Initial Evaluation

All team members must be involved from the outset in the initial assessment and quantification of barriers to the patient’s recovery. This effort should be led by the physician member of the team, who, along with the nursing staff, performs a standard outpatient medical examination to review history, physical findings, and relevant radiologic or other diagnostic data. The intent of this visit is fourfold. First, the physician should look for medical barriers that were overlooked during previous evaluations and ensure that existing tissue damage is unlikely to improve with additional surgical intervention or activity limitation. Second, the physician should assess the degree to which psychosocial distress is causing other physiologic barriers such as insomnia, hypomobility, anxiety-related hypertension, or inorganic signs that will undermine the success of the individual patient and potentially the therapeutic milieu. The physician should document his or her impression of the patient’s degree of insight into or denial of psychosocial barriers such as depression, anxiety, fear, and anger to compare later with the quantitative assessment provided by the psychologic team. Third, the physician should identify and document the patient’s desired outcome from this programmatic intervention. As the team leader, the physician should take care to avoid a confrontation at this meeting (this is occasionally the desired outcome of some patients) by reassuring the patient that he or she has a choice and that the shared outcome of this visit is that the patient gives the program a chance. Often this is achieved by empowering the patient to evaluate the program at the same time the program is evaluating him or her. Simultaneously, the physician should take note of specific declared goals of the patient and pass these along to the evaluating team to ensure early bonding through shared understanding that team members are aware of and that support the patient’s functional goals. Additionally, this is the first of many expectation management opportunities during which the physician and nursing staff collaborate to make plain that the primary outcome of the program is functional return and introduce the concept that disability is a choice. The physician should initiate the first of many quantitative evaluations in this office visit. He or she should measure the range of motion (ROM) of the impaired functional unit(s) along with its relevant “effort factor.” Before referring the patient to the rest of the team for their portion of the quantitative assessment, the physician or nurse should ensure that a follow-up visit is scheduled to discuss the findings of the comprehensive quantitative functional evaluation. At this later meeting, the patient can tell the physician whether he or she will give the program a trial effort.

The quantitative functional capacity evaluation (FCE) is the physical assessment portion of the visit. As discussed later in the quantitative evaluation of physical function portion of this chapter, in a tertiary setting, pain and hypo-mobility fail to be accurate guides anymore. The point of assessment for an interdisciplinary program is to gather quantitative information not necessarily seen with single-specialty qualitative analysis when lower levels of care have failed. In other words, this portion of the exam is intended to “set the speedometer” of the patient’s current functional state in several physical domains. Most important is the assessment of mobility and strength around the putative weak link or dysfunctional motion segment. Building on the initial physician assessment, both the physical and occupational therapists collaborate by evaluating first range of motion, then dynamic strength, and finally endurance of the functional unit, checking each against both an internal validation method, effort factor, and an external validation method, normative database, that is adjusted for age, weight, and gender (see “Isolated Trunk Strength Assessment” later). The next domain is a whole-body performance assessment, usually the province of the occupational therapist, to give information to the team about the degree of deconditioning in noninjured segments of the body and to look for paradoxical discrepancies that portend nonfunctional, compensatory injury behaviors. Finally, cardiovascular measures give important data on deconditioning, materials handling performance, positional tolerance, effort, and gym tolerance of the prospective patient. The complexities of performing an FCE on a chronic pain patient are discussed in greater detail in an American Medical Association publication.¹⁷ All of this information is collated into a form to be interpreted by the physician when formulating the comprehensive program.

The psychologic assessment comprises a complex interplay of tests administered with the help of a staff psychologist comparing self-report scores, functional questionnaires, and affective inventories to quantify objective levels of depression, anxiety, fear, inhibition, and occasionally antisocial or manipulative traits (see “Psychologic Assessment” later). These data are collated with the structured clinical interview (SCID) to assess for barriers to participation and, more importantly, barriers to eventual functional return. Like the physical and occupational therapist, the psychologist tallies the quantified data for the physician to assess the degree of psychologic intervention and possible need for pharmacologic adjuncts in determining program length.

Finally, the most frequently overlooked but critically important part of the assessment is with the disability case manager (disability assessment). The disability manager is often the only one who has the time and intimate knowledge to assess the patient’s likelihood of achieving declared vocational or societal goals. Many patients can meet their gym and psychologic goals, but they retain such unrealistic expectations that they end up functional failures, although they might have been programmatic “paper” successes. The disability manager provides links with family, employers, state agencies, and retraining sites to ensure that a patient can fulfill the expectation of functional return after graduation.

Second Visit

The physician team leader takes the four departmental quantitative evaluations and must initiate a frank discussion with the patient on the basis of firm data. Hopefully, in the course of the day-long assessment process, the patient has bonded with one or more of the staff members and has enjoyed the milieu of function at the facility. If the patient agrees to proceed, the physician collates the various domains and plans the length of the program on the basis of achieving functional stability rather than fixing the patient. Instead of making the patient “good as new,” the team tries to refocus the patient and manage his or her expectations toward reaching a plateau where the patient possesses the physical strength and endurance to remain at a job and the psychologic tools to cope with daily stressors (lack of coping skills exacerbating the suffering is a common theme in this population). Hopefully, this important meeting readjusts patient expectations to internalize the concept of continued recovery after the program—keeping the patient focused on getting good enough rather than perfect. On the basis of data rather than pain reports, the patient has set his or her own speedometer for programmatic length and intensity. Finally, the patient’s agreement to enter the program is a tacit acceptance of graduation functional goals that are primarily vocational and societal but may also include familial and educational enrichment goals.

