Facilitating Unequivocal and Durable Decisions in Workers' Compensation Patients Eligible for Elective Orthopedic Surgery


      Timely intervention and recovery is beneficial to patients with chronic disabling occupational musculoskeletal disorders. Therefore, a surgical option process was developed for use in a functional restoration program (FRP) to allow chronic disabling occupational musculoskeletal disorder patients who were undecided about elective orthopedic surgery to participate in interdisciplinary rehabilitation, rather than suspending treatment, until the surgical option could be resolved. A consecutive cohort of 295 chronic disabling occupational musculoskeletal disorder patients with an unresolved surgical option was admitted to an FRP and their surgical preference at FRP midpoint was determined. The majority of patients declined surgery (n = 164) and were invited to complete the FRP. The remainder elected to pursue surgery and either underwent surgery (n = 43) or had their surgical request denied (n = 38). In the post-FRP year, only .8% of patients reversed their original decision and underwent surgery. Patients whose surgical preferences were accommodated (ie, the declined-surgery/underwent-surgery groups) demonstrated significant psychosocial improvement and excellent socioeconomic outcomes, which were similar to those of FRP patients without a surgical option. Patients whose request for surgery was denied had poorer outcomes than the other groups, but still outperformed FRP dropouts. This suggests that the addition of a formal surgical option process to an interdisciplinary FRP facilitated the surgical decision-making process and helped prevent delayed recovery.


      This study introduces a surgical option process to improve outcomes for patients with chronic disabling occupational musculoskeletal disorders who are undecided about elective orthopedic surgery. The addition of a surgical option process to interdisciplinary rehabilitation may resolve surgical indecision, improve outcomes, promote psychosocial recovery, and facilitate progression to Maximum Medical Improvement.

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        • Anagnostis C.
        • Gatchel R.J.
        • Mayer T.G.
        The Pain Disability Questionnaire: A new psychometrically sound measure for chronic musculoskeletal disorders.
        Spine. 2004; 29: 2290-2302
        • Angst F.
        • Verra M.L.
        • Lehmann S.
        • Brioschi R.
        • Aeschlimann A.
        Clinical effectiveness of an interdisciplinary pain management programme compared with standard inpatient rehabilitation in chronic pain: A naturalistic, prospective controlled cohort study.
        J Rehabil Med. 2009; 41: 569-575
        • Beaudreuil J.
        • Kone H.
        • Lasbleiz S.
        • Vicaut É.
        • Richette P.
        • Cohen-Solal M.
        • Lioté F.
        • de Vernejoul M.-C.
        • Nizard R.
        • Yelnik A.
        • Bardin T.
        • Orcel P.
        Efficacy of a functional restoration program for chronic low back pain: Prospective 1-year study.
        Joint Bone Spine. 2010; 77: 435-439
        • Brady S.
        • Mayer T.G.
        • Gatchel R.J.
        Physical progress and residual impairment quantification after functional restoration. Part II: Isokinetic trunk strength.
        Spine. 1994; 19: 395-400
      1. Brede E, Mayer TG, Worzer WE, Shea M, Garcia C, Gatchel RJ: Facilitating surgical decisions for patients who are uncertain: A pilot surgical option process within an interdisciplinary functional restoration program. Spine J. 2013 Nov 11. pii: S1529-9430(13)01636-7. [Epub ahead of print]

