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Temporomandibular joint and muscle disorder (TMJMD) is one of the most prevalent types of musculoskeletal disorders. The major goal of the study was to more objectively quantify clinically meaningful relief for TMJMD treatment outcomes by using the new metric of minimal clinically important difference (MCID). Pre- to post-treatment changes on a number of self-report measures were evaluated in a cohort of 101 acute TMJMD patients. An anchor-based MCID approach was employed, with an objective chewing performance measure serving as the clinical outcome of interest. Using a Receiver Operating Curve analysis, it was found that the Physical Component Scale (PCS) of the SF-36 was the most robust self-report measure to use as the MCID in a TMJMD patient population.

Central Sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term Central Sensitivity Syndrome (CSS) has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs, and quantifies the degree of these symptoms. The utility of the CSI, to differentiate among different types of chronic pain patients that presumably have different levels of CS impairment, was then evaluated. Study 1 demonstrated strong psychometric properties (test-retest reliability = 0.817; Cronbach's alpha = 0.879) of the CSI in a cohort of normative subjects. A factor analysis (including both normative and chronic pain subjects) yielded 4 major factors (all related to somatic and emotional symptoms), accounting for 53.4% of the variance in the dataset. In Study 2, the CSI was administered to four groups: fibromyalgia (FM); chronic widespread pain (CWP) without FM; work-related regional chronic low back pain (CLBP); and normative control group. Analyses revealed that the FM patients reported the highest CSI scores, and the normative population the lowest (p

Background: The Pain Anxiety Symptoms Scale (PASS) was developed to measure fear and anxiety responses to pain. Many studies have found associations between PASS scores and self-report measures of pain, anxiety, and disability as well as among inhibited movement patterns and activity avoidance behaviors (eg, kinesophobia). This study aimed to identify clinically meaningful cut-off points to identify high or low levels of pain anxiety and to determine if the PASS provides additional useful information in a functional restoration (FR) treatment program for chronic disabling occupational musculoskeletal disorder (CDOMD) patients. Methods: A consecutive cohort of 551 patients with CDOMD, who entered and completed a FR program, was administered a battery of psychosocial assessments, including the PASS, at admission and discharge. Socioeconomic outcomes were collected 1 year after discharge. After identifying clinical ranges for mild, moderate, and severe pain anxiety, the three groups were compared on self-report measures of psychosocial distress, clinical diagnoses of psychosocial disorders, and 1-year socioeconomic outcomes. Results: Correlations between the PASS and all measures of pain, anxiety, and disability were statistically significant. However, only the Pain Disability Questionnaire showed a large correlation coefficient (r > 0.5). Patients with the highest PASS scores were more likely to be diagnosed with a number of Axis I (depression, opioid dependence) or Axis II (Borderline Personality) psychiatric disorders. They were more likely to display treatment-seeking behavior at 1 year after discharge. However, the PASS failed to differentiate between any other 1-year outcomes. Conclusions: The PASS is elevated when other measures of psychosocial distress are also elevated. However, the PASS fails to discriminate between different indices of depression and anxiety and it is not highly related to 1-year outcomes in a CDOMD cohort. If time and resources are limited, a different measure of psychosocial distress that does relate to socioeconomic outcomes might be a better option in a CDOMD evaluation process. Language: en

To identify the prevalence, risk factors, and treatment outcomes of patients with chronic disabling occupational musculoskeletal disorders (CDOMD) who met criteria for fibromyalgia.This was a prospective prognostic study of a consecutive cohort of CDOMD patients (n = 449) admitted for treatment. Patients were assessed for chronic widespread pain and fibromyalgia. The measures included demographic, injury-related and occupational information, psychosocial measures, and 1-year work status follow-up.The CDOMD patients with fibromyalgia reported higher-level psychosocial distress. Women with fibromyalgia were 9.6 times less likely to return to work 1-year posttreatment and, of those who did, were 4.3 times less likely to retain work.Of this cohort, 23.2% patients met criteria for fibromyalgia. Patients with fibromyalgia were found to show greater psychosocial distress and significantly poorer rates of work return and work retention 1-year postrehabilitation.

Earlier findings demonstrated that the comprehensive muscular activity profile (CMAP) system was a powerful clinical method for evaluating lumbar range of motion (ROM) and lifting capacity (LC) while also documenting participant effort. A subsequent study also reported the CMAP’s clinical utility for patients with musculoskeletal pain claims. Building upon these studies, the present investigation evaluated the CMAP’s ability to reliably differentiate between healthy individuals versus those with low back pain (LBP). Twenty LBP patients and 20 demographically matched healthy subjects were administered the CMAP protocol (measuring ROM and LC). For ROM, there were no significant differences between the groups for overall performance and for degree of effort. However, for the LC, there were significant differences between groups: the LBP patients displayed lower performance relative to normals. Results demonstrate the clinical utility of the CMAP for the objective quantification of functional differences between the two groups.

