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Siaton BC, Hogans BB, Frey-Law LA, Brown LM, Herndon CM, Buenaver LF. Pain, comorbidities, and clinical decision-making: conceptualization, development, and pilot testing of the Pain in Aging, Educational Assessment of Need instrument. FRONTIERS IN PAIN RESEARCH 2024; 5:1254792. [PMID: 38455875 PMCID: PMC10918012 DOI: 10.3389/fpain.2024.1254792] [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] [Received: 07/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Pain is highly prevalent in older adults and often contextualized by multiple clinical conditions (pain comorbidities). Pain comorbidities increase with age and this makes clinical decisions more complex. To address gaps in clinical training and geriatric pain management, we established the Pain in Aging-Educational Assessment of Need (PAEAN) project to appraise the impacts of medical and mental health conditions on clinical decision-making regarding older adults with pain. We here report development and pilot testing of the PAEAN survey instrument to assess clinician perspectives. Methods Mixed-methods approaches were used. Scoping review methodology was applied to appraise both research literature and selected Medicare-based data. A geographically and professionally diverse interprofessional advisory panel of experts in pain research, medical education, and geriatrics was formed to advise development of the list of pain comorbidities potentially impacting healthcare professional clinical decision-making. A survey instrument was developed, and pilot tested by diverse licensed healthcare practitioners from 2 institutions. Respondents were asked to rate agreement regarding clinical decision-making impact using a 5-point Likert scale. Items were scored for percent agreement. Results Scoping reviews indicated that pain conditions and comorbidities are prevalent in older adults but not universally recognized. We found no research literature directly guiding pain educators in designing pain education modules that mirror older adult clinical complexity. The interprofessional advisory panel identified 26 common clinical conditions for inclusion in the pilot PAEAN instrument. Conditions fell into three main categories: "major medical", i.e., cardio-vascular-pulmonary; metabolic; and neuropsychiatric/age-related. The instrument was pilot tested by surveying clinically active healthcare providers, e.g., physicians, nurse practitioners, who all responded completely. Median survey completion time was less than 3 min. Conclusion This study, developing and pilot testing our "Pain in Aging-Educational Assessment of Need" (PAEAN) instrument, suggests that 1) many clinical conditions impact pain clinical decision-making, and 2) surveying healthcare practitioners about the impact of pain comorbidities on clinical decision-making for older adults is highly feasible. Given the challenges intrinsic to safe and effective clinical care of older adults with pain, and attendant risks, together with the paucity of existing relevant work, much more education and research are needed.
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Affiliation(s)
- Bernadette C. Siaton
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States
| | - Beth B. Hogans
- Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Laura A. Frey-Law
- Department of Physical Therapy and Rehabilitative Science, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Lana M. Brown
- Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Christopher M. Herndon
- Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, United States
- Department of Family and Community Medicine, St. Louis University School of Medicine, St. Louis, MO, United States
| | - Luis F. Buenaver
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Heikkala E, Oura P, Paananen M, Ho E, Ferreira P, Tanguay-Sabourin C, Karppinen J. Chronic disease clusters are associated with prolonged, bothersome, and multisite musculoskeletal pain: a population-based study on Northern Finns. Ann Med 2023; 55:592-602. [PMID: 36773018 PMCID: PMC9930817 DOI: 10.1080/07853890.2023.2177723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Chronic diseases often accumulate with musculoskeletal (MSK) pain. However, less evidence is available on idiosyncratic patterns of chronic diseases and their relationships with the severity of MSK pain in general MSK pain populations. MATERIAL AND METHODS Questionnaire-based data on physician-diagnosed chronic diseases, MSK pain and its dimensions (frequency, intensity, bothersomeness, and the number of pain sites), and confounders were collected from the Northern Finland Birth Cohort 1966 at the age of 46. Latent Class Analysis (LCA) was used to identify chronic disease clusters among individuals who reported any MSK pain within the previous year (n = 6105). The associations between chronic disease clusters, pain dimensions, and severe MSK pain, which was defined as prolonged (over 30 d within the preceding