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Harris JD, Hinojosa M, Williams JM, Stepke K, DuMont G. The Critical Importance of Recognition, Evaluation, and Management of Mental Health on Outcomes Following Hip Arthroscopy - A Synthetic Narrative Review: Current Concepts. J ISAKOS 2024:S2059-7754(24)00135-4. [PMID: 39059584 DOI: 10.1016/j.jisako.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Abstract
Mental health and wellness influence patients with hip pain and dysfunction secondary to Femoroacetabular Impingement Syndrome, acetabular dysplasia, and labral injury. Disorders of mental wellness may impact hip preservation surgery patients both before and after surgery. Major depression and generalized anxiety are the two most common diagnoses that affect hip preservation surgery patients. There are dozens of unique questionnaires that can subjectively and objectively characterize the mental health of patients with hip pain. Pain threshold and pain tolerance are two issues that must be recognized to optimally predict treatment outcome in an informed consent shared decision-making discussion. Patient expectations may also significantly influence preoperative symptoms and postoperative outcome. Pain threshold, pain tolerance, and patient expectations are entities traditionally viewed as qualitative and unmeasurable. However, many valid and reliable methods exist to quantitatively assess these patient-specific variables. Recent original research and synthetic review publications have consistently concluded similar findings: patients with disorders of mental wellness generally have lower preoperative patient-reported outcome scores, do improve following surgery, albeit to a lesser magnitude than non-mental disorder patients, and ultimately have lower postoperative scores at their final follow. As with most Orthopedic Surgery literature, the investigation of mental health and hip preservation is primarily via retrospective level four evidence with small numbers of patients from a single-center and single-surgeon at short-term follow-up. Although hip preservation surgeons are Orthopedic Surgeons by training and practice, they must be able to recognize mental wellness disorders and either treat or refer when suspected or identified.
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Affiliation(s)
- Joshua D Harris
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030.
| | - Miriam Hinojosa
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030
| | - Julia M Williams
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030
| | - Katherine Stepke
- Houston Methodist Hospital, Department of Sports Medicine and Orthopedics, 6565 Fannin Street, Houston, TX, 77030
| | - Guillaume DuMont
- Lexington Orthopaedics and Sports Medicine, 3016 Longtown Commons Drive, Suite 200, Columbia, SC 29229
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Cabell GH, Kwon NF, Sutton KF, Lentz TA, Lewis BD, Olson S, Mather RC. Pain-Associated Psychological Distress Is of High Prevalence in Patients With Hip Pain: Characterizing Psychological Distress and Phenotypes. Arthrosc Sports Med Rehabil 2024; 6:100846. [PMID: 38260823 PMCID: PMC10801259 DOI: 10.1016/j.asmr.2023.100846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/11/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose To identify common pain-related psychological factors among patients seeking care for athletic hip pain, as well as characterize psychological distress phenotypes and compare hip-specific quality-of-life measures across those phenotypes. Methods A total of 721 patients were recruited from hip preservation clinics. The Optimal Screening for Prediction of Referral and Outcome-Yellow Flag Assessment Tool (OSPRO-YF) was used to identify the presence or absence of 11 different pain-associated psychological distress characteristics (yellow flags), while the International Hip Outcome Tool-12 (iHOT-12) was used to assess hip-related quality of life. Latent class analysis identified patient subgroups (phenotypes) based on naturally occurring combinations of distress characteristics. An analysis of variance was used to compare demographics, number of yellow flags, and iHOT-12 scores across phenotypes. Results The median (interquartile range) number of yellow flags was 6 (3-9), with 13.5% of the sample reporting 11 yellow flags. Latent class analysis (L2 = 543.3, classification errors = 0.082) resulted in 4 phenotypes: high distress (n = 299, 41.5%), low distress (n = 172, 23.9%), low self-efficacy and acceptance (n = 74, 10.3%), and negative pain coping (n = 276, 24.4%). Significant differences in mean yellow flags existed between all phenotypes except low self-efficacy and negative pain coping. There were no differences in demographics between phenotypes. The high distress class had the lowest mean iHOT-12 score (mean [SD], 23.5 [17.6]), with significant differences found between each phenotypic class. Conclusions There was a high prevalence of pain-associated psychological distress in patients presenting to tertiary hip arthroscopy clinics with hip pain. Furthermore, hip quality-of-life outcome scores were uniformly lower in patients with higher levels of psychological distress. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Grant H Cabell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Nicholas F Kwon
- Department of Orthopaedic Surgery, Stanford Medicine, Redwood City, California, U.S.A
| | - Kent F Sutton
- Duke University School of Medicine, Durham, North Carolina, U.S.A
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
- Duke Clinical Research Institute, Durham, North Carolina, U.S.A
| | - Brian D Lewis
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Steven Olson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
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Allahabadi S, Chapman RS, Fenn TW, Browning RB, Nho SJ. The Gluteus-Score-7 Predicts the Likelihood of Both Clinical Success and Failure Following Surgical Repair of the Hip Gluteus Medius and/or Minimus. Arthroscopy 2024; 40:343-351.e4. [PMID: 37207918 DOI: 10.1016/j.arthro.2023.03.035] [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: 02/07/2023] [Revised: 02/20/2023] [Accepted: 03/19/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To identify patient preoperative history, examination, and imaging characteristics that increase the risk of postoperative failure of gluteus medius/minimus repair, and to develop a decision-making aid predictive of clinical outcomes for patients undergoing gluteus medius/minimus repair. METHODS Patients from 2012 to 2020 at a single institution undergoing gluteus medius/minimus repair with minimum 2-year follow-up were identified. MRIs were graded according to the "three-grade" classification system: grade 1: partial-thickness tear, grade 2: full-thickness tears with <2 cm of retraction, grade 3: full-thickness tears with ≥2 cm retraction. Failure was defined as undergoing revision within 2 years postoperatively or not achieving both a cohort-calculated minimal clinically important difference (MCID) and responding "no" to patient acceptable symptom state (PASS). Inversely, success was defined as reaching both an MCID and responding "yes" to PASS. Predictors of failure were verified on logistic regression and a predictive scoring model, the Gluteus-Score-7, was generated to guide treatment-decision making. RESULTS In total, 30 of 142 patients (21.1%) were clinical failures at mean ± SD follow-up of 27.0 ± 5.2 months. Preoperative smoking (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.0-8.4; P = .041), lower back pain (OR, 2.8; 95% CI, 1.1-7.3; P = .038), presence of a limp or Trendelenburg gait (OR, 3.8; 95% CI, 1.5-10.2; P = .006), history of psychiatric diagnosis (OR, 3.7; 95% CI, 1.3-10.8; P = .014), and increased MRI classification grades (P ≤ .042) were independent predictors of failure. The Gluteus-Score-7 was generated with each history/examination predictor assigned 1 point and MRI classes assigned corresponding 1-3 points (min 1, max 7 score). A score of ≥4/7 points was associated with risk of failure and a score ≤2/7 points was associated with clinical success. CONCLUSIONS Independent risk factors for revision or not achieving either MCID or PASS after gluteus medius and/or minimus tendon repair include smoking, preoperative lower back pain, psychiatric history, Trendelenburg gait, and full-thickness tears, especially tears with ≥2 cm retraction. The Gluteus-Score-7 tool incorporating these factors can identify patients at risk of both surgical treatment failure and success, which may be useful for clinical decision-making. LEVEL OF EVIDENCE Level IV, prognostic case series.