Chronic pain is a costly and debilitating condition that has proven difficult to treat, solely with medical interventions, due to the complex interplay of biological, psychological, and social factors in its onset and persistence. Many studies have demonstrated the effectiveness of interdisciplinary treatment that includes psychosocial interventions for low back pain. Nevertheless, these interventions continue to be under-utilized due to concerns of cost and applicability. The present study utilized a cost utility analysis to evaluate effectiveness and associated costs of interdisciplinary early intervention for individuals with acute low back pain that was identified as high-risk for becoming chronic. Treatment effectiveness was evaluated using a standard pain measure and quality-adjusted life years, and associated medical and employment costs were gathered for 1 year. Results indicated that subjects improved significantly from pretreatment to 1-year follow-up, and that the early intervention group reported fewer health-care visits and missed workdays than the treatment as usual group. The majority of 1,000 bootstrapped samples demonstrated the dominance of the early intervention program as being both more effective and less costly from a societal perspective. The early intervention treatment was the preferred option in over 85% of samples within an established range of acceptable costs. These results are encouraging evidence for the cost-effectiveness of interdisciplinary intervention and the benefits of targeted early treatment.

This current Special Issue of Psychological Injury and Law focuses on traumatically induced pain and its medicolegal aspects. Because many individuals suffering from chronic pain have sustained their painful injuries as a result of trauma, it is common for them to become involved in litigation. As we know, chronic pain is a complex syndrome, characterized not only by persistent physical discomfort but also by a deleterious impact on numerous aspects of one’s life (potentially including vocational, financial, social, sexual, recreational, and emotional functioning). Clearly, chronic pain is not merely an affliction of a body; rather, it should be conceptualized as an illness of the person (Schatman 2010a, b). This is not to suggest, however, that psychosocial factors are necessarily at the root of chronic pain (Melzack and Katz 2006). In fact, there is as much empirical evidence supporting chronic pain as the cause of psychopathology as there is supporting the primacy of psychosocial factors in the etiology of chronic pain (Gureje 2007; van’t Land et al. 2010). Rejecting the unidirectionality argument as explanatory of the psychosocial factor-pain experience relationship, mutual maintenance models hold that physiological, affective, and behavioral components of emotional distress maintain or exacerbate symptoms of pain and, similarly, that cognitive, affective, and behavioral components of chronic musculoskeletal pain maintain or exacerbate symptoms of emotional distress. These models have been applied to, and empirically supported in, examinations of co-morbidities of chronic pain such as depression (Bair et al. 2003; Dworkin et al. 1992; von Korff and Simon 1996), post-traumatic stress disorder (PTSD) (Asmundson and Taylor 2006; Otis et al. 2003; Sharp and Harvey 2001), as well as general quality of life among chronic pain patients (Wahl et al. 2009). Relatively recent research has identified a shared biologic process underlying chronic pain and depression, in which serotonin and norepinephrine are involved in the dorsal raphe nucleus and locus ceruleus (Jann and Slade 2007). The identification of this shared mechanism lends additional support to the hypothesis of a bidirectional interaction between chronic pain and psychosocial factors. Also to be considered is the diathesis-stress model of psychopathology and chronic pain, which has ultimately developed into the dominant overarching theoretical perspective. This model, initially articulated by Gatchel and colleagues (Dersh et al. 2006, 2001, 2002; Gatchel 1991, 1996), assumes the presence of premorbid yet semi-dormant characteristics of the patient that exist prior to the onset of pain, which are then activated in response to the stress of the painful condition and its psychiatric sequelae. Moreover, the wide-ranging impact of pain becomes even more complex when injured parties choose to pursue litigation relating to their pain-producing injuries. Results of an early meta-analysis (Rohling et al. 1995), for example, suggested that receiving financial compensation was associated with a greater experience of pain and reduced treatment efficacy, with the authors positing causal attribution. However, subsequent reviews have questioned this validity of the proposed causal relationship (Kolbinson et al. 1996; Scholten-Peeters et al. 2003; Sterner and Gerdle 2004) or have suggested that it has not been adequately studied to presume that litigation has an impact on prognosis (Carroll et al. 2008). M. E. Schatman (*) Pain and Addiction Study Foundation, 1215 120th Ave. NE, Suite 201, Bellevue, WA 98005, USA e-mail: headdock@comcast.net

The present article discusses the three major components of behavior that are used for assessing pain—self-report, overt behavior/function, and physical indices. Issues concerning the reliable operational definitions of these three behavioral referents of pain are reviewed, as well as the fact that a high degree of concordance or precise overlap among the three cannot be automatically assumed. The best biopsychosocial assessment approved to be used when discordance occurs—a stepwise approach to assessment—is then presented. Finally, in addition to the often complex interactions among the three behavioral referents of pain, what makes this assessment area even more complicated is that there may also be complex interactions among the construct of pain and the two related constructs of impairment and disability. These potential complexities are also discussed.

