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Background: Unremitting health-care-seeking behaviors have only infrequently been addressed in the literature as an outcome of treatment for chronic disabling work-related musculoskeletal disorders. The limited research has never focused on the patient as the "driver" of health-care utilization, to our knowledge. As a result, little attention has been paid to the differences between treated patients who seek additional health care from a new provider and those who do not. The purpose of this project was to examine the demographic and socioeconomic outcome variables that characterize patients with a chronic disabling work-related musculoskeletal disorder who pursue additional health-care services from a new provider following the completion of a tertiary rehabilitation treatment program. A prospective comparison cohort design was employed to assess characteristics and outcomes of these patients, all of whom were treated with the same interdisciplinary protocol., Methods: A cohort of 1316 patients who had been consecutively treated with a rehabilitation program for functional restoration was divided into two groups on the basis of whether they had sought treatment from a new health-care provider in the year following completion of treatment. Group 0 (966 patients) did not visit a new health-care provider for treatment of their original occupational injury, and Group 1 (350 patients) visited a new provider on at least one occasion. A structured clinical interview to assess socioeconomic outcomes was carried out one year after discharge from the treatment program; this interview addressed pain, health-care utilization, work status, recurrent injury, and whether the Workers' Compensation case had been closed., Results: The percentage of Group-0 patients who had undergone pre-rehabilitation surgery was significantly lower than the percentage of Group-1 patients who had done so (12% compared with 21%, odds ratio = 1.9 [95% confidence interval = 1.3, 2.7]; p < 0.001). One year after treatment, 90% of the Group-0 patients had returned to work compared with only 78% of the Group-1 patients (odds ratio = 2.6 [95% confidence interval, 1.9, 3.6]; p < 0.001). Similarly, 88% of the Group-0 patients were still working at one year compared with only 62% of the patients in Group 1 (odds ratio = 4.5 [95% confidence interval, 3.3, 6.0]; p < 0.001). Whereas 96% of the Group-0 patients had resolved all related legal and/or financial disputes by one year, only 77% of the Group-1 patients had done so (odds ratio = 6.9 [95% confidence interval, 4.5, 10.5]; p < 0.001). Only a negligible percentage (0.4%) of the patients in Group 0 had undergone a new operation at the site of the original injury, whereas 12% of the Group-1 patients had done so (odds ratio = 31.0 [95% confidence interval, 11.0, 87.3]; p < 0.001). When the above outcome variables were analyzed by dividing Group 1 according to the number of visits to a new service provider, there was a trend for poorer socioeconomic outcomes to be associated with an increasing number of health-care visits., Conclusions: To our knowledge, the present study represents the first large-scale examination of patients with a chronic disabling work-related musculoskeletal disorder who persist in seeking health-care following the completion of tertiary rehabilitation. The results demonstrate that about 25% of patients with a chronic disabling work-related musculoskeletal disorder pursue new health-care services after completing a course of treatment, and this subgroup accounts for a significant proportion of lost worker productivity, unremitting disability payments, and excess health-care consumption., Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

Study Design: A two-part investigation was conducted: 1) a prospective study of asymptomatic subjects quantitatively comparing trunk mobility to surface electromyographic (sEMG) signals from the erector spinae during trunk flexion; and 2) a prospective repeated-measures cohort study of patients with chronic disabled work-related spinal disorder tested for the flexion-relaxation (FR) phenomenon while measured simultaneously for lumbar spine inclinometric range of motion (ROM)., Objectives: To describe a theoretical model for the potential use of FR unloaded in assessing patients with chronic low back pain patients before and after rehabilitation, and to establish a normative database (Part 1) for subsequent use in comparison to patients with chronic low back pain (Part 2). The second part of the study assessed the clinical utility of combined sEMG and ROM measurements for assessing the FR phenomenon as a test to assist potentially in planning rehabilitation programs, guiding patients' individual rehabilitation progress, and identifying early posttreatment outcome failures., Summary of Background Data: The FR phenomenon has been recognized since 1951, and it can be reproducibly assessed in normal subjects with FR unloaded. It can be found intermittently in patients with chronic low back pain. Recent studies have moved toward deriving formulas to identify FR, but only a few have examined a potential relation between inclinometric lumbar motion measures and the sEMG signal. No previous studies have developed normative data potentially useful for objectively assessing nonoperative treatment progress, effort, or the validity of permanent impairment rating measures., Methods: In Part 1, 12 asymptomatic subjects were evaluated in an intra- and interrater repeated-measures protocol to examine reliability of sEMG signal readings in FR, as well as ROM measures at FR and maximum voluntary flexion. The mean sEMG signal averaging right-left electrode recordings, as well as the gross, true, and sacral lumbar ROM measurements, were recorded as normative data. In Part 2, 54 patients with chronic disabled work-related spinal disorder referred as candidates for tertiary functional restoration rehabilitation participated in a standardized assessment protocol for sEMG and ROM measurement before rehabilitation. Those who completed the program were retested with the identical methodology after rehabilitation (n = 34) using the empirically derived cutoff scores for sEMG readings at FR and ROM from Part 1 and prior scientific literature. Pain disability self-reported scores were correlated with sEMG and ROM. Sensitivity and specificity of the sEMG for identifying abnormal motion were assessed., Results: In Part 1, the ability of the experienced testers to measure ROM and sEMG reliably at FR was high (r >or= 0.92; P < 0.001). All asymptomatic subjects achieved FR at a tightly clustered range of mean sEMG signals from 1 to 2.3 microV. Most of the variation between motion at FR and maximum voluntary flexion occurred through the hip (sacral) motion component of the gross (or total) motion measured at T12. In Part 2, posttreatment reliability for ROM, sEMG, and the ability to detect the FR point was high (r >or= 0.82; P < 0.001). More than 30% of the 54 patients tested before treatment demonstrated ability to achieve FR, with FR usually associated with higher ROM than in the non-FR patients. After treatment, 94% of those who completed the program achieved FR, including all those who achieved FR before treatment. Flexion-relaxation was associated with major improvement in ROM and pain disability self-report., Conclusions: Flexion-relaxation measures a point at which true lumbar flexion ROM approaches its maximum in asymptomatic subjects. This also is the point at which lumbar extensor muscle contraction relaxes, allowing the lumbar spine to hang on its posterior ligaments. The gluteal and hamstring muscles then lower the flexed trunk even further by allowing the pelvis to rotate around the hips. This phenomenon was subsequently found in Part 2 to offer a potentially promising method for individualizing rehabilitation treatment, decreasing unnecessary utilization, identifying potential postrehabilitation treatment failures, and assessing permanent impairment rating validity. Moreover, this is the first study to demonstrate systematically that an absence of FR in patients with chronic low back pain can be corrected with treatment.

