Tertiary Rehabilitation Program Outcomes

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CHAPTER 113 Tertiary Rehabilitation Program Outcomes

Robert J. Gatchel, Tom G. Mayer

Pain is usually broadly defined as either acute, chronic, or recurrent, depending on its time course.¹

Acute pain is often indicative of tissue damage, and it is characterized by momentary intense noxious sensations (i.e. nociception). It serves as an important biological signal of potential tissue/physical harm. Some anxiety may initially be precipitated, but prolonged physical and emotional distress usually is not. Indeed, anxiety, if mild, can be quite adaptive in that it stimulates behaviors needed for recovery, such as the seeking of medical attention, rest, and removal from the potentially harmful situation. As the nociception decreases, acute pain usually subsides.

Chronic pain is defined as pain that lasts 6 months or longer, well past the normal healing period one would expect for its protective biological function. Arthritis, back injuries, and cancer can produce chronic pain syndromes and, as the pain persists, it is often accompanied by emotional distress such as depression, anger, and frustration. Such pain can also often significantly interfere with activities of daily living.

Recurrent pain refers to intense, episodic pain, reoccurring for more than 3 months. Recurrent pain episodes are usually brief (as are acute pain episodes); however, the reoccurring nature of this type of pain makes it similar to chronic pain in that it is very distressing to patients. Such episodes may develop without a well-defined cause, and then may begin to generate an array of emotional reactions, such as anxiety, stress, and depression/helplessness. Often, pain medication is used to control the intensity of the recurrent pain, but it is not usually helpful in reducing the frequency of the episodes that a person experiences. It should also be noted that, many times, patients find it difficult to distinguish between chronic and recurrent pain. Patients will often present with ‘chronic-like’ symptoms from prolonged episodes of, say, headache or back pain. These do not always fit the description of chronic pain, but are usually persistent and can be as disabling.

Of course, the above types of pain require different treatment approaches.² In discussing back pain rehabilitation, for example, primary care is applied usually to acute cases of pain of limited severity. Basic symptom control methods are utilized in relieving pain during the normal early healing period. Frequently, some basic psychological reassurance that the acute pain episode is temporary, and will soon be resolved, is quite effective. There is now evidence for safety, treatment- and cost-effectiveness of evidence-based guidelines for the management of acute low back pain in primary care.³ Secondary care represents ‘reactivation’ treatment administered to those patients who do not improve simply through the normal healing process. It is administered during the transition from acute (primary) care to the eventual return to work. Such treatment has been designed in order to promote return to productivity before advanced physical deconditioning and significant psychosocial barriers to returning to work occur. At this phase, more active psychosocial intervention may need to be administered to those patients who do not appear to be progressing. Finally, tertiary care requires an interdisciplinary and intensive treatment approach. It is intended for those patients suffering the effects of physical deconditioning and chronic disability. In general, it differs from secondary treatment in regard to the intensity of rehabilitation services required, including psychosocial and disability management.

THE BIOPSYCHOSOCIAL MODEL OF PAIN

Before discussing tertiary care, which is a topic of the present chapter, it is important to first review the underlying theoretical model of pain upon which tertiary rehabilitation is based – the biopsychosocial model of pain. Today, this biopsychosocial model is accepted as the most heuristic perspective to the understanding and treatment of chronic pain disorders.^4,⁵ This model views physical disorders such as pain as the result of a complex and dynamic interaction among physiologic, psychologic, and social factors that perpetuate and may even worsen the clinical presentation. Each individual experiences pain uniquely, as the result of the range of psychologic, social, and economic factors that can interact with physical pathology to modulate that individual’s report of symptoms and subsequent disability. The development of this biopsychosocial approach has grown rapidly during the past decade, and a great deal of scientific knowledge has been produced in this short period of time concerning the best care of individuals with complex pain problems, as well as pain prevention and coping techniques.

