Cervical nonorganic signs: a new clinical tool to assess abnormal illness behavior in neck pain patients: a pilot study.

OBJECTIVE: To develop and assess the reliability of a group of cervical nonorganic physical signs to be used as a simple screening tool for identifying patients with low neck pain who exhibit abnormal illness behavior. DESIGN: Survey, consecutive sample. DATA SET: Double masked. SETTING: Functional restoration program. PATIENTS: Twenty-six consecutive patients with complaints of chronic neck pain (greater than 4 months duration). Each patient was evaluated by a physician and then again by either a physical or occupational therapist, for the presence of specific cervical nonorganic signs. Both of the evaluations occurred on the same day. MAIN OUTCOME MEASURES: Five categories consisting of eight tests were appraised: (1) tenderness, (2) simulation, (3) range of motion, (4) regional disturbance, and (5) overreaction. RESULTS: The percent agreement between raters ranged from a high of 100% for regional sensory disturbance, to a low of 68% for one of the simulation tests. The average agreement between raters across all of the nonorganic test signs was 84.6%. Likewise, kappa coefficients ranged from 1.00 to .16, reflecting differences in strength of agreement. CONCLUSION: For many years, the lumbar nonorganic signs (developed by Waddell and colleagues) have been a useful screening tool in the assessment of abnormal illness behavior in the low back pain population. For the first time, a group of cervical nonorganic signs have been developed, standardized, and proven reliable.

Outcomes comparison of treatment for chronic disabling work-related upper-extremity disorders and spinal disorders.

Since 1986, the percentage of upper-extremity musculoskeletal disorders (UEMSDs) has increased from 1% to 4% of all occupational injury claims, while the average total medical and compensation cost is 80% higher than the average of all other claims. Because chronic disability leads to the highest cost, systematic evaluation of this growing occupational condition is needed. We performed a prospective case-series cohort study of patients (n = 163) with UEMSDs, compared with a matched group of spinal disorder (SD) patients (n = 163) treated with the same protocol. UEMSD patients were subclassified as those with one or more neuropathic diagnoses or those with non-neuropathic diagnoses. The neuropathic UEMSD subgroup had the poorest outcomes, with significantly higher surgery rates, higher health care utilization rates, and lower work retention when compared with the SD group. Rehabilitation outcomes for UEMSDs are similar to those for SDs. However, neuropathic-diagnosis patients are at risk for high-cost injuries and/or poorer prognoses.

Toward more accurate use of the Beck Depression Inventory with chronic back pain patients.

OBJECTIVE: To improve the accuracy of the Beck Depression Inventory (BDI) in assessing depression in chronic back pain (CBP) patients, the pattern of depression symptomatology was evaluated. DESIGN: Analyses of BDI data obtained from nondepressed and depressed CBP patients were conducted to identify the major factors that differentiated among the patient groups. SETTING: CBP patients were recruited from a tertiary rehabilitation center. PATIENTS: One hundred one nondepressed and 99 depressed CBP patients from the tertiary treatment center. OUTCOME MEASURES AND RESULTS: Analyses of the BDI data revealed a general factor of depression severity that excluded items reflecting weight loss, sleep disturbance, and work inhibition. In addition, these analyses yielded a second factor reflecting somatic concerns and disability. Weight loss, sleep disturbance, and work inhibition failed to differentiate the depressed from the nondepressed CBP subjects, suggesting that these symptoms have poor diagnostic potential for CBP patients. CONCLUSIONS: This study demonstrated that the BDI can be used to generate important information about the severity of interference posed by pain on the functioning of an individual, while allowing for an independent evaluation of subjective indices of depression and somatic disturbances that need to be attended to by clinicians.

Early childhood abuse in chronic spinal disorder patients. A major barrier to treatment success.

