Abstracts

Introduction: There are controversial data in the literature concerning the permanent and partial disability outcome of patients with sciatica. In Switzerland disability due to either diseases or injuries are compensated through the Swiss Federal Disability Insurance (SFDI). Applications cannot be submitted until the patient has been unable to work for 1 year from onset of work absenteeism. The aim of this study was to explore the occurrence of permanent or partial disability among patients with severe sciatica in a previously published cohort of patients with severe treated sciatica.

Method: Between 1993 and 1998 we conducted a prospective study of 82 (mean age 43+ 10.3, 66% men) patients admitted to the hospital for conservative standardized management of acute severe sciatica of radicular origin. The patients were followed for one year (1). In July 1999 a subgroup of 24 patients (those with duration of sciatica pain between 1 and 21 days at the time of their admission to hospital) were evaluated again after a mean duration of follow-up of 46.3 months. At this time the subjects were asked about their professional activities and application for disability pension. In May 2000 the insurance was approached in order to know how many of the patients in the cohort (n=82) had applied for a disability pension. Data was collected in terms of acceptance or refusal from the insurance as well as the percentage of disability covered by permanent or partial disability.

Results: Among the 24 subjects evaluated in July 1999, 2Ê (8%) had submitted applications for disability pension according to their own responses whilst 10 patients (42%) have modified in different ways their work or activity after their treatment for acute severe sciatica. In this subgroup, patients who had surgery for disk herniation reported worse perceivedÊ ãfunctionalä outcome than those who did not require surgery. This was not a randomized controlled study designed to evaluate the role of surgery; therefore this data has to be interpreted with great caution. In May 2000, we obtained information from the insurance about 80 out of the 82 subjects of our cohort (98% response rate). Of those, 19 (24%) had already applied for disability pensions. In all but 5 cases a decision had already been made by the insurance, who accepted 11 cases and rejected 3 applications. Among the accepted cases, none was declared disabled less than 50% and in two cases the maximal disability of 100% was recognized. Disability was approved at some level for 68% of the applicants.

Summary: Patients with severe treated sciatica are at high risk for partial or permanent disability in Switzerland. One out of four patients were classified as disabled at some level. Possibly this could be due to the insurance system itself, however it is probably more due to the disabling nature of diagnosis. Further studies need to elucidate this question.

References.

BalaguŽ F, Nordin M, Sheikzadeh A, et al: Recovery of Severe Sciatica. Spine 24 (23): 2516-2524, 1999. BalaguŽ F, Nordin M, Sheikzadeh A, et al: Recovery of Impaired Muscle Function in Severe Sciatica. European Spine, in press.

F. BalaguŽ¹, A. Sheikhzadeh², M. Nordin ²

¹Department of Rheumatology, Physical Medicine and Rehabilitation, Cantonal Hospital, Fribourg, Switzerland

²Occupational and Industrial Orthopaedic Center, Hospital for Joint Diseases, Mount Sinai NYU Health, New York, NY, USA

Corresponding address:

Federico BalaguŽ, MD
Hopital Cantonal de Fribourg
Department of Rheumatology,
Physical Medicine and Rehabilitation,
1708 Fribourg
Switzerland

Tel +41 26 426 7383
Fax +41 26 426 7387

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Clinical Neurophysiology and Back Pain

Aleksandar Beric, MD, DSc

Several clinical neurophysiology techniques have been used in assessment of back pain. Some have been used in routine investigations and some have been used as a research tool.

Nerve conduction (NC) studies are used routinely in a diagnosis of neurologic disorders that may exhibit back pain as one of its symptoms. More often NC studies are used to diagnose abnormalities of axons (axonopathies) or abnormalities of a myelin sheath enclosing the axon (demyelinating disorders). Both motor and sensory NC can be assessed. Sensory nerve action potentials (SNAPs) are particularly useful in localization of a nerve lesion to a root level (radiculopathy) or more distally (plexus lesion). As a sensory ganglion is located outside the spinal canal and more peripherally than the root, intact SNAP in a proximal nerve lesion/dysfunction is practically synonymous with a radiculopathy.

Needle electromyography (EMG) is a very sensitive technique for detecting any neurogenic or myogenic process. By appropriate muscle sampling at appropriate intervals it can localize a nerve lesion (root, plexus, and peripheral nerve) and assess dynamics of the lesion progression or a stage of its repair-regeneration. It is a technique of choice in excluding a significant root lesion as a cause of back pain. This technique, however, samples only a portion of muscle fibers and corresponding axons and motor neuron cells in the spinal cord (motor units) and therefore can not reliably sample a representative functional activity of the trunk and back muscle groups.

Surface or wire EMG is a more appropriate technique for sampling a large and complex muscle function under different conditions. Surface and wire EMGs are not routinely used in diagnostic work-ups of back pain because of a difficulty in their standardization. Their advantage is in multi channel dynamic recordings. A disadvantage of the surface EMG recording is a lack of a required specificity to the exact source of the activity. The fine wire recording disadvantage is due to its limited sampling that may not be representative of the intended functional muscle group assessment.

A number of reflex techniques have been used in back pain research. From the recording of tendon reflexes (T-waves), Hoffman reflexes (H-wave), to pseudo reflex activity (F-wave) and complex withdrawal reflexes. All these reflex testings either assess the excitability of the corresponding spinal cord segments or add in localization of the nerve lesion above and beyond the standard NC studies.

Somatosensory evoked potential (SEP) technique is useful in elderly patients to confirm a spinal stenosis, otherwise it is an insensitive technique for isolated root lesions. It can be abnormal in suprasegmental lesions (spinal cord dysfunction, demyelinating disease-multiple sclerosis). It is invariably normal in back pain patients.

Assessment of small fiber function is a routine test in the diagnosis of the small fiber neuropathies. It is capable of assessing the A delta (small myelinated fibers) and C fiber (unmyelinated fibers) function in peripheral nerve lesion/dysfunction conditions. It is, however, not useful in assessment of back pain patients.

In conclusion, routine clinical neurophysiology techniques are useful in diagnosing underlying neurogenic or myogenic conditions that may lead to or may contribute to back pains. These techniques are more frequently used to exclude neurologic disease in patients with back pain. On the other hand, clinical neurophysiology techniques have been used as a research tool to further our understanding of the complex underlying causes of back pain.

Corresponding address:

Aleksandar Beric, MD, DSc
Department of Neurology
Hospital for Joint Diseases
Mount Sinai/NYU Health
301 East 17^th Street
New York, NY 10003
USA

Tel. +1 212 598 6185
Fax +1 212 598 6009

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A Theoretical Model of the Implementation of Early-Return-to-Work Measures

Raymond Baril, PhD¹ and Diane Berthelette, PhD²

Most studies of the rehabilitation of occupational-accident victims emphasize the characteristics of the victims and their injuries. Publications about workplace based approach to occupational rehabilitation are essentially prescriptive or descriptive. In fact, few evaluative research have attempted to either identify the organizational characteristics underlying the implementation of early return-to-work measures or to evaluate the outcomes of such interventions. This exploratory study was undertaken to remedy this situation, by identifying the components of interventions that promote early return to work (RTW) and establishing a theoretical model capable of explaining variation in the way early-RTW measures are implemented.

The study population was composed of companies who reported injuries to the regional offices of the Quebec Commission de la santŽ et de la sŽcuritŽ du travail (Quebec WCB) and whose injuries had been recorded between January 1994 and March 1997, in the WCB's administrative file created to allow follow-up of return to work. Data from this WCBâs administrative file enabled the identification of workers who benefited from early-RTW (n=2 933) from those who did not (n=10 795). A multiple case study design and theoretical sampling procedure were used in order to oppose firms in which early-RTW measures had been provided to workers (n=8) to firms in which such measures had not been implemented (n=8). Companies were equally distributed in each of Quebec WCBâs furniture, lodging, sawmill, and printing sectors. Six of the companies were small, seven medium-sized, and three large. Nine companies were unionized.

