The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain

BACKGROUND

Musculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities.

OBJECTIVE

Explore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP.

METHODS

A longitudinal assessment of individuals 18-90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain.

RESULTS

532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (β) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((β = 0.6; 95%CI: 0.1, 1.1), and prior surgery (β = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (β = -0.2, 95%CI: -0.3, -0.02).

CONCLUSIONS

Depression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.

Incomplete reporting of manual therapy interventions and a lack of clinician and setting diversity in clinical trials for neck pain limits replication and real-world translation. A scoping review

INTRODUCTION

Neck pain is a leading cause of disability, and manual therapy (MT) is a common intervention used across disciplines and settings to treat it. While there is consistent support for MT in managing neck pain, questions remain about the feasibility of incorporating MT from research into clinical practice. The purpose of this scoping review was to assess the adequacy of MT intervention descriptions and the variability in clinician and setting for MT delivery in trials for neck pain.

METHODS

Medline (via PubMed), CINAHL, PEDRo, and the Cochrane Central Registry for Controlled Trials were searched for clinical trials published from January 2010 to November 2021. A 11-item tool modified from the Consensus on Exercise Reporting Template was used to assess appropriateness of intervention reporting. Clinicians, subclassifications of neck pain, and clinical settings were also extracted.

RESULTS

113 trials were included. A low percentage of studies provided the recommended level of detail in the description of how MT was delivered (4.4%), while 39.0% included no description at all. Just over half of trials included clinician's qualifications (58.4%), dose of MT (59.3%), and occurrence of adverse events (55.8%). The proportion of trials with clinicians delivering MT were physical therapists (77.9%), chiropractors (10.6%), and osteopaths (2.7%).

DISCUSSION/CONCLUSION

These results reveal incomplete reporting of essential treatment parameters, and a lack of clinician diversity. To foster reproducibility, researchers should report detailed descriptions of MT interventions. Future research should incorporate a variety of MT practitioners to improve generalizability.

Physical therapy students' application of an imaging decision rule for acute knee pain

BACKGROUND

Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students.

OBJECTIVE

The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy.

METHODS

An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool.

RESULTS

Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.

Identifying Conservative Interventions for Individuals with Subacromial Pain Syndrome Prior to Undergoing a Subacromial Decompression: A Scoping Review

Background

Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that SAD provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care "best practice" before undergoing surgery.

Purpose

To describe conservative interventions received by individuals with SAPS prior to undergoing a SAD.

Study Design

Scoping review.

Methods

An electronic search using MEDLINE, CINAHL, PubMed, and Scopus databases was conducted. Peer-reviewed randomized controlled control trials and cohort studies published between January 2000 and February 2022 that included subjects diagnosed with SAPS who progressed to receive a SAD were eligible. Subjects who received previous or concurrent rotator cuff repair with SAPS were excluded. Conservative interventions and treatment details that subjects received prior to undergoing a SAD were extracted.

Results

Forty-seven studies were included after screening 1,426 studies. Thirty-six studies (76.6%) provided physical therapy (PT) services, and six studies (12.8%) included only a home exercise program. Twelve studies (25.5%) specifically detailed the delivered PT services, and 20 studies (42.6%) stated who provided the PT interventions. Subacromial injections (SI) (55.3%, n=26) and non-steroidal anti-inflammatories (NSAIDs) (31.9%, n=15) were the next most frequently delivered interventions. Thirteen studies (27.7%) included combined PT and SI. The duration of conservative care varied from 1.5 months to 16 months.

Conclusion

Conservative care that individuals with SAPS receive to prevent advancement to SAD appears inadequate based on the literature. Interventions, such as PT, SI, and NSAIDs, are either underreported or not offered to individuals with SAP prior to advancing to surgery. Many questions regarding optimal conservative management for SAPS persists.

Level of Evidence

n/a.

