Establishing Central Sensitization-Related Symptom Severity Subgroups: A Multicountry Study Using the Central Sensitization Inventory.

OBJECTIVES: The goal of this study was to identify central sensitization-related symptom severity subgroups in a large multicountry sample composed of patients with chronic pain and pain-free individuals using the Central Sensitization Inventory (CSI). METHODS: A large, pooled international (N = 8 countries) sample of chronic pain patients plus healthy subjects (total N = 2,620) was randomly divided into two subsamples for cross-validation purposes. First, a hierarchical cluster analysis (HCA) was performed using CSI item-level data as clustering variables (test sample; N = 1,312). Second, a latent profile analysis (LPA) was conducted to confirm the optimal number of CSI clusters (validation sample; N = 1,308). Finally, to promote implementation in real-world clinical practice, we built a free online Central Sensitization Inventory Symptom Severity Calculator. RESULTS: In both HCA (N = 1,219 valid cases) and LPA (N = 1,245 valid cases) analyses, a three-cluster and three-profile solution, respectively, emerged as the most statistically optimal and clinically meaningful. Clusters were labeled as follows: (i) Low Level of CS-Related Symptom Severity, (ii) Medium Level of CS-Related Symptom Severity, and (iii) High Level of CS-Related Symptom Severity. CONCLUSIONS: Our results indicated that a three-cluster solution clearly captured the heterogeneity of the CSI data. The calculator might provide an efficient way of classifying subjects into the cluster groups. Future studies should analyze the extent to which the CSI cluster classification correlates with other patient-reported and objective signs and symptoms of CS in patients with chronic pain, their associations with clinical outcomes, health-related costs, biomarkers, (etc.), and responsiveness to treatment.

Does the Length of Disability between Injury and Functional Restoration Program Entry Affect Treatment Outcomes for Patients with Chronic Disabling Occupational Musculoskeletal Disorders?

Purpose Functional restoration programs (FRPs), for patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), have consistently demonstrated positive socioeconomic treatment outcomes, including decreased psychosocial distress and increased work return. The pre-treatment length of disability (LOD), or time between injury and treatment admission, has been shown to influence FRP work outcomes. Some studies have found that shorter LOD is associated with better work outcomes. However, few studies have actually examined cohorts with LOD duration longer than 18 months. This present study evaluated the effects of extended LOD (beyond 18 months) on important treatment outcomes. Methods A total cohort of 1413 CDOMD patients entered an FRP. Of those, 312 did not complete the program, so they were eliminated from outcome analyses. The 1101 patients who completed the FRP were classified based on LOD: Late Rehabilitation (LR, 3-6 months, n = 190); Chronic Disability (CD, 7-17 months, n = 494); and Late Chronic Disability (LCD). The LCD, in turn, consisted of four separate subgroups: 18-23 months (LCD-18, n = 110); 24-35 months (LCD-24, n = 123); 36-71 months (LCD-36, n = 74); and 72+ months (LCD-72, n = 110). Patients were evaluated upon admission and were reassessed at discharge. Those patients who chose to pursue work goals post-treatment (n = 912) were assessed 1-year later. Results Longer LOD was associated with less likelihood of completing the FRP (p < .001). Compared to the other LOD groups, a relatively large percentage of patients (47%) in the longest- disability group were receiving social security disability benefits. Associations were found between longer LOD and more severe patient-reported pain, disability, and depressive symptoms at treatment admission. At discharge, symptom severity decreased for these patient-reported variables in all LOD groups (p < .001). Using binary logistic regressions, it was found that LOD significantly predicted work-return (Wald = 11.672, p = .04) and work-retention (Wald = 11.811, p = .04) after controlling for covariates. Based on the LOD groups, the percentage of patients returning to, and retaining work, ranged from 75.6 to 94.1%, and from 66.7 to 86.3%, respectively. The odds of LCD-24 and LCD-72 patients returning to work were 2.9, and 7.4, respectfully, less likely, compared to LR patients. Furthermore, the odds of LCD-24 and LCD-72 patients retaining work were 3.3 and 3.8 times, respectively, less likely, compared to LR patients. Conclusions Long LOD was a risk factor for FRP non-completion, and was associated with more severe patient-reported variables, including pain intensity and perceived disability. Furthermore, long LOD was a significant predictor for work outcomes at 1 year following FRP discharge. Nevertheless, a large percentage of longer LOD (>24 months) patients had returned to work within the year after discharge (above 85%), and had retained at least part-time work 1-year later (above 66%). These results support the effectiveness of the FRP in mitigating the effects of extended LOD in a large percentage of long-term LOD patients.

