1999 North American Spine Society Presidential Address. The millennium threshold: is it the economy, stupid?
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Delivery of Health Care↗
Biomedical subjects
T G Mayer
Publications and source records attributed to T G Mayer.
Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful?
OBJECTIVES: To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises. DESIGN: Preliminary 2-part study: (1) presentation of a technique for, identifying lumbar segmental rigidity based on physical observation of the spine's lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises. SETTING: An outpatient tertiary rehabilitation facility providing interdisciplinary functional restoration for chronic disabling work-related spinal disorders. PATIENTS: Chronically disabled patients with lumbar spinal disorder (n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2. INTERVENTIONS: Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1-4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected. MAIN OUTCOME MEASURES: Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically. RESULTS: Patients' mobility improved significantly (p < .01-.0001) across all 4 motions. A large majority (71%-97%) of individuals improved on motion. According to self-reports made over the postinjection period, most patients improved their disability (83%) and pain intensity (63%) ratings. CONCLUSIONS: A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improvements in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticosteroid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improvements cannot be determined from the present study, but warrants future investigation.
Adult↗
Outcomes of disabling cervical spine disorders in compensation injuries. A prospective comparison to tertiary rehabilitation response for chronic lumbar spinal disorders.
STUDY DESIGN: A prospective, longitudinal cohort study assessing quantitative socioeconomic outcomes of tertiary rehabilitation for chronically disabled patients with cervical spinal disorders compared with those with more common chronic lumbar spinal disorders. OBJECTIVES: To assess 1-year socioeconomic outcomes of a worst-case cohort of consecutive patients with chronic cervical spinal disorders compared with those of patients with lumbar spinal disorders and to assess differences in an array of variables between those patients who reported any period of work during the posttreatment year and those who did not. SUMMARY OF BACKGROUND DATA: Few investigators have evaluated outcomes in patients with cervical spinal disorders. None have specifically studied distinctions in socioeconomic outcomes in patients with chronic cervical spinal disorders and in patients with other spinal disorders. Reports of pain are noted to persist in a high percentage of patients with whiplash receiving compensation even 10 years after injury, but the status of work, use of health care resources, financial disputes, or recurrent injury are unknown. METHODS: A cohort of consecutive chronically disabled patients with spinal disorders (N = 1198) was assessed for prospectively collected demographic, self-report, and physical performance data. A subset of patients (n = 421) with work-related cervical spinal disorders was compared with a group with various lumbar spinal disorders (n = 777). A structured clinical interview was administered 1 year after patients entered an interdisciplinary functional restoration program. RESULTS: High rates of return to work and continuation of work were recorded in the cervical and lumbar spinal disorder groups, with low rates of recurrent injury, new surgery in the injured area, and use of health care resources. There were no statistically significant differences between the groups. Multivariate analyses showed several variables that differentiated between those patients who had any reported period of work during the post-treatment year versus those who did not in the cervical and the lumbar spinal disorder groups. CONCLUSIONS: This first large cohort study of outcomes in chronically disabled patients with work-related cervical spinal disorder produced results similar to those found in tertiary functional restoration rehabilitation in chronic lumbar spinal disorders. In spite of poor outcomes reported in the literature for similar cervical and lumbar spinal disorders in patients receiving workers' compensation for disability, successful outcomes can be anticipated after effective rehabilitation, regardless of response to prerehabilitation treatment.
Activities of Daily Living↗
Rehabilitation: what do we do with the chronic patient?
Neurologists are often called on to see patients who have low back pain presenting with significant chronicity and disabling pain. Even in situations of chronic low back pain, it has been estimated that a structural diagnosis is made only 60% of the time. Even when a physical diagnosis is made in these cases, it may be irrelevant to the primary causes of persistent pain and disability. This article is designed to point out that, when nonstructural factors are adequately rehabilitated, even in a worst-case occupational injury cohort, remarkable outcomes can be anticipated irrespective of the structural pathology, patient age, or postoperative impairment.
Disability Evaluation↗
Outcomes comparison of treatment for chronic disabling work-related upper-extremity disorders and spinal disorders.