Home Exercise Programs Are Infrequently Prescribed in Trials of Supervised Exercise for Individuals With Low Back Pain: A Scoping Review of 292 Randomized Controlled Trials

OBJECTIVES: To (1) determine how often home exercise programs (HEPs) are prescribed in supervised exercise trials for low back pain (LBP) and (2) describe characteristics of the HEP programs (design, purpose, dose, and adherence). DESIGN: Scoping review. LITERATURE SEARCH: PubMed, CINAHL, and Ovid MEDLINE were searched from January 1, 2010, to August 17, 2021. STUDY SELECTION CRITERIA: Randomized controlled trials that included adults with LBP who received exercise interventions. DATA SYNTHESIS: The presence or absence of a prescribed HEP and any details of the HEP including design, dose, and adherence were extracted and summarized. RESULTS: Of 2689 potentially relevant trials, 292 were eligible for inclusion. Ninety-four trials (32%) included a HEP. The most commonly prescribed home exercises were core stability, trunk strengthening, and motor control exercises. There was great variation in the frequency and duration with which HEPs were prescribed. Adherence to HEPs was measured in fewer than half of the trials, and the methods for measuring adherence were inconsistent. Adherence to HEPs ranged from 29% to 82% in the 21 trials that reported adherence. CONCLUSION: Home exercise programs are not regularly prescribed in supervised exercise trials for LBP. There was considerable variation in prescribing HEPs and monitoring exercise adherence in trials of exercise-based treatments for adults with LBP. There is no consistent method used to measure participants' adherence to HEPs, and adherence percentages vary widely. J Orthop Sports Phys Ther 2023;53(3):120-142. Epub: 16 January 2023. doi:10.2519/jospt.2023.11448.

Reproducibility of resistance exercise therapy interventions in trials for chronic low back pain is challenging: A systematic review

OBJECTIVE

Determine reproducibility of resistance exercise regimens in trials for CLBP and determine if recently available checklists are effective.

METHODS

Four databases (Medline, PubMed, Cochrane and CINAHL) were searched for keywords related to back pain and resistance exercise. Reproducibility was assessed using two checklists, the 12-item Template for Intervention Description and Replication (TIDieR) and the 19-item Consensus on Exercise Reporting Template (CERT). The proportion reporting was analysed, with additional comparison of trials pre- and post-availability of each checklist. A generalised linear regression was conducted with checklist items as the dependent variable and year of publication as the independent (PROSPERO ID = #CRD42020186036).

RESULTS

Overall, details that facilitate reproducibility were under-reported. No trials reported all checklist items, while only 18 trials (35.5%) and 5 trials (9.8%) reported 75%+ of checklist items for the TIDieR and CERT, respectively. A median of 8 (IQR 2) of 12 TIDieR criteria were reported and a median of 9 (IQR 7) of 19 criteria were reported for the CERT. There was no difference pre/post checklist publication (TIDieR median before = 8 (IQR 2), after = 8 (IQR 2.25); CERT mean before = 9 (IQR 5.25), after = 9 (IQR 7)). Regression failed to support improved reporting over time. The majority of studies (86.3%) were scored as having an elevated risk of bias.

CONCLUSIONS

Reproducibility of resistance exercise in CLBP trials appears questionable due to low levels of reporting. The publication reporting checklists have not resulted in improvement. Real-world reproducibility is questionable. There is a need to improve reporting to maximise reproducibility.

IMPACT STATEMENT

The present results reveal a demand in improved reporting to ensure both enhanced clinical translation in the real-world and replicability to enhance knowledge of best-practice for resistance exercise in the CLBP population.

What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain?

OBJECTIVE

To investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain.

DESIGN

Retrospective cohort study.

SETTING

Military Health System.

PARTICIPANTS

Individuals (n = 92,319) ages 17-60 diagnosed with patellofemoral pain between 2010-2011.

INTERVENTIONS

Therapeutic exercise.

MAIN OUTCOME MEASURES

Frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan-Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury.