As Turk and Monarch ⁵ and Gatchel and Maddrey⁶ have discussed in their comprehensive reviews of the biopsychosocial perspective on chronic pain, people differ significantly in how frequently they report physical symptoms, in their tendency to visit physicians when experiencing identical symptoms, and in their responses to the same treatments. Often, the nature of a patient’s response to treatment has little to do with his or her objective physical condition. For example, White and colleagues⁷ have noted that less than one-third of all individuals with clinically significant symptoms consult a physician. On the other hand, 30–50% of patients who seek treatment in primary care do not have specific diagnosable disorders!⁸ Turk and Monarch⁵ also make the distinction between disease and illness in better understanding chronic pain. The term disease is basically used to define ‘an objective biological event’ that involves the disruption of specific body structures or organ systems caused by either anatomical, pathological, or physiological changes. Illness, in contrast, is generally defined as a ‘subjective experience or self-attribution’ that a disease is present. An illness will produce physical discomfort, behavioral limitations, and psychosocial distress. Thus, illness refers to how a sick individual and members of his or her family live with, and respond to, symptoms and disability. This distinction between disease and illness is analogous to the distinction made between pain and nociception. Nociception involves the stimulation of nerves that convey information about tissue damage to the brain. Pain, on the other hand, is a more subjective perception that is the result of the transduction, transmission, and modulation of sensory input. This input may be filtered through a person’s genetic composition, prior learning history, current physiological status, and sociocultural influences. Pain, therefore, cannot be comprehensively assessed without a full understanding of the individual who is exposed to the nociception. The biopsychosocial model focuses on illness, which is the result of the complex interaction of biological, psychological, and social factors. With this perspective, a diversity in pain or illness expression (including its severity, duration, and psychosocial consequences) can be expected. The interrelationships among biological changes, psychological status, and the sociocultural context all need to be taken into account in fully understanding the pain patient’s perception and response to illness. A model or treatment approach that focuses on only one of these core sets of factors will be incomplete. Indeed, the treatment efficacy of a biopsychosocial approach to pain has consistently demonstrated the heuristic value of this model.⁵

THE BIOPSYCHOSOCIAL APPROACH TO TERTIARY PAIN MANAGEMENT

Thus, the biopsychosocial approach to tertiary pain management appropriately conceptualizes pain as a complex and dynamic interaction among physiologic, psychologic, and social factors that often results in, or at least maintains, pain. It cannot be broken down into distinct, independent psychosocial or physical components. Each person also experiences pain uniquely. The complexity of pain is especially evident when it persists over time, as a range of psychological, social, and economic factors can interact with pathophysiology to modulate a patient’s report of pain and subsequent disability. The model utilizes physiologic, biologic, cognitive, affective, behavioral, and social factors, as well as their interplay, when explaining a patient’s report of pain. As will be discussed, there have been a number of reviews that have documented the clinical effectiveness of such interdisciplinary treatment of patients with chronic pain.⁹^–¹² Interdisciplinary programs are needed for patients with chronic pain who have complex needs and requirements. One variant of interdisciplinary tertiary pain management programs – functional restoration (FR) – has been comprehensively presented in Chapter 112. It has also been described in detail in a number of publications.¹³^–¹⁹ The primary goal of this rehabilitation process is to improve function and deal with any potential psychosocial and economic barriers to attaining this goal. As will be noted, these components are amenable to systematic outcome quantification. Indeed, this FR approach to the treatment of low back pain disability has received increasing attention in recent years because of its documented clinical effectiveness. Research has shown that the FR program, when fully implemented, is associated with substantive improvement in various important societal outcome measures (e.g. return to work and resolution of outstanding legal and medical issues) in chronically disabled patients with spinal disorders in a 6-month follow-up study,²⁰ 1-year follow-up studies,²¹^–²⁶ as well as a 2-year follow-up study.²⁷ For example, in the 2-year follow-up study by Mayer et al.,²⁷ 87% of the FR treatment group was actively working at 2 years as compared to only 41% of a nontreatment comparison group. Moreover, about twice as many of the comparison group of patients had both additional spine surgery and unsettled workers’ compensation litigation relative to the treatment group. The comparison group continued with approximately a fivefold higher rate of patient visits to health professionals and had higher rates of recurrence or reinjury. Thus, the results demonstrate the striking impact that an FR program can have on these important outcome measures in a chronic group consisting primarily of workers’ compensation cases (traditionally the most difficult cases to treat successfully).

