Search

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. [ABSTRACT FROM AUTHOR]

Background context For chronic pain patients, recovery may be slowed by indecisiveness over optional surgery. These patients may be delayed from participating in interdisciplinary functional restoration (FR), pending resolution of the surgical decision. Uncertainty about surgery or rehabilitation leads to delayed recovery. A surgical option process (SOP) was developed to permit patients with chronic disabling occupational musculoskeletal disorders to enter FR, make a final determination halfway through treatment, and return to complete rehabilitation after surgery, if surgery was elected. Purpose This study assessed the frequency with which an FR program can resolve an uncertain surgical option. It also assessed program completion rate and 1-year post-program outcomes for subgroups that decline surgery, request and receive surgery, or request surgery but are denied by surgeon or insurance carrier. Study design Retrospective study of a consecutive cohort. Patient sample A cohort of 44 consecutively treated chronic disabling occupational musculoskeletal disorder patients were admitted to an FR program and identified as candidates for a surgical procedure but were either ambivalent about undergoing surgery, had a difference of opinion by two or more surgeons, or were denied a surgical request by an insurance carrier. Patients attended half (10 full day visits) of an FR program before making their own final determination to pursue a request or decline surgery. Outcome measures Patients were assessed on surgical requests and whether surgery was ultimately performed, program completion status after the surgical determination, demographic variables, and 1-year outcomes on work status, additional surgery, and other health utilization measures. Methods Patients became part of the SOP on program entry and were included in the study if they participated in a surgical-decision interview halfway through the program. Those who elected to decline surgery (DS) completed the program without delay, but those requesting surgery were placed on hold from the program while consultation and preauthorization steps took place. Those requesting surgery, but denied (RSD), and those undergoing surgery (US) were given the opportunity to complete FR following postoperative physical therapy or resolution of the surgical re-evaluation process. Results There were 32 DS patients (73%), indicating that a large majority of patients declined the surgery that was still being considered when offered participation in the SOP. Of the 12 patients wanting a surgery, there were four US patients who received surgery previously denied (9% of cohort), and eight RSD patients (18% of cohort). Patients from the DS group completed the FR program at an 88% rate, as did 75% of US patients. However, despite an opportunity to re-enter and complete rehab, only 50% of RSD patients completed the FR option. Overall, patients who persistently sought surgery, contrary to the recommendations of a surgeon, had poorer outcomes. These 1-year post-FR outcomes included lower return-to-work and work retention rates, with higher rates of treatment seeking from new providers (resulting in higher rates of post-discharge surgery) and higher rates of recurrent injury claims after work return. Conclusions A SOP tied to participation in an interdisciplinary FR program resolves uncertainty regarding surgical options in a high proportion of cases, resulting in a large majority declining surgery and completing the FR program. Timely surgery is also promoted decisively when needed. Findings suggest that patients who persistently seek surgery, contrary to the recommendations of a surgeon, frequently fail to complete FR and have poorer outcomes overall. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Abnormal pretreatment flexion-relaxation in chronic disabling occupational lumbar spinal disorder patients has been shown to improve with functional restoration rehabilitation. Little is known about the effects of prior lumbar surgeries on flexion-relaxation and its responsiveness to treatment. Purpose: To quantify the effect of prior lumbar surgeries on the flexion-relaxation phenomenon and its responsiveness to rehabilitative treatment. Study design/setting: A prospective cohort study of chronic disabling occupational lumbar spinal disorder patients, including those with and without prior lumbar spinal surgeries. Patient sample: A sample of 126 chronic disabling occupational lumbar spinal disorder patients with prior work-related injuries entered an interdisciplinary functional restoration program and agreed to enroll in this study. Fifty-seven patients had undergone surgical decompression or discectomy (n=32) or lumbar fusion (n=25), and the rest had no history of prior injury-related spine surgery (n=69). At post-treatment, 116 patients were reevaluated, including those with prior decompressions or discectomies (n=30), lumbar fusions (n=21), and no surgery (n=65). A comparison group of 30 pain-free control subjects was tested with an identical assessment protocol, and compared with post-rehabilitation outcomes. Outcome measures: Mean surface electromyography (SEMG) at maximum voluntary flexion; subject achievement of flexion-relaxation (SEMG≤3.5 μV); gross lumbar, true lumbar, and pelvic flexion ROM; and a pain visual analog scale self-report during forward bending task. Identical measures were obtained at pretreatment and post-treatment. Methods: Patients entered an interdisciplinary functional restoration program, including a quantitatively directed, medically supervised exercise process and a multimodal psychosocial disability management component. The functional restoration program was accompanied by a SEMG-assisted stretching training program, designed to teach relaxation of the lumbar musculature during end-range flexion, thereby improving or normalizing flexion-relaxation and increasing lumbar flexion ROM. At 1 year after discharge from the program, a structured interview was used to obtain socioeconomic outcomes. Results: At pre-rehabilitation, the no surgery group patients demonstrated significantly better performance than both surgery groups on absolute SEMG at maximum voluntary flexion and on true lumbar flexion ROM. Both surgery groups were less likely to achieve flexion-relaxation than the no surgery patients. The fusion patients had reduced gross lumbar flexion ROM and greater pain during bending compared with the no surgery patients, and reduced true lumbar flexion ROM compared with the discectomy patients. At post-rehabilitation, all groups improved substantially on all measures. When post-rehabilitation measures were compared with the pain-free control group, with gross and true lumbar ROM corrected by 8° per spinal segment fused, there were no differences between any of the patient groups and the pain-free control subjects on spinal ROM and only small differences in SEMG. The three groups had comparable socioeconomic outcomes at 1 year post-treatment in work retention, health-care utilization, new injury, and new surgery. Conclusions: Despite the fact that the patients with prior surgery demonstrated greater pretreatment SEMG and ROM deficits, functional restoration treatment, combined with SEMG-assisted stretching training, was successful in improving all these measures by post-treatment. After treatment, both groups demonstrated ROM within anticipated limits, and the majority of patients in all three groups successfully achieved flexion-relaxation. In a chronic disabling occupational lumbar spinal disorder cohort, surgery patients were nearly equal to nonoperated patients in responding to interdisciplinary functional restoration rehabilitation on measures investigated in this study, achieving close to normal performance measures associated with pain-free controls. The responsiveness and final scores shown in this study suggests that flexion-relaxation may be a useful, objective diagnostic tool to measure changes in physical capacity for chronic disabling occupational lumbar spinal disorder patients. [Copyright &y& Elsevier]

