The Journal of Bone and Joint Surgery (American). 2006;88:317-325.
doi:10.2106/JBJS.D.02968
© 2006 The Journal of Bone and Joint Surgery, Inc.
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High Pain Ratings Predict Treatment Failure in Chronic Occupational Musculoskeletal Disorders

Donald D. McGeary, PhD1, Tom G. Mayer, MD2 and Robert J. Gatchel, PhD3

1 PRIDE (Productive Rehabilitation Institute of Dallas for Ergonomics) Research Foundation, 5701 Maple Avenue, Dallas, TX 75235
2 Department of Orthopedic Surgery, University of Texas Southwestern Medical Center at Dallas, 5701 Maple Avenue, Suite 100, Dallas, TX 75235. E-mail address: tgmayer{at}pridedallas.com
3 Department of Psychology, College of Science, University of Texas at Arlington, 501 South Nedderman Drive, #313, Arlington, TX 76019-0528

Investigation performed at the Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE), Dallas; the Departments of Orthopedic Surgery and Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas; and the Department of Psychology, University of Texas at Arlington, Arlington, Texas

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health Grants IK05 MH071892, 2R01 MH46452 and 2R01 DE107138. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Pain intensity is one of the most widely used measures in the treatment of patients with chronic disabling occupational musculoskeletal disorders. Few studies have comprehensively investigated the relationship of pain intensity at the time of rehabilitation to objective socioeconomic outcomes at one year after treatment. This study evaluated the ability of pain intensity ratings, measured with a visual analog scale, to predict rehabilitation outcomes and to identify patients who are "at risk" for a poor outcome.

Methods: A cohort of 3106 patients with chronic disabling occupational musculoskeletal disorders in a multidisciplinary occupational tertiary rehabilitation program was divided into four groups on the basis of the pain intensity ratings (0 to 3, 4 to 5, 6 to 7, and 8 to 10) before and after rehabilitation. A structured interview to assess the socioeconomic outcomes, including work status, health-care utilization, recurrent injury, and whether there had been resolution of Workers' Compensation or third-party financial disputes, was conducted one year after rehabilitation.

Results: High pain intensity before rehabilitation was linearly associated with declining rates of program completion and higher rates of self-reported depression and disability after rehabilitation. Although higher pain ratings both before and after rehabilitation were associated linearly with a declining quality of socioeconomic outcomes, extremely high pain ratings (8 to 10) after rehabilitation were most predictive of poor outcomes. At the post-rehabilitation evaluation, patients with extreme pain were far more likely than those with mild pain to seek surgical treatment (risk ratio = 11.2 [95% confidence interval, 4.3, 29.5]) or to persist in seeking health care from new providers (risk ratio = 3.3 [95% confidence interval, 2.4, 4.5]). They were less likely to either return to work (risk ratio = 3.9 [95% confidence interval, 2.6, 6.0]) or to retain work (risk ratio = 4.2 [95% confidence interval, 2.9, 6.0]). They were also twice as likely to claim a new injury to the same musculoskeletal site after returning to work and to fail to settle Workers' Compensation or third-party financial disputes.

Conclusions: High pain ratings before rehabilitation are associated with higher rehabilitation dropout rates. The patients with chronic disabling occupational musculoskeletal disorders who reported extreme pain after completing a full course of extended treatment (13% of 2573) were at risk for poor outcomes in terms of lost productivity, high utilization of health care, and cost-shifting of state Workers' Compensation payments to federal resources.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.


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