Time to drink: Activating lateral hypothalamic area neurotensin neurons promotes intake of fluid over food in a time-dependent manner.

The lateral hypothalamic area (LHA) is essential for ingestive behavior but has primarily been studied in modulating feeding, with comparatively scant attention on drinking. This is partly because most LHA neurons simultaneously promote feeding and drinking, suggesting that ingestive behaviors track together. A notable exception are LHA neurons expressing neurotensin (LHANts neurons): activating these neurons promotes water intake but modestly restrains feeding. Here we investigated the connectivity of LHANts neurons, their necessity and sufficiency for drinking and feeding, and how timing and resource availability influence their modulation of these behaviors. LHANts neurons project broadly throughout the brain, including to the lateral preoptic area (LPO), a brain region implicated in modulating drinking behavior. LHANts neurons also receive inputs from brain regions implicated in sensing hydration and energy status. While activation of LHANts neurons is not required to maintain homeostatic water or food intake, it selectively promotes drinking during the light cycle, when ingestive drive is low. Activating LHANts neurons during this period also increases willingness to work for water or palatable fluids, regardless of their caloric content. By contrast, LHANts neuronal activation during the dark cycle does not promote drinking, but suppresses feeding during this time. Finally, we demonstrate that the activation of the LHANts â†’ LPO projection is sufficient to mediate drinking behavior, but does not suppress feeding as observed after generally activating all LHANts neurons. Overall, our work suggests how and when LHANts neurons oppositely modulate ingestive behaviors.

Invasive Treatments for Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS: Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS: Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION: Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Establishing Central Sensitization-Related Symptom Severity Subgroups: A Multicountry Study Using the Central Sensitization Inventory.

OBJECTIVES: The goal of this study was to identify central sensitization-related symptom severity subgroups in a large multicountry sample composed of patients with chronic pain and pain-free individuals using the Central Sensitization Inventory (CSI). METHODS: A large, pooled international (N = 8 countries) sample of chronic pain patients plus healthy subjects (total N = 2,620) was randomly divided into two subsamples for cross-validation purposes. First, a hierarchical cluster analysis (HCA) was performed using CSI item-level data as clustering variables (test sample; N = 1,312). Second, a latent profile analysis (LPA) was conducted to confirm the optimal number of CSI clusters (validation sample; N = 1,308). Finally, to promote implementation in real-world clinical practice, we built a free online Central Sensitization Inventory Symptom Severity Calculator. RESULTS: In both HCA (N = 1,219 valid cases) and LPA (N = 1,245 valid cases) analyses, a three-cluster and three-profile solution, respectively, emerged as the most statistically optimal and clinically meaningful. Clusters were labeled as follows: (i) Low Level of CS-Related Symptom Severity, (ii) Medium Level of CS-Related Symptom Severity, and (iii) High Level of CS-Related Symptom Severity. CONCLUSIONS: Our results indicated that a three-cluster solution clearly captured the heterogeneity of the CSI data. The calculator might provide an efficient way of classifying subjects into the cluster groups. Future studies should analyze the extent to which the CSI cluster classification correlates with other patient-reported and objective signs and symptoms of CS in patients with chronic pain, their associations with clinical outcomes, health-related costs, biomarkers, (etc.), and responsiveness to treatment.

Non-Invasive and Minimally Invasive Management of Low Back Disorders.

OBJECTIVE: This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Low Back Disorders Guideline reviews the evidence and recommendations developed for non-invasive and minimally invasive management of low back disorders. METHODS: Systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking. A total of 70 high-quality and 564 moderate-quality trials were identified for non-invasive low back disorders. Detailed algorithms were developed. RESULTS: Guidance has been developed for the management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 121 specific recommendations. CONCLUSION: Quality evidence should guide treatment for all phases of managing low back disorders.

Differential expression of nicotine withdrawal as a function of developmental age in the rat.

