Is early differentiation between psychogenic and somatogenic lumbago-ischialgia syndrome patients possible by anamnesis? Results of a screening study

Low back pain (LBP) is one of the most frequent causes for early retirement, hospital treatment and loss of days of work (Raspe u. Kohlmann 1993). Further differentiation and earlier diagnosis of psychogenic LBP could significantly reduce health costs. We interviewed 101 patients with LBP in the departments of Neurology and Neurosurgery (Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke) with the "structured biographical interview for patients with pain" (Egle 1992). This questionnaire has been used successfully differentiating between patients with organic and psychogenic chronic pain syndromes. It is a semi-standardised instrument based on observations, mainly made by Engel (1959), showing that many patients suffering from chronic benign pain syndromes had experienced psychic traumatisation during childhood. We compared a group of patients with clear neurological deficits and organic pain origin (n = 47) with a group of patients with psychogenic LBP (n = 25). Parameters were among others their biographical family constellations, their past medical history (also looking for symptoms of dissociation [conversion]), their present life and their coping with pain. In comparison with other studies examining similar aspects in patients who had pain in other parts of the body (Egle et al. 1991), our groups showed less discriminating results concerning biographical aspects. We found that also 40% of patients with organic pain origin hat traumatic constellations in their childhood. The following factors differentiated best between the both groups and characterised the psychogenic group: Intensity of pain was judged to be significantly higher with the "visual analog scale": age of the patient less than 40 years; distraction does not alter the pain; preceding experiences with physicians had often been negative; pain leads to impairment of familiar contacts; conflicts with parents during childhood could not adequately discussed with them at that time. These seven aspects can very well be part of a clinical history taking in a general medical setting, so that patients with LBP can be differentiated more effectively.     

The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain

STUDY DESIGN: In this prospective, observational, cohort study of 192 individuals with chronic low back pain, the group of individuals was divided based on compensation involvement, and their presentation pain and disability, treatment recommendations, and compliance were compared. For 85 of these individuals who completed a spine rehabilitation program, their pain and disability at 3 and 12 months were compared. OBJECTIVES: To test the theory that individuals with compensation involvement presented with greater pain and disability and would report less change of pain and disability after rehabilitation efforts. BACKGROUND: Previous studies have produced conflicting results concerning this issue. METHODS: Individuals were recruited as consecutive patients referred for consultation at a spine rehabilitation center. Pain, depression, and disability were assessed using self-report questionnaires at evaluation and at 3 and 12 months. Rehabilitation services consisted of aggressive, quota-based exercises aimed at correcting impairments in flexibility, strength, endurance, and lifting capacity, identified through quantification of back function. Multifactoral analysis of variance models were used to control for baseline differences between compensation and noncompensation patients during analysis of target variables. RESULTS: The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and noncompensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow-up visit, pain scores improved for the noncompensation group, but not for the compensation group. CONCLUSIONS: In chronic low back pain, compensation involvement may have an adverse effect on self-reported pain, depression, and disability before and after rehabilitation interventions.     

An optimal filtering technique to reduce the influence of low-frequency noise on click-evoked otoacoustic emissions

The aim of this paper was to study the physical performance, pain, pain behavior and disability in patients with subacute low back pain (LBP). The patients were blue-collar workers and had been sick-listed for 8 weeks due to subacute low back pain. A total of 103 patients were randomized, 51 of them to the intervention group and the other to a control group. Recordings of physical performance and complaints of LBP were done before and after treatment in the intervention group. The proportion of patients with no complaints of LBP was significantly greater in the intervention group than in the control group at the one-year follow-up. The patients who intra-individually improved their physical performance also intra-individually decreased their complaints of LBP. The intra-individual improvements were suggested to be important for the individual return to work.     

Should extended disability be an exclusion criterion for tertiary rehabilitation? Socioeconomic outcomes of early versus late functional restoration in compensation spinal disorders

