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Rhon DI, George SZ, Greenlee TA, Farrokhi S, Lentz TA. General and Pain-Associated Psychological Distress Phenotypes Among Patients With Low Back Pain in the Military Health System. Arthritis Care Res (Hoboken) 2024; 76:943-952. [PMID: 38383982 DOI: 10.1002/acr.25315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/17/2024] [Accepted: 02/20/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE The primary objective was to describe rates of general and pain-related psychological distress for individuals with low back pain (LBP) in the Military Health System (MHS). We identified common phenotypes defined by rates of general and pain-related psychological distress and compared phenotypes on their level of pain interference, physical function, anxiety, and depression. METHODS We created a cohort from two completed trials assessing nonpharmacological treatment for LBP in the MHS (n = 510 total). The Optimal Screening for Prediction of Referral and Outcome Yellow Flag assessment tool identified the presence of 11 different yellow flags. Latent class analysis (LCA) used yellow flag indicators to identify common psychological phenotypes. We then compared Patient-Reported Outcomes Measurement Information Systems measures of pain interference, physical function, sleep disturbance, depression, and anxiety across phenotypes. RESULTS LCA identified five phenotypes (percentage of the sample): low distress (32%), high distress (27%), poor pain coping and low self-efficacy (18%), low self-efficacy and acceptance (14%), and poor pain coping (10%). Highly distressed phenotypes reported higher levels of pain interference, sleep disturbance, depression, and anxiety than those with other phenotypes, whereas the low distress phenotype had significantly lower pain interference and higher physical function scores than those characterized by all other phenotypes. CONCLUSION These phenotypes provide opportunities for clinicians and researchers to develop novel LBP treatment pathways tailored to patients with different profiles of psychological distress. Future work is needed to validate their predictive capabilities for clinical outcomes.
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Affiliation(s)
- Daniel I Rhon
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, Uniformed Services University, Bethesda, Maryland, and The Geneva Foundation, Tacoma, Washington
| | | | - Tina A Greenlee
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, Uniformed Services University, Bethesda, Maryland, and The Geneva Foundation, Tacoma, Washington
| | - Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, San Diego, California
| | - Trevor A Lentz
- Duke Clinical Research Institute, Durham, North Carolina
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Tan BY. CORR Insights®: What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis? Clin Orthop Relat Res 2024; 482:645-647. [PMID: 38416421 PMCID: PMC10936974 DOI: 10.1097/corr.0000000000003023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Bryan Yijia Tan
- Department of Orthopedic Surgery, Woodlands Health, National Healthcare Group, Singapore , Singapore
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Jayakumar P, Crijns TJ, Misciagna W, Manickas-Hill O, Malay M, Jiranek W, Mather RC, Lentz TA. What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis? Clin Orthop Relat Res 2024; 482:633-644. [PMID: 38393957 PMCID: PMC10937005 DOI: 10.1097/corr.0000000000003003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 01/11/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care. QUESTIONS/PURPOSES (1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors? METHODS We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores. RESULTS Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated. CONCLUSION This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Prakash Jayakumar
- The Musculoskeletal Institute, The University of Texas at Austin, Dell Medical School, Austin, TX, USA
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Tom J. Crijns
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Will Misciagna
- The Musculoskeletal Institute, The University of Texas at Austin, Dell Medical School, Austin, TX, USA
| | - Olivia Manickas-Hill
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Morven Malay
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Department of Physical Therapy and Occupational Therapy, Duke University, Durham, NC, USA
| | - William Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Richard C. Mather
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Trevor A. Lentz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Burke C, Fillipo R, George SZ, Goode AP. Transition from Acute to Chronic Low Back Pain in a Community-Based Cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.19.24304350. [PMID: 38562827 PMCID: PMC10984070 DOI: 10.1101/2024.03.19.24304350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The transition from acute to chronic low back pain (LBP) in community settings has yet to be well understood. We recruited n=131 participants with acute LBP from the community and followed them for 3 and 6-month outcomes. Acute LBP was defined by a duration of < 4 weeks, and participants must have reported a 30-day LBP-free period before the current acute episode. Chronic LBP was defined as pain most or every day over the past 3 months. Baseline psychological, social, and demographic factors were examined as predictors of transition to chronic LBP at 3 months or continuation of chronic LBP at 6 months. The transition from acute to chronic LBP at 3 months was 32.2% ( 38/118). At 6 months, 80.7% (25/111) of participants who transitioned at 3 months continued to have chronic LBP. At 6 months, participants who identified as Black or African American were more likely than white participants to transition to chronic LBP (RR=1.76, 95% CI 1.05, 2.95) and more likely to continue to have chronic LBP (RR=2.19, 95% CI 1.14, 4.21). Those classified at baseline by both LBP most or every day and intensity of at least 30/100 were more likely to transition to chronic LBP (RR=3.13, 95% CI 1.84, 5.30) and continue to have chronic LBP at 6 months (RR=2.58, 95% CI 1.43, 4.16). The STarT Back Screening Tool and the OSPRO-YF were associated with the transition to chronic LBP at 3 months and continuation at 6 months. Participants with higher PROMIS General Health and PROMIS Physical Health scores were less likely to transition to chronic LBP or continue to have chronic LBP at 6 months. These findings identify factors of acute LBP in the community that may predict the transition to chronic LBP. Larger studies are needed to confirm these findings and better understand the mechanisms driving the transition to chronic LBP.
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George SZ, Horn ME. Acute Intermittent Hypoxia Did Not Alter Pain Sensitivity or Pain Intensity Ratings for Individuals with Chronic Low Back Pain: A Pilot Study. J Pain Res 2024; 17:421-429. [PMID: 38328018 PMCID: PMC10848823 DOI: 10.2147/jpr.s433685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
Aims and Objective The purpose of this pilot study was to explore whether AIH produces changes in pain sensitivity or in reports of self-reported pain intensity for individuals with low back pain. Methods In a quasi-experimental, cross-over design we compared participants (n = 9) exposed to normal room air and hypoxia using a commercially available gas blender. The treatment period consisted of 5 consecutive days of randomly assigned to AIH or room air. For the participants initially randomized to AIH there was cross-over to receive 5 more consecutive days of room air. Therefore, this design allowed for between group and within subject assessment of AIH effects. Pain sensitivity was assessed with quantitative sensory testing (QST) for posterior superior iliac spine pressure threshold, plantar thermal threshold, and peak pain ratings. Self-reported pain intensity for low back pain was assessed via the Brief Pain Inventory. Results There were no between group differences for AIH and room air in pain sensitivity or self-reported pain intensity. In the within subject analyses larger effect sizes favoring AIH were detected for plantar measures of pain sensitivity but not for self-reported pain intensity. Conclusion This study, while presenting null findings, describes an initial step in determining whether AIH can be used to increase pain relief. Based on this pilot study we offer guidance for future research including study design, AIH dosage, participant selection, and using AIH in combination with non-pharmacologic treatments.