Since 1986, the percentage of upper-extremity musculoskeletal disorders (UEMSDs) has increased from 1% to 4% of all occupational injury claims, while the average total medical and compensation cost is 80% higher than the average of all other claims. Because chronic disability leads to the highest cost, systematic evaluation of this growing occupational condition is needed. We performed a prospective case-series cohort study of patients (n = 163) with UEMSDs, compared with a matched group of spinal disorder (SD) patients (n = 163) treated with the same protocol. UEMSD patients were subclassified as those with one or more neuropathic diagnoses or those with non-neuropathic diagnoses. The neuropathic UEMSD subgroup had the poorest outcomes, with significantly higher surgery rates, higher health care utilization rates, and lower work retention when compared with the SD group. Rehabilitation outcomes for UEMSDs are similar to those for SDs. However, neuropathic-diagnosis patients are at risk for high-cost injuries and/or poorer prognoses.
Adult↗
Should extended disability be an exclusion criterion for tertiary rehabilitation? Socioeconomic outcomes of early versus late functional restoration in compensation spinal disorders.
STUDY DESIGN: A prospective cohort design with two groups of patients representing short-term or long-term disability (n = 497) who were selected from a larger cohort (n = 938) of consecutively treated spinal disorder patients with chronic compensation injuries. OBJECTIVES: To prospectively evaluate the impact of length of spinal disability on socioeconomic outcomes of medically directed rehabilitation. SUMMARY OF BACKGROUND DATA: Despite an increasing tendency of managed care organizations to limit rehabilitation services for disabled workers with chronic spinal disorders, there has been a surprising lack of prospective research evaluating the impact of length of disability on objective socioeconomic treatment outcomes. Although only approximately 10% of all patients with spinal disorders are disabled beyond 4 months, they account for nearly 80% of all workers' compensation expenditures. Little is known about whether relatively early intervention improves outcomes after chronicity has been established or whether any predictors distinguish between these groups. METHODS: Two comparison groups of functional restoration tertiary treatment graduates were identified from the same community referral pool. The "long-term disabled" group involved a minimum of 18 months of disability (n = 252). This group was compared with a "short-term disabled" group (n = 245), no more than 8 months since injury, but chronic based on a minimum of 4 months after injury. The long-term disabled group showed significantly higher rates of pretreatment surgery than the short-term disabled group (P < 0.001). All patients were evaluated prospectively with specific physical, psychological, and occupational measurements. They also underwent a structured interview 1 year after treatment evaluating work status, health care use, and recurrent injury. RESULTS: The short-term disabled group showed statistically higher return to work (P < 0.001) and work retention (P < 0.05) relative to the long-term disabled group. However, health care use and recurrent lost time injury claims were low in both groups and did not differ significantly. No predictors of outcome were found among the prospectively collected physical performance or psychosocial variables. CONCLUSIONS: This study suggests that early tertiary nonoperative care, once patients with chronic spinal disorders are identified as having potentially high-cost chronic pain and disability, is efficacious in achieving goals of better work return and work retention. Such early rehabilitation may also prevent significant indemnity expense, as well as some late surgical interventions sought by progressively more desperate patients. However, individuals with long-term disability achieve respectable work return and retention rates, while faring no worse on other socioeconomic outcomes that represent major "cost drivers" to the workers' compensation system. Early intervention is not a panacea or a necessary condition for the successful rehabilitation of workers with disabling chronic spinal disorders.
Adult↗
Cognitive predictors of depression in chronic low back pain: toward an inclusive model.
Previous research has linked cognitive distortion, perceived interference with instrumental activities, and self-control to depression in chronic pain patients, though to date no study has examined all three variables concurrently. The present study investigated these three cognitive mediators in a comprehensive model to determine whether each variable represented an independent dimension in the pain-depression relationship. Results in a sample of 74 chronic low back pain patients revealed that a regression model containing all three cognitive variables had the strongest association with depressive symptoms. Consistent with a cognitive mediational model of the pain-depression relation, when self-control, cognitive distortion, and interference were held constant, pain and disability did not have a significant association with self-reported depression. These findings indicate that a comprehensive cognitive model of depression and chronic pain will need to incorporate all three cognitive variables.
Activities of Daily Living↗
Pain management in orthopedics.
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Humans↗
Early childhood abuse in chronic spinal disorder patients. A major barrier to treatment success.
