Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders?

Strong Association of Depression and Anxiety With the Presence of Back Pain While Impact of Spinal Imaging Findings is Limited: Analysis of an MRI Cohort Study

Development of back pain is multifactorial, and it is not well understood which factors are the main drivers of the disease. We therefore applied a machine-learning approach to an existing large cohort study data set and sought to identify and rank the most important contributors to the presence of back pain amongst the documented parameters of the cohort. Data from 399 participants in the KORA-MRI (Cooperative health research in the region Augsburg-magnetic resonance imaging) (Cooperative Health Research in the Region Augsburg) study was analyzed. The data set included MRI images of the whole body, including the spine, metabolic, sociodemographic, anthropometric, and cardiovascular data. The presence of back pain was one of the documented items in this data set. Applying a machine-learning approach to this preexisting data set, we sought to identify the variables that were most strongly associated with back pain. Mediation analysis was performed to evaluate the underlying mechanisms of the identified associations. We found that depression and anxiety were the 2 most selected predictors for back pain in our model. Additionally, body mass index, spinal canal width and disc generation, medium and heavy physical work as well as cardiovascular factors were among the top 10 most selected predictors. Using mediation analysis, we found that the effects of anxiety and depression on the presence of back pain were mainly direct effects that were not mediated by spinal imaging. In summary, we found that psychological factors were the most important predictors of back pain in our cohort. This supports the notion that back pain should be treated in a personalized multidimensional framework. PERSPECTIVE: This article presents a wholistic approach to the problem of back pain. We found that depression and anxiety were the top predictors of back pain in our cohort. This strengthens the case for a multidimensional treatment approach to back pain, possibly with a special emphasis on psychological factors.

Is There an Association between Post-Traumatic Stress Disorder and the Incidence of Chronic Low Back Pain?

BACKGROUND

Preliminary research suggests post-traumatic stress disorder (PTSD) is a risk factor for chronic low back pain (CLBP). However, this literature displays some limitations. Therefore, this study aimed to investigate the association between PTSD and the 10-year cumulative incidence of CLBP in adults from Germany.

METHODS

The present retrospective cohort study included adults diagnosed with PTSD in 1 of 1284 general practices in Germany in 2005-2020 (index date). Individuals without PTSD were matched to those with PTSD (1:1) using a propensity score based on age, sex, index year, duration of follow-up, and the mean number of consultations during follow-up. In patients without PTSD, the index date was a randomly selected visit date.

RESULTS

There were 60,664 patients included in the study. After adjusting for frequent comorbidities, there was a positive but non-significant association between PTSD and incident CLBP in the overall population (HR = 1.07, 95% CI = 0.99-1.15). Nonetheless, the relationship between PTSD and CLBP was statistically significant in the age group >60 years (HR = 1.24, 95% CI = 1.05-1.46).

CONCLUSIONS

Conversely to previous research, PTSD was not associated with incident CLBP in this large German sample. Further longitudinal studies are warranted to corroborate these findings before drawing any firm conclusions.

Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty

INTRODUCTION

Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship.

METHODS

This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data.

RESULTS

Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68).

DISCUSSION

Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies.

LEVELS OF EVIDENCE

Prognostic, Level III: Comparative study.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Impact of anxiety and depression disorders on sustained return to work after work-related musculoskeletal strain or sprain: a gender stratified cohort study

Objective:

The aim of this study was to examine the impact of anxiety and depression disorders on sustained return to work (RTW) for men and women with musculoskeletal strain or sprain.

Methods:

Accepted lost-time claims for spine and upper-extremity strain or sprain were extracted for workers in the Canadian province of British Columbia from 2009 to 2013 (N=84 925). Pre-existing and new onset anxiety and depression disorders were identified using longitudinal health claims data. Probability of sustained RTW was analyzed using Cox proportional hazards models, stratified by gender and adjusted for potential confounders.

Results:

For pre-existing disorders, compared to men with no anxiety and no depression, men with anxiety only [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.84–0.93], depression only (HR 0.94, 95% CI 0.89–1.00), and anxiety and depression (HR 0.93, 95% CI 0.90–0.97) had lower probabilities of sustained RTW in adjusted models. The same direction of effect was found for women, but anxiety only had a smaller effect size among women compared to men (HR anxiety only 0.95, 95% CI 0.92–0.99; HR depression only 0.98, 95% CI 0.93–1.03, HR anxiety and depression 0.94, 95% CI 0.91–0.97). Among men and women, new onset disorders were associated with lower probability of sustained RTW and the effect estimates were larger than for pre-existing disorders.

Conclusions:

Findings suggest that workers’ compensation benefits and programs intended to improve RTW after musculoskeletal injury should take pre-existing and new onset anxiety and depression disorders into consideration and that gender-sensitive work disability strategies may be warranted.

Prevalence and risk factors for anxiety and depression disorders in workers with work-related musculoskeletal strain or sprain in British Columbia, Canada: a comparison of men and women using administrative health data

OBJECTIVE

To examine the prevalence and risk factors for medically treated anxiety and depression disorders among men and women with musculoskeletal strain or sprain work injury in British Columbia, Canada.

METHODS

A retrospective population-based cohort of accepted workers' compensation lost-time claims from 2000 to 2013 was constructed using linked administrative health data. Anxiety and depression disorders were identified using diagnoses from physician, hospital and pharmaceutical records. The 1-year period prevalence was estimated for the year before and the year after injury. Sociodemographic, clinical and work-related risk factors for prevalent and new onset anxiety and depression disorders were examined using multinomial regression.