RESULTS

After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76-0.81), hip (HR = 0.93, 95% CI 0.87-0.98) or ankle-foot (HR = 0.86, 95% CI 0.83-0.90) injury.

CONCLUSION

The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.

The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury

PURPOSE

This study aimed to investigate the burden of knee, hip, and lumbar spine disorders occurring in the year after an ankle sprain and the influence therapeutic exercise (TE) has on this burden.

METHODS

A total of 33,361 individuals diagnosed with ankle sprain in the Military Health System between 2010 and 2011 were followed for 1 yr. The prevalence of knee, hip, and lumbar care-seeking injuries sustained after sprain was identified. Relationships between demographic groups, ankle sprain type, and use of TE with rate of proximal injuries were evaluated using Cox proportional hazard models to determine hazard rate effect modification by attribute. The observed effect of TE for ankle sprain on rate of injury to proximal joints was evaluated using Kaplan-Meier survival analyses.

RESULTS

Of the total cohort, 20.5% ( n = 6848) of patients sustained a proximal injury. Specifically, 10.1% of the cohort sustained a knee ( n = 3356), 2.9% a hip ( n = 973), and 10.3% a lumbar injury ( n = 3452). Less than half of the cohort received TE after initial sprain. Patients that did were less likely to have subsequent knee (HR = 0.87, 95% confidence interval [CI] = 0.80-0.94), hip (HR = 0.68, 95% CI = 0.58-0.79), or lumbar (HR = 0.82, 95% CI = 0.76-0.89) injuries.

CONCLUSIONS

One in five individuals that sought care for an ankle sprain experienced a proximal joint injury in the following year. TE for the management of the initial ankle sprain reduced the likelihood of proximal injury diagnosis and should be considered in treatment plans for return to work and sport protocols after ankle sprains.

Exercise therapy reporting in clinical trials for chronic neck pain: A systematic review

OBJECTIVE

The aim of this systematic review was to assess the reproducibility of exercise therapy used in clinical trials for chronic neck pain (CNP) based on reported items from the Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) checklists.

METHODS

Two researchers systematically searched, screened, and selected trials that assessed exercise therapy for CNP between 2000 and 2021 from PubMed, CINAHL, and Ovid Medline. Included studies were published in English, and study participants experienced neck pain for longer than 3 months. Thoroughness of reporting of exercise therapy was assessed using the TIDierR and CERT checklists. Methodological quality of each study was screened with the Revised Cochrane Risk of Bias Tool. Data analysis was performed for descriptive and correlational statistics.

RESULTS

Sixty-three clinical trials using exercise therapy for treatment of CNP met the inclusion criteria. No study reported all TIDieR or CERT items. The mean number of items reported was 5.44 (SD 2.40, range of 1-11) on the TIDieR, and 8.27 (SD 4.14, range of 0-17) for the CERT. Risk of bias was high for 30 studies (47.6%), somewhat concerning for 20 studies (31.7%), and low for 13 studies (21.7%). Higher risk of bias was associated with a lower number of TIDieR and CERT items reported.

DISCUSSION & CONCLUSION

The majority of exercise therapy trials for CNP lack proper reporting, limiting reproducibility of the interventions in real world clinical practice and follow-on research. After checklists were published, reporting did not improve.

The influence of manual therapy dosing on outcomes in patients with hip osteoarthritis: a systematic review

OBJECTIVE

To 1) Determine if specific dosing parameters of manual therapy are related to improved pain, disability, and quality of life outcomes in patients with hip osteoarthritis and 2) to provide recommendations for optimal manual therapy dosing based on our findings.

DESIGN

A systematic review of randomized controlled trials from the PubMed, CINAHL, and OVID databases that used manual therapy interventions to treat hip osteoarthritis was performed. Three reviewers assessed the risk of bias for included studies and extracted relevant outcome data based on predetermined criteria. Baseline and follow-up means and standard deviations for outcome measures were used to calculate effect sizes for within and between-group differences.

