Physical demand levels in individuals completing a sports performance-based work conditioning/hardening program after lumbar fusion

BACKGROUND CONTEXT: Pain and disability after lumbar fusion surgery contributes to the over $20 billion dollars spent in health-care costs and estimated $28 billion in lost wages annually. With the goal of returning to work, an intensive program designed to build functional strength may be used. Previous interventions for this subgroup report the outcome measure of return to work (RTW), but do not account for the physical demand of the job to which they are returning. This may account for varying RTW and re-injury rates. PURPOSE: To examine the effectiveness of a sports performance-based work conditioning/hardening (SPWC/H) program on increasing an individual's strength measured by achievement of physical demand level (PDL) job classification of individuals followed by workers' compensation having had lumbar fusion surgery. STUDY DESIGN/SETTING: An uncontrolled multicenter, retrospective observational study of visits from 1999-2002 in an outpatient physical therapy setting. PATIENT SAMPLE: Fifty-four patients having undergone lumbar fusion surgery, managed by workers' compensation, that successfully completed a SPWC/H program. OUTCOME MEASURE: Physiologic measures: Deadlift and overhead press lifts, defined as maximum weight, a patient is able to lift between 8 and 15 repetitions. Functional measures: Calculated deadlift and overhead press volume (DLv, OHv) and estimated one repetition maximum (DLm, OHm). Physical demand level (PDL) for first (pre) and last week (post) are defined as: light (L<20lb occasionally), light/medium (LM>20lb occasionally), medium (M, 50lb occasionally), medium heavy (MH, 75lb occasionally), heavy (H, 100lb occasionally), and very heavy (VH>100lb occasionally), where 'occasionally' for the purposes of this article, is defined as in the 8-15 repetition range. METHODS: Patients completed a greater than or equal to 4 week, 4-5 days/wk, SPWC/H program. This program combines traditional concepts of strength and endurance training of work conditioning (WC) and hardening (WH) programs, with the sports performance concept of periodization in resistance training volume and intensity. Best set overhead and press lifts were obtained from each patient during the first and last week of the program. RESULTS: Significant increase between pre- and post-DLv, DLm, OHv, and OHm (all p<0.0001) existed when grouping all subjects. When adjacent groups are merged into M/MH and H/VH, significant differences existed between groups and pre- and postlifts (p<0.05). There was a median increase of three classifications when grouping by pre-PDL. There was no difference in outcomes found by grouping by single or multiple levels fused. Overall, numbers in each starting PDL were: 41 (75.9%) light, 6 (11.1%) LM, and 7 (13%) in medium. Numbers ending in each PDL group were: 1 (1.9%) light, 2 (3.7%) LM, 7 (13%) medium, 19 (35.2%) medium/heavy, 5 (9.3%) heavy, and 20 (37%) at very high. CONCLUSIONS: Post-lumbar spinal fusion patients are typically at the light PDL (<20lb occasionally) on completion of traditional physical therapy program. After an SPWC/H program, significant increase strength of deadlift and overhead lift volume and one repetition maximum demonstrated a median three-level increase in classification of PDL. We were also able to determine that there was no difference in strength outcome between those with a single- vs. multiple-level fusion surgery. Although the vast majority of individuals entered the program at the lowest PDL (20lb or less occasionally), more than 80% of patients completed the program at PDL of medium (50lb occasionally) or above, and 37% of patients achieved the maximum PDL (over 100lb occasionally). Future studies are needed to determine if increases in strength determined by PDL classification such as these relates to increased RTW rates and decreased re-injury rates.     

„Work hardening“ bei chronischen Rückenschmerzen

Work hardening is aimed at a reestablishment of the potentials needed in occupational everyday life. Fundamental motor abilities, such as strength, stability, flexibility and persistence, are restored and merged into the everyday life so that psychological contents, such as fear avoidance behavior will be positively affected. The design of work hardening is interdisciplinary in the sense of a holistic approach to back pain. Handling the pain under load requires sophisticated treatment and the training demands a high degree of individual design. A trusting and mutual agreement between therapist and patient is essential. Work hardening represents an important part of the therapy of chronic back pain and greatly supports regaining confidence in the physical efficiency and the ability to control the body.     

Microcomputer program for the determination of haemodynamic indices using measurements obtained with a balloon-tipped pulmonary artery catheter

A microcomputer program is described which facilitates the calculation of data from physiological variables measured using a flow directed, balloon-tipped thermal dilution pulmonary artery catheter. Eleven variables may be calculated and left ventricular function may be displayed graphically using as coordinates left ventricular stroke work index and pulmonary artery wedge pressure. Successive measurements may be easily compared and the program has proved valuable in the management of patients monitored with a right heart catheter.     

