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Zhang D, Dyer GSM, Earp BE. The significance of subjective mechanical symptoms in rotator cuff pathology. J Shoulder Elbow Surg 2024; 33:2441-2447. [PMID: 38580068 DOI: 10.1016/j.jse.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND The presence of subjective mechanical symptoms, such as clicking or popping, is common in patients presenting for shoulder pain and dysfunction, with unclear clinical significance. The primary objective of this study was to assess whether subjective mechanical symptoms in the affected shoulder were associated with full-thickness rotator cuff tearing in a consecutive, prospective cohort of patients undergoing shoulder magnetic resonance imaging (MRI) for suspected rotator cuff pathology. METHODS A prospective cohort study was performed of 100 consecutive patients with suspected rotator cuff tendinopathy and/or tearing who underwent shoulder MRI. The presence of subjective shoulder mechanical symptoms, including clicking or popping, was documented prior to MRI. Indications for MRI included weakness on isolated testing of rotator cuff muscle(s) or symptoms refractory to conservative treatment including at least a 6-week course of physical therapy. The primary outcome variable was the presence of full-thickness rotator cuff tearing; secondary outcome variables included any (full-thickness or partial-thickness) rotator cuff tearing and biceps long head subluxation. Radiographic parameters, including critical shoulder angle, Goutallier grade, tear retraction, and tear size were quantified. One patient was lost to follow-up, and 99 patients completed MRI imaging. RESULTS In our cohort, 60% of patients reported subjective mechanical symptoms in the affected shoulder. Full-thickness rotator cuff tearing was identified in 42% of patients, any rotator cuff tearing in 69% of patients, and biceps long head subluxation in 14% of patients. Subjective mechanical symptoms were not associated with full-thickness rotator cuff tearing, any rotator cuff tearing, biceps long head subluxation, critical shoulder angle, Goutallier grade, tear size, or tear retraction. Older age was associated with full-thickness and any rotator cuff tearing. As a diagnostic test for full-thickness rotator cuff tearing, subjective shoulder mechanical symptoms has a sensitivity of 64%, a specificity of 44%, and Youden's index of 0.08, consistent with poor diagnostic accuracy. CONCLUSIONS Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. Patients may be reassured that a sensation of clicking or popping alone does not necessarily entail structural shoulder derangement.
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Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - George S M Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Brinkman N, Thomas JE, Teunis T, Ring D, Gwilym S, Jayakumar P. Recovery of Comfort and Capability After Upper Extremity Fracture Is Predominantly Associated With Mindset: A Longitudinal Cohort From the United Kingdom. J Orthop Trauma 2024; 38:557-565. [PMID: 39325053 DOI: 10.1097/bot.0000000000002868] [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] [Accepted: 07/02/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVES To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. METHODS DESIGN Secondary use of longitudinal data. SETTING Single Level-1 trauma center in Oxford, United Kingdom. PATIENT SELECTION English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded. OUTCOME MEASURES AND COMPARISONS Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2-4 weeks, and 6-9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects. RESULTS Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: β = 4.1, 3: β = 7.5, and 4: β = 17) and pain intensity (group 3: β = 0.70 and 4: β = 1.4) (P < 0.01). Higher fracture severity (β = 4.5), high-energy injury (β = 4.0), and nerve palsy (β = 8.1) were associated with worse baseline incapability (P < 0.01), and high-energy injury (β = 0.62) and nerve palsy (β = 0.76) with worse baseline pain intensity (P < 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (β = 1.3, β = 7.0) and pain intensity (β = 0.19, β = 1.1) (P < 0.02). CONCLUSIONS Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Niels Brinkman
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Jacob E Thomas
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
- Department of Kinesiology and Health Education, College of Education, The University of Texas at Austin, Austin, TX; and
| | - Teun Teunis
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, United Kingdom
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
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Teunis T, Burnier M, Chin AYH, Ring D. Pain and instability ascribed to the distal radioulnar ligaments and central disc as part of the triangular fibrocartilage complex: a round table discussion. J Hand Surg Eur Vol 2024:17531934241254705. [PMID: 39275970 DOI: 10.1177/17531934241254705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2024]
Affiliation(s)
- Teun Teunis
- Department of Plastic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marion Burnier
- Institut Chirurgical de la Main et du Membre Supérieur, Lyon, France
| | - Andrew Y H Chin
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | - David Ring
- Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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Broekman M, Brinkman N, Davids F, van den Bekerom M, Ring D, Doornberg J, Ramtin S, Jayakumar P. Surgeon Prioritization of Mental, Social, and Pathophysiological Aspects of Health Among People With Traumatic and Nontraumatic Musculoskeletal Conditions. J Am Acad Orthop Surg 2024; 32:e869-e879. [PMID: 38810227 DOI: 10.5435/jaaos-d-23-00962] [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: 10/16/2023] [Accepted: 04/15/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health factors than with variation in pathophysiology severity. This study sought factors that could limit the integration of this evidence into more comprehensive care models. METHODS In two scenario-based experiments, surgeon participants in an international collaborative, the Science of Variation Group, reviewed scenarios of (a) nontraumatic (83 participants) and (b) trauma-related (130 participants) pathophysiologies for which tests and treatments were discretionary. The following demographic, mental, and social health elements were varied randomly: sex, age, race/ethnicity, mindsets, social health aspects, and specific pathophysiologies. For each scenario, participants rated their likelihood to offer surgery (continuous) and their sense of presence of an opportunity to address better mental or social health in treatment (yes or no). Factors associated with each rating were sought in multivariable analysis. RESULTS Greater likelihood to offer discretionary surgery for nontraumatic pathophysiologies was associated with greater pathophysiology severity, trapeziometacarpal arthritis, and greater distress and unhelpful thoughts regarding symptoms. Lateral elbow enthesopathy was associated with a lower likelihood. For trauma-related pathophysiologies, an ankle fracture with slight articular subluxation was associated with greater likelihood to offer surgery, and several other trauma-related pathophysiologies were associated with a lower likelihood. For both nontraumatic and trauma-related pathophysiologies, surgeons noticed unhelpful thinking, distress, and social issues as reasons to consider addressing mental and social health in treatment, relatively independent of pathophysiology. CONCLUSION Surgeons seem to recognize opportunities to address mental and social needs but ultimately base their decision to offer discretionary surgery on pathophysiological factors. CLINICAL RELEVANCE Comprehensive, whole-person care for musculoskeletal illness might be supported by strategies for ensuring that aspects of stress and distress that contribute to greater symptom intensity are not misinterpreted as a reflection of greater pathophysiology severity.
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Affiliation(s)
- Melle Broekman
- From the Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX (Broekman, Brinkman, Davids, Ring, Ramtin, and Jayakumar), Faculty of Behavioural and Movement Sciences, Vrije Universiteit van Amsterdam, Amsterdam, the Netherlands (Broekman and van den Bekerom), the Department of Orthopaedic Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, the Netherlands (Doornberg)
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Brinkman N, Ring D, van den Bekerom M. Reply to the Letter to the Editor: Variations in 1-year Trajectories of Levels of Pain and Capability After Shoulder Arthroplasty Are Associated With Baseline Mental Health. Clin Orthop Relat Res 2024; 482:1726-1727. [PMID: 38905452 PMCID: PMC11343541 DOI: 10.1097/corr.0000000000003165] [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: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Niels Brinkman
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Michel van den Bekerom
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit van Amsterdam, Amsterdam, the Netherlands
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Amsterdam, the Netherlands
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Ramtin S, Ngoue M, Ring D, Teunis T. The Central Sensitization Inventory Measures Thoughts and Emotions. J Patient Exp 2024; 11:23743735241273589. [PMID: 39148748 PMCID: PMC11325304 DOI: 10.1177/23743735241273589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
To determine if the Central Sensitization Inventory questionnaire (CSI) functions as a mental health measure among a cross-section of people seeking musculoskeletal specialty care, we asked: (1) What is the association of CSI total score and item groupings identified in factor analysis with mental health measures? and (2) What is the association between specific CSI items that represent each factor well and specific mental health measures? One hundred and fifty-seven adults seeking specialty care for musculoskeletal symptoms completed the CSI, a measure of catastrophic thinking, and 3 measures of distress (symptoms of health anxiety, general anxiety, and depression). Exploratory factor analysis was used to identify item groupings. Exploratory factor analysis identified 4 item groupings (factors): (1) thoughts and feelings (mental health), accounting for 52% of the variation in the CSI, (2) urinary and visual symptoms (15%) (3) body aches (10%), and (4) jaw pain (8.1%). More than half the variation in both the CSI total score (51%) and the thoughts and feelings factor (57%) were accounted for by variation in measures of catastrophic thinking and distress. Specific items that account for large amounts of the variation in the CSI also had notable correlations with mental health measures. The strong relationship between the CSI and thoughts and emotions suggests that the CSI functions largely as a mental health measure. If the concept of central sensitization is to help people get and stay healthy, it will depend on evidence that central sensitization can be measured and quantified distinct from mental health.
