Functional capacity evaluation as a performance measure - Evidence for a new approach for clients with chronic back pain

Objectives: To report the research and development of a new approach to Functional Capacity Evaluation, the Gibson Approach to Functional Capacity Evaluation (GAPP FCE) for chronic back pain clients. Methods: Four Studies, including pilot and feasibility testing, expert review, and preliminary interrater reliability examination, are described here. Participants included 7 healthy young adults and 19 rehabilitation clients with back pain who underwent assessment using the GAPP FCE. Thirteen therapists were trained in the approach and were silently observed administering the Functional Capacity Evalutions by at least 1 other trained therapists or the first investigator Or both. An expert review using 5 expert occupational therapists was also conducted. Results: Study 1, the pilot with healthy individuals, indicated that the GAPP FCE was a feasible approach with good utility. Study 2, a pilot using 2 trained therapists assessing 5 back pain clients, supported the clinical feasibility of the approach. The expert review in Study 3 found support for GAPP FCE. Study 4, a trial of the approach with 14 rehabilitation clients, found support for the interrater reliability of recommendations for return to work based on performance in the GAPP FCE. Discussion: The evidence thus far available supports the GAPP FCE as ail approach that provides a Sound method for evaluating the performance of the physical demands of work with clients with chronic back pain. The tool has been shown to have good face and content validity, to meet acceptable test standards, and to have reasonable interrater reliability. Further research is occurring to look at a larger interrater reliability study, to further examine content validity, and to examine predictive validity.

Safety issues in functional capacity evaluation: Findings from a trial of a new approach for evaluating clients with chronic back pain

Although safety is recognized as a critical issue in functional capacity evaluations (FCEs), it has rarely been investigated. This paper reports on the findings of a study which examined safety aspects of a new approach to FCE. Fourteen rehabilitation clients with chronic back pain participated in the study. Aspects examined included the pre-FCE screening procedures, the monitoring of performance and safety during the FCE, and the end of FCE measures and follow-up procedures. Support was found for the screening procedures of the approach, particularly blood pressure measurement, and for the combined approach to monitoring of the persons performance from biomechanical, physiological and psychophysical perspectives. Issues for FCE safety in general are identified and discussed, including the importance of screening procedures to determine readiness for FCEs and the issue of load handling in FCEs, especially in relation to clients with chronic back pain.

The relationship of adult attachment to emotion, catastrophizing, control, threshold and tolerance, in experimentally-induced pain

Although insecure attachment has been associated with a range of variables linked with problematic adjustment to chronic pain, the causal direction of these relationships remains unclear. Adult attachment style is, theoretically, developmentally antecedent to cognitions, emotions and behaviours (and might therefore be expected to contribute to maladjustment). It can also be argued, however, that the experience of chronic pain increases attachment insecurity. This project examined this issue by determining associations between adult attachment characteristics, collected prior to an acute (coldpressor) pain experience, and a range of emotional, cognitive, pain tolerance, intensity and threshold variables collected during and after the coldpressor task. A convenience sample of 58 participants with no history of chronic pain was recruited. Results demonstrated that attachment anxiety was associated with lower pain thresholds; more stress, depression, and catastrophizing; diminished perceptions of control over pain; and diminished ability to decrease pain. Conversely, secure attachment was linked with lower levels of depression and catastrophizing, and more control over pain. Of particular interest were findings that attachment style moderated the effects of pain intensity on the tendency to catastrophize, such that insecurely attached individuals were more likely to catastrophize when reporting high pain intensity. This is the first study to link attachment with perceptions of pain in a pain-free sample. These findings cast anxious attachment as a vulnerability factor for chronic pain following acute episodes of pain, while secure attachment may provide more resilience. (c) 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Experimental hand pain delays recognition of the contralateral hand: Evidence that acute and chronic pain have opposite effects on information processing?

Recognising the laterality of a pictured hand involves making an initial decision and confirming that choice by mentally moving one's own hand to match the picture. This depends on an intact body schema. Because patients with complex regional pain syndrome type 1 (CRPS1) take longer to recognise a hand's laterality when it corresponds to their affected hand, it has been proposed that nociceptive input disrupts the body schema. However, chronic pain is associated with physiological and psychosocial complexities that may also explain the results. In three studies, we investigated whether the effect is simply due to nociceptive input. Study one evaluated the temporal and perceptual characteristics of acute hand pain elicited by intramuscular injection of hypertonic saline into the thenar eminence. In studies two and three, subjects performed a hand laterality recognition task before, during, and after acute experimental hand pain, and experimental elbow pain, respectively. During hand pain and during elbow pain, when the laterality of the pictured hand corresponded to the painful side, there was no effect on response time (RT). That suggests that nociceptive input alone is not sufficient to disrupt the working body schema. Conversely to patients with CRPS1, when the laterality of the pictured hand corresponded to the non-painful hand, RT increased similar to 380 ms (95% confidence interval 190 ms-590 ms). The results highlight the differences between acute and chronic pain and may reflect a bias in information processing in acute pain toward the affected part.