        • Chou R.
        • Loeser J.D.
        • Owens D.K.
        • Rosenquist R.W.
        • Atlas S.J.
        • Baisden J.
        • Carragee E.J.
        • Grabois M.
        • Murphy D.R.
        • Resnick D.K.
        • Stanos S.P.
        • Shaffer W.O.
        • Wall E.M.
        Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-based clinical practice guideline from the American Pain Society.
        Spine. 2009; 34: 1066-1077
        • Cohen J.
        Statistical Power Analysis for the Behavioral Sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale, NJ1988
        • Curtis L.
        • Mayer T.G.
        • Gatchel R.J.
        Physical progress and residual impairment quantification after functional restoration. Part III: Isokinetic and isoinertial lifting capacity.
        Spine. 1994; 19: 401-404
        • Daniell W.E.
        • Fulton-Kehoe D.
        • Franklin G.M.
        Work-related carpal tunnel syndrome in Washington State workers' compensation: Utilization of surgery and the duration of lost work.
        Am J Ind Med. 2009; 52: 931-942
        • DeBerard M.S.
        • LaCaille R.A.
        • Spielmans G.
        • Colledge A.
        • Parlin M.A.
        Outcomes and presurgery correlates of lumbar discectomy in Utah workers' compensation patients.
        Spine J. 2009; 9: 193-203
        • DeBerard M.S.
        • Masters K.S.
        • Colledge A.L.
        • Schleusener R.L.
        • Schlegel J.D.
        Outcomes of posterolateral lumbar fusion in Utah patients receiving workers' compensation: A retrospective cohort study.
        Spine. 2001; 26: 738-746
        • Denniston P.J.
        • Kennedy Jr., C.W.
        2013 Official Disability Guidelines.
        Work-Loss Data Institute, San Diego, CA2013
        • Faul F.
        • Erdfelder E.
        • Lang A.
        • Buchne A.
        G*power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 761-770
        • Frost H.
        • Lamb S.E.
        • Shackleton C.H.
        A functional restoration programme for chronic low back pain: A prospective outcome study.
        Physiotherapy. 2000; 86: 285-293
        • Gatchel R.J.
        • Mayer T.G.
        • Theodore B.R.
        The pain disability questionnaire: Relationship to one-year functional and psychosocial rehabilitation outcomes.
        J Occup Rehabil. 2006; 16: 72-91
        • Hashemi L.
        • Webster B.S.
        • Clancy E.A.
        • Volinn E.
        Length of disability and cost of workers' compensation low back pain claims.
        J Occup Environ Med. 1997; 39: 937-945
        • Hazard R.G.
        • Fenwick J.W.
        • Kalisch S.M.
        • Redmond J.
        • Reeves V.
        • Reid S.
        • Frymoyer J.W.
        Functional restoration with behavioral support: A one-year prospective study of patients with chronic low-back pain.
        Spine. 1989; 14: 157-161
      2. Hegman KT: Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, 2nd ed., 2008 rev. Elk Grove Village, IL, American College of Occupational and Environmental Medicine, 2008