RESULTS

Ten studies were included in the final analyses totaling 768 participants, and half were graded as high risk of bias. Trends emerged: 1) large effect sizes were seen using long-axis distraction, mobilization and thrust manipulation, 2) mobilization with movement showed large effects for pain and range of motion, and (3) small effects were associated with graded mobilization. Durations of 10 to 30 minutes per session, and frequency 2-3 times per week for 2-6 weeks were the most common dosing parameters.

CONCLUSIONS

There were varied effect sizes associated with pain, function, and quality of life for both thrust and non-thrust mobilizations, and mobilization with movement into hip flexion and internal rotation. Due to the heterogeneity of MT dosage, it is difficult to recommend a specific manual therapy dosage for those with hip osteoarthritis.

How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury?

Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70-2.79), increasing age (OR 1.03, 95% CI 1.02-1.04), female sex (OR 1.58, 95% CI 1.28-1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03-1.09), female sex (OR 2.73, 95% CI 1.74-4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03-2.89), and active-duty status (OR 2.28, 95% CI 1.38-3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28-0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries.

Prevalence and extent of low back pain and low back-related disability in non-care-seeking working-age adults

OBJECTIVE

To explore the prevalence and extent of low back pain (LBP) and low back-related disability in working-age adults not seeking care.

METHODS

A convenience sample of 101 working-age adults not seeking care for LBP completed the Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMDQ) as measures of disability and completed questionnaires that collected information on various demographic and health-related variables. Those reporting current LBP also completed a Numeric Pain Rating Scale (NPRS). Prevalence was assessed based on a dichotomization of whether any disability or pain was reported and also as a continuous variable to assess the extent of pain and disability present for each participant.

RESULTS

Of the 101 participants, 72.3% reported some level of disability (ODI mean = 7.91%, RMDQ mean = 2.63) and 46.5% reported some level of pain (NRPS mean = 3.68). Previous care-seeking for LBP was associated with increased odds of reporting disability (ODI odds ratio [OR] 7.91, 95% confidence interval [CI], 2.43 to 31.18; RMDQ OR 2.69, 95% CI, 1.05 to 7.24), as was reporting any current LBP (ODI OR 9.45, 95% CI, 3.15 to 33.21; RMDQ OR 7.03, 95% CI, 2.82 to 18.89). No other demographic or health-related variables were associated with the presence or extent of pain or disability.

CONCLUSION

Many non-care-seeking individuals reported some level of LBP and/or disability, suggesting that some level of pain and disability may be considered normal, acceptable, or manageable. One-third of individuals with no pain reported some disability.

A Population-Level Summary of Health Care Utilization for the Management of Patellar Tendinopathy in the Military Health System

Patellar tendinopathy (PT) is a common nontraumatic orthopaedic disorder of the knee suffered by many service members. Understanding the make-up of usual care for PT at the system level can better frame current clinical gaps and areas that need improvement. Exercise therapy is recommended as a core treatment for PT, but it is unclear how often it is used as a part of usual care for PT within the Military Health System (MHS). The purpose of the study was to identify interventions used in the management of PT and the timing of these interventions. A secondary purpose was to determine if exercise therapy use was associated with reduced recurrence of knee pain. In total, 4,719 individuals aged 17 to 50 years in the MHS diagnosed with PT between 2010 and 2011 were included. Pharmacological and nonpharmacological interventions, visits to specialty providers, and imaging services were captured. Descriptive statistics were used to report the findings. Interventions were further categorized as being part of initial care (within the first 7 days), the initial episode of care (within the first 60 days), or the 2-year time period after diagnosis. Linear regression assessed the relationship between the number of exercise therapy visits in the initial episode of care and recurrences of knee pain. In total, 50.6% of this cohort had no more than one medical visit total for PT. Exercise therapy (18.2%) and nonsteroidal anti-inflammatory drugs (4.3%) were the two most used interventions in the initial episode of care. Radiographs were ordered for 23.1% of the cohort in the initial episode of care. The number of exercise therapy visits a patient received during the initial episode of care was not associated with recurrences of knee pain. Half of the individuals received no further care beyond an initial visit for the diagnosis of PT. Exercise therapy was the most common intervention used during the initial episode of care, but exercise therapy did not influence the recurrence of knee pain.

