functional restoration in chronic low back pain

Scand J Med Sci Sports 1996: 6: 88-97

Printed in Denmark. Af l rights reserved Copyright 0 Munksgaard 1996

Scandinavian Journul of MEDICINE & SCIENCE

I N S P O R T S ISSN 0905-7188

Functional restoration in chronic low back pain

Bendix T, Bendix AF, Busch E, Jordan A. Functional restoration in chronic low back pain. Scand J Med Sci Sports 1996: 6: 88-97.0 Munksgaard, 1996

Conventional treatments have not slowed down the ever expanding low back pain (LBP) problem. Traditional treatment has most probably contributed to the growth of the problem. Therefore, in a search for new solutions, ‘functional restoration’ has been devised. In connection with chronic LBP the term has been associated with a full-day program lasting from 3 to 5 weeks. It includes multidisciplinary treatment of patients in groups with intensive physical and ergonomic training, psychological pain management, back school, as well as teaching in social/work related issues. The key concepts are ‘acceptance of the pain’, ‘activity’, ‘self-responsibility’ , ‘multidisciplinary’ and ‘quantitative functional evaluation (QFE)’. The latter is aimed so that the participants can feel the physical improvement, encouraging them to be able to go back to work, or at least to lead a more active life style. Several controlled studies suggest a lasting effect in terms of regaining their ability to work and improving pain behavior for a good part of disabled chronic LBP patients. However, it is noteworthy that randomized studies seemingly show poorer results than studies not employing randomized controls.

It is not easy to rehabilitate disabled, chronic low back pain (LBP) patients effectively. The LBP problem has increased considerably through the last few decades. Days off and LBP pension-caused loss of work days has increased about 40 times from 1960 through to 1990 in Sweden (1). Corresponding data from other industrialized countries denote similar trends (2, 3 ) . In Denmark, the percentage of LBP pensions of the total amount of health-induced pensions increased from 11% in 1980 to 17% in 1990

There are no indications that deleterious patho- logical changes could be responsible for the increase of the LBP problem. Sitting has been impli- cated as being responsible for the increase in LBP, particularly based on the Magora study from 1972 (5) , which showed that LBP among people sitting for more than 4 hours daily approximated with people with physically demanding jobs. The smallest amount of LBP was reported among the people with physically varying jobs. However, newer and more extensive studies have not demonstrated so clear a

(4).

T. Bendix, A. F. Bendix, E. Busch, A. Jordan Copenhagen Back Center, Medical Orthopedic Department T 7521, Rigshospitalet/National Hospital, Copenhagen, Denmark

Key words: functional restoration; chronic low back pain; pain behavior; work hardening; quantitative functional evaluation Tom Bendix, MD, Copenhagen Back Center, Medical Orthopedic Dept. T 7521, Rigshospitaleb‘National Hospital, Tagensvej 20, DK 2200 Copenhagen, Denmark Accepted for publication November 21, 1995

correlation between sedentary work and LBP (6,7). It is also noteworthy that in Sweden, for example, the ever increasing LBP problem has parallelled ergonomic ‘improvements’ at the workplace.

It seems more and more clear that behavioral issues are the predominant cause of the escalation of the problem (8). The following issues should be considered.

The acceptance of pain diminishes along with the improved ability to cure other illnesses. Examples are: hipknee arthrosis with hipknee replacement, ventricular ulcer treated effectively with medication, kidney and even heart transplantation, etc., etc. There is an enormous number of treatments avail- able and the threshold for various health care per- sonnel to offer them is low, no matter what the level of the LBP problem and regardless of whether there is any proof of its effectiveness. This attitude leaves the patient with the impres- sion: ‘I was treated the last time I had back pain. It must be because I was sick, why else was I offered

88

Exercise in rehabilitation

a treatment. My present back pain obviously also requires treatment. ’ The concept of physical loads deteriorating the

accelerated by the procedure. Even in the case of a documented effective treatment, LBP most often reappears at a later date. Chronic LBP (defined as >

discs has brought fear to many people during the last decades, as witnessed by warnings of forward bending during lifting, sitting, etc. The disc-pressure approach unfortunately seems to have been a misinterpretation of the otherwise elegant basic research provided by Nachemson and his group starting back in the 1960s (9). Today a specific diagnosis is demanded for most people. ‘Any trouble with a car can be diagnosed exactly, ... so why not my back pain?’ The diagnosis ‘lumbago’ is just not accepted any more by the patient, but paradoxically it meets increasing acceptance among back researchers. The focus on back pain in the media may also contribute to people suffering with minor back pain searching for solutions. Hadler (10) even considers the increasing problem to be based on the fact that historically, the laws behind pension, workmen’s compensation, and other economic ‘awards’ have been based on the ability to ‘prove’ a given impairment. ‘Anyone who has to prove that he/she is ill cannot get better. ’

‘Functional restoration’ YS ‘treatment/cure’

Numerous treatments have been tried to improve LBP patient symptoms (11). Before choosing any treatment, one should scrutinize where on a LBP- impact scale the specific patient is positioned. Due to the natural history of LBP, the term ‘treatment’ should be handled with care. Most people define ‘cure’ as the goal for and result of a treatment. Acute episodes often resolve irrespective of intervention; in these cases the ‘treatment’ program cannot be credited for the improvement unless it is

I / for ‘ funct ional restort ion’ / I I

no L B P

to ta l ly d i s a b l e d

Fig. 1. Everybody in a population is placed somewhere on this scale. From (left) the 20% being those never experiencing LBP in their lifetime towards those being disabled and on pension (right). The area emphasized represents those relevant for the intensive functional restoration programs discussed in this article.