A clinical protocol is reviewed, which utilizes supportive intervention, education, and surface EMG biofeedback to facilitate movement and to maximize effective stretching with chronic musculoskeletal pain patients. Support for this clinical protocol is provided with an overview of the physiological basis of stretching, surface EMG patterns associated with stretching, and the effects of pain and emotional factors on stretching and movement inhibition.

Therapeutic stretching is a vital component of chronic musculoskeletal pain rehabilitation for increasing range of motion and counteracting the effects of physical deconditioning. Surface EMG biofeedback is currently being used to facilitate movement and to maximize effective stretching with patients in an interdisciplinary chronic pain rehabilitation program for disabled workers. A clinical protocol with case examples is presented.

Study Design: A longitudinal cohort study involving 1749 patients with chronically disabling spine disorder (CDSD) who underwent tertiary rehabilitation investigated the relation between the Million Visual Analog Scale (MVAS) score and treatment outcome., Objectives: To determine whether the pretreatment MVAS rating of disability severity is associated with the ability to complete functional restoration rehabilitation, and to determine whether pre- or posttreatment MVAS disability perception is associated with 1-year posttreatment socioeconomic outcomes. The relation of the MVAS to pre- and posttreatment psychosocial measures and physical performance levels also was evaluated., Summary of Background Data: The MVAS yields a total functional disability score ranging from 0 to 150. Like other "disability inventories," the MVAS differs from a "pain inventory" in that the focus is on disability and function, as opposed to self-reported pain. The MVAS may currently be the most powerful functional rating scale because all its questions relate to the patient's ability to perform activities of daily living. It also has the advantage of a visual analog format, which typically is considered more effective than other commonly used self-report formats., Methods: A large cohort of 1749 patients with CDSD who underwent tertiary rehabilitation was divided into groups by their severity of disability, rated on the MVAS, both at pre- and posttreatment assessment. The patients were divided into groups ranging from "no reported disability" (MVAS = 0) to "extreme disability" (MVAS = 131-150). The distribution into the six groups was assessed on both pre- and posttreatment MVAS ratings. The patients underwent a 3-week functional restoration program consisting of daily quantitatively directed exercise progression and multimodal disability management. Physical capacity and psychosocial assessments, performed before and after treatment, were correlated with the MVAS scores. A 1-year posttreatment clinical interview obtained information on socioeconomic outcomes, which also were correlated with the MVAS ratings., Results: Mantel-Haenszel linear analyses showed a number of relations between demographic variables and both pre- and posttreatment MVAS scores. Most importantly, the findings showed that severe pretreatment MVAS scores were associated with a lower program completion rate (94% vs 89%; P < 0.001) and a higher rate of postrehabilitation health care use from a new provider (12% vs 41%; P < 0.001). Prerehabilitation scores also were linearly related to lower levels of pretreatment physical performance and higher rates of pretreatment depression. More severe posttreatment MVAS scores were associated linearly with a drop in the work return rate from 93% to 63%, a drop in the work retention rate 1 year after rehabilitation from 86% to 44%, and a drop in the financial settlement rate from 94% to 79% (P < 0.001). A linear trend also was found in the rate of postrehabilitation surgeries, with the percentages rising from 0% in the group with no reported disabilities to 12% in the group with extreme disabilities (P < 0.001)., Conclusions: The current study represents the first large-scale examination of the relation between MVAS ratings and treatment outcomes in a CDSD population. These results demonstrate the effectiveness of a simple disability rating scale, such as the MVAS, for systematic disability assessment in potentially predicting treatment outcomes in patients with CDSD. Despite the popularity of other questionnaires, the MVAS is the first disability inventory with demonstrated effectiveness for this purpose in a large CDSD population.