RESULTS

13.2% of men and 29.8% of women had medically treated anxiety, depression or both in the year before injury. Only a slight increase (~2%) in the prevalence of these disorders was observed in the year after injury. Somatic and mental comorbidities were both strong risk factors for pre-existing and new onset anxiety and depression for both men and women, but these relationships were stronger for men.

CONCLUSION

Anxiety and depression disorders including those from prior to injury are common in workers with musculoskeletal strain or sprain and are associated with a complicated clinical profile. Gender-sensitive and sex-sensitive mental healthcare is an important consideration for work disability management.

Suicide and drug-related mortality following occupational injury

BACKGROUND

Drug overdoses and suicides have been rising since 2000 and are major contributors to a 3-year decline in US life expectancy. Studies suggest that injured workers have elevated rates of depression and opioid use, but no studies have measured excess mortality related to these risks.

MATERIALS AND METHODS

We linked New Mexico workers' compensation data for 100 806 workers injured in 1994 through 2000 with Social Security Administration earnings and mortality data through 2013 and National Death Index cause of death data. We then estimated the association between receiving lost-time workers' compensation benefits and mortality hazard ratios (HRs) and 95% confidence intervals (CIs) based on Fine and Gray cause-specific subdistribution hazards for common causes of death and for drug-related, suicide, and alcohol-related mortality.

RESULTS

There was almost a 3-fold increase in combined drug-related and suicide mortality hazard among women (HR = 2.63, 95% CI = 1.91-3.64) and a substantial increase among men (HR = 1.42, 95% CI = 1.13-1.79). Circulatory disease mortality hazard was elevated for men (HR = 1.25, 95% CI = 1.05-1.50).

CONCLUSION

Workplace injuries severe enough to require more than a week off work may impair workers' long-term health and well-being. Drug-related deaths and suicides may be important contributors to the long-term excess mortality of injured workers. Improved workplace conditions, improved pain treatment, better treatment of substance use disorders, and treatment of postinjury depression may substantially reduce mortality consequent to workplace injuries.

Post-traumatic Stress Disorder Symptoms are Associated With Incident Chronic Back Pain: A Longitudinal Twin Study of Older Male Veterans

STUDY DESIGN

A longitudinal cotwin control study of the Vietnam Era Twin Registry.

OBJECTIVE

The aim of this study was to examine the association of post-traumatic stress disorder (PTSD) symptoms with incident chronic back pain (CBP), while controlling for genetic factors and early family environment.

SUMMARY OF BACKGROUND DATA

It is unknown whether PTSD symptoms are associated with an increased incidence of CBP.

METHODS

In 2010 to 2012, a baseline survey was undertaken as part of a large-scale study of PTSD. Study participants completed the PTSD Symptom Checklist (PCL) and a self-report measure of CBP. In 2015 to 2017, a follow-up survey was sent to all 171 monozygotic (MZ) twin pairs (342 individuals) where both cotwins had no history of CBP at baseline, but only one cotwin in the pair met criteria for having current PTSD symptoms (one twin with PCL <30 and the cotwin with PCL ≥30). No other inclusion/exclusion criteria were applied. CBP at 5-year follow-up was defined as back pain of duration ≥3 months in the low back or mid/upper back. Covariates included age, race, education, income, Veterans Affairs health care use, disability compensation, smoking, body mass index, and depression. Statistical analysis estimated the cumulative incidence of CBP according to baseline PTSD symptoms. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were estimated in matched-pair cotwin control analyses adjusting for familial factors.

RESULTS

Among 227 males completing 5-year follow-up, including 91 MZ twin pairs, the mean age was 62 years. Five-year incidence of CBP in those without and with baseline PTSD symptoms was 40% and 60%, respectively. Baseline PTSD symptoms were significantly associated with incident CBP in crude and multivariable-adjusted within-pair analyses (RR 1.6, 95% CI 1.2-2.1; P = 0.002).

CONCLUSION

PTSD symptoms were associated with an increased incidence of CBP, without confounding by genetic factors or early family environment. PTSD symptoms may be a modifiable risk factor for prevention of CBP.

LEVEL OF EVIDENCE

3.

Using Patient-reported Outcomes Measurement Information System Measures to Understand the Relationship Between Improvement in Physical Function and Depressive Symptoms

INTRODUCTION

This investigation determined whether improved physical function and decreased pain would reduce depressive symptoms using the Patient-reported Outcomes Measurement Information System (PROMIS).

METHODS

This cohort study analyzed PROMIS Depression, Physical Function, and Pain Interference CAT scores from 3,339 patients presenting to a tertiary orthopaedic center. Patients demonstrating at least a-five point (effect size, 0.5) improvement in PROMIS Physical Function between consecutive visits were eligible for inclusion.

RESULTS

Patients presented, on average, with Physical Function and Pain Interference scores nearly one SD worse than population averages and Depression scores that approximated the normal population. Improved Physical Function and Pain Interference scores demonstrated no correlation with change in Depression scores (r = -0.13; r = 0.25).

CONCLUSION

Substantial early improvement in PROMIS Physical Function scores is not associated with change in PROMIS Depression scores. PROMIS Depression scores likely reflect underlying mental health rather than situational depressive symptoms.

LEVEL OF EVIDENCE

Prognostic, level III.