STUDY DESIGN: A prospective cohort design with two groups of patients representing short-term or long-term disability (n = 497) who were selected from a larger cohort (n = 938) of consecutively treated spinal disorder patients with chronic compensation injuries. OBJECTIVES: To prospectively evaluate the impact of length of spinal disability on socioeconomic outcomes of medically directed rehabilitation. SUMMARY OF BACKGROUND DATA: Despite an increasing tendency of managed care organizations to limit rehabilitation services for disabled workers with chronic spinal disorders, there has been a surprising lack of prospective research evaluating the impact of length of disability on objective socioeconomic treatment outcomes. Although only approximately 10% of all patients with spinal disorders are disabled beyond 4 months, they account for nearly 80% of all workers' compensation expenditures. Little is known about whether relatively early intervention improves outcomes after chronicity has been established or whether any predictors distinguish between these groups. METHODS: Two comparison groups of functional restoration tertiary treatment graduates were identified from the same community referral pool. The "long-term disabled" group involved a minimum of 18 months of disability (n = 252). This group was compared with a "short-term disabled" group (n = 245), no more than 8 months since injury, but chronic based on a minimum of 4 months after injury. The long-term disabled group showed significantly higher rates of pretreatment surgery than the short-term disabled group (P < 0.001). All patients were evaluated prospectively with specific physical, psychological, and occupational measurements. They also underwent a structured interview 1 year after treatment evaluating work status, health care use, and recurrent injury. RESULTS: The short-term disabled group showed statistically higher return to work (P < 0.001) and work retention (P < 0.05) relative to the long-term disabled group. However, health care use and recurrent lost time injury claims were low in both groups and did not differ significantly. No predictors of outcome were found among the prospectively collected physical performance or psychosocial variables. CONCLUSIONS: This study suggests that early tertiary nonoperative care, once patients with chronic spinal disorders are identified as having potentially high-cost chronic pain and disability, is efficacious in achieving goals of better work return and work retention. Such early rehabilitation may also prevent significant indemnity expense, as well as some late surgical interventions sought by progressively more desperate patients. However, individuals with long-term disability achieve respectable work return and retention rates, while faring no worse on other socioeconomic outcomes that represent major "cost drivers" to the workers' compensation system. Early intervention is not a panacea or a necessary condition for the successful rehabilitation of workers with disabling chronic spinal disorders.     

Factors associated with rehabilitation outcome in patients with low back pain (LBP): Prediction of employment outcome at 9-month follow-up.

Examined which admission and treatment change variables predicted return to work for 117 male patients (mean age 40.2 yrs) with work-related LBP. Pain and disability perception, coping strategies, depression, and functional status were examined at admission and discharge for Ss who participated in an interdisciplinary work rehabilitation program. Discriminant function analyses, using employment status 9 mo later as the dependent variable, resulted in correct classification rates of 79% when admission and treatment change scores were used as predictors. Psychological factors at admission were the salient variables that predicted employment outcome at follow-up. Of the treatment change variables, physical status and S's perception of his/her disability significantly predicted return to work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up

STUDY DESIGN: A multicenter, randomized, single-blinded controlled trial with 1-year follow-up. OBJECTIVES: To evaluate the efficiency of progressively graded medical exercise therapy, conventional physiotherapy, and self-exercise by walking in patients with chronic low back pain. SUMMARY AND BACKGROUND DATA: Varieties of medical exercise therapy and conventional physiotherapy are considered to reduce symptoms, improve function, and decrease sickness absence, but this opinion is controversial. METHODS: Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 52 weeks (Sickness Certificate II) were included. The treatment lasted 3 months (36 treatments). Pain intensity, functional ability, patient satisfaction, return to work, number of days on sick leave, and costs were recorded. RESULTS: Of the 208 patients included in this study, 71 were randomly assigned to medical exercise therapy, 67 to conventional physiotherapy, and 70 to self-exercise. Thirty-three (15.8%) patients dropped out during the treatment period. No difference was observed between the medical exercise therapy and conventional physiotherapy groups, but both were significantly better than self-exercise group. Patient satisfaction was highest for medical exercise therapy. Return to work rates were equal for all 3 intervention groups at assessment 15 months after therapy was started, with 123 patients were back to work. In terms of costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner (NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560 ($254,200.00), compared with the self-exercise group. CONCLUSIONS: The efficiency of medical exercise therapy and conventional physiotherapy is shown. Leaving patients with chronic low back pain untampered poses a risk of worsening the disability, resulting in longer periods of sick leave.     

Professional psychologists in general health care settings: A review of the financial efficacy of direct treatment interventions.

Research is reviewed that evaluates the extent to which psychologists can reduce medical costs of health problems while still maintaining treatment effectiveness. Specific areas on cost-effectiveness include the following: preparation for anxiety provoking medical procedures, smoking cessation, detection and treatment of somatizing patients, psychological intervention in general rehabilitation, rehabilitation of chronic pain patients, behavioral treatment of cardiovascular disorders, and adherence to medical regimens. Major conclusions on these areas are presented. Difficulties with the research are discussed along with areas for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of transcutaneous electrical nerve stimulation (CODETRON) to determine its benefits in a rehabilitation program for acute occupational low back pain

The authors report the results of a randomized controlled trial to examine the effectiveness of transcutaneous electrical nerve stimulation (TENS/CODETRON) when added to a standard exercise program for industrial workers with acute low back pain (LBP). Fifty-eight work-injured patients with LBP of 3-10 weeks duration were randomized into two groups that received actual or placebo stimulation in combination with the exercise regimen. The groups were compared on the primary outcome measures of disability, pain, and return to work. No significant differences between the experimental and placebo groups were discovered on any of the measured outcomes. Exercise alone, when continued over 4 weeks, reduced disability and pain scores significantly. Under the experimental conditions of this trial, no additional benefits of TENS/CODETRON were detected when added to an active exercise regimen.     