Finally, it should be noted that the original FR program was independently replicated by Hazard et al.²³ in this country, as well as Bendix and Bendix²⁴ and Bendix et al.²⁵ in Denmark, Jousset et al. in France,²⁰ Hildebrandt et al.²⁶ in Germany, and Corey et al.²⁸ in Canada. The fact that different clinical treatment teams, functioning in different states (Texas and Vermont) and different countries, with markedly different economic/social conditions and workers’ compensation systems, produced comparable outcome results speaks highly for the robustness of the research findings and utility, as well as the fidelity, of the FR approach. In addition, Burke et al.²⁹ have demonstrated its efficacy in 11 different rehabilitation centers across 7 states. Hazard³⁰ has also reviewed the overall effectiveness of FR.

Thus, the clinical effectiveness of FR has been well documented. Indeed, Gatchel and Turk ³¹ and Turk³² have reviewed both the therapeutic- and cost-effectiveness of interdisciplinary programs, such as functional restoration, for the wide range of chronic pain conditions. One of the hallmarks of FR since its development by Mayer and Gatchel¹⁶ has been the objective documentation of outcomes, even before it became a requirement in today’s evidence-based medicine environment.

THE IMPORTANCE OF TREATMENT OUTCOMES EVALUATION

As Mayer et al.³³ have noted, healthcare costs are continuing to increase at an alarming rate in the United States. Therefore, changes in healthcare policy and demands for improved allocations of health resources have recently placed great pressure on healthcare professionals to provide the most cost-effective treatment for pain syndromes and to validate treatment efficacy. As a result, treatment-outcome monitoring has gained new importance in healthcare. Indeed, as highlighted in an Outcomes Symposium sponsored by the American Orthopedic Association, the current outcomes movement has begun to revolutionize clinical research, with the concomitant increased emphasis on the use of well-validated outcome measures.³⁴ Healthcare professionals are now themselves being monitored to determine the effectiveness of the treatments they provide, as well as patient satisfaction with their treatment. Often, a ‘scorecard’ is maintained by third-party payers to monitor practitioners’ efficacy.¹ Healthcare professionals also need to monitor such outcomes for quality assurance purposes. In addition, data are also needed that can provide third-party payers with demonstrations of treatment efficacy. This can be an important marketing strategy to highlight the effectiveness of one’s pain management program.

Unfortunately, many healthcare professionals do not have a background in conducting program or treatment evaluations because of the requisite experimental methodology and statistical tools needed for such evaluations. One needs to set up a database with appropriate psychometrically sound measures to use at baseline and follow-up evaluations. Such data then need to be statistically analyzed. Fortunately, there are now templates and reviews available for conducting such evaluations. Flores et al.,³⁵ Gatchel,³⁶ and Mayer et al.³⁷ have provided such overviews. These will be discussed below. Morley and Williams³⁸ have also presented a comprehensive review of how to conduct and evaluate treatment outcome studies.

It should also be noted that, at an early point in time, Blanchard ³⁹ highlighted six important dimensions that one should consider in evaluating clinical applications and effectiveness of therapeutic modalities, using biofeedback as an example. These same six dimensions would similarly be appropriate for the evaluation of various pain management procedures. These dimensions consist of the following:

• The percentage or fraction of the treated patient sample that demonstrated significant therapeutic improvement.

• The degree of clinical meaningfulness of the therapeutic changes that were obtained.

• The degree of transfer of changes that were obtained in the clinical setting to the patient’s natural environment.

• The degree of change in the biopsychosocial response for which the treatment was prescribed.

• The degree of replicability of the results by different clinicians and clinical sites.

• The extent and thoroughness of the follow-up data for pain.

Each of these dimensions is important, and should be considered when evaluating the therapeutic effectiveness of any pain management intervention. Finally, in any discussion of treatment outcomes monitoring, clinicians now need to be aware of the HIPAA Privacy Rules. These rules establish patients’ rights concerning the use and disclosure of their healthcare information (including when it is being used for research outcomes purposes). Besides the usual informed consent obtained according to each institution’s review board monitoring the safety of subjects involved in any clinical research trial, an additional HIPAA consent form must also be obtained. Healthcare professionals may order HIPAA Privacy Rules from their specialty organizations. For example, HIPAA for Psychologists can be ordered by going to www.apapractice.org.