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Affiliation(s)
- Steven Z George
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Departments of Orthopaedic Surgery and Population Health Science, Duke University, Durham, NC, USA
| | - Maggie E Horn
- Departments of Orthopaedic Surgery and Population Health Science, Duke University, Durham, NC, USA
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Cook CE, O’Halloran B, McDevitt A, Keefe FJ. Specific and shared mechanisms associated with treatment for chronic neck pain: study protocol for the SS-MECH trial. J Man Manip Ther 2024; 32:85-95. [PMID: 37819161 PMCID: PMC10795632 DOI: 10.1080/10669817.2023.2267391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Treatment mechanisms involve the steps or processes through which an intervention unfolds and produces change in an outcome variable. Treatment mechanisms can be specific to the intervention provided (i.e. pain modulation) or shared with other treatments (i.e. reduced fear of movement). Whether specific and shared treatment mechanisms are different across interventions and whether they lead to the outcomes seen in trials is largely unknown. The management of individuals with chronic neck pain routinely include manual therapy (MT) and resistance exercise (RE), as both approaches are included in clinical practice guidelines and both yield similar outcomes. OBJECTIVES Our study plans to answer two research questions: 1) what are the specific mechanisms associated with MT versus interventions (and are these different), and 2) what are the shared mechanisms associated with these interventions, and do specific or shared mechanisms mediate clinical outcomes? METHODS This study will involve a 2-group parallel (1:1) single-blinded randomized trial to compare the specific and potential shared treatment mechanisms between these two approaches. We will enroll individuals with a history of chronic neck pain and evaluate whether specific or shared mechanisms mediate clinical outcomes. RESULTS We hypothesize that MT and RE approaches will both exhibit different specific treatment mechanisms, and that both approaches will exhibit shared treatment mechanisms, which will notably influence outcomes at both discharge and 6-months. CONCLUSIONS This study is important because it will help identify what specific or shared treatment mechanisms are associated with different interventions and, how different treatment mechanisms influence clinical outcomes.
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Affiliation(s)
- Chad E. Cook
- Department of Physical Therapy, School of Health Professions, Saint Joseph’s University, Philadelphia, PA, USA
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
- Duke Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Bryan O’Halloran
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Amy McDevitt
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Francis J. Keefe
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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McGrath RL, Shephard S, Parnell T, Verdon S, Pope R. Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review. Physiother Theory Pract 2023:1-31. [PMID: 38009858 DOI: 10.1080/09593985.2023.2284823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/05/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope. OBJECTIVE To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress. METHODS A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically. RESULTS 3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management. CONCLUSION While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.
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Affiliation(s)
- Ryan L McGrath
- Department of Rural Health, University of Melbourne, Shepparton, Australia
- School of Allied Health, Exercise and Sports Sciences, Charles Sturt University, Albury, Australia
- Allied Health Education and Research Unit, Goulburn Valley Health, Shepparton, Australia
| | - Sophie Shephard
- School of Allied Health, Exercise and Sports Sciences, Charles Sturt University, Albury, Australia
| | - Tracey Parnell
- Department of Rural Health, University of Melbourne, Shepparton, Australia
| | - Sarah Verdon
- Department of Rural Health, University of Melbourne, Shepparton, Australia
| | - Rodney Pope
- Department of Rural Health, University of Melbourne, Shepparton, Australia
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Leech JB, MacPherson KL, Klopper M, Shumway J, Salvatori RT, Rhon DI, Young JL. The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study. PM R 2023; 15:1371-1381. [PMID: 37041723 DOI: 10.1002/pmrj.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice. OBJECTIVE To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge. DESIGN Retrospective cohort study. SETTING Hospital-based outpatient physical therapy. PARTICIPANTS Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis. MAIN OUTCOME MEASURES Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge. RESULTS A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region. CONCLUSION These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.
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Affiliation(s)
- Joseph B Leech
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- The University of St. Augustine for Health Sciences, College of Rehabilitative Sciences, Doctor of Physical Therapy Program, Austin, Texas, USA
| | - Kevin L MacPherson
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- South College, School of Physical Therapy, Doctor of Physical Therapy Program, Atlanta, Georgia, USA
| | - Mareli Klopper
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Joshua Shumway
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Robert T Salvatori
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- The University of St. Augustine for Health Sciences, College of Rehabilitative Sciences, Doctor of Physical Therapy Program, Austin, Texas, USA
| | - Daniel I Rhon
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Jodi L Young
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
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Taylor KA, Burke C, George SZ, Danyluk S, Kingsbury CA, Kapos FP, Seebeck K, Lewis CE, Ford E, Plez C, Kosinski A, Filippo R, Brown M, Goode AP. Characterizing Acute Low Back Pain in a Community-Based Cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.02.23296149. [PMID: 37873225 PMCID: PMC10592986 DOI: 10.1101/2023.10.02.23296149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Acute low back pain (LBP) is a common experience, however, the associated pain severity, pain frequency, and characteristics of individuals with acute LBP in community settings have yet to be well understood. The purpose of this manuscript is to categorize and compare acute LBP groups for differences in the following characteristics: 1) sociodemographic, 2) general and physical health, and 3) psychological. This cross-sectional study used baseline data from 131 community-based participants with acute LBP (<4 weeks duration before screening and > 30 pain-free days before acute LBP onset). Two LBP categorization definitions were used based on LBP frequency combined with either: 1) pain interference frequency (impact-based) or 2) pain intensity (intensity-based). Descriptive associations were calculated as prevalence ratios for categorical variables and Hedges' g for continuous variables. Our analyses identified several large associations for impact-based and intensity-based categories for pain interference with activity and with enjoyment in life, global mental health, STarT Back Screening Tool risk category, general health, and Fear Avoidance Beliefs Questionnaire-Physical Activity subscale. Larger associations were found with social constructs (racially and ethnically minoritized, performance of social roles, and isolation) when using the intensity-based versus impact-based categorization. This study adds to the literature by providing standard ways to characterize community-based individuals experiencing acute LBP. The robust differences observed between these categorization approaches suggest they may be used to improve the early identification of factors potentially contributing to the development of chronic LBP.