Modifiable risk factors for chronic back pain: insights using the co-twin control design

BACKGROUND

Inconsistent associations between modifiable risk factors and chronic back pain (CBP) may be due to the inability of traditional epidemiologic study designs to properly account for an array of potential genetic and environmental confounding factors. The co-twin control research design, comparing modifiable risk factors in twins discordant for CBP, offers a unique way to remove numerous confounding factors.

PURPOSE

The study aimed to examine the association of modifiable lifestyle and psychological factors with lifetime CBP.

STUDY DESIGN/SETTING

This is a cross-sectional co-twin control study in a nationwide sample of male twin members of the Vietnam Era Twin Registry.

PATIENT SAMPLE

The sample is composed of 7,108 participants, including 1,308 monozygotic (MZ) pairs and 793 dizygotic pairs.

OUTCOME MEASURE

The outcome measure is the self-reported lifetime history of CBP.

METHODS

Lifestyle factors included body mass index (BMI), smoking history, alcohol consumption, habitual physical activity, and typical sleep duration. Psychological factors included depression (Patient Health Questionnaire-9) and posttraumatic stress disorder (PTSD) symptoms (PTSD Checklist). Covariates included age, race, education, and income. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated for the association of risk factors with lifetime CBP when considering twins as individuals, and a within-pair co-twin control analysis that accounted for familial and genetic factors. Funding was through VA Grant 5IK2RX001515; there were no study-specific conflicts of interest.

RESULTS

The mean age of respondents was 62 years and the prevalence of lifetime CBP was 28%. All lifestyle factors were associated with CBP in the individual level analysis. However, none of these persisted in the within-pair analyses, except for severe obesity (BMI ≥35.0), which was associated with lifetime CBP in both individual-level (OR=1.6, 95% CI: 1.3-1.9) and within-pair analyses (MZ analysis: OR=3.7, 95% CI: 1.2-11.4). Symptoms of PTSD and depression were strongly associated with lifetime CBP in both the individual-level (moderate or severe depression: OR=4.2, 95% CI: 3.6-4.9, and severe PTSD: OR=4.8, 95% CI: 4.0-5.7) and within-pair (MZ) analyses (moderate or severe depression: OR=4.6, 95% CI: 2.4-8.7, and severe PTSD: OR=3.2, 95% CI: 1.6-6.5).

CONCLUSIONS

Many associations between modifiable lifestyle risk factors and CBP are due to confounding by familial and genetic factors. Severe obesity, depression, and PTSD should be considered in the development of intervention strategies to reduce the prevalence of CBP.

Gender Differences in the Longitudinal Association between Work-Related Injury and Depression

Little is known about gender differences in the association between occupational injury and depression. We investigated the bidirectional association and gender differences between work-related injury and depression using the same cohort in the US Medical Expenditure Panel Survey (MEPS). In Analysis 1, the association of occupational injury and subsequent depression was investigated from 35,155 employees without depression. Analysis 2 included 32,355 participants without previous injury and examined the association of depression and work-related injury. The multivariable-adjusted odds ratio was estimated using a discrete time-proportional odds model. Male workers who had experienced workplace injury were more vulnerable to post-injury depression than non-injured male workers (OR = 2.35, 95% CI: 1.52, 3.65). Female workers with depression were more prone to get injured at the workplace than the non-depressed female workers (OR = 1.44, 95% CI: 1.07, 1.96). These results did not hold in the reverse direction for both genders. Workers compensation benefit was positively associated with the risk of post-injury depression among males, whereas anti-depressant medication and duration of depression were related to workplace injury among females. Gender differences in the direction and associated factors of the relationship between occupational injury and depression highlight the need for gender-specific intervention to the vicious cycle of workplace injury and depression.

Course of Depressive Symptoms Following a Workplace Injury: A 12-Month Follow-Up Update

Introduction To estimate the prevalence, incidence and course of depressive symptoms, their relationship with return-to-work, and prevalence of depression diagnosis/treatment 12 months following a lost-time workplace musculoskeletal injury. Methods In a prospective cohort study, 332 workers' compensation claimants with a back or upper extremity musculoskeletal disorder completed interviews at 1, 6 and 12 months post-injury. Participants self-reported they had not received a depression diagnosis 1 year pre-injury. Cutoff of 16 on the CES-D defined a high level of depressive symptoms. Self-reported data on depression diagnosis and treatment and work status since injury were collected. Results Cumulative incidence of high depressive symptom levels over 12 months was 50.3 % (95 % CI 44.9-55.7 %). At 12 months, 24.7 % (95 % CI 20.1-29.3 %) of workers exhibited high levels. Over 12 months, 49.7 % (95 % CI 44.3-55.1 %) had low levels at all 3 interviews, 14.5 % (95 % CI 10.7-18.2 %) had persistently high levels, and 25.6 % (95 % CI 20.9-30.3 %) demonstrated improvements. Among workers with low baseline levels, incidence of high levels at 12 months was 6.0 % (95 % CI 2.7-9.3 %). For workers with high baseline levels, 36.1 % (95 % CI 27.9-44.3 %) exhibited persistent high symptoms at 6 and 12 months, while 38.4 % (95 % CI 30.1-46.6 %) experienced low levels at 6 and 12 months. Problematic RTW outcomes were common among workers with a poor depressive symptom course. Among workers with persistent high symptoms, 18.8 % (95 % CI 7.7-29.8 %) self-reported receiving a depression diagnosis by 12 months and 29.2 % (95 % CI 16.3-42.0 %) were receiving treatment at 12 months. Conclusions Depressive symptoms are common in the first year following a lost-time musculoskeletal injury and a poor depressive symptom course is associated with problematic RTW outcomes 12 months post-injury. While symptoms appear to improve over time, the first 6 months appear to be important in establishing future symptom levels and may represent a window of opportunity for early screening.