REVIEW OF OUTCOME MEASURES

The article by Flores and colleagues ³⁵ reviewed the three broad categories of measures that have been used to objectively evaluate functional improvement in patients with spinal pain disability: physical, psychological and socioeconomic. Moreover, within each of these three categories, some of the major measures utilized were discussed. This review started with the following folk tale:

It was six men of Indostan to learning much inclined

Who went to see the Elephant (though all of them were blind)

That each by observation Might satisfy his mind.

The First approached the Elephant

And happening to fall against his broad and sturdy side

At once began to bawl: ‘Bless me! but the Elephant is very like a wall!’

The Second, feeling of the tusk, cried, ‘Ho! what have we

here, so very round and smooth and sharp? To me ‘tis mighty clear

This wonder of an Elephant is very like a spear!’

The Third approached the animal, and happening to take the squirming trunk within his hands

Thus boldly up and spake: ‘I see,’ quoth he, ‘the Elephant is very like a snake!’

And so these men of Indostan disputed loud and long

Each in his own opinion exceeding stiff and strong

Though each was partly in the right, and all were in the wrong”!

The Blind Men and the Elephant: An Old Indian Folk Tale, version written by John Godfrey Saxe

Just as the blind men in this folk tale viewed and described the ‘whole,’ or the elephant, in quite different terms, depending on what part of it each measured or touched, so too, may functional measures of improvement might be described quite differently depending on what referent or measure of function one decides to touch or quantify. Indeed, when trying to quantify functional change in spinal disorders, there are three broad categories of measures that have been used – physical, psychological and overt behavior (i.e. observable behaviors such as activities of daily living, return-to-work, etc.). Of course, at first blush, they may not appear to be closely related in describing the ‘whole.’ However, upon more careful scrutiny and analysis, they are merely measuring different parts of a whole person’s functional performance. At the outset, though, it should be clearly noted that these three different categories of measures may not always display high concordance with one another in all situations. Such less than perfect concordance among these behavioral referents of a construct such as function or functional improvement is not, however, unique to the area of spinal disorders or rehabilitation medicine in general. For example, it has long been noted in the psychology literature that self-report, overt behavior, and physiological indices of behavior sometimes show low correlations among one another. Thus, if one uses a self-report measure as a primary index of a construct and compares it to the overt behavior or physiologic index of the same construct, direct overlap cannot automatically be assumed. Moreover, two different self-report indices or physiological indices of the same construct may not be as highly correlated as one would desire (Fig. 113.1). In general, what has often plagued the evaluation arena has been the lack of agreement on the wide variation of measures used to document a construct and changes in that construct.

Fig. 113.1 The often low concordance among and within physical, psychosocial, and overt behavior measures.⁸⁵

Rights were not granted to include this figure in electronic media. Please refer to the printed book.

From Gatchel 1998,⁵² with permission of American Pain Society.

Thus, the literature is full with many different measurement techniques and tests of a construct such as function. Recently, though, the literature has begun to demonstrate which measures of function and functional improvement appear to be most reliable and valid. For example, Mayer et al.⁴⁰ have reviewed the evaluation process of outcomes associated with FR. Because of the emphasis on the return to productivity inherent in FR, socioeconomic outcomes should be evaluated. Some of these outcomes include work status, healthcare utilization, recurrent injury, etc. Such socioeconomic outcomes will be reviewed in greater detail below. Other less objective outcomes that are used, such as validated psychosocial questionnaires, will also be subsequently discussed. Finally, physical assessment as used by the Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE) involves the evaluation of many variables (such as range-of-motion, strength lifting, and aerobic capacity), normalized to age, gender, or body mass. Once all of these variables are collected, then pre- to postrehabilitation change can be prospectively monitored in order to document improvement.