Fifteen WCB professionals active in the participating companies' sectors were consulted, and 20 workplace respondents ÷ 16 managers responsible for occupational injuries and 4 worker representatives consented to semi-directed interviews. The mean duration of the interviews was one hour. This data was complemented by content analysis of the collective agreements of the nine unionized companies. Qualitative data analysis was performed using the Atlas/ti software package.

The results indicate that early-RTW measures were in fact in place in 15 of the 16 companies. They suggest that company size and sector determine the structure of early-RTW measures, particularly the following resource-related parameters: attitudes towards early RTW, workers, and OHS; individual OHS competency; the extent to which the teams involved in promoting early RTW are bipartite; and the financial resources allocated to early-RTW measures. These parameters in turn affect the following determinants of early RTW: formalization and standardization of procedures; systematic case analysis; flexibility of temporary reassignment; and continuity of services available to workers. Finally, it appears that organizational (firmâs culture, formal rules, work organization, injury incidence rates and intra-organizational relations) and environmental (social proximity, occupational health and safety network) variables modify the relation between structure and process in early RTW. This theoretical model will be tested in the second phase of the study, which will begin shortly.

Corresponding address:

(1) Raymond Baril, PhD
Institut de recherche en santŽ et en sŽcuritŽ du travail
505 boul. de Maisonneuve Ouest
Montreal, PQ H3A 3C2
Canada

(2) Diane Berthelette, PhD
Department of Organization and Human Resources
Business School of Administration and Groupe de recherche interdisciplinaire en santŽ, UniversitŽ du QuŽbec ˆ MontrŽal
C.P. 6192, Succ. Centre-Ville
Montreal, PQ H3C 4R2
Canada

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The AHCPR Guidelines

Stanley J. Bigos, MD

The U.S. Department of Healthâs AHCPR (Agency for Health Care Policy and Research) published Guideline its Low Back Guideline Panel December 8, 1994. The recommendations were based upon a critical review of the literature seeking reliable data for the assessment and treatment of patients with back problems, defined as activity intolerance due to back pain or back related leg symptoms. The methodological process aimed at providing Doctors of medicine and chiropractic, nurse practitioners, therapist and patients alike with a better understanding for this most common and expensive musculoskeletal problem. Twenty-three national experts and seven international consultants representing 19 disciplines led a review of over 10,000 abstracts, and evaluation of over 4,600 articles. This effort was to establish scientifically how any clinician can: 1) safely be sure that the patient only has a back problem, 2) offer safe options for comfort, and 3) concentrate on the real treatment for an activity intolerance by attempting to avoid the debilitation of inactivity or building activity tolerance through safe conditioning. The basic premise -- activity, not rest, begets more comfortable activity tolerance. Evidence tables and their subsequent derivation as ãFinding and Recommendation Statementsä provide an understanding of what medical science can and cannot presently support as reliable. To date over 40 countries and their agencies have used the methodological review of this panel as the basis for their guidelines for the treatment of back problems. Of AHCPRâs published guidelines, the Low Back Guideline received twice as many web site visits than the next most common guideline. The methodological process was intended to view where the science is and is not in order to guide further research aimed at providing the needed reliable data. The methodological process continues today to promote reliable data as the basis for care of patients with back problems.

Key words: low back problems, evidence-based guidelines, medical science

Stanley J. Bigos, MD, Jane E. McKee, ARNP

Corresponding address:

Stanley J. Bigos, MD
Professor, Dept. of Orthopaedics
School of Medicine, University of Washington
Seattle, WA, USA

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Can We Affect the Providers?

ClaireÊ Bombardier, MD, FRCPC

Limited information is available on what affects changes in clinical practice. This paper reviews the current evidence on wich interventions are more succesful in changing providers behaviour in general, with secial focus on how this knowledge can be applied to the treatment and rehabilitation of low back pain patients.

Providers report three main reasons for change: organisational factors, education, and contact with professionals, with education accounting for only one sixth of the reasons for change. Despite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice. Studies on the effectiveness of different strategies to promote the implementation ofÊ research findings suggest tha passive dissemination of information through formal education programs is generally ineffective. The use of computerised decision support systems has led

to improvements in the performance of doctors in terms of decisions on drug dosage, the provision of preventive care, and the general clinical management of patients. Educational outreach visits have resulted in improvements in prescribing decisions. Patient mediated interventions also seem to improve the provision of preventive care. Multifaceted interventions seem to be more effective than single interventions. There is insufficient evidence to assess the effectiveness of some interventions for example the identification and recruitment of local opinion leaders (practitioners nominated by their colleagues as influential). Most interventions lead to modest improvements in performance.

Specific studies of interventions for low back pain management are rare and the most promising strategies for future studies on how to affect providers will be discussed.

Corresponding address:

*ClaireÊ Bombardier, MD, FRCPC
Senior Scientist, Coordinator, Clinical Research
Institute for Work and Health,
250 Bloor St. East
Toronto, ON M4W 1E6
Canada

Tel: +1 416 927 2027
Fax: +1 416 927 4167

*Affiliated with University Health Network and Mount Sinai Hospital,
Toronto, Ontario, Canada

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Delayed Recovery in Community Populations with Low Back Pain

Kim Burton, PhD, DO, Eur Erg

The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions. However, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed. A systematic review of prospective cohort studies in low back pain will be reported.

A systematic literature search was followed by the application of three sets of criteria to each study found: methodological quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care, pain clinics and workplace based studies.

Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from depressive mood and, to lesser extent, somatisation emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophising as a coping strategy. In general, the influence of psychological factors was at least as great as that of clinical factors.

In conclusion, both depressive mood and somatisation are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors, there is a need to clarify their role in back-related disability through rigorous prospective studies.

Kim Burton, Tamar Pincus, Steve Vogel, Andy Field

Corresponding address:

ÊKim Burton, PhD, DO, Eur Erg
Director - Spinal Research Unit
University of Huddersfield
30 Queen Street
Huddersfield, HD1 2SP
UK

Tel: +44 1484 535200
Fax: +44 1484 435744
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The Physical Examination

Kim Burton, PhD, DO, Eur Erg

A wide range of physical examination methods are used for assessing low back pain, some of which are common to all disciplines but others are special to professional groups.

Current clinical guidelines are in general agreement that a basic clinical examination should involve the taking of a clinical history together with a general physical examination. The main purpose is to identify Îred flagsâ and inform the triage process ö to distinguish between simple back pain manageable at the primary care level and those pathological conditions requiring specialist referral.

However, conventional clinical tests of spinal function and neurological function are of limited value in determining appropriate clinical or occupational management of non-specific back pain. Furthermore, Îdiagnostic labellingâ may have detrimental effects on outcome. For the most part, discipline specific physical tests are of unknown or inadequate sensitivity and specificity to reliably guide effective treatment.

Specialised tests such as imaging, back function testing machines and electromyography are generally considered inappropriate for acute back pain because they offer little or nothing to the choice of early management.

The scientific evidence and recommendations from various clinical guidelines will be reviewed and used to present a consensus view.

Corresponding address:

Kim Burton, PhD, DO, Eur Erg
Director - Spinal Research Unit
University of Huddersfield
30 Queen Street
Huddersfield, HD1 2SP
UK

Tel: +44 1484 535200
Fax: +44 1484 435744

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Work ConditioningöA Model Clinic

Marco Campello, MA, PT

Introduction: Studies have shown that early intervention yields the best outcome in managing NSLBD.

In 1990, the Occupational Industrial Orthopaedic Center (OIOC) received a 5-year grant from the National Institute for Occupational Safety and Health, Centers for Disease Control (NIOSH/CDC)Ê to establish a Model Clinic for the treatment of occupational low back pain and the prevention of chronic disability.ÊÊÊÊ The Model Clinic provides an algorithm for patient care from the primary care facility (Occupational Medical department) to a secondary facility care (OIOC).

