The Cognitive Symptom Checklist-Work in cancer patients is related with work functioning, fatigue and depressive symptoms: a validation study

Purpose

The study objectives are to translate the 21-item Cognitive Symptom Checklist-Work (CSC-W21) to Dutch (CSC-W DV) and to validate the CSC-W DV in working cancer patients.

Methods

The CSC-W21 was cross-culturally translated and adapted to a Dutch version. In this 19-item version, the dichotomous response option was changed to an ordinal five-point scale. A validation study of the CSC-W DV was conducted among cancer patients who had returned to work during or following cancer treatment. Internal consistency (Cronbach’s α), structural validity (exploratory factor analysis) and construct validity (hypothesis testing) were evaluated.

Results

In a cohort of 364 cancer patients, 341 (94 %) completed the CSC-W DV (aged 50.6 ± 8.6 years, 60 % women). Exploratory factor analysis revealed two subscales ‘working memory’ and ‘executive function’. The internal consistency of the total scale and subscales was high (Cronbach’s α = 0.93–0.95). Hypothesis testing showed that self-reported cognitive limitations at work were related to work functioning (P < 0.001), fatigue (P = 0.001) and depressive symptoms (P < 0.001), but not to self-rated health (P = 0.14).

Conclusions

The CSC-W DV showed high internal consistency and reasonable construct validity for measuring work-specific cognitive symptoms in cancer patients. The CSC-W DV was associated in expected ways with work functioning, fatigue and depressive symptoms.

Implications for Cancer Survivors

It is important to enhance knowledge about cognitive symptoms at work in cancer patients, to guide and support cancer patients as good as possible when they are back at work and to improve their work functioning over time.

Optimal port placement and enhanced guidance in robotically assisted cardiac surgery

BACKGROUND

Optimal port placement and enhanced guidance in robotically assisted cardiac surgery is required to improve preoperative planning and intraoperative navigation.

METHODS

Offline optimal port placement is planned on a three-dimensional virtual reconstruction of the patient's computed tomography scan. Using this data, an accurate in vivo port placement can be performed, which is achieved by augmented reality techniques superimposing virtual models of the thorax and the teleoperator arms on top of the real worldview.

RESULTS

A new system incorporating both port placement planning and intraoperative navigation in robotically assisted minimally invasive heart surgery was established to aid the operative workflow. A significant reduction of operation time by improved planning and intraoperative support is anticipated.

CONCLUSIONS

The enhanced intraoperative orientation possibilities may lead to further decrease in operation time and have the continuing ability to improve quality.

Clinical tools to facilitate workplace accommodation after treatment for an upper extremity disorder

Failure to implement work site accommodations for work-related upper extremity disorders (WRUEDs) may be a factor contributing to delayed functional recovery and relapse. The present study describes the use of the 38-item Job Requirements and Physical Demands (JRPD) scale, a self-report measure of ergonomic exposure, and other case management tools to improve accommodation efforts for 101 workers (75 women, 26 men) returning to work after lost time related to a WRUED. Items were categorized into five subscales based on item content: administrative, computer-related, workstation design, environmental, and equipment. Administrative risk factors were elevated among office clerks, whereas postal clerks and letter carriers reported more workstation design risk factors, and letter carriers and electrical/mechanical workers cited more equipment-related risk factors (p < 0.05). All occupational categories rated computer-related risk factors highest. The Integrated Case Management (ICM) approach, which relies on the JRPD scale to guide recommendations, was used with a subgroup of these workers (n = 53), resulting in 1.4 times more workplace accommodations per worker than with a non-ICM approach. Clinical use of the self-reported exposure measure within the overall workplace accommodation process may have been a factor contributing to more frequent accommodation in the ICM group. This study of a subgroup of workers' compensation cases highlights the need for additional investigation of tools to integrate ergonomic approaches within the workplace accommodation process.

Working with low back pain: workplace and individual psychosocial determinants of limited duty and lost time

BACKGROUND

Few studies have identified the risk factors associated with lost time in employees working with occupational low back pain (OLBP) despite the presence of pain. Such data could assist in the development of evidenced-based secondary prevention programs.

METHODS

The present investigation was a case-control study (n = 421) of demographic, health behavior, ergonomic, workplace and individual psychosocial factors hypothesized to be associated with lost time in young, full-time employees (i.e., soldiers) with OLBP. Analyses of the burden of OLBP in terms of the number of days on limited duty and lost time status were also computed.

RESULTS

Logistic regression analysis indicated that female gender, education beyond HS/GED, longer time working in military, higher levels of daily life worries, no support from others, higher levels of ergonomic exposure, stressful work, increased peer cohesion, and greater perceived effort at work placed a worker at a greater likelihood for OLBP-related lost work time. Lower levels of innovation, involvement, and supervisor support were also associated with lost time. Linear regression indicated that the number of days of lost time and limited duty was associated with lower levels of physical health and higher levels of symptom severity.

CONCLUSIONS

The results support the potential utility of interventions targeting ergonomic, workplace and individual psychosocial risk factors in secondary prevention.

Working with low back pain: workplace and individual psychosocial determinants of limited duty and lost time

BACKGROUND

Few studies have identified the risk factors associated with lost time in employees working with occupational low back pain (OLBP) despite the presence of pain. Such data could assist in the development of evidenced-based secondary prevention programs.

METHODS

The present investigation was a case-control study (n = 421) of demographic, health behavior, ergonomic, workplace and individual psychosocial factors hypothesized to be associated with lost time in young, full-time employees (i.e., soldiers) with OLBP. Analyses of the burden of OLBP in terms of the number of days on limited duty and lost time status were also computed.

RESULTS

Logistic regression analysis indicated that female gender, education beyond HS/GED, longer time working in military, higher levels of daily life worries, no support from others, higher levels of ergonomic exposure, stressful work, increased peer cohesion, and greater perceived effort at work placed a worker at a greater likelihood for OLBP-related lost work time. Lower levels of innovation, involvement, and supervisor support were also associated with lost time. Linear regression indicated that the number of days of lost time and limited duty was associated with lower levels of physical health and higher levels of symptom severity.