STUDY DESIGN: Prevalence rates of childhood abuse, socioeconomic outcome data, and levels of psychopathology were evaluated for graduates of a functional restoration program for chronically disabled spinal disorder patients in a workers' compensation environment. OBJECTIVES: To describe psychological profiles and evaluate treatment outcomes for chronic spinal disorder patients with a history of childhood abuse. SUMMARY OF BACKGROUND DATA: There is increasing evidence to indicate that traumatic childhood events may leave adult survivors psychologically distressed. It is possible that because of this level of psychological distress, chronic spinal disorder patients may be unable to return to a productive life-style after completing a rehabilitation program. METHODS: Two hundred ninety-nine male and 174 female patients from a cohort (N = 473) of consecutive graduates of a functional restoration program were assessed for the presence of childhood abuse by structured interview. Prevalence rates were compared with a comparison group of subjects without a history of chronic spinal disorder disability. In addition, the 79 chronic spinal disorder patients with a history of childhood abuse were compared on several socioeconomic outcomes with a matched group of workers with chronic spinal disorders without a history of childhood abuse. Psychopathology in the two groups of chronic spinal disorder patients was evaluated using Diagnostic and Statistical Manual of Mental Disorders criteria, the Minnesota Multiphasic Personality Inventory, and Symptom Checklist-90-Revised. RESULTS: A history of childhood abuse was found to be related to a higher level of psychological distress in chronic spinal disorder patients. In addition, poorer socioeconomic outcomes, such as lower work retention rates and higher postrehabilitation operations to the same area of injury, were found in the chronic spinal disorder patients with a history of childhood abuse compared with workers without a history of childhood abuse in whom chronic spinal disorders developed. CONCLUSIONS: These results demonstrate that although a history of childhood abuse is associated with greater psychosocial disturbances in chronically disabled spinal disorder patients, such disturbances do not interfere with an initial positive response to an effective tertiary rehabilitation program such as functional restoration. However, a history of childhood abuse may be related to poorer socioeconomic outcomes after discharge from rehabilitation programs. Additional treatment options may be needed for these patients.

A prospective study of Waddell signs in patients with chronic low back pain. When they may not be predictive.

STUDY DESIGN: Analysis of the treatment-outcome predictive power of Waddell signs by evaluating them before and after functional restoration, with assessment of 1-year socioeconomic outcomes. OBJECTIVE: To evaluate the presence of Waddell nonorganic signs in a group of patients with chronic low back pain presenting for functional restoration, and to determine whether they were predictive of treatment success of failure. SUMMARY OF BACKGROUND DATA: Waddell has described "nonorganic" physical signs in patients with chronic low back pain indicative of somatization. Other researchers have correlated high Waddell scores with psychosocial barriers that required additional consultation, and have suggested that diminution of a Waddell score during physical rehabilitation is predictive of subsequent therapeutic success. METHODS: Total positive Waddell signs score and individual sign scores were assessed at initial presentation for functional restoration treatment and at discharge in a group of 50 patients with chronic low back pain (average length of disability = 17.9 months; average age = 38.5 years). Patients were then tracked and assessed with a 1-year follow-up structured interview to evaluate outcome variables such as return to work, work retention, re-injury rate, health utilization, and subsequent surgery. RESULTS: Statistical analyses of these data revealed no significant associations between Waddell total positive score or changes in score and therapeutic success as measured by any of the behavioral outcomes such as return to work. Also, no predictive value was found for the individual positive signs of their changes and therapeutic success. CONCLUSIONS: Although positive Waddell signs have been found to be predictive in patients with short-term chronic low back pain, the current results suggest that, in patients who have longer duration of pain and who undergo a comprehensive functional restoration program, these signs are not significantly prognostic. Because functional restoration is an interdiscipilinary approach that effectively manages somatization complaints in a consistent manner by all treatment personnel, such complaints do not create any major barriers to recovery. Therefore, although Waddell signs may be predictive of treatment outcome in less intensive rehabilitation programs, they do not provide any predictive power in a comprehensive functional restoration program, which has a basic goal of managing barriers to recovery in a clinically efficacious manner.

Objectification of functional improvement after nonoperative care.

