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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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DeNovio AC, Ballenger JF, Boyapati RM, Novicoff WM, Yarboro SR, Hadeed MM. Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2639-2644. [PMID: 38739294 DOI: 10.1007/s00590-024-03972-0] [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: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. METHODS A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). RESULTS VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. CONCLUSIONS There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.
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Affiliation(s)
- Anthony C DeNovio
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd, Charlottesville, VA, 22903, USA
| | - John F Ballenger
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd, Charlottesville, VA, 22903, USA
| | - Rohan M Boyapati
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd, Charlottesville, VA, 22903, USA
| | - Wendy M Novicoff
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd, Charlottesville, VA, 22903, USA
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd, Charlottesville, VA, 22903, USA
| | - Michael M Hadeed
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd, Charlottesville, VA, 22903, USA.
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Ee JS, Dogbey GY, Fitzpatrick JK, Agnello RN, Skelly SK, Chang MH, Frost LS. Factors Associated With Chronic Pain Intensity in U.S. Army Soldiers. Mil Med 2023; 188:340-345. [PMID: 37948252 DOI: 10.1093/milmed/usad137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/17/2023] [Accepted: 04/27/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Chronic pain is prevalent among U.S. military personnel and veterans. The effectiveness of evidence-based pain treatments can be boosted with knowledge of factors associated with chronic pain perception. This study examined the factors that influence soldiers' self-rating of their chronic pain intensity. MATERIALS AND METHODS The study design was a retrospective review of the intake questionnaire from 203 soldiers seen at an Interdisciplinary Pain Management Center. The intake covered various aspects of soldiers' chronic pain experience, including pain intensity, interference in functioning, emotional sequelae, and pain-related catastrophic thinking. Pain intensity and impact were measured using the Defense and Veterans Pain Rating Scale. The mood was measured using the depression (Patient Health Questionnaire [PHQ]-9) and the anxiety (Generalized Anxiety Disorder-7) scales from the PHQ. Pain-related catastrophic thinking was measured using the Pain Catastrophizing Scale (PCS). Pain interference was assessed using a five-item scale that inquired about concentration, life and recreation enjoyment, task performance, and socializing. Data were analyzed using descriptive statistics and linear regression analyses. RESULTS The mean duration of pain was 34.73 ± 38.66 months. Regression analysis using scores from the PHQ-9, Generalized Anxiety Disorder-7, three PCS subscales (rumination, magnification, and helplessness), and pain interference scale as predictors showed that pain interference and PCS helplessness factors were significant predictors of average pain rating (R2 = 24%, P < .001). CONCLUSIONS Pain interference in functioning and pain-related thoughts of helplessness accounted for a significant degree of the variance in soldiers' self-rating of their chronic pain. The findings suggest that added attention should be directed at helping patients boost their self-efficacy in using pain-coping methods to improve their functioning and address the perception of helplessness about their pain.
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Affiliation(s)
- Juliana S Ee
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Godwin Y Dogbey
- Department of Research and Medical Education, Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - John K Fitzpatrick
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Robert N Agnello
- Department of Family Medicine, Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Stephanie K Skelly
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Min Ho Chang
- Department of Medicine, Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | - Landon S Frost
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
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Myhre L, Featherall J, O’Neill D, Rothberg D, Haller J, Higgins T, Marchand L. Patient-reported Anxiety Scores Are Associated With Lower Physical Function in Patients Experiencing Orthopaedic Trauma. Clin Orthop Relat Res 2023; 481:967-973. [PMID: 36728246 PMCID: PMC10097580 DOI: 10.1097/corr.0000000000002516] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The outcomes of orthopaedic trauma are not solely determined by injury severity or surgical treatment. Studies of numerous orthopaedic outcomes have found that psychosocial factors are also important. Symptoms of anxiety have been linked to long-term pain and disability. Although the existence of a relationship between psychosocial factors and functional outcomes is accepted across multiple disciplines, quantification of this association in patients who have experienced orthopaedic trauma has remained limited. Measuring the anxiety experienced by these individuals and the association with long-term functional outcomes remain poorly understood. QUESTIONS/PURPOSES (1) Is there an association between early