What Is the Impact of Comorbidities on Self-rated Hand Function in Patients With Symptomatic Trapeziometacarpal Arthritis?

BACKGROUND

The thumb trapeziometacarpal joint is one of the most common sites of arthritic degeneration prompting specialty care. Surgical treatment algorithms are based on radiographic arthritic progression. However, the pain and disability attributable to trapeziometacarpal arthritis do not correlate with arthritic stage, and depression has independently predicted poorer self-rated hand function both at baseline and after treatment in patients' atraumatic hand conditions.

QUESTIONS/PURPOSES

(1) Does thumb trapeziometacarpal osteoarthritis impact both self-perceived general health and hand function? (2) Do depression and other comorbid conditions differentially impact patient-rated hand function based on the presence or absence of symptomatic trapeziometacarpal arthritis? (3) How do disease-specific, patient demographics and comorbid conditions impact self-reported hand function in patients with trapeziometacarpal osteoarthritis?

METHODS

This cross-sectional study compared patients with symptomatic trapeziometacarpal osteoarthritis (n = 47) with matched control subjects without a symptomatic hand condition (n = 47). All participants self-reported medical (including depression) and musculoskeletal comorbidities and completed the SF-36 and the Michigan Hand Questionnaire (MHQ). Bivariate statistical analyses contrasted the patients with trapeziometacarpal osteoarthritis to control subjects. Linear regression modeling determined the impact of subject demographic data, comorbidity burden, and examination findings on total MHQ scores in patients with trapeziometacarpal arthritis.

RESULTS

Patients with scored trapeziometacarpal osteoarthritis indicated poorer perceived general health on the SF-36 categories of limitations resulting from physical health (52 ± 29 versus 71 ± 31, mean difference 19 [95% confidence interval {CI}, 7-31], p = 0.003) and limitations resulting from emotional problems (50 ± 27 versus 67 ± 50, mean difference 17 [95% CI, 3-33], p = 0.022) compared with control subjects. Self-reported depression was associated with worse hand function (total MHQ score) in patients with trapeziometacarpal arthritis (69 ± 20 versus 49 ± 22: mean difference -20 [95% CI, -5 to-36], p = 0.012) but not in control patients (90 ± 13 versus 84 ± 20: mean difference -5 [95% CI, -8 to 19], p = 0.404). In multivariate modeling, depression (β -20, [95% CI, -5 to -34], p = 0.009) and upper extremity comorbidities (β -25, [95% CI, -10 to -40], p = 0.002) were both associated with reduced total MHQ scores in patients with trapeziometacarpal osteoarthritis, and those factors accounted for 34% of the variance in the MHQ score.

CONCLUSIONS

When interpreting patient-rated hand disability in patients presenting with symptomatic trapeziometacarpal osteoarthritis, scores should be interpreted after accounting for the presence of depression and upper extremity comorbidities.

LEVEL OF EVIDENCE

Level III, prognostic study.

Insomnia in a chronic musculoskeletal pain with disability population is independent of pain and depression

BACKGROUND CONTEXT

Insomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population.

PURPOSES

This study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population.

STUDY DESIGN/SETTING

This was a retrospective study of prospectively captured data.

PATIENT SAMPLE

A consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol.

OUTCOME MEASURES

Insomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0-7); subthreshold insomnia (score, 8-14); moderate clinical insomnia (score, 15-21); and severe clinical insomnia (score, 22-28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire.

METHODS

Patients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses.

RESULTS

The presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia.

CONCLUSION

This research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population.

The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions

BACKGROUND

Prior studies have suggested that patient-rated hand function is impacted by depression and pain catastrophization. We studied the impact that these comorbidities have on treatment outcomes.

METHODS

Two hundred and fifty-six patients presenting to an orthopaedic hand clinic were followed in this prospective cohort investigation. Patients who were prescribed treatment for atraumatic hand/wrist conditions were eligible for inclusion. At enrollment, all patients completed the Center for Epidemiologic Studies Depression (CES-D) scale, the Pain Catastrophizing Scale (PCS), and the Michigan Hand Outcomes Questionnaire (MHQ; scale of 0 to 100, with 100 indicating the best hand performance). One month and three months after treatment, patients again completed the MHQ. Participants' psychological comorbidity status was categorized as either affected (a CES-D score of ≥16, indicating depression, or a PCS score of ≥30, indicating catastrophization) or unaffected (a CES-D score of &lt;16 and a PCS score of &lt;30). Diagnoses and treatments for both the affected and unaffected groups were examined. The effect of time and patient status, and their interaction, on MHQ scores was evaluated by mixed modeling.

RESULTS

Fifty patients were categorized as affected and 206 as unaffected. Diagnoses and treatments differed minimally between the two groups. At the time of enrollment, the mean MHQ score of the unaffected group (64.9; 95% confidence interval [CI], 62.5 to 67.3) was significantly higher than that of the affected group (48.1; 95% CI, 43.3 to 53.0). Both groups demonstrated similar significant absolute improvement over baseline at three months after treatment (an increase of 12.5 points [95% CI, 7.5 to 17.4] in the affected group and 12.8 points [95% CI, 10.4 to 15.3] in the unaffected group). Thus, at the time of final follow-up, the rating of hand function by the affected patients (60.6 [95% CI, 55.0 to 66.2]) was still significantly poorer than the rating by the unaffected patients (77.7 [95% CI, 75.0 to 80.5]).