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Affiliation(s)
- Sachin Allahabadi
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Reagan S Chapman
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Thomas W Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - Robert B Browning
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
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Smith C, Nero L, Holleyman R, Khanduja V, Malviya A. Hip Arthroscopy for Femoroacetabular Impingement Is Associated With Improved Sexual Function And Quality of Life. Arthroscopy 2023:S0749-8063(23)01019-8. [PMID: 38154530 DOI: 10.1016/j.arthro.2023.12.015] [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: 05/16/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE The purpose of this study was to investigate changes in sexual function and activity after arthroscopic hip surgery for femoroacetabular impingement using the United Kingdom Non-Arthroplasty Hip Registry dataset. Subanalyses were performed between males and females, and patients over 40 and under 40 years old. METHODS Patients who had arthroscopic hip surgery between January 1, 2012, and October 31, 2020, were aged over 16, and completed the relevant patient-reported outcome measures were included. Question 9 of the International Hip Outcome Tool-12 (sexual activity question [SAQ]) refers to problems with sexual activity, and responses to this were compared before surgery and at 6 and 12 months after surgery. Subanalyses were also performed, including SAQ scores by patients' sex or age. SAQ scores were correlated with Euroqol-5 dimension-5 level self-reporting tool (EQ-5D-5L) scores using Spearman's rank coefficient. RESULTS SAQ was answered by 2,547 patients before and at 6 months after surgery (62.3% female, median age = 36.2, interquartile range [IQR] = 29-44 years) and by 2,314 at 12 months (61.9% female, median age = 36.2, IQR = 29-44 years). Scores for sexual activity increased from 35.0 before surgery to 70.0 at 6 months (P < .001) and were maintained at 12 months (P < .001). Female patients demonstrated a significantly greater improvement in their scores for sexual function from before surgery (median = 30.0, IQR = 14-50) to 6 months (median = 60, IQR = 28-86, P < .001) and 12 months (median = 62.0, IQR = 29-90, P < .001), compared to male patients (preoperative median = 50.0, IQR 25-84; 6-month median = 80, IQR = 45-97; 12-month median = 80, IQR = 41-98). The effect of age on improvements in sexual function did not demonstrate a significant difference. A significant positive correlation was found between improvements in sexual function and quality of life, as measured by the EQ-5D-5L, at 6 and 12 months (P < .001). CONCLUSION Hip arthroscopy for symptomatic femoroacetabular impingement produces an improvement in sexual function and activity. Scores for sexual function improved regardless of patient age or sex; however, female patients experienced a greater improvement in sexual function than males. LEVEL OF EVIDENCE Level III (Retrospective cohort study).
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Affiliation(s)
- Christian Smith
- Northumbria Healthcare NHS Trust, Newcastle Upon Tyne, United Kingdom.
| | - Lucca Nero
- University of Newcastle, Newcastle Upon Tyne, United Kingdom
| | - Richard Holleyman
- Northumbria Healthcare NHS Trust, Newcastle Upon Tyne, United Kingdom
| | - Vikas Khanduja
- Cambridge University NHS Foundation Trust, Cambridge, United Kingdom
| | - Ajay Malviya
- Northumbria Healthcare NHS Trust, Newcastle Upon Tyne, United Kingdom
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DeMargel RD, Steger-May K, Haroutounian S, Zorn P, Cheng A, Clohisy JC, Harris-Hayes M. Personal factors and baseline function in patients undergoing non-operative management for chronic hip-related groin pain: a cross-sectional study. BMJ Open Sport Exerc Med 2023; 9:e001685. [PMID: 37937305 PMCID: PMC10626773 DOI: 10.1136/bmjsem-2023-001685] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Aim Little is known about the relationship between personal factors and perception of hip-related function among patients with chronic hip-related groin pain (HRGP) seeking non-operative management. This analysis was performed to determine if depressive symptoms, central sensitisation, movement evoked pain (MEP), pressure hypersensitivity and activity level were associated with patients' perception of hip-related function, represented by the International Hip Outcome Tool (iHOT-33). Methods This cross-sectional study used baseline data from a pilot randomised clinical trial. Participants had anterior hip symptoms for at least 3 of the past 12 months reproduced on examination. Depressive symptoms, central sensitisation and activity level were quantified with self-report questionnaires. MEP was assessed during step down and squat. Pain pressure threshold (PPT) was used to assess pressure hypersensitivity. Statistical analysis was performed to assess bivariate association between variables and independent association of variables with iHOT-33. Results Data from 33 participants (aged 18-40 years) with HRGP were analysed. Greater depressive symptoms (rs=-0.48, p=0.005), higher MEP during step down (rs=-0.36, p=0.040) and squat (rs=-0.39, p=0.024), and greater central sensitisation (rs=-0.33, p=0.058) were associated with lower (worse) iHOT-33 scores. Greater depressive symptoms (β=-0.47, 95% CI -0.76 to -0.17; p=0.003) and higher MEP during squat (β=-0.38, 95% CI -0.68 to -0.08; p=0.014) accounted for 37% of variability in iHOT-33. After adjusting for depressive symptoms and MEP, PPT, central sensitisation symptoms and activity level were not associated iHOT-33. Conclusions In patients with HRGP seeking non-operative management, greater depressive symptoms and MEP are independently associated with worse self-perceived hip function. Trial registration number NCT03959319.
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Affiliation(s)
- Rebecca D DeMargel
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri, USA
| | - Karen Steger-May
- Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Simon Haroutounian
- Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patricia Zorn
- Patricia Zorn Center for Physical Therapy and Spine Rehabilitation, St Louis, Missouri, USA
| | - Abby Cheng
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - John C Clohisy
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Marcie Harris-Hayes
- Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Jochimsen KN, Kim JS, Jayabalan P, Lawrence C, Lewis CL, Prather H, Bostrom MP. Arthritis Foundation/HSS Workshop on Hip Osteoarthritis, Part 3: Rehabilitation and Exercise. HSS J 2023; 19:447-452. [PMID: 37937088 PMCID: PMC10626932 DOI: 10.1177/15563316231192098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 11/09/2023]
Abstract
Far more publications are available for osteoarthritis of the knee than of the hip. Recognizing this research gap, the Arthritis Foundation (AF), in partnership with the Hospital for Special Surgery (HSS), convened an in-person meeting of thought leaders to review the state of the science of and clinical approaches to hip osteoarthritis. This article summarizes the recommendations gleaned from 5 presentations given on hip-related rehabilitation at the 2023 Hip Osteoarthritis Clinical Studies Conference, which took place on February 17 and 18, 2023, in New York City.
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Affiliation(s)
- Kate N Jochimsen
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | | | - Prakash Jayabalan
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cecelia Lawrence
- Acute Care Rehabilitation, Hospital for Special Surgery, New York, NY, USA
| | - Cara L Lewis
- Department of Physical Therapy, Boston University, Boston, MA, USA
| | - Heidi Prather
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
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Kuhn AW, Clohisy JC, Troyer SC, Cheng AL, Hillen TJ, Pascual-Garrido C, Tatman J, Bloom N, Schoenecker PL, Nepple JJ. Team Approach: Hip Preservation Surgery. JBJS Rev 2023; 11:01874474-202310000-00001. [PMID: 37793005 DOI: 10.2106/jbjs.rvw.23.00041] [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: 10/06/2023]
Abstract
The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.