year), bothersome (Numerical Rating Scale >5), and multisite (two or more pain sites) pain, were analyzed using logistic regression and general linear regression models, adjusted for sex and educational level (n for the full sample = 4768). RESULTS LCA resulted in three clusters: Metabolic (10.8% of the full sample), Psychiatric (2.9%), and Relatively Healthy (86.3%). Compared to the Relatively Healthy cluster, the Metabolic and Psychiatric clusters had higher odds for daily pain and higher mean pain intensity, bothersomeness, and the number of pain sites. Similarly, the odds for severe MSK pain were up to 75% (95% confidence interval: 44%-113%) and 155% (81%-259%) higher in the Metabolic and Psychiatric clusters, respectively, after adjustments for sex and educational level. CONCLUSIONS Distinct patterns of chronic disease accumulation can be identified in the general MSK pain population. It seems that mental and metabolic health are at interplay with severe MSK pain. These findings suggest a potential need to screen for psychiatric and metabolic entities of health when treating working-aged people with MSK pain.Key messagesThis large study on middle-aged people with musculoskeletal pain aimed to examine the idiosyncratic patterns of chronic diseases and their relationships with the severity of musculoskeletal pain. Latent class cluster analysis identified three chronic disease clusters: Psychiatric, Metabolic, and Relatively Healthy. People with accumulated mental (Psychiatric cluster) or metabolic diseases (Metabolic cluster) experienced more severe pain than people who were relatively healthy (Relatively Healthy cluster). These findings suggest a potential need to screen for psychiatric and metabolic entities of health when treating working-aged people with MSK pain.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Rovaniemi Health Center, Rovaniemi, Finland
| | - Petteri Oura
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Markus Paananen
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Western Uusimaa Wellbeing Services County, Social and Health Care Services, Espoo, Finland
| | - Emma Ho
- Sydney Musculoskeletal Health, School of Health Sciences, Charles Perkins Centre, University of Sydney, Sydney, Australia.,Sydney Musculoskeletal Health, The Kolling Institute, School of Health Sciences, University of Sydney, Sydney, Australia
| | - Paulo Ferreira
- Sydney Musculoskeletal Health, School of Health Sciences, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Christophe Tanguay-Sabourin
- Alan Edwards Pain Centre for Research on Pain, McGill University, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Jaro Karppinen
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
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Marunica Karšaj J, Benjak T, Stojanović L, Grubišić F, Balen D, Grazio S. CHRONIC MULTIMORBIDITY OF LOW BACK PAIN OR OTHER CHRONIC BACK DISORDERS IN THE REPUBLIC OF CROATIA. Acta Clin Croat 2023; 62:141-152. [PMID: 38304360 PMCID: PMC10829955 DOI: 10.20471/acc.2023.62.01.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2024] Open
Abstract
The aim was to assess the prevalence of chronic multimorbidity in patients with chronic low back pain or other chronic back disorders (BD). We analyzed data from the population-based cross-sectional European Health Interview Survey (EHIS) performed in the Republic of Croatia 2014-2015 by the Croatian Institute of Public Health. Outcome was the point-prevalence of chronic multimorbidity defined as having ≥2 chronic illnesses out of 14 contained in the EHIS questionnaire, after adjustment for ten sociodemographic, anthropometric and lifestyle confounders. Amoung fourteen targeted illnesses were asthma, allergies, hypertension, urinary incontinence, kidney diseases, coronary heart disease or angina pectoris, neck disorder, arthrosis, chronic obstructive pulmonary disease, diabetes mellitus, myocardial infarction, stroke, depression, and the common category "other". We analyzed data on 268 participants with BD and 511 without it. Participants with BD had a significantly higher relative risk of any chronic multimorbidity (RRadj=2.12; 95% CI 1.55, 2.99; p<0.001), as well as of non-musculoskeletal chronic multimorbidity (RRadj=2.29; 95% CI 1.70, 3.08; p=0.001) than participants without BD. All chronic comorbidities except for asthma and liver cirrhosis were significantly more prevalent in participants with BD than in participants without BD. In the population with BD, the participants with multimorbidity had three to four times higher odds for unfavorable self-reported health outcomes than the participants with no comorbid conditions, whereas the existence of only one comorbidity was not significantly associated with a worse outcome compared to the population with no comorbidities. In conclusion, the population suffering from BD has a higher prevalence of chronic multimorbidity than the population without BD and this multimorbidity is associated with unfavorable health outcomes.
