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Vranceanu AM, Jochimsen KN, Brewer JR, Briskin EA, Parker RA, Macklin EA, Ring D, Jacobs C, Ly T, Archer KR, Conley CEW, Harris M, Matuszewski P, Obremskey WT, Laverty D, Bakhshaie J. A Brief Mind-body Intervention Is Feasible and May Prevent Persistent Pain After Acute Orthopaedic Traumas: A Randomized Controlled Trial. Clin Orthop Relat Res 2024:00003086-990000000-01640. [PMID: 38899924 DOI: 10.1097/corr.0000000000003111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/11/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population. QUESTIONS/PURPOSES (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function? METHODS This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks. RESULTS Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness. CONCLUSION TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Ana-Maria Vranceanu
- Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kate N Jochimsen
- Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Julie R Brewer
- Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
| | - Ellie A Briskin
- Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
| | - Robert A Parker
- Harvard Medical School, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Eric A Macklin
- Harvard Medical School, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Cale Jacobs
- Massachusetts General Brigham Sports Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Thuan Ly
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Physical Medicine & Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Caitlin E W Conley
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Mitchel Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Matuszewski
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Laverty
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Jafar Bakhshaie
- Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Brightwell BD, Van Wyngaarden JJ, Samaan MA, Matuszewski PE, Jacobs CA, Noehren B. Factors Associated With Long-Term Quadriceps Muscle Function After Surgical Fixation of Lower Extremity Fractures. Phys Ther 2023; 103:pzad108. [PMID: 37581587 PMCID: PMC11009693 DOI: 10.1093/ptj/pzad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 04/18/2023] [Accepted: 06/12/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE The long-term performance of the quadriceps femoris muscle and physical function following surgical repair of a lower extremity fracture remains largely undefined. The purpose of this study was to investigate between-limb differences in quadriceps performance 12 months after surgical fixation of a lower extremity fracture. It was hypothesized that the injured limb would be significantly weaker, have a lower rate of torque development (RTD), and that there would be a reduced step-down performance compared to the uninjured limb 12 months after surgery. Additionally, this study sought to identify demographic, surgical, and psychological factors associated with poor quadriceps function 12 months after surgery. METHODS Quadriceps performance was measured bilaterally in 95 participants (49 female), aged 42 (SD = 14.5) years, 12 months after surgical fixation of a lower extremity fracture. Isometric quadriceps strength and RTD were quantified using isometric dynamometry, and a timed step-down test was used to evaluate quadriceps performance. Independent predictor variables from the time of surgery were extracted from participants' medical records. Kinesiophobia was screened at the time of testing. Wilcoxon signed-rank tests and linear regression analyses were used to assess between-limb differences in quadriceps performance and to determine factors associated with quadriceps performance 12 months after surgery. RESULTS Significant between-limb differences in each measure of quadriceps performance were identified (peak torque involved: 1.37 [0.71] Nm × kg-1; uninvolved: 1.87 [0.74] Nm × kg-1; RTD involved: 4.16 [2.75] Nm × kg-1 × s-1; uninvolved: 6.10 [3.02] Nm × kg-1 × × -1; and single-leg step-downs involved: 12.6 [5.0]; uninvolved: 21.7 [14.8]). Female biological sex, external fixation, and kinesiophobia at 12 months were associated with reduced after-surgery quadriceps performance outcomes. CONCLUSION Quadriceps performance is impaired 12 months after surgical repair of a lower extremity fracture, particularly in female participants, in cases requiring external fixation, and in those with higher kinesiophobia 12 months after surgery. IMPACT Because long-term quadriceps weakness negatively impacts functional mobility, targeted strengthening should be emphasized after surgical repair of lower extremity fracture.