CONCLUSIONS

Although patients affected by depression and/or pain catastrophization reported worse self-rated hand function at baseline and at the time of follow-up, these patients showed similar absolute improvement in self-rated hand function following treatment compared with patients with unaffected status.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

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

PURPOSE

The Multidimensional Pain Inventory (MPI) was designed to help capture unique characteristics of chronic pain patients. The present study examined the proportion of subgroups classified by the MPI in a chronic disabling occupational musculoskeletal disorder (CDOMD) patient cohort, and described characteristics of MPI profile groups in terms of other psychosocial variables.

METHODS

A cohort of 1,270 CDOMD patients undergoing an interdisciplinary functional restoration program was studied. Before the start of the program, all patients received a standard psychosocial assessment battery. A MPI computer program scored and identified pre-defined MPI subgroups: Adaptive Coper (AC); Interpersonally Distressed (ID); and Dysfunctional (DYS).

RESULTS

The distribution of MPI profiles for CDOMD patients was similar with those of highly disabled patients, with the largest proportion of patients having the DYS profile (44 %), followed by AC (33 %) and ID (23 %). The DYS profile group showed the highest level of pain severity, and psychosocial distress; the ID group had a moderate level; and the AC profile group had the lowest level. Higher rates of psychiatric disorders were also found in the DYS and ID groups. The DYS profile group was less likely to complete the treatment program.

CONCLUSION

The present study further demonstrated the clinical utility of the MPI classification in a large cohort of CDOMD patients, indicating that the MPI profiles successfully distinguish among patients who may require extra psychosocial attention to achieve successful treatment gains and program completion.

Alcohol dependence as a chronic pain disorder

Dysregulation of pain neurocircuitry and neurochemistry has been increasingly recognized as playing a critical role in a diverse spectrum of diseases including migraine, fibromyalgia, depression, and PTSD. Evidence presented here supports the hypothesis that alcohol dependence is among the pathologies arising from aberrant neurobiological substrates of pain. In this review, we explore the possible influence of alcohol analgesia and hyperalgesia in promoting alcohol misuse and dependence. We examine evidence that neuroanatomical sites involved in the negative emotional states of alcohol dependence also play an important role in pain transmission and may be functionally altered under chronic pain conditions. We also consider possible genetic links between pain transmission and alcohol dependence. We propose an allostatic load model in which episodes of alcohol intoxication and withdrawal, traumatic stressors, and injury are each capable of dysregulating an overlapping set of neural substrates to engender sensory and affective pain states that are integral to alcohol dependence and comorbid conditions such as anxiety, depression, and chronic pain.

Dynamic risk factors in the misuse of opioid analgesics

OBJECTIVE

Identify the risk factors for prescription opioid misuse among patients taking prescription opioids to deal with chronic pain.

METHODS

We examined the literature for a variety of dynamic risk factors associated with opioid misuse among the chronic pain population in order to present a narrative review. Considered were: taking single or multiple opioids, pain intensity, mental health disorders, including a history of preadolescent sexual abuse, personal and familial history of substance abuse, a history of legal problems, being a crime victim, drug-seeking behaviors, drug craving, and age.

RESULTS

A variety of risk factors have been studied in the literature. Risk factors in chronic opioid therapy patients are dynamic in that they can change with disease progression, tolerance, changes in pain quality, mental health, comorbidities, other drug therapies or drug interactions, and changes in the patient's lifestyle.

CONCLUSION

Opioid analgesic therapy must be tailored to carefully monitor all patients in order to minimize misuse and abuse, since the risk is constant and dynamic and therefore every patient is at some degree of risk for opioid misuse.

Mental health status of Ontario injured workers with permanent impairments

OBJECTIVE

Each year, approximately 31,000 Canadian injured worker claimants are certified to have permanent impairments associated with the initial workplace incident. Permanent impairments are characterized by ongoing pain, and limitations in physical function and activity participation--all predisposing factors to mental health problems. Here we examine the post-accident mental health status of a sample of Ontario injured workers with permanent impairments.

METHODS

We analyze data from a cross-sectional telephone survey of 494 injured workers. Mental health status is examined using nine dichotomous diagnostic, symptomatic and functional mental health indicators identified by survey respondents as non-present, or having pre- or post-injury onset, and the CES-D. We describe the relationship of these indicators and work injury, demographic and socio-economic factors.

RESULTS

Post-injury onset mental health problems are elevated compared to pre-injury onset in seven of nine indicators. Diagnosed depression, medication abuse, inability to concentrate, and sleep problems are elevated compared to general Canadian population prevalence. Diagnosed depression is elevated compared to populations with pain and chronic health conditions. Higher education and pre-injury income are associated with lower depressive symptoms. Men and older individuals are less likely to report a diagnosis of depression. Older individuals are less likely to report concentration problems.

CONCLUSION

These data paint a troubling mental health picture among injured workers with permanent impairments. Implications for return-to-work and income recovery, health service access and rehabilitation within and outside the compensation system are discussed.