Relationship Between Attitudes and Beliefs About Sleep, Sleep Disturbance, and Pain Interference in Patients With Spinal Pain

OBJECTIVES

Sleep impairments are a strong predictor of pain, making sleep a potential interest when treating patients with spine pain. Typical beliefs about the importance of sleep in patients seeking care for spinal pain are unknown. The purpose of this study was to describe the beliefs and attitudes about sleep in patients seeking care for spinal pain and to examine the relationships between dysfunctional beliefs and attitudes about sleep (DBAS), disordered sleep, and pain interference.

MATERIALS AND METHODS

This cross-sectional study included patients presenting to physical therapy with spine pain. Participants completed questionnaires including demographics, medical history, pain interference (pain, enjoyment, and general activity), DBAS-16, and sleep-related impairment (Patient-Reported Outcome Measurement Information System). Correlations were calculated between DBAS-16 scores and measures of sleep quality/quantity, and a generalized linear model was used to investigate the predictive ability of DBAS-16 scores on pain interference.

RESULTS

The mean DBAS-16 score was 4.22 (SD=2.03), with 52.5% of participants having DBAS. There was a strong relationship between DBAS-16 and Patient-Reported Outcome Measurement Information System ( rs =0.7; P <0.001). For every point higher score on the DBAS-16, pain interference scores increased by approximately half a point (B=0.46; 95% CI 0.33, 0.59, 1.80; P <0.001).

DISCUSSION

These results highlight a strong relationship between beliefs and attitudes about sleep and measures of sleep quality/quantity and a linear association with pain interference scores. These findings provide a rationale for targeting beliefs and attitudes about sleep when managing pain-related symptoms in patients seeking care for spine pain.

What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment

BACKGROUND

Patient expectations related to physical therapy outcomes are commonly collected through surveys and close-ended questionnaires. These methods may not optimally capture patients' expectations for physical therapy, especially in the patients' own words. Louis Gifford identified four questions attempting to guide clinicians' understanding of patients' expectations for physical therapy. However, a qualitative assessment mapping the expectations that patients have prior to starting physical therapy appears to be undocumented.

OBJECTIVES

The aim of this study was to determine patient expectations prior to beginning physical therapy for individuals with musculoskeletal conditions.

DESIGN

Qualitative analysis with structured interviews and open-ended participant responses.

METHODS

Twenty-five people (18 female, 7 male; mean age: 47.04 years) were interviewed prior to their initial physical therapy evaluation using a pragmatic approach rooted in phenomenology. Data were transcribed, coded, and thematized using qualitative data analysis software.

RESULTS

Outcome, education, exercise, evaluation, and cause of pain were key themes expressed by participants. Participants appear to want to better understand their symptoms, how they can improve symptoms, what the clinician will do, and how long they will attend physical therapy. Many participants were not certain where physical therapy fit within their overall healthcare plan, and perceptions of manual therapy were vague.

CONCLUSIONS

These identified themes highlight what patients may expect from a physical therapy experience and clinicians should work to identify and satisfy each patient's individual expectations to optimize outcomes.

An exploration of clinical variables that enhance therapeutic alliance in patients seeking care for musculoskeletal pain: A mixed methods approach

INTRODUCTION/OBJECTIVES

Therapeutic alliance (TA) is an integral part of building a patient and clinician relationship. TA begins at the initial encounter; however, the specific TA behavioural practices that are most impactful and linked to pain reduction and improved function remain unclear. The primary objective of this study was to explore physical therapist behaviours and interactions during the initial physical therapy evaluation and how they related to the patient's perception of TA. A secondary objective was to explore the relationship between TA, pain intensity, and function.