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Ramirez MM, Shepherd MH, Melnick SJ, Hanebuth C, Bazemore C, Couce L, Hendren S, Horn ME. Patient-reported outcome measures in physical therapy practice for neck pain: an overview of reviews. J Patient Rep Outcomes 2023; 7:97. [PMID: 37782344 PMCID: PMC10545655 DOI: 10.1186/s41687-023-00637-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy. METHODS An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2. RESULTS Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies). CONCLUSION This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.
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Affiliation(s)
- Michelle M Ramirez
- Department of Population Health Sciences, Department of Orthopaedic Surgery, Duke University School of Medicine, 215 Morris Street, Suite 200, Durham, NC, 27708, USA.
| | - Mark H Shepherd
- Department of Physical Therapy, Bellin College, 3201 Eaton Rd, Greenbay, WI, 54311, USA
| | - S Jacob Melnick
- Doctor of Physical Therapy Program, Hawai'i Pacific University, 500 Ala Moana Blvd, Honolulu, HI, 96813, USA
| | - Cannon Hanebuth
- Division of Physical Therapy, Duke University School of Medicine, DUMC Box 104002, Durham, NC, 27710, USA
| | - Caroline Bazemore
- Division of Physical Therapy, Duke University School of Medicine, DUMC Box 104002, Durham, NC, 27710, USA
| | - Logan Couce
- Sugar House Health Center, University of Utah, 1280 E. Stringham Ave, Salt Lake City, UT, 84106, USA
| | - Steph Hendren
- Research & Education Librarian, Duke University Medical Center Library & Archives, Seeley G. Mudd Bldg., 103, Durham, NC, 27710, USA
| | - Maggie E Horn
- Department of Orthopaedic Surgery, Division of Physical Therapy, Department of Population Health Sciences, Duke University School of Medicine, DUMC Box 104002, Durham, NC, 27710, USA
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Siverling S, Schultz P. A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist's Perspective. Curr Pain Headache Rep 2023; 27:329-337. [PMID: 37515744 DOI: 10.1007/s11916-023-01140-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE OF REVIEW Migraine is common and interventions to treat or manage it vary. Physical therapists possess a varied skill set that can assess and treat limitations related to migraine and its symptoms. Conservative and non-pharmacological examination and treatment techniques for migraine and headache management are reviewed in terms of efficacy and relevance in order to describe the physical therapist's abilities and clinical reasoning process when confronting a patient with migraine symptoms. RECENT FINDINGS A thorough examination is necessary to detect red flags and will reveal a person with migraine's biopsychosocial limitations to manage their symptoms. Strength, endurance, cervical mobility, and visual deficits are common in those reporting headaches and examination techniques, along with patient-reported outcome measures, can elicit objective data for re-assessment during an episode of care. Exercise interventions, manual therapy, biofeedback techniques, and vestibular therapy have become viable and efficacious non-pharmacological interventions in recent years to assist the patient with managing and mitigating their migraine symptoms, along with mindfulness-based exercises. A case study, with individualized treatment approaches based on examination findings, current evidence, and accrued expertise, demonstrates the clinical applicability of a physical therapist's multimodal approach to treating migraine. Psychologically- informed physical therapy with mindfulness-based approaches and biofeedback can help a patient gain more control over their symptoms and their body's response to head pain, while exercise and vestibular therapy can assist the system with recovery and adaptation from deficits related to migraine symptoms. A thorough examination, with an individually- tailored rehabilitation plan incorporating movement and mindfulness-based therapies, is recommended.
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Affiliation(s)
- Scott Siverling
- Clinical Lead, Hospital for Special Surgery, 535 E. 70th Street, NY, 10021, New York City, USA.
- Adjunct Faculty, Tufts University School of Medicine Doctor of Physical Therapy Program, 136 Harrison Avenue, Boston, MA, 02111, USA.
- Adjunct Instructor, Rutgers School of Health Professions Doctor of Physical Therapy Program, 65 Bergen St Ste 120, Newark, NJ, 07107, USA.
| | - Peter Schultz
- Clinical Lead, Hospital for Special Surgery, 535 E. 70th Street, NY, 10021, New York City, USA
- Physical Therapist/Owner, Dynamic Sports PT, 6 E 39th St Ste 504, NY, 10016, New York City, USA
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12
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Morriss NJ, Kim BI, Poehlein E, Park CN, Lentz TA, Green CL, Lau BC. Association Between Preoperative Multidimensional Psychological Distress and Physical Function After Surgery for Sports-Related Injury. Orthop J Sports Med 2023; 11:23259671231163854. [PMID: 37113137 PMCID: PMC10126611 DOI: 10.1177/23259671231163854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/27/2023] [Indexed: 04/29/2023] Open
Abstract
Background Psychological distress after orthopaedic surgery can lead to worse outcomes, including higher levels of disability and pain and lower quality of life. The 10-item Optimal Screening for Prediction for Referral and Outcome-Yellow Flag (OSPRO-YF) survey screens for multiple psychological constructs relevant to recovery from orthopaedic injury and may be useful to preoperatively identify patients who may require further psychological assessment and possible intervention after surgery. Purpose/Hypothesis To determine the association between the OSPRO-YF and physiological patient-reported outcomes (PROs). It was hypothesized that higher OSPRO-YF scores (indicating worse psychological distress) would be associated with worse PRO scores at time of return to sport. Study Design Case series; Level of evidence, 4. Methods This study evaluated 107 patients at a single, academic health center who were assessed at a sports orthopaedics clinic and ultimately treated surgically for injuries to the knee, shoulder, foot, or ankle. Preoperatively, patients completed the OSPRO-YF survey as well as the following PRO measures: Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, numeric rating scale for pain; American Shoulder and Elbow Surgeons standardized shoulder assessment form for patients with shoulder injuries, the International Knee Documentation Committee score (for patients with knee injuries), and the Foot and Ankle Ability Measure (FAAM; for patients with foot or ankle injuries). At the time of anticipated full recovery and/or return to sport, patients again completed the same PRO surveys. Multivariable regression was used to evaluate the association between total OSPRO-YF score at baseline and PRO scores at the time of functional recovery. Results The baseline OSPRO-YF score predicted postoperative PROMIS Physical Function and FAAM Sports scores only. A 1-unit increase in the OSPRO-YF was associated with a 0.55-point reduction in PROMIS Physical Function (95% CI, -1.05 to -0.04; P = .033) indicating worse outcomes. Among patients who underwent ankle surgery, a 1-unit increase in OSPRO-YF was associated with a 6.45-point reduction in FAAM Sports (95% CI, -12.0 to -0.87; P = .023). Conclusion The study findings demonstrated that the OSPRO-YF survey predicts certain long-term PRO scores at the time of expected return to sport, independent of baseline scores.