Abstract: Background context: Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this “at risk” population, has been suggested as a possible solution. Purpose: To compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery. Study design/setting: A prospective cohort study of chronic disabling occupational lumbar disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program. Patient sample: A consecutive cohort of 564 patients with prerehabilitation surgery completed a functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, N=331) and nonfusion lumbar spine surgery (NF group, N=233). An unoperated comparison group was matched for length of disability (U group, N=349). Outcome measures: Validated patient-reported measures of pain, disability, and depression were administered pre- and postrehabilitation. Socioeconomic outcomes were collected via a structured 1-year “after” interview. Methods: All patients completed an intensive, medically supervised functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. The writing of this article was supported in part by National Institutes of Health Grant 1K05-MH-71892; no conflicts of interest are noted among the authors. Results: The F group had a longer length of disability compared with the NF and U groups (M=31.6, 21.7, and 25.9 months, respectively, p<.001). There were relatively few statistically significant differences for any socioeconomically relevant outcome among groups, with virtually identical postrehabilitation return-to-work (F=81%, NF=84%, U=85%, p=.409). The groups differed significantly after surgery on diagnosis of major depressive disorder and opioid dependence disorder as well as patient-reported depressive symptoms and pain intensity prerehabilitation. However, no significant differences in patient-reported outcomes were found postrehabilitation. Prerehabilitation opioid dependence disorder significantly predicted lower rates of work return and work retention as well as higher rates of treatment-seeking behavior. Higher levels of prerehabilitation perceived disability and depressive symptoms were significant risk factors for poorer work return and retention outcomes. Conclusions: Lumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable to CDOLD patients treated nonoperatively. This study suggests that surgeons have the opportunity to improve lumbar surgery outcomes in the WC system, even for complex fusion CDOLD patients with multiple prior operations, if they control postoperative opioid dependence and prevent an excessive length of disability. Through early referral of patients (who fail to respond to usual postoperative care) to interdisciplinary rehabilitation, the surgeon determining this continuum of care may accelerate recovery and achieve socioeconomic outcomes of relevance to the patient and WC jurisdiction through the combination of surgery and postoperative rehabilitation. [Copyright &y& Elsevier]