CONCLUSIONS

The results support the potential utility of interventions targeting ergonomic, workplace and individual psychosocial risk factors in secondary prevention.

Back and upper extremity disorders among enlisted U.S. Marines: burden and individual risk factors

Although musculoskeletal disorders of the low back and upper extremities can affect military readiness, little is known about their extent and risk factors in the U.S. Marine Corps. Using the Defense Medical Epidemiology and Defense Medical Surveillance System databases, back and upper extremity diagnostic categories were among the top four sources of outpatient visits and duty limitation among enlisted Marines. Back disorders were also found to be the fifth most common cause for lost time. Subsequently, high-risk occupations were identified, age-related trends for clinic visit rates were determined, and rate ratios were computed for the top 15 low back and upper extremity diagnoses among enlisted Marines from 1997 through 1998. Occupational categories with the highest rates of musculoskeletal-related outpatient visits included image interpretation, auditing and accounting, disturbsing, surveillance/target acquisition, and aircraft launch equipment. Significantly increasing linear trends in rates across age groups were found for most diagnoses. For 1998, age-specific rate ratios indicated significantly higher rates for most low back and upper extremity disorders for females; lower rank (i.e., E1-E4) was also a risk, but for fewer diagnoses. The findings emphasize the need to identify modifiable (e.g., work-related, individual) risk factors and to develop focused primary and secondary prevention programs for musculoskeletal disorders in the Marine Corps. Subsequently, these efforts can assist in reducing associated effects, maximizing resource utilization, and enhancing operational readiness.

Case management services for work related upper extremity disorders. Integrating workplace accommodation and problem solving

A case manager's ability to obtain worksite accommodations and engage workers in active problem solving may improve health and return to work outcomes for clients with work related upper extremity disorders (WRUEDs). This study examines the feasibility of a 2 day training seminar to help nurse case managers identify ergonomic risk factors, provide accommodation, and conduct problem solving skills training with workers' compensation claimants recovering from WRUEDs. Eight procedural steps to this case management approach were identified, translated into a training workshop format, and conveyed to 65 randomly selected case managers. Results indicate moderate to high self ratings of confidence to perform ergonomic assessments (mean = 7.5 of 10) and to provide problem solving skills training (mean = 7.2 of 10) after the seminar. This training format was suitable to experienced case managers and generated a moderate to high level of confidence to use this case management approach.

A new tetratertiary phosphine ligand and its use in Pd-catalyzed allylic substitution

A new tetraphosphine, the cis-cis-cis-1,2,3,4-tetrakis(diphenylphosphinomethyl)cyclopentane (Tedicyp) 1 has been synthesized, characterized, and used in Pd-catalyzed allylic substitutions. The Tedicyp was easily prepared in seven steps from the commercially available himic anhydride. The structure of the complex Tedicyp-borane was determined by X-ray analysis. The tetraphosphine in combination with [Pd(eta(3)-C(3)H(5))Cl](2) affords a very efficient catalyst for allylic substitution of several allylic acetates. Under mild conditions, very high turnover numbers and turnover frequencies have been obtained.

Job stress, upper extremity pain and functional limitations in symptomatic computer users

BACKGROUND

Research suggests that exposure to occupational stressors are related to the presence and/or exacerbation of work-related upper extremity symptoms in office workers. Also worker's response to work demands and/or job stressors (i.e., workstyle) may exacerbate symptom severity and impact function. The present study examines the association among work demands, job stress and workstyle on pain and function.

METHODS

124 symptomatic female office workers completed a questionnaire measuring demographics, medical history, work demands, perception of the work environment, workstyle, pain intensity, functional impact, and time lost from work.

RESULTS

Heightened job stress and the tendency to continue to work in a way that contributes to pain to ensure high quality (dimension of workstyle) were related to pain intensity at work and decreased function. These variables, in addition to hours worked per year, were related to increased pain experienced across the work week. The model tested did not predict the occurrence of lost time.

CONCLUSIONS

The present findings provide support for the association between job stress, workstyle, upper extremity pain and function. While it is not possible to determine the exact direction of the observed relationships, these results are consistent with prior research indicating the potential significance of job stress and workstyle on symptom exacerbation and functional limitations. Implications for evaluation and intervention are discussed.

Development of a screen for predicting clinical outcomes in patients with work-related upper extremity disorders

This study prospectively examined the extent to which a set of medical, physical, ergonomic, occupational psychosocial, and individual psychosocial variables would predict clinical outcome associated with a diverse set of work-related upper extremity disorders in recently diagnosed individuals. This investigation was designed to develop a tool for use in a clinical setting to assist in identifying patients at risk for poorer outcome. Outcome was measured at 1, 3, and 12 months after completing a baseline questionnaire. Outcome status was based on a median split of a standardized composite index (symptoms, function, workdays lost, and mental health). Logistic regression indicated that predictors of poorer outcome at 1 month were: upper extremity comorbidity (risk ratio [RR], 1.58), pain severity (RR, 1.45), ergonomic risk exposure (RR, 1.07), low job support (RR, 1.03), and pain coping style (RR, 1.54). At 3 months, poorer outcome was predicted by: symptom severity (RR, 10.46), job stress (RR, 1.20), and pain coping style (RR, 1.98). The number of prior treatments/providers (RR, 1.77), past recommendation for surgery (RR, 6.43), and pain coping style were found to predict poorer outcome at 12 months. Sensitivity and specificity, respectively, for the models were 77.4% and 71.8% at 1 month, 80.6% and 82.4% at 3 months, and 80.6% and 83.3% at 12 months. The results indicate that baseline measures of ergonomic and psychosocial stress, pain severity, and pain coping style predict clinical outcome at shorter intervals, whereas number of past treatments/providers, recommendation for surgery and pain coping style predict longer-term outcome. The resulting prognostic screen provides a simple tool that assesses the multidimensional nature of work-related upper extremity disorders and predicts clinical outcome. Furthermore, the findings suggest the importance of early intervention that addresses both physical and psychosocial stressors at work. Specific recommendations to reduce the impact of observed risk factors are discussed.