3 months) often fluctuates in intensity irrespective of successful intervention. LBP lasting for years will only seldomly disappear whatever the intervention utilized. Moreover, using the term ‘treatment’ to the patient may induce the often unrealistic hope that the pain can disappear permanently.

Thus, the goal for a chronic, disabled LBP patient should be to accept a certain level of pain, and to restore a reasonable functional level of daily living, giving himher an active and good quality of life in spite of the back pain. The term ‘functional restoration’ includes any intervention aimed at restoring a reasonable functional level for daily life, irrespective of where on the scale in Fig. 1 the patient is placed. The term, however, is mostly reserved for a specific program, first evaluated by Mayer et al. (12-14). Several other studies have followed, and will be discussed below. These principles have also demonstrated effectiveness in terms of ‘returning- to-work rates’ for patients placed more to the left on the scale (15).

The ‘functional restoration’ program

Principles

Active methods: passive treatments are generally abandoned. Although some passive treatments may be effective, e.g. spinal manipulation (16), for patients from other placements on the scale in Fig. 1, there is no indication that they will help the chronic patients requiring the functional restoration program. Passive treatment is in fact philosophi- cally in opposition to the strategy of patients taking an active part in pain management. Most participants have already been through a long series of conventional treatments, experiencing no more than a short-lived effect. The only passive modality used in the program is cold packs, used with acute pain exacerbation occurring during training, in order to secure further participation.

Self-responsibility. Using the active methods of training creates the possibility of giving the patient a great deal of responsibility for treatment results. This is additionally supported during the psychological part of the program. The staff act as supporters, teachers, helpers, etc., but the final outcome and the decision regarding attitudes towards daily activities and work tasks in the future rests of course with the patient. To get there, the staff teach the patient how to cope with pain in a nondestructive way.

89

Bendix et al.

Multidisciplinary. This is desirable because pain behavior includes many aspects resulting in a need for several therapeutic components in the program. Moreover, it is characteristic that many patients try different pathways with different health-care indi- viduals in order to obtain more compassion, a desired pension, morphine medication, etc.

Quantitative functional evaluation (QFE). Several programs with treatment durations and components somewhat similar to the one evaluated by Mayer already existed before he presented his program, e.g. in Sundsvall, Sweden (17). The predominant contribution of Mayer and his group in PRIDE (Pro- ductive Rehabilitation Institute of Dallas for Ergo- nomics) was that: (a) the intensity of the physical part of the treatment was more demanding than in other such programs; (b) the particular focus was on functional testing (QFE); and (c) the effect was assessed in a controlled, clinical trial.

QFE consisted of several measures taken upon entering the program so that the participant could follow hisher improvement during its course, and have the feeling of being able to manage daily work. ‘Function’ alludes to physical as well as psychological issues.

Muscle-function measures have always been con- troversial (1 8). Correlation between back muscle strength and LBP is poor. Strength measures - isometric or dynamic - are relevant in sports medicine, but less so in chronic LBP, except for patients working physically very hard. This is so in spite of the fact that several sports medicine principles are included in the functional restoration program. To some extent, back muscle endurance can predict future LBP (19). However, endurance time probably reflects patient ‘will power’ in addition to true phys-

Fig. 2. The aerobics training is rather intensive.

90

iological qualities. A firm causal relationship between high endurance levels and the prevention of LBP has not yet been firmly established.

It would appear that the most important muscle quality is coordination (20). As regards optimizing trunk control in the inevitably awkward and taxing movements and positions involved in everyday activities, it is obviously important to avoid deleterious end-point movements. This is a quality which is difficult to measure. However, a recent EMG study showed double latency time and lower amplitudes in LBP people compared to those without LBP during a standardized, suddenly unexpected, removal of a horizontal traction on the trunk while standing upright (21). The difficiencies could be improved through training. However, this field of research is new and not widespread at the present time. Future studies will hopefully deliniate whether reduced coordination is primary or secondary to LBP.

Muscle function has predominantly been assessed using impressive machines for isokinetic testing. In itself this may provide a positive bias to the participant. Isokinetic testing has shown somewhat better reproduceability than conventional isometric testing, although neither are generally convincing (1 8). At present, it has not been shown which type of muscle testing provides the participants with the optimal trust and ability to work.