The term malingering has a negative connotation, in that it is considered to intentionally project exaggerated physical and/or psychosocial symptoms for the purpose of gaining some external rewards/secondary gain. The present article will review a number of misconceptions about malingering, as well as the inherent problem in objectively measuring this construct. It will be suggested that a more comprehensive biopsychosocial approach should be used to evaluate potential barriers to recovery, as well as suboptimal performance that may delay, or prevent, recovery over an expected time period for musculoskeletal pain disorders. Such an approach will eliminate the common misuse and misdiagnosis of the construct of malingering.

Objectives Lumbar flexion-relaxation is a well-known phenomenon that can reliably be seen in normal participants, but not in most chronic low back pain (CLBP) participants. No earlier studies have investigated any specific clinical intervention designed to correct abnormal flexion-relaxation. The objective of this study was to evaluate the contribution of a surface EMG-assisted stretching (SEMGAS) biofeedback training protocol, within a functional restoration treatment program, on flexion range of motion (ROM) and erector spinae surface EMG (SEMG) during maximum voluntary flexion (MVF). Methods Lumbar flexion ROM and MVF SEMG were assessed in 2 groups of CLBP patients at the beginning and end of rehabilitation. One group participated in functional restoration only, whereas the other group participated in functional restoration plus SEMGAS biofeedback training. Both treatment groups were compared with a separate control group of normal, pain-free participants. Results Pretreatment ROM and MVF SEMG measures were similar in both treatment groups, but were very different than the control group. At posttreatment, the functional restoration only group remained statistically different than the control group on MVF SEMG and some ROM measures, but the SEMGAS group was statistically equivalent to the control participants on all posttreatment measures, including the ability to show flexion-relaxation. Discussion Interdisciplinary functional restoration rehabilitation of CLBP participants is effective for increasing ROM and other functional measures, but the addition of a SEMGAS biofeedback training protocol can result in normalization of the flexion-relaxation phenomenon, so that these participants are comparable with a pain-free control group.

Introduction In an earlier study, Gatchel et al. (J Occup Rehabil 13:1–9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment. Methods Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment. Results At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care. Conclusion The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.

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.

Burnout is especially disruptive among emergency room (ER) nurses. This report covers the influencing factors and outcomes related to burnout in ER nursing populations, with the goal of providing helpful information to a professional audience. The present article includes a literature review on burnout as it occurs in the ER. Interviews from a small sample of ER nurses (n = 5) are analyzed through a combination of deductive thematic analysis and computerized text analysis. Research from various related fields have been pooled together and briefly described. Experiences, comments, and recommendations concerning burnout collected from interviews seem to align with findings from empirical research, and recommendations given by interview nurses closely resemble the recommendations given by researchers. Sentiment analysis revealed a pattern of positive word use when the nurses discussed resources, and a pattern of negative word use when workload was discussed. A better understanding of burnout, both anecdotal and empirical, is valuable information for any professional who works in the ER. Many options exist for reducing or mitigating burnout, including interventions at the individual, team, and organizational levels. More involvement of ER nurses in burnout reduction strategies should be made a priority.

The degree of physical impairment, often due to a soft-tissue injury, is an important first step in evaluating musculoskeletal pain disorders in a workers' compensation population. The Comprehensive Muscular Activity Profile (CMAP) is a recent innovation for measuring such soft tissue injuries. A total of 114 consecutive patients with musculoskeletal pain claims were evaluated by medical examination and CMAP administration. Results indicated a 6.8 times increase in the odds of case closure when there was concordance between CMAP results and the physician's independent diagnoses. There was also a significant reduction of overall medical costs after the CMAP was conducted. These preliminary findings indicate good clinical utility for the CMAP. Implications and additional interpretations of these results are discussed.