Predictors of change in pain and physical functioning among post-menopausal women with recurrent pain conditions in the women's health initiative observational cohort

Pain complaints are commonly reported symptoms among postmenopausal women and can have significant effects on health-related quality of life. We sought to identify medical and psychosocial factors that predict changes in pain and overall physical functioning over a 3-year period among postmenopausal women with recurrent pain conditions. We examined data from postmenopausal women age 50 to 79 with recurrent pain conditions (low back pain, neck pain, headache or migraines, or joint pain or stiffness) over a 3-year period using the Women's Health Initiative Observational Study Cohort (N = 67,963). Multinomial logistic regression models controlling for demographic and clinical characteristics were used to identify baseline predictors of change in the SF-36 subscales for pain and physical functioning between baseline and 3-year follow-up. Body mass index (BMI) was associated with worsening of pain (OR [95% CI] 1.54 [1.45-1.63] for BMI ≥30) and physical functioning (1.83 [1.71-1.95] for BMI ≥30). A higher reported number of nonpain symptoms, higher medical comorbidity, and a positive screen for depression (1.13 [1.05-1.22] for worsened pain) were also associated with worsening of pain and physical functioning. Baseline prescription opioid use was also associated with lack of improvement in pain (OR .42, 95% CI .36-.49) and with worsened physical functioning (1.25 [1.04-1.51]).

PERSPECTIVE

This study presents prospective data on change in pain and physical functioning in postmenopausal women over a 3-year period. Our results suggest depression, nonpain physical symptoms, obesity, and possibly opioid treatment are associated with worse long-term pain outcomes in this population.

Cognitive-behavioral therapy for hand and arm pain

Cognitive-behavioral therapy (CBT) is a psychological treatment that emphasizes the interrelation among thoughts, behaviors, feelings, and sensations. CBT has been proved effective not only for treatment of psychological illness but also for teaching adaptive coping strategies in the context of chronic illnesses, including chronic pain. The present article provides general information on CBT, specific information on CBT for pain, as well as guidelines and strategies for using CBT for hand and arm pain patients, as part of multidisciplinary care models.

Level of education and back pain in France: the role of demographic, lifestyle and physical work factors

PURPOSE

To investigate the pathways from level of education to low back pain (LBP) in the adult population, especially concerning the role of physical working constraints, and personal factors (overweight, tobacco consumption, and tallness).

METHODS

The study population consisted of 15,534 subjects from the National Health Survey, with data on LBP, level of education, personal factors, and physical working constraints. Logistic models for LBP (pain more than 30 days during the previous 12 months) were compared in order to check the consistency of the data with specific causal pathways.

RESULTS

Low back pain was strongly associated with level of education. This association was almost completely explained if present or past exposure to tiring work postures and handling of heavy loads were taken into account. For men, the OR for "no diploma", adjusted only for age, was 1.75; it was 1.02 after additional adjustment on physical work factors. Personal factors played also a role, especially overweight for women. Among them, the OR associated with a body mass index = 27 or more was 1.58 after adjustment on all the other factors.

CONCLUSIONS

In this national population the main pathways from education to LBP were through occupational exposure and lifestyle factors.

Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study

Background

Comorbid psychopathology is an important predictor of poor outcome for many types of treatments for back or neck pain. But it is unknown if this applies to the results of medial branch blocks (MBBs) for chronic low back or neck pain, which involves injecting the medial branch of the dorsal ramus nerves that innervate the facet joints. The objective of this study was to determine whether high levels of psychopathology are predictive of pain relief after MBB injections in the lumbar or cervical spine.

Methods

This was a prospective cohort study. Consecutive patients in a pain medicine practice undergoing MBBs of the lumbar or cervical facets with corticosteroids were recruited to participate. Subjects were selected for a MBB based on operationalized selection criteria and the procedure was performed in a standardized manner. Subjects completed the Brief Pain Inventory (BPI) and the Hospital Anxiety and Depression Scale (HADS) just prior to the procedure and at one-month follow up. Scores on the HADS classified the subjects into three groups based on psychiatric symptoms, which formed the primary predictor variable: Low, Moderate, or High levels of psychopathology. The primary outcome measure was the percent improvement in average daily pain rating one-month following an injection. Analysis of variance and chi-square were used to analyze the analgesia and functional rating differences between groups, and to perform a responder analysis.

Results

Eighty six (86) subjects completed the study. The Low psychopathology group (n = 37) reported a mean of 23% improvement in pain at one-month while the High psychopathology group (n = 29) reported a mean worsening of -5.8% in pain (p < .001). Forty five percent (45%) of the Low group had at least 30% improvement in pain versus 10% in the High group (p < .001). Using an analysis of covariance, no baseline demographic, social, or medical variables were significant predictors of pain improvement, nor did they mitigate the effect of psychopathology on the outcome.

Conclusion

Psychiatric comorbidity is associated with diminished pain relief after a MBB injection performed with steroid at one-month follow-up. These findings illustrate the importance of assessing comorbid psychopathology as part of a spine care evaluation.

Criticisms of the biopsychosocial model in spine care: creating and then attacking a straw person

STUDY DESIGN

Spine update on some major misconceptions of the biopsychosocial model.

OBJECTIVE

To refute some of the erroneous beliefs about the weaknesses of the application of the biopsychosocial model to spine care.

SUMMARY AND BACKGROUND DATA

Currently, the biopsychosocial model of illness is the most heuristic perspective in understanding the etiology, assessment, treatment, and prevention of pain-related disorders such as spinal pain and disability. Only the misuse of the biopsychosocial model by inappropriately trained health care specialists decreases its maximum utility and validity.