STUDY DESIGN: In this article, the authors review the three broad categories of measures that have been used to objectify functional improvement after nonoperative care of painful spinal disorder patients-physical, psychological, and socioeconomic. For each of the three categories, the major measures used are discussed, as well as research relating to the efficacy of the measures. OBJECTIVE: To point out the many differences that still exist among research studies regarding which functional outcome measures to use and when to use them. SUMMARY OF BACKGROUND DATA: During the past few decades, it has been made abundantly clear that painful spinal disorders, particularly when associated with work disability and/or financial benefits, result from a complex interaction of medical, psychological, and social factors. This has resulted in frequent confusion regarding what constitutes the primary roots of the disabling process. Currently, a more comprehensive biopsychosocial perspective of chronic pain and disability has emerged that has significant implications for diagnostic and treatment philosophies of practitioners. METHODS: Identifying the measures frequently used to address the important biopsychosocial factors, and evaluating their relative benefits and drawbacks. RESULTS AND CONCLUSIONS: It is demonstrated that there has been an overall trend in recent years toward using more objective, quantifiable instruments, encompassing the physical, psychological, and socioeconomic parameters of outcomes research in painful spinal disorders. These changes will certainly improve the ability of researchers to tease out which factors tap more directly into such tissue as physical impairment, as well as create greater uniformity of measures that will permit direct comparisons between studies.

Occupational disorders and the management of chronic pain.

Chronic pain affects a small proportion of patients with an occupational injury but can result in astronomical costs for future medical care, indemnity, and social service utilization. To provide adequate treatment, medical practitioners must make a conceptual shift from the disease-intervention model to visualizing chronic pain as a multifactorial syndrome with alterable components. Focusing on deconditioning and disability provides a means to subjective and objective improvement for these patients and gives a better measure of therapeutic success.

Changes in psychopathology following functional restoration of chronic low back pain patients: A prospective study.

Past research has consistently demonstrated high rates of psychopathology in patients disabled with chronic low back pain. The purpose of the present study was to evaluate whether functional restoration treatment of these patients would lead to significant changes in psychopathology. Fifty-six patients were evaluated for current psychiatric disorders, using a structured clinical interview for DSM-III-R disorders, upon admission to a comprehensive 3 week functional restoration program, and again at 6 months following their rehabilitation. Results clearly documented significant decreases in prevalence rates of psychiatric disorders, particularly somatoform pain disorder and major depression. Such findings demonstrate that effective rehabilitation can significantly decrease the high rates of psychopathology commonly found in chronic low back pain patients.

The dominant role of psychosocial risk factors in the development of chronic low back pain disability.

STUDY DESIGN: An inception cohort design was used in which 421 patients were evaluated systematically with a standard battery of psychosocial assessment tests (Structured Interview for DSM-III-R Diagnosis, Minnesota Multiphasic Personality Inventory, and Million Visual Pain Analog Scale) within 6 weeks of acute back pain onset. OBJECTIVES: The present study evaluated the predictive power of a comprehensive assessment of psychosocial and personality factors in identifying acute low back pain patients who subsequently develop chronic pain disability problems (as measured by job-work status at 1-year follow-up evaluation). SUMMARY OF BACKGROUND DATA: There has been a relative paucity of prospective research in the United States comprehensively evaluating potential psychosocial risk factors that are associated with those injured workers who subsequently fail to return to work and productivity after 1 year because of low back pain disability. Such research has been quite limited because of the time and cost involved in conducting prospective studies. METHODS: All study patients were symptomatic with lumbar pain syndrome for no more than 6 weeks. These acute patients were tracked every 3 months, culminating in a structured telephone interview being conducted 1 year after the initial evaluation to document return-to-work status. RESULTS: Logistic regression analyses, conducted to differentiate between patients who were back at work after 1 year versus patients who were not because of the original back injury, revealed the importance of three psychosocial measures: self-reported pain and disability, scores on Scale 3 of the Minnesota Multiphasic Personality Inventory, and workers' compensation and personal injury insurance status. The model generated correctly classified 90.7% of the cases. Results revealed that major psychopathology, such as depression and substance abuse, did not precede or cause the development chronic pain disability. CONCLUSIONS: These results show the presence of a robust "psychosocial disability factor" that is associated with those injured workers who are likely to develop chronic low back pain disability problems. Based on these data, a statistical algorithm has been generated that can identify those acute patients who will require early intervention to prevent the development of chronic disability. The second major result is that preinjury or concomitant psychopathology does not appear to predispose patients to chronic pain disability, although high rates of psychopathology have been shown in chronic low back pain. Future research should be directed at emotional vulnerability and psychosocial events in the period after the injury that may lead to chronicity.