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Affiliation(s)
- Nicholas J. Morriss
- Duke University School of Medicine,
Durham, North Carolina, USA
- Nicholas J. Morriss, BA,
Duke University School of Medicine, Duke University Medical Center, 200 Trent
Drive, Durham, NC 27710, USA (
)
| | - Billy I. Kim
- Duke University School of Medicine,
Durham, North Carolina, USA
| | - Emily Poehlein
- Department of Biostatistics and
Bioinformatics, Duke University School of Medicine Durham, North Carolina,
USA
| | - Caroline N. Park
- Department of Orthopaedic Surgery, Duke
University School of Medicine, Durham, North Carolina, USA
| | - Trevor A. Lentz
- Department of Orthopaedic Surgery, Duke
University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke
University, Durham, North Carolina, USA
| | - Cynthia L. Green
- Department of Biostatistics and
Bioinformatics, Duke University School of Medicine Durham, North Carolina,
USA
- Duke Clinical Research Institute, Duke
University, Durham, North Carolina, USA
| | - Brian C. Lau
- Department of Orthopaedic Surgery, Duke
University School of Medicine, Durham, North Carolina, USA
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Russek LN, Block NP, Byrne E, Chalela S, Chan C, Comerford M, Frost N, Hennessey S, McCarthy A, Nicholson LL, Parry J, Simmonds J, Stott PJ, Thomas L, Treleaven J, Wagner W, Hakim A. Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations. Front Med (Lausanne) 2023; 9:1072764. [PMID: 36743665 PMCID: PMC9893781 DOI: 10.3389/fmed.2022.1072764] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/29/2022] [Indexed: 01/19/2023] Open
Abstract
Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.
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Affiliation(s)
- Leslie N. Russek
- Department of Physical Therapy, Clarkson University, Potsdam, NY, United States,St. Lawrence Health System, Potsdam, NY, United States,*Correspondence: Leslie N. Russek,
| | - Nancy P. Block
- Advanced Therapy Programs PT, San Jose, CA, United States
| | - Elaine Byrne
- Central Health Physiotherapy, London, United Kingdom
| | - Susan Chalela
- The Chalela Physical Therapy Institute for EDS/CCI, Charleston, SC, United States
| | - Cliffton Chan
- Department of Health Sciences, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Mark Comerford
- Performance Rehab, Brisbane, QLD, Australia,Comera Movement Science, Bristol, United Kingdom
| | | | | | - Ann McCarthy
- Central Health Physiotherapy, London, United Kingdom
| | - Leslie L. Nicholson
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jason Parry
- Central Health Physiotherapy, London, United Kingdom,University College London Hospital Trust, London, United Kingdom
| | - Jane Simmonds
- Central Health Physiotherapy, London, United Kingdom,Faculty of Population Health Sciences, University College London, London, United Kingdom
| | | | - Lucy Thomas
- Neck and Head Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Julia Treleaven
- Performance Rehab, Brisbane, QLD, Australia,Neck and Head Research Unit, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia
| | | | - Alan Hakim
- University College London Hospital Trust, London, United Kingdom,The Ehlers-Danlos Society, London, United Kingdom
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Four Variables Were Sufficient for Low Back Pain: Determining Which Patient-Reported Tools Pain and Disability Improvements. J Orthop Sports Phys Ther 2022; 52:685-693. [PMID: 35960508 DOI: 10.2519/jospt.2022.11018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE: To predict 30- and 180-day improvements in disability and pain for patients seeking physical therapy care for low back pain (LBP). DESIGN: Longitudinal cohort. METHODS: Baseline assessment was completed by 259 patients with chief complaint of LBP, and the assessment includes psychosocial measures (Keele STarT Back Screening [SBST] and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag [OSPRO-YF] tools), the Optimal Screening for Prediction of Referral and Outcome Review of Symptoms (OSPRO-ROS) and the Review of Symptoms Plus (OSPRO-ROS+) tools, the Charlson Comorbidity Index (CCI), the Area Deprivation Index (ADI), and the National Institute of Health Chronic Pain Criteria (NIH-CP). Using the Modified Low Back Disability Questionnaire (MDQ) and the Numeric Pain Rating Scale (NPRS) as primary outcomes, statistical analysis determined multiple sets of predictor variables with similar model performance. RESULTS: The parsimonious "best model" for prediction of the 180-day MDQ change included 3 predictors (Admit MDQ, NIH-CP, and OSPRO ROS+) because it had the lowest penalized goodness-of-fit statistic (BIC = -35.21) and the highest explained variance (R2 = 0.295). The parsimonious "best model" for 180-day NPRS change included 2 variables (Admit NPRS and OSPRO-ROS+) with the lowest penalized goodness-of-fit statistic (BIC = -18.2) and the highest explained variance (R2 = 0.190). CONCLUSION: There were many model options with similar statistical performance when using established measures to predict MDQ and NPRS outcomes. A potential variable set for a standard predictive model that balances statistical performance with pragmatic considerations included the OSPRO-ROS+, OSPRO-YF, NIH-CP definition, and admit MDQ and NPRS scores. J Orthop Sports Phys Ther 2022;52(10):685-693. Epub: 12 August 2022. doi:10.2519/jospt.2022.11018.