Methodology: A n advisory board including representatives from management, union, medical, safety, human resource staff, andÊ theÊ research group was formed to address the companyâs need and minimize obstacles to implementation of the Model clinic.

The following 3 phase program was implemented:Ê education of medical personnel at the primary care facility by OIOC staff. clinical protocol at the primary and secondary care level, and research and evaluation. This program was a 16-hour theoretical and practical presentation about proper management of occupational Low back disorders. A 16 hour education program was conducted in accordance with the AHCPR Guidelines for the treatment of acute low back pain. The clinical protocol at the primary site consisted of an evaluation to screen the worker for the presence of red flags and the establishment of a treatment program. Progress was monitored periodically at the medical department.Ê Patients unable to return to work at 4 weeks were referred to the OIOC (secondary care facility). There, a multidisciplinary team conducted an evaluation.Ê The physician screened workers for theÊ Return-to Work Program (Work Conditioning). If the worker agreed to participateÊ he or she was evaluated by the psychologist and the physical therapist.

The RTW program is conducted in small groups of 2-6 individuals. It consists of intensive physical therapy/fitness, education, and pain and stress management. Work-adapted exercises are taught based on individualized work profiles. Objective feedback is provided each week. The program runs up to four weeks, five days a week, for four hours a day. After completing the program, participants are followed for one year.Ê

Clinical and patient history data was collected from theÊ workerâs first visit to the medical department until one yearÊ after the end of the program.

Results: SinceÊ program implementation, workers with occupational NSLBD returned to work faster than those with non-occupational NSLBD.Ê

ÊAn outcome study of 90 consecutive RTW participants indicates a 92% rate of return to any work and 68% return to regular duty. The mean duration of time out of work for this cohort was 9.4 months prior to their treatment at the OIOC Model Clinic

Summary: Proper management of injured workers is crucial for the treatment of NSLBD. A Model Clinic Program can decrease work time loss and disability.

Corresponding address:

M. Campello, M.A., P.T.
Associate Clinical Director

Occupational and Industrial Orthopaedic Center
Hospital for Joint Diseases
63 Downing Street
New York, NY 10014
USA

Tel: +1 212 255 6690
Fax: +1 212 255 6754

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Differences in Culture and Cultural Differences

Christine Cedraschi, PhD

Pain and suffering are at the same time totally universal and strictly personal experiences. Universal insofar as they are common to all individuals whatever their social or cultural memberships.Ê And personal because of their subjective characteristics and the difficulty to transmit them.

Pain is thus somehow at the crossroads of the individual and the group. It sets into play physiological and psychological mechanisms, but it is also inserted within the social and cultural context to which the individual belongs. This context modulates variables such as the meaning and the expression of pain. In this sense, pain is as much a social and cultural construct as the result of biological and psychological processes.

Culture has been shown to affect not only the expression of pain and the response to pain complaints but also factors such as views concerning pain responsibility and the mind-body worlds in both patients and health care providers¹. In a study conducted in the United States and in Puerto Rico, Bates et al.¹ showed that in contrast to Anglo-American health care professionals, Puerto Rican care providers considered an outward expression of pain as appropriate, indicating that patients were in need of prompt treatment. Contrary to Puerto Rican patients, Anglo-American patients considered inquiries into psychosocial aspects as evidence that the doctor thought that the pain was due to psychological factors and was thus not real. This dichotomous mind-body view is part of a set of cultural assumptions which make identifying a somatic cause central to legitimize pain^1,2. In this regard, when the cultural background is predominantly influenced by the biomedical model, for the patients, diagnostic tests that allow to see into the body convey hope for solving the equation: what is not clearly ãbodyä might be considered as only ãmindä².

Cultural factors may affect both the type and quality of health care and the perception and responses of the patients¹. Rainville et al.'s study³ indicate that there is a variety of pain attitudes and beliefs in health care providers and thus probably a variety of advices concerning how to deal with chronic low back pain. Accordingly, seeking desired advice may be one reason for ãhealth care shoppingä, with patients looking for providers who have pain beliefs close to their own. Cultural differences in social acceptance, attention, as well as in coping with pain both cognitively and emotionally have also been proposed to account for differences in dealing with chronic low back pain, especially differences in the patientsâ self-perceived level of dysfunction⁴. Differences in people's threshold for reporting symptoms have been suggested as yet another factor contributing to explain cross-cultural differences in the prevalence rates for back pain complaints⁵.

Thus, in the field of chronic pain, where somatic and psychosocial factors ãride in tandemä, the modulations of the meaning and the expression of pain need to be taken into account. Indeed, patients' as well as therapistsâ behaviors and expectations are inserted within the social and cultural context to which the individuals belong.

1) Bates MS, Rankin-Hill L, Sanchez-Ayendez M: The effects of the cultural context of health care on treatment of and response to chronic pain and illness. Soc Sci Med 1997; 45: 1433-47

2) Rhodes LA, McPhilipps-Tangum CA, Markham C, Klenk R: The power of the visible: the meaning of diagnostic tests in chronic back pain. Soc Sci Med 1999; 48: 1189-1203

3) Rainville J, Bagnall D, Phalen L: Health care providers' attitudes and beliefs about functional impairments and chronic back pain. Clin J Pain 1995; 11: 287-95

4) Sanders SH, Brena SF, Spier CJ, Beltrutti D, McConnell H, Quintero O: Chronic low back pain patients around the world: cross-cultural similarities and differences. Clin J Pain 1992; 8: 317-23

5) Lau EMC, Egger P, Coggon D, Cooper C, Valenti L, O'Connell: Low back pain in Hong-Kong: prevalence and characteristics compared with Britain. J Epidemiol Community Health 1995; 49: 492-4

Corresponding address:

Christine Cedraschi, PhD
Division of Rheumatology
Division of Clinical pharmacology
Multidisciplinary Pain Center
University Hospital
26, Ave. Beau-Sejour
CH-1211 Geneva 14
Switzerland

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Preventing Chronicity and Disability Due to Back Pain: What is the Evidence?

Richard A. Deyo, MD, MPH

Recent research has demonstrated disconcerting wide geographic variations in clinical care for patients with low back pain.Ê For example, international comparison demonstrate that the United States performs back surgery at about twice the rate of most developed countries, and five times the rate of the United Kingdom.Ê Even within the United States, wide geographic variations are seen, with sevenfold differences among hospital market areas.Ê These geographic variations are quite stable over time, and may represent a ãsurgical signatureä for each area.Ê Recent research demonstrates that clinical outcomes may sometimes be best where the surgical rates are the lowest.Ê Thus, the geographic variations prompt concerns on the part of employers, insurance companies, and the government regarding the adequacy of professional consensus on therapy and the need to reimburse care that exceeds some average or norm.Ê The professional response has been to promise better outcomes research to define which practice patterns are associated with the best patient results, and to develop clinical guidelines to help bring more consistency to clinical practice.

In part, these variations may be attributed to differences in clinical practice styles and health care systems, but also to professional uncertainty.Ê For example, recent evidence shows that bedrest is not helpful for the vast majority of patients with back pain and even sciatica, and that imaging should be highly selective.Ê Nonetheless, there is ongoing evidence that excessive bedrest is prescribed and excessive imaging is common.Ê Prescribing excessive bedrest leads directly to increased work absenteeism, and there is indirect evidence that excessive imaging may lead to the adverse consequences of ãlabelingä including excessive illness behavior, possibly unnecessary treatments, and excessive work disability.Ê Innovative changes in the structure of health care, referral patterns, and diagnostic protocols have been shown to substantially modify practice patterns where they have been tried, and time will tell whether these are associated with reduced work disability.