Cigarette smoking and resultant nicotine dependence remain major public health problems. Most smokers begin before the age of 18, yet preclinical models have insufficiently characterized the development of nicotine dependence in adolescence. To categorize the short-term effects of chronic nicotine administration throughout adolescence and adulthood, we exposed male Sprague Dawley rats to 14 days of continuously delivered nicotine (0, 1.2 or 4.8 mg/kg/d) using a subcutaneous osmotic minipump, starting between postnatal day 33 (p33) and p96. Next, to explore the effects of extended exposure to chronic nicotine, we exposed male Sprague Dawley rats to 42 days of continuous nicotine starting in adolescence (p33) or early adulthood (p68). Somatic and affective signs of precipitated withdrawal (PW) were observed after a mecamylamine (1.5 mg/kg, i.p.) challenge as compared to a saline injection. Short term nicotine exposure starting at p96, well within the adult period, elicited a significant increase in somatic PW as measured by a composite behavioral score. In contrast, adolescent exposure to nicotine elicited a unique behavioral profile, dependent on the starting age of exposure. Late adolescence exposure was characterized by scratching while adult exposure was characterized by facial tremors and yawns. Extended exposure to nicotine resulted in age specific characteristic nicotine withdrawal behaviors, including scratches, ptosis and locomotion, distinct from the short-term exposure. Thus, nicotine dependence severity, based on the expression of total somatic PW behaviors, is not observed until the adult period, and differences between adolescents and adults are observed using a more nuanced behavioral scoring approach. We conclude that age of nicotine initiation affects somatic withdrawal signs and their magnitude. These data serve as a foundation for understanding the underlying brain mechanisms of nicotine dependence and their development over adolescence and early adulthood.

Diagnostic Tests for Low Back Disorders.

OBJECTIVE: The aim of this study was to summarize evidence-based diagnostic guidelines for low back disorders. METHODS: A comprehensive literature review was conducted. A total of 101 articles of high or moderate quality addressing low back disorders diagnostic evaluation met the inclusion criteria. Evidence-based recommendations were developed and graded from (A) to (C) in favor and against the specific diagnostic test, with (A) level having the highest quality body of literature. Expert consensus was employed for insufficient evidence (I) to develop consensus guidance. RESULTS: Recommendations are given for these diagnostic tests: functional capacity evaluations, roentgenograms (x-rays), magnetic resonance imaging (MRI), computerized tomography, myelography, bone scans, single proton emission computed tomography, electromyography, surface electromyography, ultrasound, thermography, fluoroscopy, videofluoroscopy, lumbar discography, MRI discography, and myeloscopy. CONCLUSION: Diagnostic testing is not indicated for the majority of patients with low back pain.

Does the Length of Disability between Injury and Functional Restoration Program Entry Affect Treatment Outcomes for Patients with Chronic Disabling Occupational Musculoskeletal Disorders?

Purpose Functional restoration programs (FRPs), for patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), have consistently demonstrated positive socioeconomic treatment outcomes, including decreased psychosocial distress and increased work return. The pre-treatment length of disability (LOD), or time between injury and treatment admission, has been shown to influence FRP work outcomes. Some studies have found that shorter LOD is associated with better work outcomes. However, few studies have actually examined cohorts with LOD duration longer than 18 months. This present study evaluated the effects of extended LOD (beyond 18 months) on important treatment outcomes. Methods A total cohort of 1413 CDOMD patients entered an FRP. Of those, 312 did not complete the program, so they were eliminated from outcome analyses. The 1101 patients who completed the FRP were classified based on LOD: Late Rehabilitation (LR, 3-6 months, n = 190); Chronic Disability (CD, 7-17 months, n = 494); and Late Chronic Disability (LCD). The LCD, in turn, consisted of four separate subgroups: 18-23 months (LCD-18, n = 110); 24-35 months (LCD-24, n = 123); 36-71 months (LCD-36, n = 74); and 72+ months (LCD-72, n = 110). Patients were evaluated upon admission and were reassessed at discharge. Those patients who chose to pursue work goals post-treatment (n = 912) were assessed 1-year later. Results Longer LOD was associated with less likelihood of completing the FRP (p < .001). Compared to the other LOD groups, a relatively large percentage of patients (47%) in the longest- disability group were receiving social security disability benefits. Associations were found between longer LOD and more severe patient-reported pain, disability, and depressive symptoms at treatment admission. At discharge, symptom severity decreased for these patient-reported variables in all LOD groups (p < .001). Using binary logistic regressions, it was found that LOD significantly predicted work-return (Wald = 11.672, p = .04) and work-retention (Wald = 11.811, p = .04) after controlling for covariates. Based on the LOD groups, the percentage of patients returning to, and retaining work, ranged from 75.6 to 94.1%, and from 66.7 to 86.3%, respectively. The odds of LCD-24 and LCD-72 patients returning to work were 2.9, and 7.4, respectfully, less likely, compared to LR patients. Furthermore, the odds of LCD-24 and LCD-72 patients retaining work were 3.3 and 3.8 times, respectively, less likely, compared to LR patients. Conclusions Long LOD was a risk factor for FRP non-completion, and was associated with more severe patient-reported variables, including pain intensity and perceived disability. Furthermore, long LOD was a significant predictor for work outcomes at 1 year following FRP discharge. Nevertheless, a large percentage of longer LOD (>24 months) patients had returned to work within the year after discharge (above 85%), and had retained at least part-time work 1-year later (above 66%). These results support the effectiveness of the FRP in mitigating the effects of extended LOD in a large percentage of long-term LOD patients.