Establishing Clinically Relevant Severity Levels for the Central Sensitization Inventory.

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

The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance.

Pain-related fear avoidance (FA), a common problem for patients with painful medical conditions, involves pain-related catastrophizing cognitions, hypervigilance, and avoidance behaviors, which can ultimately lead to decreased functioning, depression, and disability. Several patient-reported instruments have been developed to measure FA, but they have been criticized for limited construct validity, inadequate item specificity, lack of cutoff scores, and missing important FA components. The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Psychometric evaluation of the FACS found high internal consistency (α = 0.92) and high test/retest reliability (r = 0.90-0.94, P < 0.01). FACS scores differentiated between 2 separate chronic pain patient samples and a nonpatient comparison group. When clinically relevant severity levels were created, FACS severity scores were highly associated with FA-related patient-reported psychosocial and objective lifting performance variables. These results suggest that the FACS is a psychometrically strong and reliable measure that can help healthcare providers assess FA-related barriers to function and recovery.

The Potential Utility of the Patient Health Questionnaire as a Screener for Psychiatric Comorbidity in a Chronic Disabling Occupational Musculoskeletal Disorder Population.

OBJECTIVES: The patient health questionnaire (PHQ) is designed for screening psychopathology in primary care settings. However, little is known about its clinical utility in other chronic pain populations, which usually have high psychiatric comorbidities. DESIGN: A consecutive cohort of 546 patients with chronic disabling occupational musculoskeletal disorder (CDOMD) was administered and compared upon psychosocial assessments, including the PHQ and a structured clinical interview for DSM-IV (SCID). Four PHQ modules were assessed: major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and alcohol use disorders (AUD) [including both alcohol abuse and dependence]. Based on the SCID diagnosis, sensitivity and specificity were determined. RESULTS: The specificity of the PHQ ranged from moderate to high for all 4 PHQ modules (MDD, 0.79; GAD, 0.67; PD, 0.89; AUD, 0.97). However, the sensitivity was relatively low: MDD (0.58); GAD (0.61); PD (0.49); and AUD (0.24). The PHQ was also associated with psychosocial variables. Patients whose PHQ showed MDD, GAD, or PD reported significantly more depressive symptoms and perceived disability than patients who did not (Ps < 0.001). Patients with MDD or GAD reported significantly higher pain than those without (Ps < 0.001). CONCLUSIONS: The strong specificity of the PHQ appears to be its primary strength for this cohort. Due to its high specificity, the PHQ could be employed as an additional screening tool to help rule out potential psychiatric comorbidity in patients with CDOMD. The low sensitivity of the PHQ in this population, however, remains a weakness of the PHQ.

Cost-effectiveness of early versus delayed functional restoration for chronic disabling occupational musculoskeletal disorders.

PURPOSE: Despite extensive evidence for the treatment effectiveness of interdisciplinary functional restoration (FR) for chronic disabling occupational musculoskeletal disorders (CDOMD), there is little documentation on the cost-effectiveness of early rehabilitation using FR. METHODS: A total of 1,119 CDOMD patients were classified according to duration of disability on FR entry, corresponding to early rehabilitation (ER: 4-8 months of disability, N = 373), intermediate duration (ID: 9-18 months, N = 373), and delayed rehabilitation (DR: >18 months, N = 373). Groups were matched on sex, age, ethnicity, and injured musculoskeletal region. One-year post-rehabilitation outcomes included return-to-work, work retention and healthcare utilization. Economic analyses included a cost-effectiveness analysis of the FR program, and estimation of the total cost-of-illness. RESULTS: At 1-year post-rehabilitation, all groups were comparable on return-to-work (overall 88%), work retention (overall 80%), and additional healthcare utilization (overall, 2.2% of patients received re-operations/new surgeries, 2 visits to new healthcare provider). Savings of up to 64% in medical costs, and up to 80% in disability benefits and productivity losses was associated with the ER group. The cost of rehabilitation was also up to 56% lower when administered early. Overall, ER resulted in estimated cost savings of up to 72% (or almost $170,000 per claim). CONCLUSIONS: Duration of disability does not negatively impact objective work or healthcare utilization outcomes following interdisciplinary FR. However, early rehabilitation is more likely to be a cost-effective solution compared to cases that progress >8 months and receiving FR as a treatment of "last resort".