Item validity of the physical demands from the Dictionary of Occupational Titles for the functional capacity evaluation of clients with chronic back pain

This study assessed the item validity of 15 of the physical demands from the Dictionary of Occupational Titles (DOT), as evaluated in a new approach to functional capacity evaluation (FCE) for clients with chronic back pain, the Gibson Approach to FCE (GAPP FCE). Fifty-two occupational therapists were sent the specifications of the items in the GAPP FCE procedures and were asked to rate the items in terms of item-objective congruence, relevance and difficulty. A response rate of 59.2% was obtained. The majority of the therapists agreed that most of the items were congruent with the objectives based on the definition of the physical demands from the DOT. The items evaluating Balancing and Pushing and Pulling had the lowest item-objective congruence. The evaluation of Balancing and the Lifting, Carrying and Pushing and Pulling of loads greater than light-medium weight (10–16 kg) were not considered significantly relevant. Concerns were raised about the difficulty and safety of the evaluation of Lifting, Carrying and Pushing and Pulling with clients with chronic back pain, particularly if the therapist evaluates the manual handling of medium to heavy loads. These results may have implications for other FCEs, particularly those which are based on the DOT, or when assessing clients with chronic back pain.

Upper limb recovery after stroke: The stroke survivors' perspective

Purpose. This study investigated stroke survivors' perspective of upper limb recovery after stroke. The aim was to determine factors other than medical diagnosis and co-morbidities that contribute to recovery. The objectives were to explore how stroke survivors define recovery, identify factors they believe influence recovery and determine strategies used to maximize upper limb recovery. Method. A qualitative study consisting of three focus groups and two in-depth interviews was conducted with stroke survivors (n = 19) and spouses ( n = 9) in metropolitan, regional and rural Queensland, Australia. Data were analysed using principles of grounded theory. Results. Stroke survivors maximize upper limb recovery by 'keeping the door open' a process of continuing to hope for and work towards improvement amidst adjusting to life with stroke. They achieve this by 'hanging in there', 'drawing on support from others', 'getting going and keeping going with exercise', and 'finding out how to keep moving ahead'. Conclusions. This study provides valuable insight into the personal experience of upper limb recovery after stroke. It highlights the need to develop training strategies that match the needs and aspirations of stroke survivors and that place no time limits on recovery. It reinforces the benefits of stroke support groups and advocates their incorporation into stroke recovery services. These findings can be used to guide both the development and evaluation of stroke survivor centred upper limb training programmes.

Widespread sensory hypersensitivity is a feature of chronic whiplash-associated disorder but not chronic idiopathic neck pain

Objectives: To investigate sensory changes present in patients with chronic whiplash-associated disorders and chronic idiopathic neck pain using a variety of quantitative sensory tests to better understand the pain processing mechanisms underlying persistent symptoms. Methods: A case control study was used with 29 subjects with chronic whiplash-associated disorders, 20 subjects with chronic idiopathic neck pain, and 20 pain-free volunteers. Pressure pain thresholds were measured over the articular pillars of C2-C3, C5-C6, the median, radial, and ulnar nerve trunks in the arm and over a remote site, the muscle belly of tibialis anterior. Heat pain thresholds, cold pain thresholds, and von Frey hair sensibility were measured over the cervical spine, tibialis anterior, and deltoid insertion. Anxiety was measured with the Short-Form of the Spielberger State Anxiety Inventory. Results: Pressure pain thresholds were decreased over cervical spine sites in both subject groups when compared with controls (P < 0.05). In the chronic whiplash-associated disorders group, pressure pain thresholds were also decreased over the tibialis anterior, median, and radial nerve trunks (P < 0.001). Heat pain thresholds were decreased and cold pain thresholds increased at all sites (P < 0.03). No differences in heat pain thresholds or cold pain thresholds were evident in the idiopathic neck pain group at any site compared with the control group (P > 0.27). No abnormalities in von Frey hair sensibility were evident in either neck pain group (P > 0.28). Discussion: Both chronic whiplash-associated disorders and idiopathic neck pain groups were characterized by mechanical hyperalgesia over the cervical spine. Whiplash subjects showed additional widespread hypersensitivity to mechanical pressure and thermal stimuli, which was independent of state anxiety and may represent changes in central pain processing mechanisms. This may have implications for future treatment approaches.