Dimensionality and Reliability of the Central Sensitization Inventory in a Pooled Multicountry Sample.

Central sensitization (CS) involves the amplification of neural signaling within the central nervous system, which evokes pain hypersensitivity. The Central Sensitization Inventory (CSI) assesses 25 overlapping health-related symptom dimensions that have been reported to be associated with CS-related disorders. Previous studies have reported satisfactory test-retest reliability and internal consistency, but factor analyses have exhibited conflicting results in different language versions. The purpose of this cross-sectional study was to thoroughly examine the dimensionality and reliability of the CSI, with pooled data from 1,987 individuals, collected in several countries. The principal component analysis suggested that 1 general factor of CS best described the structure. A subsequent confirmatory factor analysis revealed that a bifactor model, which accounted for the covariance among CSI items, with regard to 1 general factor and 4 orthogonal factors, fit the CSI structure better than the unidimensional and the 4-factor models. Additional analyses indicated substantial reliability for the general factor (ie, Cronbach α = .92; ω = .95; and ω hierarchical = .89). Reliability results for the 4 specific factors were considered too low to be used for subscales. The results of this study clearly suggest that only total CSI scores should be used and reported. PERSPECTIVE: As far as we know, this is the first study that has examined the factor structure and reliability of the CSI in a large multicountry sample. The CSI is currently considered the leading self-report measure of CS-related symptoms worldwide.

Use of the Central Sensitization Inventory (CSI) as a treatment outcome measure for patients with chronic spinal pain disorder in a functional restoration program.

BACKGROUND CONTEXT: The Central Sensitization Inventory (CSI) is a valid and reliable patient-reported instrument designed to identify patients whose presenting symptoms may be related to central sensitization (CS). Part A of the CSI measures a full array of 25 somatic and emotional symptoms associated with CS, and Part B asks if patients have previously been diagnosed with one or more specific central sensitivity syndromes (CSSs) and related disorders. The CSI has previously been validated in a group of patients with chronic pain who were screened by a trained psychiatrist for specific CSS diagnoses. It is currently unknown if the CSI can be a useful treatment-outcome assessment tool for patients with chronic spinal pain disorder (CSPD) who are not screened for comorbid CSSs. It is known, however, that previous studies have identified CS-related symptoms, and comorbid CSSs, in subsets of patients with CSPDs. Studies have also shown that CS-related symptoms can be influenced by cognitive and psychosocial factors, including abuse history in both childhood and adulthood, sleep disturbance, catastrophic and fear-avoidant cognitions, and symptoms of depression and anxiety. PURPOSE: This study aimed to evaluate CSI scores, and their associations with other clinically relevant psychosocial variables, in a cohort of patients with CSPD who entered and completed a functional restoration program. STUDY DESIGN/SETTING: A retrospective study of prospectively collected data from a cohort study of patients with CSPD, who completed the CSI at admission to, and discharge from, an interdisciplinary function restoration program (FRP) was carried out. PATIENT SAMPLE: A cohort of 763 patients with CSPD comprised the study sample. OUTCOME MEASURES: Clinical interviews evaluated mood disorders and abuse history. A series of self-reported measures evaluated comorbid psychosocial symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance, at FRP admission and discharge. METHODS: Patients were grouped into five severity level groups, from mild to extreme, based on total CSI scores, at FRP admission, and then again at discharge. The FRP included a quantitatively directed and medically supervised exercise process, as well as a multimodal psychosocial disability management component. RESULTS: The CSI severity groups were strongly associated with Major Depressive Disorder and previous abuse history (p<.01), which are known risk factors for CS-related symptoms and diagnoses. The CSI scores were also strongly associated with patient-reported CSS diagnoses on CSI Part B. The percentage of patients who reported a comorbid CSS diagnosis increased in each higher CSI-severity group, from 11% in the Subclinical group, to 56% in the Extreme group. The CSI severity groups were significantly related to other CS-related patient-reported symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance (p's<.001). The CSI scores, along with all other psychosocial measures, decreased at treatment discharge. CONCLUSIONS: In the present study, admission CSI scores were highly associated with previous CSS diagnoses, CS-related symptoms, and clinically relevant patient-reported psychosocial variables. All psychosocial variables, as well as scores on the CSI, were significantly improved at FRP discharge. The CSI may have important clinical utility, as a screener and as a treatment outcome measure, for patients with CSPD participating in an interdisciplinary FRP.