Does the economy affect functional restoration outcomes for patients with chronic disabling occupational musculoskeletal disorders?

PURPOSE: To determine how the economy affects psychosocial and socioeconomic treatment outcomes in a cohort of chronic disabling occupational musculoskeletal disorder (CDOMD) patients who completed a functional restoration program (FRP). METHODS: A cohort of 969 CDOMD patients with active workers' compensation claims completed an FRP (a medically-supervised, quantitatively-directed exercise progression program, with multi-modal disability management). A good economy (GE) group (n = 532) was released to work during a low unemployment period (2005-2007), and a poor economy (PE) group (n = 437) was released during a higher unemployment period (2008-2010). Patients were evaluated upon admission for demographic and psychosocial variables, and were reassessed at discharge. Socioeconomic outcomes, including work return and work retention 1 year post-discharge, were collected. RESULTS: Some significant differences in psychosocial self-report data were found, but most of the effect sizes were small, so caution should be made when interpreting the data. Compared to the PE group, the GE group reported more depressive symptoms and disability at admission, but demonstrated a larger decrease in depressive symptoms and disability and increase in self-reported quality of life at discharge. The PE group had lower rates of work return and retention 1-year after discharge, even after controlling for other factors such as length of disability and admission work status. CONCLUSIONS: CDOMD patients who completed an FRP in a PE year were less likely to return to, or retain, work 1-year after discharge, demonstrating that a PE can be an additional barrier to post-discharge work outcomes. A difference in State unemployment rates of <3% (7 vs. 5%) had a disproportionate effect on patients' failure to return to (19 vs. 6%) or retain (28 vs. 15%) work.

The clinical utility of the Multidimensional Pain Inventory (MPI) in characterizing chronic disabling occupational musculoskeletal disorders.

PURPOSE: The Multidimensional Pain Inventory (MPI) was designed to help capture unique characteristics of chronic pain patients. The present study examined the proportion of subgroups classified by the MPI in a chronic disabling occupational musculoskeletal disorder (CDOMD) patient cohort, and described characteristics of MPI profile groups in terms of other psychosocial variables. METHODS: A cohort of 1,270 CDOMD patients undergoing an interdisciplinary functional restoration program was studied. Before the start of the program, all patients received a standard psychosocial assessment battery. A MPI computer program scored and identified pre-defined MPI subgroups: Adaptive Coper (AC); Interpersonally Distressed (ID); and Dysfunctional (DYS). RESULTS: The distribution of MPI profiles for CDOMD patients was similar with those of highly disabled patients, with the largest proportion of patients having the DYS profile (44 %), followed by AC (33 %) and ID (23 %). The DYS profile group showed the highest level of pain severity, and psychosocial distress; the ID group had a moderate level; and the AC profile group had the lowest level. Higher rates of psychiatric disorders were also found in the DYS and ID groups. The DYS profile group was less likely to complete the treatment program. CONCLUSION: The present study further demonstrated the clinical utility of the MPI classification in a large cohort of CDOMD patients, indicating that the MPI profiles successfully distinguish among patients who may require extra psychosocial attention to achieve successful treatment gains and program completion.

Prediction of failure to retain work 1 year after interdisciplinary functional restoration in occupational injuries.