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Affiliation(s)
- Jelena Marunica Karšaj
- University Department of Rheumatology, Physical and Rehabilitation Medicine, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | | | | | - Frane Grubišić
- University Department of Rheumatology, Physical and Rehabilitation Medicine, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Diana Balen
- University Department of Rheumatology, Physical and Rehabilitation Medicine, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Simeon Grazio
- University Department of Rheumatology, Physical and Rehabilitation Medicine, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Mertens MG, Meeus M, Noten S, Verborgt O, Fransen E, Lluch Girbés E, Aguilar Rodríguez M, Navarro-Ledesma S, Fernandez-Sanchez M, Luque-Suarez A, Struyf F, Dueñas L. Understanding the clinical profile of patients with frozen shoulder: a longitudinal multicentre observational study. BMJ Open 2022; 12:e056563. [PMID: 36410809 PMCID: PMC9680192 DOI: 10.1136/bmjopen-2021-056563] [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] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION There is a large diversity in the clinical presentation of frozen shoulder (FS) and the clinical outcome is not always satisfactory. The aim of the current study was to examine to what extent range of motion (ROM) limitation, metabolic factors (diabetes mellitus and thyroid disorders), autonomic symptoms and pain sensitivity may contribute to the prognosis in terms of shoulder pain and disability and quality of life in patients with FS. METHODS Patients with stage 1 or 2 FS were longitudinally followed-up during 9 months after baseline assessment. They completed six questionnaires and underwent quantitative sensory testing (pressure pain thresholds, temporal summation and conditioned pain modulation) and ROM assessment. RESULTS One hundred and forty-nine patients with FS were initially recruited and 121 completed at least one follow-up measurement. Shoulder pain and disability improved over time and diabetes mellitus was found to be a prognostic factor for final outcome. Several domains of quality of life also improved over time and external rotation ROM, diabetes mellitus, thyroid disorder and autonomic symptoms were found to be prognostic factors for final outcome. These prognostic factors explained 2.5%-6.3% of the final outcome of shoulder pain and disability and quality of life. DISCUSSION AND CONCLUSION In patients with FS, prognostic variables were able to predict different outcomes, indicating that outcomes in this population can be variable-dependent. Other variables not explored in this study might contribute to the prognosis of patients with FS, which should be investigated in future research. In clinical practice, baseline assessment of prognostic factors and focusing on a more holistic approach might be useful to inform healthcare practitioners about progression of patients with FS during a 9-month period.
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Affiliation(s)
- Michel Gcam Mertens
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Belgium
- Pain in Motion international Research Group, www.paininmotion.be, Belgium
| | - Mira Meeus
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Belgium
- Pain in Motion international Research Group, www.paininmotion.be, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Suzie Noten
- Department of Rehabilitation Medicine, Erasmus MC University medical Center, Rotterdam, The Netherlands
- Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - Olivier Verborgt
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Belgium
- Department of Orthopedic Surgery and Traumatology, AZ Monica, Antwerpen, Belgium
- Department of Orthopedic Surgery, University Hospital Antwerp, Edegem, Belgium
| | - Erik Fransen
- StatUa Center for Statistics, University of Antwerp, Antwerpen, Belgium
| | - Enrique Lluch Girbés
- Pain in Motion international Research Group, www.paininmotion.be, Belgium
- Physiotherapy in Motion, Multi-Specialty Research Group (PTinMOTION), Department of Physical Therapy, University of Valencia, Valencia, Spain
- Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Vrije Universiteit Brussel, Brussels, Belgium
| | - Marta Aguilar Rodríguez
- Physiotherapy in Motion, Multi-Specialty Research Group (PTinMOTION), Department of Physical Therapy, University of Valencia, Valencia, Spain
| | | | | | | | - Filip Struyf
- Rehabilitation Sciences, Universiteit Antwerpen Campus Drie Eiken, Wilrijk, Belgium
| | - Lirios Dueñas
- Physiotherapy in Motion, Multi-Specialty Research Group (PTinMOTION), Department of Physical Therapy, University of Valencia, Valencia, Spain