Treating individuals with chronic illness and disability requires attention to physical, psychological, and social factors. These unique challenges are optimally addressed by utilizing a biopsychosocial approach, while considering the potential array of both gains and losses that chronic pain patients experience. The benefits a patient receives from remaining ill are often referred to as secondary gain. In medicolegal settings, a common example of a secondary gain issue is the effort to obtain financial compensation. While secondary gain can be one factor that contributes to perpetuating illness and disability, there are often more powerful losses that lead to such perpetuation. The losses associated with pain and disability are not frequently discussed. The overall purpose of this paper is to identify primary, secondary, and tertiary loss issues in chronic pain patients, and address issues related to how these factors are important within a medicolegal/forensic context.

The present study represents the next stage in the development of a psychometrically sound, self-report screening tool used for assessing the potential pain-medication-misuse risk. A revised Pain Medication Questionnaire (PMQ) was initially designed to successfully evaluate such risk. A subsequent series of two additional studies further documented the clinical utility of the PMQ. A new shortened version of the PMQ was developed, and its psychometric properties, along with its predictive accuracy in identifying risk for medication misuse, were evaluated. Results revealed that the new version maintained the strong psychometric properties of the original PMQ. Moreover, its predictive accuracy was found to be high (85.5% accuracy). Thus, this revised, shortened PMQ can aid physicians in assessing for potential medication misuse, allowing them to more closely monitor at-risk patients during pain management treatment.

Resumen El desarrollo de un ensayo clinico comprende varias etapas de planificacion y ejecucion. Los tres mayores componentes del ensayo clinico son el manejo o gestion de los datos, el control de calidad que asegure la integridad de los datos, y la interpretacion de los datos al finalizar el ensayo. Aunque cada proceso se distingue por diferentes actividades, nivel de esfuerzo y conocimientos necesarios, los tres procesos estan fuertemente vinculados. Metodos de gestion de datos incluyen el proceso de entrada de datos y un planteamiento completo y organizado de control de calidad. En este articulo se elaboran ciertas guias y recomendaciones para encarar el control de calidad y resolver problemas de ocurrencia comun en la gestion de datos clinicos, como son la ausencia de datos, la invalidez de casos, la presencia de “outliers” (sujetos atipicos o inusuales), y el incumplimiento de supuestos distribucionales en los analisis estadisticos. Para facilitar la interpretacion de los datos, se examinan condiciones necesarias para permitir inferencias causales. Se destaca la necesidad de tener en cuenta las caracteristicas basales de la muestra de pacientes, como extension de los principios de validez interna de un estudio. Se examinan las amenazas mas communes a la validez de las conclusiones estadisticas, como la inflacion de errores de Tipo I y el problema de las pruebas sobredominantes. Finalmente se considera el concepto de tamano del efecto, importante complemento al concepto de significancia estadistica, y como se pueden interpretar los distintos metodos de medicion de tamano del efecto en el marco de un ensayo clinico.

Resumen El crecimiento en la medicina basada en la evidencia ha creado la necesidad de obtener resultados confiables basados en evidencia para documentar reacciones a un tratamiento o para evaluar la eficacia y rendimiento economico de distintas modalidades de tratamientos. Segun el modelo biopsicosocial, el dolor se conceptualiza como una compleja interaccion de multiples factores biologicos, psicologicos y sociales, que en conjunto juegan un papel en el desarrollo, agudizacion y prolongacion del dolor. Por consiguiente, los resultados asociados con la gestion del dolor son por necesidad de naturaleza compleja y multifactorial. El presente articulo desarrolla dos categorias generales de resultados basados en la evidencia en la gestion del dolor: resultados reportados por pacientes y resultados objetivos. Los resultados reportados por pacientes se explican en el ambito de las medidas de dolor, la calidad de vida relacionada con la salud, y los modelos psico-sociales. Los resultados objetivos se desarrollan en el ambito ocupacional y el grado de utilizacion de los servicios de salud. Cada seccion elabora singulares modelos de cada una de las medida de resultados y destaca su concordancia con normas actuales de evidencia y con el estado actual de conocimiento en la investigacion del dolor.

Chronic pain, a debilitating medical condition affecting approximately 15% of the US population, leads to individual suffering and costs to society in terms of health care dollars and lost productivity. To examine the effectiveness of a comprehensive pain management program, data from 108 program participants were evaluated. Preprogram, postprogram, and 6-month follow-up data were collected from 80 participants, and preprogram, postprogram, and 1-year data were collected from 46 participants. Outcomes data from several domains were assessed: pain severity, emotional distress, interference of pain on function, perceived control of pain, treatment helpfulness, and number of hours resting. Within-subject repeated-measure analyses of variance found statistically significant findings on the six outcome measures utilized in this study for both the 6-month and 1-year samples. Examination of 95% confidence intervals revealed no overlap in pretreatment scores with 6-month and 1-year outcomes in five of the six domains studied. Mean scores on emotional distress did not maintain statistical significance in the 6-month or 1-year review. Overall, this study strengthens the case for interdisciplinary care for chronic pain management and provides evidence for the long-term effectiveness of this therapy. Furthermore, this study lends support to the notion that interdisciplinary treatments are effective in targeting multiple domains affected by the pain condition.