OBJECTIVE: To identify risk factors for work retention (a patients' ability to both obtain and retain employment) at 1 year after treatment for a chronic disabling occupational musculoskeletal disorder (CDOMD). DESIGN: Prospective cohort study. SETTING: Consecutive patients undergoing interdisciplinary functional restoration treatment in a regional rehabilitation referral center. PARTICIPANTS: A sample of 1850 consecutive CDOMD patients, who were admitted to and completed a functional restoration program, were subsequently classified as work retention or nonwork retention at a 1-year posttreatment evaluation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measures, including medical evaluations, demographic and occupational data, psychosocial diagnostic evaluation, and validated measures of pain, disability, and depressive symptoms, were obtained at admission to, and discharge from, the program. RESULTS: Using a multivariate logistic regression analysis, the following variables were found to be significant predictors of failure to retain work: older age (odds ratio [OR]=1.84; 95% confidence interval [CI], 1.33-2.54), female sex (OR=1.46; 95% CI, 1.09-1.94), nonworking status at discharge (OR=1.65; 95% CI, 1.11-2.45), extreme disability at admission (OR=1.46; 95% CI, 1.06-2.00), antisocial personality disorder (OR=2.11; 95% CI, 1.09-4.08), receipt of government disability benefits at admission (OR=2.28; 95% CI, 1.06-4.89), and dependence on opiate pain medications (OR=1.43; 95% CI, 1.02-2.00). The final model improved prediction by 75% over assigning all patients to the larger (work retention) group. CONCLUSIONS: This study identified demographic, psychosocial, and occupational factors that were predictive of failure to retain work. These risk factors may be used to individualize treatment plans for CDOMD patients in order to provide optimal functional restoration.

The development and psychometric validation of the central sensitization inventory.

Central sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term "central sensitivity syndrome (CSS)" has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs and quantifies the degree of these symptoms. The utility of the CSI, to differentiate among different types of chronic pain patients who presumably have different levels of CS impairment, was then evaluated. Study 1 demonstrated strong psychometric properties (test-retest reliability = 0.817; Cronbach's alpha = 0.879) of the CSI in a cohort of normative subjects. A factor analysis (including both normative and chronic pain subjects) yielded 4 major factors (all related to somatic and emotional symptoms), accounting for 53.4% of the variance in the dataset. In Study 2, the CSI was administered to 4 groups: fibromyalgia (FM); chronic widespread pain without FM; work-related regional chronic low back pain (CLBP); and normative control group. Analyses revealed that the patients with FM reported the highest CSI scores and the normative population the lowest (P < 0.05). Analyses also demonstrated that the prevalence of previously diagnosed CSSs and related disorders was highest in the FM group and lowest in the normative group (P < 0.001). Taken together, these 2 studies demonstrate the psychometric strength, clinical utility, and the initial construct validity of the CSI in evaluating CS-related clinical symptoms in chronic pain populations.

The Pain Anxiety Symptoms Scale fails to discriminate pain or anxiety in a chronic disabling occupational musculoskeletal disorder population.

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

Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: analysis of treatment-resistant personality characteristics.

OBJECTIVE: To identify the risk factors for noncompletion of a functional restoration program for patients with chronic disabling occupational musculoskeletal disorders. DESIGN: Prospective cohort study. SETTING: Consecutive patients undergoing functional restoration treatment in a regional rehabilitation referral center. PARTICIPANTS: A sample of 3052 consecutive patients, classified as either completers (n=2367) or noncompleters (n=685), who entered a functional restoration program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The measures used included medical evaluations, demographic data, Diagnostic and Statistical Manual of Mental Disorders psychiatric diagnoses, the Minnesota Multiphasic Personality Inventory, and validated questionnaires evaluating pain, depression, and occupational factors. RESULTS: The findings revealed that patients who did not complete the program had a longer duration of total disability between injury and admission to treatment (completers=20mo vs noncompleters=13mo; P<.001). Furthermore, patients who were opioid-dependent were 1.5 times more likely to drop out of rehabilitation, and patients diagnosed with a socially problematic Cluster B Personality Disorder were 1.6 times more likely to drop out. CONCLUSIONS: Although some risk factors associated with program noncompletion may be addressed in treatment, socially maladaptive personality disorders, long-neglected disability, and chronic opioid dependence are the major barriers to successful treatment completion. The patients identified with personality disorders may display resistance to treatment and may be difficult for the treatment staff to deal with. Early recognition of these treatment-resistant personality characteristics in the functional restoration process may assist the treatment team in developing more effective strategies to help this dysfunctional group.