Social and economic factors also have an important effect on clinical behavior.Ê As just one example, Loeser and colleagues reviewed the relation between workerâs compensation benefits and the frequency and duration of disability claims, comparing states with varying compensation benefits.Ê These investigators estimated that a 10% increase in compensation benefits was associated with a 1-11% increase in the frequency and duration of claims.Ê In some jurisdictions, investigators have found that workerâs compensation claims are highest where regional unemployment rates are the highest, suggesting that compensation benefits may function as part of the social ãsafety netä in difficult economic times.Ê Among patients with back pain the level of functioning and severity of symptoms after treatment are worse among those who retain an attorney, initiate litigation, or become involved in workerâs compensation proceedings than in those who do not, even after adjusting for clinical findings.Ê In related conditions such as whiplash, studies suggest that the design and benefits of insurance programs may have a major effect on patient behavior.Ê For example, jurisdictions with ãno faultä insurance have substantially fewer claims and shorter duration of claims for whiplash injuries than jurisdictions with tort systems, in which claimants are allowed to sue for pain and suffering.

Considering both clinical and social factors, a new approach to preventing work disabilities seems to be in order.Ê The old paradigm was teaching patients how to lift, using liberal imaging studies, prescribing bedrest, instructing patients not to return to work until they were ã100%ä, and leaving patients on their own to navigate the disability system.Ê The new paradigm would emphasize instead the use of exercise programs to optimize or restore patient fitness, very selective use of advanced imaging studies, rapid return to normal activity rather than bedrest, the selective use of advanced imaging studies, rapid return to normal activity rather than bed rest, the routine availability of light duty options from employers, and interaction with employees who are off work, to encourage their return and offer to help resolve administrative issues.Ê This new paradigm is supported by recent randomized trials demonstrating the failure of even extensive training programs in proper lifting techniques and by preliminary studies from a variety of occupational settings. In summary, wide geographic variations in care suggest a poor professional consensus on optimal management of back problems.Ê There is evidence that more care is not necessarily better care, and for many traditional interventions ãless is moreä.Ê Unnecessary labeling of patients with diagnostic terms and incidental imaging findings can be disabling in itself.Ê Public policy and regional economic factors may affect patient behavior in ways that are just as strong as physiologic factors.Ê Finally, the new paradigm of managing back pain calls for relatively modest medical intervention and early return to normal activities.

Corresponding address:

Richard A. Deyo, MD, MPH
Section Head, Division of General Internal Medicine
Dept. of Medicine
University of Washington
1959 NE Pacific St. Box 356429
Seattle, WA 98195
USA

Tel: +1 206 616 5360
Fax: +1 206 616 5365

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Diagnostic Imaging in Low Back Pain

Thomas J. Errico, MD

Diagnostic imaging of the patient with low back pain remains enigmatic.Ê Ideally imaging techniques would allow for an accurate description of all Pathologic Anatomy and be able to differentiate between clinically relevant and non-relevant pathological changes.Ê Unfortunately this deciphering task falls to the clinicianÊ through an integration ofÊ the history, physical, and an assorted battery of diagnostic tests.Ê The clinician furtherÊ handicapped by inaccurate clinical information supplied by the patient, physical finding that can vary with waxing and waning symptoms, radiologist's interpretations of radiologic images isolated from other testings, and the human tendency to concentrate our diagnoses on the areas we understand best.

There are three basic categories of spine pathology that cause back and leg symptoms.Ê The first and best understood is spinal canal constriction such as in spinal stenosis or disc herniation.Ê The second is pathologic changes of the posterior elements as in various manifestations of facet disease and spondylolysis/spondylolisthesis.Ê The third and least understood diagnosis is pain emanating from the disc itself commonly referred to as Discogenic Pain.Ê

Diagnostic testing for the varying diagnoses of Spinal Canal Constriction including plain radiographs, CT scanning, MRI scanning, and CT-Myelography are very accurate and well understood.Ê The same battery of diagnostic test employed in Posterior element disease while depicting the pathologic anatomy are more difficult to correlate to the patients symptoms.Ê The diagnosis of Discogenic Disc DiseaseÊ has many synonyms such as Internal Disc Derangement, Discogenic Back Pain, and Black Disc Disease.Ê To accurately make this diagnosis one needs to employ Discography or CT-Discograpy.Ê Discography is a controversial test since the results while partly objective rely heavily on the subjective interpretation of both the patient and the discographer.ÊÊ Although a positive result yields the diagnosis of Discogenic Disc Disease the exact pathological entity responsible for the positive result is unknown.ÊÊ

Our lecture today will center around the scientific data available to us although sparse.Ê We will cover the strengths and weaknesses of the tests available to us for each of the diagnoses.ÊÊÊ A strategy of correlating the positive pathologic entities uncovered with the patients symptoms will be developed.Ê Lastly we will try to unravel a portion of the mystery as to the lack of correlation between diagnostic testing, appropriate surgical intervention, and patient outcome.

Corresponding address:

Thomas J. Errico, MD
Spine Care Orthopedics
530 First Ave, Suite 8U
New York, NY 10016
USA

Tel: +1 212 263 7182
Fax:+1 212 263 7180
spinecare@worldnet.att.netÊÊÊÊÊÊÊÊÊÊÊ

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Injections: New techniques for treatment of spinal segmental sensitization (discopathy-radiculopathy) and Triggerpoints.

Andrew A. Fischer, MD, PhD

Objective: is to review new injection techniques for treatment of musculoskeletal pain.

M&M: Outcomes using the new treatment techniques are reviewed. Results in 120 patients with musculoskeletal pain were reported in a clinical retrospective open study(1).

Results: A pentad of signs was described, that is a common cause of musculoskeletal pain. The pentad of discopathy÷radiculopathy consists of 1) narrowed disc space and neural foramen on imaging. This is manifested clinically by 2) narrowed space between spinous processes and 3) a sprained (tender) supraspinous ligament. 4) There is palpable paraspinal muscle spasm, which causes 5) radicular compression and dysfunction with spinal segmental sensitization (SSS). The pentad was identified as the cause of symptoms in 82% of patients. The pain caused by radiculopathy was alleviated and functional limitations improved in 87% of treatments by ãparaspinous blockä. Most of the patients failed by other treatments. This new injection technique blocks the nociceptive impulses from the sprained supra- and interspinous ligaments, that is an irritative focus, causing spinal segmental sensitization. Lidocaine is spread along the spinous processes at the level of sensitized spinal segment. The second part of the injection, consist of needling and infiltration of the sprained interspinous ligament, which assures long-term results.

2.) Two new trigger point injection techniques were described, which improve substantially the success rate of treatment: Preinjection block (PIB) anesthetizes the sensitive, painful area, which is supposed to be injected.Ê Needling and infiltration of entire taut band associated with trigger points render long-term relieve. Results of treatment with needling and infiltration of taut bands: Reduction in pain rating was confirmed by pressure algometry and followed up over an average of 2 years. The % of patients in each diagnostic group suffering from Myofascial pain syndrome and the (%) improved by needling and infiltration of taut bands are as follows (1-8): Plantar fasciitis 100% (85%). Return to work was shortened from 21.1 weeks with conventional treatment to ks to 3.4 weeks with injections. This was a randomized controlled study by M.Imamura confirmed by Pressure Algometry with 2 years follow up(4.); Failed back surgery 100% ( 82 %) also confirmed by Pressure Algometry with 2 years follow up (5); Hip pathology 100% (80 %)(6) ; CRPS (RSD) 82 % ( 86%)(7); Cumulative Trauma Disorders 94.5% (62.6%) (8).

Conclusions: New injection techniques can relieve pain and signs caused by radicular compression. Paraspinous block frequently achieves such improvement instantaneously by relieving paraspinal muscle spasm, which causes the root compression. (1,2) New injection techniques improved success rate and achieved long-term relieve of pain caused by trigger points and tender spots.(1,2).

References:

1).Fischer A.A,Imamura M.:New concepts in diagnosis and management of musculoskeletal pain in Lennard T.A. (ed): Pain procedures in Clinical Practice, 2^nd edition. Philadelphia PA.Ê Henley & Belfus, Inc., 2000.pp 213-229

2). Fischer AA (ed): Myofascial pain-Update in Diagnosis and Treatment. Phys Med Rehabil Clin North Am. Philadelphia, W.B. Saunders, 1997 3)

3). Fischer AA (ed): Muscle pain syndromes and Fibromyalgia. New York, The Haworth Medical press, 1998.