STUDY DESIGN: Prevalence rates of childhood abuse, socioeconomic outcome data, and levels of psychopathology were evaluated for graduates of a functional restoration program for chronically disabled spinal disorder patients in a workers' compensation environment. OBJECTIVES: To describe psychological profiles and evaluate treatment outcomes for chronic spinal disorder patients with a history of childhood abuse. SUMMARY OF BACKGROUND DATA: There is increasing evidence to indicate that traumatic childhood events may leave adult survivors psychologically distressed. It is possible that because of this level of psychological distress, chronic spinal disorder patients may be unable to return to a productive life-style after completing a rehabilitation program. METHODS: Two hundred ninety-nine male and 174 female patients from a cohort (N = 473) of consecutive graduates of a functional restoration program were assessed for the presence of childhood abuse by structured interview. Prevalence rates were compared with a comparison group of subjects without a history of chronic spinal disorder disability. In addition, the 79 chronic spinal disorder patients with a history of childhood abuse were compared on several socioeconomic outcomes with a matched group of workers with chronic spinal disorders without a history of childhood abuse. Psychopathology in the two groups of chronic spinal disorder patients was evaluated using Diagnostic and Statistical Manual of Mental Disorders criteria, the Minnesota Multiphasic Personality Inventory, and Symptom Checklist-90-Revised. RESULTS: A history of childhood abuse was found to be related to a higher level of psychological distress in chronic spinal disorder patients. In addition, poorer socioeconomic outcomes, such as lower work retention rates and higher postrehabilitation operations to the same area of injury, were found in the chronic spinal disorder patients with a history of childhood abuse compared with workers without a history of childhood abuse in whom chronic spinal disorders developed. CONCLUSIONS: These results demonstrate that although a history of childhood abuse is associated with greater psychosocial disturbances in chronically disabled spinal disorder patients, such disturbances do not interfere with an initial positive response to an effective tertiary rehabilitation program such as functional restoration. However, a history of childhood abuse may be related to poorer socioeconomic outcomes after discharge from rehabilitation programs. Additional treatment options may be needed for these patients.
Adolescent↗
Spinal range of motion. Accuracy and sources of error with inclinometric measurement.
STUDY DESIGN: A quantitative construct assessing accuracy and component analysis of sources of error rather than reliability coefficients was tested prospectively in human performance measurements of lumbar spine motion using a cohort of healthy individuals. OBJECTIVES: To evaluate the accuracy of lumbar spine sagittal motion measurements using a computerized inclinometer, which involved progressive analysis of sources of error to identify the most problematic sub-components of the measurement process and device. SUMMARY OF BACKGROUND DATA: Many previous studies have described the reliability of inclinometric lumbar motion measurement techniques, but with inconsistent analysis about sources of error to explain identified variability. Similar deficiencies exist in identifying sources of error leading to variability for other human performance measurements (e.g., strength, endurance. lifting capacity, etc.). Yet, range of motion has important clinical applications in monitoring progress and assessing temporary and/or permanent impairment. This makes it especially important for clinicians to be able to recognize and correct factors that limit accurate measurements affecting clinical utility. METHODS: A computerized inclinometer was used for measuring the sagittal lumbar mobility of 38 healthy individuals after bench testing the device itself for device error. The human performance test conditions were: 1) initial test on study participants by untrained test administrators with no control of human performance or procedural variables, 2) identical tests by procedurally trained test administrators controlling human performance variability by monitoring and controlling total motion, and 3) test by procedurally trained test administrators without controlling for human performance variability. RESULTS: The accuracy of the methodology progressively was degraded by the various sources of error. Device error was negligible relative to error associated with the test process itself. Lack of test administrator training and the magnitude of the measured quantity were the major factors in test degradation. Combined (gross) lumbar flexion was the most accurate measure (worst case > 95% accuracy for overall test conditions), whereas pelvic extension was the least accurate (worst case > 36%). CONCLUSIONS: Clinical utility of lumbar spine sagittal motion measurement is highly sensitive to test administrator training to bridge pitfalls to measurement accuracy (bony landmarks, "rocking" of inclinometer on sacrum, etc.). Magnitude of the measurement is another important accuracy factor because absolute error tends to remain relatively constant. Device accuracy is usually an insignificant component of overall test accuracy. Analysis of human performance measurements, such as spinal range of motion, may be facilitated by physics-based assessment of accuracy and procedural error in providing more sophisticated analysis than is customarily accessible through reliability coefficients. Previous studies often failed to recognize correctable procedural errors, rarely addressed them, and almost never quantitated them.
Adult↗
A prospective study of Waddell signs in patients with chronic low back pain. When they may not be predictive.