Early results of Bankart repair with a patient-controlled rehabilitation program

A standard protocol for patient rehabilitation after open Bankart procedure has been used in our clinic for more than 5 years. This protocol emphasizes the patient's role in controlling his or her rehabilitation over a 16-week period that results in a full return to work and sport. We have retrospectively reviewed 100 patients (104 shoulders) with a minimum follow-up of 6 months on the program to assess the program's effectiveness. The patients were assessed in terms of their satisfaction in relation to home, work, and sporting activities and the speed with which they returned to work and sport. All patients found the program acceptable. For home activities 100 (96%) of the shoulders were rated good or excellent, for work 94 (90%) were rated good or excellent, and 78 (76%) were rated good or excellent for sport. The shoulders of 5 patients redislocated, and a further 5 patients described ongoing symptoms but no redislocations.     

Residency reform: anticipated effects of ACGME guidelines on general surgery and internal medicine residency programs

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) has recently amended guidelines for resident work environment. This study was conducted to evaluate opinions of program directors regarding the impact of the changes on residents and residency programs. METHODS: General surgery and internal medicine program directors were sent a 19-question survey. Questions were asked regarding anticipated effects on patient safety, resident well-being, education, medical errors, implementation costs, and methods needed for compliance. Data were analyzed using the chi-square test, the Mann-Whitney method, and the independent samples t-test where appropriate. RESULTS: Responses were received from 153 surgery program directors and 126 medicine program directors. Differences noted were hours worked (surgery 84.2 hours vs medicine 68.7 hours, p < 0.0005), current compliance (49% vs 73%, p < 0.0005), and allowance of internal (13% vs 54%, p < 0.0005) and external (24% vs 58%, p < 0.0005) moonlighting. CONCLUSIONS: Program directors anticipate improved resident safety and well-being. However, education, continuity of care, and board certification success are not expected to improve. Increased cost to institutions is anticipated. Surgery program directors feel medical errors will not decrease; medicine program directors are neutral. To facilitate compliance, surgery program directors anticipate employing physicians' assistants and technology, whereas medicine program directors may implement night float. Neither surgery nor medicine program directors expects increased quantity or quality of applicants. Program directors agree resident work hour reform is essential; however, varied methodology and outcomes are expected.     

Immediate breast reconstruction with subpectoral implantation after transaxillary subcutaneous mastectomy for siliconoma

Immediate breast reconstruction on 14 patients suffering from breast hardening after augmentation mammaplasty by injection of silicone gel was performed. Transaxillary subcutaneous mastectomy was done followed by insertion of a double-lumen prosthesis into the subpectoralis plane. The result was greatly influenced by the amount of injected silicone gel. The patient was carefully observed after surgery, and the prosthesis was immediately removed when abnormal skin changes became apparent. Seven cases had no hardening on either side and 1 case had hardening on one side, 3 cases had hardening on both sides and 1 case on one side, 2 cases had the prosthesis removed from both sides and 2 cases from one side. All other cases with hardening or prosthesis removal, except one with removal from both sides, were subsequently reconstructed after more than three months.     

Functional restoration with behavioral support. A one-year prospective study of patients with chronic low-back pain

Patients with chronic disabling low-back pain have poor prospects of returning to work. The authors tested a treatment program of functional restoration with behavioral support through 1 year prospective observation of patients disabled for an average of 19 months without evidence of surgically correctable disease. Ninety patients were studied: 59 program graduates, five program dropouts, 17 patients denied program authorization by their insurance carriers, and six crossover patients. Three patients were admitted but refused to participate in the treatment program. Initial demographic, physical, and self-assessment attributes were similar for all four groups. At year's end, 81% of program graduates, 40% of the dropouts, and 29% of those denied the program had returned to work. All six crossover patients were working 6 months after treatment. Program graduates showed significant improvements in self-assessed pain, disability, and depression, and in physical capacities after 3 weeks of treatment. These improvements were maintained through the year except for partial decreases in frequent lifting, cycling endurance, and isokinetic trunk extension strength. Functional restoration with behavioral support is an effective treatment for patients with chronic, disabling low-back pain, as measured by self-assessments, physical capacities, and return to work.     

Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioral therapy approach.