Abstract: Timely intervention and recovery is beneficial to patients with chronic disabling occupational musculoskeletal disorders. Therefore, a surgical option process was developed for use in a functional restoration program (FRP) to allow chronic disabling occupational musculoskeletal disorder patients who were undecided about elective orthopedic surgery to participate in interdisciplinary rehabilitation, rather than suspending treatment, until the surgical option could be resolved. A consecutive cohort of 295 chronic disabling occupational musculoskeletal disorder patients with an unresolved surgical option was admitted to an FRP and their surgical preference at FRP midpoint was determined. The majority of patients declined surgery (n = 164) and were invited to complete the FRP. The remainder elected to pursue surgery and either underwent surgery (n = 43) or had their surgical request denied (n = 38). In the post-FRP year, only .8% of patients reversed their original decision and underwent surgery. Patients whose surgical preferences were accommodated (ie, the declined-surgery/underwent-surgery groups) demonstrated significant psychosocial improvement and excellent socioeconomic outcomes, which were similar to those of FRP patients without a surgical option. Patients whose request for surgery was denied had poorer outcomes than the other groups, but still outperformed FRP dropouts. This suggests that the addition of a formal surgical option process to an interdisciplinary FRP facilitated the surgical decision-making process and helped prevent delayed recovery. Perspective: This study introduces a surgical option process to improve outcomes for patients with chronic disabling occupational musculoskeletal disorders who are undecided about elective orthopedic surgery. The addition of a surgical option process to interdisciplinary rehabilitation may resolve surgical indecision, improve outcomes, promote psychosocial recovery, and facilitate progression to Maximum Medical Improvement. [Copyright &y& Elsevier]

Abstract: Background context: The minimal clinically important difference (MCID) is defined as the smallest change in an outcome that a patient would perceive as meaningful. The Initiative on Methods, Measurement and Assessment in Clinical Trials (IMMPACT) group proposed defining the MCID as a 30% improvement in self-reported pain or function. However, this MCID threshold has not been validated against an objective physical measure. Purpose: To test the validity of the IMMPACT-based MCID threshold, using an objective physical measure as an external anchor. Study design/setting: Prospective study of chronic disabling occupational lumbar disorder (CDOLD) patients completing a functional restoration program. Patient sample: A consecutive cohort of 743 CDOLD patients. Outcome measures: Self-report measures of pain-related function were compared with an objective lifting measure, the progressive isoinertial lifting evaluation (PILE), obtained after treatment. Methods: The association between reporting 30% or greater improvement (the IMMPACT's MCID key criterion) and the PILE score after treatment was assessed. Results: A 30% or greater improvement on the self-report measures was significantly associated with improvement in physical function on the PILE task. Conclusions: Despite extensive use of the MCID to evaluate effects of treatment in spinal disorders, this is the first empirical documentation of the validity of the IMMPACT's 30% change criterion compared with an objective physical anchor. [Copyright &y& Elsevier]

The article presents research on chronic pain and disability population as it relates to work retention (WR) status. It references a prospective study by Hilary D. Wilson and colleagues published in the 2011 issue of "Spine." It discusses findings on the association of WR status with changes in Oswestry Disability Index (ODI), Mental Component Summary (MCS), and Physical Component Summary (PCS) of the Short Form-36 (SF-36).