STUDY DESIGN: Analysis of the treatment-outcome predictive power of Waddell signs by evaluating them before and after functional restoration, with assessment of 1-year socioeconomic outcomes. OBJECTIVE: To evaluate the presence of Waddell nonorganic signs in a group of patients with chronic low back pain presenting for functional restoration, and to determine whether they were predictive of treatment success of failure. SUMMARY OF BACKGROUND DATA: Waddell has described "nonorganic" physical signs in patients with chronic low back pain indicative of somatization. Other researchers have correlated high Waddell scores with psychosocial barriers that required additional consultation, and have suggested that diminution of a Waddell score during physical rehabilitation is predictive of subsequent therapeutic success. METHODS: Total positive Waddell signs score and individual sign scores were assessed at initial presentation for functional restoration treatment and at discharge in a group of 50 patients with chronic low back pain (average length of disability = 17.9 months; average age = 38.5 years). Patients were then tracked and assessed with a 1-year follow-up structured interview to evaluate outcome variables such as return to work, work retention, re-injury rate, health utilization, and subsequent surgery. RESULTS: Statistical analyses of these data revealed no significant associations between Waddell total positive score or changes in score and therapeutic success as measured by any of the behavioral outcomes such as return to work. Also, no predictive value was found for the individual positive signs of their changes and therapeutic success. CONCLUSIONS: Although positive Waddell signs have been found to be predictive in patients with short-term chronic low back pain, the current results suggest that, in patients who have longer duration of pain and who undergo a comprehensive functional restoration program, these signs are not significantly prognostic. Because functional restoration is an interdiscipilinary approach that effectively manages somatization complaints in a consistent manner by all treatment personnel, such complaints do not create any major barriers to recovery. Therefore, although Waddell signs may be predictive of treatment outcome in less intensive rehabilitation programs, they do not provide any predictive power in a comprehensive functional restoration program, which has a basic goal of managing barriers to recovery in a clinically efficacious manner.
Adult↗
Tricuspid papillary muscle rupture after coronary artery bypass surgery: identification by transesophageal echocardiography.
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Aged↗
Occupational disorders and the management of chronic pain.
Chronic pain affects a small proportion of patients with an occupational injury but can result in astronomical costs for future medical care, indemnity, and social service utilization. To provide adequate treatment, medical practitioners must make a conceptual shift from the disease-intervention model to visualizing chronic pain as a multifactorial syndrome with alterable components. Focusing on deconditioning and disability provides a means to subjective and objective improvement for these patients and gives a better measure of therapeutic success.
Chronic Disease↗
The dominant role of psychosocial risk factors in the development of chronic low back pain disability.
STUDY DESIGN: An inception cohort design was used in which 421 patients were evaluated systematically with a standard battery of psychosocial assessment tests (Structured Interview for DSM-III-R Diagnosis, Minnesota Multiphasic Personality Inventory, and Million Visual Pain Analog Scale) within 6 weeks of acute back pain onset. OBJECTIVES: The present study evaluated the predictive power of a comprehensive assessment of psychosocial and personality factors in identifying acute low back pain patients who subsequently develop chronic pain disability problems (as measured by job-work status at 1-year follow-up evaluation). SUMMARY OF BACKGROUND DATA: There has been a relative paucity of prospective research in the United States comprehensively evaluating potential psychosocial risk factors that are associated with those injured workers who subsequently fail to return to work and productivity after 1 year because of low back pain disability. Such research has been quite limited because of the time and cost involved in conducting prospective studies. METHODS: All study patients were symptomatic with lumbar pain syndrome for no more than 6 weeks. These acute patients were tracked every 3 months, culminating in a structured telephone interview being conducted 1 year after the initial evaluation to document return-to-work status. RESULTS: Logistic regression analyses, conducted to differentiate between patients who were back at work after 1 year versus patients who were not because of the original back injury, revealed the importance of three psychosocial measures: self-reported pain and disability, scores on Scale 3 of the Minnesota Multiphasic Personality Inventory, and workers' compensation and personal injury insurance status. The model generated correctly classified 90.7% of the cases. Results revealed that major psychopathology, such as depression and substance abuse, did not precede or cause the development chronic pain disability. CONCLUSIONS: These results show the presence of a robust "psychosocial disability factor" that is associated with those injured workers who are likely to develop chronic low back pain disability problems. Based on these data, a statistical algorithm has been generated that can identify those acute patients who will require early intervention to prevent the development of chronic disability. The second major result is that preinjury or concomitant psychopathology does not appear to predispose patients to chronic pain disability, although high rates of psychopathology have been shown in chronic low back pain. Future research should be directed at emotional vulnerability and psychosocial events in the period after the injury that may lead to chronicity.
Adult↗
Spine rehabilitation. Secondary and tertiary nonoperative care.