Initial Phase

The program’s initial phase often involves patient accommodation to scheduled attendance at a full day of program activities. This simple concept is often more difficult than it seems. Atrophy is not just limited to the body but may include attention and mood. The initial phase helps to rapidly build tolerance for a full day of activity. The early physical portion concentrates on rapidly advancing mobility, establishing a home cardiovascular training program, and performance of home exercise to aid transition to the intensive phase. Detoxification or tapering down from medications like alcohol, opioids, muscle relaxants, and anxiolytic medications is also a necessary first step. Sports medicine literature clearly shows the incompatibility of these medicines with a progressive, quota-based program of resistive exercise. The physician often substitutes nonsteroidal or adjuvant medication to control new symptoms created by the initial phase of physical activation after months of hypomobility. Additionally, in consultation with a skilled psychiatrist or pain management specialist, antidepressant, antiinsomnia, and occasionally anxiolytic medications are prescribed to try to normalize factors that may eventually be barriers to functional improvement. By the end of the initial phase, a patient should be moving toward tolerating full days of activity, sleeping through the night, integrating socially into the facility milieu, finishing their detoxification program, and developing their vocational plan for graduation while maintaining attendance and compliance standards as essential for progressing to the intensive phase.

Intensive Phase

This phase is the most team intensive because the multimodal disability management that is the hallmark of a program requires excellent interstaff communication. The patient’s attendance is 8 hours per day, 3 to 5 days per week, and 2 to 8 weeks in duration, depending on the degree of quantified impairment, disability chronicity, and assessed psychosocial or vocational barriers seen at the initial visit. Before beginning the intensive phase, the patient usually undergoes another quantitative functional assessment and psychologic inventory to assess progress and potentially adjust the trajectory of the rehabilitation program to account for job-specific physical requirements and overall progress from initial evaluation.

Quota-based strengthening exercises, aerobic fitness, and stretching are combined with work simulation, positional tolerance, and materials handling activities in the physical portion of the program. The remainder of the day combines education, group and individual counseling, classes on anatomy and physiology, assertiveness training, rational/emotive therapy, stress management, quantitative testing, and vocational planning. The educational sessions are intended to inform the patient and help him or her modify elements of structure, function, and behavioral choice that are critical not just to recovery but to changing the life path that landed him or her in this situation. Occupational counseling helps the patient hone an established vocational plan to return to productivity. Under ideal circumstances such as at PRIDE in Texas, additional coordination with the state vocational rehabilitation agency is available and can be easily facilitated, whenever necessary, immediately after medical rehabilitation. Although vocational rehabilitation services are employed in only a minority of patients, their effectiveness is dramatically enhanced by receiving medically rehabilitated patients, physically and mentally prepared to retain employment.

Work Transition Phase

Occasionally, for patients with lengthy preprogram chronicity or for patients returning to a physically demanding or stressful job, a work transition phase will be added. This low utilization phase (2 to 4 half days over 2 to 4 weeks) involves further strengthening of the injured area, work simulation with activity modification training when necessary, and assistance with case closure of any outstanding occupational, legal, and/or administrative issues, which, in the experience of PRIDE, can potentially sabotage good outcomes.

Outcome Tracking Phase

This important program phase allows continued evaluation of long-term effectiveness of the program, both from the patient’s point of view and for the facility’s continuous quality improvement (CQI) initiative. A long-term care plan (LTCP) may be offered to the patient for quarterly visits to the supervising physician, who can provide medications to assist in meeting program goals (i.e., work return, home exercise, and decreased health utilization). The opportunity to return, as needed, for symptom exacerbation for focused interventions consistent with functional restoration philosophy is important for maintaining cost effectiveness. The patient is given the opportunity to consolidate gains, obtain feedback, and maintain his or her physical capacity plateau by repeated quantitative FCEs performed at regular prescribed intervals. A patient also has the opportunity to present himself or herself for team feedback at one full-team staffing after the intensive phase. Telephone outcome tracking is administered at 3-, 6-, and 12-month graduation anniversaries by the staff, with assistance sought from treating doctors, adjusters, and attorneys whenever needed if new problems arise (see Table 107–1). Effort is made during this phase to reinforce independence in the patient so that return visits are minimized to evaluations only, unless a new crisis requires a few “refresher sessions.” An added benefit for retaining contact is the willingness of team members to help with problems that arise after the program. Patient perception of an environment of care that extends beyond their graduation leads to a high rate of compliance in repeat testing and telephone tracking. This high contact rate, in turn, allows performance of 1- and 2-year follow-up studies such as has been performed at PRIDE.^18–20

