radiofrequency (pRF) has been anecdotally reported as safe and reliable method. However, formal efficacy study has not been published. Ostensibly evidence‐based validation of a new method is necessary for both scholastic and practical purposes.

Redesigning Delivery of Opioids to Optimize Pain Management, Improve Outcomes, and Contain Costs

INTRODUCTION Chronic pain is a public health concern, and in the last decade, there has been a dramatic increase in the use and abuse of prescription opioids for chronic non-cancer pain. METHODS We present an overview of a five-component model of pain management implemented at the University of Washington Division of Pain Medicine designed to facilitate recent state guidelines to reduce the risks associated with long-term use of prescription opioids. RESULTS Central to the model described are guidelines for best clinical practice, a collaborative care approach, telehealth solutions, comprehensive prescription-monitoring, and measurement-based care. DISCUSSION The model presented is a patient-centered, efficient, and cost-effective approach to the management of chronic pain.

The Role of Fear of Movement in Subacute Whiplash-Associated Disorders Grades I and II

Summary Fear of movement plays and important role in individuals with subacute whiplash‐associated disorders and it should be directly targeted in treatment. ABSTRACT Fear and avoidance of activity may play a role in fostering disability in whiplash‐associated disorders (WAD). This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear. People still symptomatic from WAD grade I‐II injuries approximately 3 months previously (n = 191) completed questionnaires (eg, Neck Disability Index [NDI]) and were randomized to 1 of the treatments: (1) informational booklet (IB) describing WAD and the importance of resuming activities, (2) IB + didactic discussions (DD) with clinicians reinforcing the booklet, and (3) IB + imaginal and direct exposure desensitization (ET) to feared activities. DD and ET participants received three 2‐hour treatment sessions. Absolute improvements in NDI were in predicted direction (ET = 14.7, DD = 11.9, IB = 9.9). ETs reported significantly less posttreatment pain severity compared with the IB (Mean = 1.5 vs 2.3, P < .001, d = 0.6) and DD (M = 1.5 vs 2.0, P = .039, d = 0.6) groups. Reduction in fear was the most important predictor of improvement in NDI (β = 0.30, P < .001), followed by reductions in pain (β = 0.20, P = .003) and depression (β = 0.18, P = .004). The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome. Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and/or educational interventions to improve function.