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15
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Willingness to use nonpharmacologic treatments for musculoskeletal pain in the emergency department: a cross-sectional study. Pain Rep 2022; 7:e1027. [PMID: 35999902 PMCID: PMC9387978 DOI: 10.1097/pr9.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/06/2022] [Accepted: 06/25/2022] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Patients in emergency department with musculoskeletal pain report high willingness to try nonpharmacologic treatments, and health care provider encouragement correlated with greater nonpharmacologic treatment use. Objectives: Pain is an individual experience that should incorporate patient-centered care. This study seeks to incorporate patient perspectives toward expanding nonpharmacologic treatment options for pain from the emergency department (ED). Methods: In this cross-sectional study of adult patients in ED with musculoskeletal neck, back, or extremity pain, patient-reported outcomes were collected including willingness to try and prior use of various nonpharmacologic pain treatments, sociodemographics, clinical characteristics, functional outcomes, psychological distress, and nonmusculoskeletal symptoms. Least absolute shrinkage and selection operator regression identified variables associated with (1) willingness to try and (2) having previously tried nonpharmacologic treatments. Results: Responses were analyzed from 206 adults, with a mean age of 45.4 (SD 16.4) years. The majority (90.3%) of patients in ED were willing to try at least one form of nonpharmacologic pain treatment, with 70.4%, 81.6%, and 70.9% willing to try respective subcategories of active (eg, exercise), passive (eg, heat), and psychosocial (eg, prayer) modalities. Only 56.3% of patients had previously tried any, with 35.0%, 52.4%, and 41.3% having tried active, passive, and psychosocial modalities, respectively. Patient-level factors associated with willingness included pain in upper back, more severe pain-related symptoms, and functional impairments. The factor most consistently associated with treatment use was health care provider encouragement to do so. Conclusions: Patients in ED report high willingness to try nonpharmacologic treatments for pain. Higher pain severity and interference may indicate greater willingness, while health care provider encouragement correlated with treatment use. These findings may inform future strategies to increase the introduction of nonpharmacologic treatments from the ED.
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16
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van Bijsterveld SC, Barten JA, Molenaar EALM, Bleijenberg N, de Wit NJ, Veenhof C. Psychometric evaluation of the Decision Support Tool for Functional Independence in community-dwelling older people. JOURNAL OF POPULATION AGEING 2022; 16:1-23. [PMID: 35368880 PMCID: PMC8960690 DOI: 10.1007/s12062-022-09361-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/11/2022] [Indexed: 11/06/2022]
Abstract
Background The aging population is increasingly faced with daily life limitations, threatening their Functional Independence (FI). These limitations extend different life domains and require a broad range of community-care professionals to be addressed. The Decision Support Tool for Functional Independence (DST-FI) facilitates community-care professionals in providing uncontradictory recommendations regarding the maintenance of FI in community-dwelling older people. The current study aims to determine the validity and reliability of the DST-FI. Methods Sixty community-care professionals completed a twofold assessment. To assess construct validity, participants were asked to assign predefined recommendations to fifty cases of older people to maintain their level of FI. Hypotheses were tested regarding the expected recommendations per case. Content validity was assessed by questions on relevance, comprehensiveness, and comprehensibility of the current set of recommendations. Twelve participants repeated the assessment after two weeks to enable both within- and between rater reliability properties, expressed by an Intraclass Correlation Coefficient. Results Seven out of eight predefined hypotheses confirmed expectations, indicating high construct validity. As the recommendations were indicated 'relevant' and 'complete', content validity was high as well. Agreement between raters was poor to moderate while agreement within raters was moderate to excellent, resulting in moderate overall reliability. CONCLUSION The DST-FI suggests high validity and moderate reliability properties when used in a population of community-dwelling older people. The tool could facilitate community-care professionals in their task to preserve FI in older people. Future research should focus on psychometric properties like feasibility, acceptability, and developing and piloting strategies for implementation in community-care.
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Affiliation(s)
- S. C. van Bijsterveld
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - J. A. Barten
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, The Netherlands
| | - E. A. L. M. Molenaar
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, The Netherlands
| | - N. Bleijenberg
- Julius Center for Health Sciences and Primary Care, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
- Research Group Proactive Care in Older People, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, The Netherlands
| | - N. J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - C. Veenhof
- Department of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Research Group Innovation of Human Movement Care, Research Centre for Healthy and Sustainable Living, Utrecht University of Applied Sciences, Utrecht, The Netherlands
- Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht, The Netherlands
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Maschke B, Palmsten A, Nelson EO, Obermeier MC, Reams M, Heiderscheit B, Russell H, Chmielewski TL. Injury-related psychological distress and the association with perceived running ability in injured runners. Phys Ther Sport 2022; 54:36-43. [PMID: 34999561 PMCID: PMC8872088 DOI: 10.1016/j.ptsp.2021.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Examine injury-related psychological distress and association with perceived running ability in injured runners. DESIGN Prospective longitudinal study. PARTICIPANTS Forty-three patients with a running-related injury. MAIN OUTCOME MEASURES Data collection at initial physical therapy visit and 12-16 weeks later included Optimal Screening for Prediction of Referral and Outcome - Yellow Flag (OSPRO-YF) and Athlete Fear Avoidance Questionnaire (AFAQ) for injury-related psychological distress, and University of Wisconsin Running and Recovery Index (UWRI) for perceived running ability. OSPRO-YF composite score, total yellow flags, and yellow flags in each domain (negative mood, fear-avoidance, positive affect/coping) were calculated. RESULTS UWRI score and OSPRO-YF composite score and yellow flags significantly improved over time, while AFAQ score and yellow flags in OSPRO-YF negative mood domain did not. AFAQ scores were significantly correlated with UWRI score at baseline, follow-up and change over time, while OSPRO-YF composite score and yellow flags were not. Baseline OSPRO-YF composite score and AFAQ score were not correlated with follow-up UWRI score. CONCLUSIONS Injury-related psychological distress is elevated when injured runners start rehabilitation, and generally improves; however, negative mood and athletic fear-avoidance may persist. Higher athletic fear-avoidance is associated with lower perceived running ability at the same time point or interval.
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Affiliation(s)
- Benjamin Maschke
- TRIA Orthopedic Center, 8100 Northland Drive, Bloomington, MN 55431, United States.
| | - Allison Palmsten
- TRIA Orthopedic Center, 8100 Northland Drive, Bloomington, MN 55431, United States.
| | - Evan O. Nelson
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, 4190 Medical Sciences Center, 1300 University Avenue, Madison, WI 53706, United States
| | - Michael C. Obermeier
- TRIA Orthopedic Center, 8100 Northland Drive, Bloomington, MN 55431, Bloomington, MN, United States
| | - Megan Reams
- TRIA Orthopedic Center, 8100 Northland Drive, Bloomington, MN 55431, United States.
| | - Bryan Heiderscheit
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 685 Highland Ave, MFCB 1636, Madison, WI 53705, United States.
| | - Hayley Russell
- Gustavus Adolphus College, 800 W College Ave, Saint Peter, MN 56082, United States.