Neural pathways mediating bilateral interactions between the upper limbs

The ease with which we perform tasks such as opening the lid of a jar, in which the two hands execute quite different actions, belies the fact that there is a strong tendency for the movements of the upper limbs to be drawn systematically towards one another. Mirror movements, involuntary contractions during intended unilateral engagement of the opposite limb, are considered pathological, as they occur in association with specific disorders of the CNS. Yet they are also observed frequently in normally developing children, and motor irradiation, an increase in the excitability of the (opposite) homologous motor pathways when unimanual movements are performed, is a robust feature of the mature motor system. The systematic nature of the interactions that occur between the upper limbs has also given rise to the expectation that functional improvements in the control of a paretic limb may occur when movements are performed in a bimanual context. In spite of the ubiquitous nature of these phenomena, there is remarkably little consensus concerning the neural basis of their mediation. In the present review, consideration is given to the putative roles of uncrossed corticofugal fibers, branched bilateral corticomotoroneuronal projections, and segmental networks. The potential for bilateral interactions to occur in various brain regions including the primary motor cortex, the supplementary motor area, non-primary motor areas, the basal ganglia, and the cerebellum is also explored. This information may provide principled bases upon which to evaluate and develop task and deficit-specific programs of movement rehabilitation and therapy. (c) 2005 Elsevier B.V. All rights reserved.

Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain

The way people with chronic low back pain think about pain can affect the way they move. This case report concerns a patient with chronic disabling low back pain who underwent functional magnetic resonance imaging scans during performance of a voluntary trunk muscle task under three conditions: directly after training in the task and, after one week of practice, before and after a 2.5 hour pain physiology education session. Before education there was widespread brain activity during performance of the task, including activity in cortical regions known to be involved in pain, although the task was not painful. After education widespread activity was absent so that there was no brain activation outside of the primary somatosensory cortex. The results suggest that pain physiology education markedly altered brain activity during performance of the task. The data offer a possible mechanism for difficulty in acquisition of trunk muscle training in people with pain and suggest that the change in activity associated with education may reflect reduced threat value of the task.

Postural activity of the abdominal muscles varies between regions of these muscles and between body positions

The abdominal muscles have an important role in control and movement of the lumbar spine and pelvis. Given there is new evidence of morphological and functional differences between distinct anatomical regions of the abdominal muscles, this study investigated whether there are regional differences in postural activity of these muscles and whether recruitment varies between different body positions. Eleven subjects with no history of low back pain that affected function or for which they sought treatment participated in the study. Electromyographic (EMG) activity of the upper, middle and lower regions of transversus abdominis (TrA), the middle and lower regions of obliquus internus abdominis (OI) and the middle region of obliquus externus abdominis (OE) was recorded using intramuscular electrodes. All subjects performed rapid, unilateral shoulder flexion in standing and six subjects also moved their upper limb in sitting. There were regional differences in the postural responses of TrA with limb movement. Notably, the onset of EMG of the upper region was later than that of the lower and middle regions. There were no differences in the EMG onsets of lower and middle TrA or OI. The postural responses of the abdominal muscles were also found to differ between body positions, with recruitment delayed in sitting compared to standing. This study showed that there is regional differentiation in TrA activity with challenges to postural control and that body position influences the postural responses of the abdominal muscles. These results may reflect variation in the contribution of abdominal muscle regions to stability of the trunk. (c) 2004 Elsevier B.V. All rights reserved.

Occupational therapists' decision making in three therapy settings in Australia

Can a work setting with its organizational, cultural, and practical considerations influence the way occupational therapists make decisions regarding client interventions? There is currently a paucity of evidence available to answer this question. This study aimed to investigate the influence of work setting on therapists’ clinical reasoning in the management of clients with cerebral palsy and upper limb hypertonicity. Specifically the study aimed to examine therapists’ objective and stated policies, and their intervention decisions using Social Judgement Theory methodology. Participants were eighteen occupational therapists with more than five years experience with clients with cerebral palsy who were asked to make intervention decisions for clients represented by 90 case vignettes. They worked in three settings, hospitals (5), schools (6), and community (6). The results indicated that therapy settings did influence therapists’ decisions about intervention choices but not their objective and subjective policy decisions.

Adult attachment, anxiety, and pain self-efficacy as predictors of pain intensity and disability

Pain self-efficacy and anxiety have each been shown to contribute substantially to pain intensity and pain-related disability. Although adult attachment theory has been related separately to chronic pain, anxiety, and self-efficacy, it has not before been investigated with either pain self-efficacy or anxiety in the context of chronic pain. This study investigated the interrelations between these aspects of the chronic pain experience and their relative contributions towards pain intensity and disability. A clinical sample of 152 chronic pain patients participated in this study, completing self-report measures of attachment, self-efficacy, pain intensity, and disability, prior to attending a multidisciplinary pain clinic. Results revealed that fearful and preoccupied (anxious) attachment categories were associated with low pain self-efficacy, while high scores on the attachment dimension of comfort with closeness were linked with high pain self-efficacy, particularly for males. Insecure attachment (whether defined in terms of categories or dimensions) was related to higher levels of anxiety. Pain self-efficacy proved a stronger predictor of pain intensity than did anxiety and was a stronger predictor of disability than pain intensity or anxiety. In addition, comfort with closeness moderated the associations between pain self-efficacy and disability, pain self-efficacy and pain intensity, and anxiety and disability. Together, these findings support the value of adopting an attachment theoretical approach in the context of chronic pain. Treatment considerations and future research directions are considered. (c) 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.