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population.

OBJECTIVES: To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure. MATERIALS AND METHODS: In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge. Associations with objective lifting performance and other patient-reported psychosocial measures were determined at admission and discharge, and objective work outcomes for this predominantly disabled cohort, were assessed 1 year later. RESULTS: Those patients in the severe and extreme FACS severity groups at admission were more likely to "drop out" of treatment than those in the lower severity groups (P=0.05). At both admission and discharge, the FACS severity groups were highly and inversely correlated with objective lifting performance and patient-reported fear-avoidance-related psychosocial variables, including kinesiophobia, pain intensity, depressive symptoms, perceived disability, perceived injustice, and insomnia (Ps<0.001). All variables showed improvement at FRP discharge. Patients in the extreme FACS severity group at discharge were less likely to return to, or retain, work 1 year later (P≤0.02). A factor analysis identified a 2-factor solution. DISCUSSION: Strong associations were found among FACS scores and other patient-reported psychosocial and objective lifting performance variables at both admission and discharge. High discharge-FACS scores were associated with worse work outcomes 1 year after discharge. The FACS seems to be a valid and clinically useful measure for predicting attendance, physical performance, distress, and relevant work outcomes in FRP treatment of chronic musculoskeletal pain disorder patients.

Establishing Clinically Relevant Severity Levels for the Central Sensitization Inventory.

OBJECTIVES: The aim of this study was to create and validate severity levels for the central sensitization inventory (CSI), a valid and reliable patient-reported outcome instrument designed to identify patients whose presenting symptoms may be related to a central sensitivity syndrome (CSS; eg, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome), with a proposed common etiology of central sensitization (CS). METHODS: Based on CSI score means and standard deviations from previously published subject samples, the following CSI severity levels were established: subclinical = 0 to 29; mild = 30 to 39; moderate = 40 to 49; severe = 50 to 59; and extreme = 60 to 100. The concurrent validity of the CSI severity levels was then confirmed in a separate chronic pain patient sample (58% with a CSS diagnosis and 42% without) by demonstrating associations between CSI scores and (1) the number of physician-diagnosed CSSs; (2) CSI score distributions in both CSS and non-CSS patient samples; (3) patient-reported history of CSSs; and (4) patient-reported psychosocial measures, which are known to be associated with CSSs. RESULTS: Compared to the non-CSS patient subsample, the score distribution of the CSS patient subsample was skewed toward the higher severity ranges. CSI mean scores moved into higher severity levels as the number of individual CSS diagnoses increased. Patients who scored in the extreme CSI severity level were more likely to report previous diagnoses of fibromyalgia, chronic fatigue syndrome, temporomandibular joint disorder, tension/migraine headaches, and anxiety or panic attacks (P < 0.01). CSI severity levels were also associated with patient-reported depressive symptoms, perceived disability, sleep disturbance, and pain intensity (P ≤ 0.02). CONCLUSION: This study provides support for these CSI severity levels as a guideline for healthcare providers and researchers in interpreting CSI scores and evaluating treatment responsiveness.