To achieve desirable behavioral outcomes, physicians treating spinal pain patients should be aware of appropriate algorithms for conservative care. Lower cost secondary rehabilitation can be effective if deconditioning, severity of physical symptoms, surgical equivocation, or psychosocial barriers to recovery are not present. Patients who have extended disability in excess of 6 months, recognized psychosocial barriers (depression, substance abuse, personality disorders, secondary gain), or severe deconditioning have a better prognosis with tertiary care.
Humans↗
Physical progress and residual impairment quantification after functional restoration. Part III: Isokinetic and isoinertial lifting capacity.
There is currently a great need to expand the knowledge base of various functional capacity measures used in the rehabilitation of chronic low back pain (CLBP) patients. In the current study, the functional performance of lifting capacity differences among four separate CLBP patient groups were examined by using standardized isokinetic and isoinertial lifting performance measurements. One hundred ninety-three consecutive patients were assessed at three separate points in time: at initial evaluation (PRE), at admission to the intensive 3-week phase of a functional restoration program (ADM), and after program discharge and follow up (FU) (an average of 12 weeks later). Group 1 (n = 26) consisted of postdiscectomy CLBP men; Group 2 (n = 91) consisted of nonsurgical CLBP men; Group 3 (n = 17) consisted of postdiscectomy women; and Group 4 (n = 59) consisted of nonsurgical women. Results comparing admission scores to postdischarge scores revealed that all four groups demonstrated a significant increase (P < 0.01) in Liftask and progressive isoinertial lifting evaluation performance. Increases in performance were virtually identical for nonoperative and postoperative patients, with postdiscectomy men and women actually achieving peak isokinetic lifting forces higher than unoperated patients at the program's conclusion. This achievement in human performance was not found for the progressive isoinertial lifting evaluation test. Overall, these findings illustrate the utility of quantitative functional capacity measures, and provides objective evidence of the gains achieved by the patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Psychopathology and the rehabilitation of patients with chronic low back pain disability.
Recent research has clearly demonstrated the important role that psychopathology and other psychosocial factors can play in chronic low back pain disability (CLBPD). The purpose of this study was to evaluate whether diagnosed psychopathology is a significant limiting factor in the successful rehabilitation of patients with CLBPD. One hundred fifty-two CLBPD patients (97 men, 55 women) were given a structured psychiatric interview for official DSM-III-R diagnosis of psychopathology upon entering an intensive 3-week functional restoration treatment program. All patients were assessed for the presence of Axis I clinical disorders and Axis II personality disorders. They were subsequently tracked for 1 year after program completion, with treatment outcome being defined as return-to-work status at this 1-year time period. Results demonstrated that, though more than 90% of patients obtained at least one Axis I diagnosis, and more than 50% obtained at least one Axis II diagnosis, neither type nor degree of psychopathology were significantly predictive of a patient's ability to successfully return to work. These prospective study results suggest that if a treatment program is structured to appropriately manage psychopathology, as is the case of an intensive functional restoration program, then psychopathology does not have to interfere with successful treatment outcome.
Adult↗
Psychiatric illness and chronic low-back pain. The mind and the spine--which goes first?
Two hundred chronic low-back pain patients entering a functional restoration program were assessed for current and lifetime psychiatric syndromes using a structured psychiatric interview to make DSM-III-R diagnoses. Results showed that, even when the somewhat controversial category of somatoform pain disorder was excluded, 77% of patients met lifetime diagnostic criteria and 59% demonstrated current symptoms for at least one psychiatric diagnosis. The most common of these were major depression, substance abuse, and anxiety disorders. In addition, 51% met criteria for at least one personality disorder. All of the prevalence rates were significantly greater than the base rate for the general population. Finally, and most importantly, of these patients with a positive lifetime history for psychiatric syndromes, 54% of those with depression, 94% of those with substance abuse, and 95% of those with anxiety disorders had experienced these syndromes before the onset of their back pain. These are the first results to indicate that certain psychiatric syndromes appear to precede chronic low-back pain (substance abuse and anxiety disorders), whereas others (specifically, major depression) develop either before or after the onset of chronic low-back pain. Such findings substantially add to our understanding of causality and predisposition in the relationship between psychiatric disorders and chronic low-back pain. They also clearly reveal that clinicians should be aware of potentially high rates of emotional distress syndromes in chronic low-back pain and enlist mental health professionals to help maximize treatment outcomes.
Anxiety Disorders↗