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Affiliation(s)
- Andrew W Kuhn
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - John C Clohisy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Abby L Cheng
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Travis J Hillen
- Department of Radiological Science, Washington University in St. Louis, St. Louis, Missouri
| | | | - Justin Tatman
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Nancy Bloom
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri
| | - Perry L Schoenecker
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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Cheng AL, Leo AJ, Calfee RP, Dy CJ, Armbrecht MA, Abraham J. What Are Orthopaedic Patients' and Clinical Team Members' Perspectives Regarding Whether and How to Address Mental Health in the Orthopaedic Care Setting? A Qualitative Investigation of Patients With Neck or Back Pain. Clin Orthop Relat Res 2023; 481:1415-1429. [PMID: 36480637 PMCID: PMC10263201 DOI: 10.1097/corr.0000000000002513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/10/2022] [Accepted: 11/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Across virtually all orthopaedic subspecialties, symptoms of depression, anxiety, and unhelpful thinking are associated with worse patient-reported satisfaction with orthopaedic treatment and increased postoperative complications. In the orthopaedic community, there is growing interest in patients' mental health in the orthopaedic care setting, but addressing mental health is still not a focus of orthopaedic clinical training. There is a persistent awareness gap about how to address mental health in orthopaedic care in a manner that is simultaneously feasible in a busy orthopaedic practice and acceptable to patients who are presenting for treatment of a musculoskeletal condition. QUESTIONS/PURPOSES (1) What are orthopaedic patients' and clinical team members' current perceptions and motivators regarding addressing mental health as part of orthopaedic care? (2) What barriers do patients and clinicians face regarding addressing mental health as part of orthopaedic care? (3) What are facilitators for patients and clinicians related to addressing mental health as part of orthopaedic care? (4) What are practical, acceptable implementation strategies to facilitate addressing mental health as part of orthopaedic care? METHODS This was a single-center, qualitative study conducted from January through May 2022 in the orthopaedic department of a large, urban, tertiary care academic medical center. Semistructured interviews were conducted with members of two stakeholder groups: orthopaedic patients and orthopaedic clinical team members. We interviewed 30 adult patients (of 85 patients who were eligible and approached) who had presented to our orthopaedic department for management of neck or back pain lasting for 3 or more months. By prescreening clinic schedules, patients were purposively sampled to include representatives from varied sociodemographic backgrounds and with a range of severity of self-reported symptoms of depression and anxiety (from none to severe on the Patient-Reported Outcomes Measurement Information System Depression and Anxiety measures) (mean age 59 ± 14 years, 70% [21 of 30] women, 60% [18 of 30] White, median pain duration 3.3 [IQR 1.8 to 10] years). We also interviewed 22 orthopaedic clinicians and clinical support staff members (of 106 team members who were eligible and 25 who were approached). Team members were purposively sampled to include representatives from the full range of adult orthopaedic subspecialties and early-, mid-, and late-career physicians (11 of 22 were women, 16 of 22 were White, and 13 of 22 were orthopaedic surgeons). Interviews were conducted in person or via secure video conferencing by trained qualitative researchers. The interview guides were developed using the Capability, Opportunity, Motivation, Behavior model of behavior change. Two study team members used the interview transcripts for coding and thematic analysis, and interviews with additional participants from each stakeholder group continued until two study team members independently determined that thematic saturation of the components of the Capability, Opportunity, Motivation, Behavior model had been reached. Each participant statement was coded as a perception, motivator, barrier, facilitator, or implementation strategy, and inductive coding was used to identify themes in each category. RESULTS In contrast to the perceptions of some orthopaedic clinicians, most patients with orthopaedic conditions expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopaedic care plan. Motivation to address mental health was expressed the most strongly among orthopaedic clinical team members who were aware of high-quality evidence that demonstrated a negative impact of symptoms of depression and anxiety on metrics for which they are publicly monitored or those who perceived that addressing patients' mental health would improve their own quality of life. Barriers described by patients with orthopaedic conditions that were related to addressing mental health in the context of orthopaedic care included clinical team members' use of select stigmatizing words and perceived lack of integration between responses to mental health screening measures and the rest of the orthopaedic care encounter. Orthopaedic clinical team members commonly cited the following barriers: lack of available mental health resources they can refer patients to, uncertainty regarding the appropriateness for them to discuss mental health, and time pressure and lack of expertise or comfort in discussing mental health. Facilitators identified by orthopaedic clinical teams and patients to address mental health in the context of orthopaedic care included the development of efficient, adaptable processes to deliver mental health interventions that preferably avoid wasted paper resources; initiation of mental health-related discussion by an orthopaedic clinical team member in a compassionate, relevant context after rapport with the patient has been established; and the availability of a variety of affordable, accessible mental health interventions to meet patients' varied needs and preferences. Practical implementation strategies identified as suitable in the orthopaedic setting to increase appropriate attention to patients' mental health included training orthopaedic clinical teams, establishing a department or institution "mental health champion," and integrating an automated screening question into clinical workflow to assess patients' interest in receiving mental health-related information. CONCLUSION Orthopaedic patients want their mental health to be acknowledged as part of a holistic orthopaedic care plan. Although organization-wide initiatives can address mental health systematically, a key facilitator to success is for orthopaedic clinicians to initiate compassionate, even if brief, conversations with their patients regarding the interconnectedness of mental health and musculoskeletal health. Given the unique challenges to addressing mental health in the orthopaedic care setting, additional research should consider use of a hybrid effectiveness-implementation design to identify effective methods of addressing mental health that are feasible and appropriate for this clinical setting. CLINICAL RELEVANCE Orthopaedic clinicians who have had negative experiences attempting to address mental health with their patients should be encouraged to keep trying. Our results suggest they should feel empowered that most patients want to address mental health in the orthopaedic care setting, and even brief conversations using nonstigmatizing language can be a valuable component of an orthopaedic treatment plan.
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Affiliation(s)
- Abby L. Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashwin J. Leo
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan P. Calfee
- Division of Hand and Wrist, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher J. Dy
- Division of Hand and Wrist, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Melissa A. Armbrecht
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Joanna Abraham
- Department of Anesthesiology & Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA
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9
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Zhang W, Singh SP, Clement A, Calfee RP, Bijsterbosch JD, Cheng AL. Improvements in Physical Function and Pain Interference and Changes in Mental Health Among Patients Seeking Musculoskeletal Care. JAMA Netw Open 2023; 6:e2320520. [PMID: 37378984 PMCID: PMC10308248 DOI: 10.1001/jamanetworkopen.2023.20520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/23/2023] [Indexed: 06/29/2023] Open
Abstract
Importance Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health. Objective To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care. Design, Setting, and Participants This cohort study included adult patients treated by an orthopedic department of a tertiary care US academic medical center from June 22, 2015, to February 9, 2022. Eligible participants presented between 4 and 6 times during the study period for 1 or more musculoskeletal conditions and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit. Exposure PROMIS Physical Function and Pain Interference scores. Main Outcomes and Measures Linear mixed effects models were used to determine whether improvements in PROMIS Anxiety and PROMIS Depression scores were associated with improved PROMIS Physical Function or Pain Interference scores after controlling for age, gender, race, and PROMIS Depression (for the anxiety model) or PROMIS Anxiety (for the depression model). Clinically meaningful improvement was defined as 3.0 points or more for PROMIS Anxiety and 3.2 points or more for PROMIS Depression. Results Among 11 236 patients (mean [SD] age, 57 [16] years), 7218 (64.2%) were women; 120 (1.1%) were Asian, 1288 (11.5%) were Black, and 9706 (86.4%) were White. Improvements in physical function (β = -0.14; 95% CI, -0.15 to -0.13; P < .001) and pain interference (β = 0.26; 95% CI, 0.25 to 0.26; P < .001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of 21 PROMIS points or more (95% CI, 20-23 points) on Physical Function or 12 points or more (95% CI, 12-12 points) on Pain Interference would be required. Improvements in physical function (β = -0.05; 95% CI, -0.06 to -0.04; P < .001) and pain interference (β = 0.04; 95% CI, 0.04 to 0.05; P < .001) were not associated with meaningfully improved depression symptoms. Conclusions and Relevance In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms, and were not associated with any meaningful improvement in depression symptoms. Patients seeking musculoskeletal care clinicians providing treatment cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety.