Predictors of occupational low back disability: implications for secondary prevention

Over the past decade, studies have identified a combination of demographic, physical/medical, ergonomic, and psychosocial factors in the development of work disability related to occupational low back pain. Using such data on disability risk factors, investigators have begun to develop risk identification and disability prevention programs. As part of an ongoing effort to develop a secondary prevention program, the present case-control study identified the relative contribution of demographic, physical demand, physical fitness, as well as occupational and individual psychosocial variables to back-related work disability in the US Army. Soldiers (n = 174) diagnosed with a lumbosacral strain and medically discharged from the Army were compared with non-disabled controls (n = 173). Dependent measures were obtained from the US Army Health Risk Appraisal (HRA). For cases, these data pre-dated disability determination by 1 to 3 years. For controls, the HRA was completed during the same time period. Significant predictors of low back disability were: age (odds ratio [OR] = 1.13 per year), lower rank (E2/E3) (OR = 4.08/OR = 3.02), infrequent aerobic exercise (OR = 2.2), higher work stress (OR = 2.71), worries (OR = 2.17), and lower social support (OR = 5.07). The model correctly classified 73.13% of all subjects. These results highlight the importance of considering age, status level in the organization, frequency of aerobic exercise, occupational stress, general worries, and social support for the early detection of soldiers at increased risk for back-related disability. Additionally, the findings support past research indicating the multivariate nature of work disability and emphasize the importance of considering such factors in future secondary prevention efforts.

Work-related upper-extremity disorders: prospective evaluation of clinical and functional outcomes

The purpose of this study was to describe the demographic, vocational, medical, workplace, and psychosocial characteristics of patients treated for work-related upper-extremity disorders, to document treatment patterns in a community-practice setting, and to determine which of these factors predicts subsequent employment and functional status outcomes. A questionnaire was administered by mail or telephone to 112 patients seen at the University of Massachusetts Occupational Upper Extremities Disorders Clinic and included measures of disease-specific functional status, pain, reactions to pain, employer-employee relations, and number and type of interventions used to treat the disorder. Results were compared with baseline data obtained, on average, 16 months prior to follow-up. Of the original cohort (n = 124), 112 participated in the prospective study. Although most patients reported improvement in pain severity, fear of pain, life situation, and functional status, there was little change in employment status. Patients' self-reported intentions of return to work at baseline did not predict work status at follow-up. In general, those who were employed at baseline remained employed, had a greater reduction in symptom severity over time, and were significantly more likely to report improvement in their problem than those who were unemployed. The efficacy of various interventions was examined by type, mix, and intensity (number of different interventions undergone by the patient). No positive relationship was found between these measures and employment status, self-reported change in the problem, or self-reported improvement in functional status. Significant negative relationships were found between surgery, psychotherapeutic interventions, and outcomes. This was likely to have occurred because of a selection bias toward the more chronic and severely disabled patients for these treatments. However, the relative ineffectiveness of such intensive interventions as surgery in improving the work and health status of chronically symptomatic work-related upper-extremity patients cannot be overlooked. The findings suggest that more emphasis be placed on interventions aimed at resolving differences between employers and injured employees. More careful selection of patients for expensive and invasive procedures is recommended.

Occupational back disability in U.S. Army personnel

Musculoskeletal disorders represent a prevalent source of outpatient visits, lost work time, hospitalization, and disability in the military. Recent research has identified patterns among military occupations, gender, and musculoskeletal disability. Although back disorders accounted for a high percentage of all cases, little is known about the relationship between job type and disability in soldiers. The present study analyzed 41,750 disability cases to determine (1) prevalence of work-related back disability diagnoses, (2) specific jobs associated with greater risk of back disability, and (3) association among gender, job type, and disability. The results indicate that (1) lumbosacral strain and intervertebral disc syndrome represent the most prevalent diagnoses for back disability, (2) certain occupations were associated with higher back disability risk, and (3) specific jobs were identified in which females experienced higher rates of back disability than males. The nature of these high-risk jobs, and recent research on work disability factors in U.S. Army soldiers, suggest that a combination of ergonomic and individual/organizational psychosocial factors may play a role in the development, exacerbation, and maintenance of work disability. Future research that identifies specific job factors contributing to increased back disability risk should assist in the development of empirically based work site prevention programs to improve musculoskeletal health and readiness.

Clinical management of carpal tunnel syndrome: a 12-year review of outcomes

Carpal tunnel syndrome (CTS) is a disorder frequently encountered by occupational health care specialists. The health care management of this disorder has involved a diverse set of clinical procedures. The present article is a review of the literature related to CTS with an emphasis on occupational-related CTS. MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycLIT, and NIOSHTIC databases from 1985-1997 were searched for treatment outcome studies related to CTS. Treatments of interest included surgery, physical therapy, drug therapy, chiropractic treatment, biobehavioral interventions, and occupational rehabilitation. A systematic review of the effects of these interventions on symptoms, medical status, function, return to work, psychological well-being, and patient satisfaction was completed. Compared to other treatments, the majority of studies assessed the effects of surgical interventions. Endoscopic release was associated with higher levels of physical functioning and fewer days to return to work when compared to open release. Limited evidence indicated: 1) steroid injections and oral use of B6 were associated with pain reduction; 2) in comparison to splinting, range of motion exercises appeared to be associated with less pain and fewer days to return to work; 3) cognitive behavior therapy yielded reductions in pain, anxiety, and depression; and, 4) multidisciplinary occupational rehabilitation was associated with a higher percentage of chronic cases returning to work than usual care. Workers' compensation status was associated with increased time to return to work following surgery. Conclusions are preliminary due to the small number of well-controlled studies, variability in duration of symptoms and disability, and the broad range of reported outcome measures. While there are several opinions regarding effective treatment, there is very little scientific support for the range of options currently used in practice. Despite the emerging evidence of the multivariate nature of CTS, the majority of outcome studies have focused on single interventions directed at individual etiological factors or symptoms and functional limitations secondary to CTS.