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Affiliation(s)
- Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Marielle Ngoue
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Teun Teunis
- Department of Orthopaedic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
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Dwyer D, Ramachandran SS, McCall K, Ragsdale M, Ring D, Ramtin S. Potential Misinformation in the Official Disability Guidelines About the Diagnosis and Treatment of Rotator Cuff Tendinopathy. J Occup Environ Med 2024; 66:e355-e358. [PMID: 38729188 DOI: 10.1097/jom.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
OBJECTIVE We selected statements in the Official Disability Guidelines that had the potential to reinforce misconceptions regarding symptoms from rotator cuff tendinopathy. These statements were revised and presented with the original statement to specialists. METHODS Twelve statements regarding rotator cuff tendinopathy were identified as deviating from principles based on ethics, values, and the evidence regarding both pathophysiology and human illness behavior. One hundred fifteen upper extremity surgeons reviewed both original and revised versions of the statements and indicated their preference. RESULTS We found that upper extremity surgeons preferred 3 revised statements, 4 Official Disability Guidelines statements, and 5 were rated as neutral between the 2 statements. CONCLUSIONS Statements revised for evidence, ethics, and healthy mindset were not preferred by specialists, which may indicate limited awareness about how negative thoughts and distressing symptoms impact human illness.
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Affiliation(s)
- Darby Dwyer
- From the Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
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Longo UG, Marino M, Candela V, Greco A, Piergentili I, Arias C, de Sire A, D’Hooghe P. Anxiety, Depression, and Quality of Sleep Vary in Their Correlation to Postoperative Outcomes of Rotator Cuff Repair: A Prospective Study. J Clin Med 2024; 13:3340. [PMID: 38893051 PMCID: PMC11173232 DOI: 10.3390/jcm13113340] [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: 02/24/2024] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: Recent studies imply that psychological factors and sleep quality play a role in the outcomes of surgical procedures, including in orthopedic surgery. The aim of the present study is to evaluate possible correlations between preoperative depression, anxiety, and quality of sleep and functional 6-month postoperative scores in patients having undergone rotator cuff repair (RCR). Methods: All patients included in the study performed the Hospital Anxiety and Depression Scale (HADS) and Pittsburgh Sleep Quality Index (PSQI) questionnaires preoperatively and 36-item Short-Form Health Survey (SF-36), Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and PSQI questionnaires at the six-month postoperative follow-up. A total of 47 patients were included in the analysis. Results: Statistically significant differences between preoperative anxious and not-anxious groups were found in the postoperative SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and PSQI score. The correlation of the preoperative depression score to postoperative outcome measures revealed a strong positive correlation between the preoperative HADS-D score and the 6-month PCS, MCS, and OSS scores. The correlation of preoperative sleep quality to postoperative outcome measures revealed a strong positive correlation between the preoperative PSQI score and 6-month MCS score. Conclusions: Anxious patients had worse postoperative RCR outcomes. Depression may be influenced by factors related to RC pathology; however, there were no statistically significant correlations. Sleep quality generally improves postoperatively, and no significant association was found between bad preoperative sleepers and worse outcomes.
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Affiliation(s)
- Umile Giuseppe Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (M.M.); (V.C.); (A.G.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
| | - Martina Marino
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (M.M.); (V.C.); (A.G.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
| | - Vincenzo Candela
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (M.M.); (V.C.); (A.G.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
| | - Alessandra Greco
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (M.M.); (V.C.); (A.G.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
| | - Ilaria Piergentili
- CNR-IASI, Laboratorio di Biomatematica, Consiglio Nazionale delle Ricerche, Istituto di Analisi dei Sistemi ed Informatica, 00128 Rome, Italy;
| | - Claudia Arias
- Hospital Nacional Edgardo Rebagliati Martins, Lima 15072, Peru;
| | - Alessandro de Sire
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy;
- Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Pieter D’Hooghe
- Aspetar Orthopedic and Sports Medicine Hospital, Aspire Zone, 1, Sportscity Street, Doha P.O. Box 29222, Qatar;
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Nwankpa C, Razi A, Ring D, Ramtin S. Inordinate attention to minor pathophysiology variations in musculoskeletal research: example of rotator cuff tendinopathy. J Shoulder Elbow Surg 2024; 33:e302-e307. [PMID: 38000730 DOI: 10.1016/j.jse.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Evidence suggests variation in pathophysiology is less relevant to musculoskeletal illness than variation in mental health factors. For diseases such as rotator cuff tendinopathy, attention may be placed on aspects of tendon thinning and suture techniques when studies show that variations in muscle quality and defect size have limited association with comfort and capability compared with variations in thoughts and feelings regarding symptoms. Using rotator cuff tendinopathy as an example, we studied the degree to which research addresses relatively minor degrees of variation in pathophysiology and relatively minor differences in treatments to better understand the relative emphasis on pathophysiology. We asked the following questions: What factors are associated with relative pathophysiology severity in comparative therapeutic studies of musculoskeletal conditions? What factors are associated with relative differences in interventions in comparative therapeutic studies of musculoskeletal conditions? METHODS We systematically reviewed clinical trials of patients with rotator cuff tendinopathy for the relative severity of pathophysiology (low, moderate, or high) and variation in interventions (minimal, moderate, or large). An example of a relatively minor variation in rotator cuff tendon pathophysiology is bursal- vs. articular-sided thinning of the tendon. An example of a relatively minor variation in treatment is single- vs. double-row defect closure. RESULTS Most studies of rotator cuff tendinopathy treatment addressed low (39%) or medium (50%) levels of pathophysiology. Greater relative pathology severity was independently associated with operative treatment (odds ratio, 12 [95% confidence interval, 3.2-45]; P < .001). Of 127 studies, 113 (89%) were rated as comparing treatments with minimal difference. CONCLUSION Despite the evidence of limited variation in comfort and capability due to pathophysiological variations, a large percentage of research on rotator cuff tendinopathy addresses relatively limited severity of pathophysiology and relatively minor variations in treatment. This may be typical of musculoskeletal research and suggests a possibility of focusing, on the one hand, on more impactful interventions such as treatments that can delay or avoid rotator cuff arthropathy and, on the other hand, on management strategies that optimize accommodation of common age-related changes in the rotator cuff tendons.