Chronicity of back problems during working life

STUDY DESIGN: A follow-up study of a cohort of 444 patients aged 16 to 59 years who consulted with their general practitioners (GPs) in 1987-1988 for an incident episode of back pain. OBJECTIVES: To determine the proportion of patients with back pain in whom chronic back problems develop after a follow-up of 7 years, to compare health outcomes and labor force participation of patients with and without chronic back problems and to identify determinants of chronicity. SUMMARY OF BACKGROUND DATA: The incidence and prevalence of back pain are very high. A large proportion of the costs related to medical consumption, absence from work, and disability are probably caused by chronic back problems. It is unknown what proportion of back problems become chronic, especially after a long follow-up period, and which factors can predict chronicity. METHODS: Data on the course of the symptoms and medical consumption from the period between 1987-1988 and 1991 were gathered retrospectively. Data on several health outcomes, including LFP, and data on some work characteristics were collected prospectively in 1991. A more extensive data set on health outcomes including psychologic status and working situation was collected in 1994. RESULTS: Chronic back problems developed in 28% of the patients. These patients reported more pain, higher levels of medical resource consumption, worse health outcomes, and lower labor force participation. Episodes of back pain before 1987-1988, severe pain in 1991, and disability score in 1991 were positively associated with chronicity in 1994, difficulties with job performance in 1991, and frequent stooping in the subgroup of patients who held a paying job in the follow-up period. CONCLUSIONS: Even after a follow-up of 7 years, the proportion of people with chronic back problems was high. The consequences for quality of life, labor force participation, and consumption of medical resources are clear. Further research is necessary to examine determinants and ways to prevent chronicity.     

Trends in disability duration and cost of workers' compensation low back pain claims (1988-1996)

Previously published epidemiologic studies of low back pain (LBP) have reported that the prevalence of low back disability has increased dramatically. These studies based their findings on either the number of disability claims filed, the disability duration, or both. This information was from countries other than the United States or from the US Social Security Disability Insurance data, with findings reported only to the early 1980s. More recent studies of US workers' compensation LBP claims reported a decrease in the incidence rate from the late 1980s to the mid-1990s. No studies have been found that report on the trends of disability duration for workers' compensation LBP claims. This study examined recent trends in the length of disability (LOD) for LBP claims and associated costs, using a large sample of claims from the privately insured US workers' compensation market. LOD and cost information were derived for injuries from 1988, 1990, 1992, 1994, and 1996. For each year, the distributions of LOD and cost were skewed, with the small percentage of claims that lasted more than one year (4.6%-8.8%, depending on the year) accounting for a large percentage of the total disability days (77.6%-90.1%) and cost (64.9%-84.7%). From 1988 to 1996, the average LOD decreased 60.9%, from 156 days to 61 days. The probability of being on disability for a long period of time has decreased over the years. Over the study period, the average cost of a claim decreased 41.4%, while the median cost increased 19.7%. The most influential change in the LOD and cost distributions was a reduction in expensive claims with a long disability duration. The evolution of LOD and cost is also detailed for different disability durations for the study period.     

Effects of galanin on 8-OH-DPAT induced decrease in body temperature and brain 5-hydroxytryptamine metabolism in the mouse