Health care and indemnity costs across the natural history of disability in occupational low back pain

STUDY DESIGN

The administrative database maintained by the National Council on Compensation Insurance (United States) was used to compare health care use and indemnity costs within the natural history of work-related low back pain disability.

OBJECTIVES

To determine the relative costs of health care services and indemnity at different phases of work disability.

SUMMARY OF BACKGROUND DATA

Existing studies have compared total costs along the work disability continuum. This study replicates and extends these earlier studies by providing detailed evaluations of costs by service categories along this continuum.

METHODS

Total health care and indemnity costs accrued along the disability curve were examined. Based on the number of days workers were absent from work and receiving indemnity payments (disability days), detailed mean health care costs by type of medial service were computed and compared across four time intervals for the sample.

RESULTS

Health care costs were disproportionately distributed along the disability curve, with 20% of claimants disabled 4 months or more, accounting for 60% of health care costs. The most costly service category was diagnostic procedures (25% of total medical costs), with surgical costs (21%) and physical therapy (20%) representing the next two most costly categories. Mental health and chiropractic care represented a small percentage of overall costs (0.4% and 2.9%, respectively).

CONCLUSIONS

These data provide policy-makers, program development, and health care industry groups with cost information from which to establish benchmarks for future decisions that facilitate the allocation of resources for more cost-effective management and prevention of work disability.

Occupational upper-extremity-related disability: demographic, physical, and psychosocial factors

Occupational upper-extremity disorders have been associated with prolonged pain and work disability. Using the U.S. Army Physical Disability Agency database, the present case-control studies (n = 434 and n = 342) investigated the contribution of demographic, physical, occupational psychosocial, and individual psychosocial factors to work disability in soldiers with upper-extremity disorders. Age (odds ratio [OR] = 1.11), rank (private E-2: OR = 3.79; private first class: OR = 4.39; specialist or corporal: OR = 2.17), ethnic group (white: OR = 1.54), and occupational stress ("often": OR = 2.46) were found to predict disability. The results highlight the importance of occupational stress as a predictor of disability and the potential utility of addressing this factor in the development of empirically based disability prevention strategies. This investigation also emphasizes the need for research that delineates the biobehavioral mechanisms linking occupational stress to prolonged symptoms and subsequent work disability.

Occupational upper extremity disorders in the federal workforce. Prevalence, health care expenditures, and patterns of work disability

Upper extremity disorders (UEDs) account for a significant number of work-related illnesses in the US workforce. Little information exists on the distribution of UEDs, their associated health care and indemnity costs, or patterns of work disability. The study presented is an analysis of upper extremity claims within the federal workforce. In this study, the universe consisted of all claims accepted by the US Department of Labor, Office of Workers' Compensation Programs (OWCP), from October 1, 1993, through September 30, 1994. A total of 185,927 claims of notices of injury were processed during the study period, and of these, 8,147 or 4.4% had an UED diagnosis coded according to the International Classification of Diseases, Clinical Modification (ICD-9-CM). 5,844 claims involved a single UED diagnosis and were the only claims field by these employees between October 1, 1990, and September 30, 1994. These single claims with single diagnoses comprised the sample for further analysis. Mononeuritis and enthesopathies of the upper limb were the most common diagnoses, accounting for 43% and 31% of the claims, respectively. Women had a higher proportion of carpal tunnel syndrome, "unspecified" mononeuritis, and "unspecified" enthesopathies. The majority of claimants for both the mononeuritis- and enthesopathy-related diagnoses were between 31 and 50 years of age, received only health care benefits, and did not incur wage loss. Health care costs for mononeuritis and enthesopathy claims were $12,228,755 (M = $2,849). Carpal tunnel syndrome (CTS) and enthesopathy of the elbow were the most costly diagnoses, accounting for 57% and 16% of the total, respectively. Surgical services represented the highest expenditures in CTS claims. Physical therapy accounted for the majority of health care costs for enthesopathy cases. The mean number of workdays lost for CTS and enthesopathy claims were 84 and 79, and the average indemnity costs were $4,941 and $4,477, respectively. These findings indicate that while UEDs represent a relatively small percentage of all workers' compensation cases, the health care and indemnity costs are considerable. Also mean duration and pattern of work disability revealed that these disorders can result in chronic work disability similar to that observed in low back pain. The results highlight the need to determine whether interventions that account for the majority of costs significantly impact long-term outcomes. There is also a need to identify risk factors for prolonged disability in those who experience problems with delayed recovery.

Computer keyboard force and upper extremity symptoms

This case-control study assessed whether office workers who report more severe levels of musculoskeletal symptoms of the upper extremities demonstrate higher levels of keyforce in comparison to controls with less severe symptoms. Office workers reporting working on computer keyboards for four hours per day were classified as cases or controls based upon a median split on a Composite Symptom Severity score (cases = 23, controls = 25). Keyboard force and keying rate were measured during a 15-minute keyboarding task. Measures of task-related discomfort, muscular fatigue, pain, upper extremity symptoms, psychological distress and force were collected at baseline, post-keyboard task, and recovery. Ratings of perceived effort and task credibility were also obtained. Measures of work demands, perceived job stress, and upper extremity strength and flexibility were also collected. The results indicated group equivalence on reported work demands and upper extremity strength. Cases were more likely to receive a medical diagnosis of upper extremity cumulative trauma disorder, awaken from sleep due to symptoms, report higher levels of pain during work, experience greater impact of pain on function, and report higher workload pressure and lower support. Cases generated significantly higher keyboarding forces than controls, although both groups produced forces well above that required to operate the keyboard (4-5 times activation force). Cases reported higher levels of upper extremity symptoms and discomfort than controls, and these measures were highest after the keyboarding task for both groups. No significant correlation between keyforce and key rate was observed in either group. Results suggest that generation of excessive force while working on a computer keyboard may contribute to the severity of upper extremity symptoms. Clinically, the findings suggest that evaluating how an individual worker performs keyboarding tasks, or his or her workstyle, may be helpful in the management of these symptoms and disorders.