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Affiliation(s)
- Wei Zhang
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Som P. Singh
- University of Missouri–Kansas City School of Medicine, Kansas City
| | - Amdiel Clement
- Washington University School of Medicine, St Louis, Missouri
| | - Ryan P. Calfee
- Division of Hand and Wrist, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Janine D. Bijsterbosch
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Abby L. Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri
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Cheng AL, Carbonell KV, Prather H, Hong BA, Downs DL, Metzler JP, Hunt DM. Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain. PM R 2023; 15:761-771. [PMID: 35567523 PMCID: PMC9659670 DOI: 10.1002/pmrj.12847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/20/2022] [Accepted: 05/01/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Factors that motivate musculoskeletal patients to pursue an intensive, lifestyle medicine-based approach to care are poorly understood. OBJECTIVE To determine whether, compared to patients seeking musculoskeletal care through traditional pathways, patients who choose an intensive lifestyle medicine program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and/or more biopsychosocial comorbidities. DESIGN Cross-sectional analysis of existing medical records from 2018 to 2021. SETTING Orthopedic department of one academic medical center. PATIENTS Fifty consecutive patients who enrolled in an intensive lifestyle medicine program to address a musculoskeletal condition. Comparison groups were the following: (1) 100 patients who presented for standard nonoperative musculoskeletal care, and (2) 100 patients who presented for operative evaluation by an orthopedic surgeon and qualified for joint arthroplasty. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Primary outcomes were age-adjusted, between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS) physical and psychological health measures. Secondary outcomes were between-group differences in sociodemographic and medical history characteristics. RESULTS Patients who enrolled in the intensive lifestyle medicine program were more racially diverse (non-White race: lifestyle cohort 34% vs. comparison cohorts 16%-18%, p ≤ .029) and had a higher prevalence of obesity and diabetes than both comparison groups (mean body mass index: lifestyle cohort 37.6 kg/m2 vs. comparison cohorts 29.3-32.0, p < .001; diabetes prevalence: lifestyle cohort 32% vs. comparison cohorts 12%-16%, p ≤ .024). Compared to standard nonoperative patients, there were no clear between-group differences in PROMIS physical or psychological health scores. Compared to standard operative evaluation patients, patients in the lifestyle program reported worse anxiety but less pain interference (PROMIS Anxiety: B = 3.8 points [95% confidence interval, 0.1 to 7.4], p = .041; Pain interference: B = -3.6 [-6.0 to -1.2], p = .004). CONCLUSIONS Compared to musculoskeletal patients who sought care through traditional pathways, patients who chose an intensive lifestyle medicine pathway had a higher prevalence of metabolic comorbidities, but there was substantial overlap in patients' physical, psychological, and sociodemographic characteristics.
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Affiliation(s)
- Abby L Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | | | - Heidi Prather
- Department of Physiatry, Hospital for Special Surgery, Weill Cornell Medical College, New York City, New York, USA
| | - Barry A Hong
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Dana L Downs
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - John P Metzler
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Devyani M Hunt
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Cheng AL, Leo AJ, Calfee RP, Dy CJ, Armbrecht MA, Abraham J. Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis. BMC Psychiatry 2023; 23:347. [PMID: 37208668 DOI: 10.1186/s12888-023-04868-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/13/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care. METHODS This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention. RESULTS Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care. CONCLUSIONS Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Abby L Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
| | - Ashwin J Leo
- Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Ryan P Calfee
- Division of Hand and Wrist, Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Christopher J Dy
- Division of Hand and Wrist, Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Melissa A Armbrecht
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joanna Abraham
- Department of Anesthesiology & Institute for Informatics, Washington University School of Medicine, 4990 Children's Place, St. Louis, MO, 63110, USA
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12
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Probst DT, Sookochoff MF, Harris-Hayes M, Prather H, Lipsey KL, Cheng AL. What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2023; 53:286–306. [PMID: 36892224 PMCID: PMC10176100 DOI: 10.2519/jospt.2023.11666] [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] [Indexed: 03/10/2023]
Abstract
OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.
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Affiliation(s)
- Daniel T Probst
- Summit Orthopedics, Twin Cities, MN USA
- Deparment of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Michael F Sookochoff
- Deparment of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Marcie Harris-Hayes
- Deparment of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO USA
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO USA
| | - Heidi Prather
- Department of Physical Medicine and Rehabilitation, Weill Cornell Medical College, New York City, NY USA
| | - Kim L Lipsey
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, MO USA
| | - Abby L Cheng
- Deparment of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO USA
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13
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Albertoni DB, Gianola S, Bargeri S, Hoxhaj I, Munari A, Maffulli N, Castellini G. Does femoroacetabular impingement syndrome affect range of motion? A systematic review with meta-analysis. Br Med Bull 2023; 145:45-59. [PMID: 36368014 DOI: 10.1093/bmb/ldac027] [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] [Accepted: 10/03/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND It is unclear whether femoroacetabular impingement syndrome (FAIS) affect hip range of motion (ROM). SOURCES OF DATA We performed a systematic review with meta-analysis searching six electronic databases from inception to March 21, 2022. We included studies assessing hip ROM in FAIS, FAI morphology without symptoms (FAIm), and healthy controls. Mean differences between groups were measured in ROM degrees with 95% confidence interval (CI). AREAS OF AGREEMENT A total of 17 studies (1702 hips) were included. Comparison of FAIS patients versus healthy controls showed that hip ROM was clinically and statistically reduced in FAIS for internal rotation (90° hip flexion, -8.01°, 95% CI: -11.21, -4.90; 0° hip flexion -6.38°, 95% CI: -9.79, -2.97); adduction (90° hip flexion, -4.74°, 95% CI: -8.13, -1.34); flexion (-5.41°, 95% CI: -7.05, -3.49), abduction (0° hip flexion, -5.76°, 95% CI: -8.38, -3.23), and external rotation (90° hip flexion, -3.5°, 95% CI: -5.32, -1.67) ranging from low to high certainty of evidence. Comparison of FAIm versus healthy controls showed no statistically significant differences in any direction of movement, albeit with uncertainty of evidence. AREAS OF CONTROVERSY The certainty of evidence was unclear, particularly for asymptomatic FAIm. GROWING POINTS Hip ROM may be reduced in all directions except extension in FAIS compared to controls. Hip ROM may not be restricted in asymptomatic FAIm. AREAS TIMELY FOR DEVELOPING RESEARCH Further studies are needed to resolve the uncertainty of evidence about ROM restrictions in asymptomatic FAIm compared to healthy controls.
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Affiliation(s)
- Davide Bruno Albertoni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Bargeri
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Ilda Hoxhaj
- Sezione di Igiene, Dipartimento Universitario di Scienze della Vita e Sanità Pubblica, Istituto di Sanità Pubblica, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Alice Munari
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Nicola Maffulli
- Department of Orthopaedics, School of Medicine, Surgery and Dentistry, Salerno, Italy
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK
- Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK
| | - Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
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Leo H, Shelton T, Bradley H. Criteria-Based Rehabilitation Following Revision Hip Arthroscopy: A Clinical Commentary. Int J Sports Phys Ther 2023; 18:477-492. [PMID: 37020439 PMCID: PMC10069339 DOI: 10.26603/001c.71355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/15/2023] [Indexed: 04/04/2023] Open
Abstract
Hip revision arthroscopy is becoming an increasingly popular surgery for those with unsatisfactory outcomes following primary hip arthroscopy. With the relatively uncommon but potentially increased difficulty of rehabilitation from this surgery, a lack of established research regarding rehabilitative programs remains. Therefore, the purpose of this clinical commentary is to propose a criterion-based progression that considers the intricacies present following a hip revision arthroscopy from early rehabilitation through return to sport. Criteria are presented clearly to promote objective progression through rehabilitation as opposed to relying on time since surgery as revision surgeries do not always follow traditional tissue healing time-frames. This criterion based progression promotes range of motion (ROM), strength, gait, neuromuscular control, load introduction and gradual return to play. Level of Evidence 5.
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15
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Gruskay JA, Martin MB, Shelton TJ, Comfort SM, Day HK, Philippon MJ. Improved Mental Health Status and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement. Am J Sports Med 2023; 51:1525-1530. [PMID: 36942740 DOI: 10.1177/03635465231160289] [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: 03/23/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is often a chronic problem, which can lead to a decrease in mental well-being. PURPOSE/HYPOTHESIS The purpose of this study was to determine patient mental health improvement after hip arthroscopy and if this improvement correlated with improved outcomes. It was hypothesized that patients with low mental health (LMH) status would improve after hip arthroscopy for FAI and that their patient-reported outcomes (PROs) would significantly improve after surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who underwent hip arthroscopy with labral repair between 2008 and 2015 were included. The minimum follow-up was 2 years. PROs included the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports (HOS-Sports), and 12-Item Short Form Health Survey (SF-12). The minimal clinically important difference and Patient Acceptable Symptom State (PASS) were determined for HOS-ADL, HOS-Sports, and the mHHS based on previously published studies. Patients who scored <46.5 on the SF-12 Mental Component Summary (MCS) were in the LMH group, and those who scored ≥46.5 were in the high mental health (HMH) group. RESULTS In total, 120 (21%) of the 566 patients were in the LMH group and 446 (79%) patients were in the HMH group preoperatively. There was no difference in age or sex between groups. Patients in the LMH group had lower mHHS, HOS-ADL, and HOS-Sports at the mean 4-year follow-up and were less likely to reach PASS for the scores. Postoperatively, 84% (478/566) of the entire group was in the HMH group. A total of 88 (73%) of the LMH group improved to HMH. A multiple linear regression model for change in MCS identified independent predictors of changes in preoperative MCS to be LMH group preoperatively, change in HOS-Sports, and change in mHHS (r2 = 0.4; P < .001). CONCLUSION HMH was achieved in 84% of the patients after hip arthroscopy for FAI. Improvement in MCS was correlated with function and activity, as indicated by a significant correlation with HOS-ADL and HOS-Sports. A small percentage of patients did see a decline in their MCS score. This study showed that patients with LMH scores before hip arthroscopy for FAI can improve to normal/high mental health, and this correlated with higher PROs.
