Emily Brede

The quantified lumbar flexion-relaxation phenomenon is a useful measurement of improvement in a functional restoration program.

Study Design. A prospective cohort study evaluating the quantitative lumbar flexion-relaxation phenomenon (QLFRP), measured with surface electromyographic (SEMG) signals from the erector spinae during trunk flexion pre- and postrehabilitation, in patients with chronic disabling occupational lumbar disorders (CDOLD). Objectives. To assess the responsiveness of the QLFRP in documenting change in functional performance during a functional restoration program for CDOLD patients. Summary of Background Data. A recent theoretical construct suggests that QLFRP is responsive to change in lumbar range of motion (ROM) during rehabilitation, with high sensitivity and specificity for abnormal QLFRP predicting ROM. Methods. A cohort of normal subjects was tested for QLFRP correlated to inclinometric lumbar ROM measures. The cutoff score was applied to a group of CDOLD patients entering a functional restoration program (N = 135), and to program completers (N = 104). Pain and functional self-report scores were compared with SEMG and ROM measures. Results. The CDOLD group averaged 23.7 months off work. Surgical treatment was provided prerehabilitation to 51% of patients, with 29% receiving lumbar fusions. From pre- to post-treatment, achievement of QLFRP rose from 31% to 74% of patients, while normal ROM rose from 8% to 63% of patients. Compared to the 16% of patients still demonstrating both abnormal QLFRP and ROM, the other groups showed significantly greater improvement in self-reported pain and function, with the best improvements occurring in patients showing normal ROM and QLFRP. The QLFRP showed high sensitivity, but only modest predictive validity and specificity for predicting ROM postrehabilitation. Improvement in sensitivity and predictive validity occur when surgical cases were excluded from the analysis. Conclusion. A majority of patients in an interdisciplinary functional restoration program failed to demonstrate either the QLFRP or normal ROM on admission to the program. A majority of program completers, however, achieved both normal ROM and QLFRP and another 30% demonstrated either normal QLFRP or normal ROM. Both QLFRP and ROM measures were responsive to relevant self-report scales.

Insomnia in a chronic musculoskeletal pain with disability population is independent of pain and depression.

BACKGROUND CONTEXT Insomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population. PURPOSES This study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population. STUDY DESIGN/SETTING This was a retrospective study of prospectively captured data. PATIENT SAMPLE A consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol. OUTCOME MEASURES Insomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0-7); subthreshold insomnia (score, 8-14); moderate clinical insomnia (score, 15-21); and severe clinical insomnia (score, 22-28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire. METHODS Patients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses. RESULTS The presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia. CONCLUSION This research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population.

WHAT IS THE BEST SURFACE EMG MEASURE OF LUMBAR FLEXION-RELAXATION FOR DISTINGUISHING CHRONIC LOW BACK PAIN PATIENTS FROM PAIN-FREE CONTROLS?

Objectives:Lumbar flexion-relaxation (FR) is a well-known phenomenon that can reliably be seen in normal subjects but not in most chronic low back pain (CLBP) patients. The purpose of this study was to determine which surface electromyographic (SEMG) measures of FR best distinguish CLBP patients from pain-free control subjects. Standing SEMG and lumbar flexion range of motion (ROM) were also evaluated. Methods:A cohort of 218 CLBP patients, who were admitted to a functional restoration program, received a standardized SEMG and ROM assessment during standing trunk flexion and reextension. An asymptomatic control group of 30 nonpatients received an identical assessment. Both groups were compared on 8 separate SEMG and 3 flexion ROM measures. Results:A receiver operating characteristic curve analysis was used to determine how well each measure distinguished between the CLBP patients and the pain-free control subjects. All SEMG measures of FR performed acceptably. Between 79% and 82% of patients, and 83% and 100% of controls were correctly classified. Standing SEMG performed less well. Gross flexion ROM was the best single classification measure tested, correctly classifying 88% of patients and 83% of controls. A series of discriminant analyses found that certain combinations of SEMG and ROM performed slightly better than gross ROM alone for correctly classifying the 2 subjects groups. Discussion:Because all SEMG measures of FR performed acceptably, the determination of which SEMG measure of FR is “best” is largely dependent on one’s specific purpose. In addition, ROM measures were found to be important components of the FR assessment.

The Pain Anxiety Symptoms Scale Fails to Discriminate Pain or Anxiety in a Chronic Disabling Occupational Musculoskeletal Disorder Population

Background:  The Pain Anxiety Symptoms Scale (PASS) was developed to measure fear and anxiety responses to pain. Many studies have found associations between PASS scores and self‐report measures of pain, anxiety, and disability as well as among inhibited movement patterns and activity avoidance behaviors (eg, kinesophobia). This study aimed to identify clinically meaningful cut‐off points to identify high or low levels of pain anxiety and to determine if the PASS provides additional useful information in a functional restoration (FR) treatment program for chronic disabling occupational musculoskeletal disorder (CDOMD) patients.

