Psychological Factors’ Influence on Patient-Reported Outcomes of Outpatient Rehabilitation in People With Lumbar Spine Impairments

PURPOSE: Current evidence indicates that emotional health, including depression, somatization, and fear avoidance beliefs related to pain, negatively impact rehabilitation outcomes in people affected by disorders of the lumbar spine (Beneciuk et al., 2012; Hart et al., 2011). The purpose of this study was to determine how depression, somatization, and fear-avoidance beliefs impact patient-reported global ratings of change versus clinician-reported global ratings of change among individuals with lumbar spine disorders (Juniper et al., 1994).

METHOD: This study involved analysis of survey question data previously collected by Focus On Therapeutic Outcomes, Inc. (FOTO; Knoxville, TN), a web-based patient assessment system that reports functional status measures. FOTO provided us with deidentified data from patients who met our inclusion criteria: age 18 or older, managed for an orthopedic impairment of the lumbar spine, received outpatient physical therapy, and completed the Lumbar Computerized Adaptive Test survey.

A global rating of change (from –7 to +7) was reported by the patients (N = 425) and the clinicians (N = 407) and was used as the dependent variable in our hierarchical regression analysis. At intake and discharge, a single-item screen was used to identify level of fear-avoidance beliefs ranging from 0 (completely disagree) to 4 (completely agree; (Hart et al., 2009). In addition, the Symptom Checklist–90–Revised was used to determine the presence of somatization and depressive symptoms (Hart et al., 2011).

The following independent variables were included in the three blocks used for the regression analysis: Block 1, age and gender; Block 2, duration of treatment, days having condition, intake and discharge functional status scores, number of surgeries, and intake and discharge pain levels within the past 24 hours; and Block 3, intake fear avoidance, discharge fear avoidance, intake depression, discharge depression, intake somatization, and discharge somatization. Model R-squared change values were used to determine the amount of variance explained by each block and were considered significant at p = .05. All analyses were conducted using IBM SPSS Statistics Version 24 (IBM Corp., Armonk, NY).

RESULTS: In predicting patients’ global change rating, Block 1 was not significant (R-squared change = .004, F change = .817, p = .442); however, Blocks 2 (R-squared change = .376, F change = 35.944, p < .000) and 3 (R-squared change = .032, F change = 3.73, p = .001) were significant. In contrast, for the clinicians’ global rating of change, Blocks 1 (R-squared change = .001, F change = .213, p = .809) and 3 (R-squared change= .007, F change = .931, p = .472) were not significant, whereas Block 2 (R-squared change = .536, F change = 65.557, p < .000) was significant.

CONCLUSION: These findings indicate that when assessing global rating of change, clinicians seem to rely on traditional health-related characteristics, whereas patients also consider their emotional health. A limitation of this study was that we did not have information regarding how this sample of clinicians used information on their patient’s emotional health.

IMPACT STATEMENT: In order to further improve rehabilitation outcomes and patient satisfaction with rehabilitation, clinicians should not ignore the assessment and management of psychological variables in people with lumbar spine disorders.

References

Beneciuk, J. M., Robinson, M. E., & George, S. Z. (2012). Low back pain subgroups using fear-avoidance model measures: Results of a cluster analysis. Clinical Journal of Pain, 28, 658–666. https://doi.org/10.1097/AJP.0b013e31824306ed

Hart, D. L., Werneke, M. W., Deutscher, D., George, S. Z., Stratford, P. W., & Mioduski, J. E. (2011). Using intake and change in multiple psychosocial measures to predict functional status outcomes in people with lumbar spine syndromes: A preliminary analysis. Physical Therapy, 91, 1812–1825. https://doi.org/10.2522/ptj.20100377

Hart, D. L., Werneke, M. W., George, S. Z., Matheson, J. W., Wang, Y.-C., Cook, K. F., . . . Choi, S. W. (2009). Screening for elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient therapy. Physical Therapy, 89, 770–785. https://doi.org/10.2522/ptj.20080227

Juniper, E. F., Guyatt, G. H., Willan, A., & Griffith, L. E. (1994). Determining a minimal important change in a disease-specific quality of life questionnaire. Journal of Clinical Epidemiology, 47, 81–87. https://doi.org/10.1016/0895-4356(94)90036-1