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Affiliation(s)
- Jordan A Gruskay
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
| | | | - Trevor J Shelton
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
| | | | - Hannah K Day
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
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16
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Zhang W, Singh SP, Clement A, Calfee RP, Bijsterbosch JD, Cheng AL. Relationships between improvement in physical function, pain interference, and mental health in musculoskeletal patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.12.23285824. [PMID: 36824736 PMCID: PMC9949185 DOI: 10.1101/2023.02.12.23285824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Importance Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health. Objective To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care. Design Retrospective cohort study from June 22, 2015 to February 9, 2022. Setting Orthopedic department of a tertiary care US academic medical center. Participants Consecutive sample of adult patients who presented to the musculoskeletal clinic 4 to 6 times during the study period and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit. Exposure PROMIS Physical Function and Pain Interference scores. Main Outcomes and Measures Linear mixed effects models were used to determine whether: 1) PROMIS Anxiety and 2) PROMIS Depression scores improved as a function of improved PROMIS Physical Function or Pain Interference scores, after controlling for age, gender, race, and PROMIS Depression (for the Anxiety model) and PROMIS Anxiety (for the Depression model). Clinically meaningful improvement was defined as ≥3.0 points for PROMIS Anxiety and ≥3.2 points for PROMIS Depression. Results Among 11,236 patients (mean [SD] age 57 [16] years), 9,706 (86%) were White, and 7,218 (64%) were women. Improvements in physical function (β=-0.14 [95% CI -0.15- -0.13], p<0.001) and pain interference (β=0.26 [0.25-0.26], p<0.001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of ≥21 [20-23] PROMIS points on Physical Function or ≥12 [12-12] points on Pain Interference would be required. Improvements in physical function (β=-0.05 [- 0.06- -0.04], p<0.001) and pain interference (β=0.04 [0.04-0.05], p<0.001) were not associated with meaningfully improved depression symptoms. Conclusions and Relevance In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms and were not associated with any meaningful improvement in depression symptoms. Among patients seeking musculoskeletal care, musculoskeletal clinicians and patients cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety. Key Points Question: Among patients seeking musculoskeletal care, are improvements in physical function and pain interference associated with meaningful changes in symptoms of anxiety and depression?Findings: In this large cohort study, improvement by ≥2.3 population-level standard deviations (SD) on PROMIS Physical Function or ≥1.2 SD on PROMIS Pain Interference were required for any association with meaningful improvement in anxiety symptoms. Improvements in physical function and pain interference were not associated with meaningfully improved depression symptoms.Meaning: Musculoskeletal clinicians and patients cannot assume that exclusively addressing the physical aspect of a musculoskeletal condition will improve symptoms of depression or potentially even anxiety.
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Kaveeshwar S, Rocca MP, Oster BA, Schneider MB, Tran A, Kolevar MP, Adib F, Henn RF, Meredith SJ. Depression and anxiety are associated with worse baseline function in hip arthroscopy patients. Knee Surg Sports Traumatol Arthrosc 2022; 30:3563-3569. [PMID: 35416491 DOI: 10.1007/s00167-022-06963-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/25/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to analyze the correlation between baseline depression and anxiety and preoperative functional status in hip arthroscopy patients. METHODS A prospective, institutional review board-approved orthopaedic registry was used to retrospectively study 104 patients undergoing hip arthroscopy. Enrolled patients were administered baseline questionnaires for Patient-Reported Outcomes Measurement Information System (PROMIS) domains, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) preoperative expectations, and Numeric Pain Scale (NPS). RESULTS The average baseline PROMIS Depression and Anxiety scores were 49.9 ± 9.8 and 55.5 ± 9.3, respectively. Bivariate analysis demonstrated that greater baseline PROMIS Anxiety correlated with worse preoperative PROMIS PI (p < 0.001), Fatigue (p < 0.001), Social Satisfaction (p < 0.001), and NPS score (p = 0.013). Bivariate analysis showed that greater PROMIS Depression correlated with worse preoperative PROMIS PF (p = 0.001), PI (p < 0.001), Fatigue (p < 0.001), SS (p < 0.001), and NPS score (p = 0.004). After controlling for confounders, multivariable analysis confirmed increased PROMIS Depression as an independent predictor of worse preoperative PROMIS PF (p = 0.009), MODEMS Expectations (p = 0.025), and NPS score (p = 0.002). Increased PROMIS Anxiety was predictive of worse baseline PROMIS PI (p < 0.001), Fatigue (p < 0.001), and Social Satisfaction (p < 0.001). A previous clinical diagnosis of depression or anxiety was only an independent predictor of worse baseline PROMIS Fatigue (p = 0.002) and was insignificant in all other models. CONCLUSION Increasing severity of depression and anxiety correlated with and predicted worse functional status at baseline in hip arthroscopy patients. As compared to clinical diagnosis of anxiety and depression, PROMIS metrics have superior utility in recognizing potentially modifiable mental health concerns that predict worse preoperative status. Ultimately, the study identifies an at-risk population undergoing hip arthroscopy that requires particular attention and potential mental health intervention in the preoperative setting. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Samir Kaveeshwar
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Michael P Rocca
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Brittany A Oster
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Matheus B Schneider
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Andrew Tran
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Matthew P Kolevar
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Farshad Adib
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
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Schaffer JC, Kuhns B, Reuter J, Sholtis C, Karnyski S, Goldblatt JP, Bronstein RD, Maloney MD, Baumhauer J, Mannava S. Clinically Depressed Patients Having Anterior Cruciate Ligament Reconstruction Show Improved but Inferior Rate of Achieving Minimum Clinically Important Difference for Patient-Reported Outcomes Measurement Information System Compared With Situationally Depressed or Nondepressed Patients. Arthroscopy 2022; 38:2863-2872. [PMID: 35550418 DOI: 10.1016/j.arthro.2022.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/07/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the preoperative diagnosis of depression predicted worse postoperative outcomes, including physical therapy (PT) compliance, return-to-sport, and patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System (PROMIS) after anterior cruciate ligament (ACL) reconstruction. METHODS A multisurgeon series of consecutive patients who had undergone ACL reconstruction with minimum 2-year follow-up were included. Chart review was conducted to determine depression diagnosis status, demographic data, rehabilitation PT compliance, return to sports, and patient-reported outcome data using PROMIS. Patients who met the PROMIS threshold for mild depression but did not carry a clinical diagnosis of depression were classified as "situationally depressed." RESULTS Ninety-five of 115 consecutive patients (81%) met inclusion criteria with an average follow-up of 34 ± 1.9 months. Fourteen patients (15%) had a preoperative diagnosis of depression, whereas 21 (22%) were considered situationally depressed. Clinically depressed patients had a greater rate of PT noncompliance (33.2% ± 17.6% vs 21.9% ± 12.6%; P = .02) and a lower postoperative PROMIS Physical Function (50.8 ± 7.7 vs 57.8 ± 11.0; P = .03 compared with patients without depression. Situationally depressed patients had lower preoperative physical function (35.4 vs 42.5; P = .04) with no differences in postoperative outcomes scores compared to the non-depressed cohort.19/21 (90.5%) of situationally depressed patients had postoperative resolution of their depressive symptoms. CONCLUSIONS Situationally depressed patients without a clinical diagnosis of depression can expect significant improvements in both pain and function, as well as a resolution of their depressed mood based on PROMIS scores as they progress through recovery after ACL reconstruction. Clinically depressed patients also experience significant improvements; however, their rate of achieving the minimum clinically important difference for PROMIS outcomes may be less than their nondepressed or situationally depressed counterparts. LEVEL OF EVIDENCE III, prognostic comparative trial.
