Rowland G. Hazard

Functional restoration with behavioral support: a one-year prospective study of patients with chronic low-back pain

Patients with chronic disabling low-back pain have poor prospects of returning to work. The authors tested a treatment program of functional restoration with behavioral support through 1 year prospective observation of patients disabled for an average of 19 months without evidence of surgically correctable disease. Ninety patients were studied: 59 program graduates, five program dropouts, 17 patients denied program authorization by their Insurance carriers, and six crossover patients. Three patients were admitted but refused to participate in the treatment program. Initial demographic, physical, and self-assessment attributes were similar for all four groups. At years end, 81% of program graduates, 40% of the dropouts, and 29% of those denied the program had returned to work. All six crossover patients were working 6 months after treatment. Program graduates showed significant improvements in self-assessed pain, disability, and depression, and in physical capacities after 3 weeks of treatment. These improvements were maintained through the year except for partial decreases in frequent lifting, cycling endurance, and isokinetic trunk extension strength. Functional restoration with behavioral support is an effective treatment for patients with chronic, disabling low-back pain, as measured by self-assessments, physical capacities, and return to work.

Early prediction of chronic disability after occupational low back injury

Study Design An inception cohort design was used to study a consecutive sample of back‐injured workers. Objective To refine and to test the Vermont Disability Prediction Questionnaires ability to indicate an individuals relative risk for chronic disability after occupational low back injury. Summary of Background Data Although most back‐injured workers return to work quickly, the minority who do not account for the majority of associated costs and health care. Early identification of workers at high risk for disability would facilitate intervention strategies. Methods During the study recruitment period, people aged 18–60 years reporting occupational low back injury to the Vermont Department of Labor and Industry within 11 days of onset were eligible. A Vermont Disability Prediction Questionnaire was mailed to the 442 subjects who could be contacted and who gave informed consent. One hundred sixty‐three of the 166 subjects who completed and returned the questionnaire within 15 days of initial injury were telephoned 3 months later to determine work status. Those who returned the questionnaire were compared with those who would not consent or did not return the questionnaire in time according to age, sex, residence, wages, work hours per week, and length of employment. Employment status (inability to work because of low back pain) was evaluated by telephone interview 3 months after initial injury. Results The follow‐up interviewer was blinded to the Vermont Disability Prediction Questionnaire scores. Of the 163 subjects, 16 (10%) were not working because of low back pain. Using a simple dichotomous scoring system for 11 questionnaire items, a cut‐off score of 0.48 identified 3‐month postinjury work status, with 0.94 sensitivity and 0.84 specificity. Conclusions The Vermont Disability Prediction Questionnaire is a brief, easily administered and scored tool for identifying back‐injured workers at relative risk for chronic disability. Such early identification should increase the efficiency of disability prevention strategies by directing them toward people who need them most. The accuracy of the questionnaire needs to be tested in a variety of different clinical and socioeconomic settings.

Chronic low back pain : the relationship between patient satisfaction and pain, impairment, and disability outcomes

Study Design. Treatment outcomes for low back pain have been measured by varying standards of pain, impairment, and disability. This study examines the relationship between these three outcomes and treatment satisfaction in patients with chronic low back pain (CLBP). Methods. Ninety CLBP patients underwent initial pain (VAS), impairment (PIS), and disability (OPQ) evaluations. Results. Correlation coefficients between initial VAS, PIS, and OPQ were all less than 0.50. At 5-year follow-up, pain and disability scores were closely matched, more with lower mean scores among workers (P = 0.04 and 0.001). For 65 rehabilitation participants, 5-year patient satisfaction scores did not relate closely with VAS, PIS, and OPQ improvements during treatment (r = 0.15, 0.01, and 0.14). Five-year satisfaction correlated weakly with current pain and disability (r = 0.32, −0.36). Satisfaction levels were higher for workers after 1 year (P = 0.01), and after 5 years (P = 0.34). Conclusions. This study suggests that CLBP patients and their health care practitioners mutually set distinct pretreatment pain, impairment, and disability goals and judge outcomes accordingly.

Disability exaggeration as a predictor of functional restoration outcomes for patients with chronic low-back pain.