Predicting outcome of chronic back pain using clinical predictors of psychopathology: a prospective analysis.

This study evaluated whether a comprehensive assessment of psychosocial measures is useful in characterizing those acute low back pain patients who subsequently develop chronic pain disability problems. A cohort of 324 patients was evaluated, with all patients being administered a standard battery psychological assessment tests. A structured telephone interview was conducted 6 months after the psychological assessment to evaluate return-to-work status. Analyses, conducted to differentiate between those patients who were back at work at 6 months versus those who were not because of the original back injury, revealed the importance of 3 measures: self-reported pain and disability, the presence of a personality disorder, and scores on Scale 3 of the Minnesota Multiphasic Personality Inventory. These results demonstrate the presence of a psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems.

Psychopathology and the rehabilitation of patients with chronic low back pain disability.

Recent research has clearly demonstrated the important role that psychopathology and other psychosocial factors can play in chronic low back pain disability (CLBPD). The purpose of this study was to evaluate whether diagnosed psychopathology is a significant limiting factor in the successful rehabilitation of patients with CLBPD. One hundred fifty-two CLBPD patients (97 men, 55 women) were given a structured psychiatric interview for official DSM-III-R diagnosis of psychopathology upon entering an intensive 3-week functional restoration treatment program. All patients were assessed for the presence of Axis I clinical disorders and Axis II personality disorders. They were subsequently tracked for 1 year after program completion, with treatment outcome being defined as return-to-work status at this 1-year time period. Results demonstrated that, though more than 90% of patients obtained at least one Axis I diagnosis, and more than 50% obtained at least one Axis II diagnosis, neither type nor degree of psychopathology were significantly predictive of a patient's ability to successfully return to work. These prospective study results suggest that if a treatment program is structured to appropriately manage psychopathology, as is the case of an intensive functional restoration program, then psychopathology does not have to interfere with successful treatment outcome.

Prevalence of psychopathology in carpal tunnel syndrome patients.

This study assessed the prevalence rates of psychopathology in acute carpal tunnel syndrome (CTS) and acute low back pain (LBP) patients. Psychopathology was assessed with the Structured Clinical Interview for the DSM-III-R (SCID). The results showed that the CTS patients had significantly higher rates of anxiety disorders, both current and lifetime, than the LBP patients. However, LBP patients had significantly higher rates of lifetime substance abuse than the CTS patients. In regard to other types of psychopathology, such as depression, current substance abuse, and somatoform pain disorders, CTS patients had similar rates as the LBP patients. It was concluded that anxiety disorders may be a concomitant of carpal tunnel syndrome, and that treating psychological problems along with physical aspects of the syndrome may increase the patient's chance of a successful therapeutic outcome.

Psychiatric illness and chronic low-back pain. The mind and the spine--which goes first?