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Affiliation(s)
- Joseph C Schaffer
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Benjamin Kuhns
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A.
| | - John Reuter
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Connor Sholtis
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Steven Karnyski
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - John P Goldblatt
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Robert D Bronstein
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael D Maloney
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Judith Baumhauer
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Sandeep Mannava
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
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Digital Care Programs for Chronic Hip Pain: A Prospective Longitudinal Cohort Study. Healthcare (Basel) 2022; 10:healthcare10081595. [PMID: 36011251 PMCID: PMC9408636 DOI: 10.3390/healthcare10081595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic hip pain is a cause of disability worldwide. Digital interventions (DI) may promote access while providing proper management. This single-arm interventional study assesses the clinical outcomes and engagement of a completely remote multimodal DI in patients with chronic hip pain. This home-based DI consisted of exercise (with real-time biofeedback), education, and cognitive-behavioral therapy. Outcomes were calculated between baseline and program end, using latent growth curve analysis. Primary outcome was the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes were pain, intent to undergo surgery, mental health, productivity, patient engagement (exercise sessions frequency), and satisfaction. Treatment response was assessed using a 30% pain change cut-off. A completion rate of 74.2% (396/534), alongside high patient engagement (2.9 exercise sessions/week, SD 1.1) and satisfaction (8.7/10, SD 1.6) were observed. Significant improvements were observed across all HOOS sub-scales (14.7−26.8%, p < 0.05), with 66.8% treatment responders considering pain. Marked improvements were observed in surgery intent (70.1%), mental health (54%), and productivity impairment (60.5%) (all p < 0.001). The high engagement and satisfaction reported after this DI, alongside the clinical outcome improvement, support the potential of remote care in the management of chronic hip conditions.
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Lippold B, Tarkunde YR, Cheng AL, Hannon CP, Adelani MA, Calfee RP. Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses. Arthroplast Today 2022; 15:215-219.e1. [PMID: 35774874 PMCID: PMC9237258 DOI: 10.1016/j.artd.2022.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications. Material and methods This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms. Results Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (β 7.1; P < .001) and with medication (β 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (β 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001). Conclusion One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.
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Affiliation(s)
- Brandon Lippold
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Yash R. Tarkunde
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Abby L. Cheng
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Charles P. Hannon
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Muyibat A. Adelani
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan P. Calfee
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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21
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Beurel E, Medina-Rodriguez EM, Jope RS. Targeting the Adaptive Immune System in Depression: Focus on T Helper 17 Cells. Pharmacol Rev 2022; 74:373-386. [PMID: 35302045 PMCID: PMC8973514 DOI: 10.1124/pharmrev.120.000256] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
There is a vital need to understand mechanisms contributing to susceptibility to depression to improve treatments for the 11% of Americans who currently suffer from this debilitating disease. The adaptive immune system, comprising T and B cells, has emerged as a potential contributor to depression, as demonstrated in the context of lymphopenic mice. Overall, patients with depression have reduced circulating T and regulatory B cells, "immunosuppressed" T cells, and alterations in the relative abundance of T cell subtypes. T helper (Th) cells have the capacity to differentiate to various lineages depending on the cytokine environment, antigen stimulation, and costimulation. Regulatory T cells are decreased, and the Th1/Th2 ratio and the Th17 cells are increased in patients with depression. Evidence for changes in each Th lineage has been reported to some extent in patients with depression. However, the evidence is strongest for the association of depression with changes in Th17 cells. Th17 cells produce the inflammatory cytokine interleukin (IL)-17A, and the discovery of Th17 cell involvement in depression evolved from the well established link that IL-6, which is required for Th17 cell differentiation, contributes to the onset, and possibly maintenance, of depression. One intriguing action of Th17 cells is their participation in the gut-brain axis to mediate stress responses. Although the mechanisms of action of Th17 cells in depression remain unclear, neutralization of IL-17A by anti-IL-17A antibodies, blocking stress-induced production, or release of gut Th17 cells represent feasible therapeutic approaches and might provide a new avenue to improve depression symptoms. SIGNIFICANCE STATEMENT: Th17 cells appear as a promising therapeutic target for depression, for which efficacious therapeutic options are limited. The use of neutralizing antibodies targeting Th17 cells has provided encouraging results in depressed patients with comorbid autoimmune diseases.
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Affiliation(s)
- Eléonore Beurel
- Department of Psychiatry and Behavioral Sciences (E.B., E.M.M.-R., R.S.J.) and Department of Biochemistry and Molecular Biology Miller School of Medicine (E.B., R.S.J.), University of Miami, Miami, Florida and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida (E.M.M.-R., R.S.J.)
| | - Eva M Medina-Rodriguez
- Department of Psychiatry and Behavioral Sciences (E.B., E.M.M.-R., R.S.J.) and Department of Biochemistry and Molecular Biology Miller School of Medicine (E.B., R.S.J.), University of Miami, Miami, Florida and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida (E.M.M.-R., R.S.J.)
| | - Richard S Jope
- Department of Psychiatry and Behavioral Sciences (E.B., E.M.M.-R., R.S.J.) and Department of Biochemistry and Molecular Biology Miller School of Medicine (E.B., R.S.J.), University of Miami, Miami, Florida and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida (E.M.M.-R., R.S.J.)
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Kunze KN, Polce EM, Clapp IM, Alter T, Nho SJ. Association Between Preoperative Patient Factors and Clinically Meaningful Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Machine Learning Analysis. Am J Sports Med 2022; 50:746-756. [PMID: 35006010 DOI: 10.1177/03635465211067546] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The International Hip Outcome Tool 12-Item Questionnaire (IHOT-12) has been proposed as a more appropriate outcome assessment for hip arthroscopy populations. The extent to which preoperative patient factors predict achieving clinically meaningful outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remains poorly understood. PURPOSE To determine the predictive relationship of preoperative imaging, patient-reported outcome measures, and patient demographics with achievement of the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) for the IHOT-12 at a minimum of 2 years postoperatively. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were analyzed for consecutive patients who underwent hip arthroscopy for FAIS between 2012 and 2018 and completed the IHOT-12 preoperatively and at a minimum of 2 years postoperatively. Fifteen novel machine learning algorithms were developed using 47 potential demographic, clinical, and radiographic predictors. Model performance was evaluated with discrimination, calibration, decision-curve analysis and the brier score. RESULTS A total of 859 patients were identified, with 685 (79.7%) achieving the MCID, 535 (62.3%) achieving the PASS, and 498 (58.0%) achieving the SCB. For predicting the MCID, discrimination for the best-performing models ranged from fair to excellent (area under the curve [AUC], 0.69-0.89), although calibration was excellent (calibration intercept and slopes: -0.06 to 0.02 and 0.24 to 0.85, respectively). For predicting the PASS, discrimination for the best-performing models ranged from fair to excellent (AUC, 0.63-0.81), with excellent calibration (calibration intercept and slopes: 0.03-0.18 and 0.52-0.90, respectively). For predicting the SCB, discrimination for the best-performing models ranged from fair to good (AUC, 0.61-0.77), with excellent calibration (calibration intercept and slopes: -0.08 to 0.00 and 0.56 to 1.02, respectively). Thematic predictors for failing to achieve the MCID, PASS, and SCB were presence of back pain, anxiety/depression, chronic symptom duration, preoperative hip injections, and increasing body mass index (BMI). Specifically, thresholds associated with lower likelihood to achieve a clinically meaningful outcome were preoperative Hip Outcome Score-Activities of Daily Living <55, preoperative Hip Outcome Score-Sports Subscale >55.6, preoperative IHOT-12 score ≥48.5, preoperative modified Harris Hip Score ≤51.7, age >41 years, BMI ≥27, and preoperative α angle >76.6°. CONCLUSION We developed novel machine learning algorithms that leveraged preoperative demographic, clinical, and imaging-based features to reliably predict clinically meaningful improvement after hip arthroscopy for FAIS. Despite consistent improvements after hip arthroscopy, meaningful improvements are negatively influenced by greater BMI, back pain, chronic symptom duration, preoperative mental health, and use of hip corticosteroid injections.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Evan M Polce