Measuring functional outcomes in work-related upper extremity disorders. Development and validation of the Upper Extremity Function Scale

Questionnaire-based measures of function have been validated extensively in studies of chronic illness and work-related low back pain. These measures have only recently been developed for upper extremity disorders (UEDs), and there is little information on their utility in evaluation of injured workers. We developed the Upper Extremity Function Scale (UEFS), an eight-item, self-administered questionnaire, to measure the impacts of UEDs on function. This instrument was tested in a cohort of 108 patients with work-related UEDs and 165 patients with the carpal tunnel syndrome (CTS); both groups were enrolled in prospective follow-up studies. The UEFS demonstrated excellent psychometric properties, including good internal consistency (Cronbach's alpha > 0.83), relative absence of floor effects, and excellent convergent and discriminant validity, compared with measures of symptom severity and clinical findings. In the CTS group, the UEFS was more responsive to significant improvements over time than clinical measures such as grip and pinch strength. These data support the use of a self-reported functional scale as a measure of outcome in studies of work-related UEDs. Further investigations in working populations are needed to substantiate its utility in workers with UEDs who have not yet sought medical care.

Guinea pig model for Staphylococcus aureus native valve endocarditis

We present a new experimental model of Staphylococcus aureus infective endocarditis in guinea pigs. Permanent aortic valve damage was produced by electrocoagulation after catheterization of the right carotid artery, which allowed avoidance of the intracardiac catheter to produce cardiac vegetations. Our model closely mimics pathological mechanisms of native valve endocarditis.

Musculoskeletal-related disability in US Army personnel: prevalence, gender, and military occupational specialties

Research on military populations indicates that musculoskeletal-related disorders represent a prevalent source of outpatient visits, lost work time, hospitalization, and disability. Despite the increasing role of women in the military, little is known regarding the association among military occupations, gender, and disability. The study presented here analyzed 41,750 disability cases to determine: (1) prevalence of work-related musculoskeletal disability, (2) specific jobs associated with greater risk of musculoskeletal disability, and (3) association among gender, job-type, and disability. Results indicate: (1) back-related disorders represent the most prevalent sources of disability, (2) certain occupations were associated with higher disability risk, (3) women experienced higher overall, and musculoskeletal, disability risk, and (4) specific jobs were identified in which women experienced higher rates of musculoskeletal disability. These findings highlight the need to consider the interaction between workplace factors and gender on disability in the military work force.

Predicting post treatment spinal strength and flexibility in work-disabled low back pain patients

This study examined whether posttreatment trunk strength and flexibility could be predicted from initial trunk strength and flexibility, age, gender, pain severity, diagnosis, length of work disability, return-to-work expectations, anxiety, and fear of reinjury among a group of 96 injured workers with chronic occupational low back pain who completed a multidisciplinary work rehabilitation program. The results indicate that initial average torque in trunk extension, age, gender, and average pain severity contribute significantly to prediction of final average torque in trunk extension. Initial average torque in trunk flexion, age, and gender contributed significantly to prediction of final average torque in trunk flexion, and age and initial range of motion contributed significantly to the prediction of final trunk range of motion. The results indicate that prediction of trunk strength and range of motion can be accomplished from measures of trunk strength and flexibility and pain obtained prior to the onset of rehabilitation. Psychological measures were not predictive of posttreatment trunk strength and flexibility. The ability to predict posttreatment trunk strength should facilitate clinical decision making in these complex cases.

Characterisation of sodium cations in dehydrated zeolite NaX by 23Na NMR spectroscopy

23Na MAS, 2D nutation MAS, and DOR NMR spectroscopy has been applied to characterise the location of sodium cations in dehydrated zeolite NaX (Si/Al = 1.23). The 23Na MAS NMR spectra recorded at three different magnetic field strengths were decomposed by computer simulation into five lines, which were attributed to five crystallographically distinct cation sites known from X-ray diffraction studies. The assignments of the lines follow from electric field gradient calculations at the 23Na nuclei applying a simple point charge model based on crystal structure data. A weak Gaussian line at low field (delta iso = -6 ppm) is assigned to sodium cations at site I, two broad quadrupole patterns at the high-field side of the spectra are attributed to site I' (delta iso = -19 ppm, QCC = 5.2 MHz, eta = 0) and site II cations (delta iso = -15 ppm, QCC = 4.6 MHz, eta = 0), and two quadrupolar lines dominating the central region of the spectra originate from Na+ at two different III' sites (delta iso = -13 and -29 ppm, QCC = 2.6 and 1.6 MHz, eta = 0.7 and 0.9, respectively). Na+ ions located on a second I' site could be identified from the DOR NMR spectra. The line assignment is further corroborated by the reasonable agreement of the site occupancies estimated from the line intensities with those determined by X-ray diffraction. In addition, sodium site populations of five dehydrated zeolites NaX and NaY with Si/Al ratios between 1.09 and 4.0 were derived from the 23Na MAS NMR spectra.

Pain expectancies, pain, and functional self-efficacy expectancies as determinants of disability in patients with chronic low back disorders

This study tested the relative predictive power of self-efficacy expectations of physical capabilities (functional self-efficacy [FSE]), expectations of pain, and expectations of reinjury on physical function in chronic back patients. Before behavioral assessment of function, 85 patients rated their abilities to perform essential job tasks (FSE) and the likelihood that their performances would be accompanied by pain and reinjury. Partial correlations revealed that FSE was significantly related to function when reinjury and pain were partialed out. Neither reinjury nor pain expectancies correlated significantly with function when FSE was partialed out. Further support for an FSE approach came from regression analyses that found pain intensity, gender, and FSE--not expected pain or reinjury--related consistently with physical performance. Thus, performance-specific cognitions may have greater explanatory power over disability than pain-specific ones.