        • Howard K.J.
        • Mayer T.G.
        • Gatchel R.J.
        Comparison of chronic occupational upper extremity versus lumbar disorders for differential disability-related outcomes and predictor variables.
        J Occup Environ Med. 2012; 54: 1002-1009
        • Howard K.J.
        • Mayer T.G.
        • Theodore B.R.
        • Gatchel R.J.
        Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: Analysis of treatment-resistant personality characteristics.
        Arch Phys Med Rehabil. 2009; 90: 778-785
        • Jensen M.P.
        • Chen C.
        • Brugger A.M.
        Interpretation of visual analog scale ratings and change scores: A reanalysis of two clinical trials of postoperative pain.
        J Pain. 2003; 4: 407-414
        • Jordan K.
        • Mayer T.G.
        • Gatchel R.J.
        Should extended disability be an exclusion criterion for tertiary rehabilitation? Socioeconomic outcomes of early versus late functional restoration compensation spinal disorders.
        Spine. 1998; 23: 2110-2117
        • Juratli S.M.
        • Franklin G.M.
        • Mirza S.K.
        • Wickizer T.M.
        • Fulton-Kehoe D.
        Lumbar fusion outcomes in Washington State workers’ compensation.
        Spine. 2006; 31: 2715-2723
        • Mahmud M.A.
        • Webster B.S.
        • Courtney T.K.
        • Matz S.
        • Tacci J.A.
        • Christiani D.C.
        Clinical management and the duration of disability for work-related low back pain.
        J Occup Environ Med. 2000; 42: 1178-1187
        • Mayer E.K.
        • Mayer T.G.
        The interdisciplinary treatment of the patient with chronic pain.
        in: Rao R.D. Smuck M. Orthopedic Knowledge Update: Spine 4. American Academy of Orthopaedic Surgeons, Rosemont, IL2012: 161-180
        • Mayer T.
        • Gatchel R.
        Functional Restoration for Spinal Disorders: The Sports Medicine Approach.
        Lea & Febiger, Philadelphia, PA1988
        • Mayer T.
        • Gatchel R.
        • Kishino N.
        • Keeley J.
        • Capra P.
        • Mayer H.
        • Barnett J.
        • Mayer H.
        Objective assessment of spine function following industrial injury. A prospective study with comparison group and one-year follow-up.
        Spine. 1985; 10: 482-493
        • Mayer T.
        • McMahon M.J.
        • Gatchel R.J.
        • Sparks B.
        • Wright A.
        • Pegues P.
        Socioeconomic outcomes of combined spine surgery and functional restoration in workers' compensation spinal disorders with matched controls.
        Spine. 1998; 23: 598-605
        • Mayer T.
        • Tabor J.
        • Bovasso E.
        • Gatchel R.J.
        Physical progress and residual impairment quantification after functional restoration. Part I: Lumbar mobility.
        Spine. 1994; 19: 389-394
        • Mayer T.G.
        • Gatchel R.J.
        • Mayer H.
        • Kishino N.
        • Keeley J.
        • Mooney V.
        A prospective two-year study of functional restoration in industrial low back injury: An objective assessment procedure.
        J Am Med Assoc. 1987; 258: 1763-1767
        • Mayer T.G.
        • Smith S.S.
        • Keeley J.
        • Mooney V.
        Quantification of lumbar function. Part 2: Sagittal plane trunk strength in chronic low-back pain patients.
        Spine. 1985; 10: 765-772
        • McGeary D.D.
        • Mayer T.G.
        • Gatchel R.J.
        High pain ratings predict treatment failure in chronic occupational musculoskeletal disorders.
        J Bone Joint Surg. 2006; 88-A: 317-325
        • Nguyen T.H.
        • Randolph D.C.
        • Talmage J.
        • Succop P.
        • Travis R.
        Long-term outcomes of lumbar fusion among workers' compensation subjects: A historical cohort study.
        Spine. 2011; 36: 320-331
        • Norrefalk J.R.
        • Ekholm J.
        • Borg K.
        Ethnic background does not influence outcome for return-to-work in work-related interdisciplinary rehabilitation for long-term pain: 1- and 3-year follow-up.
        J Rehabil Med. 2006; 38: 87-92
        • Proctor T.
        • Mayer T.G.
        • Theodore B.R.
        • Gatchel R.J.
        Failure to complete a functional restoration program for chronic musculoskeletal disorders: A prospective 1-year outcome study.
        Arch Phys Med Rehabil. 2006; 86: 1509-1515
        • Roche G.
        • Ponthieux A.
        • Parot-Shinkel E.
        • Jousset N.
        • Bontoux L.
        • Dubus V.
        • Penneau-Fontbonne D.
        • Roquelaure Y.
        • Legrand E.
        • Colin D.
        • Richard I.
        • Fanello S.
        Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: A randomized controlled trial.
        Arch Phys Med Rehabil. 2007; 88: 1229-1235
        • Shirado O.
        • Ito T.
        • Kikumoto T.
        • Takeda N.
        • Minami A.
        • Strax T.E.
        A novel back school using a multidisciplinary team approach featuring quantitative functional evaluation and therapeutic exercises for patients with chronic low back pain: The Japanese experience in the general setting.
        Spine. 2005; 30: 1219-1225
        • Smith S.S.
        • Mayer T.G.
        • Gatchel R.J.
        • Becker T.J.
        Quantification of lumbar function. Part 1: Isometric and multispeed isokinetic trunk strength measures in sagittal and axial planes in normal subjects.
        Spine. 1985; 10: 757-764
        • Wright A.
        • Mayer T.G.
        • Gatchel R.J.
        Outcomes of disabling cervical spine disorders in compensation injuries: A prospective comparison to tertiary rehabilitation response for chronic lumbar spinal disorders.
        Spine. 1999; 24: 178-183