ORIGINAL ARTICLE
Evaluation of Functional Restoration Outcomes for Chronic Disabling Occupational Cervical Disorders Meredith M. Hartzell, MS, Tom G. Mayer, MD, Sali Asih, MS, Randy Neblett, MA, LPC, BCB, and Robert J. Gatchel, PhD, ABPP Objective: To systematically evaluate the effectiveness of an interdisciplinary functional restoration program (FRP) for treating chronic cervical disorders. Methods: Consecutive chronic occupational lumbar disorder patients (n = 898) and chronic occupational cervical disorder patients (n = 215) were admitted to an FRP from 2001 to 2011. Patients were compared on demographics, work-related and psychosocial factors, and socioeconomic outcomes 1 year after discharge. Results: Compared with lumbar patients, cervical patients were more likely to be female, have preadmission surgery, perform white-collar work, and have a longer time between injury and treatment admission. Cervical patients were similar to lumbar patients on most psychosocial self-report outcome measures. In addition, both groups exhibited high work return and work retention rates 1 year after FRP discharge. Conclusions: An FRP seems to be equally efficacious for treating both chronic occupational cervical and lumbar disorders.
O
ccupational musculoskeletal injuries are highly prevalent and account for higher costs to the US health care system than any other occupational disorder.1 For back and neck pain alone, it is estimated that $100 billion is spent annually on health care utilization and work productivity losses.2 Among musculoskeletal injuries, the majority occur in the lumbar spine (45.4%). Because of the high prevalence of injuries to the lumbar spine versus injuries to other body parts, most studies that have evaluated risk factors and treatment methods for work-related musculoskeletal disorders have looked at chronic lumbar disorder populations only. Occupational cervical injuries are ubiquitous, however, and prevalence varies across occupations, with 17% to 48% in office and computer workers,3–7 17% to 85% in dentists,8,9 and 13% in electric utility workers.10 With the increasing use of computers and other sedentary work, cervical injuries have become a significant and growing predictor of time away from work in the general working population,11 especially for white-collar workers.12 In addition, whiplash from motor vehicle accidents is quite common. It is estimated that up to 60% of patients with whiplash develop persistent problems, including chronic cervical pain.13 The results of The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders found a moderate to high prevalence of neck pain in general working population samples in the United Kingdom (33%), Norway (27%), and Canada (48%).8 Furthermore, 11% to 14% of the workers in this study reported limitations in workplace activities because of cervical injuries and/or pain.8 Another study also found a similar result, in which 10% of workers suffered from chronic neck pain associated with functional limitations.14 Last, the rate of reoccurrence of cervical disorders and associated symptoms is between 50% and 85% within 1 to 5 years after the initial episode.15 From the PRIDE Research Foundation (Ms Hartzell and Ms Asih and Ms Neblett), Dallas, Tex; Department of Orthopedic Surgery (Dr Mayer), The University of Texas Southwestern Medical Center at Dallas; and Department of Psychology (Dr Gatchel), College of Science, The University of Texas at Arlington. There are no conflicts of interest or sources of funding to declare. Address correspondence to: Tom G. Mayer, MD, Department of Orthopedic Surgery, The University of Texas Southwestern Medical Center at Dallas, 5701 Maple Ave #100, Dallas, TX 75235 ([email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000204
Although cervical disorders are a significant occupational problem, the majority of the occupational injury and rehabilitation literature still focuses on lumbar injuries. This study compared the treatment efficacy of an interdisciplinary functional restoration program (FRP) between chronic occupational cervical and lumbar disorders. An FRP, first introduced by Mayer and Gatchel in 1988, is an interdisciplinary, medically directed program that has consistently demonstrated positive outcomes for patients with chronic occupational musculoskeletal disorders,16 including lumbar disorders17–23 and cervical disorders.24,25 It should also be noted that randomized controlled trials demonstrating positive outcomes of