4). Imamura M, Fischer A, Imamura ST. et al. Treatment of Myofascial pain components in Plantar Fasciitis speeds up recovery: In Fischer AA.(ed) Muscle pain Syndromes and Fibromyalgia. New York: The Haworth Press. 1998; 91-110.

5). Imamura ST, Fischer AA, Imamura M, et al.Pain management using myofascialÊ approach when other treatment failed. Phys Med Rehabil Clinics North Am 1997;.8: 179-196

6).Imamura ST,Ê Riberto M , Fischer AA et al. Successful pain relief by Treatment of Myofascial components in Patients with Hip pathology scheduled for Total Hip replacement. In Fischer AA. (ed) Muscle pain Syndromes and Fibromyalgia. New York: The Haworth Press. 1998; 73-89.

7.Imamura ST, Lin TY, Texeira MJ et al.: The importance of Myofascial pain syndrome in Reflex sympathetic dystrophy ( or Complex regional pain syndrome). . Phys Med Rehabil Clinics North Am 1997;.8: 207-211.

8.Lin TY, Teixeira MJ,Fischer AA et al.Work-Related Musculoskeletal Disorders in. Phys Med Rehabil Clinics of North Am 1997; 8: 113-117.

Corresponding address:

Andrew Fischer, MD, PhD
17 Wooley Lane East
Great Neck, NY 11021,
USA

Associate Clinical Professor of Rehabilitation Medicine, Mt. Sinai School of Medicine, CUNY, New York.Ê
Tel/Fax 516 829 9332
E-mail: paintreat@aol.com

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Guidelines and Industry

Marianne Forsyth-Bee, RN, MA, COHN

Medical practice can vary significantly from one specialty to another, as well as from one region of the country to another. This variation in practice can result in different treatments, outcomes and ultimate length of disability.

For health professionals practicing in occupational settings this variation in practice can pose difficulties. Workers experiencing the same occupational injury or illness but treated by different practitioners/specialists might receive very different types of treatment. Some physicians recommend extensive diagnostic tests while others might suggest unreasonable disability. Considering that the practice of medicine is both an ãartä and a ãscienceä we expect and even encourage some variations in practice. Wide differences however, make case management of the occupational injury more difficult. These variations in practice can also have a significant impact on costs, which are controlled under the workers compensation system.

Occupational health professionals practicing in industry have found various practice guidelines to be useful in determining appropriateness of treatment and disability, and ultimately costs. Guidelines such as the U.S. Department of Health and Human Services publication on Acute Low Back Problems in Adults have been advantageous and assist practitioners in the prevention, diagnoses, treatment and management of clinical conditions. (U.S. Dept of Health and Human Services, Agency for Health Care Policy and Research Number 14, 1994).

Other guidelines such as The Medical Disability Advisor assist the disability manager in identifying disability duration guidelines for lost time cases. (The Medical Disability Advisor, 1997)

Other algorithms and professional guidelines have also been useful in supporting industry in the management of work related medical disorders.

Corresponding address:

Marianne Forsyth-Bee, RN, MA, COHN
Director - Health & Safety Services
Sony Music Entertainment, Inc.
555 Madison Ave., Suite 1362
New York, NY 10022-3311
USA
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A PRIDE-like Program-Three Randomized Studies

Ane Friis Bendix, MD, PT

Problem: It is well known that in patients with chronic low back pain (CLBP) the pathology and objective signs often correlate poorly with subjective physical capacity and pain behaÐvior. It is also shown that CLBP patients experience substantial limitations in recreational activities, social interaction, home management and general mobility. As a consequence, bio-psycho-social treatment models have been developed, including physical, psychologiÐcal and social elements in order to reconstruct the patient's total situation. Results from such a Îfunctional restorationâ (FR) program - the PRIDE program - was first described by two centers in the USA (1,2). Both centers reported successful outcome after 1 and 2 years in terms of return-to-work rate, better overall functioning and other parameters for patients with CLBP. Other similar Ðprograms from USA showed good results as well. However, studies from countries outside the USA, like Finland and Canada did not exhibit influence on return-to-work rate, but did so in different other outcome parameters. However, none of the studies from USA were randomized or observer-blinded and the control groups composed of patients not treated in the FR program due to denial from their insurance companies. Due to this and the differences in cultural, social and security systems in the USA and Denmark, three randomized, controlled and observer blindÐed trials with up to five years of follow-up were carried out at the Copenhagen Back Center.

Objective: The overall objective was to test short and long term effects of an intensive, multi-disciplinary rehabilitation program (a PRIDE program) for patients with disabling CLBP.

Design: The FR program was, in three randomized parallel-group studies, tested against a control group receiving no treatment (project A) and three different, less intensive treatment programs (projects B and C).

Methods: Altogether 354 patients with chronic, disabling low back pain participated in the studies. The patients in projects A and B were followed-up after 4 and 12 months (short-term) and 2 and 5 years (long-term). In project C the only follow-up was at 12 months. Outcome parameters such as work-situation, pain- and disability level, contacts to the health care system, days of sick leave, subjective overall assessment and others were analyzed using non-parametric statistical methods.

Results: In the projects A and B, short-term outcome from participation in the FR program was superior to short-term outcome from participation in a less intensive program or in a control group. Difference in outcome between groups was reduced over time and was only found in project B after 2 and 5 years. ÎOverall assessmentâ was the only outcome variable showing difference between groups in project C. This difference was seen in favor of the FR treatment. (3,4).

Conclusions: The FR program in many ways seems to be an effective treatment for that part of the chronic low back pain patients with many days of sick leave and in risk of loosing contact to the work force. The effect from the FR program is reduced over time, and due to that it should be considered to extend the program with a Îrevival courseâ; chronic low back pain patients with less impact of disability seem to benefit just as well from a less intensive program with active exercises as from a FR program.

References:

1) Mayer T, Gatchel RJ, Mayer H, Kishino ND, Keeley J, Mooney V. A prospective two‑year study of functional restoration in industrial low back injury. An objective assessment procedure. JAMA 1987; 258: 1763‑Ð7.

2) Hazard RG, Fenwick JW, Kalisch SM, Redmond J, Reeves V, Reid S, Frymoyer JW. Functional restoration with behavioral support. A one‑year prospective study of patients with chronic low‑back pain. Spine 1989; 14: 157‑61.

3) Bendix AF, Bendix T, Labriola, M, B_kgaard P. Functional restoration for chronic low back pain. Two-year follow-up of two randomized clinical trials. Spine 1998; 23:717-25.

4) Bendix AF, Bendix T, H_strup C, Busch E. A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients. Eur Spine J 1998; 7:111-9.

A. Friis Bendix, T. Bendix

Corresponding address:

Ane Friis Bendix, MD, PT

Clinical Dept. of Disease Prevention
Bispebjerg Hospital, opg. 20 C
DK-2400 Copenhagen NV
Denmark
Tel: +45 35313095
E-mail: afb01@bbh.hosp.dk

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Spondylolysis, Spondylolisthesis and Degenerative Spondylolisthesis

Robert Gunzburg, MD, PhD

Despite the vast amount of clinical and basic science research on the subject, the etiopathogenesis of these conditions is still open to debate. A congenital theory appears unfounded, as the lesion was never found on a foetus or a stillborn child and that incidence increases with age. Traumatic spondylolisthesis is rare but possible, yet major trauma is required. The most generally accepted etiopathogenesis, however, is that of a stress or fatigue fracture. Spondylolysis occurs between 5 and 6% of the white population. Occupational factors may play a role as the lesion is more often found in subjects performing heavy manual work and in high-level sportsmen or acrobats. Gymnasts, divers and weight lifters, all of whom practice their sports with movements of hyperextension, are reported to be more likely to present a spondylolysis.