Lumbar flexibility is believed to reflect lumbar spinal function to some degree, at least in terms of intraindividual variation across a certain period of time/a certain intervention. It may be assessed simply by means of a ‘modified Schober test’, e.g. the increase during maximal lumbar flexion of a 15-cm vertical line from 5 cm below the level of the superior, posterior, iliac spines to 10 cm above this level. Another measure, advocated by the American Med- ical Association (22), is subtracting the inclinations of two measuring devices placed respectively on the lumbosacral and thoracolumbar junctions during standing as well during full flexion (23).

In the study from Vermont (24) cycling endurance correlated with the likelihood of returning to work. Therefore aerobic capability is test$d in most programs, most often as introduced by Astrand & Rodahl (25). However, other studies have not demonstrated this relationship.

Attempts at evaluating coordination have included standing on one leg, as is presently being done at the Copenhagen Back Center.

Ergonomic capability is also tested with more or less sophisticated machines in the different existing programs. Lifting capacity is certainly often inhib- ited by fear of re-injury. In most programs, the participant is told in the testing situation to lift free style, i.e. lift as he/she immediately feels comfortable


Fig. 3. Ergonomic training is partly aimed at physical improvement, and partly to give ideas for optimal working conditions. In this case, digging with ergonomic optimal tools is being trained.

with (for training, see below). A simple and widely used lifting test is ‘progressive isoinertial lifting evaluation’ (14), in which a box is lifted repeatedly from floor to waist height paced by a metronome, and with increasingly heavy weights in it. Regardless of whether pain, lack of motivation, or general exhaus- tion stops the procedure, it reflects capabilities of lifting in real life. Sitting endurance represents a threshold between working / not working for many people. It can be tested simply by doing paper work while sitting in an office chair at a table adjusted according to the participant’s own preference. In the Copenhagen Back Center, the test stops after a maximum of 1 hour. Also several other activities of daily living, walking, running, carrying bags up/down stairs, etc., are tested in most programs.

Numerous test procedures have been developed for assessing psychosocial status. The most widespread today is probably the Millon Behavioral Health Inventory (MBHI) (26), consisting of 150 questions, elucidating several psychological aspects: depression, hypochondria, somatization, etc.

Also Beck’s depression scale is widely used (27). The classic Minnesota Multiphasic Health Inven- tory (MMPI) (28) is much too extensive, and is basicly addressed towards psychiatric patients. Sev- eral other testing procedures exist.

Assessing the level of workability is much more difficult than previously believed, and some variation across countries exist. In the Copenhagen Back Center we use an ll-point scale.

1. At work - full time/part time - obtaining a sal- ary from the workplace. Housewife included. During any leave from this work, not caused by LBP, the person is still placed there.

2. Studying, not paid by rehabilitation authorities due to sickness; may be associated with a few hours part-time paid work.

3. Pension not due to sickness, maybe before normal pension age.

4. Unemployed caused by the work market situation, and not by health issues.

5. Long-term unemployed, but no longer paid from an unemployment fund.

6. In rehabilitation, may be engaged in work testing or rehab-paid education.

7. Sick listed from a job. For housewives, workability must be significantly reduced.

8. Sick listed and lost job. Not ready for another job due to sickness.

9. Advanced age pension, given due to health issues other than LBP.

10. Health-induced pension in process. 1 1. Health-induced pension obtained.

To assess self-reported level of pain, visual ana- logue scales (VAS) or box scales (29) are most often used.

Patient profile

Most published studies deal with patients in their working age, 40 years old on average. They have had a total of 360 days of sick leave.

They have often lost part of their self-confidence and also confidence towards the treatment system, developed along their way through ‘doctor shop- ping’. Their ‘social deroute’ is threatening, and many might be termed ‘professional patients’. Pro- longed disuse produces physical deconditioning that consists of reduced cardiovascular fitness, soft tissue flexibility and muscular strength. They show poor basic one-foot weight bearing and poor bal- ance/coordination and movement velocity. Their body language expresses ‘fear of flying’ ! Patient status is often complicated by psychosocial stres- sors, such as depression, loss of work, etc.

91

Bendix et al.

Schedule

One of the concepts in a full-time functional restoration program is that the schedule is comparable to a usual work situation as regards times, thus giving the participant the feeling of being able to manage a job. According to work habits in the US, the programs are mostly 9 hours a day, whereas the European programs usually last 8 hours. Three weeks are used in most programs, because usually that will significantly improve the participants’ function and, on the other hand, does not last for so long that they may get the feeling of having a permanent need for treatment. However, there is a varying degree of pre- and post- intervention: from 2 to 6 weeks training twice weekly prior to the 3-week intensive period (30) + l ? days weekly ‘post-treatment’ for 6 weeks. Some programs include only the intensive 3-week program (3).

The schedule in Table 1 refers to the version of the program in use at the Copenhagen Back Center. It is adopted from the original Dallas (12-14) and Ver- mont (3, 24) version, from which it varies only slightly.