Patients with nonspecific mechanical low back pain (n = 103), examined by an orthopaedic surgeon and a social worker, were randomized to an activity group (n = 51) and a control group (n = 52). Patients with defined orthopaedic, medical, or psychiatric diagnoses were excluded before randomization. No patients were excluded due to place of birth or difficulties in speaking or understanding the Swedish language. The purpose of the study was to compare mobility, strength and fitness after traditional care and after traditional care plus a graded activity program with a behavioral therapy approach. A graded activity program, with a behavioral therapy approach was given under the guidance of a physical therapist. The endpoint of the graded activity program was return to work. This program significantly increased mobility, strength, and fitness more than could be explained by only a time recovery effect, especially in males. The patients in the activity group returned to work earlier than did the patients in the control group. Spinal rotation, abdominal muscle endurance time and lifting capacity were significantly correlated to rate of return to work. Traditional care plus a graded activity program were superior to only traditional care, evaluated in terms of mobility, strength and fitness. The graded activity program proved to be a successful method of restoring occupational function and facilitating return to work in subacute low back pain patients. The patients in the graded activity program learned that it is safe to move, while regaining function.     

Rehabilitation after aorto-coronary bypass and return to work

In Quebec, deceptively few patients who have successfully undergone coronary artery bypass have been returning to work. Those aged 55 to 64 years, blue collar workers or those who were off work for 13 weeks or more were likely not to return to work after surgery. From Jan. 1, 1983, all patients aged 64 years and younger, who successfully underwent coronary artery bypass grafting were invited to attend a 6-week rehabilitation program, starting 6 weeks after operation. The aim of the program was to improve the rate of return to work through a low-intensity physical activity course (60% to 70% maximal working capacity and calisthenics ). Up to Mar. 31, 1984, 68 patients had participated in the program. The proportion of patients returning to work was significantly (p less than 0.01) improved and the trend was observed in all age groups, and for all types of employment and length of time off work before operation.     

Study protocol: the effects of work-site exercise on the physical fitness and work-ability of older workers

Background  

Older workers have a higher rate and cost of injury than younger workers and with a rapidly ageing work force there is a need to identify strategies to address this problem. Older workers are less physically active and fit than younger workers and so have reduced work ability. The reduced work ability means they are more likely to be fatigued at work and so at greater risk of injury. Exercise could potentially assist this problem. Exercise training has been previously shown to improve fitness in older people however there has been no evaluation of workplace exercise program for older workers. We do not know if the programs are feasible and can improve the fitness and work ability of older workers. We have designed a randomised controlled trial to evaluate whether exercise improves fitness and perceived work-ability of older workers.     

Rehabilitation of the patient with chronic back pain. A search for outcome predictors

This prospective study was initiated 3 years ago to evaluate the outcome and to identify predictors of success or failure in patients admitted to a rehabilitation program for chronic low-back pain. Multiple parameters were evaluated, including psychologic data (MMPI, personal interview, pain drawing, etc.), physical measurements (flexibility, strength and endurance), and demographic data concerning the patient's home and working environment. Information was available on each patient admitted to the program prior to his admission, at completion of the program, 6 weeks following completion of the program and 3 months following completion of the program. A telephone interview was carried out 2 1/2 years following the patient's discharge from the program. Linear regression analysis was used to identify the important independent variables with regard to the dependent variables of relief of back pain, return to work and increased activities at home. Demographic data were of no value as a predictor with the exception of age and returning to work. The patients over the age of 50 returned to work with much less frequency than those less than 50. Psychologic information from the MMPI and similar tests were of no value. The personal preadmission interview of a trained psychologist, however, was a good predictor of an individual's eventual return to work and overall improvement. Worker's Compensation and other litigation was a negative factor in a patient's prognosis. The treatment team's prognosis at the time of discharge from the program was the best overall predictor of a patient's chance of success or failure in the longterm.     

Education of the Modern Surgical Resident: Novel Approaches to Learning in the Era of the 80-Hour Workweek