The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance.

Pain-related fear avoidance (FA), a common problem for patients with painful medical conditions, involves pain-related catastrophizing cognitions, hypervigilance, and avoidance behaviors, which can ultimately lead to decreased functioning, depression, and disability. Several patient-reported instruments have been developed to measure FA, but they have been criticized for limited construct validity, inadequate item specificity, lack of cutoff scores, and missing important FA components. The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Psychometric evaluation of the FACS found high internal consistency (α = 0.92) and high test/retest reliability (r = 0.90-0.94, P < 0.01). FACS scores differentiated between 2 separate chronic pain patient samples and a nonpatient comparison group. When clinically relevant severity levels were created, FACS severity scores were highly associated with FA-related patient-reported psychosocial and objective lifting performance variables. These results suggest that the FACS is a psychometrically strong and reliable measure that can help healthcare providers assess FA-related barriers to function and recovery.

The Potential Utility of the Patient Health Questionnaire as a Screener for Psychiatric Comorbidity in a Chronic Disabling Occupational Musculoskeletal Disorder Population.

OBJECTIVES: The patient health questionnaire (PHQ) is designed for screening psychopathology in primary care settings. However, little is known about its clinical utility in other chronic pain populations, which usually have high psychiatric comorbidities. DESIGN: A consecutive cohort of 546 patients with chronic disabling occupational musculoskeletal disorder (CDOMD) was administered and compared upon psychosocial assessments, including the PHQ and a structured clinical interview for DSM-IV (SCID). Four PHQ modules were assessed: major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and alcohol use disorders (AUD) [including both alcohol abuse and dependence]. Based on the SCID diagnosis, sensitivity and specificity were determined. RESULTS: The specificity of the PHQ ranged from moderate to high for all 4 PHQ modules (MDD, 0.79; GAD, 0.67; PD, 0.89; AUD, 0.97). However, the sensitivity was relatively low: MDD (0.58); GAD (0.61); PD (0.49); and AUD (0.24). The PHQ was also associated with psychosocial variables. Patients whose PHQ showed MDD, GAD, or PD reported significantly more depressive symptoms and perceived disability than patients who did not (Ps < 0.001). Patients with MDD or GAD reported significantly higher pain than those without (Ps < 0.001). CONCLUSIONS: The strong specificity of the PHQ appears to be its primary strength for this cohort. Due to its high specificity, the PHQ could be employed as an additional screening tool to help rule out potential psychiatric comorbidity in patients with CDOMD. The low sensitivity of the PHQ in this population, however, remains a weakness of the PHQ.

Does Classification of Chronic Musculoskeletal Disorder Patients Into Psychosocial Subgroups Predict Differential Treatment Responsiveness and 1-Year Outcomes After a Functional Restoration Program?

OBJECTIVES: The objectives of this study: (1) to assess whether Multidimensional Pain Inventory (MPI) profiles predicted differential responses to a functional restoration program (FRP) in chronic disabling occupational musculoskeletal disorder (CDOMD) patients; (2) to examine whether coping style improves following FRP; and (3) to determine whether discharge MPI profiles predict discharge psychosocial and 1-year socioeconomic outcomes. METHODS: Consecutive CDOMD patients (N=716) were classified into Adaptive Coper (AC, n=209), Interpersonally Distressed (ID, n=154), Dysfunctional (DYS, n=310), and Anomalous (n=43) using the MPI, and reclassified at discharge. Profiles were compared on psychosocial measures and 1-year socioeconomic outcomes. An intent-to-treat sample analyzed the effect of drop-outs on treatment responsiveness. RESULTS: The MPI classification significantly predicted program completion (P=0.001), although the intent-to-treat analyses found no significant effects of drop-out on treatment responsiveness. There was a significant increase in the number of patients who became AC or Anomalous at FRP discharge and a decrease in those who were ID or DYS. Patients who changed or remained as DYS at FRP discharge reported the highest levels of pain, disability, and depression. No significant interaction effect was found between MPI group and time for pain intensity or disability. All groups improved on psychosocial measures at discharge. DYS patients had decreased work retention and a greater health care utilization at 1 year. CONCLUSIONS: An FRP was clinically effective for CDOMD patients regardless of initial MPI profiles. The FRP modified profiles, with patients changing from negative to positive profiles. Discharge DYS were more likely to have poor 1-year outcomes. Those classified as Anomalous had a good prognosis for functional recovery similar to ACs.