postoperative anxiety symptoms and late recovery of self-reported physical function in patients with orthopaedic trauma? (2) What was the impact of other factors such as demographic variables and comorbidities on late recovery physical function scores, and how did the magnitude of these factors compare with the association with anxiety score? (3) Did patients who presented as trauma activations differ regarding their anxiety symptoms and late-recovery self-reported physical function? METHODS A total of 1550 patients with lower extremity fractures and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and physical function scores treated between January 1, 2014, and January 1, 2021, at an academic Level I trauma center in North America were assessed. We performed a bivariate regression between the initial PROMIS anxiety and physical function, as well as a multivariate regression including age, gender, BMI, and American Society of Anesthesiologists class to control for potential confounding variables. In a subgroup of 787 patients presenting as trauma activations, we performed a separate regression including Injury Severity Score. RESULTS PROMIS anxiety was associated with decreased late-recovery physical function (β = -2.64 [95% CI -3.006 to -2.205]; p < 0.001). The relationship between PROMIS anxiety and physical function remained after controlling for confounding variables in our overall cohort (β = -2.54 [95% CI -2.93 to -2.15]; p < 0.001) and in the trauma activation cohort (β = -2.71 [95% CI -3.19 to -2.23]; p < 0.001). Age and American Society of Anesthesiologists score were associated with worse PROMIS physical function scores, while being a man was associated with better PROMIS physical function scores (age: β= -1.26 [95% CI -1.50 to -1.02]; American Society of Anesthesiologists class: β=-2.99 [95% CI -3.52 to -2.46]; men: β = 0.95 [95% CI 0.16 to 1.75]). There were no differences in initial anxiety symptoms or late-recovery physical function between patients who presented as trauma activations and those who did not. Injury Severity Scores were independently associated with worse function (β = -1.45 [95% CI -2.11 to -0.79]. CONCLUSION Initial patient self-reported anxiety is negatively associated with patient-reported physical function at the final follow-up interval in a broad cohort of patients with orthopaedic lower extremity injuries undergoing surgery. Identifying patients with high initial PROMIS anxiety scores may allow us to determine which patients will report lower functional scores at the final follow-up. Future investigations could focus on the effect of psychosocial interventions such as cognitive behavioral therapy and mindfulness on functional scores. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Luke Myhre
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Joseph Featherall
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Dillon O’Neill
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - David Rothberg
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Justin Haller
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Thomas Higgins
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Lucas Marchand
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
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Diotaiuti P, Corrado S, Mancone S, Cavicchiolo E, Chirico A, Siqueira TC, Andrade A. A psychometric evaluation of the Italian short version of the Fear of Pain Questionnaire-III: Psychometric properties, measurement invariance across gender, convergent, and discriminant validity. Front Psychol 2023; 13:1087055. [PMID: 36726497 PMCID: PMC9886064 DOI: 10.3389/fpsyg.2022.1087055] [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: 11/02/2022] [Accepted: 12/12/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction The Fear of Pain Questionnaire-III (FPQ-III) is a self-assessment instrument developed specifically to measure fear based on various pain stimuli converging on three factors: severe pain, medical pain, and minor pain. It actually remains the most studied and internationally used tool even in its short versions. The aim of this work was to propose a new validation study oriented to confirm the good psychometric properties of a short model of the FPQ-III for the Italian context. Methods A large sample of participants was recruited (n = 1,064) and Exploratory Factor Analysis (EFA) as well as Confirmatory Factor Analysis (CFA) were performed. Measurement invariance of the FPQ-III across gender was also evaluated. In order to examine convergent validity, a further convenient sample (n = 292) was used and variables related to the individual's pain experience, locus of control and coping orientations were assessed. A final discriminant assessment using experimental manipulation through fear eliciting videos was performed. Results The three factors structure of the 13-item version of the questionnaire was confirmed (χ2 = 148.092, CFI = 0.971, TLI = 0.962, RMSEA = 0.046, RMSEA 90% CI = 0.037-0.056) as well as the measurement invariance across gender. Item internal reliability was satisfactory. The results provided evidence of the good predictive validity of the FPQ-III and the discriminant assessment demonstrated that the instrument is suitable in detecting changes in fear of pain induced by specific situational conditions. Discussion The scale in this short version is suitable for quickly and efficiently gathering information about the perceived intensity of such anticipatory fears that might affect even the healthy person dysfunctionally.