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Kittelson AJ, Schmiege SJ, Maluf K, George SZ, Stevens-Lapsley JE. Determination of Pain Phenotypes in Knee Osteoarthritis Using Latent Profile Analysis. PAIN MEDICINE 2021; 22:653-662. [PMID: 33367906 DOI: 10.1093/pm/pnaa398] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To identify clinical phenotypes of knee osteoarthritis (OA) using measures from the following domains: 1) multimorbidity; 2) psychological distress; 3) pain sensitivity; and 4) knee impairment or pathology. DESIGN Data were collected from 152 people with knee OA and from 31 pain-free individuals. In participants with knee OA, latent profile analysis (LPA) was applied to the following measures: normalized knee extensor strength, Functional Comorbidity Index (FCI), Pain Catastrophizing Scale (PCS), and local (knee) pressure pain threshold. Comparisons were performed between empirically derived phenotypes from the LPA and healthy older adults on these measures. Comparisons were also made between pheonotypes on pain intensity, functional measures, use of health care, and history of knee injury. RESULTS LPA resulted in a four-group solution. Compared with all other groups, group 1 (9% of the study population) had higher FCI scores. Group 2 (63%) had elevated pain sensitivity and quadriceps weakness relative to group 4 and healthy older adults. Group 3 (11%) had higher PCS scores than all other groups. Group 4 (17%) had greater leg strength, except relative to healthy older adults, and reduced pain sensitivity relative to all groups. Groups 1 and 3 demonstrated higher pain and worse function than other groups, and group 4 had higher rates of knee injury. CONCLUSION Four phenotypes of knee OA were identified using psychological factors, comorbidity status, pain sensitivity, and leg strength. Follow-up analyses supported the replicability of this phenotype structure, but future research is needed to determine its usefulness in knee OA care.
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Affiliation(s)
- Andrew J Kittelson
- School of Physical Therapy and Rehabilitation Science, University of Montana, Missoula, Montana, USA.,Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA
| | - Sarah J Schmiege
- Department of Biostatistics & Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Katrina Maluf
- Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA.,Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Denver, Colorado, USA
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6
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Lentz TA, Hellkamp AS, Bhavsar NA, Goode AP, Manhapra A, George SZ. Assessment of Common Comorbidity Phenotypes Among Older Adults With Knee Osteoarthritis to Inform Integrated Care Models. Mayo Clin Proc Innov Qual Outcomes 2021; 5:253-264. [PMID: 33997625 PMCID: PMC8105527 DOI: 10.1016/j.mayocpiqo.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To establish the frequency of concordant, discordant, and clinically dominant comorbidities among Medicare beneficiaries with knee osteoarthritis (KOA) and to identify common concordant condition subgroups. Participants and Methods We used a 5% representative sample of Medicare claims data to identify beneficiaries who received a diagnosis of KOA between January 1, 2012, and September 30, 2015, and matched control group without an osteoarthritis (OA) diagnosis. Frequency of 34 comorbid conditions was categorized as concordant, discordant, or clinically dominant among those with KOA and a matched sample without OA. Comorbid condition phenotypes were characterized by concordant conditions and derived using latent class analysis among those with KOA. Results The study sample included 203,361 beneficiaries with KOA and 203,361 non-OA controls. The largest difference in frequency between the two cohorts was for co-occurring musculoskeletal conditions (23.7% absolute difference), chronic pain syndromes (6.5%), and rheumatic diseases (4.5%), all with a higher frequency among those with knee OA. Phenotypes were identified as low comorbidity (53% of cohort with classification), hypothyroid/osteoporosis (27%), vascular disease (10%), and high medical and psychological comorbidity (10%). Conclusions Approximately 47% of Medicare beneficiaries with KOA in this sample had a phenotype characterized by one or more concordant conditions, suggesting that existing clinical pathways that rely on single or dominant providers might be insufficient for a large proportion of older adults with KOA. These findings could guide development of integrated KOA-comorbidity care pathways that are responsive to emerging priorities for personalized, value-based health care.