Physical training

Every morning the patients partake in aerobic exercises for 1 hour led by a physical therapist (PT) instructor. The aim of this first hour of daily treatment is to stimulate cardiovascular fitness, to pro- voke motor activity (outputs) by using maximal stimulatory inputs, i.e. music, mirror, cuing, coach- ing and commands and may be even encourage the production of endorphines.

Stimulation of the coordination of the trunWex- tremities, movement velocity, one-foot weight bearing, and trunk rotation take place. Most of the patients experience a very positive start to their day.

From 9 to 10 a.m. the participants do strengthen- ing exercises in the fitness machines. The PT’s encourage them to do submaximal contractions of 30 repetitions in each of 9 machines - combined with stretching exercises.

Table 1. The daily schedule, as used in the Copenhagen Back Center.

08.00 - 09.00 09.00 - 10.00 10.00 - 11.30 11.30 - 12.00 12.00 - 13.30 13.30 - 14.00 14.00 - 15.00

15.00 - 16.00

Aerobic exercises Fitness machines Occupational therapy (work therapy) Lunch Group therapy (psychology) Stretching exercises Theory: basic anatomy, pathology including x-ray, sports medicine, etc. Recreational activities

Occupational therapy (OT)

From 10 to 11.30 a.m. ergonomic training is carried out, led by an OT instructor. The components are the following.

Lifting at different heights. Even picking up LEG0 blocks from the floor to a wall plate at face height and creating pictures is included in order to train lumbar flexibility, and to facilitate confidence in performing such movements. Small weights (female: <9 kg; male: c12 kg) are lifted with almost stretched legs and flexed back (‘back lift’), whereas the opposite (‘leg lift’) is used when greater weights are lifted. The philosophy behind using back lift, in spite of a demonstrated higher load on the back as compared with leg lift (31), is the fact that people largely use the back- lifting technique irrespective of their learning/ warning, because the energy demand is much lower: the trunk acts as a spring that in a low- energy way returns the forwardly flexed trunk back to vertical due to the elasticity of back muscles, ligaments, anterior disc compression, etc. Moreover, only the upper part of the trunk has to be moved compared to leg lifting, which requires movement of the entire body excluding the feet. Push and pull exercises. Sitting and standing working positions, including kitchen work, for the purpose of finding individual and optimal adjustments for the working place. Working at a sidstand workplace is attempted. Muscular tensions during sedentary work are relieved via ‘bio-feedback’ , where the exertions are registered electronically by means of surface electrodes, a sound gives feedback to the participant, and encourages hindher to work with more relaxed muscles, e.g. in the shoulders.

Psychology

From 12.00 to 1.30 p.m. ‘pain management and coping’ is carried out in groups guided by a psychologist. Also individual psychological sessions of approximately 1 hour are included 4-6 times during the 3 weeks and the 3 follow-up visits.

The specific goals for the psychological therapy are the following: 0 make the patients understand the importance of

greater responsibility for coping with pain in a more positive way;

0 setting up realistic personal goals, short-term as well as long-term;

0 changing the negative sensation of pain into a more positive philosophy of life;

0 increased self-acknowledgment;

92


Effectiveness

Controlled clinical trials

The first study on functional restoration with behavioral support (12, 13) compared patients at about 20-60 years of age (average 40 years), with an average sick leave of about 360 days over the last few years, with a control group. The program in this US study, as well as the one by Hazard et al. (24), were largely as described above, except one additional fitness machine session per day and more theory on two of three Saturdays. The control group did not receive any treatment in the center, but were free to visit any outside health-care professional; this was recorded during the follow-up period. The control group was not selected by randomization, but rather according to the fact that their insurance company in general did not agree to pay for this type of rehabilitation. When comparing several zero-point variables, the two groups were largely equal, including workmen’s compensation frequencies. However, the male/female ratio was significantly greater among those treated than the controls. The study was not assessed by a blinded observer, but most effect parameters were given as self-reported question- naires.

In all of these studies, return-to-work is presented as the most important outcome measure. One can discuss the reasonableness of this choice. Basically, the primary goal is to improve the quality of life and levels of daily functioning. Problems arise when comparing results between different countries and even between different states in the US. This is believed to be due to factors such as high unemployment rates, unemployment social benefits, etc., being more significant determinators of returning to work than improved physical performance.

Of other outcome variables, health-care contacts and sick leave in the follow-up period were reduced in most of the studies presented in this section.

At 1-year and 2-year follow-up, about 80% of those starting the program were back at work, as op- posed to about 40% of the controls. Moreover, the number of health-care contacts, (additional) surgery and re-injury favored the functional restoration program. The pain level was not improved, which actu- ally was in accordance to the goal: to restore function in spite of pain, where there was no realistic hope of cure from traditional care.

The second published study was performed by Hazard et al. in Vermont, US (24). The methods were a duplicate of those of PRIDE. The results obtained by the intervention group were almost identi- cal in the two studies, but the return-to-work rate among the controls was only about 30%. Statistical variation? Different spontaneous work options

93

Fig. 4. Recreational activities are aimed to obtain the feeling that ‘play’ can - and should - still be a natural part of life.