In addition to the Level II to III evidence for Therapeutic Studies cited earlier, many research publications of prognostic interest have been provided through the PRIDE Research Foundation. Since 1993, all entering and completing patients provide a large database of prospectively collected data on physical function, psychosocial function, occupational issues, and demographics. Data are updated through repeat tests/interviews on program completion and ultimately compared with the objective outcomes on work, health utilization, and recurrent injury status. To date, more than 5000 program completers and 2000 noncompleters have been studied and have become the focus of numerous prognostic cohort studies delivering Level I scientific evidence. These studies have examined the effect of demographic factors such as length of disability, age, or gender,^21–23 as well as a comparison of patients with neck and upper extremity problems with those with lumbar injuries.^24–26 They have also compared lumbar discectomy with fusion²⁷ and investigated prerehabilitation psychologic status.^28–31 Finally, the effect of program behaviors including final ratings of pain/disability and health utilization have provided Level I scientific evidence.^32–37

Range-of-Motion Assessment

Trunk motion is a compound movement combining intersegmental spine and hip motion components. A patient with a completely fused spine can often bend forward to perform toe touches using hip motion alone. Although it is difficult to measure intersegmental motion nonradiologically, inclinometers may be used to separate the hip motion component from the lumbar spine motion component and derive valuable information.^49,50 The basic information on inclinometry comes from British rheumatology, and the system has been used, in one form or another, in Europe for nearly 40 years.⁵¹ As in all physical capacity measures, range-of-motion information is only useful when compared with a normative database and contextualized by an identifiable effort factor. For lumbar range of motion, the effort factor is the comparison between the hip motion component and the spine straight leg raise test measurement.^50,52 These measurements are isolated anatomic/physiologic physical capacity measurements, assessing the capabilities of a single functional unit of the body. It is these isolated functional unit measurements that ultimately supply context to general functional or whole body measurements taken when a synthetic task such as bending, climbing, or lifting is performed.

In the sagittal plane the inclinometers, which are available in analogue or digitized computer forms from various manufacturers, enable measurement at multiple standardized points. Measurements are taken in both flexion and extension and checked against the effort factor of leg raising. A further effort factor is the comparison of test-retest reproducibility (Spearman-Brown or kappa) of the test within the same individual, looking to see whether the critical measurements are within 5 degrees or ±10% on three consecutive test repetitions. There are many reasons for limitation of effort in any single test, so the effort factor is neither an observation of, nor a surrogate marker for, malingering; instead, the effort factor helps determine the need for greater team remediation of functional limitations. Reduction of effort that impedes functional test validity may be produced by pain, fear of injury, physiologic perception of excess load, neuromuscular inhibition, or multiple psychologic factors of anxiety/depression, as well as the rare cases of conscious effort to mislead the examiner.

In addition to sagittal movement of the spine, coronal movement can be assessed by rotating the inclinometer 90 degrees in the axial plane. Rotation may also be assessed where it is important, namely in the cervical and thoracic spines, through relatively simple techniques.⁵³ The greater the limitation of ROM in any given direction, the less reliable the test. However, if done in a standardized fashion with good effort, these quantitative measurement techniques are highly reproducible, giving both the patient and the interdisciplinary team insight into the weak link.

The multi-inclinometer measurement techniques can demonstrate the actual ROM in the T12-S1 segment in the sagittal and coronal planes, as well as the T1-T12 sagittal/torsional movement, or the occiput-T1 cervical movement in all three planes. Functional assessment aids the rehabilitation process, and in cases of arbitrating disputed compensation it can be used for impairment evaluation purposes. As stated earlier, these tests can also be performed at multiple time intervals to document progress. Suboptimal effort in this portion should lead to careful scrutiny of other components of the functional capacity test battery and trigger greater team involvement. However, even in the presence of poor effort, the determination of “normal” or “abnormal” motion can be made by comparing the spine and hip motion ratios. In the normally mobile lumbar spine the sequence of forward bending generally involves spinal flexion before initiation of the hip flexion component, which proceeds until the spine is “hanging on its ligaments.” At this point, hip motion increases while further spine motion is constrained.⁵⁰ If, even in the presence of suboptimal effort, a normal spine/hip ratio exists, the clinician can usually conclude that normal spine mobility would have been present if the patient had provided sufficient effort. However, in the presence of an abnormal spine/hip ratio, with or without good effort, actual limitation of spine mobility is likely present (postfusion ankylosis or postoperative/disuse scarring or stiffness). The technique is also important in the work capacity evaluation whether or not the patient completes the interdisciplinary functional restoration program. ROM assessment is usually included as one part of the quantitative functional evaluation, a specific battery of quantitative, internally validated physiologic tests for mobility, strength, endurance, and synthetic task performance.^20,52,54 There may be initial resistance to use of measurement techniques by the interdisciplinary team because of concerns about the testing being time consuming, equipment intensive, and cumbersome. With mechanical devices (such as inexpensive carpenter’s levels), two inclinometers must be used simultaneously and the calculations done by hand after measurements are taken. The advantage of versatility and internal calculation (at greater expense) is provided by computerized devices. Once mastered, both techniques are less time consuming than obtaining blood pressure but are far more useful in this population where physician measurements replace the overlimiting, dysfunctional, inhibitory belief that stems from the patient’s perception of pain. Many medical specialists will prefer to perform the tests themselves, though these measurements are often competently performed by well-trained therapists, nurses, or technicians.