| | - Terese L. Chmielewski
- TRIA Orthopedic Center, 8100 Northland Drive, Bloomington, MN 55431, Bloomington, MN, United States
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18
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Lentz TA, Kallen MA, Deutscher D, George SZ. Development of Reliable and Valid Negative Mood Screening Tools for Orthopaedic Patients with Musculoskeletal Pain. Clin Orthop Relat Res 2022; 480:313-324. [PMID: 34878414 PMCID: PMC8747611 DOI: 10.1097/corr.0000000000002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Negative mood is an important risk factor for poor clinical outcomes among individuals with musculoskeletal pain. Screening for negative mood can aid in identifying those who may need additional psychological interventions. Limitations of current negative mood screening tools include (1) high response burden, (2) a focus on single dimensions of negative mood, (3) poor precision for identifying individuals with low or high negative mood levels, and/or (4) design not specific for use in populations with orthopaedic conditions and musculoskeletal pain. QUESTIONS/PURPOSES (1) Can item response theory methods be used to construct screening tools for negative mood (such as depression, anxiety, and anger) in patients undergoing physical therapy for orthopaedic conditions? (2) Do these tools demonstrate reliability and construct validity when used in a clinical setting? METHODS This was a cross-sectional study involving outpatients having physical therapy in tertiary-care settings. A total of 431 outpatients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions were enrolled between December 2014 and December 2015, with 24% (103 of 431) seeking care after orthopaedic surgery. Participants completed three validated psychological questionnaires measuring negative mood, resulting in 39 candidate items for item response theory analysis. Factor analysis was used to identify the dimensions (factors) assessed by the candidate items and select items that loaded on the main factor of interest (negative mood), establishing a unidimensional item set. Unidimensionality of an item set suggests they are assessing one main factor or trait, allowing unbiased score estimates. The identified items were assessed for their fit to the graded item response theory model. This model allows for items to vary by the level of difficulty they represent and by their ability to discriminate between patients at different levels of the trait being assessed, in this case, negative mood. Finally, a hierarchical bifactor model where multiple subfactors are allowed to load on an overall factor was used to confirm that the items identified as representing a unidimensional item set explained the large majority of variance of the overall factor, providing additional support for essential unidimensionality. Using the final item bank, we constructed a computer adaptive test administration mode, and reduced item sets were selected to create short forms including items with the highest information (reliability) at targeted score levels of the trait being measured, while also considering clinical content. RESULTS We identified a 12-item bank for assessment of negative mood; eight-item and four-item short-form versions were developed to reduce administrative burden. Computer adaptive test administration used a mean ± SD of 8 ± 1 items. The item bank's reliability (0 = no reliability; 1 = perfect reliability) was 0.89 for the computer adaptive test administration, 0.86 for the eight-item short form, and 0.71 for the four-item short form. Reliability values equal to or greater than 0.7 are considered acceptable for group level measures. Construct validity sufficient for clinical practice was supported by more severe negative mood scores among individuals with a previous episode of pain in the involved anatomical region, pain and activity limitations during the past 3 months, a work-related injury, education less than a college degree, and income less than or equal to USD 50,000. CONCLUSION These newly derived tools include short-form and computer adaptive test options for reliable and valid negative mood assessment in outpatient orthopaedic populations. Future research should determine the responsiveness of these measures to change and establish score thresholds for clinical decision-making. CLINICAL RELEVANCE Orthopaedic providers can use these tools to inform prognosis, establish clinical benchmarks, and identify patients who may benefit from psychological and/or behavioral treatments.
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Affiliation(s)
- Trevor A. Lentz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Michael A. Kallen
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Deutscher
- Net Health Systems Inc, Pittsburgh, PA, USA
- Maccabitech Institute for Research & Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Steven Z. George
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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19
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Lentz TA, Kallen MA, Deutscher D, George SZ. Efficient Screening for Fear of Movement in Outpatient Settings: Short Form and Computer Adaptive Tests for Fear Avoidance and Negative Pain Coping. Phys Ther 2022; 102:6504625. [PMID: 35022785 DOI: 10.1093/ptj/pzab256] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/15/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of this study was to develop screening measures using item response theory (IRT) for 2 factors highly relevant to fear of movement (FoM): fear avoidance and negative pain coping. METHODS A total of 431 patients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions seeking physical therapy completed 8 validated psychological questionnaires measuring fear avoidance and negative pain coping, resulting in 97 candidate items for IRT analysis. Unidimensionality and local independence were assessed using exploratory factor analyses followed by confirmatory factor analyses. Items were assessed for model fit to the graded response model for ordinal items. Using the final item bank, a computer adaptive test (CAT) administration mode was constructed, and reduced item sets were selected to create short forms (SFs), including items with highest information (reliability) at the different levels of the trait being measured while also considering clinical content. RESULTS The results supported a 28-item bank for fear avoidance and 16-item bank for negative pain coping. A 10-item and 8-item SF were developed for fear avoidance and negative pain coping, respectively. Additionally, 4-item form versions were created to provide options with lower administrative burden. CAT administration used a mean (median) of 7.7 (8) and 7.0 (7) items for fear avoidance and negative pain coping, respectively. All factors demonstrated construct validity by discriminating patient groups in expected clinical patterns. CONCLUSION These newly derived SFs and CAT administration modes provide reliable, valid, and efficient options to screen for fear avoidance and negative pain coping in populations with musculoskeletal pain. IMPACT These tools, collectively referred to as the Screening for Pain Vulnerability and Resilience tools, address a critical need for standard FoM screening processes that aid in clinical decision-making to identify who might benefit from psychologically informed approaches.
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Affiliation(s)
- Trevor A Lentz
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Michael A Kallen
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel Deutscher
- Net Health Systems, Inc., Pittsburgh, Pennsylvania, USA.,Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Chimenti RL, Pacha MS, Glass NA, Frazier M, Bowles AO, Valantine AD, Archer KR, Wilken JM. Elevated Kinesiophobia Is Associated With Reduced Recovery From Lower Extremity Musculoskeletal Injuries in Military and Civilian Cohorts. Phys Ther 2021; 102:6427350. [PMID: 34935980 PMCID: PMC9432473 DOI: 10.1093/ptj/pzab262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/09/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to examine associations between level of kinesiophobia and improvement in physical function during recovery from lower extremity injury. METHODS A total 430 adults (mean [SD]: age = 27.3 [6.4] years; sex = 70.5% men; body mass index = 27.6 [5.2] kg/m2) were included in the analyses. Using the Patient-Reported Outcomes Measurement Information System, physical function was evaluated in parallel with treatment from a physical therapist at the initial visit and every 3 weeks until final visit or up to 6 months. A Tampa Scale of Kinesiophobia (TSK-17) score of >41 indicated elevated TSK. Four TSK groups were identified: (1) TSK score improved from >41 at initial visit to <41 by final visit (TSK_I), (2) TSK score was <41 at initial and final visits (TSK-), (3) TSK score was >41 at initial and final visits (TSK+), and (4) TSK score worsened from <41 at initial visit to ≥41 by final visit (TSK_W). Linear mixed effects models were used to examine differences between groups in improved physical function over time, with adjustment for depression and self-efficacy. RESULTS Groups with elevated kinesiophobia at the final visit had smaller positive improvements in physical function (mean change [95% CI]: TSK+ = 7.1 [4.8-9.4]; TSK_W: 6.0 [2.6-9.4]) compared with groups without elevated kinesiophobia at the final visit (TSK_I = 9.8 [6.4-13.3]; TSK- = 9.7 [8.1-11.3]) by 12 weeks. CONCLUSIONS Elevated kinesiophobia that persists or develops over the course of care is associated with less improvement in physical function within military and civilian cohorts. IMPACT The findings of this prospective longitudinal study support the need to assess for elevated kinesiophobia throughout the course of care because of its association with decreased improvement in physical function. LAY SUMMARY To help improve your physical function, your physical therapist can monitor the interaction between fear of movement and your clinical outcomes over the course of treatment.