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Affiliation(s)
- Christina Nwankpa
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Amin Razi
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
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Ring D. CORR Insights®: High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review. Clin Orthop Relat Res 2024; 482:672-674. [PMID: 38019128 PMCID: PMC10936973 DOI: 10.1097/corr.0000000000002920] [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: 10/04/2023] [Accepted: 10/16/2023] [Indexed: 11/30/2023]
Affiliation(s)
- David Ring
- Associate Dean for Comprehensive Care, Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA
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Ring D, Vranceanu AM. Editorial Comment: The Third Annual I-MESH Symposium. Clin Orthop Relat Res 2024; 482:602-603. [PMID: 38411222 PMCID: PMC10936984 DOI: 10.1097/corr.0000000000003012] [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: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Affiliation(s)
- David Ring
- Associate Dean for Comprehensive Care, Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA
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Greif DN, Shaikh HJ, Neumanitis J, Ramirez G, Maloney MD, Bronstein RD, Giordano B, Nicandri GT, Voloshin I, Mannava S. Arthroscopic subacromial decompression improved outcomes in situationally depressed patients compared to clinically depressed or nondepressed patients. JSES Int 2024; 8:304-309. [PMID: 38464455 PMCID: PMC10920123 DOI: 10.1016/j.jseint.2023.11.012] [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] [Indexed: 03/12/2024] Open
Abstract
Background The purpose of this study is to evaluate patient reported outcomes after arthroscopic extensive débridement of the shoulder with subacromial decompression (SAD) for subacromial impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) system and evaluate if depression (Dep) (clinical or situational) impacts patients achieving a Minimal Clinically Important Difference (MCID). Methods Preoperative PROMIS Physical function (PF), Mood, and Dep scores were obtained at the closest date prior to arthroscopic rotator cuff repair and postoperative scores were collected at every clinical visit thereafter. Final PROMIS score used for data analysis was determined by the patients final PROMIS value between 90 to 180 days. Clinical Dep was determined by patients having a formal diagnosis of "Depression or Major Depressive Disorder" at the time of their surgery. Situationally depressed patients, those without a formal diagnosis yet exhibited symptomatic depressive symptoms, were classified by having a PROMIS-Dep cutoff scores larger than 52.5. Results A total of 136 patients were included for final statistical analysis. 13 patients had a clinical but not situational diagnosis of Dep, 86 patients were identified who had no instance of clinical or situational Dep (nondepressed). 35 patients were situationally depressed. All three cohorts demonstrated a significant improvement in postoperative PROMIS Dep, PI, and PF score relative to their preoperative value (P = .001). Situationally depressed patients achieved greater delta PROMIS-Dep compared to patients with major depressive disorder. Depressed patients had a higher chance of achieving MCID for PROMIS-Dep compared to nondepressed patients (P = .01). Logistic regression analysis demonstrated that underlying Dep did not alter the odds of obtaining MCID compared to nondepressed patients. Nonsmoking patients had significantly greater odds of achieving MCID for PF (P = .02). Discussion Patients improved after undergoing SAD regardless of underlying Dep or depressive symptoms. Depressed patients exhibited greater change in PROMIS scores compared to nondepressed patients. Smoking remains a risk factor for postoperative outcomes in patients undergoing SAD for subacromial impingement. Identifying and counseling patients with underlying depressive symptoms without a formal major depressive disorder diagnosis may lead to improved outcomes. These findings may help guide clinicians in deciding who would benefit the most from this procedure.