As in all other physiologic measurements, there is variation within the asymptomatic population. Interestingly, our normative data show that mean true lumbar motion is almost the same in males and females, even though females tend to have greater hip and straight leg raising mobility components. Patient values are expressed as a “percent normal” as related to mean scores of the symptomatic subject population, normalized for variables like age, gender, and body weight (when applicable).^41–43 The system allows the clinician to judge the significance of small variations from the anticipated value and, more importantly, to track the progress of the rehabilitation process between examinations.

Isolated Trunk Strength Assessment

Several devices are commercially available for assessing isometric, isotonic, or isokinetic trunk strength in various planes of motion. Most involve some type of pelvic stabilization with application of force through a line projecting between sternum and scapulae and thus represent trunk strength as torque (torsional force) around a pelvic fulcrum with a lever arm individualized to a subject’s height. Cervical dynamic strength measurement devices have been seen in prototype form, but are not currently available, leaving isometrics as the only alternative. Isokinetic devices stabilize the variables of acceleration and velocity in order to provide torque as the primary independent variable. Isokinetic testing narrows the Gaussian distribution of values by limiting the number of independent variables, which, in our opinion, provides a more valid test. Other available devices may be purely isometric or isoinertial. For historic interest, isometric test models employing strain gauges have been used for more than 60 years. Though commercially available, dynamic, isokinetic trunk strength testing has only been available since 1985, there is abundant literature demonstrating efficacy in identifying isolated motion-segment dysfunction (differentiating weakness and/or decreased endurance) and quantifying outcome improvements. Only a few commercially available isometric or isokinetic devices still exist. PRIDE currently uses a dynamometer connected to a sagittal semi-seated torso testing device detailed in the latter half of Chapter 5 in which lumbar muscle anatomy and function are discussed (Fig. 107–1).

FIGURE 107–1 A detachable sagittal trunk testing unit connected to a multi-dynametric system (Biodex 4, Biodex Inc., Shirley, NY). It allows measurements of isolated trunk strength to be compared with normative databases related to age, gender, and body weight.

Results of normal subject testing have been compared with chronic spine disorder (CSD) patients, with and without prior surgery.^{42,43,55–58} Substantial differences have been shown between these groups, initially with incremental trunk strength improvement demonstrated during rehabilitation of chronically disabled spine pain patients (Figs. 107-2 and 107-3).^18–2057 The intent of all of the devices is to isolate and challenge the trunk strength component of the thoracolumbar functional unit by stabilizing above and below the area to be tested. The isolation of the vulnerable “weak link” portion of the vertebral biomechanical chain linking the shoulder girdle to the pelvis is intended to assess muscle strength and endurance, just as measuring quadriceps and hamstrings is of prima facie importance to knee function. For any of the devices to be useful, the dynamometer must give accurate and reproducible measurements and the testing protocol must conform to the one employed when the normative database was created. Moreover, such a database must be available to express the individual’s results as a “percent of normal” and the clinician must have a method for assessing effort-validity of each test.

FIGURE 107–2 Trunk extensor strength at two speeds (60 degrees and 120 degrees per second) for torque versus time for a normal subject on a Biodex 4 testing device.

FIGURE 107–3 Trunk extensor strength performance at 60 degrees/sec (Biodex 4, Biodex Inc., Shirley, N.Y.) demonstrating changes in strength curves anticipated during functional restoration (torque vs. time). A, Typical curve for a normal subject maintaining force throughout the contraction. B, Typical postrehabilitation patient curve demonstrating slower onset of torque (impulse) and lower torque, but with force well sustained through the contraction. C, Typical prerehabilitation patient demonstrating physical inhibition (also termed fear-avoidance or kinesophobia) with low impact, maximum torque, and ability to sustain torque through the predetermined test distance/time.

Cardiovascular Fitness Assessment

The inactivity (often self-imposed) that leads to deconditioning in patients with spinal disorders also reduces cardiovascular fitness, thus creating a feed-forward effect on decreasing weak-link endurance and overall functional tolerance. Treadmill, bicycle, and upper body ergometry have long been used to measure the cardiovascular response to a measured work load. Significant deficits in aerobic capacity are frequently present in chronic and postoperative back pain patients, somewhat proportional to the duration of disability and the degree of inactivity. Because inactivity may also produce deconditioning of the arm or leg skeletal musculature, the patient may quit the ergometry test due to limb fatigue rather than reduced cardiovascular fitness. However, these alternative scenarios can usually be distinguished either by interval monitoring of the heart rate delta achieved at the point of voluntary test termination or by comparing the upper and lower body ergometric results. In most deconditioned patients exerting full effort, an exaggerated heart rate response to relatively low workloads is customarily the limiting factor of the test. Such testing leads to a determination of the extent to which aerobic capacity training and/or lower and upper extremity strength training need to be added to the functional restoration program.

Whole Body Task Performance Assessment (Functional Capacity)

The whole body task performance assessment, usually the province of the occupational therapist (OT), requires a skilled eye and a highly burnished insight. Whereas the quantification of the weak link has multiple internal checks, the whole-body performance component is subject to the intrusion of all manner of biopsychosocial baggage—the precise reason the patient graduated to a tertiary-level care in the first place. As an example, a “rigid spine,” like one might see with complete thoracolumbar to sacral fusion, is actually a biomechanically sound construct. Its functional utility is reliant on biomechanical redundancies to accommodate for diminished efficiency, as in gait modification in lumbar constructs.⁵⁹ The whole body performance assessment is divided into two major subsections that can be classified as materials handling and positional tolerance. Because of the complex reciprocal action of deconditioning-mediated physical limitations (to both the injured functional unit and other body parts, see earlier discussion) with fear-related and belief-related inhibition, the histogram of “normal” is widened. Therefore when obtaining “real-world” information, different methods of executing the same task using different postures and metrics are employed to quantify consistency, as well as performance.