Many of the individual biological, psychological, and social factors attributed to low-back disability have been tested previously for their ability to predict treatment outcomes. To test the assumption that disability exaggeration affects treatment outcomes, models were developed to quantify this complex characteristic and to test its predictive value. Two hundred fifty-eight patients with chronic back disability entering a program of functional restoration were initially evaluated with a battery of tests, including measurements of trunk flexibility, lifting capacity, cycling endurance, self-assessments of pain and disability, and psychological attributes. On the basis of these measurements, patients were characterized as disability exaggerators if by peer comparison their self-assessments of pain and disability were in the most severe range despite high levels of physical capacity. Program completion and work status 1 and 2 years after treatment were compared between disability exaggerators and their peers. Individual initial attributes associated with program completion included pain intensity and Million Visual Analogue scores, lifting capacity, trunk flexibility, some Minnesota Multiphasic Personality Inventory and Million Behavioral Health Inventory scales, and cigarette smoking. One-year re-employment was associated with Minnesota Multiphasic Personality Inventory Scale 8, Wechsler Adult Intelligence Score-Revised, and cycling endurance. There were no significant associations between any individual factor and 2-year work status. Only two of the 12 disability exaggeration models distinguished between program graduates and dropouts, and none of the models accurately predicted return to work following treatment. Prescription of intensive multidisciplinary treatment should not be denied on the basis of any individual patient attribute or of disability exaggeration, as measured in this study. Measurement of disability exaggeration may be improved by the use of taskspecific comparisons of self-perceived and observed physical capacities. Disability exaggeration may be more useful in predicting outcomes of treatments that neglect its psychosocial components.

A controlled trial of an educational pamphlet to prevent disability after occupational low back injury

STUDY DESIGN Randomized controlled trial. OBJECTIVE To test the ability of an educational pamphlet to improve recovery in terms of pain, work status, and health care utilization after occupational low back injury. BACKGROUND Low back pain and disability persist as occupational health problems of epidemic proportions. Because interventions based on biomechanical models have had limited impact, recent educational approaches to preventing back problems have stressed psychosocial recovery issues. METHODS A pamphlet was developed by compiling activity resumption, self-care, and attitudinal advice from recent publications. The pamphlet was sent at random to half of all consenting workers reporting back pain within 11 days of occupational injury between 7/96 and 6/97. Three and 6 months later, back pain, work status, health care use, and pamphlet impact outcomes were assessed through structured telephone interviews. RESULTS Of the 726 eligible workers, 486 consented to participate. Consenters and nonconsenters and intervention and control groups were similar in initial demographic variables. The pamphlet had no statistically significant impact at the 0.05 significance level on pain severity or reduction, health care visits, or work absence. Of the 229 pamphlet recipients, 129 thought it had provided useful information, but only 25 thought it had helped them return to work more quickly. CONCLUSIONS In this trial, a pamphlet stressing psychosocial recovery issues did not prevent or reduce postinjury pain, health care use, or work absence.

Occupational low back pain: Recovery curves and factors associated with disability

Review of the literature shows significant variation in the rates of recovery from an episode of low back pain (LBP). Two hundred and seven workers filing a “First Report of Injury” form with the Vermont Department of Labor and Industry were contacted 3 months post-injury to determine time until first return-to-work, work status, lost workdays, and factors such as pain intensity and satisfaction with health care. Overall, 69.4% of the workers had first returned to work within 1 week, 85.9% within 1 month, and 93.7% by 3 months. Three months post-injury, 8.7% of these workers were not working (disabled) due to their LBP. On a scale of 0–10, the disabled reported substantially more pain in the past few days (p=.0001) and a higher level of “worst pain since injury” (p=.004). Those disabled were less likely to feel they had received the right treatment for their LBP (p=.05). Researchers and clinicians need a clear understanding of recovery curves to assess the effectiveness of any interventions.

Isokinetic trunk and lifting strength measurements: variability as an indicator of effort.

This study examines the hypothesis that force/distance curve variability distinguishes submaximal from maximal efforts in isokinetic trunk and lifting strength tests. Thirty normal subjects were tested on the Cybex Trunk Extension/ Flexion (TEF) and Liftask (LT) machines during maximal (100%) and submaximal (50%) efforts. Considering each test separately, visual assessments of curve variability were indeterminate of degree of effort in 28% of TEF and 34% of LT tests. Measurement models of curve variability were more clearly discriminating. When a given subjects test curves were considered together, scaled visual assessments identified the degree of effort in 91% of TEF and 86% of LT results. The measurement models were accurate 90–92% of TEF and 79–92% of LT results. Clinical judgment is required in evaluating effort during tests of isokinetic trunk and lifting strength.