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Affiliation(s)
- Trevor A Lentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Nrupen A Bhavsar
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adam P Goode
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Ajay Manhapra
- Department of Psychiatry, Yale School of Medicine, New Haven, CT.,Hampton VA Medical Center, Hampton, VA.,Departments of Physical Medicine & Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, VA
| | - Steven Z George
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
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7
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Lentz TA, George SZ, Manickas-Hill O, Malay MR, O'Donnell J, Jayakumar P, Jiranek W, Mather RC. What General and Pain-associated Psychological Distress Phenotypes Exist Among Patients with Hip and Knee Osteoarthritis? Clin Orthop Relat Res 2020; 478:2768-2783. [PMID: 33044310 PMCID: PMC7899410 DOI: 10.1097/corr.0000000000001520] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Psychological distress can negatively influence disability, quality of life, and treatment outcomes for individuals with hip and knee osteoarthritis (OA). Clinical practice guidelines recommend a comprehensive disease management approach to OA that includes the identification, evaluation, and management of psychological distress. However, uncertainty around the best psychological screening and assessment methods, a poor understanding of the heterogeneity of psychological distress in those with OA, and lack of guidance on how to scale treatment have limited the growth of OA care models that effectively address individual psychological needs. QUESTIONS/PURPOSES (1) Across which general and pain-related psychological distress constructs do individuals seeking conservative care for hip or knee OA report higher scores than the general population of individuals seeking conservative care for musculoskeletal pain conditions? (2) What common psychological phenotypes exist among nonsurgical care-seeking individuals with hip or knee OA? METHODS The sample included participants from the Duke Joint Health Program (n = 1239), a comprehensive hip and knee OA care program, and the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort studies (n = 871) comprising individuals seeking conservative care for knee, shoulder, low back, or neck pain. At the initial evaluation, patients completed the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool, which assesses 11 general and pain-related psychological distress constructs (depression, anxiety, fear of movement, self-efficacy for managing one's own pain). We used OSPRO-YF scores to compare levels of psychological distress between the cohorts. Cohen's d effect sizes were calculated to determine the magnitude of differences between the groups, with d = 0.20, d = 0.50, and d = 0.80 indicating small, medium, and large effect sizes, respectively. We used a latent class analysis to derive psychological distress phenotypes in people with OA based on the 11 OSPRO-YF psychological distress indicators. Psychological distress phenotypes are characterized by specific mood, belief, and behavioral factors that differentiate subgroups within a population. Phenotyping can help providers develop scalable treatment pathways that are better tailored to the common needs of patients. RESULTS Patients with OA demonstrated higher levels of general and pain-related psychological distress across all psychological constructs except for trait anxiety (that is, anxiety level as a personal characteristic rather than as a response to a stressful situation, like surgery) with small-to-moderate effect sizes. Characteristics with the largest effect sizes in the OA and overall OSPRO cohort were (Cohen's d) general anxiety (-0.66, lower in the OA cohort), pain catastrophizing (the tendency to ruminate over, maginfiy, or feel helpless about a pain experience, 0.47), kinesiophobia (pain-related fear of movement, 0.46), pain self-efficacy (confidence in one's own ability to manage his or her pain, -0.46, lower in the OA cohort), and self-efficacy for rehabilitation (confidence in one's own ability to perform their rehabilitation treatments, -0.44, lower in the OA cohort). The latent class analysis yielded four phenotypes (% sample): high distress (52%, 647 of 1239), low distress (26%, 322 of 1239), low