Introduction Implementation of the 80-hour work week has resulted in limitations on the hours available for resident education, creating a need for innovative approaches to teach surgical residents successfully. Herein we report the methods and results of an innovative didactic learning program at a large academic surgerical residency program. Methods Between 2004 and 2005, based on known principles of adult education and innovative learning techniques, a didactic learning program was instituted in a major academic surgery program. The course work consisted of a structured reading program using Schwartz’s Textbook of Surgery, with weekly testing and problem-based learning (PBL) groups led by surgical faculty. The residents’ progress was assessed by American Board of Surgery In-Training Examination (ABSITE) training scores before and after program implementation. A resident survey was also conduced to assess residents’ attitudes toward the new program. Results were reported as a mean, and categoric variables were compared using a paired Student’s t-test. Results During the academic year of the structured reading program, the mean ABSITE score improved by 10% (P = 0.02) from the previous year. The postgraduate year 4 class had the largest change, with a score increase of 17% over the previous year’s performance (P = 0.02). Survey results demonstrated that 64% of the responders agreed that the small-group PBL was preferable for achieving educational goals. Furthermore, 89% of residents responded that the PBL groups improved interaction between residents and faculty members. Conclusions An innovative formal learning program based on a major surgical textbook with weekly testing and small group sessions can significantly improve surgical training in the modern era of work-hour restrictions. Furthermore, surgical trainees find this format to be innovative and useful for improving didactic teaching.     

Active functional restoration and work hardening program returns patient with 2?-year-old elbow fracture-dislocation to work after 6 months: a case report

The rehabilitation of elbow fracture and dislocation is not generally considered a mainstream chiropractic concern. The clinician who is able to successfully manage the elbow articulation will rely upon his/her knowledge of functional anatomy, pathobiomechanics, history and examination principles, when selecting the appropriate treatment available. A case is presented of an individual that sustained a radial head fracture and dislocation following a motor vehicle accident. Subsequent to receiving 1½ years of physiotherapy for post-surgical complications (decreased range of motion, pain, stiffness and tingling to the 4th and 5th fingers), the patient was referred to a multidisciplinary clinic for a Work Hardening/Conditioning Program. This article discusses the need for active functional restoration vs. passive therapy, work hardening regimens and outcome measures. After 6 months of rehabilitation and 3 years following his motor vehicle accident, the patient has successfully returned to his previous work environment. A summary of the sequential steps in providing appropriate management has been provided.     

Anaesthesia training and development in Nepal 1985–1990

In 1985 a diploma program in anaesthesia was established in Kathmandu, Nepal, as a joint venture between the Institute of Medicine in Kathmandu and the University of Calgary. Development of the program and of the specialty in the capital city of Kathmandu was continuously documented during the next five years by local and visiting faculty. In 1990 teams of two Nepali and one Canadian anaesthetist also conducted a survey of each of the seven 50-100 bed zonal hospitals which did not previously have a trained anaesthetist and which are now staffed by graduates of the diploma program. In 1985 Nepal, with a population of 16 million, had seven trained Nepali anaesthetists all of whom worked in two hospitals in Kathmandu. By the end of 1989, 19 physicians had graduated. Seven of these continue to work in Kathmandu hospitals, nine work in zonal hospitals throughout the country and two are taking higher anaesthesia training in the United Kingdom. Additional Nepali anaesthetists have returned from training abroad, and the Society of Anaesthesiologists of Nepal, which joined the World Federation of Societies of Anaesthesiologists in 1988, now has 34 members. An annual anaesthesiology symposium is held, and weekly clinical meetings are organized in the major hospitals in Kathmandu. Anaesthetists who work in the zonal hospitals have limited supplies of drugs and equipment and opportunities for continuing medical education are virtually nonexistent.(ABSTRACT TRUNCATED AT 250 WORDS)     

低龄老年人社区内工作重建方案的构建与实践

目的 构建低龄老年人社区内工作重建方案，观察实践效果。方法 建立工作重建干预团队，构建低龄老年人社区内工作重建干预方案，选取社区20名低龄老年人展开实践，6个月后评价效果。结果 20名低龄老年人共参加10类工作重建项目，均按计划获得相应报酬；工作重建后老年人生活满意度、正性情绪得分显著提升，负性情绪得分显著下降(均P<0.05)。结论 社区内工作重建可使参与者获益，提升主观幸福感。     

Costs analysis of successful rotator cuff repair surgery: An outcome study. Comparison of gatekeeper system in surgical patients

In an effort to determine the cost effectiveness of rotator cuff repair surgery in workers' compensation patients, a financial analysis of 50 consecutive patients with a “successful” result was performed. Treatment cots were analyzed from the date of initial injury through all evaluations, diagnostic studies, surgical reconstruction, physical therapy and work hardening. Additionally, all workers' compensation payments and the cost of settlement was analyzed. The average cost of medical care was $50,302.25 per patient. The average time to return to unrestricted duty from the date of injury was 11 months. However, patients referred to a specialist immediately following the diagnosis of a rotator cuff tear had total costs that averaged $25,870.64 and returned to work an average of 7 months postoperatively. Patients managed via a “gatekeeper” system averaged 100,280.10 in total costs and the average return to work was 18 months. These differences in cost and return to work were both statistically significant. P < .05. In conclusion, immediate referral of rotator cuff tears for specialized care results in decreased cost and earlier return to work.     