Improved functional capacity evaluation performance predicts successful return to work one year after completing a functional restoration rehabilitation program.

OBJECTIVE: To evaluate whether functional capacity evaluation (FCE) scores are responsive to functional restoration treatment, and to assess the ability of FCEs at program discharge to predict work outcomes. DESIGN: An interdisciplinary cohort study of prospectively collected data. SETTING: A functional restoration center. PATIENTS: A consecutive sample of 354 patients with chronic disabling occupational musculoskeletal disorders (CDOMDs) completed a functional restoration program consisting of quantitatively directed exercise progression and multi-modal disability management with interdisciplinary medical supervision. METHODS: Each patient participated in an FCE at admission and discharge from treatment. The results of each FCE yielded the physical demand level (PDL) at which patients were functioning. Patients were initially divided into 5 PDL groups, based on job-of-injury lifting, carrying, and pushing/pulling requirements, for the pre- to posttreatment responsiveness analyses. Patients were subsequently divided into 5 PDL groups, based on their performance on the FCE upon program completion. MAIN OUTCOME MEASURES: Outcome measures included admission-to-discharge changes in PDLs and 2 specific FCE lifting tasks: isokinetic lifting; and the Progressive Isoinertial Lifting Evaluation (PILE). Socioeconomic outcomes were also evaluated, including post-discharge work return and work retention 1-year after treatment completion. RESULTS: Overall, 96% of the patients demonstrated improvement in their PDLs from admission to discharge. A majority of patients (56%) were able to achieve a discharge PDL that was comparable to their estimated job-of-injury lifting requirement or higher (P < .001). Lifting ability improved from admission to discharge by approximately 50% (all P < .001). Discharge PDLs predicted both work return (P < .001) and work retention (P < .001) 1 year later. CONCLUSIONS: FCE scores were responsive to functional restoration treatment, and the associated discharge PDLs predicted work return after treatment completion and work retention 1 year later.

Does the economy affect functional restoration outcomes for patients with chronic disabling occupational musculoskeletal disorders?

PURPOSE: To determine how the economy affects psychosocial and socioeconomic treatment outcomes in a cohort of chronic disabling occupational musculoskeletal disorder (CDOMD) patients who completed a functional restoration program (FRP). METHODS: A cohort of 969 CDOMD patients with active workers' compensation claims completed an FRP (a medically-supervised, quantitatively-directed exercise progression program, with multi-modal disability management). A good economy (GE) group (n = 532) was released to work during a low unemployment period (2005-2007), and a poor economy (PE) group (n = 437) was released during a higher unemployment period (2008-2010). Patients were evaluated upon admission for demographic and psychosocial variables, and were reassessed at discharge. Socioeconomic outcomes, including work return and work retention 1 year post-discharge, were collected. RESULTS: Some significant differences in psychosocial self-report data were found, but most of the effect sizes were small, so caution should be made when interpreting the data. Compared to the PE group, the GE group reported more depressive symptoms and disability at admission, but demonstrated a larger decrease in depressive symptoms and disability and increase in self-reported quality of life at discharge. The PE group had lower rates of work return and retention 1-year after discharge, even after controlling for other factors such as length of disability and admission work status. CONCLUSIONS: CDOMD patients who completed an FRP in a PE year were less likely to return to, or retain, work 1-year after discharge, demonstrating that a PE can be an additional barrier to post-discharge work outcomes. A difference in State unemployment rates of <3% (7 vs. 5%) had a disproportionate effect on patients' failure to return to (19 vs. 6%) or retain (28 vs. 15%) work.