Flores and colleagues also pointed out two major ‘assumption traps’ that clinicians and researchers need to avoid when considering the best measure of function or functional improvement. First, one cannot assume on an a priori basis that one measure will necessarily be more valid or reliable than another measure. In general, the more objectively quantified the measure, the more likely it can be empirically established as a reliable and valid referent or marker. Second, one cannot assume that a physical measure will always be more objective than self-report or psychological measures. As Rudy and Stacey ⁴¹ had earlier noted, no matter what the level of accuracy or sophistication of a mechanical device used to collect physiological measures, human interpretation must ultimately be used in the understanding of these findings. Moreover, a patient’s performance during a physical assessment protocol may be greatly influenced by fear of pain or injury, instructional set, motivation, etc. With these caveats in mind, Flores and colleagues provided a comprehensive review of the three broad classes of functional measures, which are presented in Table 113.1.

Table 113.1 Major Categories of Measures that can be used to Document Functional Improvement

PHYSICAL MEASURES
	Range of motion
	Spine strength
	Lifting capacity
	Other tests of human performance capability
PSYCHOLOGICAL MEASURES
	Psychological test measures
	Self-report measures of pain and disability
	The clinical interview
	Clinician rating of overt pain behavior
SOCIOECONOMIC MEASURES
	Work status
	New health utilization
	Recurrent injury claim
	Financial claim resolution

NORTH AMERICAN SPINE SOCIETY’S COMPENDIUM OF OUTCOME INSTRUMENTS FOR ASSESSMENT AND RESEARCH OF SPINAL DISORDERS

With the increased scrutiny of healthcare utilization costs and effectiveness by the Federal government and third-party payers, the North American Spine Society ⁴² felt it important to develop a resource for its membership that provided the most reliable and valid measures to utilize for assessment and research purposes. A guiding principle used in selecting the best measures to include in the Compendium was the following quote by Tukey:⁴³

When the right thing can only be measured poorly, it tends to cause the wrong to be measured well. And it is often much worse to have a good measurement of the wrong thing – especially when, as is so often the case, the wrong thing will IN FACT be used as an indicator of the right thing – than to have a poor measurement of the right thing.

With this quotation in mind, the Compendium was developed to avoid the many pitfalls often encountered when attempting to measure the right thing (e.g. functional improvement) with good measurements, those that have been reviewed in the Compendium.

Table 113.2 presents a summary of the various measures included in this Compendium. It should also be noted that for more comprehensive reviews of the various measures included in the Compendium, as well as other important works, the following are highly recommended: ACC and the National Health Committee,⁴⁴ Beurskens et al.,⁴⁵ Deyo et al.,⁴⁶ Kopec and Esdaile,⁴⁷ and Turk and Melzack.⁴⁸ Some of the questionnaires more commonly used to evaluate pain and disability will be briefly reviewed next.

Table 113.2 Summary of Outcome Measures Included in the Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders

MAJOR BIOPSYCHOSOCIAL MEASURES
	Range of motion
	Spine strength
	Lifting capacity (functional measure)
	Other tests of human performance capacity
	Psychological test measures
	Self-reported measures of pain and disability
	Clinical interview
	Clinician rating of overt pain behavior
PRETREATMENT TO POST-TREATMENT EFFICACY/OUTCOME MEASURES
	Range of motion, spine strength, lifting capacity and other tests of human performance capacity
	Self-report measures of pain and disability
	Psychological measures monitoring functional improvement
	Socioeconomic measures
	Treatment helpfulness

Gatchel RJ. 2001.⁴²

The Oswestry Low Back Pain Disability Questionnaire

The Oswestry Low Back Pain Disability Questionnaire ⁴⁹ is the oldest and most thoroughly researched instrument designed to assess functional status and disability.^45,^50,⁵¹ A strength of the Oswestry is that it possesses strong psychometric properties and has been thoroughly investigated.^49,⁵²^–⁶⁰ Moreover, a number of studies have shown the Oswestry to be a very responsive self-report instrument in detecting clinically meaningful change.^50,⁶¹^–⁶⁶ A possible weakness of the Oswestry, though, are studies suggesting a possible floor effect, such that extremely low scores may not be as accurate as more moderate or high scores.^50,^52,⁶⁷ Also, as noted by Kopec,⁵² the majority of currently available disability indices (including the Oswestry) focus primarily on the physical activities of daily living, with only minimal attention given to psychosocial concerns. In fact, no items on the Oswestry directly inquire about one’s emotional or psychological state, despite the fact that research has indicated that psychological factors play an integral role in the development and maintenance of disability.^68,⁶⁹