Work-related upper-extremity disorders and work disability: clinical and psychosocial presentation

Work-related upper-extremity disorders (WRUEDs) are an increasingly common cause of work-related symptoms and disability. Although most upper-extremity disorders are acute and self-limited, a small percentage of workers with symptoms go on to permanent disability and account for the majority of costs associated with these conditions. Little is known, however, about this progression from symptoms to disability and how it might be prevented. In this study, we evaluate the demographic, vocational, medical, and psychosocial characteristics of patients with WRUEDs and examine several hypotheses regarding the differences between working and work-disabled patients. One hundred twenty-four consecutive patients were evaluated in a clinic specializing in occupational upper-extremity disorders. Patients currently working (n = 55) and work-disabled patients (n = 59) were similar with regard to age, gender, and reported job demands. The work-disabled group reported less time on the job, more surgeries, a higher frequency of acute antecedent trauma, and more commonly had "indeterminate" musculoskeletal diagnoses. They also reported higher pain levels, more anger with their employer, and a greater psychological response or reactivity to pain. These findings, though cross-sectional in nature, suggest that, in addition to medical management, more aggressive approaches to pain control, prevention of unnecessary surgery, directed efforts to improve patients' abilities to manage residual pain and distress, and attention to employer-employee conflicts may be important in preventing the development of prolonged work disability in this population.

Biobehavioral factors affecting pain and disability in low back pain: mechanisms and assessment

Patients with recurrent or persistent low back pain (LBP) and disability represent a formidable challenge to physical therapists. Classic models of disease and pain mechanisms do not adequately explain the commonly observed discrepancies between the extent of pathology and reported pain, or the level of pain and disability. Research over the past decade that considers the interactive role of biological, environmental, and psychological processes in pain and disability has supported the involvement of a number of biobehavioral factors in these conditions. Physical therapists and other health care providers have become more aware of these factors and their impact on the evaluation, treatment, and management of LBP. Despite this recognition, little information is available that translates the implications of this research to direct care within physical therapy practice. The purposes of this article are (1) to provide an operational definition of biobehavioral factors; (2) to review the role of these factors in the clinical presentation of LBP, functional limitation, and disability; (3) to identify commonly used approaches for their recognition and quantification; (4) to illustrate how an understanding of biobehavioral factors can assist the physical therapist in evaluation and treatment of patients with LBP; and (5) to identify certain gaps in current knowledge of the role of biobehavioral factors and their application in physical therapy. Given the central role assumed by many physical therapists in the management of LBP, acknowledging and addressing these factors in clinical practice should assist in the prevention of chronic LBP and disability, as well as potentially improve physical therapy interventions and management.

ICD therapy in survivors of sudden cardiac death awaiting heart transplantation

The impact of implantable cardioverter defibrillator (ICD) therapy on survival of heart transplant candidates is of major socioeconomic and ethical interest. However, efficacy is even uncertain for patients at highest risk of tachyarrhythmic death on the waiting list. We studied 60 selected heart transplant candidates (mean age, 55.8 years; mean left ventricular ejection fraction, 0.15; functional class III and IV) with a history of successful resuscitation by external electric defibrillation for spontaneous, syncopal ventricular tachyarrhythmia during the study period from March 1992 through September 1994. At the time of registration for transplantation, 30 patients had ICD devices implanted, whereas 30 patients lacked ICD therapy for various nonmedical reasons. Both therapy groups were comparable in clinical and hemodynamic characteristics as well as in intention to transplant (median waiting time to transplantation, 5.7 and 6 months, respectively; not significant by log-rank method). Survival on the waiting list was significantly improved by ICD therapy; only 1 of the 30 ICD patients (19 transplanted) but 7 of the 30 non-ICD patients (14 transplanted) died on the waiting list (p < 0.05 by log-rank method). Implantable cardioverter defibrillator therapy did not affect survival after transplantation as compared with non-ICD patients (not significant by log-rank method). During the waiting time, 26 of the ICD patients (87%) experienced adequate ICD discharges, and 12 of the non-ICD patients were treated successfully by external electric defibrillation (40%).(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic back pain and work disability: Vocational outcomes following multidisciplinary rehabilitation

Studies indicate that work disabled chronic back pain patients out of work for longer than three months have a reduced probability of returning to work. The escalating personal and economic costs (indemnity and health care) associated with such long term disability have facilitated efforts at multiple levels to prevent and more effectively manage work disability. Multidisciplinary rehabilitation (MDR) targeted at return to work represents one such approach. The approach is based upon a multidimensional conceptualization of work disability and integrates medical, physical, psychological, educational and vocational interventions to increase physical function, reduce pain, increase stress coping skills and facilitate return to work. Seven outpatient multidisciplinary rehabilitation outcome studies for chronic back pain were identified that met the following selection criteria: 1) diagnosis of back pain, low back pain, spinal disorder (specific and nonspecific diagnosis), 2) chronic back pain of either longer than three months since injury or longer than three months absence from work, 3) use of an outpatient multidisciplinary rehabilitation approach that included some combination of medical management, physical conditioning, pain and stress management, vocational counseling/placement and education regarding back safety and health, and 4) work reentry was the primary focus of outcome. These were reviewed to determine the effectiveness of MDR in terms of return to work outcome. Analyses revealed that an average of 71 percent of work disabled chronic back pain patients who completed a multidisciplinary rehabilitation program were working or involved in vocational rehabilitation efforts at 12 month follow-up in contrast to an average of 44 percent in corresponding comparison groups. While these studies suggest the clinical utility of a multidisciplinary approach as compared to usual care in facilitating return to work for chronic back pain patients, the literature was characterized by several methodological limitations including the absence of randomization in the majority of studies, use of insurance company denials as control groups, heterogenous samples in terms of duration of work disability, job availability at discharge, extent of impairment and disability, age and duration of pain disorder, lack of specification as to exact treatment delivered in the control or usual care groups and varying definitions of return to work outcome. Research on predictors of return to work outcome following MDR were identified and included variables in five categories: demographics, medical history, physical findings, pain and psychological characteristics. The literature provides support for the use of integrated approaches that target the medical, physical, ergonomic and psychosocial factors that can exacerbate and/or maintain work disability. Future research should address current methodological limitations in the literature and focus on: 1) identifying critical treatment components of such approaches, 2) developing innovative screening methods to identify high risk cases to facilitate earlier more targeted efforts to assist such individuals, and 3) consider variations in the staging of various combinations of interventions in an effort to develop more cost-effective variations in the multidisciplinary approach.

