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Facilitation of Surgical Decisions Within a Functional Restoration

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Facilitation of Surgical Decisions Within a Functional Restoration FACILITATION OF SURGICAL DECISIONS WITHIN A FUNCTIONAL RESTORATION PROGRAM FOR CHRONIC DISABLING OCCUPATIONAL MUSCULOSKELETAL DISORDERS by EMILY BREDE Presented to the Faculty of the Graduate School of The University of Texas at Arlington in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY THE UNIVERSITY OF TEXAS AT ARLINGTON December 2012 Copyright © by Emily Brede 2012 All Rights Reserved ii ACKNOWLEDGEMENTS I would like to thank the members of my committee, Dr. Angela Dougall, Dr. Yuan Peng, and Dr. Robert Gatchel, for their guidance and advice in the writing of this paper. I would also like to thank Dr. Tom Mayer and the staff of the Productive Rehabilitation Institute of Dallas for Ergonomics for allowing me to participate in their research program. Finally, I would like to thank my family for their love and support. November 9, 2012 iii ABSTRACT FACILITATION OF SURGICAL DECISIONS WITHIN A FUNCTIONAL RESTORATION PROGRAM FOR CHRONIC DISABLING OCCUPATIONAL MUSCULOSKELETAL DISORDERS Emily Brede, PhD The University of Texas at Arlington, 2012 Supervising Professor: Robert J. Gatchel Preventing delayed recovery is an important treatment goal in the treatment of chronic disabling occupational musculoskeletal disorders (CDOMDs). However, when CDOMD patients are potentially eligible for elective surgical procedures, decisions about whether or not to pursue surgery can be complicated by surgical uncertainty, which can decrease the likelihood of complete recovery from injury. Resolution of surgical uncertainty allows treatment to proceed, so that patients can reach Maximum Medical Improvement, and ideally return to productivity. The purpose of the current study was to resolve surgical uncertainty while preventing delayed recovery through a surgical option process. Patients who were undecided about pursuing elective surgical procedures were admitted to an interdisciplinary functional restoration program. After completing half of the treatment (usually 10 full day sessions) the patients re-evaluated whether or not to pursue surgery. Patients were divided into three groups for comparison based on the outcome of the surgical decision meeting: (1) declined surgery (DS, N = 164), (2) underwent surgery (US, N = 43), and (3) iv requested surgery but had the request denied (RSD, N = 38). These three groups were compared to a matched comparison group of patients who lacked a surgical option at admission (COMP, N = 272). All patients were offered the opportunity to complete the functional restoration program after resolving the surgical option. At one-year after discharge from functional restoration (or discontinuation of treatment), patients were contacted for a structured interview to assess socioeconomic outcomes. Results of the SOP program were excellent. Although unable to select a treatment option prior to the SOP, 83% of patients were able to make a decision of whether or not to pursue surgery, and 84% of those patients ultimately received the treatment they preferred. Over two- thirds of the patients in the SOP made a personal choice not to pursue surgery, and the majority of patients who chose to pursue surgery went on to receive the requested procedure. The RSD group was less likely than the other groups to complete the full course of functional restoration. A non-significant trend for the RSD group to show less improvement in psychosocial distress measures over the course of functional restoration treatment was identified. RSD patients were less likely to return to work after discharge and were less likely to remain at work compared to the patients in the other three groups. Most patients (99%) adhered to the treatment course they chose during the SOP, and did not have surgery after discharge from functional restoration. Patients who received their desired treatment (DS and US groups) showed significant improvements in pain, disability, depressive symptoms, and health-related quality of life. These patients also had very high rates of return to work and work retention, as well as low levels of excessive healthcare utilization, similar to the COMP group. This suggests that participation in a surgical option process within the context of a functional restoration program can resolve surgical uncertainty for most patients and can help prevent delayed recovery by offering earlier access to high-quality rehabilitation treatment. v TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................................................ iii ABSTRACT ...................................................................................................................................... iv LIST OF ILLUSTRATIONS .............................................................................................................. ix LIST OF TABLES ............................................................................................................................. x Chapter Page 1. INTRODUCTION .............................................................................................................. 1 1.1 Introduction ....................................................................................................... 1 1.2 Pilot Data .......................................................................................................... 4 2. SPINAL DISORDERS. ..................................................................................................... 6 2.1 Neck Pain ......................................................................................................... 6 2.2 Low Back Pain ................................................................................................ 11 3. SHOULDER DISORDERS ............................................................................................. 25 3.1 Shoulder Impingement Syndrome (SIS)......................................................... 25 3.2 Rotator Cuff Damage ...................................................................................... 27 3.3 Shoulder Surgery Recommendations ............................................................ 29 4. WRIST DISORDERS ...................................................................................................... 31 5. KNEE DISORDERS ....................................................................................................... 34 5.1 Meniscus Surgery ........................................................................................... 34 5.2 Total Knee Arthroplasty .................................................................................. 37 6. EFFECTS OF DELAYED TREATMENT AND EARLY INTERVENTIONS .................... 41 7. WORKERS’ COMPENSATION SYSTEMS .................................................................... 46 7.1 Texas Workers’ Compensation System ......................................................... 46 7.2 Benefits Mandated by Texas Workers’ Compensation Law........................... 48 7.3 Resolution of Disputes.................................................................................... 50 vi 7.4 Delays in the Workers’ Compensation System .............................................. 52 7.5 Surgical Outcomes in Worker’s Compensation Patients ................................ 53 8. METHODS ...................................................................................................................... 55 8.1 Surgical Option Process ................................................................................. 55 8.2 Functional Restoration.................................................................................... 57 8.3 Participants ..................................................................................................... 58 8.4 Measures ........................................................................................................ 65 8.5 Hypotheses ..................................................................................................... 68 8.6 Statistical analysis .......................................................................................... 69 9. RESULTS ....................................................................................................................... 73 9.1 Evaluation of Assumptions ............................................................................. 73 9.2 Description of the SOP Patient Groups .......................................................... 74 9.3 Univariate Test Results for the SOP Subgroups and the Non-SOP Comparison Group .................................................................. 79 9.4 Repeated Measures Analysis ......................................................................... 96 9.5 Regression Analysis of One-Year Socioeconomic Outcomes ..................... 101 9.6 Comparison of Surgical Areas ...................................................................... 115 10. DISCUSSION ............................................................................................................. 124 10.1 Evaluation of Hypotheses ........................................................................... 126 10.2 Limitations .................................................................................................. 131 10.3 Future Directions ........................................................................................ 133 10.4. Conclusions ............................................................................................... 134 vii APPENDIX
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