Evidence-informed management of chronic low back pain with functional restoration.

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

Psychological evaluation of the spine patient.

The biopsychosocial perspective focuses on the interaction among biologic, psychological, and medicolegal variables of patients coping with a persistent medical condition. It is considered the most comprehensive and heuristic approach to psychological evaluation in the spine patient. Assessment proceeds in three steps, from global indices of emotional distress to evaluation of more specific diagnoses of psychopathology. Step 1, the initial screening, uses psychometrically sound instruments to determine the level of patient distress. Step 2, the psychosocial interview, indicates whether additional psychological testing is needed. Step 3, the presurgical evaluation, assesses patients being considered for a surgical procedure. This stepwise assessment approach significantly aids in yielding evidence-based outcomes as well as in identifying the patient who may be most recalcitrant to treatment intervention.

Dimensionality and Reliability of the Central Sensitization Inventory in a Pooled Multicountry Sample.

Central sensitization (CS) involves the amplification of neural signaling within the central nervous system, which evokes pain hypersensitivity. The Central Sensitization Inventory (CSI) assesses 25 overlapping health-related symptom dimensions that have been reported to be associated with CS-related disorders. Previous studies have reported satisfactory test-retest reliability and internal consistency, but factor analyses have exhibited conflicting results in different language versions. The purpose of this cross-sectional study was to thoroughly examine the dimensionality and reliability of the CSI, with pooled data from 1,987 individuals, collected in several countries. The principal component analysis suggested that 1 general factor of CS best described the structure. A subsequent confirmatory factor analysis revealed that a bifactor model, which accounted for the covariance among CSI items, with regard to 1 general factor and 4 orthogonal factors, fit the CSI structure better than the unidimensional and the 4-factor models. Additional analyses indicated substantial reliability for the general factor (ie, Cronbach α = .92; ω = .95; and ω hierarchical = .89). Reliability results for the 4 specific factors were considered too low to be used for subscales. The results of this study clearly suggest that only total CSI scores should be used and reported. PERSPECTIVE: As far as we know, this is the first study that has examined the factor structure and reliability of the CSI in a large multicountry sample. The CSI is currently considered the leading self-report measure of CS-related symptoms worldwide.

Use of the Central Sensitization Inventory (CSI) as a treatment outcome measure for patients with chronic spinal pain disorder in a functional restoration program.