Lifting capacity has long been the “gold standard” for spine-related, materials-handling functional capacity. Because of its perceived importance as the mode of industrial injury, lifting capacity is still the measurement of greatest concern to those medical and nonmedical personnel who judge the patient’s work capacity or vocational suitability. The isometric lift task employed in the NIOSH (National Institute of Occupational Safety and Health) guidelines is still in wide use and has a large comparative database that does not quite rectify the inherent nongeneralizability of isometric measurements. To give the full picture of any materials-handling task, several measures including isometric,⁶⁰ isokinetic,⁶¹ and isoinertial^62–65 must be combined. Specifically, though isokinetic devices can also be used for isometric measures, their results are not interchangeable and neither gives the picture of real-world lifting as does an isoinertial test.⁶¹ Moreover, only limited correlation exists between isokinetic and isoinertial, dynamic-lifting measures, just as only limited correlation exists between lifting capacity measures and trunk strength measures because of substitution in performing whole body tasks. With such confusing data underlying the fear-related issues of a patient who was educated by another health provider to “never lift anything more than a beer can,” it is difficult to get a sense of capacity for task performance.

The advantage of quantifying effort is that the data can be compared in validated ways to assess effort and inhibition and are available to any member of the team. For example, data from dynamic testing can be checked against the effort factor in terms of curve reproducibility at 0.10-second intervals, while interval heart rate checks during the progressive isoinertial lifting evaluation (PILE test), a simplified test combining psychophysical and isoinertial protocols to provide an unconstrained lifting assessment, serve as an effort monitor. Incomplete rehabilitation is assessed by comparing the peak lifting force to the power generated at any given speed on an isokinetic test because the power is represented by area beneath the force versus velocity curve. As the rehabilitation progresses, the convergence of power and force garnered from training and repeated testing can demonstrate whether or not the patient is compliant and exerting effort.

Tests are standardized in a way to provide interpretable, quantifiable information to assess the “speedometer” of the patient and the proximity to job-specific task performance, thereby keeping the patient accountable to a specific outcome of choice. Within the domain of whole body task performance, the subdomains of materials handling (e.g., floor-to-waist lifting, waist-to-shoulder lifting, carrying, pushing, pulling) and nonmaterials handling or postural tolerance (e.g., sitting, standing, balance, stair/ladder climbing, and decent, fitness testing) each have to be assessed and collated for the physician team leader. Repeated longitudinal testing adds validity to programmatic compliance and credibility to the physician’s attestation of task-specific suitability to the eventual employer. In addition, longitudinal studies demonstrating sufficiently large differences in prerehabilitation and postrehabilitation performance measures are an effective justification of the program’s relevance and validity. When quantified preprogram and postprogram data are combined with outcomes such as employment retention (see Table 107–1), stakeholders appreciate a program’s effectiveness in treating a variable and complex patient population and may act to influence the referral pattern.^40,57 Additionally, some large employers including state and federal agencies that require further documentation of task-specific preparedness do not need any further attestation than the data acquired during the program. A quantitative FCE has been developed for use in or after the PRIDE program, and a typical summary for a prerehabilitation chronic pain patient (15 months total disability and 11 months after L4 discectomy) is demonstrated in Figure 107–4. The principles underpinning an FCE in a chronic pain population are discussed in an American Medical Association book on FCE by Genovese and Galper.¹⁷

FIGURE 107–4 Functional capacity evaluation summary for a prerehabilitation patient.

In summary, quantification of physical function is a relatively new, important, but still underused tool in assessing patients with chronic painful spinal disorders. Although the measures are still evolving to maximize specificity, accuracy, and reproducibility, experience with extremity rehabilitation suggests that these tests may replace sophisticated but expensive imaging devices that cannot measure the suffering and hopelessness that has led this patient to fail other modalities. Quantification of physical functional capacity requires patient motivation, but because an effort factor can be identified with each physical capacity test, suboptimal effort can be recognized and used by the physician team leader to design a program that helps sublimate counter-functional cognitive-behavior irrationalities.

Self-Report Tests

Self-report scores are totally subjective in that they mirror only a patient’s perception of pain, depression, anxiety, kinesophobia, and disability. As such, they have only limited value. However, in the past 15 years, a number of tests have been devised giving quantitative measures of self-report through various questionnaire formats that allow a number to be applied to the patient’s level of perceived pain, discomfort, or disability. These instruments are simple to use and are repeated frequently during a course of rehabilitation to compare a patient’s pain perception at one point in time with another. Many factors may increase pain, depression, and disability self-report (other than recurrence) of injury, and the knowledge of such changes within any one individual is useful. The large majority of chronic pain patients tend to be somatizing individuals (e.g., more pain sensitive and likely to exaggerate bodily responses compared with the general population). As such, their responses cannot be compared with a normative database but instead can only be compared within the same individual to an initial, or baseline, score obtained before treatment. The repeated management of the self-report tests assists the interdisciplinary staff in identifying barriers to recovery and dealing with them in order to help the patient meet agreed functional goals. The goal is to move from a disjointed consideration of preexisting psychologic issues to a focused disability management process.