Industrial back belts and low back pain: Mechanisms and outcomes

The recent increased utilization of industrial back belts as personal protective equipment in the workplace has generated considerable controversy among occupational health and safety professionals in the United States. The purpose of this article is to review the literature regarding proposed mechanisms of action of these devices and studies related to outcome of belt utilization in the prevention of low back pain and disability in the workplace. At the present time, neither the suspected mechanisms of action nor the efficacy of these devices in the primary, secondary, and tertiary prevention of work-related low back pain has been adequately demonstrated in clinical trials. As a result, generally accepted guidelines regarding the safe use of belts in the occupational setting have not been established. Based on this review it is recommended that further well-controlled, prospective, randomized clinical trials are necessary to evaluate the effectiveness of these devices as personal protective equipment. During the interim, the decision to prescribe belts to employees in the workplace should be at the discretion of an adequately trained occupational health care provider. These devices should not be provided as an alternative to appropriate administrative and/or engineering controls.

Development of a multidisciplinary research clinic for patients with work-related upper extremity disorders

The health care reform debate has focused attention on the need for outcomes research performed in ambulatory care settings. In this article, the authors describe the development of a research clinic focusing on symptomatic, functional, and vocational outcomes of patients with work-related upper extremity disorders. The authors describe the programmatic and research challenges associated with performing such research and emphasize the need for balancing the research and clinical agendas. Research efforts in this setting require careful consideration of the patient selection process and allocation of sufficient time for the clinical staff to collect and record essential research data.

clinical ergonomic job analysis and consultation: Facilitating work reentry in a case with upper extremity cumulative trauma-related disability

The management of work-related recurrent and chronic upper extremity cumulative trauma disorders (UECTDs) represents a challenge particularly when return to work is a treatment goal. Many of these work-related UECTDs may be the consequence of exposure to such physical stressors as repetition, excessive force, awkward and sustained posture in addition to psychosocial stressors in the workplace. Pain and associated disability can be exacerbated by these ergonomic and psychosocial stressors. The application of ergonomic principles and techniques in the context of clinical management of UECTDs may assist in efforts to return the injured worker to work and reduce the likelihood of increased symptoms, discomfort, and disability. This paper presents a case of a 43-year-old dental hygientist unable to work for a period of 2 months due to recurrent episodes of pain in the neck, right shoulder, and arm radiating to the right thumb experienced episodically over a 10-year duration. The case is presented to illustrate the application of ergonomic principles and techniques in the clinical management of a chronic episodic UECTD. The implementation of an ergonomic job analysis and subsequent ergonomic interventions at the workplace that occurred in conjunction with rehabilitation was associated with anecdotal improvements in pain, function, and comfort levels upon returning to work. While the case highlights the potential utility of ergonomics in the management of an occupational musculoskeletal upper extremity disorder, the need for reliable, valid, cost effective, and time efficient methods to assess ergonomic exposure within a clinical context remain to be developed.

Workers' compensation reform in New York State: A proposal to address medical, ergonomic, and psychological factors associated with work disability

This paper presents testimony before the New York State Assembly Joint Hearings on Workers' Compensation. The testimony first establishes the background of the speaker in relation to the problems in the workers' compensation system. A brief summary of the problem including the increased prevalence of work-related musculoskeletal disorders and their contribution to work disability, the rising costs of insurance premiums, indemnity, and medical costs, and the percentage of payroll that workers' compensation costs consume in New York State is then presented. A review of problems injured workers and health care providers face is also considered. Following this, two proposals that represent a compromise position in relation to business and labor concerns are presented. The first relates to the implementation of state mandated prevention programs to reduce the risk of injury/illness and associated disability in areas accounting for the majority of the workers' compensation injuries/illnesses-low back and upper extremity disorders. It is proposed that individual employers receive incentives in the form of premium savings based upon actual program outcomes. The second proposal relates to the establishment of mutually agreed upon standards of health care for low back and upper extremity disorders similar to what currently exists in Minnesota. The potential benefits of these plans are discussed in relation to increasing costs and human suffering associated with work-related injuries/illness and disability. This paper is presented as an example of an approach to advocacy that health care providers can take to contribute to reform in the workers' compensation systems of their own states.

Multidisciplinary rehabilitation of chronic work-related upper extremity disorders. Long-term effects

The prevalence of work-related upper extremity disorders has significantly increased in the past decade. Persistent pain, loss of function, and associated work disability in patients with work-related upper extremity disorders appears to be affected by multiple factors including physical capabilities in relation to work demands, ergonomic risk factors on the job, and psychological factors related to worker traits, psychological readiness to return to work, and ability to manage symptoms. The complex nature of these disorders suggests the utility of a multidisciplinary program targeted at these factors. The present study is an investigation of the long-term vocational outcome of a multicomponent rehabilitation program that includes physical conditioning, work conditioning, work-related pain and stress management, ergonomic consultation, and vocational counseling/placement. Two groups equivalent on measures of duration of work disability, pain severity, fear of reinjury, psychological distress, perceived work environment, age, and education level were exposed to either the comprehensive work rehabilitation intervention (n = 19) or usual care (n = 15). Return-to-work status was determined at an average of 17 months posttreatment (range, 3 to 35 months) for the treatment group and an average of 18 months postevaluation (range, 5 to 30 months) for the usual care group. Findings indicated that 74% of the treatment group returned to work or were involved in state-supported vocational training in contrast to 40% of the control group (P < .05). For those who returned to work, 91% of the treatment group were working full-time in contrast to 50% of the control group (P < .05). Although the treatment group demonstrated a higher return-to-work rate than controls, the work reentry rate was not as high as similar approaches with work-related low back pain (80% to 88% return-to-work rate). These findings suggest the need to modify treatment components to facilitate an increased return-to-work rate. Areas that may prove useful include a greater emphasis ergonomic modifications at the workplace to reduce the risks of repetitiveness, force, awkward posture, and insufficient work/rest cycles, as well as efforts to modify work style directly in order to reduce the impact of ergonomic stressors on the ability to perform essential job tasks. In combination with traditional work hardening efforts directed at improving strength and flexibility of the upper extremities and work-related pain and stress management training, these ergonomic and work-style modification efforts may contribute to increases in the percentage of work disabled cases who successfully return to competitive work.