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ian Michael Clapp
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas Alter
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Saks BR, Glein RM, Jimenez AE, Ankem HK, Sabetian PW, Maldonado DR, Lall AC, Domb BG. Patients Obtain Meaningful Clinical Benefit After Hip Arthroscopy Despite Preoperative Psychological Distress: A Propensity-Matched Analysis of Mid-Term Outcomes. Arthroscopy 2022; 38:773-782. [PMID: 34019982 DOI: 10.1016/j.arthro.2021.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/20/2021] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the influence of baseline psychological distress on patient-reported outcomes (PROs) after arthroscopic hip surgery for femoroacetabular impingement at a minimum of 5 years. METHODS Demographic and intraoperative data were prospectively collected from patients who underwent primary arthroscopic hip surgery for femoroacetabular impingement and labral tears after failure of conservative management between June 2012 and December 2014. Included patients had preoperative and minimum 5-year postoperative PROs and visual analog scale scores for pain and satisfaction. The 12-item Short Form Health Survey (SF-12) Mental Component Summary (MCS) score was used to stratify patients into 2 cohorts: Patients with an average or above-average score (SF-12 MCS score ≥ 50) were considered psychologically non-distressed, whereas those who scored below average (SF-12 MCS score < 50) were considered to have psychological distress. Distressed patients were propensity matched by age, sex, and body mass index to an equal number of non-distressed patients. RESULTS Of the 153 hips that met the inclusion criteria, 117 (76.5%) had minimum 5-year follow-up. Eighty-two hips were included in the final analysis after propensity matching, with 41 in both the distressed and non-distressed cohorts. Preoperatively, patients in the distressed cohort reported inferior scores for all PROs. There was a significant difference in the SF-12 MCS score between groups at 2 years, but similar scores were observed for all other PROs. At minimum 5-year follow-up, there were no differences between groups for any PRO. There were no differences in the rates of achieving the minimal clinically important difference for all PROs or in achieving the patient acceptable symptomatic state for the modified Harris Hip Score. CONCLUSIONS Patients with baseline psychological distress may have a lower functional status at the time of presentation but still gain meaningful clinical benefit and pain improvement from arthroscopic hip surgery, with mid-term outcomes comparable to those obtained by patients without preoperative psychological distress. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Benjamin R Saks
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A.; AMITA Health St. Alexius Medical Center, Hoffman Estates, Illinois, U.S.A
| | - Rachel M Glein
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Andrew E Jimenez
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Hari K Ankem
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Payam W Sabetian
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - David R Maldonado
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A.; American Hip Institute, Chicago, Illinois, U.S.A
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois, U.S.A.; American Hip Institute, Chicago, Illinois, U.S.A..
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Leo AJ, Schuelke MJ, Hunt DM, Miller JP, Areán PA, Cheng AL. Digital Mental Health Intervention Plus Usual Care Compared to Usual Care Only and Usual Care Plus In-Person Psychological Counseling for Orthopedic Patients with Symptoms of Depression and/or Anxiety: Cohort Study (Preprint). JMIR Form Res 2022; 6:e36203. [PMID: 35507387 PMCID: PMC9118017 DOI: 10.2196/36203] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 02/06/2023] Open
Abstract
Background Depression and anxiety frequently coexist with chronic musculoskeletal pain and can negatively impact patients’ responses to standard orthopedic treatments. Nevertheless, mental health is not routinely addressed in the orthopedic care setting. If effective, a digital mental health intervention may be a feasible and scalable method of addressing mental health in an orthopedic setting. Objective We aimed to compare 2-month changes in mental and physical health between orthopedic patients who received a digital mental health intervention in addition to usual orthopedic care, those who received usual orthopedic care only (without a specific mental health intervention), and those who received in-person care with a psychologist as part of their orthopedic treatment plan. Methods In this single-center retrospective cohort study involving ancillary analysis of a pilot feasibility study, 2-month self-reported health changes were compared between a cohort of orthopedic patients who received access to a digital mental health intervention (Wysa) and 2 convenience sample comparison cohorts (patients who received usual orthopedic care without a specific mental health intervention and patients who received in-person care with a psychologist as part of their orthopedic treatment plan). All patients were 18 years or older and reported elevated symptoms of depression or anxiety at an orthopedic clinic visit (Patient-Reported Outcomes Measurement Information System [PROMIS] Depression or Anxiety score ≥55). The digital intervention was a multi-component mobile app that used chatbot technology and text-based access to human counselors to provide cognitive behavioral therapy, mindfulness training, and sleep tools, among other features, with an emphasis on behavioral activation and pain acceptance. Outcomes of interest were between-cohort differences in the 2-month longitudinal changes in PROMIS Depression and Anxiety scores (primary outcomes) and PROMIS Pain Interference and Physical Function scores (secondary outcomes). Results Among 153 patients (mean age 55, SD 15 years; 128 [83.7%] female; 51 patients per cohort), patients who received the digital mental health intervention showed clinically meaningful improvements at the 2-month follow-up for all PROMIS measures (mean longitudinal improvement 2.8-3.7 points; P≤.02). After controlling for age and BMI, the improvements in PROMIS Depression, Pain Interference, and Physical Function were meaningfully greater than longitudinal changes shown by patients who received usual orthopedic care (mean between-group difference 2.6-4.8 points; P≤.04). Improvements in PROMIS Physical Function were also meaningfully greater than longitudinal changes shown by patients who received in-person psychological counseling (mean between-group difference 2.4 points; P=.04). Conclusions Patients who received a digital mental health intervention as part of orthopedic care reported greater 2-month mean improvements in depression, pain interference, and physical function than patients who received usual orthopedic care. They also reported a greater mean improvement in physical function and comparable improvements in depression, anxiety, and pain interference compared with orthopedic patients who received in-person psychological counseling.
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Affiliation(s)
- Ashwin J Leo
- Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Matthew J Schuelke
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Devyani M Hunt
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - J Philip Miller
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Patricia A Areán
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Abby L Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States
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Srikumar S, Feingold JD, Swartwout EL, Roberts SA, Ranawat AS. The predictive value of self-reported allergies for reoperation after index hip arthroscopy. J Hip Preserv Surg 2022; 9:22-27. [PMID: 35651712 PMCID: PMC9142203 DOI: 10.1093/jhps/hnac002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/06/2021] [Accepted: 01/24/2022] [Indexed: 11/14/2022] Open
Abstract
The purpose of this study is to compare the rate of reoperation after index hip arthroscopy for symptomatic femoroacetabular impingement in patients with, and without, at least one self-reported allergy. Data were collected prospectively in 1468 patients whose records were retrospectively reviewed. After the application of inclusion and exclusion criteria, two cohorts were formed: (i) a study cohort (n = 261) composed of patients with a self-reported allergy and (ii) a control cohort. (n = 666). The allergy cohort had a significantly larger [P < 0.001] reoperation rate (24.1% [63/261]) compared to the control cohort (9.6% [64/66]). Univariate analysis (UVA) and multivariate analysis (MVA) were then performed to better understand the implications of allergy status on the arthroscopic outcome. On UVA the presence of an allergy increased the odds of reoperation after index hip arthroscopy by 2.99 [OR (95% CI): 2.99 (2.04, 4.39); P < 0.001] and for each additional allergy a patient reported, their odds of subsequent surgery increased by 1.27 per allergy [OR (95% CI): 1.27 (1.15, 1.39); P < 0.001]. However, on the MVA, allergy status was not an independent risk factor for reoperation. These findings suggest that allergy status is associated with a higher reoperation rate, however, allergy status alone cannot prognosticate the risk of subsequent surgery. Therefore, allergy status and its association with future surgery after hip arthroscopy should be considered in the context of multiple patient-specific factors that influence the surgical outcome. An understanding of this association enables patient-centered care and will strengthen the physician–patient relationship.