The objective of this study was to describe the health care utilization and prospective predictors of high-cost primary-care back pain patients. In the primary-care clinics of a large, staff model health maintenance organization in western Washington State, 1059 subjects were selected from consecutive patients presenting for back pain. The design was a 1-year prospective cohort study. Patients' were interviewed 1 month after an index primary-care back pain visit. Costs (back pain and total) and utilization (back pain primary-care follow-up visits, back pain specialty visits, back pain hospitalizations, back pain radiologic procedures, and pain medicine fills) were tracked over the next 11 months. Predictors assessed at 1 month were back pain diagnosis (disc disorder/sciatica, arthritis, vs. other), chronic pain grade (measure of pain intensity and related dysfunction), pain persistence (days with pain in prior 6 months), depressive symptomatology, and back pain-related disability compensation (ever/never). For the sample, 21% of patients with back pain costs > or = $600 (high back pain costs) accounted for 66% of back pain costs, 42% of total costs, 55% of primary-care follow-up visits for back pain, 91% of back pain specialty visits, 100% of back pain hospitalizations, 51% of back pain radiologic procedures, and 52% of pain medicine fills. The 21% with total costs > or = $2700 (high total costs) accounted for 67.7% of total costs, 52% of back pain costs, 29% of primary-care follow-up visits for back pain, 66% of back pain specialty visits, 100% of back pain hospitalizations, 39% of back pain radiologic procedures, and 42% of pain medicine fills. Multivariable logistic regression analyses indicated that increasing chronic pain grade, more persistent pain, and disc disorder/sciatica were strong independent predictors of high total and high back pain costs. Increasing depressive symptoms significantly predicted high total but not high back pain costs. Back pain disability compensation predicted high back pain but not high total costs. A minority of primary-care back pain patients accounted for a majority of health-care costs. Patients with high back pain costs accounted for more back pain-related health-care utilization than did patients with high total costs. Factors predicting subsequent high costs suggest behavioral interventions targeting dysfunction, pain persistence, and depression may reduce health-care utilization and prevent accumulation of high health-care costs among primary-care back pain patients.     

The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries

A prospective randomized study of 542 injured workers with continuing pain compared 271 workers who were treated at either one of two clinics that provided functional restoration with a control group of 271 subjects. Chronic pain was caused by low back injury in 78% of patients; 79% of those treated were at work 12 months after completion of treatment compared with 78% of the control subjects. When the patients were divided into subsets, based on the accident date and followed monthly, the duration of absence from work, the compensation costs, the disability award costs, and the total costs were less for those treated than the control subjects, but these were not statistically significant. Using the difference in total costs as a measure of relative success, back injuries had better results than other injuries in this study.     

Acute cholecystitis and gallbladder neoplasms: the experience of 2215 cases

PURPOSE: To argue the case that patients who are severely disabled by stroke may benefit from rehabilitation. To identify critical areas where more research may be helpful. METHOD: Discussion of four negative views which could be cited as drawbacks to rehabilitation in this group. These are: (1) that patients with severe stroke do not recover; (2) that they are too ill to receive rehabilitation; (3) that rehabilitation is ineffective even when possible; and (4) that even if rehabilitation is effective, it is not cost-effective. RESULTS: There is little work in this area. There are problems with measurement of disability in this group. None of the four negative views are supported by current evidence, and what little evidence there is provides grounds for optimism that further work could be worthwhile. CONCLUSIONS: Specific recommendations for further work include: (1) the development of better measurement scales; (2) to determine the cost of care of severely disabled stroke patients; (3) to gain a better appreciation of the value of changes in disability states; and (4) to perform an overview analysis of rehabilitation interventions examining the degree to which severity of disability affects the response to treatment.     

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 of 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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quality of life in patients with ankylosing spondylitis

Quality of life encompasses the net effects that a patient perceives an illness to have on his or her life. Quality of life commonly includes symptoms, physical functioning, work ability, social interaction, psychological functioning, treatment side effects, and financial costs. In ankylosing spondylitis, although symptoms of pain, stiffness, and fatigue are common and moderately severe, few patients develop severe functional disability and most remain employed. The limited information available suggests that most patients with ankylosing spondylitis have few problems with social interactions, although depression is not uncommon. Direct medical costs of ankylosing spondylitis are low, compared with those of other rheumatic diseases.     

Occupational upper extremity disorders in the federal workforce. Prevalence, health care expenditures, and patterns of work disability