The Roland-Morris Disability Questionnaire

This questionnaire primarily evaluates a person’s physical abilities, such as dressing, walking, and lifting. The Roland-Morris ⁷⁰ was originally intended to be used for research purposes, but it subsequently was found useful in clinical practice.⁵⁰ The Roland-Morris was derived from the 136-item Sickness Impact Profile,⁷¹ which was developed as a generic health status indicator for use in a variety of chronic diseases, but not specifically for back or musculoskeletal injury.⁷² While the validity and reliability of the Roland-Morris have been proven over time, the responsiveness of the instrument has been the subject of some scrutiny. In fact, it has been shown to be the least responsive measure to clinically meaningful change when compared to other prominent indices of functional status.^47,⁷³ In addition, the Roland-Morris is less sensitive at detecting change when disability is classified as severe, likely a shortcoming that can be attributed to the two-level response format of the questionnaire.^47,⁵⁰

The Million Visual Analog Scale

This is a 15-item measure designed to assess disability and physical functioning useful primarily in chronic low back pain disorders. Its visual analog scale provides a simple, easy to understand format that causes little difficulty for patients.⁷⁴ The instrument has been the focus of few studies since its development and, as a result, very little is known about the Million’s psychometric properties outside of the original validation study.⁵³

The SF-36

This is a multipurpose health survey with 36 questions, but was not initially developed with a musculoskeletal pain disability population in mind.⁷⁵ While it is generally not considered to be a traditional functional status or disability instrument, the SF-36 has been employed as an outcome measure in numerous studies investigating low back pain.^62,^76,⁷⁷ Despite the psychometric strengths of the SF-36, its clinical utility as a valuable outcome instrument within the musculoskeletal patient population is uncertain.⁷⁷ Gatchel and colleagues,⁷⁷ in an investigation of the SF-36 with a chronically disabled back pain population, found that SF-36 scores demonstrated its utility in documenting group changes over time, but evidenced inadequacies when the instrument was used for individual patient assessment. Furthermore, it was reported that other instruments, such as the Oswestry and the Million Visual Analog Scale, were more useful in providing clinical data on an individual basis. Other studies confirmed these findings.⁷⁶

Other studies

Other less studied indices, such as the Waddell Disability Index ⁷⁸ the Low Back Outcome Score,⁷⁹ the Quebec Back Pain Disability Scale,⁵² or the Functional Rating Index,⁵¹ show promising beginnings, but have a small research literature relative to the Oswestry and Roland-Morris.⁴⁵ Furthermore, each primarily assesses activities of daily living, while placing little emphasis on psychosocial factors. Due to the lack of studies investigating these measures, or describing their psychometric properties, an unequivocal statement regarding their utility cannot be made at this point in time.

Pain Disability Questionnaire

Finally, one measure developed subsequent to the publication of the Compendium that shows great promise for monitoring change in chronic musculoskeletal disorders is the Pain Disability Questionnaire (PDQ) developed by Anagnostis, Gatchel and Mayer.⁸⁰ The PDQ was developed as a new measure of functional status. As noted by Anagnostis et al.,⁸⁰ the measurement of clinical outcomes is an essential element of any musculoskeletal treatment. The PDQ was developed for this purpose, and it yields a total functional disability score ranging from 0 to 150. The focus of the PDQ, much like other health inventories, is primarily on disability and function. Unlike most other measures, however, the PDQ is also designed for the full array of chronic disabling musculoskeletal disorders, rather than purely low back pain alone. Moreover, psychosocial variables, which recent studies have shown to play an integral role in the develop and maintenance of chronic pain disability, formed an important core of the PDQ. The psychometric properties of the PDQ have been found to be excellent, demonstrating stronger reliability, responsiveness, and validity relative to many other existing measures of functional status, such as the Oswestry, Million Visual Analog Scale and SF-36 instruments. In addition, a factor analysis of the PDQ revealed two independent factors that can be evaluated: a functional status component and a psychosocial component. Analyses demonstrated each of these two components to be valid in assessing their theorized constructs.