METHODS

This is a point-by-point response to a previous article in Spine, which inaccurately discussed some assumed limitations of the biopsychosocial model as related to spine care. It is also a more comprehensive review of the model and related clinical applications. Articles from the scientific literature are cited in refuting those assumed limitations.

RESULTS

The previous article in Spine provided a superficial, and often erroneous, review of the biopsychosocial model of illness. In providing a point-by-point refutation of that review, a number of important clarifications were delineated. For example, concerns raised about the sole reliance of self-report outcomes are shown to be unfounded. By definition, the "bio" "psycho" "social" underscores the important interactive contribution of factors in each of these defining domains, and requires their individual assessments. It was also erroneously stated that there was an inherent "disconnect" between physical pathology and self-report in this model. However, the richness of the biopsychosocial model is the recognition of the need to continue to understand the pathoanatomic and pathophysiological explanations of spinal disorders (the bio part of the equation), as well as the psychosocial factors that may also be important (the psychosocial part of biopsychosocial). Other questions raised about the scientific status of the model, the effectiveness of treatments based on the model, and so forth, were also addressed.

CONCLUSION

In agreement with the earlier Spine update, the "...biopsychosocial model has been readily adapted to all aspects of spine care with many positive implications." However, the author then raised some apparently major concerns. These concerns were shown to be unfounded. In point-of-fact, there is an ever-growing scientific literature demonstrating the heuristic value of this model in developing more effective assessment and treatment methods for spinal disorders, as well as guiding greater "cutting-edge" research on their etiologies and potential prevention techniques.

Prescription opioid dependence is associated with poorer outcomes in disabling spinal disorders

STUDY DESIGN

Prospective outcomes study involving patients with chronic disabling occupational spinal disorders (CDOSD) diagnosed with (n = 199) or without (n = 1124) postinjury opioid-dependence disorder (ODD), based on the Diagnostic and Statistical Manual of Mental Disorders-fourth edition cirteria.

OBJECTIVE

To determine whether prescription opioid dependence, assessed at the beginning of rehabilitation treatment, is associated with poorer treatment outcomes in patients with CDOSDs attending an interdisciplinary rehabilitation program.

SUMMARY OF BACKGROUND DATA

Controversy exists regarding the risk of iatrogenic ODD and treatment outcomes when long-term opioid therapy is used in the treatment of chronic nonmalignant pain conditions.

METHODS

A consecutive sample of patients with CDOSDs [n = 1323; mean (SD) length of disability = 18.8 (20.7) months] attending a tertiary referral center received intensive physical reactivation and pain/disability management interventions, based on a functional restoration model, including detoxification from opioids. One-year outcomes included return to work, work retention, healthcare utilization, new surgeries, recurrent injuries, and disability claim settlement.

RESULTS

Prevalence of ODD in this CDOSD population on entering the rehabilitation program was 15%. Even after adjusting for relevant demographic factors and comorbid psychiatric disorders, opioid-dependent patients were 1.7 times [95% confidence interval (CI): 1.0, 2.7] less likely to return to work, 2 times (95% CI: 1.3, 3.0) less likely to retain work at the 1-year interview, and 1.7 times (95% CI: 1.2, 2.5) more likely to engage in healthcare utilization from new providers, compared with nonopioid-dependent patients.

CONCLUSIONS

Iatrogenic prescription opioid dependence may be a risk factor for less successful long-term work and health outcomes, even after detoxification from opioids as part of an interdisciplinary functional rehabilitation program. Chronic prescription opioid dependence in this patient population is also associated with a significantly higher prevalence of comorbid psychiatric conditions, both axis I and II.

Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis

BACKGROUND

Opioids can provide relief for people with chronic pain. However, a minority may develop aberrant drug behaviors. A critical issue is identifying "at-risk" patients.

OBJECTIVE

To synthesize the evidence of published strategies for identifying at-risk patients to guide clinicians' decisions and practices for prescribing opioid treatment for chronic pain patients (CPP).

DATA SOURCES

MEDLINE database search from 1966 to March 20, 2007, searching the bibliographies from all retrieved articles, and articles available in the authors' files. Studies were limited to human studies in the English language related to screening for predictors of aberrant drug behaviors in CPP who were prescribed long-term opioids. We included studies reviewing, developing measures, or investigating outcomes related to screening for aberrant opioid behaviors in CPP.

RESULTS

We identified 6 published articles addressing clinician-based predictors of substance misuse of opioids and 9 published studies evaluating the predictive ability of clinical interviews and self-report measures for aberrant opioid behaviors in CPP. Several attempts have been made to develop procedures to identify at-risk patients including urine toxicology screening, structured interviews, observation, and self-report questionnaires. In general, the psychometric properties of the published questionnaires and interview protocols are weak; moreover, the samples included in the studies are often small and unrepresentative. Thus, none of them can be recommended for use with any confidence.

CONCLUSION

Review of the published studies reveals that no one procedure or set of predictor variables is sufficient to identify CPP at-risk for opioid misuse or abuse. There is a scarcity of evidence regarding characteristics that predict aberrant behavior before beginning long-term opioids. Several predictors have been identified. Strong predictors include a personal history of illicit drug and alcohol abuse. Demographic factors have also been reported, but the results are not consistent. Prospective studies, especially ones with CPP who have not already been started on chronic opioid therapy, are needed.

