Rheumatology 2001; 40: 552-554
© 2001 British Society for Rheumatology
Original Papers |
The association of the involvement of financial compensation with the outcome of cervicobrachial pain that is treated conservatively
Spine Clinic, Department of Rheumatology, Hjoerring Hospital, DK-9800 Hjoerring,
1 Spine Clinic, Department of Rheumatology, Aalborg Hospital, DK-9000 Aalborg and
2 Department of Internal Medicine B, Hjoerring Hospital, DK-9800 Hjoerring, Denmark
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Abstract |
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Objectives. To examine the influence of the involvement of financial compensation on the results of physiotherapeutic McKenzie treatment on cervicobrachial pain.
Methods. A prospective study was carried out with a cohort of 60 patients referred to two spine clinics after they had experienced at least 5 weeks of neck pain radiating to the arm. Follow-up was performed 1 yr later using a validated questionnaire to measure the outcomes of neck and arm pain, disability, the use of analgesics and the perceived effect of the treatment as reported by the patient.
Results. At follow-up, there was no improvement in the group of patients for whom financial compensation was involved, whereas the group for whom compensation was involved showed highly significant improvement.
Conclusions. Despite uniform selection criteria and similarity of complaints and treatment protocols, the involvement of financial compensation seemed to be associated with an adverse effect on treatment results for patients with cervicobrachial pain who were treated conservatively.
KEY WORDS: Cervical radicular pain, Cervical radiculopathy, Litigation, Worker's compensation, Physiotherapy, McKenzie, Outcome.
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Introduction |
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Cervicobrachial pain is a common clinical disorder and its cause is not always apparent. The optimal treatment is not clearly established, but initial conservative treatment is generally recommended [1–3]. Several studies have shown that the involvement of financial compensation is a negative influence on the results of many spinal treatments [4]. The aim of the study was to examine the effect of compensation involvement on the result of physiotherapeutic McKenzie treatment for cervicobrachial pain.
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Materials and methods |
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The county of North Jutland (485 000 inhabitants) has two departments of rheumatology and each department has an out-patient spine clinic. Patients attending the spine clinics were selected solely on the basis of information given in referral letters from general practitioners to the departments of rheumatology. Patients were included if their duration of symptoms was between 4 weeks and 6 months. All spine patients were classified prospectively as part of a quality assurance programme.
All neck patients examined at the county's two spine clinics were included in the study. The referral letters did not contain information about the involvement of financial compensation. After referral and before the initial visit to the clinic, all patients completed a validated questionnaire, which comprised a neck and arm pain scale and a disability index, The Copenhagen Neck Functional Disability Scale [5]. The maximum score was 30 points for both neck and arm pain. The disability index was based on 15 questions, all to be answered individually. The maximum score (100%) indicated that the individual was extremely disabled because of neck and/or arm trouble, whereas a score of 0% indicated that no neck trouble was present. Consumption of analgesics (consumption of a drug meant its use for a minimum of 4 days a week) was also recorded, and was converted to a scale from 0 to 10 in which 0=no use of analgesics and 10=use of morphine; intermediate scores were given to the use of paracetamol, non-steroidal anti-inflammatory drugs and tramadole. As many doses and combinations were possible, the conversion of analgesic consumption to a scale was carried out by one person (CR); the conversion process proved to be robust on retesting. Finally, the patients were asked five specific questions to ascertain if any financial compensation issues were involved. Patients who gave incomplete information about financial compensation issues were excluded from the study.
At the spine clinics, all patients were examined by a rheumatologist, and all results were recorded on a standardized chart that was designed for the analysis of cervical radicular pain for later computer processing. On the first visit they were also examined by the physiotherapist, who used a standard McKenzie examination chart, and these results were also transferred by the physiotherapist to a chart designed for computer processing (at the Aalborg clinic only). All the staff of the spine clinics took care to avoid giving different information to individual patients about the causes of pain and disability, and emphasized the probability of a good spontaneous recovery [6]. After the first visit, which also included thorough provision of information and instruction (about 3 h), many patients were able to treat themselves in accordance with the treatment protocol. Some received additional treatment from an extramural physiotherapist, and some used a supporting collar in the initial phases. On average, the patients were seen at two additional visits, usually at an interval of 3 weeks.
The follow-up assessment was carried out 1 yr after the initial visit (median 365 days, range 136–424 days). Follow-up was carried out by means of a postal questionnaire, which included the pain scales mentioned above, a disability index, and a record of the consumption of analgesics. In addition, the patients were also asked to record their perception of the effect of the treatment.
The study was reported to the Danish Registry Inspection (1998-1200-213) and the local ethics committee (2-16-4-0001-98).
Statistical methods
Standard non-parametric statistics were used. The Wilcoxon rank sum test was used for comparative paired statistical tests, and the Mann–Whitney U-test for unpaired comparative analysis. The 
2 test was used to compare proportional data. Statistical significance was accepted at the 5% level.
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Results |
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Seventy-nine patients were examined at the spine clinics, of whom 60 had completed the initial questionnaire before their first visit and were therefore included in the study. The 19 patients who were excluded had given incomplete information about financial compensation. Fifty-eight of the 60 patients participated in the follow-up assessment. On the first visit the following 92 positive neurological signs were registered in the 60 patients: paresis 28; sensory dysaesthesia 36; reflex disturbances 28. No patient had medullary signs. Four patients had undergone neck surgery previously, and three later underwent neck surgery. Fifteen patients had at least one financial compensation claim pending: six patients had a claim for disability pension, seven for worker's compensation, 10 for other financial compensation and one for public hospital insurance. At the first clinic visit, patients with and without involvement of compensation were similar in regard to the disability index, neck and arm pain, the use of analgesics and objective findings (Table 1
). At the follow-up assessment a highly significant improvement was seen in the group of patients for whom financial compensation was not involved. In contrast, the group of patients for whom financial compensation was involved were unchanged in the four outcome measures and in perceived effect (Table 2).
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Discussion |
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The results indicated that patients with cervicobrachial pain and for whom there is no financial compensation involved can achieve good results when treated by the McKenzie method. For patients with similar complaints, selected with the same referral criteria and treated with the same protocol, the results also indicated that the involvement of compensation may be associated with an adverse effect on the outcome of treatment.
The findings are in agreement with studies in other countries that examined the effect of involvement of financial compensation on the results of treatment for painful low back disorders. Why the patients with compensation involvement reported more pain and disability at follow-up is difficult to explain. Some authors argue that if you have to prove you are ill, you cannot get well [7–9]. The prognostic consequences in the making of the initial medical diagnosis of work-related back injuries seems to act as a negative factor for recovery [10]. Can a possible improvement in the patient's disability be hindered by subsequent demands from the labour market which the patient may not feel capable of fulfilling? The identification of financial compensation as an illness-modifying risk factor may be important in recognizing the possibility of poor treatment results [11].
Our study was limited by the number of patients included and the consequent reduction in the ability to control for potential confounding variables. Patients for whom compensation is or is not involved may differ in variables that were not examined in our study, especially the duration of symptoms before referral. A history of trauma or psychological problems may have been more prevalent in the compensation group.
Our level of intervention was very low, as many of the patients were able to treat themselves after careful instruction.
We conclude that this study corroborates existing evidence that the involvement of financial compensation may be associated with an adverse effect on the outcome of this category of painful, disabling disorders.
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Notes |
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Correspondence to: C. Rasmussen.
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References |
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