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Affiliation(s)
- Dylan N. Greif
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Hashim J.F. Shaikh
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - James Neumanitis
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Gabriel Ramirez
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Michael D. Maloney
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Robert D. Bronstein
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Brian Giordano
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Gregg T. Nicandri
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Ilya Voloshin
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
| | - Sandeep Mannava
- University of Rochester Department of Orthopaedics and Physical Rehabilitation, Rochester, NY, USA
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Romere C, Ramtin S, Nunziato C, Ring D, Laverty D, Hill A. Is Pain in the Uninjured Leg Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Lower Extremity Injury? Clin Orthop Relat Res 2023; 481:2368-2376. [PMID: 37249315 PMCID: PMC10642885 DOI: 10.1097/corr.0000000000002703] [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: 01/18/2023] [Revised: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery. QUESTIONS/PURPOSES We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms? METHODS Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors. RESULTS Greater pain intensity in the uninjured leg (regression coefficient [RC] 0.09 [95% CI 0.02 to 0.16]; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 [95% CI 0.08 to 0.27]; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 [95% CI -0.38 to -0.12]; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms. CONCLUSION A patient's report of concerns regarding pain in the uninjured limb (such as, "I'm overcompensating for the pain in my other leg") can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Chase Romere
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Carl Nunziato
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Laverty
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Austin Hill
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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Ueki H, Yoshimura H. Long-lasting decreased pain threshold negatively affects functional recovery after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2023; 31:5970-5978. [PMID: 37882879 DOI: 10.1007/s00167-023-07632-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE The relationship between sensitization and postoperative function in patients undergoing arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the effect of pre-and postoperative reductions in the pressure pain threshold (PPT) on postoperative clinical outcomes in patients with ARCR and investigate changes in PPT and clinical outcomes resulting from postoperative administration of weak opioids activating the central inhibitory system. METHODS This retrospective study included patients who underwent primary ARCR, categorized into Group A (excellent/good Constant scores) and B (fair/poor Constant scores). In a complementary study, patients were randomized to the Control or Tramadol groups. Both studies evaluated the PPT, visual analog scale, active range of motion (ROM), Constant score, and retear rates pre-and postoperatively. RESULTS In the primary study with 158 patients, those with poor clinical outcomes exhibited significantly lower PPT at the affected shoulder preoperatively at 3 months postoperatively compared to those with good outcomes. The PPT of the affected side was lower than that of the uninvolved side not only at 1 and 3 months but also preoperatively and at 6 months in the poor outcome group. In the secondary study involving 96 patients, weak opioid administration was associated with increased PPT for 3 months, improved ROM at 3 months postoperatively, and reduced postoperative pain 1 year postoperatively. CONCLUSION Patients experiencing poor postoperative clinical outcomes exhibited prolonged lowered PPT. Lowered PPT due to sensitization may adversely affect functional recovery and pain perception. Elevating PPT using weak opioids improved clinical outcomes during the acute perioperative period after ARCR. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hiroko Ueki
- Kawaguchi Kogyo General Hospital, 1-18-15, Aoki, Kawaguchi-City, Saitama, 332-0031, Japan
| | - Hideya Yoshimura
- Kawaguchi Kogyo General Hospital, 1-18-15, Aoki, Kawaguchi-City, Saitama, 332-0031, Japan.
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15
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Broekman MM, Ring D, van den Bekerom MPJ. Resolution of Sleep Disturbance and Improved Functional Outcomes After Rotator Cuff Repair: Letter to the Editor. Am J Sports Med 2023; 51:NP64. [PMID: 38031744 DOI: 10.1177/03635465231202517] [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] [Indexed: 12/01/2023]
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16
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Ramtin S, Reichel L, Ring D, Gallagher S, Teunis T. Do Items Addressing Thoughts and Emotions Regarding Symptoms Measure Distinct Aspects of Musculoskeletal Health? J Patient Exp 2023; 10:23743735231211776. [PMID: 37941584 PMCID: PMC10629317 DOI: 10.1177/23743735231211776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Abstract
A prior experiment identified separate thought and feeling item groupings among items in measures of unhelpful thinking (ie, catastrophic thinking, kinesiophobia). This study sought to confirm the utility of separating these factors using a subset of selected items. One hundred and thirty-six adult patients visiting a musculoskeletal specialist completed the surveys. Confirmatory factor analysis measured the association between variation in scores on a specific item with variation in scores in separate groupings for thoughts and feelings, and a combined item grouping. Cronbach alpha (internal consistency) and Spearman correlation with magnitude of capability were also measured for the three separate item groupings. The association of variation in specific items with variation in a group of items addressing thoughts, a group of items addressing feelings, and the combination of all items was comparable. The internal consistency and strength of association with magnitude of capability were also comparable. The finding of no advantage to separation of items addressing thoughts and feelings regarding symptoms suggests that just a few items may be able to represent unhealthy mindsets regarding musculoskeletal symptoms.