BACKGROUND CONTEXT: The Central Sensitization Inventory (CSI) is a valid and reliable patient-reported instrument designed to identify patients whose presenting symptoms may be related to central sensitization (CS). Part A of the CSI measures a full array of 25 somatic and emotional symptoms associated with CS, and Part B asks if patients have previously been diagnosed with one or more specific central sensitivity syndromes (CSSs) and related disorders. The CSI has previously been validated in a group of patients with chronic pain who were screened by a trained psychiatrist for specific CSS diagnoses. It is currently unknown if the CSI can be a useful treatment-outcome assessment tool for patients with chronic spinal pain disorder (CSPD) who are not screened for comorbid CSSs. It is known, however, that previous studies have identified CS-related symptoms, and comorbid CSSs, in subsets of patients with CSPDs. Studies have also shown that CS-related symptoms can be influenced by cognitive and psychosocial factors, including abuse history in both childhood and adulthood, sleep disturbance, catastrophic and fear-avoidant cognitions, and symptoms of depression and anxiety. PURPOSE: This study aimed to evaluate CSI scores, and their associations with other clinically relevant psychosocial variables, in a cohort of patients with CSPD who entered and completed a functional restoration program. STUDY DESIGN/SETTING: A retrospective study of prospectively collected data from a cohort study of patients with CSPD, who completed the CSI at admission to, and discharge from, an interdisciplinary function restoration program (FRP) was carried out. PATIENT SAMPLE: A cohort of 763 patients with CSPD comprised the study sample. OUTCOME MEASURES: Clinical interviews evaluated mood disorders and abuse history. A series of self-reported measures evaluated comorbid psychosocial symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance, at FRP admission and discharge. METHODS: Patients were grouped into five severity level groups, from mild to extreme, based on total CSI scores, at FRP admission, and then again at discharge. The FRP included a quantitatively directed and medically supervised exercise process, as well as a multimodal psychosocial disability management component. RESULTS: The CSI severity groups were strongly associated with Major Depressive Disorder and previous abuse history (p<.01), which are known risk factors for CS-related symptoms and diagnoses. The CSI scores were also strongly associated with patient-reported CSS diagnoses on CSI Part B. The percentage of patients who reported a comorbid CSS diagnosis increased in each higher CSI-severity group, from 11% in the Subclinical group, to 56% in the Extreme group. The CSI severity groups were significantly related to other CS-related patient-reported symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance (p's<.001). The CSI scores, along with all other psychosocial measures, decreased at treatment discharge. CONCLUSIONS: In the present study, admission CSI scores were highly associated with previous CSS diagnoses, CS-related symptoms, and clinically relevant patient-reported psychosocial variables. All psychosocial variables, as well as scores on the CSI, were significantly improved at FRP discharge. The CSI may have important clinical utility, as a screener and as a treatment outcome measure, for patients with CSPD participating in an interdisciplinary FRP.

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population.

OBJECTIVES: To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure. MATERIALS AND METHODS: In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge. Associations with objective lifting performance and other patient-reported psychosocial measures were determined at admission and discharge, and objective work outcomes for this predominantly disabled cohort, were assessed 1 year later. RESULTS: Those patients in the severe and extreme FACS severity groups at admission were more likely to "drop out" of treatment than those in the lower severity groups (P=0.05). At both admission and discharge, the FACS severity groups were highly and inversely correlated with objective lifting performance and patient-reported fear-avoidance-related psychosocial variables, including kinesiophobia, pain intensity, depressive symptoms, perceived disability, perceived injustice, and insomnia (Ps<0.001). All variables showed improvement at FRP discharge. Patients in the extreme FACS severity group at discharge were less likely to return to, or retain, work 1 year later (P≤0.02). A factor analysis identified a 2-factor solution. DISCUSSION: Strong associations were found among FACS scores and other patient-reported psychosocial and objective lifting performance variables at both admission and discharge. High discharge-FACS scores were associated with worse work outcomes 1 year after discharge. The FACS seems to be a valid and clinically useful measure for predicting attendance, physical performance, distress, and relevant work outcomes in FRP treatment of chronic musculoskeletal pain disorder patients.

High pain ratings predict treatment failure in chronic occupational musculoskeletal disorders.

BACKGROUND: Pain intensity is one of the most widely used measures in the treatment of patients with chronic disabling occupational musculoskeletal disorders. Few studies have comprehensively investigated the relationship of pain intensity at the time of rehabilitation to objective socioeconomic outcomes at one year after treatment. This study evaluated the ability of pain intensity ratings, measured with a visual analog scale, to predict rehabilitation outcomes and to identify patients who are "at risk" for a poor outcome. METHODS: A cohort of 3106 patients with chronic disabling occupational musculoskeletal disorders in a multidisciplinary occupational tertiary rehabilitation program was divided into four groups on the basis of the pain intensity ratings (0 to 3, 4 to 5, 6 to 7, and 8 to 10) before and after rehabilitation. A structured interview to assess the socioeconomic outcomes, including work status, health-care utilization, recurrent injury, and whether there had been resolution of Workers' Compensation or third-party financial disputes, was conducted one year after rehabilitation. RESULTS: High pain intensity before rehabilitation was linearly associated with declining rates of program completion and higher rates of self-reported depression and disability after rehabilitation. Although higher pain ratings both before and after rehabilitation were associated linearly with a declining quality of socioeconomic outcomes, extremely high pain ratings (8 to 10) after rehabilitation were most predictive of poor outcomes. At the post-rehabilitation evaluation, patients with extreme pain were far more likely than those with mild pain to seek surgical treatment (risk ratio = 11.2 [95% confidence interval, 4.3, 29.5]) or to persist in seeking health care from new providers (risk ratio = 3.3 [95% confidence interval, 2.4, 4.5]). They were less likely to either return to work (risk ratio = 3.9 [95% confidence interval, 2.6, 6.0]) or to retain work (risk ratio = 4.2 [95% confidence interval, 2.9, 6.0]). They were also twice as likely to claim a new injury to the same musculoskeletal site after returning to work and to fail to settle Workers' Compensation or third-party financial disputes. CONCLUSIONS: High pain ratings before rehabilitation are associated with higher rehabilitation dropout rates. The patients with chronic disabling occupational musculoskeletal disorders who reported extreme pain after completing a full course of extended treatment (13% of 2573) were at risk for poor outcomes in terms of lost productivity, high utilization of health care, and cost-shifting of state Workers' Compensation payments to federal resources.