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Affiliation(s)
- Benjamin D Brightwell
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Kinesiology and Health Promotion, University of Kentucky, Lexington, Kentucky, USA
| | - Joshua J Van Wyngaarden
- Army-Baylor University Doctoral Program in Physical Therapy, Department of Physical Therapy, Baylor University, San Antonio, Texas, USA
| | - Michael A Samaan
- Department of Kinesiology and Health Promotion, University of Kentucky, Lexington, Kentucky, USA
| | - Paul E Matuszewski
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Cale A Jacobs
- Mass General Brigham Sports Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brian Noehren
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky, USA
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Anagnostopoulos F, Paraponiari A, Kafetsios K. The Role of Pain Catastrophizing, Emotional Intelligence, and Pain Intensity in the Quality of Life of Cancer Patients with Chronic Pain. J Clin Psychol Med Settings 2022:10.1007/s10880-022-09921-5. [PMID: 36342590 PMCID: PMC10390631 DOI: 10.1007/s10880-022-09921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/09/2022]
Abstract
AbstractPain catastrophizing (PC) is a negative cognitive distortion to actual or anticipated pain. This study aims to investigate the relationship between pain catastrophizing, emotional intelligence, pain intensity, and quality of life (QoL) in cancer patients with chronic pain. Eighty-nine outpatients with chronic pain attending pain clinics and palliative care units were recruited. Participants were men (42.7%) and women (57.3%) with an average age of 56.44 years (SD = 14.82). Self-report psychological measures were completed, including a measure of emotional intelligence, a standard measure of PC, a scale assessing pain intensity, and a scale measuring QoL. The PC scale was found to assess three correlated yet different dimensions of pain catastrophizing (helplessness, magnification, and rumination). Moreover, as expected, patients with PC scale scores ≥ 30 had lower scores in functional QoL dimensions and higher scores in the fatigue, pain, and insomnia symptom dimensions. Regression analyses demonstrated that PC (B = − 0.391, p = 0.004), pain intensity (B = − 1.133, p < 0.001), and education (B = 2.915, p = 0.017) remained the only significant variables related to QoL, when controlling for demographic and clinical confounders. Regarding mediating effects, PC and pain intensity were jointly found to be significant mediators in the relationship between emotional intelligence and QoL. Results are discussed in the context of the clinical implications regarding interventions designed to improve cancer patients’ quality of life and offer new insight, understanding, and evaluation targets in the field of pain management.
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Van Wyngaarden JJ, Archer KR, Pennings JS, Matuszewski PE, Noehren B. Psychosocial Predictors of Chronic Pain 12 Months After Surgical Fixation for Lower Extremity Fracture: A Prospective Study. Phys Ther 2022; 102:6655886. [PMID: 35926071 DOI: 10.1093/ptj/pzac101] [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: 06/25/2021] [Revised: 03/07/2022] [Accepted: 05/29/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pain is a common outcome after lower extremity fracture (LEF) requiring surgical fixation. Although psychosocial characteristics have meaningful associations with adverse outcomes, no studies have evaluated how psychosocial characteristics throughout recovery are associated with pain outcomes. The primary purpose of this study was to determine whether psychosocial characteristics are early risk factors for pain outcomes in patients following LEF who have no history of chronic pain. METHODS Participants, 122 patients with a LEF, consented to this single-center, prospective cohort study. Measurements of depression, pain self-efficacy, pain catastrophizing, and fear of movement were completed at 1 week, 6 weeks, 3 months, 6 months, and 12 months after LEF. Chronic pain development and pain intensity were assessed at 12 months. Univariate analyses assessing the difference between means and corresponding effect sizes were evaluated between those individuals with and without chronic pain at 12 months. Separate logistic and linear regression models using psychosocial scores at each time point were used to determine the association with the development of chronic pain and pain intensity, respectively. RESULTS Of 114 patients (93.4%) who completed the study, 51 (45%) reported chronic pain at 12 months. In the univariate analysis, all psychosocial variables at 6 weeks, 3 months, 6 months, and 12 months were significantly different between those with and those without chronic pain at 12 months (Cohen d range = 0.84 to 1.65). In the multivariate regression models, all psychosocial variables at 6 weeks, 3 months, and 6 months were associated with chronic pain development (odds ratio range = 1.04 to 1.22) and pain intensity (β range = .05 to .14) at 12 months. CONCLUSION Psychosocial scores as early as 6 weeks after surgery are associated with pain outcomes 12 months after LEF. IMPACT Physical therapists should consider adding psychosocial screening throughout recovery after LEF to identify patients at increased risk for long-term pain outcomes.
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Affiliation(s)
- Joshua J Van Wyngaarden
- Army-Baylor University, Doctoral Program of Physical Therapy, Baylor University, San Antonio, Texas, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacquelyn S Pennings
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paul E Matuszewski
- College of Medicine, Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Brian Noehren
- College of Medicine, Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA.,College of Health Sciences, Department of Physical Therapy, University of Kentucky, Lexington, Kentucky, USA
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