Once a bilateral spondylolisis occurs, there only remains the underlying intervertebral disc to resist shear forces. When the disc fails, the vertebra above, and the whole spine with it, can slip: spondylolisthesis. The amount of slippage is expressed in percentage or in grades going from I to IV.

A spondylolisthesis can also occur without spondylolysis: the so-called degenerative spondylolisthesis. This condition is four times more common in women and occurs mostly at the L4-L5 level. It is the only disorder of the adult spine in which a distinct difference between genders has been observed. As a result of the slippage, spinal stenosis often occurs. Slippage rates beyond 30% are rare, indicating that the condition is self-contained.

Medico-legal implications

Although many patients with spondylolysis attribute the onset of symptoms to an injury, no fracture of the pars is sustained at the moment of trauma in the vast majority. Radiologically the early films would show irregular, nonsclerotic fracture edges with subsequent abundant callus formation. There are only very few published cases where an existing spondylolysis was proven to slip following (severe) trauma or where an existing spondylolisthesis was proven to increase. The most frequent consequence of trauma in subjects with pre-existing spondylolysis or spondylolisthesis consists of the Îawakeningâ of low back pain. Spondylolysis has been reported as an acquired condition after posterolateral spinal fusion. Problems of low back pain related to spondylolysis and spondylolisthesis lead to a series of medico-legal problems that are often empirically dealt with. There are many preconceived ideas and there is little coherence in the decision-making. This is probably due to the lack of knowledge surrounding low back pain.

The first element to be considered is the accident itself. Any accident occurring during or because of work, whatever its cause, has to be considered as a work accident. This is extended to accidents occurring on the way to or from work. Additionally, there is no need for an Îexternal agentâ as main cause of the accident. This is especially of importance for accidents or events leading to low back pain. The mere sudden occurrence of pain arising from a physical lesion during work hours is presumed to be caused by the work, unless the contrary is proven.

At times acute low back pain presents itself dramatically with pain leading to loss of consciousness, uncontrollable lumbar spasm and impossibility to move. These episodes are clearly recognised by all who are present. Yet, it often happens that after an initial flash-like acute pain, things appear to settle while work is resumed, only to appear again after some hours or even after a day or two. If an employee works in isolated conditions or if he/she does not complain immediately or reports the event immediately, his or her credibility is often put at stake.

Another problem often encountered has to do with the existence of pre-existing lesions and the appreciation of the duration of temporary total inability to work. Often, medical experts arbitrarily chose a date after which the resulting complaints are said to be due to the pre-existing lesions and not the trauma. This position which is often experienced as severe by workers, does not rest on any form of rigorous scientific research. It is rather based on moral or even moralising attitudes.

Chronic low back pain related to work occurs during work. It is after 5 or 6 hours of heavy work exacerbated by one or two hours in public transport that such subjects should be examined. Medical experts often examine these subjects when they are off work, leaving them with little opportunity to observe the symptoms related to their condition.

Theatricality and exaggerated facial and bodily expressions are often invoked to cast doubt on the authenticity of complains. One should, however, bear in mind that subjects often have difficulties to word themselves because of poor education or simply because of a language barrier in case of foreign workers. It is, however more tolerable to know that some malingerers live, poorly indeed, on benefit than to know that real LBP sufferers support stoically their pain in order to carry on providing for their families.

It is a well-established fact that standard radiographs are not of much use in the diagnosis and treatment of acute low back pain. With shrinking financial resources affecting the medical sector, there is a tendency to avoid unnecessary medical tests. There are therefore arguments in favour of not performing radiographs for acute low back pain cases. One should then, a posteriori, not claim that the symptomatology cannot have been very dramatic Îbecause radiographs were not immediately takenâ.

Permanent partial incapacity to work related to chronic low back pain or low back pain at work is often valued at 10% to 15% and often under 10%. This is often not realistic as these subjects actually are in too much pain during work to resume their activities. The possibility of alternative schooling or career re-orientation is evoked, yet these subjects are often of a low socio-cultural background making this an illusion.

Corresponding address:

R. Gunzburg, MD, PhD
Eeuwfeestkliniek
Harmoniestraat 68
2018 Antwerpen
Belgium

Tel: +32 3 240 27 05
E-mail: r.gunzburg@worldonline.be

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Keynote Address: Predicament and Disability

Nortin M. Hadler, MD, FACP, FACR, FACOEM

There is no doubt that all of us, including all of us who are otherwise well, will be faced with surmounting our intermittent and remittent regional musculoskeletal pains, back pains in particular. To be well is to be able to meet these challenges effectively; avoiding them is not possible. Furthermore, the challenge is not simply to bear the pain. The challenge, always, is to circumvent or surmount consequent functional compromise.

Most of us are a match for these predicaments, most of the time. Thatâs because most of us have options in coping that serve us well, most of the time. But not all of us are so fortunate, not all of the time. And for some of the unfortunates, the compromise extends to wage earning capacity.

For a century, the industrialized world has recognized their plight. Recourse is provided ö always with stipulations and strings attached designed to abrogate any ãmoral hazardä. Afterall, since most of us can cope most of the time, how do we know that any individual who seeks assistance for regional back pain really canât cope. We have evolved an algorithm to assistance that presents two gantlets: Is the regional back pain an ãinjuryä? Is the regional back pain severe enough to be disabling?

In accepting that these gantlets are appropriate, we have fashioned a 20^th Century social construct out of the predicament of regional back pain. In creating the social contract to operate these gantlets, we have created new ãmoral hazardsä.

There are options ö if only we could see beyond our preconceived notions and superstitions. And there is science, to light the way.

Corresponding address:

N.M. Hadler, MD, FACP, FACR, FACOEM
Professor of Medicine and Microbiology/Immunology
Department of Medicine
University of North Carolina,
Chapel Hill, North Carolina 27599-7280
USA

Tel: +1 919 966 0566
Fax: +1 919 929 6964
E-mail: nmh@med.unc.edu

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Physical Accommodations and Cost

Manny Halpern, PhD, CPE

Accommodations are interventions that reduce the exposure to job factors that may exacerbate the condition of the individual patient. This theoretical paper discusses cost issues that affect the process of implementing physical accommodations.

(i) What job demands need to be analyzed?

Epidemiological studies associated low back pain with several physical activities. The risk factors attributed to these activities are static work, dynamic work, forceful exertion, as well as environmental factors. The evaluation and documentation of such a variety of factors presents a challenge. The selection of methods to assess the job demands depends first on the cost. Indirect measures that employ surveys and questionnaires are more feasible for large-scale outcome studies, while observational methods are common in individual assessments. Direct measurement of the risk factors is most expensive because it involves instrumentation and expertise.

(ii) What information is useful for all involved in the process?

The selection of the method to assess job demands depends also on the clinical utility of the end product. A personal ability assessment needs to be linked to the job demands. Observational methods are commonly used for both assessments. The linkage offers a framework of communication between the health care provider, the employer and the patient. It may by more useful within rehabilitation settings that provide placement services for complex severe cases. Cost savings probably result from avoiding litigation[1].

Intervention strategies that aim at reducing exposure to risk factors address engineering modifications or administrative controls. As with primary prevention, accommodating individual workers may require budgetary allocations upfront in about 80% of the cases. These do not need to be expensive. Half of the accommodations for people with disabilities reportedly cost between $1 and $500. Companies reported an average return of $28.69 in benefits for every dollar invested in making an accommodation[2].

However, the association of back pain with workplace factors weakens as the condition progresses to a chronic phase. Thus, psychological issues are likely to become more relevant to treatment and return to work decisions. Consequently, modifying the activity-related risk factors may be more useful for evaluating disability than in predicting return to work.

It is not quite clear how effective is restricted duty in the accommodation process. Such accommodations have not been shown to reduce the duration of time away from work[3]. The cost of this strategy depends on whether the restrictions become permanent. The costs may be offset if the restrictions have a protective effect in recurrent episodes.