Abstract: Background Context: Various methodologies have been used in attempting to elucidate a standard method for calculating minimal clinically important difference (MCID). A consensus-based decision (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials [IMMPACT] group) suggested a 30% reduction from baseline as a means to define the MCID of self-report back pain measures. Additionally, important psychometric issues need to be addressed regarding use of an independent measure of the same construct as an external criterion, instead of simply using another self-report measure, when using an anchor-based approach to MCID. Purpose: The purpose was to test the validity of recently published guidelines regarding MCID using self-report back pain measures and objective socioeconomic outcomes. Study Design/Setting: This is a prospective study assessing change scores on commonly used spinal pain assessment measures in patients with chronic disabling occupational spinal disorders (CDOSDs) treated in a regional referral rehabilitation center performing interdisciplinary functional restoration. Patient Sample: The study consisted of consecutive cohort of patients (N=1,180) with CDOSDs completing a functional restoration program. Outcomes Measures: Self-report measures including the Oswestry Disability Index (ODI) and the physical component summary (PCS) and mental component summary (MCS) of the Short Form-36 (SF-36) obtained before and after treatment, were compared with objective socioeconomically relevant outcomes obtained 1 year after treatment (ie, work status and additional health-care utilization), that were the external criteria for evaluating MCID. Methods: Pre- to posttreatment improvement was calculated separately for each measure, and subjects were divided into two groups based on the change in scores relative to baseline: 30% or greater versus less than 30% improvement. One-year posttreatment objective socioeconomic outcomes were used as independent external criteria relevant to the CDOSD population. This population is often studied as the most costly and problematic cohort in spine care. Results: The ODI and SF-36 MCS were not associated with any of the objective 1-year outcomes used as external criteria. Reduced post-rehabilitation health-care utilization (based on the percentage of patients pursuing health care from a new provider) was weakly associated with 30% or greater improvement on the SF-36 PCS, relative to patients whose scores changed by less than 30% relative to baseline (17.0% vs. 21.1%). The same was true for the ODI and return-to-work. Conclusions: When objective and independent criteria are used (socioeconomic outcomes) in a CDOSD cohort, the 30% improvement in the ODI and SF-36 may not be a valid MCID index. This replicates similar conclusions made by an independent research group using a distribution-based approach to MCID. The validity of the MCID concept rests on future research using objective external criteria. Moreover, there remains a question whether the term “important” in MCID can be unequivocally and operationally defined as a reliable construct. [Copyright &y& Elsevier]

The article assesses the prevalence of chronic widespread pain (CWP), demographic characteristics, and associated psychiatric comorbidity among chronic disabling occupational spinal disorders (CDSOD) patients. It also attempts to determine if CWP is a risk factor for less successful one-year postrehabilitation socioeconomic outcomes.

Abstract: Editors'' preface: The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP. [Copyright &y& Elsevier]

The article presents a study conducted at a tertiary functional restoration center for patients with chronic disabling occupational spinal disorders (CDOSD), comparing treatment outcome status after 1-year posttreatment of patients with specific diagnosed psychiatric disorders to those without. The aim of the study is to evaluate if diagnosed psychopathology is a significant limiting factor in the successful interdisciplinary rehabilitation of CDOSD patients.

The article discusses a study which intends to clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSD). It is concluded that psychiatric distrubance is not a risk factor for developing a CDOSD. Moreover, psychiatric disorders are much more likely to develop after the onset of the work injury.