METHODS

A mixed methods study was conducted. Pain intensity, TA and self-reported function were assessed at three time points. Spearman's Rho (ρ) was used to quantify if there was an association between increased TA and function and reduced pain intensity, while a checklist of TA themes and behavioural practices was used for the qualitative analysis.

RESULTS

There was a statistically significant negative correlation between patient-perceived TA and pain intensity immediately after the initial evaluation (ρ = -0.39 [p = 0.048]). Behavioural practices associated with higher TA included information gathering, pausing to listen, using humour and transitions, and use of clarifying questions. Behavioural practices associated with patient-perceived lower TA interactions were lack of touch, the absence of pain neuroscience education, and not restating what the patient said during the interview.

CONCLUSION

This study highlights a relationship between TA and reduction of pain intensity after the initial evaluation and identifies key behavioural practices that could positively and negatively impact TA during the clinical encounter.

More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Opioids Long-term After Spinal Fusion: A Systematic Review

OBJECTIVE

A common expectation for patients after elective spine surgery is that the procedure will result in pain reduction and minimize the need for pain medication. Most studies report changes in pain and function after spine surgery, but few report the extent of opioid use after surgery. This systematic review aims to identify the rates of opioid use after lumbar spine fusion.

MATERIALS AND METHODS

PubMed, CINAHL, Cochrane Central Register of Controlled Trials, and Ovid Medline were searched to identify studies published between January 1, 2005 and June 30, 2020 that assessed the effectiveness of lumbar fusion for the management of low back pain.

RESULTS

Of 6872 abstracts initially identified, 329 studies met the final inclusion criteria, and only 32 (9.7%) reported any postoperative opioid use. Long-term opioid use after surgery persists for more than 1 in 3 patients with usage ranging from 6 to 85.9% and a pooled mean of 35.0% based on data from 21 studies (6.4% of all lumbar fusion studies).

DISCUSSION

Overall, opioid use is not reported in the majority of lumbar fusion trials. Patients may expect a reduced need for opioid-based pain management after surgery, but the limited data available suggests long-term use is common. Lack of consistent reporting of these outcomes limits definitive conclusions regarding the efficacy of spinal fusion for reducing long-term opioid. Patient decisions about undergoing surgery may be altered if they had realistic expectations about rates of postsurgical opioid use. Spine surgery trials should track opioid utilization out to a minimum of 6 months after surgery as a core outcome.

Evidence for the Effectiveness of Feedback from Wearable Inertial Sensors during Work-Related Activities: A Scoping Review

Background: Wearable inertial sensor technology (WIST) systems provide feedback, aiming to modify aberrant postures and movements. The literature on the effects of feedback from WIST during work or work-related activities has not been previously summarised. This review examines the effectiveness of feedback on upper body kinematics during work or work-related activities, along with the wearability and a quantification of the kinematics of the related device. Methods: The Cinahl, Cochrane, Embase, Medline, Scopus, Sportdiscus and Google Scholar databases were searched, including reports from January 2005 to July 2021. The included studies were summarised descriptively and the evidence was assessed. Results: Fourteen included studies demonstrated a 'limited' level of evidence supporting posture and/or movement behaviour improvements using WIST feedback, with no improvements in pain. One study assessed wearability and another two investigated comfort. Studies used tri-axial accelerometers or IMU integration (n = 5 studies). Visual and/or vibrotactile feedback was mostly used. Most studies had a risk of bias, lacked detail for methodological reproducibility and displayed inconsistent reporting of sensor technology, with validation provided only in one study. Thus, we have proposed a minimum 'Technology and Design Checklist' for reporting. Conclusions: Our findings suggest that WIST may improve posture, though not pain; however, the quality of the studies limits the strength of this conclusion. Wearability evaluations are needed for the translation of WIST outcomes. Minimum reporting standards for WIST should be followed to ensure methodological reproducibility.