0 thorough understanding of the patient’s relations with other people.

It is possible for patient and wifehusband to have one interview with the psychologist. Furthermore, the therapy includes pain control through relaxation and visualization procedures. Patients learn to use their imagination and visualization in order to influence their sensation of pain.

Stretching

A whole-body perspective is utilized, incorporating all major postural muscle groups.

Theory/back-school

Classes are given in anatomy, physiology and pathology, including the circumstances of the individual patient. Also medication, possible future hobbies and sexuality in relation to pain are discussed.

Recreational activities

In order to convince the participant that he/she can spend leisure time actively and to recall that ‘play’ is an important part of living, a variety of games are performed, e.g. volley ball, orienteering in the near- by park, swimming, etc.

FOIIOW-UP

Three single days follow the 3-week period of daily training. Two days are placed in the second and third week after the intensive program, and the third day after 2 months. This is planned in order to main- tain learned principles, to re-establish physical levels, and to catch up on initiated psychological processes as well as social issues.

Bendix et al.

across the two states (Texas and Vermont, respectively)? Better results in Vermont? No one can know with any degree of certainty.

In Finland, Alaranta et al. (32) have, in a large- scale, randomized study, tested a program very similar to that of PRIDE. The first author had even studied the program in US. The weekly treatment time was 37 h and the components were very similar to those described above from our Center in Copenhagen. The patients included had, however, had less sick leave compared to the US and to our studies, and they were working at the time of enrolling. Randomized controls received a more conventional rehab in-patient program, including passive components and with less intensive physical exercises. Repeated testing, aimed to stimulate physical improvements, and psychological intervention were not included. Although significant effects on several physical and disability measures and pain were found, the program did not increase the being-at-work rate more than the control treatment, and only slight improvements in sick leave were noted. It might have been significant that retain- ing work was not a primary goal.

From two Canadian parallel studies, other results including randomized groups have been published (33). Two centers were involved, and in both pain patients were randomized less than 6 months after injury to either functional restoration treatment, or to no treatment at the center. The program ran 7 hours a day over 40 days, spread over respectively 8 or 12 weeks in the two centers. The results for the extracted LBP patients were better than for other types of locomotor-system pain patients. The positive results for LBP, however, were better in the center with a particularly experienced staff only. Even in this center, the results were also less positive than in the US studies, assessed from the differ- ences between those treated and controls.

A nonrandomized multi-center study from the US demonstrated almost as much benefit from functional restoration in terms of higher return-to-work rates among those treated compared with initially comparable controls who were not enrolled in the program because of the policy of their insurance companies or their family doctors (34). The program was slightly more individualized than most other programs described here. They also showed that the effect was seen irrespective of previous disc or fusion surgery, or no surgery at all.

In Denmark, the program edition described above showed varying results in two different randomized, controlled and observer-blinded studies. One of them (project A (35)) compared the program with no treatment at the center. In the other study (project B (36-38)) the patients were randomized to one of three programs: B1, a 3-week intensive full-day

program; B2, intensive training (aerobics and fitness machines); or B3, a combination of intensive training (aerobics and fitness machines) and psychology in groups. The last two programs also included back school, and ran over 6 weeks with two visits of 2 hours every week. At 4 months (35, 36) and at 1 year follow-up (37), both studies showed a significant effect on workability as well as use of the health-care system and (only in one of the studies) pain. At 2 years questionaire follow-up (38) only project ‘B’ exhibited significant improvement as regards workability. Even the patients’ overall assessment had faded out in project ‘A’.

Clinical presentations without control groups

In several other functional restoration-like programs, a long-term effect was demonstrated, although there was no control group (3941). In the last study, improvements of spinal mobility during treatment were predictive of return-to-work.

A program somewhat similar to the American one was started in Sweden before Mayer et al. published their first results (42). The program was longer (5 weeks) in spite of patients being less disabled with less sick leave (on average below 100 days/2 years) before entry. The results were convincing in terms of sick leave, pain intensity, and several behavioral issues during the 6 months follow-up. They were all working at entry, but their work situation at follow-up was not described.

An overall meta-analysis of functional restoration and other programs based on approximately the same principles concluded that multidisciplinary back pain treatment is in general superior to no treatment or single-discipline treatment in terms of return-to-work, health-care system utilization, etc., and that the effect seemed to last (43). It seems, however, that interpretation should be taken with caution due to the somewhat divergent results.

An example of the previously mentioned issue is a Norwegian study (44) where the program was called ‘functional restoration’, which may be correct according to their goal; however, their principles were different from those described above, which has been criticized (45). Their program included passive soft tissue treatment, there was no psychologist in the team, and the daily program lasted for only 3-5 hours. They compared this program with and without hydrotraction. No difference was seen, and assessed from the low return-to-work rate it did not seem to have had any effect.

It might seem strange that the issue of contacting the workplace as a part of the rehabilitation process has largely not been addressed in any of the articles.