: Background contextStudies have revealed smoking to have a negative impact on spinal surgery. It is assumed that this is the result of the negative impact of nicotine on revascularization of damaged tissue. However, there is a paucity of research on the role of smoking with regard to nonsurgical rehabilitation, but there exists a clear bias for believing that smoking is strongly associated with poor socioeconomic and psychosocial outcome.: PurposeThis study was designed to examine the relationship between smoking and outcomes in a chronically disabled work-related spinal disorder (CDWRSD) cohort undergoing functional restoration.: Study designA prospective comparison cohort study investigating the effects of smoking status on functional restoration treatment outcomes.: Patient sampleA cohort of 1,141 consecutive CDWRSD patients were divided into four groups: Group A, patients who did not smoke (n = 710); Group B, patients who smoked less than one cigarette pack/day (n = 157); Group C, patients who smoked 1.0 to 1.9 packs/day (n = 218); Group D, patients who smoked 2.0 or more packs/day (n = 56).: Outcome measuresBefore the start of functional restoration, and upon its completion, patients received a standard psychosocial assessment battery and were assessed on a variety of physical factors. A structured clinical interview examining socioeconomic outcomes was conducted 1 year after the program.: MethodsPatients underwent an intensive functional restoration chronic pain management rehabilitation program consisting of quantitatively directed exercise progression and a multimodal disability management program for CDWRSD. The program consisted of four phases, the most significant of which involved a 3-week full-day intensive phase after preparatory preprogram phases and before a work transition phase.: ResultsAnalysis revealed that the percent of males increased as the smoking level increased (Group A = 51.8% vs Group D = 73.2%; p<.001). Also, as smoking increased, the level of education significantly decreased. In addition, as smoking level increased, the percent of patients completing the rehabilitation program decreased (from 86.3% to 75%; p = .03). No significant differences in 1-year posttreatment socioeconomic outcomes of work status, health utilization, recurrent injury or case closure were related to smoking except work retention, which decreased with more smoking (85 to 71%, p<.05). Surprisingly, the physical cumulative score at posttreatment increased as smoking frequency increased (p<.01). This finding indicates that those who smoked more performed at a higher level on physical measures. Those who smoked more frequently before treatment also appeared more depressed (p<.001), but after treatment, these differences disappeared. Self-reported pain intensity differed only after treatment, and posttreatment disability ratings showed a significant linear trend.: ConclusionsContrary to popular belief, CDWRSD patients who smoke do not differ significantly in socioeconomic or psychosocial outcomes relative to those who do not. Although this study does indicate that those who smoke more evidence lower rehabilitation completion rates, those who completed the program had identical 1-year posttreatment outcomes of socioeconomic importance except in retraining work at year end as those who did not smoke. Smokers had slightly higher posttreatment self-reported pain and disability ratings mixed and limited. Overall, there is evidence for the widely held belief that smoking negatively affects tertiary rehabilitation. [Copyright &y& Elsevier]