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Affiliation(s)
- Ruth L Chimenti
- Address all correspondence to Dr Chimenti at: . Twitter: @ruthchimenti
| | - Molly S Pacha
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
| | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mathew Frazier
- Carl R. Darnall Army Medical Center, Department of Rehabilitation and Physical Therapy Clinic, Fort Hood, Texas, USA
| | - Amy O Bowles
- Brain Injury Rehabilitation Service, Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Andrew D Valantine
- Intrepid Spirit TBI Clinic, NICoE Informatics Team, Fort Hood, Texas, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason M Wilken
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
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Rhon DI, Mayhew RJ, Greenlee TA, Fritz JM. The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial. BMC FAMILY PRACTICE 2021; 22:200. [PMID: 34627152 PMCID: PMC8502287 DOI: 10.1186/s12875-021-01549-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks. OBJECTIVE Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups. METHODS This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs. RESULTS Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention. CONCLUSION Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process. TRIAL REGISTRATION clinicaltrials.gov NCT02777983 .
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Health Sciences , Bethesda, MD, USA.
| | - Rachel J Mayhew
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
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Koç M, Bazancir Z, Apaydın H, Talu B, Bayar K. Cross-cultural adaptation and validation of the Turkish Yellow Flag Questionnaire in patients with chronic musculoskeletal pain. Korean J Pain 2021; 34:501-508. [PMID: 34593668 PMCID: PMC8494960 DOI: 10.3344/kjp.2021.34.4.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/29/2021] [Accepted: 07/23/2021] [Indexed: 11/05/2022] Open
Abstract
Background Yellow flags are psychosocial factors shown to be indicative of longterm chronicity and disability. The purpose of the study was to evaluate the psychometric properties of the Turkish Yellow Flag Questionnaire (YFQ) in patients with chronic musculoskeletal pain (CMP). Methods The cross-cultural adaptation was conducted with translation and backtranslation of the original version. Reliability (internal consistency and test-retest) was examined for 231 patients with CMP. Construct validity was assessed by correlating the YFQ with the Hospital Anxiety and Depression Scale (HADS), Orebro Musculoskeletal Pain Questionnaire (OMPQ), and Tampa Kinesiophobia Scale (TKS). Factorial validity was examined with both exploratory and confirmatory factorial analysis. Results The YFQ showed excellent test/retest reliability with an Intraclass correlation coefficient of 0.82. The internal consistency was moderate (Cronbach's alpha of 0.797). As a result of the exploratory factor analysis, there were 7 domains compatible with the original version. As a result of confirmatory factor analysis, the seven-factor structure of YFQ was confirmed. There was a statistically significant correlation between YFQ-total score and OMPQ (r = 0.57, P < 0.001), HADS-anxiety (r = 0.32, P < 0.001), HADS-depression (r = 0.44, P < 0.001), and TKS (r = 0.37, P < 0.001). Conclusions This study's results provide considerable evidence that the Turkish version of the YFQ has appropriate psychometric properties, including test-retest reliability, internal consistency, construct validity and factorial validity. It can be used for evaluating psychosocial impact in patients with CMP.
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Affiliation(s)
- Meltem Koç
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Muğ la Sıtkı Koçman University, Muğ la, Turkey
| | - Zilan Bazancir
- Department of Physiotherapy and Rehabilitation, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Hakan Apaydın
- Department of Rheumatology, Ankara City Hospital, Ankara, Turkey
| | - Burcu Talu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Inonu University, Malatya, Turkey
| | - Kılıçhan Bayar
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Muğ la Sıtkı Koçman University, Muğ la, Turkey
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23
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Abstract
BACKGROUND Psychological factors influence or are associated with physical function, pain, and health care costs among individuals with musculoskeletal pain conditions. Recent clinical practice guidelines recommend screening for psychological factors (also referred to as "yellow flags") in physical therapy practice to help understand prognosis and inform shared decision making for treatment. CLINICAL QUESTION Despite the urgings of clinical practice guidelines and evidence of the influence of psychological factors on clinical outcomes, screening for yellow flags is uncommon in clinical practice. Clinicians may feel uncertain about how to integrate screening tools into clinical practice, and how screening results might inform decision making and care coordination. KEY RESULTS We outline a 3-step framework for routine yellow flag screening in physical therapy practice: (1) establish a standard first-line screening instrument and process, (2) interpret the results to inform shared decision making, and (3) monitor treatment progress. Four case examples illustrate how yellow flag screening can help clinicians and patients decide whether the patient might benefit most from standard physical therapy, psychologically informed physical therapy, psychologically informed physical therapy with referral to another health care provider, or immediate referral. CLINICAL APPLICATION Consider incorporating a standard yellow flag screening process into usual musculoskeletal health care. We present a framework to guide yellow flag screening in practice (1) to help inform treatment pathway selection and (2) to enhance interdisciplinary communication. J Orthop Sports Phys Ther 2021;51(9):459-469. doi:10.2519/jospt.2021.10570.