Background Context: Clinicians have long hypothesized that gender may be a risk factor in treatment outcomes of patients with chronic disability associated with musculoskeletal disorders. Although the scientific literature shows a higher prevalence of occupational low back injury in men, and a higher rate of repetitive motion and neck injuries in women, few studies have comprehensively investigated the role of gender regarding cost-related outcome variables of significance after work-related injuries., Purpose: This study was designed to examine the relationship between gender and biopsychosocial treatment outcomes in a predominately chronically disabled spinal disorder (CDSD) workers' compensation cohort undergoing a tertiary functional restoration program., Study Design: A prospective comparison cohort study investigating the effect of gender on biopsychosocial treatment outcomes as risk factors for rehabilitation failure., Patient Sample: A cohort of 1,827 consecutively treated patients with CDSD were placed into two gender-based groups: men (n=1,158, average age 40.7+/-10 years) and women (n=669, average age 42.5+/-10 years)., Outcome Measures: Before the start of the program, and again upon completion of the program, all patients received a standard psychosocial assessment and were assessed on a variety of physical factors (leading to a cumulative score, calculated on the basis of the aggregates and averages of these physical measures). A structured clinical interview examining socioeconomic outcomes was conducted at 1 year after program completion, and at least partial information was obtained from this interview on all patients in the present study., Methods: All patients underwent a medically directed functional restoration program combining quantitatively guided exercise progression with a multimodal disability management approach using psychological and case management techniques., Results: Men had a significantly higher rate of lumbar injury than women, whereas women had a significantly higher rate of cervical injury. Men returned to work and retained work at a 40 hours/week job at a higher rate at 1-year follow-up. Women evidenced a higher rate of health care-seeking behaviors from new providers. On physical testing immediately after treatment, men had a significantly higher cumulative physical score (gender normalized), both before and after treatment. On depression and disability questionnaires, men showed fewer pre- and posttreatment depressive symptoms with lower pretreatment disability scores., Conclusions: The present study represents the first large-scale examination of the relationship between gender and treatment outcomes for a population with CDSD after work injuries. There was a pattern of moderately better 1-year posttreatment socioeconomic outcome for men. On psychosocial measures, men showed lower disability and depression scores than women, with higher levels of physical functioning both before and after treatment. Overall, male patients with CDSD appeared to show somewhat better biopsychosocial outcomes. This leaves the question of identifying gender-specific risk factors to explain these differences.

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.

The cost and prevalence of chronic work-related musculoskeletal pain disability in industrialized countries are extremely high. Although unrecognized psychiatric disorders have been found to interfere with the successful rehabilitation of these disability patients, few data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in chronic disability. To investigate this issue, a consecutive group of patients with work-related chronic musculoskeletal pain disability (n = 1595), who started a prescribed course of tertiary rehabilitation, were evaluated. Psychiatric disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders. Results revealed that overall prevalences of psychiatric disorders were significantly elevated in these patients compared with base rates in the general population. A majority (64%) of patients were diagnosed with at least one current disorder, compared with only 15% of the general population. However, prevalences of psychiatric disorders were elevated in patients only after the work-related disability. Such findings suggest that clinicians treating these patients must be aware of the high prevalence of psychiatric disorders and be prepared to use mental health professionals to assist in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged pain disability in a substantial number of these patients.

The present study utilized recently developed diagnostic tests that permit recognition of functional deficits in spine mobility, trunk strength, endurance, coordination, and dynamic lifting capacity. Changes in these tests were compared to changes in psychological functioning (e.g., self-report of pain) as well as to outcome criteria such as return-to-work and resolution of litigation. The study utilized these tests repeatedly during a new treatment approach to feed back objective information of the patient's functional capacity, not amenable to simple visual inspection, to both the patient and the surgeon. The program itself integrated a low back physical rehabilitation program with a multimodal pain management program and was guided by repeated functional capacity measurements. A total of 66 patients were evaluated. Results demonstrated significant improvement in physical function in these patients, which was also accompanied by changes in self-report of pain complaints. Moreover, an 82% return-to-work rate was achieved in this sample which was initially 92% unemployed. These results indicate that the physician dealing with chronic low back dysfunction can employ objective measures of functional capacity as an alternative to the sole reliance on pain patient self-report or structured tests, such as radiographic imaging, which merely document a universal, progressive degenerative process.