Background context: Spinal surgery in the workers compensation population shows evidence of less favorable outcomes than in general health cases. Although spine surgery has been alleged to be a cause of poor outcomes, such outcomes may be improved by appropriate postsurgical rehabilitation.Purpose: To compare objective demographic, physical and psychological measurements and socioeconomic outcomes of treatment in work-related disabling cervical pain for the combination of anterior cervical fusion (ACF) plus functional restoration, compared with rehabilitation alone.Study design/setting: A prospective study of patients undergoing ACF for degenerative disc disease before rehabilitation for work-related musculoskeletal disorders versus neck pain unoperated controls, with data collected in an outpatient tertiary interdisciplinary rehabilitation setting.Patient sample: A group of 52 patients completed a functional restoration treatment program after undergoing ACF (Group S) at one or two levels for degenerative cervical disc disease. During the study period, 625 patients with work-related neck pain were identified from the same study population, from which a rehabilitation (Group R) comparison group (n=150) was identified who were stratified according to the number and location of other compensable body parts.Outcome measures: Socioeconomic outcomes relevant to chronic disabling work-related cervical spinal disorders are reported based on 1-year posttreatment interviews. Pre- to posttreatment assessment of pain intensity, disability, depression and cumulative physical capability were assessed prospectively.Methods: All patients were totally or partially disabled before completing an intensive, medically supervised, functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. Preprogram preparation included drug detoxification, psychotropic medication management and preparatory aerobic and mobility training. The intensive treatment phase involved strength and endurance training, with counseling geared to goals of work return and fitness maintenance. The 1-year structured clinical interview had a contact rate of 93% to 95%, and partial information acquisition on all patients.Results: Although Group S had lower work return and work retention outcomes, the differences were not significant. Group S patients had significantly more health utilization from a new provider in the year after completion of functional restoration (46% vs 24%; OR=2.7 [1.3, 5.3], p<.004). Group S patients were also more likely to be depressed, both at pre- and postrehabilitation. There were no significant differences in recurrent injury, additional surgery, physical measures or pain/disability self-report between the groups.Conclusions: Workers compensation patients with chronic disabling work-related cervical spinal disorders who undergo a cervical fusion, combined with functional restoration, have socioeconomic outcomes after their surgery statistically similar to those for unoperated controls. Surgery patients had a higher rate of additional health-care–seeking behaviors from new providers and a greater likelihood of being clinically depressed before and after rehabilitation. This study suggests that cervical fusion for degenerative disc disease in workers compensation patients is not contraindicated, as long as interdisciplinary rehabilitation is available for complex cases after the surgical procedure. [ABSTRACT FROM AUTHOR]

Background context Insomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population. Purposes This study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population. Study design/setting This was a retrospective study of prospectively captured data. Patient sample A consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol. Outcome measures Insomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0-7); subthreshold insomnia (score, 8-14); moderate clinical insomnia (score, 15-21); and severe clinical insomnia (score, 22-28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire. Methods Patients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses. Results The presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia. Conclusion This research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population. [ABSTRACT FROM AUTHOR]

Study Design. A retrospective study of prospectively collected data. Objective. To determine whether comorbid fibromyalgia, identified in patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), resolves with a functional restoration program (FRP). Summary of Background Data. Fibromyalgia involves widespread bodily pain and tenderness to palpation. In recent studies, 23% to 41% of patients with CDOMDs entering an FRP had comorbid fibromyalgia, compared with population averages of 2% to 5%. Few studies have examined whether fibromyalgia diagnoses resolve with any treatment, and none have investigated diagnosis responsiveness to an FRP. Methods. A consecutive cohort of patients with CDOMDs (82% with spinal disorders and all reporting chronic spinal pain) and comorbid fibromyalgia (N = 117) completed an FRP, which included quantitatively directed exercise progression and multimodal disability management. Diagnosis responsiveness, evaluated at discharge, created 2 groups: those who retained fibromyalgia and those who did not. These groups were compared with chronic regional lumbar pain only patients (LO group, n = 87), lacking widespread pain and fibromyalgia. Results. Of the patients with comorbid fibromyalgia, 59% (n = 69) retained the fibromyalgia diagnosis (RFM group) and 41% (n = 48) lost the fibromyalgia diagnosis (LFM group) at discharge. Although all 3 groups reported decreased pain intensity, disability, and depressive symptoms from admission to discharge, RFM patients reported higher symptom levels than the LFM and LO groups at discharge. The LFM and LO groups were statistically similar. At 1-year follow-up, LO patients demonstrated higher work retention than both fibromyalgia groups (P < 0.03). Conclusion. Despite a significant comorbid fibromyalgia prevalence in a cohort of patients with CDOMDs entering an FRP, 41% of patients with an initial fibromyalgia diagnosis no longer met diagnostic criteria for fibromyalgia at discharge and were indistinguishable from LO patients on pain, disability, and depression symptoms. However, both fibromyalgia groups (LFM and RFM) had lower work retention than LO patients 1 year later, suggesting that an FRP may suppress symptoms of fibromyalgia in a subset of patients, but prolonged fibromyalgia-related disability may be more difficult to overcome. [ABSTRACT FROM AUTHOR]