The present study takes a new approach to understanding how presenteeism relates to chronic pain or disability patient outcomes.The sample consisted of 2191 consecutive chronic disabling musculoskeletal disorder patients, classified as either presentees (N = 704), or absentees (N = 1487), who were admitted to a functional restoration program. The measures included medical evaluations, demographic data, psychiatric diagnoses at admission, an 1 year follow-up socioeconomic outcome assessment and validated questionnaires evaluating pain, depression, and function.The findings revealed that patients classified as presentees were significantly more likely to complete the prescribed functional restoration treatment program, to return to work (full-duty or full-time), to retain work 1-year posttreatment, and not to have a decrease in job demand from preinjury to posttreatment.Both employees and employers will benefit if the ill or injured employee stays at work postinjury in lieu of short- or long-term disability.

Chronic pain related to musculoskeletal conditions is the leading cause of medical discharge from active duty military service. The present study is the first randomized controlled trial of an interdisciplinary pain treatment program (functional restoration, FR) to decrease chronic musculoskeletal pain and increase functioning in an active duty military population. Sixty-six military participants were randomly assigned to either an FR treatment group or a standard anesthesia pain clinic treatment comparison group. A repeated measures design was employed and data were analyzed for pre- to post-treatment differences, as well as for 6-months and 1-year post-treatment outcomes. Findings revealed significantly greater improvements for the FR group on self-reported pain, disability, functional status, and fitness for military duty at the post-treatment and follow-up points, relative to the comparison group. These results clearly demonstrate the efficacy and military relevance of a FR program for active duty military personnel who have chronic musculoskeletal pain disorders.

Conducting a clinical trial involves various stages of planning and implementation. The three major components involved in clinical trials are the management of data, the quality control to ensure data integrity, and the interpretation of the data at the conclusion of the trial. Although each process is distinct and involves different levels of effort and knowledge to implement, all processes are intimately linked. Data management techniques include the process of data entry and the implementation of an organized, comprehensive approach to quality control. Some guidelines for quality control screening are recommended to address various common issues related to clinical data, such as missing data, invalid cases, subject "outliers," and violation of distributional assumptions relevant to statistical analyses. In order to aid in interpreting the data, conditions that need to be met to make causal inferences are discussed. Taking into account baseline characteristics of the patient sample is also discussed as an extension to maintaining the internal validity of the study. Additionally, some common threats to statistical conclusion validity, including Type I error inflation and the problem of overpowered tests, are highlighted. Finally, the concept of the effect size as an important complement to statistical significance and how the various types of effect size measures can be interpreted within the context of a clinical trial are discussed.

The growing emphasis on evidence-based medicine dictates that reliable, evidence-based outcomes be utilized in documenting response to treatment, as well as determining the treatment efficacy and cost-effectiveness of different treatment modalities. The biopsychosocial model conceptualizes pain as a complex multifactorial interaction of biological, psychological, and social components that play a role in the development, exacerbation, and perpetuation of pain. As a result, outcomes relevant to pain management are necessarily complex and multifactorial in nature. Two broad categories of evidence-based outcomes relevant to pain management are discussed: patient-reported outcomes and objective outcomes. Patient-reported outcomes are discussed within the context of pain measures, health-related quality of life, and psychological constructs. Objective outcomes are discussed within the context of healthcare utilization and occupational status. The discussion within each section highlights the unique constructs measured by each category of outcome measure and highlights their consistency with current evidence-based guidelines and knowledge from pain research.

The biopsychosocial model provides the most heuristic account of the complex multifaceted nature of chronic pain and its associated impairment and disability. Although chronic pain, impairment, and disability are related, these are three separate constructs. In order to understand how these three constructs are interrelated, the development of pain from the acute to the chronic stage is discussed. Psychosocial factors as barriers to recovery are emphasized, including those that commonly manifest among patients receiving disability compensation. This is complemented by a review of psychometric instruments used to assess these psychosocial factors in chronic pain. Finally, the major delineation in levels of care for chronic pain is highlighted, emphasizing an interdisciplinary approach that is consistent with pain as a biopsychosocial phenomenon.