94


Only one (*) would have experienced success irrespective of treatment or not; thus, one of every four treatments would be ‘in vain’. The belief that treatment would imply success for those with less sick leave is based on the difference between the four to the upper left and the lower ‘unfilled persons’ to the left. Moreover, ideally such observations should un- dergo additional testing in future randomized, controlled trials.

The ideal patient for functional restoration programs has not really been identified. This is so in spite of the fact that there is a substantial amount of studies that exhibit predictors for future low back pain in general (19, 47-49), and for treatment results in disc disease (50, 51). There are, however, some indications for rehabilitation, including functional restoration. In CLBP, Fredrickson et al. (52) demonstrated that age, the pre-treatment assessment at the psychological interview, as well as presence of worker’s compensation and other litigation factors, were good predictors. Previous surgery exhibited no predictive value in one study (53) but did in another (34). Gender was demonstrated to be without influence in one of Mayer’s studies (53). The psychological questionnaire MBHI could, for some of its clinical dimensions, be predictive of physical outcome of functional restoration (54). On the other hand, Fredrickson et al. (52) could not demonstrate any predictive value from MMPI or corresponding psychological tests. Neither did disability exaggera-

Prediction of rehabilitation success

The next step in assessing the efficacy of functional restoration programs is ruling out which patients will respond to the program. This is obviously important these days, where health-care priorities regarding different treatments have come under increasing political focus.

One problem is, however, that the various outcome measures, e.g. pain, disability and physical impairment, most often do not correlate well (2,29,46).

Another problem is that in many correlation analyses between pre-treatment variables and treat- menthehabilitation success, the ‘spontaneous success’ among the controls has not been ‘subtracted’. Figure 5 shows a hypothetical example where rehabilitation success is well correlated to a pre-treatment variable - exlong-term sick-listing (a hypothetical but not analysed example). The shaded area is what has been chosen for success according to a pre-set goal. To the left, the variable was negatively correlated to eventual success for the treated group as well as for the untreated controls. Therefore, it would be of no relevance to use this pre-treatment variable as a predictor.

To the right, the variable still shows the same good correlation, but only for those treated. In this example, the reasonable thing to do for future plan- ning would be to recommend treatment to those placed on the left side of the vertical, dotted line.

Rehab success

0 n o n - t r e a t e d

a 0 a 0 a 0

e l i g i b l e f o r j n o t e l i g i b l e f u n c t . r e s t . ~

L 1

a a 0

a 0

0 0

e l i g i b l e f o r n o t e l i g i b l e f u n c t . r e s t .

a pre-treatment variable Fig. 5. To select chronic LBP patients for a functional restoration program based on a pre-treatment variable, e.g. number of sick days (a hypothetical, but not analysed example), it would not be a reasonable criteria if the variable also correlates to success among the nontreated controls (left). If a correlation exists for those treated, but not for the untreated population, the variable, however, would be a good predictor (right). See text.

95

Bendix et al.

tion (55) nor non-organic signs (56) demonstrate any predictive value.

A third methodological issue is that multivariate analyses should be used for predictor analyses due to the widespread covariation between different variables.

It is likely that much more attention should be paid to the individual patient’s pre-treatment expec- tation (46, 57). This might help optimize the selec- tion of patients for a functional restoration program, and also in general to identify ‘the right treatment for the right patient’.

Conclusion - interpretations

Functional restoration with behavioral support seems to be effective in terms of reducing numbers of health-care visits, and therefore improvements regarding pain behavior. However, in the truly randomized studies, the effect on return-to-work rates is less convincing than in the studies with nonrandomized controls. The seemingly best results are seen in the nonrandomized US studies. This could either be due to the fact that they are not randomized, or to the different social factors between countries. If so, this supports the ideas put forward by Hadler (10) that the more community sickness payment that can be obtained, the greater the advantage of ‘proving’ sickness by the individual. The explanation of the US success obviously could also be that their staff are performing better than those of the other centers involved in clinical studies.

Hadler reintroduces the sorting of poor street people, presented by Mayhew in 188 1-82, into three cate- gories: those who can work; those who can’t; and those who won’t. Workmen’s compensation and similar ‘awards’ have most likely expanded the third group substantially. At present, this group can be sub- divided into: those who won’t, but can be convinced that they can; and those who cannot be convinced. Those who may have back-to-work advantage from a functional restoration program may be those who won’t work but can be convinced they can. And probably only them. The problem is that it seems to be difficult to figure out who they are. This last issue should be the subject of a substantial amount of research in coming years.

So indeed, it is not easy to rehabilitate disabling, chronic LBP patients effectively.

References

1. Nachemson A. Ondt i ryggen - et samhallsproblem. Rap- port for statens bedring for utvardering av medicinsk meto- dik fra SBU-koncemen. Sverige 1990. (In Swedish)

2. Waddell G. Simple low back pain: rest or active exercise? Ann Rheum Dis 1993: 52: 317-9.

3. Hazard R. Functional restoration of the patient with chronic back pain. In: Frymoyer J, eds. The adult spine: principles and practice. New York: Raven Press Ltd, 1991: 199-209.

