Initial Evaluation

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

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

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

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

Second Visit

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

Initial Phase

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

Intensive Phase

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

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

Work Transition Phase

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

Outcome Tracking Phase

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

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

Range-of-Motion Assessment

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

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

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

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

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

Isolated Trunk Strength Assessment

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

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

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

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

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

Cardiovascular Fitness Assessment

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