Upper extremity disorders (UEDs) account for a significant number of work-related illnesses in the US workforce. Little information exists on the distribution of UEDs, their associated health care and indemnity costs, or patterns of work disability. The study presented is an analysis of upper extremity claims within the federal workforce. In this study, the universe consisted of all claims accepted by the US Department of Labor, Office of Workers' Compensation Programs (OWCP), from October 1, 1993, through September 30, 1994. A total of 185,927 claims of notices of injury were processed during the study period, and of these, 8,147 or 4.4% had an UED diagnosis coded according to the International Classification of Diseases, Clinical Modification (ICD-9-CM). 5,844 claims involved a single UED diagnosis and were the only claims field by these employees between October 1, 1990, and September 30, 1994. These single claims with single diagnoses comprised the sample for further analysis. Mononeuritis and enthesopathies of the upper limb were the most common diagnoses, accounting for 43% and 31% of the claims, respectively. Women had a higher proportion of carpal tunnel syndrome, "unspecified" mononeuritis, and "unspecified" enthesopathies. The majority of claimants for both the mononeuritis- and enthesopathy-related diagnoses were between 31 and 50 years of age, received only health care benefits, and did not incur wage loss. Health care costs for mononeuritis and enthesopathy claims were $12,228,755 (M = $2,849). Carpal tunnel syndrome (CTS) and enthesopathy of the elbow were the most costly diagnoses, accounting for 57% and 16% of the total, respectively. Surgical services represented the highest expenditures in CTS claims. Physical therapy accounted for the majority of health care costs for enthesopathy cases. The mean number of workdays lost for CTS and enthesopathy claims were 84 and 79, and the average indemnity costs were $4,941 and $4,477, respectively. These findings indicate that while UEDs represent a relatively small percentage of all workers' compensation cases, the health care and indemnity costs are considerable. Also mean duration and pattern of work disability revealed that these disorders can result in chronic work disability similar to that observed in low back pain. The results highlight the need to determine whether interventions that account for the majority of costs significantly impact long-term outcomes. There is also a need to identify risk factors for prolonged disability in those who experience problems with delayed recovery.     

Is rehabilitation psychology in need of rehabilitation?

Discusses the "Golden Age" of rehabilitation psychology, when rehabilitation of persons with traumatic brain injury was the fastest growing areas in all health care, and comments on the current state and possible future directions of the field. The author's care plan for the future includes a focus on chronic conditions in addition to the field's current primary focus on end results (disability). The new focus would involve branching out beyond the field's traditional work in inpatient and outpatient rehabilitation facilities. The author points out rehabilitation psychology's unique focus on a team approach to treatment, and notes that this model can be transported to treating other chronic conditions, typically seen in more acute or primary settings. In an effort to introduce their model into hospitals around the country, rehabilitation psychologists need to expand their clinical practices, modify their training model, and broaden the scope of their research efforts. As corporations are concerned about disability and chronic illness and are largely unaware of what rehabilitation psychology could offer them, a logical step in their care plan is to work more closely with corporations and employee benefit services. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical management of carpal tunnel syndrome: a 12-year review of outcomes

Carpal tunnel syndrome (CTS) is a disorder frequently encountered by occupational health care specialists. The health care management of this disorder has involved a diverse set of clinical procedures. The present article is a review of the literature related to CTS with an emphasis on occupational-related CTS. MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycLIT, and NIOSHTIC databases from 1985-1997 were searched for treatment outcome studies related to CTS. Treatments of interest included surgery, physical therapy, drug therapy, chiropractic treatment, biobehavioral interventions, and occupational rehabilitation. A systematic review of the effects of these interventions on symptoms, medical status, function, return to work, psychological well-being, and patient satisfaction was completed. Compared to other treatments, the majority of studies assessed the effects of surgical interventions. Endoscopic release was associated with higher levels of physical functioning and fewer days to return to work when compared to open release. Limited evidence indicated: 1) steroid injections and oral use of B6 were associated with pain reduction; 2) in comparison to splinting, range of motion exercises appeared to be associated with less pain and fewer days to return to work; 3) cognitive behavior therapy yielded reductions in pain, anxiety, and depression; and, 4) multidisciplinary occupational rehabilitation was associated with a higher percentage of chronic cases returning to work than usual care. Workers' compensation status was associated with increased time to return to work following surgery. Conclusions are preliminary due to the small number of well-controlled studies, variability in duration of symptoms and disability, and the broad range of reported outcome measures. While there are several opinions regarding effective treatment, there is very little scientific support for the range of options currently used in practice. Despite the emerging evidence of the multivariate nature of CTS, the majority of outcome studies have focused on single interventions directed at individual etiological factors or symptoms and functional limitations secondary to CTS.     

Sense of coherence as a predictor of work reentry following multidisciplinary rehabilitation for individuals with chronic musculoskeletal pain.

This study investigated the association between sense of coherence (SOC) and work reentry. One hundred and fifty-three patients with musculoskeletal pain (mean age=45.6 years, SD=9.1) were included. SOC, demographics, personal characteristics, work status, pain intensity, pain experience, anxiety, and depression were collected during a 57-week rehabilitation period. SOC significantly improved, and pain experience, anxiety, and depression significantly decreased during the rehabilitation period. SOC was found to significantly predict anxiety and depression in the nonwork reentry subsample (n=44). No significant association was found between SOC and work reentry. These data clarify the role of SOC in chronic pain and emotional distress and question the role of SOC in predicting work reentry in long-term chronic musculoskeletal pain conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)