The relationship between knee radiographs and the timing of physical therapy in individuals with patellofemoral pain

BACKGROUND

Routine knee radiographs are discouraged for individuals with non-traumatic knee pain, but they are often still ordered despite limited evidence for their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs.

OBJECTIVE

To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence.

STUDY DESIGN

Retrospective cohort.

SETTING

United States Military Health System civilian and military clinics.

PATIENTS

23,332 individuals aged 18 to 50 diagnosed with PFP between 2010 and 2011 in the United States Military Health System who received physical therapy.

INTERVENTIONS

Physical therapy provided to individuals who did or did not receive an initial radiograph.

MAIN OUTCOME MEASURES

Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs).

RESULTS

If radiographs were used, the odds of initiating physical therapy (aOR = 0.78; 95% CI 0.64 to 0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1 to 16.1) if patients had radiographs versus 6.9 (95% CI 5.2 to 9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR = 1.01; 95% CI 0.83 to 1.22).

CONCLUSIONS

Receiving knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment. This article is protected by copyright. All rights reserved.

Preferences of Physical Therapy Students Regarding Digital and Printed Textbooks

AIMS

Research has shown mixed results regarding students' preferences of digital over printed textbooks. However, none of the published studies have studied physical therapy students and few have surveyed students across more than one professional program. The purpose of this study was to identify the perceptions and use of digital textbooks and printed textbooks by students in four different physical therapy programs.

METHODS

We surveyed first-, second-, and third-year physical therapist students from four physical therapy programs in different regions of the United States. Descriptive statistics were used to report the students' responses. Chi square tests of independence were used for all comparisons between genders and years in the program with a=0.05.

RESULTS

More students had purchased or leased printed textbooks than digital textbooks. Students preferred digital textbooks for portability, cost, and search ability. Students preferred printed textbooks for studying and preparing for examinations. Printed textbooks were preferred for readability, comprehension, retention, and studying and were less tiring on the eyes. Males preferred digital textbooks and females preferred printed textbooks. Students in Years 2 and 3 of the programs preferred digital textbooks, and students in Year 1 preferred printed textbooks for some features.

CONCLUSION

Students preferred digital textbooks for convenience factors and printed textbooks for learning.

Posture of rugby league players and its relationship to non-contact lower limb injury: A prospective cohort study

OBJECTIVE

This study aimed to identify posture deviations in rugby league players, and to observe relationships between posture and the incidence of non-contact lower limb injury.

DESIGN

Prospective cohort.

SETTING

Laboratory and on-field.

PARTICIPANTS

Junior representative, semi-professional and professional rugby league players (n = 207).

MAIN OUTCOME MEASURES

Static posture scores from photographs (Watson and MacDonncha tool) in pre-season; non-contact lower limb injury surveillance and exposure data.

METHODS

Chi-square and logistic regression analyses were used to observe relationships between postural components and the incidence of non-contact lower limb injury.

RESULTS

8.7% of players sustained a quadriceps injury; 7.2% sustained a calf injury. Semi-professional and professional players had the highest injury rates. The most common posture deviations were having a forward shoulder position (46.9%), a forward head position (33.3%), a varus knee interspace (32.9%) or a lumbar lordosis (30.9%). A moderate C-scoliosis deviation was associated with a decrease in injury risk (OR 1.57 95% CI 1.00-2.46 p = 0.052). Included in the model was player weight, which was associated with an increased risk of injury (OR 1.04 95% CI 1.01-1.07 p = 0.010).

CONCLUSIONS

Although postural deviations are common in rugby league players, given the lack of association with injury, they may not warrant intervention.

Leveraging healthcare utilization to explore outcomes from musculoskeletal disorders: methodology for defining relevant variables from a health services data repository

Background

Large healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research.

Methods

The Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided.

Results

Although some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions.

Conclusion

The MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.