The present study was designed to evaluate the relative degree and type of emotional distress in high-risk acute low back pain (ALBP) subjects (defined as less than 3 months since initial injury) vs. high-risk chronic low back pain (CLBP) subjects (defined as greater than 3 months since initial injury). It is an extension of earlier findings that demonstrated the significant role that such emotional distress may play in the development of CLBP disability if not appropriately treated in the acute phase. This work stems from a conceptual three-stage model, which characterizes the progression from acute to chronic pain. Several psychosocial measures were administered that included information allowing for the classification of subjects as high-risk based upon an earlier developed screening algorithm. The ANCOVA procedure in SPSS was used to compare groups, controlling for gender, ethnicity, and age. Results revealed that CLBP subjects had higher rates of certain measures of emotional distress and depression relative to ALBP subjects. These findings further support the importance of effectively managing emotional distress factors early, when treating musculoskeletal disorders such as low back pain.

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.

Objective This study was designed to explore the stages of change involved in return to work (RTW) for a group of workers who had been suffering from chronic pain. Method The participants were 67 (mean age = 42.67) injured workers who participated in a six-week RTW program. Assessments of the participants on various measures were conducted before and during the program, and at the end of the follow-up period (3 months post-program). Results The overall RTW rate of the participants was 65.7%. Most importantly, the participants’ RTW outcomes were found to be significantly predicted by their readiness for RTW (action) at the baseline. In the third week, their RTW was significantly predicted by their confidence in returning to work and their readiness for RTW (action). By the sixth week, their RTW outcomes were predicted by their readiness for RTW (pre-contemplation). Conclusion The results enable us to better understand the stage-of-change factors that might influence injured workers’ resumption of a productive work role and the rehabilitation process of RTW.

The Pain Medication Questionnaire (PMQ), initially developed by Adams et al. (J Pain Symptom Manage. 2004; 27: 440-459), is a 26-item self-report assessment to screen for opioid-medication misuse. The PMQ has demonstrated good reliability and validity, and was predictive of early termination from treatment and identified patients who demonstrated maximal benefit from interdisciplinary treatment (Holmes et al. Pain Pract. 2006; 6: 74-88). This study was designed to further evaluate the validity of the PMQ by exploring whether the initial PMQ score would accurately predict the development of aberrant opioid-medication use behaviors relative to specific behavioral indices (ie, request for early refills, use of a medication agreement) and a physician rating of medication misuse behaviors. Patients were grouped according to the initial score on the PMQ based on the median score of 25. Patients with higher PMQ (H-PMQ) scores reported greater levels of perceived disability and decreased physical and mental functioning. Similar to earlier studies, total scores on the PMQ were moderately correlated with initial measures of physical and psychosocial functioning, and observed problematic medication use behaviors observed by physicians during evaluation. Furthermore, excessively high PMQ scores (≥30) were significantly associated with the need to use a medication agreement or requests for early refills. Five patients were identified from the H-PMQ group who demonstrated problematic opioid-medication use that fell outside of the realm of just early refill requests. Thus, although a PMQ total score ≥25 is indicative of problematic use, a score ≥30 suggests that a patient should be closely monitored when prescribed an opioid medication. Overall, this study again demonstrated that a patient’s self-report is significantly correlated with problematic behaviors observed by physicians. Therefore, when utilized in a busy clinic setting, the PMQ will aide in the identification of specific problematic behaviors and beliefs at the outset of treatment that may hinder successful treatment of a patient’s pain condition.

Background: Musculoskeletal pain disorders are the most prevalent, costly, disabling, and commonly researched conditions in the workplace, yet the development of overarching conceptual models of return to work (RTW) in these conditions has been lagging. Method: A critical review of the literature was performed using multiple medical and health search engines in order to provide an evaluation of the evolution and the state of the art of health and disability models with a focus on specific models of RTW. Results: The main tenets, implications for diagnosis, treatment, and disability compensation, are the key perspectives analyzed for the following specific models of RTW: biomedical, psychosocial, forensic, ecological/case management, biopsychosocial, and two more recent models developed by the Institute of Medicine and the World Health Organization, respectively. Conclusions: Future development of models that are truly transdisciplinary, and address temporal and multidimensional aspects of occupational disability, remains a goal.

Background The authors conducted a randomized clinical trial to evaluate the cost-effectiveness of a biopsychosocial intervention with patients who are at high risk (HR) of progressing from acute to chronic TMD-related pain. Methods The authors classified 96 patients with acute TMD (less than six months' duration) as HR according to a predictive algorithm and randomized them into an early intervention (EI) or a nonintervention (NI) group. The NI group received a biopsychosocial treatment that included cognitive behavioral skills training and biofeedback. Both groups were followed up for one year. The authors collected TMD cost data throughout the year. Results The authors found that the EI group spent significantly fewer jaw-related health care dollars, relative to the NI group, from intake to the one-year follow-up. Conclusion and Clinical Implications The reduced jaw-related health care expenditures for patients in the EI group compared with expenditures for patients in the NI group at one year suggest that an early biopsychosocial intervention is a cost-effective measure in dealing with often unnecessarily costly TMD-related pain.