REVIEW OF OBJECTIVE OUTCOME EVALUATION METHODS

Since the development of FR by Mayer and Gatchel,¹⁶ its authors have steadfastly held to the belief that the systematic tracking of socioeconomic outcomes was the best approach to documenting the effectiveness of their program. As the approach of FR began to receive national and international attention, its authors were routinely approached by other clinical researchers to help in their attempts to objectively evaluate treatment outcomes. In response to these many requests, Mayer and Gatchel published a concise description of their method used at PRIDE.³⁷ Table 113.3 presents the basic dimensions and elements of the objective monitoring of socioeconomic outcomes used in the FR program. In this publication, the ‘nuts and bolts’ of the data collection system are provided, ranging from the actual data coding sheet utilized, to more specific details such as the required structured clinical interviewing skills needed for follow-up evaluations, as well as the best method for tracking patients over a long period of time.

Table 113.3 Major Socioeconomic Outcome Measures used to Evaluate Effectiveness of Functional Restoration

RETURN-TO-WORK
	Work return
	Work retention (at 1 year)
HEALTHCARE UTILIZATION
	Surgery to injured musculoskeletal area
	Percentage of patients visiting a new healthcare provider (continued care-and-documentation-seeking behaviors)
	Number of visits to new healthcare providers
RECURRENT (SAME MUSCULOSKELETAL AREA) OR NEW (DIFFERENT AREA) INJURY CLAIMS
	Percentage with recurrent or new injury claims
	Percentage with injury claims involving work absence (lost time)
CASE CLOSURE
	Resolution of legal/administrative disputes over permanent partial/total impairment or disability resulting from occupational injury
	Resolution of related disputes (third-party personal injury or product liability claims)
	Resolution of financial claims arising from perceived permanent disability (long-term disability, social security disability income, etc.)

Mayer TG, Prescott M, Gatchel RJ. 2000.³⁷

COST-EFFECTIVENESS OF PAIN MANAGEMENT

Intimately related to the above reviewed topic of treatment outcomes evaluation is the issue of cost-effectiveness. For example, chronic pain alone is a very expensive healthcare item, with estimates as high as US$125 million annually for healthcare and indemnity costs. Specialized pain management programs are usually expensive, averaging US$8100 for comprehensive treatment programs.⁸¹ Thus, if interdisciplinary pain programs are to survive in today’s managed care environment, they will need to demonstrate that they are both clinically effective and cost-effective. Fortunately, there has been systematic evaluations of outcomes related to the issue of cost-effectiveness of interdisciplinary pain management program. For example, Turk and Okifuji⁸² reported the cost-effectiveness of such programs by calculating differences in pain medication, healthcare utilization, and disability payments. They then compared the outcome of these financial parameters to the most frequently used treatment modalities. Overall, their results demonstrated that pain rehabilitation programs were up to 21 times more cost-effective than alternative treatments such as surgery. Other publications have also reported such savings.³² It is very worthwhile to provide such scientific data to third-party payers in order to justify the clinical and cost-effectiveness of comprehensive pain management programs.

It should also be kept in mind that many treatments for pain involve a wide variety of components delivered in potentially different ways (e.g. individual versus group, inpatient versus outpatient, daily versus weekly), and may also include different healthcare providers. To date, there has been very little research conducted to isolate what features are vitally necessary and sufficient to produce the optimal outcomes. Apparently, third-party payers are insisting that healthcare providers consider cost-effectiveness. The trend for evidence-based medicine requires that we begin to demonstrate the clinical and cost-effectiveness of the treatments that are provided.⁸³ In the future, we need to pay better attention to the issue of both what is necessary and also sufficient to produce the best outcomes with specific pain syndromes. As Gatchel and Herring have noted,⁸⁴ the reasons for monitoring evidence-based outcomes include the following:

• To provide objective data to third-party payers in order to document treatment effectiveness. These data can also be used to market the clinical effectiveness of a practice.

• In order to monitor the quality assurance in one’s own practice. Regular evaluation of treatment outcomes allows the practitioners to ascertain whether there is any ‘slippage’ in the quality of care being provided.

• For those interested in contributing to the scientific literature, such evidence-based outcomes serve as a foundation for publication or presentation of data at professional meetings.