Quantified Pain Drawing

For more than a decade, quantified pain drawings have been used to give an assessment of pain location, severity, and subjective characteristics in a nonverbal communication by the patient.⁶⁹ An overlay, over the pain drawing itself, has been devised to give a numeric count of the trunk and extremity area covered, as well as whether pain is limited within the bodily confines or is outside the body. The overlay is on a transparent plastic sheet permitting easy scoring by office personnel (Fig. 107–5A).⁷⁰ There is also a visual analog score (VAS) to suggest whether the patient perceives the problem to be more axial or extremity in origin and to gauge the severity of pain (Fig. 107–5B).

FIGURE 107–5 A, The quantified pain drawing filled out by the patient; B, Pain drawing with the transparent grid overlay that allows counting the area displayed for trunk pain separated from extremity pain symptoms.

Function/Disability Questionnaires

One of the most important developments of the past decade is the use of self-report scores for assessing treatment outcomes by using the same self-report tool prerehabilitation and postrehabilitation. Several validated tools are available. One commonly used tool is the Oswestry Disability Index (ODI), which has been present for many years.⁷¹ The self-report scores have also been used with the concept of a minimum clinically important difference (MCID) in a number of recent studies.^72,73 The MCID concept can be used with both anchor-based and distribution-based approaches.^74,75 The fallacy of comparing one self-report measure with another, as well as other pitfalls of the MCID concept, are being raised as the MCID concept gains greater popularity.^76,77

The Million Visual Analog Scale (VAS) is a validated instrument useful not only for the lumbar spine like the ODI but for any spinal disorder and consists of 15 questions.⁷⁸ It describes both pain and disability, expressed over 10 cm, spanning a gamut of responses from the minimum to the maximum possible activity on each item.

A newer and more generally usable functional assessment tool, derived from the Million VAS, is the Pain Disability Questionnaire (PDQ).³⁴ This tool has been expanded to cover not only lumbar spine functional assessment (such as the ODI) but all spinal and other musculoskeletal conditions in a general way. In addition, it includes a psychosocial component, vital in the assessment of chronic spinal pain patients. Its responsiveness has been demonstrated, and it is now being used in the most updated version of the American Medical Association Guides to the Evaluation of Permanent Impairment (Fig. 107–6).^30,79

FIGURE 107–6 The English version of the Pain Disability Questionnaire, a 15-item self-reporting questionnaire used for functional assessment or documentation of self-reported disability.

More Extensive Psychologic Measures

A variety of more complex tests measure psychiatric and psychological functioning, as well as personality factors. These tests have a scoring and interpretation system that is not immediately apparent to the subject taking the test. A great many of these have been devised and “validated.” Unfortunately, however, the usefulness of any particular test in the chronic spinal pain patient remains questionable, since the prediction of patient behavior is difficult.

Clinical Interview

The interview is the most powerful clinical assessment tool available. It is difficult to standardize but is extremely important in contextualizing the psychosocial and economic factors contributing to continued disability and high pain report. Concern about specific risk factors for failure compel the interviewer to identify such important areas as depression, personal/family medical history, patient/family substance abuse history, history of head injury, history of cognitive disorders, and signs of personality disorder. Past contributing issues like finances, work (including job losses, job change, and job satisfaction), and pending litigation that make patients feel uneasy (many claim these issues are unrelated to their pain and current disabled status) dramatically affect patient behavior as “secondary gain” disincentives to return to activity. It is important for the interviewer to establish trust in order to quantify those biopsychosocial barriers identified earlier. Rehabilitation is ultimately a modification of patient behavior away from an unrealistic dependency on a medical system to “cure” the long-term source of “pain.” Instead, the patient moves toward an independent approach to achieving the highest level of function possible—the implication being a realistic level of productivity/earning given the severity of permanent impairment that the patient has sustained. The details of the transition are discussed in the next section but can be facilitated only with an understanding of the psychologic impairments keeping the patient disabled, deconditioned, dependent, and drugged. Only if they can be identified by the medical professionals can they be dealt with in an appropriate manner.

Sports Medicine Concepts and Physical Training

The physical part of the interdisciplinary approach is centered around a quantitatively based, quota-driven, sports medicine approach to comprehensive rehabilitation. The principles of sports medicine have evolved from narrowly meaning rehabilitation of the competitive athlete to a conceptual and methodologic framework that connotes active treatment protocols for all individuals who want to return to high levels of function. Its component parts are shown in Box 107–1. Much of the initial work and literary evidence was done with rehabilitation of injured limbs, but these concepts are clearly applicable to the spine as well.