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Affiliation(s)
- Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Lee Reichel
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Sean Gallagher
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Teun Teunis
- Department of Plastic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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17
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Ibezim CF, Reichel LM, Ring D. Measurement of Upper Extremity-Specific Comfort and Capability. J Am Acad Orthop Surg 2023; 31:e876-e882. [PMID: 37332222 DOI: 10.5435/jaaos-d-23-00109] [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: 02/01/2023] [Accepted: 05/05/2023] [Indexed: 06/20/2023] Open
Abstract
Patient-reported outcome measures (PROMs) quantify symptom intensity and magnitude of capability. Upper extremity PROMs were developed shortly after the advent of general health PROMs. PROMs are still primarily research tools, and their use with individual patients is still evolving. When PROMs were developed, the initial and intuitive expectation was a strong correlation of comfort and capability with pathophysiology severity. In other words, people with greater radiographic arthritis or larger degenerative tendon defects were expected to feel worse and do less. After more than 20 years of research using PROMs, it is clear that mindset and circumstances account for more of the variation in PROMs than pathophysiology severity. Mounting research establishes upper extremity PROMs and PROMs in general as useful tools for anchoring and developing comprehensive, biopsychosocial approaches to care.
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Affiliation(s)
- Chizitam F Ibezim
- From the Dell Medical School, the University of Texas at Austin, Austin, TX
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18
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Fatehi A, Brown LE, Versluijs Y, Van Maren K, Ring D, Gonzalez A, Ramtin S. The relationship of perceived empathy with levels of pain intensity and incapability among patients visiting a musculoskeletal specialist. PATIENT EDUCATION AND COUNSELING 2023; 115:107900. [PMID: 37467592 DOI: 10.1016/j.pec.2023.107900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND People that have more intense symptoms and greater incapability might have less rapport with the clinicians that care for them. OBJECTIVE This study tested the hypothesis that perceived clinician empathy is related to pain intensity and magnitude of incapability among people seeing a musculoskeletal specialist. PATIENT INVOLVEMENT After a consult with a musculoskeletal specialist, 211 adult patients completed a survey recording demographics, and measures of pain intensity, incapability, and perceived clinician empathy. RESULTS Higher perceived empathy was associated with being in a committed relationship and, to a modest degree (r = -0.16) lower pain intensity in bivariate and multivariable analyses. DISCUSSION People experiencing greater pain may be slightly less likely to perceive the clinician as empathetic. PRACTICAL VALUE Study of the relationship between the patient's experience of care and patient and clinician personal factors can inform efforts to improve patient experience. Advances may depend on experience measures with more normal distributions and less ceiling effect.
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Affiliation(s)
- Amirreza Fatehi
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - Laura E Brown
- Center for Health Communication, Moody College of Communication, University of Texas at Austin, 300 W. Dean Keaton, Austin, TX 78712-1069, USA.
| | - Yvonne Versluijs
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - Koen Van Maren
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - Amanda Gonzalez
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX 78712, USA.
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19
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McFarland EG, Brand JC, Ring D. Clinical Faceoff: Is Preventative Surgery a Good Idea for Patients With Rotator Cuff Tendinopathy? Clin Orthop Relat Res 2023; 481:1486-1490. [PMID: 37404134 PMCID: PMC10344515 DOI: 10.1097/corr.0000000000002752] [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: 03/14/2023] [Accepted: 06/05/2023] [Indexed: 07/06/2023]
Affiliation(s)
- Edward G. McFarland
- Department of Orthopaedic Surgery, Division of Shoulder Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jefferson C. Brand
- Heartland Orthopedic Specialists, 111 17th Ave E, Ste. 101, Alexandria, MN, USA
| | - David Ring
- Associate Dean for Comprehensive Care, Dell Medical School, Department of Surgery and Perioperative Care, Austin, TX, USA
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20
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Ring D. Mindsets matter for every patient and we can all help. BJPsych Open 2023; 9:e131. [PMID: 37470134 PMCID: PMC10375868 DOI: 10.1192/bjo.2023.524] [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: 07/21/2023] Open
Abstract
People seek care when a sensation becomes a symptom (a concern). Levels of discomfort and incapability are associated with feelings of distress or unhealthy misinterpretation. To limit mental health stigma, it is important to emphasise that this is about how the human mind works (mindsets) and not just about mental illness. Experts in mental health and in pathophysiology can work together, each doing their part to optimise mindset.
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Affiliation(s)
- David Ring
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
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21
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Ring D. CORR Insights®: How Do Orthopaedic Providers Conceptualize Good Patient Outcomes and Their Barriers and Facilitators After Acute Injury? A Qualitative Study. Clin Orthop Relat Res 2023; 481:1101-1103. [PMID: 36716095 PMCID: PMC10194670 DOI: 10.1097/corr.0000000000002532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/28/2022] [Indexed: 01/31/2023]
Affiliation(s)
- David Ring
- Associate Dean for Comprehensive Care, Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA
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22
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Ramtin S, Ring D, Vallier H, Wolinsky PR, Miller AN. Factors associated with surgeon recognition of mental health care opportunities and inclination to attend to mental health. J Psychosom Res 2023; 170:111368. [PMID: 37245450 DOI: 10.1016/j.jpsychores.2023.111368] [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] [Received: 09/06/2022] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE A notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals. METHODS One hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis. RESULTS Accounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office. CONCLUSION Using random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.