4. Socialministenets Statistik over Revaliderings- og Pension- snzvnets afgarelser (Statistics from the Ministry of Social Affairs), Socialministenet, Danmark, 1991. (In Danish)

5. Magora A. Investigation between low back pain and occupation. 3. Physical requirements: sitting, standing and weight lifting. Ind Med 1972: 41: 5-9.

6. Riihimiiki H, Sakari T, Videman T, Hanninen K. Low-back pain and occupation. Spine 1989: 14: 204-9.

7. Svensson H-0, Vedin A, Wilhelmsson C, Andersson GBJ. Low-back pain in relation to other diseases and cardiovascular risk factors. Spine 1983: 8: 277-85.

8. Waddell G. A new clinical model for the treatment of low- back pain. Spine 1987: 12: 632-44.

9. Nachemson A. Disc pressure measurements. Spine 1982: 6: 93-7.

10. Hadler N. The disabling backache - an international perspective. Spine 1995: 20: 64&9.

11. Wheeler A, Hanley E. Spine update - nonoperative treatment for low back pain: rest to restoration. Spine 1995: 20:

12. Mayer TG, Gatchel RJ, Kishino N et al. Objective assessment of spine function following industrial injury. A prospective study with comparison group and one-year follow- up. Spine 1985: 10: 482-93.

13. Mayer TG, Gatchel RJ, Mayer H, Kishino ND, Keeley J, Mooney V. A prospective two-year study of functional restoration in industrial low back injury. JAMA 1987: 258:

14. Mayer T, Gatchel R. Functional restoration for spinal disor- ders. The sports medicine approach. Philadelphia: Lea & Fibiger, 1988.

15. Lindstrom I, Olund C, Eek C, Wahlin L, Peterson LE, Nachemson A. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain: a randomized prospective study with a behavioral therapy approach. Spine 1992: 17: 641-52.

16. Blomberg S. A pragmatic approach to low back pain including manual therapy and steroid injections. Acta Uni- versitatis Uppsaliensis. Uppsala, Sweden, 1993. Doctoral dissertation.

17. Engstrand G. The rehabilitation institute for disabled back pain patients. A tentative assessment. Sundsvall, Sweden, 1981. (In Swedish)

IS. Biering-SGrensen F, Bendix T, JGrgensen K, Manniche C, Nielsen H. Physical activity, fitness and back pain. In: Bou- chard C, Shephard R, Stephens T et al. eds. Physical activity, fitness, and health: international proceedings and con- sensus statement. Windsor, Leeds, Kingswood, Auckland: Human Kinetics Publishers, Inc., 1994: 73748.

19. Biering-S$rensen F, Thomsen C, Hilden J. Risk indicators for low back pain. Scand J Rehab Med 1989: 21: 151-7.

20. Alaranta H, Moffroid M, Elmquist LG, Held J, Pope M, Renstrom P. Postural control of adults with musculoskeletal impairement. Crit Rev Phys Med Rehab Med 1994: 6: 337- 70.

21. Magnusson M, Aleksiev A, Wilder D, Pope M, Spratt K, Lee S, Goel V, Weinstein J. Unexpected load and asymmet- ric posture as aetologic factors in low back pain. Eur Spine J 1995: in press.

22. Engleberg A. Guides to evaluation of permanent impairment. American Medical Association, Chicago, 1988.

23. Mayer T, Tencer A, Kristoferson S, Mooney V. Use of non-

375-8.

1763-7.


and follow-up of a multi model treatment program including intensive physical training for low back pain patients. Scand J Rehab Med 1991: 23: 97-102.

41. Mellin G, Hiirkapaa K, Vanharanta H, Hupli M, Heinonen R, Jarvikoski A. Outcome of a multimodal treatment including intensive physical training of patients with chronic low back pain. Spine 1993: 18: 825-9.

42. Linton S, Bradley L, Jensen I, Spangfort E, Sundell L. The secondary prevention of low back pain: a controlled study with follow-up. Pain 1989: 36: 197-207.

43. Flor H, Fydrich T, Turk D. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992: 49: 221-30.

44. Oland G, Tveiten G. A trial of modern rehabilitation for chronic low-back pain and disability. Spine 1991: 16: 457- 9.

45. Gatchel R, Mayer T, Hazard R, Rainville J, Mooney V. Ed- itorial: functional restoration - pitfalls and evaluation efficacy. Spine 1992: 17: 988-95.

46. Hazard R, Haugh L, Green P, Jones P. Chronic back pain. The relationship between patient satisfaction and pain, impairment, and disability outcomes. Spine 1994: 19: 881-7.

47. Biering-Sqrensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 1983: 9: 10619.

48. Burton K, Tillotson K, Main C, Hollis S. Psychosocial predictors of outcome in acute and chronic low back trouble. Spine 1995: 20: 722-8.