an FRP have been performed in other industrialized nations, including Denmark,26 Germany,27 Canada,28 France,29 and Japan.23 The fact that different clinical treatment teams functioning in different states and different countries, with markedly different economic and social conditions and workers’ compensation (WC) systems, have produced comparable positive outcome results speaks highly for the robustness of the research findings and utility, as well as the fidelity, of this treatment approach for occupational injuries. For injured workers with the US state or federal compensation claims who have been unable to work, or who have been working limited duty, a major goal of an FRP was to help workers return to full function, including full-time and full-duty employment. Therefore, the primary outcomes of this study were socioeconomic, including work return (defined as obtaining employment within the year after treatment discharge), work retention (continuation of employment 1 year after treatment discharge), reduced future health care utilization (additional surgery to the injury site and seeking health care from new providers), and WC case settlement in the year after FRP discharge. In addition to socioeconomic outcomes, patient-reported measures of pain, disability, and depression were evaluated. Because they have been widely studied, and because of the large literature base from which to compare, chronic occupational lumbar disorder patients were chosen as a comparison group for the chronic occupational cervical disorder patients. It was hypothesized that an FRP would be equally as efficacious for both the chronic occupational cervical and lumbar patient groups.
MATERIALS AND METHODS Participants Figure 1 presents the flow of patients in this study. Consecutive patients with either chronic occupational lumbar disorders (n = 1189) or chronic occupational cervical disorders (n = 283) were referred to, and consented to, a prescribed course of an FRP between the years 2001 and 2011. Diagnoses were determined “compensable” for WC claim purposes by the governing jurisdiction, as is common in such claims, and therefore patients without a WC claim were excluded (n = 76). All patients met the following criteria: (1) 4 or more months had passed since work-related injury; (2) nonsurgical care failed to improve symptoms sufficient to allow full return to work; (3) surgery did not resolve the injury or was not an option; (4) severe pain and functional limitations remained; and (5) patients communicated in English or Spanish. Of the total 1472 patients meeting initial criteria who were admitted to the FRP, 359 did not complete the program, leaving 215 program completers in
JOEM r Volume 56, Number 9, September 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
959
JOEM r Volume 56, Number 9, September 2014
Hartzell et al
FIGURE 1. Patient sample flow chart. the cervical group and 898 program completers in the lumbar group for outcome comparisons. Few statistically significant differences existed between the FRP completers and noncompleters, although completers had a shorter length of disability and were less likely to have had a preadmission surgery (P < 0.05).
Procedures The FRP was medically directed and interdisciplinary, combining a quantitatively directed exercise progression protocol with a multimodal disability management approach.30–34 Patients admitted to the FRP first underwent a comprehensive history, physical examination, and psychosocial evaluation, including functional capacity and psychosocial assessment. The patients then participated in a structured exercise program, administered by physical and occupational therapists, which was guided by repeated objective physical measurements, placing the patient into a stepwise computerized progression program, normalized to age, gender, and body mass. The disability management program included cognitive–behavioral therapy, stress management, biofeedback, and pain coping skills, with medical case management to facilitate vocational reintegration. Individual and group educational sessions fostered a greater knowledge of the mechanics of musculoskeletal disorders. Patients were discharged from the program with specific instruction in a fitness maintenance program and pain coping skills. The FRP was medically supervised to allow for simultaneous medication management (including psychotropic medications and opioid tapering), as well as limited interventional procedures (if needed).