Two hundred chronic low-back pain patients entering a functional restoration program were assessed for current and lifetime psychiatric syndromes using a structured psychiatric interview to make DSM-III-R diagnoses. Results showed that, even when the somewhat controversial category of somatoform pain disorder was excluded, 77% of patients met lifetime diagnostic criteria and 59% demonstrated current symptoms for at least one psychiatric diagnosis. The most common of these were major depression, substance abuse, and anxiety disorders. In addition, 51% met criteria for at least one personality disorder. All of the prevalence rates were significantly greater than the base rate for the general population. Finally, and most importantly, of these patients with a positive lifetime history for psychiatric syndromes, 54% of those with depression, 94% of those with substance abuse, and 95% of those with anxiety disorders had experienced these syndromes before the onset of their back pain. These are the first results to indicate that certain psychiatric syndromes appear to precede chronic low-back pain (substance abuse and anxiety disorders), whereas others (specifically, major depression) develop either before or after the onset of chronic low-back pain. Such findings substantially add to our understanding of causality and predisposition in the relationship between psychiatric disorders and chronic low-back pain. They also clearly reveal that clinicians should be aware of potentially high rates of emotional distress syndromes in chronic low-back pain and enlist mental health professionals to help maximize treatment outcomes.

Prevalence of psychopathology in acute and chronic low back pain patients.

This study assessed the differential prevalence rates of psychopathology in chronic and acute low back pain patients. Psychopathology was assessed with the Structured Clinical Interview for the DSM-III-R (SCID). The results showed that chronic low back pain patients (n=90), had much higher rates of psychopathology than did patients in the acute back pain group (n=90), and much higher than general population base rates. In particular, chronic low back pain patients had high rates of major depression, substance abuse, and personality disorders. Moreover, the chronic low back patients also had high rates of premorbid psychopathology. It was concluded that psychopathology is a major concomitant of chronic low pack pain, and that treating the psychological problems, along with the physical aspects of the chronic low back pain may increase the patient's chance of a successful therapeutic outcome.

Differentiation between somatic and cognitive/affective components in commonly used measurements of depression in patients with chronic low-back pain. Let's not mix apples and oranges.

Patients with chronic low-back pain are frequently diagnosed as depressed. However, many of the neurovegetative signs of depression may also result from pain. The purpose of the present study was 1) to investigate the relationship between commonly used measurements of depression and pain perception; and 2) to examine the utility of differentiating between somatic signs and cognitive/affective symptoms of depression in patients with chronic low-back pain. The Beck Depression Inventory and the Hamilton Psychiatric Rating Scale for Depression were divided into cognitive/affective and somatic subscales. These measures, as well as the Minnesota Multiphasic Personality Inventory, were administered to 111 patients with chronic low-back pain. Analyses revealed significant correlations between depression scores and self-reported pain intensity. The cognitive/affective subscale of the Beck Depression Inventory resulted in the only nonsignificant correlation with pain intensity. These findings suggest that commonly used measurements of depression are confounded with pain symptomatology and that the cognitive/affective category of the Beck Depression Inventory may prove to be a more accurate measurement of depression in patients with chronic low-back pain.

The functional restoration approach for chronic spinal disability.

The functional restoration approach to treating chronic spinal disability consists of a medically directed, interdisciplinary team approach to physical reconditioning and a cognitive-behavioral "crisis intervention" procedure for dealing with related psychosocial problems. One- and two-year follow-up studies have demonstrated the clinical efficacy of this approach. The present article describes this approach and summarizes the research documenting its success in treating patients with chronic spinal disability. This article also highlights the pitfalls in misunderstanding and misrepresenting the components of the functional restoration approach when evaluating treatment efficacy.

A psychosociomedical prediction model of response to treatment by chronically disabled workers with low-back pain.

There has been much interest in identifying variables that can predict which individuals are susceptible to developing chronic low-back pain. There currently are a number of studies that are evaluating primary predictors (which uninjured workers are likely to develop chronic low-back pain) and secondary predictors (which workers with acute episodes will develop chronic pain). The present study reports the first results from a large-scale investigation of tertiary predictors. Specifically, it addresses the issue of what psychosociomedical variables are predictive of success/failure in response to a comprehensive Functional Restoration treatment program by workers who are chronically disabled with low-back pain. Three stages were involved in the development of this prediction model. First, a group of treatment and research professionals who had extensive experience in the area of chronic low-back pain identified an array of 42 variables, from a larger pool of quantified physical, psychosocial, and medical parameters rated to be important with this patient population.(ABSTRACT TRUNCATED AT 250 WORDS)