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Affiliation(s)
- Pierluigi Diotaiuti
- Department of Human Sciences, Society and Health, University of Cassino and Lazio, Cassino, Italy,*Correspondence: Pierluigi Diotaiuti,
| | - Stefano Corrado
- Department of Human Sciences, Society and Health, University of Cassino and Lazio, Cassino, Italy
| | - Stefania Mancone
- Department of Human Sciences, Society and Health, University of Cassino and Lazio, Cassino, Italy
| | - Elisa Cavicchiolo
- Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Andrea Chirico
- Department of Psychology of Development and Socialization Processes, Sapienza University of Rome, Rome, Italy
| | - Thais Cristina Siqueira
- Health and Sports Science Center, Department of Physical Education, CEFID, Santa Catarina State University, Florianopolis, Santa Catarina, Brazil
| | - Alexandro Andrade
- Health and Sports Science Center, Department of Physical Education, CEFID, Santa Catarina State University, Florianopolis, Santa Catarina, Brazil
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Rossano A, Al Salman A, Ring D, Guzman JM, Fatehi A. Do Unhelpful Thoughts or Confidence in Problem Solving Have Stronger Associations with Musculoskeletal Illness? Clin Orthop Relat Res 2022; 480:287-295. [PMID: 34705738 PMCID: PMC8747486 DOI: 10.1097/corr.0000000000002005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Measures of unhelpful thoughts and distress correlate with the intensity of pain and the magnitude of incapability among people seeking musculoskeletal specialty care. In this evolving knowledge area, we want to be sure we have not neglected other important mental health factors. This study addressed how measures of confidence in problem solving as well as past and current ability to achieve goals account for variation in symptoms and capability independent of unhelpful thoughts and distress. QUESTIONS/PURPOSES (1) Are measures of confidence in problem solving ability and past and current ability to achieve goals regarding future outcomes associated with variation in capability, independent of measures of symptoms of depression and anxiety (distress) and measures of unhelpful thoughts (worst-case thinking, negative pain thoughts)? (2) Are these measures independently associated with variation in pain intensity? (3) Are these measures associated with measures of symptoms of depression, symptoms of anxiety, and unhelpful thoughts? METHODS Over a 7-month period during the pandemic, we enrolled sporadically from the offices of four surgeons treating patients who sought care for various upper and lower extremity conditions. We invited approximately 200 adult new and returning patients to participate (the number of invitations was not formally tracked) and 187 accepted. Thirty-one were excluded due to markedly incomplete entries (related to a problematic attempt to use the patient's cell phone to complete questionnaires as a pandemic work around), leaving 156 for analysis. Patients completed an 11-point ordinal rating of pain intensity, two measures of unhelpful thoughts (the Pain Catastrophizing Scale and the Negative Pain Thoughts Questionnaire), the Adult Hope Scale to measure past and current ability to achieve goals, the Personal Optimism and Self-Efficacy Optimism Scale to measure confidence in problem solving ability, the Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive test to measure symptoms of anxiety, the PROMIS computer adaptive test to measure symptoms of depression, and the PROMIS physical function computer adaptive test to assess the magnitude of capability. All questionnaires were validated in previous studies. We used bivariate analyses to identify factors associated with magnitude of capability, pain intensity, confidence in problem solving ability, and past and current ability to achieve goals. All factors with a p value of less than 0.1 were included in multivariable analyses to seek associations between these measures accounting for confounders. We reported partial η2 as a measure of effect size for all multivariable regression models. The following rules of thumb are used to interpret values for partial η2: a value of 0.01 = small, 0.06 = medium, and values of 0.14 and higher show large effect size. RESULTS Greater capability was modestly associated with fewer negative pain thoughts (β = -0.63 [95% CI -1.0 to -0.22]; standard error = 0.20; partial η2 = 0.06; p = 0.003) and no self-reported comorbidities (β = 2.6 [95% CI 0.02 to 5.3]; standard error = 1.3; partial η2 = 0.03; p = 0.048) after controlling for education, symptoms of depression and anxiety, worst-case thinking, as well as past and current ability to achieve goals. In a similar multivariable model, greater pain intensity was modestly associated with greater worst-case thinking (β = 0.33 [95% CI 0.20 to 0.45]; standard error = 0.06; partial η2 = 0.16; p < 0.001) and established patients (β = -1.1 [95% CI -1.8 to -0.31]; standard error = 0.38; partial η2 = 0.05; p = 0.006). In another similar multivariable model, having more confidence in problem solving ability had a limited association with higher ratings of past and current ability to achieve goals (β = 0.15 [95% CI 0.09 to 0.21]; standard error = 0.03; partial η2 = 0.13; p < 0.001). In a final multivariable model, lower past and current ability to achieve goals was independently associated with having greater symptoms of depression (β = -0.45 [95% CI -0.67 to -0.23]; standard error = 0.11; partial η2 = 0.1; p < 0.001) and more negative pain thoughts (β = -0.49 [95% CI -0.89 to -0.09]; standard error = 0.20; partial η2 = 0.04; p = 0.02). CONCLUSION The observation that unhelpful thoughts about symptoms are more strongly associated with symptom intensity than past and current ability to achieve goals and confidence in problem solving ability add to the evidence that attentiveness to unhelpful thinking is an important aspect of musculoskeletal health. Musculoskeletal specialists can prioritize communication strategies such as relationship building and motivational interviewing that develop trust and facilitate reorientation of common unhelpful thoughts. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Ayane Rossano
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Aresh Al Salman
- 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
| | - J. Mica Guzman
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Amirreza Fatehi
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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