Measures Baseline assessments, including demographic information, occupational characteristics, and work status, were collected at the time of admission to the FRP in a structured format. Variables collected included the following: gender; age; ethnicity; length of disability, which is the amount of time that has passed from initial injury to FRP admission; total temporary disability, which is the number of months not working from injury to FRP admission; number of
960
surgeries to the injured area; attorney retention; and compensable body parts (ie, those body parts that were treated as a result of the work-related injury). Work-related variables upon admission to the FRP included current work status, job availability, type of occupation, job satisfaction, and the level of job demand. During the baseline assessment leading to program admission, a mental health evaluation was performed. It included a number of patient-reported outcome questionnaires that were repeated upon discharge. These included the pain visual analog scale (VAS),35 which has a total score ranging from 0 to 10 points; the Oswestry Disability Index,36,37 which assesses perceived disability and has a total score ranging from 0 to 100 points; the Pain Disability Questionnaire,38,39 which assesses psychosocial and functional disabilities and has a total score ranging from 0 to 150 points; and the Beck Depression Inventory (BDI),40 which has a total score ranging from 0 to 63 points. Socioeconomic outcomes were assessed 1 year after treatment. A structured face-to-face or telephone interview was conducted to determine the extent of disability recovery and return to daily activities and was compared to baseline data. The structured interview examined the following three major domains of socioeconomically relevant outcomes: work status, additional health care utilization, and the WC-related case settlement issues.30 A large majority of WC claims follow State of Texas rules, but a significant minority were covered by other state or federal jurisdictions. Return to work was defined as obtaining employment at any time during the year after treatment discharge. Work retention was defined as the ability to retain employment by being at work through 1-year interview. Additional health care utilization assessed new surgery to the original site of injury and seeking health care from a new provider (usually to obtain more intervention or opioid medication). The WC claim–related issues included case settlement rates. All data were prospectively collected as part of the patients’ standard medical charts and, thus, the study was deemed exempt by the institutional review board. The data were later retrospectively evaluated.
C 2014 American College of Occupational and Environmental Medicine
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JOEM r Volume 56, Number 9, September 2014
Statistical Methods For the statistical comparisons of demographic and workrelated variables, independent t tests and chi-square tests were used for continuous variables and categorical variables, respectively. In addition, a repeated-measures analysis of covariance (ANCOVA) was used to compare admission to discharge changes in psychosocial scores, using the significant demographic covariates of total temporary disability preadmission surgeries, attorney retention, and the number of compensable body parts. The significance level was set at α = 0.05. Effect sizes were reported for all significant variables— Cohen’s d was used for continuous variables, and odds ratios were used for categorical variables.
RESULTS Demographic Variables Table 1 summarizes the demographic and injury-specific comparisons between the two patient groups. Cervical patients were more likely to be female, have a longer length of total temporary disability, have an increased number of compensable injuries, have undergone
Functional Restoration Outcomes for Cervical Disorders
surgery prior to FRP admission, and have retained an attorney prior to admission.
Work-Related Variables Table 2 presents the preinjury work-related variables. Cervical patients were more likely to be working white-collar jobs (P < 0.01) and to have lighter job demands, on the basis of the US Department of Labor’s Dictionary of Occupational Titles (P < 0.001).41 There were no differences in the percentage of patients who were working upon admission to the FRP.