The effect of prior lumbar surgeries on the flexion relaxation phenomenon and its responsiveness to rehabilitative treatment

BACKGROUND CONTEXT Abnormal pretreatment flexion-relaxation in chronic disabling occupational lumbar spinal disorder patients has been shown to improve with functional restoration rehabilitation. Little is known about the effects of prior lumbar surgeries on flexion-relaxation and its responsiveness to treatment. PURPOSE To quantify the effect of prior lumbar surgeries on the flexion-relaxation phenomenon and its responsiveness to rehabilitative treatment. STUDY DESIGN/SETTING A prospective cohort study of chronic disabling occupational lumbar spinal disorder patients, including those with and without prior lumbar spinal surgeries. PATIENT SAMPLE A sample of 126 chronic disabling occupational lumbar spinal disorder patients with prior work-related injuries entered an interdisciplinary functional restoration program and agreed to enroll in this study. Fifty-seven patients had undergone surgical decompression or discectomy (n=32) or lumbar fusion (n=25), and the rest had no history of prior injury-related spine surgery (n=69). At post-treatment, 116 patients were reevaluated, including those with prior decompressions or discectomies (n=30), lumbar fusions (n=21), and no surgery (n=65). A comparison group of 30 pain-free control subjects was tested with an identical assessment protocol, and compared with post-rehabilitation outcomes. OUTCOME MEASURES Mean surface electromyography (SEMG) at maximum voluntary flexion; subject achievement of flexion-relaxation (SEMG≤3.5 μV); gross lumbar, true lumbar, and pelvic flexion ROM; and a pain visual analog scale self-report during forward bending task. Identical measures were obtained at pretreatment and post-treatment. METHODS Patients entered an interdisciplinary functional restoration program, including a quantitatively directed, medically supervised exercise process and a multimodal psychosocial disability management component. The functional restoration program was accompanied by a SEMG-assisted stretching training program, designed to teach relaxation of the lumbar musculature during end-range flexion, thereby improving or normalizing flexion-relaxation and increasing lumbar flexion ROM. At 1 year after discharge from the program, a structured interview was used to obtain socioeconomic outcomes. RESULTS At pre-rehabilitation, the no surgery group patients demonstrated significantly better performance than both surgery groups on absolute SEMG at maximum voluntary flexion and on true lumbar flexion ROM. Both surgery groups were less likely to achieve flexion-relaxation than the no surgery patients. The fusion patients had reduced gross lumbar flexion ROM and greater pain during bending compared with the no surgery patients, and reduced true lumbar flexion ROM compared with the discectomy patients. At post-rehabilitation, all groups improved substantially on all measures. When post-rehabilitation measures were compared with the pain-free control group, with gross and true lumbar ROM corrected by 8° per spinal segment fused, there were no differences between any of the patient groups and the pain-free control subjects on spinal ROM and only small differences in SEMG. The three groups had comparable socioeconomic outcomes at 1 year post-treatment in work retention, health-care utilization, new injury, and new surgery. CONCLUSIONS Despite the fact that the patients with prior surgery demonstrated greater pretreatment SEMG and ROM deficits, functional restoration treatment, combined with SEMG-assisted stretching training, was successful in improving all these measures by post-treatment. After treatment, both groups demonstrated ROM within anticipated limits, and the majority of patients in all three groups successfully achieved flexion-relaxation. In a chronic disabling occupational lumbar spinal disorder cohort, surgery patients were nearly equal to nonoperated patients in responding to interdisciplinary functional restoration rehabilitation on measures investigated in this study, achieving close to normal performance measures associated with pain-free controls. The responsiveness and final scores shown in this study suggests that flexion-relaxation may be a useful, objective diagnostic tool to measure changes in physical capacity for chronic disabling occupational lumbar spinal disorder patients.

Do comorbid fibromyalgia diagnoses change after a functional restoration program in patients with chronic disabling occupational musculoskeletal disorders

Study Design. A retrospective study of prospectively collected data. Objective. To determine whether comorbid fibromyalgia, identified in patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), resolves with a functional restoration program (FRP). Summary of Background Data. Fibromyalgia involves widespread bodily pain and tenderness to palpation. In recent studies, 23% to 41% of patients with CDOMDs entering an FRP had comorbid fibromyalgia, compared with population averages of 2% to 5%. Few studies have examined whether fibromyalgia diagnoses resolve with any treatment, and none have investigated diagnosis responsiveness to an FRP. Methods. A consecutive cohort of patients with CDOMDs (82% with spinal disorders and all reporting chronic spinal pain) and comorbid fibromyalgia (N = 117) completed an FRP, which included quantitatively directed exercise progression and multimodal disability management. Diagnosis responsiveness, evaluated at discharge, created 2 groups: those who retained fibromyalgia and those who did not. These groups were compared with chronic regional lumbar pain only patients (LO group, n = 87), lacking widespread pain and fibromyalgia. Results. Of the patients with comorbid fibromyalgia, 59% (n = 69) retained the fibromyalgia diagnosis (RFM group) and 41% (n = 48) lost the fibromyalgia diagnosis (LFM group) at discharge. Although all 3 groups reported decreased pain intensity, disability, and depressive symptoms from admission to discharge, RFM patients reported higher symptom levels than the LFM and LO groups at discharge. The LFM and LO groups were statistically similar. At 1-year follow-up, LO patients demonstrated higher work retention than both fibromyalgia groups (P < 0.03). Conclusion. Despite a significant comorbid fibromyalgia prevalence in a cohort of patients with CDOMDs entering an FRP, 41% of patients with an initial fibromyalgia diagnosis no longer met diagnostic criteria for fibromyalgia at discharge and were indistinguishable from LO patients on pain, disability, and depression symptoms. However, both fibromyalgia groups (LFM and RFM) had lower work retention than LO patients 1 year later, suggesting that an FRP may suppress symptoms of fibromyalgia in a subset of patients, but prolonged fibromyalgia-related disability may be more difficult to overcome. Level of Evidence: 2