Implementation of duty hour standards in otolaryngology-head and neck surgery residency training.

OBJECTIVE: To determine what impact, if any, of the recently implemented duty hour standards have had on otolaryngology-head and neck surgery residency programs from the perspective of program directors. We hypothesized that the implementation of resident duty hour limitations have caused changes in otolaryngology training programs in the United States. STUDY DESIGN AND SETTING: Information was collected via survey in a prospective, blinded fashion from program directors of otolaryngology-head and neck residency training programs in the United States. RESULTS: Overall, limitation of resident duty hours is not an improvement in otolaryngology-head and neck residency training according to 77% of the respondents. The limitations on duty hours have caused changes in the resident work schedules in 71% of the programs responding. Approximately half of the residents have a favorable impression of the work hour changes. Thirty-two percent of the respondents indicate that changes to otolaryngology support staff were required, and of those many hired physician assistants. Eighty-four percent of the respondents did not believe that the limitations on resident duty hours improved patient care, and 81% believed that it has negatively impacted resident training experience. Forty-five percent of the program directors felt that otolaryngology-head and neck faculty were forced to increase their work loads to accommodate the decrease in the time that residents were allowed to be involved in clinical activities. Fifty-four percent of the programs changed from in-hospital to home call to accommodate the duty hour restrictions. CONCLUSIONS: According to the majority of otolaryngology-head and neck surgery program directors who responded to the survey, the limitations on resident duty hours imposed by the ACGME are not an improvement in residency training, do not improve patient care, and have decreased the training experience of residents. SIGNIFICANCE: This study demonstrates that multiple changes have been made to otolaryngology-head and neck surgery training programs because of work hour limitations set forth by the ACGME.     

How Do Hepatologists Gain Access to Liver Transplant Units?

Liver transplantation has evolved from an experimental treatment to be considered as the most effective therapy for end-stage liver disease and selected cases of hepatocellular carcinoma. Transplant hepatologists must have specific knowledge and abilities to treat those patients who receive a liver transplant. In Spain, approximately 1100 liver transplants are performed each year, and most centers assume both postoperative care and long-term follow-up, which has led to a significant work load in liver transplant units. Despite previous attempts to establish an official training program in hepatology, the Spanish health system does not presently have a specific liver transplant training program to guarantee that future needs of physicians are covered. Collaboration between health authorities and scientific societies is required to guarantee adequate assistance to liver transplant recipients in the future.     

Safety, feasibility, and efficacy of negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction

STUDY DESIGN: Randomized, matched design. BACKGROUND: Optimal rehabilitation following anterior cruciate ligament reconstruction (ACL-R) requires safe and effective interventions. Negative work exercise (via eccentric muscle activity) has the potential to be highly effective at producing large quadriceps size and strength gains early after ACL-R. The purpose of this investigation was to evaluate the short-term safety and efficacy of adding a progressive negative work exercise program via eccentric (ECC) ergometry early after ACL-R. METHODS AND MEASURES: Beginning 3 weeks after ACL-R, 32 participants were randomly assigned into either a 12-week traditional (TRAD) or ECC exercise program. Safety was assessed by measuring knee pain, thigh pain, knee effusion, and knee stability prior to surgery and at 3,15, and 26 weeks after surgery. Efficacy was assessed by measuring negative work output during the 12-week training program and by measuring functional ability (ie, quadriceps peak torque, hopping distance, self-reported functional ability and activity level scales) prior to surgery and 26 weeks after ACL-R. RESULTS: There were no significant differences between groups in measures of knee and thigh pain, effusion, or stability at any period after surgery. Negative work output increased systematically throughout training, while knee and thigh pain remained at relatively low levels. A significant group-by-time interaction was observed for quadriceps peak torque, hopping distance, and activity level (P< or =.02). Quadriceps strength and hopping distance of the involved limb improved by a significantly greater amount in the ECC group compared to the TRAD group (P<.01). Activity level decreased to a lesser extent in the ECC group compared to the TRAD group (P =.02). CONCLUSIONS: Negative work via an ECC intervention was implemented safely after ACL-R. The addition of negative work exercise also induced superior short-term results in strength, performance, and activity level after surgery.