Recent efforts have identified psychosocial and biological factors influencing the pathogenesis of chronic pain. The present study attempted to identify whether these two variables interact and, in turn, represent an underlying mechanism in the transition from acute to chronic pain. Salivary cortisol samples were collected upon waking up and 20 minutes later daily for 2 weeks from acute pain patients. Analyses revealed a direct relationship between pain severity and hypothalamic–pituitary–adrenocortical activity for temporomandibular disorder, and a negative relationship between these variables for low back pain populations. These results highlight the possible interaction between neuroendocrine and psychological factors to increase the risk for chronic pain.

Background Kinesiophobia is an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury. The Tampa Scale for kinesiophobia (TSK) is a patient-reported outcome (PRO) measure designed to help identify kinesiophobia. The original version of the TSK had 17 items. A 13-item version was later found to have better psychometric properties and was used in the present study. Although the TSK-13 has been widely studied, one shortcoming is the lack of clinically meaningful score categories. The objective of the present study was to develop severity levels to help aid clinical interpretation of TSK-13 scores. Methods After creating four proposed TSK-13 severity ranges, a sample of chronic musculoskeletal pain disorder (CMPD) patients (N = 912) was grouped by TSK-13 scores into: Subclinical (score = 13–22, n = 100; 11%), mild (23–32, n = 271; 30%), moderate (33–42, n = 385; 42%) and severe (43–52, n = 156; 17%) levels of kinesiophobia. These severity groups were then validated by their associations with objective lifting performance (presumed to be highly related to one's level of kinesiophobia) and other PRO questionnaires, assessing depressive symptoms, pain intensity, pain-related anxiety and perceived disability, which all have been shown in previous research to be associated with TSK scores. Results The TSK-13 severity level groups were significantly associated with all lifting performance and PRO variables (p

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

Pain-related fear avoidance (FA), a common problem for patients with painful medical conditions, involves pain-related catastrophizing cognitions, hypervigilance, and avoidance behaviors, which can ultimately lead to decreased functioning, depression, and disability. Several patient-reported instruments have been developed to measure FA, but they have been criticized for limited construct validity, inadequate item specificity, lack of cutoff scores, and missing important FA components. The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Psychometric evaluation of the FACS found high internal consistency (α = 0.92) and high test/retest reliability (r = 0.90-0.94, P

In this paper, we present an Adaptive Multimodal Dialogue System for Depressive and Anxiety Disorders Screening (DADS). The system interacts with the user through verbal and non-verbal communication to elicit the information needed to make referrals and recommendations for depressive and anxiety disorders while encouraging the user and keeping them calm. We designed the problem using interconnected Markov Decision Processes using sub-goals to deal with the large state space. We present the problem formulation and the experimental procedure for the training data collection and the system training following the methodology of Wizard-of-Oz experiments.

The present study was undertaken to compare emotional distress and functional ability between two common pain populations—acute jaw pain (JAW; n = 135) and acute low back pain (LB; n = 71). Patient groups were evaluated and compared on a variety of biopsychosocial measures, including the Beck Depression Inventory (BDI), Multidimensional Pain Inventory (MPI), Characteristic Pain Intensity (CPI), and Ways of Coping Questionnaire. Specific diagnoses were assessed using the Structured Clinical Interview of the Diagnostic and Statistical Manual (DSM-IV)—I and II, and rates of Axis I and II diagnoses in these groups were further compared to base rates in the general population. Additionally, medication usage was evaluated to determine group differences. Results revealed that JAW patients had lower BDI and CPI scores, as well as a higher level of functioning on the Global Assessment of Functioning assessed by the DSM-IV. Both acute pain groups also had significantly more Axis I and II disorders than the general population. Additionally, it was found that the JAW group used more benzodiazepines, while the LB group used more schedule II narcotics. A logistic regression model created from these variables found a six-factor model, composed of the CPI, MPI coping style anomalous, Ways of Coping problem-solving, Global Assessment of Functioning, anxiety disorders, and Cluster C personality disorder diagnoses, that differentiated the JAW from the LB group. Overall, these findings suggest that the differences identified between these two groups should be considered in developing tailored treatments for individuals with acute low back and jaw pain.