49. Bigos S, BattiC M, Fisher L, Hansson T, Spengler D, Nach- emson A. A prospective evaluation of preemployment screening method for acute industrial back pain. Spine

50. Hassenbring M, Marienfield G, Kuhlendahl D, Soyka D. Risk factors of chronicity in lumbar disc patients. Spine

51. Manniche C, Asmussen K, Vinterberg H, Rose-Hansen E, Kramhoft J, Jordan A. Analysis of preoperative prognostic factors in first-time surgery for lumbar disc herniation, including Finneson’s and modified Spengler ’s score systems. DMB 1994: 41:11&5.

52. Fredrickson B, Trief P, VanBeveren P, Yuan H, Baum G. Rehabilitation of the patient with chronic low-back pain - a search for outcome predictors. Spine 1988: 13: 351-3.

53. Mayer T, Tabor J, Bovasso E, Gatchel R. Physical progress and residual impairment quantification after functional restoration. Spine 1994: 19: 389-94.

54. Gatchel R, Mayer T, Capra J, Barnett J, Diamond P. Millon Behavioral Health Inventory: its utility in predicting function in patients with low back pain. Arch Phys Med Rehab

55. Hazard R, Bendix A, Fenwick J. Disability exaggeration as a predictor of functional restoration outcomes for patients with chronic low-back pain. Spine 1991: 16: 1062-7.

56. Bradish C, Lloyd G, Aldam C et al. Do non-organic signs help to predict the return to activity of patients with low- back pain? Spine 1988: 13: 557-60.

57. Sandstrom J, Esbjornsson E. Return to work after rehabilitation - the significance of the patient’s own prediction. Scand J Rehab Med 1986: 18: 29-33.

1992: 17: 922-6.

1994: 19: 2759-65.

1986: 67: 878-82.

invasive techniques for quantification of spinal range-of- motion in normal subjects and chronic low-back dysfunc- tion patients. Spine 1984: 9: 588-95.

24. Hazard R, Fenwick J, Kalish S et al. Functional restoration with behavioral support. A one-year prospective study of patients with chronic low-back pain. Spine 1989: 14: 157-

25. Astrand P-0, Rodahl K. Textbook of work physiology. New York: McGraw-Hill Book Co., 1970.

26. Millon T, Green C, Meagher R. Millon Behavioral Health Inventory. Third edn. Minneapolis: Interpretive scoring system, 1982.

27. Beck A. Depression: clinical, experimental and theoretical aspects. New York: Harper & Row, 1967.

28. Greene R. The MMPI. An interpretive manual. Grune & Stratton, 1980: 194295.

29. Manniche C, Asmussen K, Lauritsen B, Vinterberg H, Kreiner S, Jordan A. Low back pain rating scale. Validation of a tool for assessment of low back pain. Pain 1994: 57:

30. Kohles S, Barnes D, Gatchel R, Mayer T. Improved physical performance outcomes after functional restoration treatment in patients with chronic low back pain - early versus recent training results. Spine 1990: 15: 13214.

31. Bendix T, Eid S. The distance between the load and the body with three bimanual lifting techniques. Appl Er- gonom 1983: 14:185-92.

32. Alaranta H, Rytokoski U, Rissanen A et al. Intensive physical and psychosocial training program for patients with chronic low back pain. Spine 1994: 19: 133949.

33. Mitchell R, Carmen G. The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries. Spine 1994: 19: 63342.

34. Burke S, Hamsconstas C, Aden P. Return to work/work retention outcomes of a functional restoration program. A multi-center, prospective study with a comparison group. Spine 1994: 19: 1880-5.

35. Bendix AF, Bendix T, MD, Vaegter K, Lund C, Frqlund L, Holm L. Intensive multidisciplinary treatment for chronic low back pain - a prospective,. randomized, observer- blinded study. Cleve Clin J Med 1996: 63: 62-9.

36. Bendix AF, Bendix T, Ostenfeld S, Bush E, Andersen A. Comparison of different active treatment programs for patients with chronic low back pain - a prospective, randomized, observer-blinded study. Eur Spine J 1995: 4: 148- 52.

37. Bendix AF, Bendix T, Lund C, Ku-kbak S, Ostenfeld S. Comparison of three intensive programs for chronic low back pain patients - a prospective, randomized, observer- blinded study with one year follow-up. Scand J Rehab Med; in press.

38. Bendix AF, Bendix T. Comparison of three intensive programs for chronic low back pain patients - a prospective, randomized, observer-blinded study with two year follow- up. Report. Copenhagen Back Center, 1996. (In Danish)

39. Lanes T, Gauron E, Spratt K, Wernimont J, Found E, Wein- stein J. Long-term follow-up of patients with chronic back pain treated in a multidisciplinary rehabilitation program. Spine 1995: 20: 801-6.

40. Estlander AM, Mellin G, Vanharanta H, Hupli M. Effects

$1.

317-26.

97

functional restoration in chronic low back pain

Documents