Employment outcomes of persons with a mental disorder and comorbid chronic pain

OBJECTIVE

This study examined the independent and interactive effects of common mental disorders and chronic pain conditions on employment and work outcomes among individuals under 65 years old.

METHODS

Cross-sectional data were analyzed from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000-2001 (N=5,328). Common mental disorders were assessed by using the short-form version of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and employment outcomes were identified by self-report. Logistic and linear regression analyses were used to provide estimates for work impairment on the basis of the presence of a mental disorder or a chronic pain condition or both.

RESULTS

The interaction between presence of a mental disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (odds ratio=2.3, 95% confidence interval=1.2-4.2) and number of days of work missed in the past month because of health (regression coefficient=1.47, SE=.59). In stratified analyses this effect persisted for women but not for men. The presence of a mental disorder and the presence of a chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days because of health, although the interaction was not significant.

CONCLUSIONS

Mental disorders and chronic pain are each associated with work disability. Mental disorders are more strongly associated with some work disability outcomes when they are accompanied by chronic pain, especially among women.

Chronic widespread pain in patients with occupational spinal disorders: prevalence, psychiatric comorbidity, and association with outcomes

STUDY DESIGN

A prospective study assessing chronic widespread pain (CWP) and psychiatric comorbidities in patients with chronic disabling occupational spinal disorders (CDOSDs).

OBJECTIVE

To assess the prevalence of CWP, demographic characteristics, and associated psychiatric comorbidity among CDOSD patients, as well as determine if CWP is a risk factor for less successful one-year postrehabilitation socioeconomic outcomes.

SUMMARY OF BACKGROUND DATA

CWP is an essential criterion for diagnosing fibromyalgia. CWP is estimated to affect between 4.1% to 13.5% of the general population and it is associated with higher rates of psychiatric disorders and growing rates of disability. The prevalence of CWP, or its associations as a comorbidity, in patients with CDOSDs are unknown.

METHODS

The socioeconomic outcomes, demographic characteristics, and psychiatric comorbidity of CDOSD patients with CWP were compared to non-CWP patients within a cohort of consecutive CDOSD patients (n = 2730), treated in an interdisciplinary functional restoration program. CWP was determined according to American College of Rheumatology criteria. Psychiatric comorbidity was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-fourth Edition at the beginning of the rehabilitation program. RESULTS.: In the CDOSD cohort, 32% of the patients (N = 878) met American College of Rheumatology criteria for CWP, relative to 4.1% to 13.5% within the general population. CWP patients (82%) were much more likely than non-CWP patients (16%) to have multisite pain complaints, leading to the finding that CDOSD patients with multisite pain showed a CWP prevalence of 70%. CWP patients were 1.5 times more likely to be female, more likely to have multiple compensable injuries, and had slightly elevated rates of pre- and postinjury Axis I psychopathology. Nevertheless, CWP was not associated with less successful 1-year socioeconomic outcomes.

CONCLUSION

A surprisingly high frequency of CDOSD patients participating in interdisciplinary rehabilitation met criteria for CWP, though the diagnosis was generally unknown to the patient. In this large workers' compensation cohort, CWP was not associated with longer periods of disability, more prerehabilitation surgery or higher pain self-report. With appropriate rehabilitation, CWP patients can have equally successful work return and health utilization outcomes compared to non-CWP patients, despite having significantly higher rates of certain psychiatric disorders.

Employment outcomes of persons with a mental disorder and comorbid chronic pain

OBJECTIVE

This study examined the independent and interactive effects of common mental disorders and chronic pain conditions on employment and work outcomes among individuals under 65 years old.

METHODS

Cross-sectional data were analyzed from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000-2001 (N=5,328). Common mental disorders were assessed by using the short-form version of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and employment outcomes were identified by self-report. Logistic and linear regression analyses were used to provide estimates for work impairment on the basis of the presence of a mental disorder or a chronic pain condition or both.

RESULTS

The interaction between presence of a mental disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (odds ratio=2.3, 95% confidence interval=1.2-4.2) and number of days of work missed in the past month because of health (regression coefficient=1.47, SE=.59). In stratified analyses this effect persisted for women but not for men. The presence of a mental disorder and the presence of a chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days because of health, although the interaction was not significant.

CONCLUSIONS

Mental disorders and chronic pain are each associated with work disability. Mental disorders are more strongly associated with some work disability outcomes when they are accompanied by chronic pain, especially among women.

Psychosocial differences between high-risk acute vs. chronic low back pain patients

The present study was designed to evaluate the relative degree and type of emotional distress in high-risk acute low back pain (ALBP) subjects (defined as less than 3 months since initial injury) vs. high-risk chronic low back pain (CLBP) subjects (defined as greater than 3 months since initial injury). It is an extension of earlier findings that demonstrated the significant role that such emotional distress may play in the development of CLBP disability if not appropriately treated in the acute phase. This work stems from a conceptual three-stage model, which characterizes the progression from acute to chronic pain. Several psychosocial measures were administered that included information allowing for the classification of subjects as high-risk based upon an earlier developed screening algorithm. The ANCOVA procedure in SPSS was used to compare groups, controlling for gender, ethnicity, and age. Results revealed that CLBP subjects had higher rates of certain measures of emotional distress and depression relative to ALBP subjects. These findings further support the importance of effectively managing emotional distress factors early, when treating musculoskeletal disorders such as low back pain.