Patient-centered evaluation of outcomes from rehabilitation for chronic disabling spinal disorders: the impact of personal goal achievement on patient satisfaction.

BACKGROUND CONTEXT: The multiplicity of biopsychosocial and economic facets of chronic disabling back and/or neck pain complicates the treatment outcomes measurement. Our previous work showed that personal functional goal achievement contributed more toward patient satisfaction with the outcome than did traditional self-reports of pain and physical function or measured strength, flexibility, and endurance among functional restoration program (FRP) graduates with chronic disabling back and/or neck pain. PURPOSE: The primary goal was to compare the impact on patient satisfaction of pain and functional goal achievement versus self-reports of pain and physical function. STUDY DESIGN: This was an observational study of all patients with chronic disabling back and/or neck pain completing an FRP between June 2008 and May 2009. OUTCOME MEASURES: Before the treatment, participants recorded personal 3-month goals for pain, work, recreation, and activities of daily living. At least 3 months later, all graduates were sent a follow-up survey displaying the patient's pretreatment functional goals and eliciting the patient's assessment of functional goal achievement; current pain magnitude, "satisfaction with the overall results for your pain problem;" and responses to the Short Form-36v2 Physical Functioning subscale (PF-10). METHODS: Pain goal achievement was calculated as the difference between the pretreatment pain goal and follow-up pain magnitude. Linear regression was used to evaluate the association between satisfaction and four variables (follow-up pain; PF-10; pain goal achievement; functional goal achievement), individually and then together in a full model. RESULTS: Of the 82 patients surveyed, 62 responded completely. Mean age was 44 years, with 48% female and 35% on worker's compensation. The model R(2) combining all four variables explained 0.6033 of the variance in satisfaction. Each variable by itself was significantly related to patient satisfaction at p<.001, but the overlap in association was large. The unique contributions (R(2)) to the variation in satisfaction were the following: functional goal achievement: 0.0471; PF-10 score: 0.0229; pain magnitude: 0.0178; and pain goal achievement: 0.0020. CONCLUSIONS: At least 3 months after the treatment, functional goal achievement had by far the greatest impact on patient satisfaction, followed by PF-10 score, pain magnitude, and, finally, pain goal achievement. Functional goal achievement has great potential as a tool for patient-centered treatment decision-making and outcomes measurement for people with chronic disabling back and/or neck pain and their health care providers.

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.

Low-back and neck pain diagnosis and treatment.

Back and neck pain are symptoms, often complaints, and sometimes causes of disability, but they are not diseases. These distinctions are critical to understanding the personal and societal impact of back and neck pain and our opportunities to discover new ways to reduce their impact. This article briefly describes current diagnosis and treatment of spinal pain, the relationship between pain and disability, and the challenges in prioritizing our resource allocations between curing pain problems and reducing disability.

Failed back surgery syndrome: surgical and nonsurgical approaches.

UNLABELLED: Failed Back Surgery Syndrome is a common and challenging clinical problem. Often the anatomic pain source is unclear. Relevant outcome studies are rarely diagnosis specific, and high level research studies comparing surgical and nonsurgical approaches to Failed Back Surgery Syndrome studies have not been published to date. Surgical strategies focus on decompressing neural impingement or fusing unstable or putatively painful intervertebral discs. Nonsurgical interventions range from nerve root specific blocks for pain relief to multidisciplinary rehabilitation programs geared toward improving function. This paper reviews the most common interventions and concludes with recommendations for the care of the individual patient. LEVEL OF EVIDENCE: Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence.

BACKGROUND: The process of returning disabled workers to work presents numerous challenges. In spite of the growing evidence regarding work disability prevention, little uptake of this evidence has been observed. One reason for limited dissemination of evidence is the complexity of the problem, as it is subject to multiple legal, administrative, social, political, and cultural challenges. PURPOSE AND METHODS: A literature review and collection of experts' opinion is presented, on the current evidence for work disability prevention, and barriers to evidence implementation. Recommendations are presented for enhancing implementation of research results. CONCLUSION: The current evidence regarding work disability prevention shows that some clinical interventions (advice to return to modified work and graded activity programs) and some non-clinical interventions (at a service and policy/community level but not at a practice level) are effective in reducing work absenteeism. Implementation of evidence in work disability is a major challenge because intervention recommendations are often imprecise and not yet practical for immediate use, many barriers exist, and many stakeholders are involved. Future studies should involve all relevant stakeholders and aim at developing new strategies that are effective, efficient, and have a potential for successful implementation. These studies should be based upon a clearer conceptualization of the broader context and inter-relationships that determine return to work outcomes.

Educating back-injured workers: What should we be teaching?

OBJECTIVE: The purpose of this study was to identify what information people with acute and chronic back pain, health care practitioners, employers and case managers felt should be included in an educational brochure for recently back-injured workers. STUDY DESIGN: Four focus groups were convened, each comprising several representatives from one of the four constituencies. Participants rated 32 information items regarding their inclusion in an educational brochure. Ratings were tabulated for ranking and for group comparisons. RESULTS: While consensus was strong for most information items, there were apparent differences between the groups for several items relating to work resumption, medical attention, and legal or compensation consultation. CONCLUSIONS: Perceived educational needs of back-injured workers may differ from those of their health care practitioners and from their employers or insurers. Future efforts to prevent back disability through education should include evaluation of the informational needs of injured workers.