The injury that the team is addressing can originate from either a massive, single, exogenous force application that overwhelms the body’s redundant (safety) components, or from multiple small traumas superimposed on the natural course of “cell death,” termed degeneration, with its predominant endogenous origin. Whatever the source of the musculoskeletal insult, the initial phases following overload are characterized by inflammation and reactive edema releasing cytokines as neuromuscular units reflexively fire to limit motion of the injured functional unit and alert the cerebral cortex with pain signals. Shortly after the initial inflammatory phase reaction, the proliferative phase begins as a response to cytokine release. The initial vascular infiltration and hypercellularity bring further release of cytokines, growth factors, and other receptor ligands to both increase vascularity and signal specialized cellular action. These actions degrade, repair, and replace injured tissue with enzymatic digestion, as well as fibroblastic deposition of procollagen woven with laminin on viable osseous, cartilaginous, or soft tissue eventually maturing in the final phase to more organized, aligned collagen fibers (primarily type I and type III collagen). This important phase may be impaired or degraded by other ongoing homeostatic insults such as diabetes, cardiovascular disease, pulmonary disease, or tobacco/nicotine use. In the final remodeling phase, the collagen fibers align along lines of stress in a generalized pattern still termed Wolff’s Law of Mesothelial Tissues. This law observes that the low tensile strength of initial tissue changes with stress as the tissue continuously remodels over weeks and months to counteract vertical and shear stresses applied to the tissue. Clearly, relatively small degrees of tissue injury, with good nutrition and low-grade remodeling-phase stresses (e.g., in a sprain or contusion) will recover to near full strength relatively rapidly. Conversely, when high stress combines with a milieu of poor tissue nutrition and an underlying, genetically determined reduction in the cellular matrix (traumatic high load/force injury to spine with avascular, possibly degenerative discs), a longer healing process may be anticipated until the tissue approximates maximal strength (12 to 16 weeks). This is generally the case for the spine and for fractures of long bones (both of which heal slower than incised, well-approximated skin tissue). Eventually, the injured area with woven scar approximates the strength and durability of the original tissue but lacks its preinjury resilience with some corresponding degradation of biomechanical performance as a consequence.

A characteristic of the musculoskeletal injury that may carry beyond the three tissue-healing phases is the tendency to splint and protect the injured area that started with a reflexive neuromuscular response.⁹² Unfortunately, in the long term, splinting leads to decreased stress and shear across the injured tissue, which translates to delayed maturation of collagen,^59,93 muscle atrophy,⁹⁴ adhesions and deficits in joint lubrication,⁹⁵ ligament atrophy,⁹³ and bone loss.⁹⁶ Subsequently, changes in endurance and aerobic fitness create a feed-forward process (vicious cycle) of physiologic and behavioral changes termed deconditioning syndrome. Deconditioning syndrome is marked by progressively declining physical capacity with each subsequent pain episode, increasing the patient’s fear, which in turn encourages a greater degree of disuse, feeding forward to further increase inactivity and decrease physical capacity.

The approach to stop the cycle of deconditioning syndrome involves quota-based, progressive exercise to interrupt the cycle in multiple ways by addressing mobility, strength, endurance, cardiovascular fitness, and agility/coordination. The exercises must progress to simulate customary physical activities in order to restore task-specific functions. Initially, exercises should be specific rather than general. Nor should exercise be ceased/limited by perceived pain but must be quota based, below known biologic injury thresholds, and focused at the specific functional unit that has become deconditioned. Exercises are eventually generalized to improve whole body functional deficits, which occurred as a response to the initial insult.

Strength in the physical portion of functional restoration may be restored after injury in a variety exercise modalities, all of which should roughly coincide with the underlying principles of DeLorme, namely, resistance progression to muscle failure. Initially, soon after injury, when continued immobilization may be necessary, isometric exercise may be the only type that can be performed by the patient. This involves repetitive muscle contraction against fixed resistance without accompanying joint motion. Although isometric exercises may be done in a cast, splint, or brace, they have many drawbacks. First, isometric exercise is the most fatiguing and least effective type of exercise.⁹⁷ The specificity of strength training to the corresponding activity is determined by muscle fiber length, which means that isometric exercise is poorly generalizable to any activity except splinting. Additionally, endurance and agility necessary for dynamic activities are not produced by isometric exercise. During the early phase after injury, isometric exercise can serve as a placeholder to maintain muscle tone and resist the body’s tendency to atrophy, but the physician should progress the patient to mobilization as soon as possible. Electrical muscle stimulation in combination with isometric exercise has been suggested to be of benefit, but electrical stimulation alone shows no gains in functional strength when the patient is mobilized.⁹⁸

As stated earlier in this chapter, dynamic muscle training has been shown to be the most efficient method of training. It involves distinct subcategories: isotonic, isokinetic, eccentric, and isoinertial, sometimes termed psychophysical (free weights).⁹⁹ Isotonic exercises are those in which the same force is applied throughout the dynamic range and is often inappropriately used for exercises in which a changing lever arm actually alters the applied torque. This type of exercise is most often associated with the variable resistance devices, using a cam to equalize muscular demands throughout the dynamic range of motion. Isokinetic training devices require a sophisticated dynamometer that limits the speed to a preset value. In this mode, speed and acceleration are controlled, allowing almost unlimited torque around a central axis, which in turn eliminates the effect of acceleration on work. These devices accommodate a force application that provides injury protection, at least in the concentric (muscle shortening while contracting) type of contraction. Unlike variable resistance devices, however, high-speed training is possible for development of agility. Pure eccentric training is far to the right on the force-speed curve and can produce rapid strength gains with a correspondingly higher likelihood of injury at high forces or high speeds with little ability to provide external control for injury prevention. Finally, isoinertial (psychophysical) strength training, using free weights, is limited to those postures in which weight can be attached to the body or held in the hands, usually against gravity. The method is occasionally termed psychophysical because the subject self-selects the amount of weight that is acceptable and recruits the appropriate neuromuscular units (agonists and antagonists) to progress the muscles surrounding a discrete joint to the failure point (hopefully stopping short of the injury point). Although this closely approximates real-world muscle loading, the maximum weight that can be handled is limited by both the weakest link in the dynamic ROM and the dynamically changing lever arm. Further, the inability to effectively coordinate agonists and antagonists around a recovering functional unit creates potential for reinjury to that unit. Exercise that specifically simulates motions and loads of a sport or work activity has been shown in multiple studies to be an effective training tool that is robustly protective against reinjury.¹⁰⁰ Psychophysical and variable resistance lifting devices enable both concentric and eccentric contraction capability. This is more difficult with greater potential for injury than with isokinetic devices, though computerized dynamometers are currently available to act as a “governor” for this type of training.