Reliability of a visual analog version of the QuickDASH.

BACKGROUND: The QuickDASH, an abbreviated form of the Disabilities of the Arm, Shoulder and Hand Questionnaire, uses a graded-adjectives ordinal measurement response scale. In order to improve the sensitivity of the measure and to make it compatible with widely used measures of pain and disability, a visual analog scale version was developed. The present study investigated the reliability of the new version over time when used for the evaluation of patients undergoing treatment. METHODS: A test-retest model with a two-day interval was used to evaluate a sample of thirty-eight consecutive patients in an interdisciplinary tertiary rehabilitation setting who were identified as having an upper extremity disorder. RESULTS: The intraclass correlation coefficient indicating test-retest reliability was 0.90 for the eleven-item QuickDASH visual analog scale questionnaire (without the work component) and 0.94 for the fifteen-item questionnaire (with the work component), neither of which was significantly different from the results reported for the original questionnaire. CONCLUSIONS: The QuickDASH visual analog scale questionnaire has acceptable reliability over time, and it can be used as an alternative to the original QuickDASH.

Improved functional capacity evaluation performance predicts successful return to work one year after completing a functional restoration rehabilitation program.

OBJECTIVE: To evaluate whether functional capacity evaluation (FCE) scores are responsive to functional restoration treatment, and to assess the ability of FCEs at program discharge to predict work outcomes. DESIGN: An interdisciplinary cohort study of prospectively collected data. SETTING: A functional restoration center. PATIENTS: A consecutive sample of 354 patients with chronic disabling occupational musculoskeletal disorders (CDOMDs) completed a functional restoration program consisting of quantitatively directed exercise progression and multi-modal disability management with interdisciplinary medical supervision. METHODS: Each patient participated in an FCE at admission and discharge from treatment. The results of each FCE yielded the physical demand level (PDL) at which patients were functioning. Patients were initially divided into 5 PDL groups, based on job-of-injury lifting, carrying, and pushing/pulling requirements, for the pre- to posttreatment responsiveness analyses. Patients were subsequently divided into 5 PDL groups, based on their performance on the FCE upon program completion. MAIN OUTCOME MEASURES: Outcome measures included admission-to-discharge changes in PDLs and 2 specific FCE lifting tasks: isokinetic lifting; and the Progressive Isoinertial Lifting Evaluation (PILE). Socioeconomic outcomes were also evaluated, including post-discharge work return and work retention 1-year after treatment completion. RESULTS: Overall, 96% of the patients demonstrated improvement in their PDLs from admission to discharge. A majority of patients (56%) were able to achieve a discharge PDL that was comparable to their estimated job-of-injury lifting requirement or higher (P < .001). Lifting ability improved from admission to discharge by approximately 50% (all P < .001). Discharge PDLs predicted both work return (P < .001) and work retention (P < .001) 1 year later. CONCLUSIONS: FCE scores were responsive to functional restoration treatment, and the associated discharge PDLs predicted work return after treatment completion and work retention 1 year later.