Biomechanical factors affecting upper extremity cumulative trauma disorders in sign language interpreters

Symptoms associated with upper extremity cumulative trauma disorders (UECTDs) recently have been reported in professional sign language interpreters. The present investigation is a case control study of potential biomechanical factors that may exacerbate or maintain UECTD-related symptoms in this occupational group. Based on the results of a medical screening, interpreters were classified into two groups: working with pain (n = 16) and working without pain (n = 13). There were no significant differences between the groups on age, gender, years signing, years interpreting, and wrist and forearm endurance and flexibility as measured during an isokinetic strength test of the upper extremities. Subjects were exposed to a standard interpreting task. Groups were compared on measures of repetitiveness of hand/wrist motion, work/rest cycle, postural stress, and smoothness of movement. Heart rate, pain, fatigue, and perceived reduction in extremity flexibility also were measured. The group working with pain demonstrated a distinct pattern of potential biomechanical risk factors previously associated with UECTDs in other occupations. By comparison with the control group, those working with pain exhibited fewer rest breaks, more frequent hand/wrist deviations from neutral, more frequent lateral excursions from an optimal work envelope, and more rapid finger/hand movements while interpreting. Significant group differences on self-report measures of pain, fatigue, and perceived limitation in range of motion also were observed. An analysis of heart-rate response to the interpreting task revealed that both groups demonstrated a modest increase in heart rate to the interpreting task, although interpreters working with pain displayed lower heart rates across all phases of the experimental task.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical analysis of upper extremity risk in Sign Langauge Interpreting

Upper extremity cumulative trauma distorders (UECTD) have been identified as an occupational health problem in professional Sign Language Interpreters (SLI). A previous study of UECTD in SLI has indicated significant differences between interpreters working with pain and those working without pain. This earlier research focused on gross measures of hand/wrist movement, work/rest cycles, and deviations from an optimal work envelope. The present paper describes a detailed biomechanical analysis of wrist and forearm activity associated with SLI. This assessment included forearm (flexion and extension) and wrist (flexion/extension and radial/ulnar deviation) measures of movement frequency, counts of individual motion, joint movement velocities and accelerations as well as range of motion. The analyses revealed that the postures required for interpreting result in the signing hand frequently held in a fully pronated position, with the palm facing out. The wrist was most frequently in an ulnar deviation and/or extension while the elbow was flexed more than 90° and held in close to the body with the fingers pointing up. The frequency of motions for the forearm and wrist were observed to be 270 per minute (4.5 Hz), which is equivalent to 13,600 per 50 minute lecture hour. The mean absolute joint movement velocity and acceleration values were relatively high in contrast to industrial jobs with wrist and forearm accelerations between 34,754 degreees/sec(2) and 36,046 degrees/sec(2), respectively. The findings from this biomechanical analysis indicates that SLI can involve highly repetitive, awkward movements with significant accelerations of the hand and wrist. Such job characteristics may predispose interpreters to upper extremity CTD-related disorders.

Perceptions of disability and occupational stress as discriminators of work disability in patients with chronic pain

Pain-related work disability can be influenced by a number of medical, physical, and psychosocial factors. The present study investigated the role of perceived disability, occupational stress, pain, and distress in patients with chronic pain disorders who work despite pain and patients who are work disabled. A total of 165 patients referred to a multidisciplinary pain treatment center for chronic pain (> 6 months) were studied. The two groups were compared on age, gender, education, marital status, duration of pain problem, pain severity, psychological distress, perceived disability, and perception of the work environment. A discriminant function analysis was computed entering pain severity, distress, perceived disability (physical and psychosocial) and work environment variables. The two groups were equivalent on age, gender, education, marital status, and duration of pain problem. The groups differed on diagnosis and insurance coverage with the work-disabled group diagnosed with low back pain and receiving Workers Compensation coverage more frequently than working controls. Univariate analyses indicated that the work-disabled group reported higher pain severity, perceived physical and psychosocial disability, and job stress than their working cohorts. The discriminant function analysis indicated that the perception of physical disability, supervisor support, distress, and work pressure were capable of correctly classifying patients with chronic pain who continued to work from those who were work disabled. These findings indicate the importance of evaluating perceived disability and job stress, and if present, directing intervention effort at these factors in order to facilitate work re-entry.

Psychological factors affecting isokinetic trunk strength testing in patients with work-related chronic low back pain

Psychological factors are assumed to play a major role in pain-related work disability. Assessment of pain-related disability using a functional capacity evaluation, usually includes assessment of trunk strength and range of motion. Isokinetic strength testing is a method used to measure strength and function of isolated muscles and has been reported to be an objective, quantifiable assessment of trunk function. Given that psychological factors are purported to play a role in pain-related disability, it would be important to assess their influence on measurement of physical function. The present study was conducted to assess the influence of psychological variables on isokinetic trunk strength performance. One hundred and eighty-six consecutive male outpatients referred to a work-rehabilitation center were given a functional capacity evaluation. All patients had been out of work for at least 3 months with the chief complaint of low back pain. The evaluation included isokinetic trunk strength testing and measurement of psychological variables (pain levels, distress, pain coping, pain behavior, somatization, expectation to return to work) that have been known to contribute to pain-related disability. Data analyses revealed significant correlations among psychological variables and measures of trunk strength and function. The findings provide support for a relationship between psychological variables and isokinetic strength testing performance.