Study design Prospective study on predicting psychopathology in chronic occupational spinal disorders (COSDs). Objective To assess prevalence of specific profiles on the Minnesota Multiphasic Personality Inventory (MMPI) and their ability to predict psychopathology in a COSD cohort. Summary of background data In the relatively small number of COSDs that develop chronic pain and disability, the MMPI-2 has been an important part of the psychosocial assessment. Certain profiles have been thought to have a high prevalence in COSD. They have also been widely popularized as predicting certain treatment outcomes, and have often been used to "screen" surgical and rehabilitation candidates. Method Of an initial cohort of 1,489 consecutive COSD patients completing a valid prerehabilitation MMPI-2, 1,185 patients (79.6%) were classifiable into one of four MMPI profile groups. A new Disability Profile (DP) group was identified, which was the most common profile. Patients attended a 5- to 7-week interdisciplinary rehabilitation program. They completed a psychosocial assessment battery, and a Structured Clinical Interview for DSM IV diagnosis (SCID-I and II) was administered as the "gold standard" for defining psychopathology. One year postrehabilitation, a structured clinical interview assessed socioeconomic outcomes. Results A previously unrecognized MMPI profile, now termed the DP, was found to have a prevalence of 53.2% of the whole group, and 66.9% of those with "classifiable" MMPI profiles in this large population of COSD patients. Only 6.9% of subjects had normal profiles (NP), while only 19.5% had profiles previously thought to occur commonly in this population. NP patients were twice as likely to retain work 1 year after treatment than the 3 abnormal MMPI groups combined. The DP group was 14 times more;1 likely to have an Axis I diagnosis (such as depression or anxiety) than the NP group, and was also almost 5 times more likely have an Axis II personality disorder diagnosis. Conclusions The prevalence of commonly cited MMPI profiles, often used for presurgical or chronic pain screening in this population, is relatively small. The prevalence of four or more elevations (DP), however, is large, representing two thirds of patients demonstrating any classifiable MMPI pattern. The DP group showed extremely high levels of associated psychopathology, which raises "red flags" to the surgeon likely to operate on such patients, or the interdisciplinary pain team. Screening COSD patients with the MMPI-2 may be effective in identifying psychopathology, but only if the physician is aware that the DP is commonplace and significant.

Objectives: The present retrospective case review study sought to analyze the cost-utility, expressed in cost/quality-adjusted life years (QALY), of current chronic spinal pain treatments. In addition, it expands upon previously published data evaluating the efficacy of interdisciplinary pain management in relation to medication management. Methods: A recently developed algorithm was used to calculate QALYs using SF-36, v. 1 responses for 121 patients receiving treatment for chronic spinal pain at a pain rehabilitation center. Treatment groups evaluated were: (1) interdisciplinary program completers who received medication management and supplementary anesthetic procedures; (2) interdisciplinary program completers receiving medication management but not anesthetic procedures; (3) patients receiving medication management alone; and (4) patients receiving medication management with supplemental anesthetic procedures. Assessments were conducted at pretreatment and 6 months after the initiation of treatment. Results: One-way analyses of covariance indicated that patients who participated in an interdisciplinary pain management program, which included medication management, psychotherapy, group education, and physical therapy, reported significantly less impairment in daily activities of living, less subjective experience of pain, and a higher quality of life and more preferred health state at the completion of their treatment phase, relative to patients receiving medication with or without anesthetic procedures. In addition, improvements in all outcome measures between pretreatment and posttreatment were significantly greater for those patients completing the interdisciplinary component of treatment. Cost-utility analyses revealed that the interdisciplinary treatment alone group was cost-saving, relative to the medication and procedures alternative, suggesting the former modality was both less costly and more effective than the latter. Discussion: Average cost-utility ratios for both interdisciplinary treatment groups, ranging from $57,627/QALY to $75,885/ QALY, were within established cost-effective parameters ($20,000 to $100,000/QALY, generally considered a good value), whereas cost-utility ratios for the standard care treatment groups were not interpretable because of a decrease in QALYs from pretreatment to posttreatment.

Dysregulation of the hypothalamic–pituitary–adrenocortical (HPA) axis is believed to be a valid biological marker of stress. This study evaluating changes in patients with temporomandibular disorders (TMD) and low back pain (LBP) to determine whether dysregulation of this system represents a marker for chronicity. Salivary cortisol samples were collected from 78 patients (TMD = 41, LBP = 37) upon waking up and 20 minutes later daily for 2 weeks. High-risk patients for chronic pain had different overall cortisol levels versus low-risk patients. High-risk patients exhibited greater variability in terms of cortisol secretion compared with low-risk patients, F(1, 1,243) = 17.73, p