Psychosocial and Pain Variables Table 3 presents the psychosocial patient-reported variables. Significant demographic and work-related covariates (eg, age, the length of disability, preadmission surgeries, attorney retention, and the number of compensable body parts) were controlled using an ANCOVA. As shown in Table 3, there were no significant differences between the cervical and lumbar groups on patient-reported outcome pain intensity (VAS), depressive symptoms, or perceived disability, at either FRP admission or discharge. In addition, repeated-measures
TABLE 1. Demographic Differences Between Chronic Occupational Cervical and Lumbar Disorder Patient Groups Entering the Functional Restoration Program, Completers Only (N = 1113) Demographic Variables (Baseline) Gender, n (% male) Age, M (SD), yr Ethnicity, n (%) White African American Hispanic Other Length of disability, M (SD), mo Total temporary disability mo, M (SD), mo Preadmission surgery, n (% yes) Attorney retained, n (% yes) Compensable body parts, M (SD)
Cervical (n = 215)
Lumbar (n = 898)
P
Effect Size (OR/d*)
100 (46.5%) 47.4 (8.5)
610 (67.9%) 45.2 (9.7)
Evaluation of Functional Restoration Outcomes for Chronic Disabling Occupational Cervical Disorders Meredith M. Hartzell, MS, Tom G. Mayer, MD, Sali Asih, MS, Randy Neblett, MA, LPC, BCB, and Robert J. Gatchel, PhD, ABPP Objective: To systematically evaluate the effectiveness of an interdisciplinary functional restoration program (FRP) for treating chronic cervical disorders. Methods: Consecutive chronic occupational lumbar disorder patients (n = 898) and chronic occupational cervical disorder patients (n = 215) were admitted to an FRP from 2001 to 2011. Patients were compared on demographics, work-related and psychosocial factors, and socioeconomic outcomes 1 year after discharge. Results: Compared with lumbar patients, cervical patients were more likely to be female, have preadmission surgery, perform white-collar work, and have a longer time between injury and treatment admission. Cervical patients were similar to lumbar patients on most psychosocial self-report outcome measures. In addition, both groups exhibited high work return and work retention rates 1 year after FRP discharge. Conclusions: An FRP seems to be equally efficacious for treating both chronic occupational cervical and lumbar disorders.
O
ccupational musculoskeletal injuries are highly prevalent and account for higher costs to the US health care system than any other occupational disorder.1 For back and neck pain alone, it is estimated that $100 billion is spent annually on health care utilization and work productivity losses.2 Among musculoskeletal injuries, the majority occur in the lumbar spine (45.4%). Because of the high prevalence of injuries to the lumbar spine versus injuries to other body parts, most studies that have evaluated risk factors and treatment methods for work-related musculoskeletal disorders have looked at chronic lumbar disorder populations only. Occupational cervical injuries are ubiquitous, however, and prevalence varies across occupations, with 17% to 48% in office and computer workers,3–7 17% to 85% in dentists,8,9 and 13% in electric utility workers.10 With the increasing use of computers and other sedentary work, cervical injuries have become a significant and growing predictor of time away from work in the general working population,11 especially for white-collar workers.12 In addition, whiplash from motor vehicle accidents is quite common. It is estimated that up to 60% of patients with whiplash develop persistent problems, including chronic cervical pain.13 The results of The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders found a moderate to high prevalence of neck pain in general working population samples in the United Kingdom (33%), Norway (27%), and Canada (48%).8 Furthermore, 11% to 14% of the workers in this study reported limitations in workplace activities because of cervical injuries and/or pain.8 Another study also found a similar result, in which 10% of workers suffered from chronic neck pain associated with functional limitations.14 Last, the rate of reoccurrence of cervical disorders and associated symptoms is between 50% and 85% within 1 to 5 years after the initial episode.15 From the PRIDE Research Foundation (Ms Hartzell and Ms Asih and Ms Neblett), Dallas, Tex; Department of Orthopedic Surgery (Dr Mayer), The University of Texas Southwestern Medical Center at Dallas; and Department of Psychology (Dr Gatchel), College of Science, The University of Texas at Arlington. There are no conflicts of interest or sources of funding to declare. Address correspondence to: Tom G. Mayer, MD, Department of Orthopedic Surgery, The University of Texas Southwestern Medical Center at Dallas, 5701 Maple Ave #100, Dallas, TX 75235 ([email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000204
Although cervical disorders are a significant occupational problem, the majority of the occupational injury and rehabilitation literature still focuses on lumbar injuries. This study compared the treatment efficacy of an interdisciplinary functional restoration program (FRP) between chronic occupational cervical and lumbar disorders. An FRP, first introduced by Mayer and Gatchel in 1988, is an interdisciplinary, medically directed program that has consistently demonstrated positive outcomes for patients with chronic occupational musculoskeletal disorders,16 including lumbar disorders17–23 and cervical disorders.24,25 It should also be noted that randomized controlled trials demonstrating positive outcomes of an FRP have been performed in other industrialized nations, including Denmark,26 Germany,27 Canada,28 France,29 and Japan.23 The fact that different clinical treatment teams functioning in different states and different countries, with markedly different economic and social conditions and workers’ compensation (WC) systems, have produced comparable positive outcome results speaks highly for the robustness of the research findings and utility, as well as the fidelity, of this treatment approach for occupational injuries. For injured workers with the US state or federal compensation claims who have been unable to work, or who have been working limited duty, a major goal of an FRP was to help workers return to full function, including full-time and full-duty employment. Therefore, the primary outcomes of this study were socioeconomic, including work return (defined as obtaining employment within the year after treatment discharge), work retention (continuation of employment 1 year after treatment discharge), reduced future health care utilization (additional surgery to the injury site and seeking health care from new providers), and WC case settlement in the year after FRP discharge. In addition to socioeconomic outcomes, patient-reported measures of pain, disability, and depression were evaluated. Because they have been widely studied, and because of the large literature base from which to compare, chronic occupational lumbar disorder patients were chosen as a comparison group for the chronic occupational cervical disorder patients. It was hypothesized that an FRP would be equally as efficacious for both the chronic occupational cervical and lumbar patient groups.