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24
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Zeppieri G, George SZ, Bialosky J, Lentz TA. Patient-centered outcomes: Domain importance predicts health care use following physical therapy. PM R 2021; 14:1044-1055. [PMID: 34296528 DOI: 10.1002/pmrj.12680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Identifying patients with musculoskeletal pain who are at risk for additional health care use is important for improving the value of physical therapists' services. We previously identified three subgroups based on the importance attached by patients to improvements in outcome domains including a (1) Pain and Function Outcomes Important subgroup; (2) Pain Important subgroup; and (3) Multiple Outcome Domains Important subgroup. OBJECTIVE The primary aim was to determine whether subgroups based on patient-determined outcomes of importance predicted any additional pain-related health care use after an episode of physical therapy. A secondary aim was to determine if subgroup membership predicted use of specific services. DESIGN Secondary analysis of a longitudinal cohort. SETTING Ambulatory outpatient physical therapy clinics. PATIENTS Two hundred forty-six patients seeking physical therapy recruited from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort study. INTERVENTIONS Patients completed a demographic and health history questionnaire, numeric pain rating scale, region-specific disability measure, and Charlson Comorbidity Index. Subgroup membership was determined based on responses to the Patient Centered Outcome Questionnaire. At 1 year, patients reported use of health care since discharge from physical therapy. Separate logistic regression models determined whether subgroup membership predicted additional health care use. RESULTS Compared to the Pain and Function Outcomes Important subgroup, the Pain Important subgroup had higher adjusted odds (95% confidence interval [CI]) for the primary outcome of any additional health care use (adjusted odds ratio [aOR] 2.47, 95% CI 1.01-6.00) and secondary outcomes of opioid use (aOR 9.45, 95% CI 2.87-31.17), injection (aOR 4.09, 95% CI 1.25-13.41), and surgery (aOR 5.10, 95% CI 1.15-22.67). There were no significant differences in health care utilization between the Pain and Function Outcomes Important and Multiple Outcome Domains Important subgroups. CONCLUSION In this cohort, patients with a singular focus on pain improvements were at higher risk for additional health care, including opioid use, injection, and surgery. These findings are exploratory and need to be confirmed in other cohorts.
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Affiliation(s)
- Giorgio Zeppieri
- Department of Rehabilitation, University of Florida Health, Gainesville, Florida, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Joel Bialosky
- University of Florida Department of Physical Therapy; Brooks-PHHP Research Collaboration, Gainesville, Florida, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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25
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Butera KA, Fox EJ, Bishop MD, Coombes SA, George SZ. Empirically derived back pain subgroups differentiated walking performance, pain, and disability. Pain 2021; 162:1806-1815. [PMID: 33306502 PMCID: PMC8765081 DOI: 10.1097/j.pain.0000000000002167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Low back pain (LBP) is a leading cause of disability. However, the processes contributing to disability are not well understood. Therefore, this study (1) empirically derived LBP subgroups and (2) validated these subgroups using walking performance, pain, and disability measures. Seventy adults with LBP underwent testing for a priori determined sensory (temporal summation; conditioned pain modulation), psychological (positive affect/coping; negative coping), and motor (trunk extensor muscle activation during forward bending and walking) measures. A hierarchical cluster analysis determined subgroups that were then validated using walking (walking speed; Timed Up and Go [TUG]; TUG-Cognitive [TUG-Cog]; obstacle negotiation) and clinical (Brief Pain Inventory; Oswestry Disability Index; low back pressure pain threshold) measures. Two subgroups were derived: (1) a "Maladaptive" subgroup (n = 21) characterized by low positive affect/coping, high negative coping, low pain modulation, and atypical trunk extensor activation and (2) an "Adaptive" subgroup (n = 49) characterized by high positive affect/coping, low negative coping, high pain modulation, and typical trunk extensor activation. There were subgroup differences on 7 of 12 validation measures. The Maladaptive subgroup had reduced walking performance (slower self-selected walking speed, TUG completion, and obstacle approach and crossing speed) and worse clinical presentation (higher pain intensity, pain interference, and disability) (moderate to large effect sizes; P's < 0.05). Findings support the construct validity of this multidimensional subgrouping approach. Longitudinal studies are needed to determine whether the Maladaptive subgroup is predictive of poor outcomes, such as pain chronicity or persistent disability.
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Affiliation(s)
- Katie A. Butera
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Emily J. Fox
- Department of Physical Therapy, University of Florida, Gainesville, FL
- Brooks Rehabilitation, Jacksonville, FL
| | - Mark D. Bishop
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | - Stephen A. Coombes
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL
| | - Steven Z. George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, NC
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26
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Horn ME, George SZ, Li C, Luo S, Lentz TA. Derivation of a Risk Assessment Tool for Prediction of Long-Term Pain Intensity Reduction After Physical Therapy. J Pain Res 2021; 14:1515-1524. [PMID: 34093037 PMCID: PMC8169054 DOI: 10.2147/jpr.s305973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022] Open
Abstract
Rationale Risk assessment tools can improve clinical decision-making for individuals with musculoskeletal pain, but do not currently exist for predicting reduction of pain intensity as an outcome from physical therapy. Aims and Objective The objective of this study was to develop a tool that predicts failure to achieve a 50% pain intensity reduction by 1) determining the appropriate statistical model to inform the tool and 2) select the model that considers the tradeoff between clinical feasibility and statistical accuracy. Methods This was a retrospective, secondary data analysis of the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort. Two hundred and seventy-nine individuals seeking physical therapy for neck, shoulder, back, or knee pain who completed 12-month follow-up were included. Two modeling approaches were taken: a longitudinal model included demographics, presence of previous episodes of pain, and regions of pain in addition to baseline and change in OSPRO Yellow Flag scores to 12 months; two comparison models included the same predictors but assessed only baseline and early change (4 weeks) scores. The primary outcome was failure to achieve a 50% reduction in pain intensity score at 12 months. We compared the area under the curve (AUC) to assess the performance of each candidate model and to determine which to inform the Personalized Pain Prediction (P3) risk assessment tool. Results The baseline only and early change models demonstrated lower accuracy (AUC=0.68 and 0.71, respectively) than the longitudinal model (0.79) but were within an acceptable predictive range. Therefore, both baseline and early change models were used to inform the P3 risk assessment tool. Conclusion The P3 tool provides physical therapists with a data-driven approach to identify patients who may be at risk for not achieving improvements in pain intensity following physical therapy.
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Affiliation(s)
- Maggie E Horn
- Duke University, Department of Orthopaedic Surgery, Durham, NC, 27701, USA
| | - Steven Z George
- Duke University, Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, 27701, USA
| | - Cai Li
- Yale University, Department of Biostatistics, New Haven, CT, USA
| | - Sheng Luo
- Duke University, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Trevor A Lentz
- Duke University, Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, 27701, USA
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