self-efficacy and acceptance (low confidence in managing and willingness to accept pain) (15%, 186 of 1239), and negative pain coping (exhibiting poor pain coping skills) (7%, 84 of 1239). The classification error rate was near zero (2%), and the median of posterior probabilities used to assign subgroup membership was 0.99 (interquartile range 0.98 to 1.00), both indicating excellent model performance. The high-distress group had the lowest mean age (61 ± 11 years) and highest levels of pain intensity (6 ± 2) and disability (HOOS JR: 50 ± 15; KOOS JR: 47 ± 15), whereas the low-distress group had the highest mean age (63 ± 10 years) and lowest levels of pain (4 ± 2) and disability (HOOS JR: 63 ± 15; KOOS JR: 60 ± 12). However, none of these differences met or exceeded anchor-based minimal clinically important difference thresholds. CONCLUSIONS General and pain-related psychological distress are common among individuals seeking comprehensive care for hip or knee OA. Predominant existing OA care models that focus on biomedical interventions, such as corticosteroid injection or joint replacement that are designed to directly address underlying joint pathology and inflammation, may be inadequate to fully meet the care-related needs of many patients with OA due to their underlying psychological distress. We believe this because biomedical interventions do not often address psychological characteristics, which are known to influence OA-related pain and disability independent of joint pathology. Healthcare providers can develop new comprehensive hip and knee OA treatment pathways tailored to these phenotypes where services such as pain coping skills training, relaxation training, and psychological therapies are delivered to patients who exhibit phenotypes characterized by high distress or negative pain coping. Future studies should evaluate whether tailoring treatment to specific psychological phenotypes yields better clinical outcomes than nontailored treatments, or treatments that have a more biomedical focus. LEVEL OF EVIDENCE Level III, diagnostic study.
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MESH Headings
- Adaptation, Psychological
- Adult
- Affect
- Aged
- Arthralgia/diagnosis
- Arthralgia/etiology
- Arthralgia/psychology
- Arthralgia/therapy
- Cross-Sectional Studies
- Disability Evaluation
- Female
- Humans
- Male
- Mental Health
- Middle Aged
- Osteoarthritis, Hip/complications
- Osteoarthritis, Hip/diagnosis
- Osteoarthritis, Hip/psychology
- Osteoarthritis, Hip/therapy
- Osteoarthritis, Knee/complications
- Osteoarthritis, Knee/diagnosis
- Osteoarthritis, Knee/psychology
- Osteoarthritis, Knee/therapy
- Pain Measurement
- Patient Acceptance of Health Care
- Phenotype
- Predictive Value of Tests
- Psychological Distress
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Self Efficacy
- Stress, Psychological/diagnosis
- Stress, Psychological/etiology
- Stress, Psychological/psychology
- Stress, Psychological/therapy
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Affiliation(s)
- Trevor A Lentz
- T. A. Lentz, S. Z. George, R. C. Mather, Duke Clinical Research Institute at Duke University, Durham NC, USA
- T. A. Lentz, S. Z. George, W. Jiranek, R. C. Mather, Department of Orthopaedic Surgery, Duke University, Durham NC, USA
| | - Steven Z George
- T. A. Lentz, S. Z. George, R. C. Mather, Duke Clinical Research Institute at Duke University, Durham NC, USA
- T. A. Lentz, S. Z. George, W. Jiranek, R. C. Mather, Department of Orthopaedic Surgery, Duke University, Durham NC, USA
| | - Olivia Manickas-Hill
- O. Manickas-Hill, J. O'Donnell, P. Jayakumar, W. Jiranek, R. C. Mather, Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Morven R Malay
- M. Malay, Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, NC, USA
| | - Jonathan O'Donnell
- O. Manickas-Hill, J. O'Donnell, P. Jayakumar, W. Jiranek, R. C. Mather, Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Prakash Jayakumar
- O. Manickas-Hill, J. O'Donnell, P. Jayakumar, W. Jiranek, R. C. Mather, Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - William Jiranek
- T. A. Lentz, S. Z. George, W. Jiranek, R. C. Mather, Department of Orthopaedic Surgery, Duke University, Durham NC, USA
| | - Richard C Mather
- T. A. Lentz, S. Z. George, R. C. Mather, Duke Clinical Research Institute at Duke University, Durham NC, USA
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