(iii) What potential problems exist in implementing the intervention?

Several issues remain open:

ðÊÊÊ Parsimony of effort is likely to reduce costs. Future studies should be directed to evaluating such criteria for selecting information on job demands.

ðÊÊÊ Patient involvement in the process determines the acceptance of the accommodations. Future studies need to examine what would increase acceptance by supervisors and co-workers.

ðÊÊÊ The insurer may also exert controls on the scope of the analysis, patient involvement, and the intervention. The efficacy of such controls needs further research.

[1] Frey W.D. and Nieuwenhuijsen E.R. 1990. The ERTOMIS assessment method: an innovative job placement strategy. In Berkowitz M. (ed.). Forging Linkages. New York: Rehabilitation International, 121-156.

[2] Presidentâs Committee on Employment of People with Disabilities. 1995. http://www50.pcepd.gov/pcepd/pubs/publicat.htm

[3] Hiebert R. 1999. Work restrictions and outcome of non-specific low back pain. (submitted to Spine).

Corresponding address:

Manny Halpern, PhD, CPE
Assistant Director for Ergonomic Services
The Occupational and Industrial Orthopaedic Center
Hospital for Joint Diseases, Mount Sinai/NYU Health
63 Downing Street
New York, NY 10014
USA

Tel: +1 212 255 6690
Fax: +1 212 255 6754

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Worker Perceptions of Functional Testing.

Kenneth J Harwood, MA, PT, CIE

For decades the ability to return to work (RTW) following disabling low back pain has been a standard outcome measure. A myriad of measurement tools have been used to predict return to work in individuals with low back pain. Among these clinical measurements is functional testing. Unfortunately, evidence supporting the use of functional tests in the return to work decision is lacking in the literature. In particular, the importance of functional tests to the individual returning to work has not been explored. The purpose of this study is to describe patient perceptions of the return to work process and the influence of functional testing on the decision to return to work.

The aim of this mixed-design study was twofold: 1) to provide an accurate and detailed description of the return to work process for individuals who were disabled with low back pain; and 2) to provide a description of the patientsâ perspectives on the effect functional testing had on the return to work decision. Seven subjects who were out of work for more than four weeks and less than six months with low back pain were followed for approximately a year. A test battery that included the Oswestry Questionnaire, Visual Analogue Scale (VAS), the SF-36, a Job Description Questionnaire and selected functional tests from the Physical Work Performance Evaluation (PWPE) by Lechner et al (1994) were instituted before and after the subjects returned to full-duty work. In addition, subject perceptions were obtained using in-depth interviewing techniques.

Descriptive statistics on the quantitative measures (means, standard deviations and pre to post RTW comparisons) were used to describe individual and sample characteristics and to elucidate themes generated through the qualitative component of the study. Qualitative analysis techniques including phenomenological reduction procedures were performed on the interview transcript data. Themes generated through the phenomenological analysis were described in detail to represent the experience of RTW and the effect of functional tests on RTW.

Corresponding address:

Kenneth J Harwood, MA, PT, CIE
Assistant Professor & Vice Chairman
Program in Physical Therapy
Columbia University
710 West 168^th Street, 8^th Floor
New York, NY 10032
USA

Tel: +1 212 305 1649
Fax: +1 212 305 4569

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System to Test Functional Capacity

Susan J. Isernhagen, PT, BS

Functional capacity evaluation bridges two dissimilar worlds: that of competitive employment, because work outcome is the focus, and that of medicine, because the worker has a medical dysfunction. The medical component must be integrated in a manner that promotes safety, but not in a manner that focuses on impairment. Whole-body work function is tested. Return to work management or disability determinations are two common uses.

Functional: Actual work activity, definable and standardized · unrestricted by non-work parameters or equipment.

Capacity: Maximum safe ability based on activity performance.

Evaluation: Professional compilation of all components including medical diagnosis, physical exam, cooperation/consistency and test performance.

The specific design of a functional capacity evaluation is dependent upon the purpose and outcome desired. Many test design types are available to researchers and clinicians. Not all can be utilized. Therefore, the design should be purposeful. Any clinician can test for passive results. Outcome directed evaluations, however, require active results. Five design points are utilized to integrate medical data, scientific reliability and work-related external validity.

Identify Work Abilities: What functional activities can the client safely perform and which work tasks must be restricted; apply the functional capacity ability list to specific jobs, job groups or work levels.

Determine End Point Causes: Are the test end points medical/physiological or behavioral?

Design for Competitive Employment: Integrate repetitiousness in items and test days for endurance projections. Integrate objective identification of maximum performance to produce a safe maximum limit. Integrate an employer/employee based outcome measurement system that measures actual levels of return to work. Analyze components for work prediction to produce better case management.

Include Relevant Work Components: Utilize the three ascending levels of specificity in work accommodation_occupational references, analysis of work sites or validated job descriptions.

Utilize Outcome Systems: Measure values that are important to the employer, worker and insurer. Safe work productivity, even in the presence of discomfort, is the focus. The medical-based FCE can assist the client in understanding symptoms and developing coping strategies. In one study, 86% of returned to work clients indicated discomfort was still present, but they could work ãwithä it by adapting their method.

In summary, the design of functional capacity testing should incorporate realistic work activity, standardized reliable components with whole-day work relevance, a focus on safe function and measurement of effort level. Outcome studies should evaluate FCE for actual work outcome including productivity, cost savings and employee/employer satisfaction.

Corresponding address:

S. Isernhagen, PT, BS
Isernhagen Work Systems
1015 E Superior Street
Duluth, MN 55806
USA
Tel.: +1 218 728 6455
Fax: +1 218 728 6454
E-mail: sisernhagen@erehab.com

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Reliability and Validity in Functional Capacity Evaluation

Deborah Lechner, PT, MS

Functional Capacity Evaluations determine a workerâs physical functional abilities to perform work and have an important role in evaluation of work disability. They are used to make major life-affecting decisions regarding return-to-work, disability, job placement, and vocational assessment. As such, reliability and validity of FCEs are of critical importance to all those involved in the workerâs compensation system: workers, employers, insurers, physicians, therapists, attorneys, and case managers. All those involved want reassurance that the FCE is accurate. This presentation will begin by defining the concepts of reliability and validity in FCE. The advantages of a well-designed FCE and the importance of scoring algorithms in the FCE process will be addressed. A brief review of the literature addressing reliability and validity in FCE will follow. The author will then discuss two studies that address the reliability and validity of the Physical Work Performance Evaluation (PWPE). The PWPE is an FCE developed through 5 years of research and clinical practice at the University of Alabama at Birmingham (UAB). In the first study, eleven therapists were trained in test administration and scoring of the PWPE. Two therapists at a time were selected to evaluate independently and simultaneously 50 patients with musculoskeletal dysfunction as they performed the test. Test results from the two independent evaluators were compared to determine inter-rater reliability. To determine validity, test results were compared to actual work status. Kappa coefficients between the two therapists on the level of work were .83. Spearman rho correlations between the predicted and actual levels of work ranged from .44 to .51. In a second study of the predictive validity of the PWPE, the test was administered to 30 patients who were admitted to a 5-week industrial rehabilitation program. The results of the evaluation were compared to work demands. Patients were re-tested at the conclusion of the test on those tasks where abilities did not meet job demands on the initial evaluation. One of three recommendations was made: return to work full duty, return to work modified duty, or no return to work. Follow-up at 1 week, and at 3 and 6 months post discharge revealed Kappa coefficients of .71, .69, and .74 respectively and an 87% agreement at 3 and 6 months. Unavailable modified duty was documented as the reason for all 13% of the individuals whose actual work status did not match our recommendations. Together these two studies provide evidence in support of reliability and concurrent and predictive validity of the PWPE. The authors conclude that PWPE can be used to accurately predict the safe level of work appropriate for individuals who have sustained a musculoskeletal injury.