Facilitating surgical decisions for patients who are uncertain: a pilot surgical option process within an interdisciplinary functional restoration program

BACKGROUND CONTEXT For chronic pain patients, recovery may be slowed by indecisiveness over optional surgery. These patients may be delayed from participating in interdisciplinary functional restoration (FR), pending resolution of the surgical decision. Uncertainty about surgery or rehabilitation leads to delayed recovery. A surgical option process (SOP) was developed to permit patients with chronic disabling occupational musculoskeletal disorders to enter FR, make a final determination halfway through treatment, and return to complete rehabilitation after surgery, if surgery was elected. PURPOSE This study assessed the frequency with which an FR program can resolve an uncertain surgical option. It also assessed program completion rate and 1-year post-program outcomes for subgroups that decline surgery, request and receive surgery, or request surgery but are denied by surgeon or insurance carrier. STUDY DESIGN Retrospective study of a consecutive cohort. PATIENT SAMPLE A cohort of 44 consecutively treated chronic disabling occupational musculoskeletal disorder patients were admitted to an FR program and identified as candidates for a surgical procedure but were either ambivalent about undergoing surgery, had a difference of opinion by two or more surgeons, or were denied a surgical request by an insurance carrier. Patients attended half (10 full day visits) of an FR program before making their own final determination to pursue a request or decline surgery. OUTCOME MEASURES Patients were assessed on surgical requests and whether surgery was ultimately performed, program completion status after the surgical determination, demographic variables, and 1-year outcomes on work status, additional surgery, and other health utilization measures. METHODS Patients became part of the SOP on program entry and were included in the study if they participated in a surgical-decision interview halfway through the program. Those who elected to decline surgery (DS) completed the program without delay, but those requesting surgery were placed on hold from the program while consultation and preauthorization steps took place. Those requesting surgery, but denied (RSD), and those undergoing surgery (US) were given the opportunity to complete FR following postoperative physical therapy or resolution of the surgical re-evaluation process. RESULTS There were 32 DS patients (73%), indicating that a large majority of patients declined the surgery that was still being considered when offered participation in the SOP. Of the 12 patients wanting a surgery, there were four US patients who received surgery previously denied (9% of cohort), and eight RSD patients (18% of cohort). Patients from the DS group completed the FR program at an 88% rate, as did 75% of US patients. However, despite an opportunity to re-enter and complete rehab, only 50% of RSD patients completed the FR option. Overall, patients who persistently sought surgery, contrary to the recommendations of a surgeon, had poorer outcomes. These 1-year post-FR outcomes included lower return-to-work and work retention rates, with higher rates of treatment seeking from new providers (resulting in higher rates of post-discharge surgery) and higher rates of recurrent injury claims after work return. CONCLUSIONS A SOP tied to participation in an interdisciplinary FR program resolves uncertainty regarding surgical options in a high proportion of cases, resulting in a large majority declining surgery and completing the FR program. Timely surgery is also promoted decisively when needed. Findings suggest that patients who persistently seek surgery, contrary to the recommendations of a surgeon, frequently fail to complete FR and have poorer outcomes overall.

Measurement of Return to Work and Stay at Work Outcomes

Millions of dollars are spent every year on interventions to help injured workers return to work. Treatment success is judged upon operational and functional criteria, centering on the specific behavioral outcomes of return to work and work retention. This chapter discusses the ways in which these outcomes can be measured in patients with musculoskeletal injuries, and other factors that may influence them. Measurements of work status, sickness absence, disability benefits, recurrence of illness or injury, work ability, and productivity are compared. In addition, examination of the impact of social insurance programs and entitlements demonstrates that the incentives and disincentives for return to work provided by the socioeconomic structure of the disability and rehabilitation system should be considered when choosing an appropriate measure of return to work. Finally, measures of return to work in clinical populations other than musculoskeletal injuries are discussed; best measures of return to work vary with the population being studied. Ultimately, it is important that health professionals accept the need to continue to define and document behavioral outcomes in their attempts to return injured or medically ill workers back to employability and functionality.

Measurement of musculoskeletal functioning

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