Early Physician Notification of Patient Disability Risk and Clinical Guidelines After Low Back Injury: A Randomized, Controlled Trial

Study Design. Back‐injured workers with high disability risk scores on a predictive questionnaire participated in a randomized, controlled trial of physician notification, with outcomes follow‐up 3 months after injury. Objectives. To test whether physician intervention improves return to work and self‐assessment outcomes for people at relatively high risk for disability. Summary of Background Data. Only a small number of back‐injured workers suffer significant disability. Ouick identification of these people would facilitate more efficient targeting and trials of interventions. Controlling variations in practice through practice guidelines has been recommended as a promising strategy for improving care and reducing disability. Methods. Workers filing back injury reports responded to a disability prediction questionnaire. Those with high risk scores were randomly assigned to control or intervention groups. Patient‐designated physicians in the intervention group received two letters identifying the patients risk and making recommendations for care, including the Agency for Health Care Policy and Researchs algorithms for acute low back pain. Predictive accuracy of the questionnaire and efficacy of physician intervention were evaluated on the basis of work status and self‐assessments 3 months after injury. Results. Of the 268 workers completing the questionnaire portion of the study, 32 (12%) were out of work because of back pain 3 months after injury. The questionnaires predictive accuracy included maximum κ of 0.277 and a receiver operating curve area of 0.78. Fifty‐three people completed the physician intervention trial. The intervention had no significant impact on return to work, self‐assessed pain, or satisfaction with health care. Conclusions. Stratification of back‐injured people according to disability risk can can increase intervention efficiency by identifying those who require treatment and sparing those who do not. The apparent failure of risk notification and practice guidelines to reduce disability in this study may be improved by different application methods in the future.

Test—retest variation in lifting capacity and indices of subject effort

UNLABELLED Tests of lifting capacity ideally produce consistent outcomes from one test to the next. Physiological indices of effort, such as heart rates, coefficients of force variation, and isokinetic force-distance curve variability, should also remain constant. This study examined the test-retest reliability of isometric, isokinetic and isoinertial maximal lifting tests in pain-free, well-motivated subjects. First, isokinetic and isoinertial maximum lifting forces and weights were quite consistent between test sessions, while isometric forces increased slightly in the second session. Second, heart rates did not vary significantly between test sessions of isokinetic and isoinertial modes. However, other indices of effort, including force variances, force-weight differences and ratios, and force-weight curve variability, varied significantly between test sessions. Test-retest variations in these non-cardiac effort indices imply that these indices may not reliably distinguish maximal from submaximal lifting efforts even in normal subjects. RELEVANCE Efforts to reduce occupational low-back injuries and disability have focused recently on measurements of lifting capacity. Accurate and reliable estimation of subject effort is critical to the validity of such measurements. This study demonstrates a need for reconsideration of previously reported indices of lifting effort.

The impact of personal functional goal achievement on patient satisfaction with progress one year following completion of a functional restoration program for chronic disabling spinal disorders.

Study Design. This prospective cohort study investigated personal goal achievement and satisfaction with progress in patients with chronic disabling spinal disorders (CDSD). Objective. This study examined the relationships between satisfaction with progress and several alternative outcome measures for CDSD patients at least 1 year after completing a functional restoration program (FRP). Summary of Background Data. Treatment outcome measures for CDSD commonly include pain, physical capacities, and functional/vocational status. These factors are weakly correlated and may not reflect individual patients’ perspectives and priorities. Methods. On enrollment in the FRP, patients’ pretreatment functional, work, and recreation goals were recorded. Pre- and end-of-program clinical measures included: pain, disability, fear avoidance, lifting, trunk flexibility, and treadmill endurance. At least 1 year after program completion surveys were mailed to consecutive FRP graduates. Nonresponders were surveyed by telephone when possible. Surveys included each patient’s personal pretreatment goals, and assessed Average Pain, SF-36 Physical Function, and satisfaction “with the progress made with your pain problem.” Each patient indicated levels of importance and achievement for each personal goal, and these scores were integrated to yield a goal achievement score (GAS). Linear regression was used to test the relationships between 1-year satisfaction with progress and the following variables: baseline to end-of-program change in clinical measures, and 1-year pain, physical function, and GAS. Results. Of the 106 surveys mailed, 89 (84%) were returned and 86 (81%) had complete data for analysis. None of the pre-post-program clinical measures was significantly correlated with satisfaction (overall R2 = 0.013, P < 0.74). In contrast, year-end Average Pain (R2 = 0.28), Physical Function (R2 = 0.29), and GAS (R2 = 0.29) were each significantly correlated (P < 0.0001) with satisfaction, with a combined R2 = 0.43, P < 0.0001. Of these variables, GAS had the highest unique contribution to satisfaction. Conclusion. For CDSD patients 1 year after completing rehabilitation, compared to more traditional outcomes, GAS provided the greatest unique contribution to patient satisfaction. Goal achievement may be a valuable patient-centered measure of treatment outcome.