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Affiliation(s)
- Sina Ramtin
- Dell Medical School at University of Texas at Austin, TX, United States of America
| | - David Ring
- Dell Medical School at University of Texas at Austin, TX, United States of America.
| | - Heather Vallier
- Case Western Reserve University, The MetroHealth System, Cleveland, OH, United States of America
| | - Philip R Wolinsky
- Dartmouth Geisel School of Medicine, Hanover, NH, United States of America
| | - Anna N Miller
- Washington University in St. Louis Department of Orthopaedic Surgery, St. Louis, MO, United States of America
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23
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Romere C, Ramtin S, Nunziato C, Ring D, Laverty D, Hill A. Is Pain in the Uninjured Arm Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Upper-Extremity Injury? J Hand Surg Am 2023:S0363-5023(23)00170-3. [PMID: 37204359 DOI: 10.1016/j.jhsa.2023.03.019] [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] [Received: 08/26/2022] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE During recovery from upper-extremity injury, patients sometimes express concerns regarding pain associated with increased use of the uninjured limb. Concerns about discomfort associated with increased use may represent a manifestation of unhelpful thoughts such as catastrophic thinking or kinesiophobia. We asked the following questions: (1) Among people recovering from an isolated unilateral upper-extremity injury, is pain intensity in the uninjured arm associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Is pain intensity in the injured extremity, magnitude of capability, or accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms? METHODS In this cross-sectional study of new or returning patients presenting to a musculoskeletal specialist for care for an upper-extremity injury, the patients completed scales that were used to measure the following: pain intensity in the uninjured arm, pain intensity in the injured arm, upper-extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis was used to evaluate factors associated with pain intensity in the uninjured arm, pain intensity in the injured arm, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors. RESULTS Greater pain intensity in both uninjured and injured arms was independently associated with greater unhelpful thinking regarding symptoms. A greater magnitude of capability and pain accommodation were independently associated with less unhelpful thinking regarding symptoms. CONCLUSIONS Given that greater pain intensity in the uninjured upper extremity is associated with greater unhelpful thinking, clinicians can be attuned to patient concerns about contralateral pain. Clinicians can facilitate recovery from upper-extremity injury by evaluating the uninjured limb as well as identifying and ameliorating unhelpful thinking regarding symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Chase Romere
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Carl Nunziato
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX.
| | - David Laverty
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Austin Hill
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
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Bruni DF, Pierson SR, Sarwar F, Ring D, Ramtin S. Are the Pathologic Features of Enthesopathy, Tendinopathy, and Labral and Articular Disc Disease Related to Mucoid Degeneration? A Systematic Review. Clin Orthop Relat Res 2023; 481:641-650. [PMID: 36563131 PMCID: PMC10013668 DOI: 10.1097/corr.0000000000002499] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/31/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tendinopathy, enthesopathy, labral degeneration, and pathologic conditions of the articular disc (knee meniscus and ulnocarpal) are sometimes described in terms of inflammation or damage, while the histopathologic findings are often consistent with mucoid degeneration. A systematic review of the histopathology of these structures at diverse locations might reconceptualize these diseases as expected aspects of human aging. The potential benefits of this evolution might include healthier patient and clinician mindsets as well as a reduced likelihood of overdiagnosis and overtreatment resulting from greater awareness of base rates of pathology. QUESTION/PURPOSE In this systematic review of studies of surgical specimens, we asked: Are there are any differences in the histopathologic findings of structural soft tissue conditions (mucoid degeneration, inflammation, and vascularity) by anatomic site (foot, elbow, or knee) or structure (tendon body, muscle or tendon origin or insertion [enthesis], labrum, or articular disc)? METHODS Studies between 1980 and 2021 investigating the histopathologic findings of specimens from surgery for trigger digit, de Quervain tendinopathy, plantar fasciitis, lateral and medial elbow enthesopathy, rotator cuff tendinopathy, posterior tibial tendinopathy, patellar tendinopathy, Achilles tendinopathy, or disease of the hip labrum, ulnocarpal articular disc, or knee meniscus were searched for in the PubMed, EMBASE, and CINAHL databases. Inclusion criteria were the prespecified anatomic location or structure being analyzed histologically and any findings described with respect to inflammation, vascularity, or mucoid degeneration. Studies were excluded if they were nonhuman studies or review articles. Search terms included "anatomy," "pathology," and "histopathology." These terms were coupled with anatomic structures or disorders and included "trigger finger," "de Quervain," "fasciitis, plantar," "tennis elbow," "rotator cuff tendinopathy," "elbow tendinopathy," "patellar tendonitis," "posterior tibial tendon," and "triangular fibrocartilage." This resulted in 3196 