Corresponding address:
Deborah Lechner, PT, MS, Research Associate Professor
Dept. of Occupational and Environmental Medicine
University of Alabama at Birmingham
Birmingham, AL 35222,Ê USA

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The Sherbrooke Model Cost-Benefit and Cost-Effectiveness

Patrick Loisel, MD, FRCP(C)

Rationale. The majority of the costs associated with low back pain are due to a small number of low-back pain sufferers, i.e. those suffering a prolonged disability. No study has demonstrated that these cases were more severe from a clinical point of view and insurers know that some cases generate excessively high costs without identified clinical severity. In order to reduce the costs associated with these long term costly disability cases, the authors have developed a comprehensive model of management of subacute occupational back pain, linking workplace, clinical and rehabilitation interventions. The model was proven effective at one year follow-up in speeding up return to the regular work, through a population based randomized clinical trial.

Methods. The cluster randomization design of the study ended to four arms: control arm (usual care, n= 26), clinical and rehabilitation intervention arm (n= 31), occupational intervention arm (n= 22) and full intervention arm adding clinical, rehabilitation and occupational interventions (n= 25). In the province of Quebec (Canada), all health care and income compensation costs due to work accidents for all the workforce are compensated by a single WCB (CSST). The costs generated by the back pain episode were calculated for each study worker in the CSST files at a mean follow-up of 6.4 years (range = 5.1to7.5). Costs generated by the interventions of the applied model were also calculated for each worker. Total and mean costs and total duration of absence from work were compiled in each randomization arm for all workers. The cost-benefit analysis calculated the amount of dollars saved by each 100$ dollar spent in the experimental interventions and the cost-effectiveness analysis calculated the costs for each saved day of absence from work in the experimental arms compared to the control arm.

Results. All experimental interventions were cost beneficial at the 6.4 year follow-up. For each $100 spent in experimental intervention costs, $496 were saved in the clinical arm, $2, 128 in the occupational arm and $562 in the combined Sherbrooke model arm. During the total follow-up period, the mean costs of the intervention per saved day of work absence were $13.53 in the clinical arm, $4.13 in the occupational arm and $11.24 in the Sherbrooke model arm. The total number of saved days of absence from work was 239.6 days for the clinical arm, 190.3 days for the occupational arm and 292.7 days for the Sherbrooke model arm. These results were mainly explained by a few cases that became chronic in the control arm.

Discussion. The hypothesis that investment in appropriate interventions paid off in the long term was confirmed. However the differences between the occupational arm, the clinical and rehabilitation arm and the combined intervention arm were not important. It is possible that an intervention close to the worker and aimed at return to work is by itself cost-effective in the long term and prevent some patients from long and costly disability.

Corresponding address:

Patrick Loisel, MD, FRCP(C)
Department of Surgery
Sherbrooke University
1111 St Charles Ouest #101
Longueuil, PQ J4K 5G4
Canada
Tel: +1 450 674 5908
Fax: +1 450 674 5237

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The PREVICAP Program: An Application of the Sherbrooke Model

Patrick Loisel, MD, FRCP(C)

Occupational back pain has the now well known characteristic of leading to prolonged disability in a limited but significant number of cases[4]. Recent studies have emphasized the need of a collaborative approach between stakeholders in the work disability process[5]. Reducing the occurrence of cases leading to prolonged disability is not only a matter of rehabilitation procedures but mainly a matter of appropriate management from the early stage of disability. Several studies have demonstrated the effectiveness of an early appropriate management, and we have designed in the early nineties a model of management (Sherbrooke model) which was tested through a population based randomized controlled trial[6]. The trial has demonstrated that linking an occupational intervention and a clinical intervention in the management of subacute occupational back pain (one to three months of absence from work) was highly effective in reducing disability to work by speeding up the return to the regular work (x 2.4) in comparison with usual care. The occupational intervention was the most effective in the result. Moreover, at a six year follow-up the model was shown to be cost beneficial (100 $ returned 562 $) and cost effective on the saved days of absence (the cost for each saved day of absence was only 11.24 CAN$).

Since these results, recent evidence tell us that the essentials for a successful return to work are reassurance upon the benign condition of back pain, encouragement to early return to normal activity and early support in the workplace facilitating progressive return to normal work. Moreover, a dialogue between the stakeholders in the disability problem, worker, employer, payer and health care provider (instead of separate or adversarial management) is key for an early successful return to work. Based on these premises, we developed the PREVICAP program and implemented it in Montreal south area in a university hospital (H™pital Charles LeMoyne) occupational rehabilitation facility. Workers are referred to the program by the Quebec workers compensation board (CSST) or by employers at a subacute or chronic stage of the disability process. Management of these cases is both clinical and occupational in the following way, applying the philosophy of the Sherbrooke model.

The first step is a disability (not disease) diagnostic step to identify the various physical, psychosocial, occupational and administrative factors possibly impeding the return to work. The following step is a work rehabilitation process named therapeutic return to work (TRW). This process combines development of physical capacities related to work, psychosocial and occupational intervention as needed following evaluation of the worker and the job demands. TRW is made in close relationship with the stakeholders in the disability problem: worker, employer, insurer, attending physician. Job modifications may be recommended and their implementation is monitored. The rehabilitation process is quickly and progressively transferred from the clinical setting to the workplace. At the end of the process, the worker is working at full duties or, if not possible, early oriented towards a different job or vocational rehabilitation. Present discussions with the Quebec WCB are underway to develop at the provincial level an occupational rehabilitation network to deliver the program for most Quebec workers having musculoskeletal disabilities before chronicity is installed.

[4} Spitzer WO, LeBlanc FE, Dupuis M. Scientific approach to the assessment and management of activity-related spinal disorders. Spine ; 1987 ; 12, 7S.
[5] Frank JW., Brooker AS., DeMaio SE., Kerr MS., Maetzel A., Shannon HS., Sullivan TJ., Norman RW., Wells RP., 1996a. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 21(24), 2918-29.
[6] Loisel P, Abenhaim L, Durand P, Esdaile JM, Suissa S, Gosselin L, Simard R, Turcotte J, Lemaire J. A Population Based Randomized Clinical Trial on Back Pain Management. Spine, 1997; 22 : 2911-18

Corresponding address:

Patrick Loisel, MD, FRCP(C)
Department of Surgery
Sherbrooke University
1111 St Charles Ouest #101
Longueuil, PQ J4K 5G4
Canada

Tel: +1 450 674 5908
Fax: +1 450 674 5237

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The Assessment of Stress and Disability

Chris J. Main PhD, FBPsS

There are a range of clinical instruments to measure stress. Stress is a broad term which includes distress as well as emotionally coloured beliefs and behaviour. The G.H.Q., or the HAD, validated originally on psychiatric populations which give a measure of distress (in terms of generalised anxiety or depression) which can be interpreted as a measure or severity or in terms of psychiatric ãcasenessä. There are also the Beck anxiety and depression scales.Ê The first three clinical scales of the MMPI and MMPI-2 also yieldÊ a measure of distress. A difficulty with the use of such instruments in the context of pain and disability is that the patients (or workers) are not psychiatrically ill. The D.R.A.M., which gives a measure of somatic anxiety and depressive symptomatology) has been validated specifically on low back populations andÊ appears to be useful as a clinical screener of the need for further evaluation, or careful management.

Such measures however do not determine the extent to which the distress is pain- or disability- specific and more focused measures may needed to guage the emotional response to treatment and rehabilitation. A large number of cognitive measures are available. Clinically, the most important parameters would appear to beÊ beliefs about the nature of pain, its controllability and the probable future course of symptoms. Pessimistic views about the likely future course of symptoms can be identified using the Catastrophising scale of the CSQ. Specific fears of hurting and harming can be assessed using the FABQ or the TSK. A more behavioural indicator of stress is the Behavioural Signs test (although its interpretation has elicited controversy). In summary, global ãstress measuresä are useful onlyÊ 1^st stage screening and do not offer a pain- or disability-specific assessment.

Disability can be assessed by self-report