MATERIALS AND METHODS Participants Figure 1 presents the flow of patients in this study. Consecutive patients with either chronic occupational lumbar disorders (n = 1189) or chronic occupational cervical disorders (n = 283) were referred to, and consented to, a prescribed course of an FRP between the years 2001 and 2011. Diagnoses were determined “compensable” for WC claim purposes by the governing jurisdiction, as is common in such claims, and therefore patients without a WC claim were excluded (n = 76). All patients met the following criteria: (1) 4 or more months had passed since work-related injury; (2) nonsurgical care failed to improve symptoms sufficient to allow full return to work; (3) surgery did not resolve the injury or was not an option; (4) severe pain and functional limitations remained; and (5) patients communicated in English or Spanish. Of the total 1472 patients meeting initial criteria who were admitted to the FRP, 359 did not complete the program, leaving 215 program completers in
JOEM r Volume 56, Number 9, September 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
959
JOEM r Volume 56, Number 9, September 2014
Hartzell et al
FIGURE 1. Patient sample flow chart. the cervical group and 898 program completers in the lumbar group for outcome comparisons. Few statistically significant differences existed between the FRP completers and noncompleters, although completers had a shorter length of disability and were less likely to have had a preadmission surgery (P < 0.05).
Procedures The FRP was medically directed and interdisciplinary, combining a quantitatively directed exercise progression protocol with a multimodal disability management approach.30–34 Patients admitted to the FRP first underwent a comprehensive history, physical examination, and psychosocial evaluation, including functional capacity and psychosocial assessment. The patients then participated in a structured exercise program, administered by physical and occupational therapists, which was guided by repeated objective physical measurements, placing the patient into a stepwise computerized progression program, normalized to age, gender, and body mass. The disability management program included cognitive–behavioral therapy, stress management, biofeedback, and pain coping skills, with medical case management to facilitate vocational reintegration. Individual and group educational sessions fostered a greater knowledge of the mechanics of musculoskeletal disorders. Patients were discharged from the program with specific instruction in a fitness maintenance program and pain coping skills. The FRP was medically supervised to allow for simultaneous medication management (including psychotropic medications and opioid tapering), as well as limited interventional procedures (if needed).