studies. After applying the inclusion criteria, 559 articles were then assessed for eligibility according to our exclusion criteria, with 52 eventually included. We recorded whether the study identified the following histopathologic findings: inflammatory cells or molecular markers, greater than expected vascularity (categorized as quantitative count, with or without controls; molecular markers; or qualitative judgments), and features of mucoid degeneration (disorganized collagen, increased extracellular matrix, or chondroid metaplasia). In the absence of methods for systematically evaluating the pathophysiology of structural (collagenous) soft tissue structures and rating histopathologic study quality, all studies that interpreted histopathology results were included. The original authors' judgment regarding the presence or absence of inflammation, greater than expected vascularity, and elements of mucoid degeneration was recorded along with the type of data used to reach that conclusion. RESULTS Regarding differences in the histopathology of surgical specimens of structural soft tissue conditions by anatomic site, there were no differences in inflammation or mucoid degeneration, and the knee meniscus was less often described as having greater than normal vascularity. There were no differences by anatomic structure. Overall, 20% (10 of 51) of the studies that investigated for inflammation reported it (nine inflammatory cells and one inflammatory marker). Eighty-three percent (43 of 52) interpreted increased vascularity: 40% (17 of 43) using quantitative methods (14 with controls and three without) and 60% (26 of 43) using imprecise criteria. Additionally, 100% (all 52 studies) identified at least one element of mucoid degeneration: 69% (36 of 52) reported an increased extracellular matrix, 71% (37 of 52) reported disorganized collagen, and 33% (17 of 52) reported chondroid metaplasia. CONCLUSION Our systematic review of the histopathology of diseases of soft tissue structures (enthesopathy, tendinopathy, and labral and articular disc) identified consistent mucoid degeneration, minimal inflammation, and imprecise assessment of relative vascularity; these findings were consistent across anatomic sites and structures, supporting a reconceptualization of these diseases as related to aging (senescence or degeneration) rather than injury or activity. CLINICAL RELEVANCE This reconceptualization supports accommodative mindsets known to be associated with greater comfort and capability. In addition, awareness of the notable base rates of structural soft tissue changes as people age might reduce overdiagnosis and overtreatment of incidental, benign, or inconsequential signal changes and pathophysiology.
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Affiliation(s)
- David F. Bruni
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - S. Ryan Pierson
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Faiza Sarwar
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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25
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Leopold SS. Editor's Spotlight/Take 5: Are the Pathologic Features of Enthesopathy, Tendinopathy, and Labral and Articular Disc Disease Related to Mucoid Degeneration? A Systematic Review. Clin Orthop Relat Res 2023; 481:636-640. [PMID: 36853888 PMCID: PMC10013662 DOI: 10.1097/corr.0000000000002604] [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: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Seth S Leopold
- Editor-in-Chief, Clinical Orthopaedics and Related Research ®, Park Ridge, IL, USA
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Teunis T, Ramtin S, Gwilym SE, Ring D, Jayakumar P. Unhelpful thoughts and distress regarding symptoms are associated with recovery from upper extremity fracture. Injury 2023; 54:1151-1155. [PMID: 36822916 DOI: 10.1016/j.injury.2023.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND There is evidence that thoughts and emotions regarding symptoms are strongly associated with levels of comfort and capability for a given injury or disease. Longitudinal data from a large cohort of people recovering from an upper extremity fracture provided an opportunity to study how these mindset factors evolve during recovery. METHODS Seven hundred and four adults (66% women, mean age 59 ± 21 years) recovering from upper extremity fracture completed two measures of reaction to symptoms (the Pain Catastrophizing Scale and the Tampa Scale of Kinesiophobia), a visual analog scale of pain intensity, and two measures of magnitude of incapability 1 week, 3 to 4 weeks, and 6 to 9 months after fracture. RESULTS Exploratory factor analysis identified distinct groupings of questions addressing unhelpful thoughts and feelings of distress regarding symptoms. The number of distinct question groupings of mindset factors diminished over time. Variations in those groupings of mindset factors were associated with a notable amount of the variation in comfort and capability at all time points. Questions pertaining to unhelpful thoughts about symptoms had stronger associations with comfort and capability than questions measuring distress about symptoms, more so as recovery progressed. CONCLUSIONS The need to integrate mental health into musculoskeletal is bolstered by the observation that mindsets-interpretation of symptoms in particular-are key contributors to comfort and capability.
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Affiliation(s)
- Teun Teunis
- University Medical Center, Utrecht, the Netherlands
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, TX, USA
| | - Stephen E Gwilym
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, TX, USA.
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, TX, USA
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