The influence of dosing on effect size of exercise therapy for musculoskeletal foot and ankle disorders: a systematic review

OBJECTIVE

The purpose of this review was to identify doses of exercise therapy associated with greater treatment effect sizes in individuals with common musculoskeletal disorders of the foot and ankle, namely, achilles tendinopathy, ankle sprains and plantar heel pain.

METHODS

AMED, EMBASE and MEDLINE were searched from 2005 to August 2017 for randomized controlled trials related to exercise for these three diagnoses. The Physiotherapy Evidence Database scale was used for methodological quality assessment. Exercise dosing variables and outcome measures related to pain and function were extracted from the studies, and standardized mean differences were calculated for the exercise groups.

RESULTS

Fourteen studies met the final inclusion. A majority of the studies showed large effects and two small trends were identified. Patients with plantar heel pain may benefit more from a daily home exercise program than two supervised visits per week (SMD=3.82), but this recommendation is based on weak evidence. In achilles tendinopathy, a relationship was also seen when sets and repetitions of eccentric exercise were performed as tolerated (SMD=1.08 for function, -1.29 for pain).

CONCLUSIONS

Session duration, frequency, total number of visits, and overall length of care may all be dosing variables with limited value for determining effective exercise prescription. However, the limited number of studies prevents any definitive conclusions. Further investigation is warranted to improve our understanding of the influence exercise dosing has on treatment effect sizes. Future randomized controlled trials comparing specific exercise dose variables should be conducted to clarify the impact of these variables.

Sunlight exposure increases vitamin D sufficiency in growing pigs fed a diet formulated to exceed requirements

Traditional confinement practices limit exposure to sunlight and vitamin D synthesis, and vitamin insufficiency occurs even with dietary supplementation. The aim of this study was to determine the effect of limited sun exposure on serum concentration of vitamin D and the expression of vitamin D synthesizing enzymes in the liver and kidney of pigs on a vitamin D sufficient diet. White-pigmented grower pigs (29.7 ± 2.3 kg) fed 15% CP diet ad libitum providing >1,200 IU vitamin D₃/kg of feed were exposed to sunlight for 1 h each day at solar noon for 14 d at the spring equinox (March pigs, n = 10) or summer solstice (June pigs, n = 5) and again before slaughter in June (March pigs) and September (June pigs). Blood for the analysis of 25(OH)D was collected before and after sunlight exposure. Traditionally housed pigs served as controls. After initial sun exposure, blood samples were collected from June pigs daily for 5 d and weekly for 8 wk to determine vitamin D3 and 25(OH)D decay, respectively. Kidney and liver samples were collected from the June pigs at slaughter after sun exposure for analysis of messenger RNA expression of vitamin D binding protein and synthesizing/degrading enzymes. Average daily gain (ADG) was not influenced (P > 0.5) by sunlight exposure. June pigs had fewer days on feed, lower (P = 0.003) ADG and were slaughtered at a lighter (P < 0.001) weight. Exposure to sunlight increased (P < 0.001) 25(OH) vitamin D for all pigs. March pigs, obtained from a Midwest producer, had lower (P < 0.001) concentration of 25(OH)D than June pigs born on-farm. Initial sunlight exposure increased serum concentration of 25(OH)D in March pigs by 200% and June pigs by 67%. Serum concentration of vitamin D3 was decreased (P < 0.05) by 72 h with 25(OH)D decreased (P < 0.05) by wk 4 after exposure. Expression of vitamin D binding protein, vitamin D synthesizing CYP2R1, CYP27A1, CYP2D25, or degrading enzyme CYP24A1 were not influenced (P ≥ 0.19) by sunlight exposure. Expression of CYP27B1 was decreased (P = 0.04) in the kidney but tended to be increased (P = 0.06) in the liver after sun exposure. These results suggest limited sun exposure can efficiently increase serum concentration of vitamin D in growing pigs with varying levels of vitamin sufficiency. The lack of major changes in vitamin synthesizing enzymes suggests the 14-d exposure period did not saturate the capacity of slaughter-weight pigs to synthesize vitamin D.