Measures Baseline assessments, including demographic information, occupational characteristics, and work status, were collected at the time of admission to the FRP in a structured format. Variables collected included the following: gender; age; ethnicity; length of disability, which is the amount of time that has passed from initial injury to FRP admission; total temporary disability, which is the number of months not working from injury to FRP admission; number of
960
surgeries to the injured area; attorney retention; and compensable body parts (ie, those body parts that were treated as a result of the work-related injury). Work-related variables upon admission to the FRP included current work status, job availability, type of occupation, job satisfaction, and the level of job demand. During the baseline assessment leading to program admission, a mental health evaluation was performed. It included a number of patient-reported outcome questionnaires that were repeated upon discharge. These included the pain visual analog scale (VAS),35 which has a total score ranging from 0 to 10 points; the Oswestry Disability Index,36,37 which assesses perceived disability and has a total score ranging from 0 to 100 points; the Pain Disability Questionnaire,38,39 which assesses psychosocial and functional disabilities and has a total score ranging from 0 to 150 points; and the Beck Depression Inventory (BDI),40 which has a total score ranging from 0 to 63 points. Socioeconomic outcomes were assessed 1 year after treatment. A structured face-to-face or telephone interview was conducted to determine the extent of disability recovery and return to daily activities and was compared to baseline data. The structured interview examined the following three major domains of socioeconomically relevant outcomes: work status, additional health care utilization, and the WC-related case settlement issues.30 A large majority of WC claims follow State of Texas rules, but a significant minority were covered by other state or federal jurisdictions. Return to work was defined as obtaining employment at any time during the year after treatment discharge. Work retention was defined as the ability to retain employment by being at work through 1-year interview. Additional health care utilization assessed new surgery to the original site of injury and seeking health care from a new provider (usually to obtain more intervention or opioid medication). The WC claim–related issues included case settlement rates. All data were prospectively collected as part of the patients’ standard medical charts and, thus, the study was deemed exempt by the institutional review board. The data were later retrospectively evaluated.
C 2014 American College of Occupational and Environmental Medicine
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JOEM r Volume 56, Number 9, September 2014
Statistical Methods For the statistical comparisons of demographic and workrelated variables, independent t tests and chi-square tests were used for continuous variables and categorical variables, respectively. In addition, a repeated-measures analysis of covariance (ANCOVA) was used to compare admission to discharge changes in psychosocial scores, using the significant demographic covariates of total temporary disability preadmission surgeries, attorney retention, and the number of compensable body parts. The significance level was set at α = 0.05. Effect sizes were reported for all significant variables— Cohen’s d was used for continuous variables, and odds ratios were used for categorical variables.
RESULTS Demographic Variables Table 1 summarizes the demographic and injury-specific comparisons between the two patient groups. Cervical patients were more likely to be female, have a longer length of total temporary disability, have an increased number of compensable injuries, have undergone
Functional Restoration Outcomes for Cervical Disorders
surgery prior to FRP admission, and have retained an attorney prior to admission.
Work-Related Variables Table 2 presents the preinjury work-related variables. Cervical patients were more likely to be working white-collar jobs (P < 0.01) and to have lighter job demands, on the basis of the US Department of Labor’s Dictionary of Occupational Titles (P < 0.001).41 There were no differences in the percentage of patients who were working upon admission to the FRP.
Psychosocial and Pain Variables Table 3 presents the psychosocial patient-reported variables. Significant demographic and work-related covariates (eg, age, the length of disability, preadmission surgeries, attorney retention, and the number of compensable body parts) were controlled using an ANCOVA. As shown in Table 3, there were no significant differences between the cervical and lumbar groups on patient-reported outcome pain intensity (VAS), depressive symptoms, or perceived disability, at either FRP admission or discharge. In addition, repeated-measures
TABLE 1. Demographic Differences Between Chronic Occupational Cervical and Lumbar Disorder Patient Groups Entering the Functional Restoration Program, Completers Only (N = 1113) Demographic Variables (Baseline) Gender, n (% male) Age, M (SD), yr Ethnicity, n (%) White African American Hispanic Other Length of disability, M (SD), mo Total temporary disability mo, M (SD), mo Preadmission surgery, n (% yes) Attorney retained, n (% yes) Compensable body parts, M (SD)
Cervical (n = 215)
Lumbar (n = 898)
P
Effect Size (OR/d*)
100 (46.5%) 47.4 (8.5)
610 (67.9%) 45.2 (9.7)