Secondary effects of a functional restoration program are also critically important. Physical training appears to have a specific beneficial effect on pain (possibly through increased synthesis of specialized neurotransmitters) and has been demonstrated to increase remodeling of scar and adhesions while improving cartilage nutrition. Mobility that maximizes flexibility through the entire functional range appears to be the key to functional return. Combining excellent ROM with normal to supernormal strength and endurance in muscles around a joint provides a synergistic benefit protecting a functional motion with reduced biomechanical efficiency. This development of protective muscular mechanisms is particularly important when a return to normal joint architecture can no longer be anticipated.

Thus the specific exercise programs that combine stretching exercises and strengthening exercises and improve cardiovascular fitness, endurance, and agility show the best and most consistent functional outcomes with less risk of future injury.¹⁰¹ The application of these exercises is individualized on the basis of quantitative testing of function (noted earlier in this chapter), with the specificity and intensity of exercise changing to minimize the likelihood of injury and to maximize improvement in specific deficits to function. A variety of weight equipment is used in the program (Fig. 107–7). Finally, a fitness maintenance program must be established and tailored to the physical and psychologic makeup of the patient to ensure compliance when building on the initial gains made after graduating the intensive, supervised program.

FIGURE 107–7 An abdominal (A) and back extension (B) weight machine used for trunk strengthening.

Psychosocial Interventions in Functional Restoration

Just like the physical interventions seen earlier, psychosocial interventions take integrated, quantified test results to set the speedometer for the degree and amount of psychologic intervention needed within a particular program. Contrary to popular patient and payer opinion, the tertiary program is not designed to cure premorbid, longstanding psychosociopathy. On the other hand, it must be acknowledged by all stakeholders that the patients who fail lower levels of care were functioning adequately before their injury. The patient undergoing tertiary-level spinal rehabilitation outwardly suffers from physical complaints that are perpetuated by prolonged disability, failed coping skills, intrusive psychosocial stressors, and exposure or development of affective or anxiety disorders.²⁸ A significant proportion of this population are “chemical copers,” who use a cocktail of opioids, centrally acting muscle relaxants, and alcohol to escape from intense feelings of hopelessness, helplessness, shame, fear, and despondency.¹⁰² Patients with a somatic focus tend to deal with anger, anxiety, and underlying unresolved emotional conflict with increased psychophysiologic responses. Traditional treatment approaches in pain management programs tend to teach patients about coping with pain and how to reduce self-defeating thoughts and behaviors but fail because of the self-defeating nature of pain as a functional guide. The traditional multidisciplinary and interdisciplinary pain clinic often add a mix of education, individual psychotherapy, supportive group therapy, group relaxation, individual biofeedback, and group cognitive behavioral therapy. Medication reduction may only be a secondary goal of treatment. The essential flaw in this type of treatment has been the continued primary emphasis on the patient’s self-report of pain. This approach is ultimately self-serving in terms of disability management (being inherently difficult to quantify and subjective) and often allows the patient to be rewarded for counterproductive choices and behaviors.

In multidisciplinary- or interdisciplinary-level functional restoration, the physician leads a team that emphasizes the return to function by setting specific, achievable goals on the basis of quantitative measures rather than qualitative assessments by observation or patient report. Meeting these goals in turn provides a shared sense of success between the patient and care team that allows the patient to overcome fear-inhibition of further injury. This then creates a converse feed-forward cycle of reconditioning in which the patient and care team collaborate to achieve functional return of strength, flexibility, aerobic capacity, and simulation of actual work activities. Functional goals in the gym are matched to goals with other team members and are set in terms of reduction of habituating medications and diminution of symptoms of depression and anxiety. The patient learns that increased function improves pain perception (though possibly not in a 1:1 fashion). By meeting stepwise goals with multiple team members, intrusive feelings of helplessness and hopelessness subside, thereby improving self-esteem and self-confidence, with further goal setting and return to vocational or avocational tasks from which they were formerly inhibited. Success leads to a reduction of thoughts, feelings, and psychophysiologic symptoms of depression and anxiety, which, in turn, leads to greater sleep pattern stability; less psychosocial strife with family, employers, and friends; and consequential reduction of pain perception. In the end, the team has provided an environment in which the rewards for being well far exceed the perceived reward for being sick.