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Affiliation(s)
| | - Jacob D Feingold
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Erica L Swartwout
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Sacha A Roberts
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Anil S Ranawat
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Leo AJ, Schuelke MJ, Hunt DM, Metzler JP, Miller JP, Areán PA, Armbrecht MA, Cheng AL. Digital mental health intervention for orthopedic patients with symptoms of depression and/or anxiety: Pilot feasibility study. JMIR Form Res 2022; 6:e34889. [PMID: 35039278 PMCID: PMC8902664 DOI: 10.2196/34889] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/09/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Symptoms of depression and anxiety commonly coexist with chronic musculoskeletal pain, and when this occurs, standard orthopedic treatment is less effective. Nevertheless, addressing mental health is not yet a routine part of standard orthopedic treatment, in part due to access related barriers. Digital mental health intervention offers the potential to be a scalable resource that could feasibly be incorporated into orthopedic care. OBJECTIVE The primary purpose of this study was to assess the feasibility of introducing a digital mental health intervention (Wysa) within an outpatient orthopedic setting to patients who endorse coexisting symptoms of depression and/or anxiety. The secondary purpose was to perform a preliminary effectiveness analysis of the intervention. METHODS In this single-arm, prospective cohort study, participants included adult patients (18 years and older) who presented to a non-surgical orthopedic specialist at a single tertiary care academic center for evaluation of a musculoskeletal condition and who self-reported symptoms of depression and/or anxiety (Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and/or Anxiety score ≥ 55). Enrollment was performed face-to-face by a research coordinator immediately after the participant's encounter with an orthopedic clinician. Participants were provided two months of access to a mobile app called Wysa, which is an established, multi-component digital mental health intervention that uses chatbot technology and text-based access to human counselors to deliver cognitive behavioral therapy, mindfulness training, and sleep tools, among other features. For this study, Wysa access also included novel, behavioral activation based features specifically developed for users with chronic pain. Primary feasibility outcomes included the study recruitment rate, retention rate, and engagement rate with Wysa (defined as engaging with a therapeutic Wysa tool at least once during the study period). Secondary effectiveness outcomes were between-group differences in mean longitudinal PROMIS mental and physical health score changes at two-month follow-up between high Wysa users and low Wysa users, defined by a median split. RESULTS The recruitment rate was 61/208 (29%), retention rate was 51/61 (84%), and engagement rate was 44/61 (72%). Compared to low users, high Wysa users achieved greater improvement in PROMIS Anxiety (between-group difference -4.2 points [95% CI -8.1 to -0.2], P=.044) at two-month follow-up. Between-group differences in PROMIS Depression (-3.2 points [-7.5 to 1.2], P=.15) and Pain Interference (-2.3 points [-6.3 to 1.7], P=.26) favored high users but did not meet statistical significance. Improvements in PROMIS Physical Function were comparable between groups. CONCLUSIONS Delivery of a digital mental health intervention within the context of orthopedic care is feasible and demonstrates potential to improve mental health and pain-related impairment to a clinically meaningful degree. Participants' engagement rates exceeded industry standards, and additional opportunities to improve recruitment and retention were identified. Further pilot study followed by a definitive, randomized controlled trial is warranted. CLINICALTRIAL ClinicalTrials.gov NCT202005219.
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Affiliation(s)
- Ashwin J Leo
- Washington University in St. Louis School of Medicine, St. Louis, US
| | - Matthew J Schuelke
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, US
| | - Devyani M Hunt
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Campus Box MSC 8233-0004-05660 South Euclid Avenue, St. Louis, US
| | - John P Metzler
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Campus Box MSC 8233-0004-05660 South Euclid Avenue, St. Louis, US
| | - J Philip Miller
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, US
| | - Patricia A Areán
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, US
| | - Melissa A Armbrecht
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Campus Box MSC 8233-0004-05660 South Euclid Avenue, St. Louis, US
| | - Abby L Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Campus Box MSC 8233-0004-05660 South Euclid Avenue, St. Louis, US
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Stone AV, Murphy ML, Jacobs CA, Lattermann C, Hawk GS, Thompson KL, Conley CEW. Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure. Cartilage 2022; 13:19476035221087703. [PMID: 35333656 PMCID: PMC9137305 DOI: 10.1177/19476035221087703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 01/19/2022] [Accepted: 02/16/2022] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs. DESIGN Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders. RESULTS A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654). CONCLUSION Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses. LEVEL OF EVIDENCE Level III, retrospective therapeutic study.
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Affiliation(s)
- Austin V. Stone
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Meredith L. Murphy
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Cale A. Jacobs
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Christian Lattermann
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory S. Hawk
- Department of Statistics, University of Kentucky, Lexington, KY, USA
| | | | - Caitlin E. W. Conley
- Department of Orthopedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
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Bodendorfer BM, Clapp IM, DeFroda SF, Malloy P, Alter TD, Parvaresh KC, Chahla J, Nho SJ. The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale. Am J Sports Med 2021; 49:3250-3260. [PMID: 34494918 DOI: 10.1177/03635465211034511] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). PURPOSE To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership. RESULTS A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores. CONCLUSION Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.
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Affiliation(s)
- Blake M Bodendorfer
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Ian M Clapp
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Steven F DeFroda
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Thomas D Alter
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Kevin C Parvaresh
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Lynch TS, Oak SR, Cossell C, Strnad G, Zajichek A, Goodwin R, Jones MH, Spindler KP, Rosneck J. Effect of Baseline Mental Health on 1-Year Outcomes After Hip Arthroscopy: A Prospective Cohort Study. Orthop J Sports Med 2021; 9:23259671211025526. [PMID: 34485585 PMCID: PMC8414618 DOI: 10.1177/23259671211025526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Patient factors, including mental health, sex, and smoking, have been found
to be more predictive of preoperative hip pain and function than
intra-articular findings during hip arthroscopy for femoroacetabular
impingement (FAI); however, little is known about how these factors may
influence patients’ postoperative outcomes. Hypothesis: We hypothesized that lower patient-reported mental health scores would be
significant risk factors for worse patient-reported outcomes (PROs) 1 year
after arthroscopic hip surgery for FAI and that baseline intra-articular
pathology would fail to demonstrate an association with outcomes 1 year
after FAI surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort of patients undergoing hip arthroscopy for FAI were
electronically enrolled. Baseline and 1-year follow-up PROs were collected,
including Hip disability and Osteoarthritis Outcome Score for pain
(HOOS-Pain), HOOS–Physical Function Short Form (HOOS-PS), and Veterans RAND
12-Item Health Survey–Mental Component Score (VR-12 MCS). Intra-articular
operative findings and treatment were documented at the time of surgery.
Proportional odds logistic regression models were built for 1-year outcomes
(HOOS-Pain, HOOS-PS, and VR-12 MCS). Risk factors included patient
characteristics and intraoperative anatomic and pathologic findings. Results: Overall, 494 patients underwent hip arthroscopy for FAI, and 385 (78%) were
evaluated at 1 year with at least 1 PRO. The median patient age was 33
years, mean body mass index was 25.5 kg/m2, and 72% were female.
Multivariable analysis demonstrated that better baseline HOOS-Pain, HOOS-PS,
and VR-12 MCS were significantly associated with improvement in the 1-year
scores for each PRO. Higher VR-12 MCS was significantly associated with
better 1-year HOOS-Pain and HOOS-PS, while current and former smokers had
worse 1-year outcomes than those who never smoked. In ranking each
variable’s relative importance, baseline HOOS-Pain and HOOS-PS and baseline
VR-12 MCS were identified as the strongest predictors of 1-year HOOS-Pain
and HOOS-PS in our multivariable model. Conclusion: During hip arthroscopy for FAI, patient factors, including baseline hip pain
and function, mental health, and smoking, were independently associated with
1-year PROs of hip pain and function, while intra-articular pathology such
as the presence of labral tear and its treatment, tear size, tear location,
and anchors placed were not independently associated.
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Affiliation(s)
- T Sean Lynch
- Columbia University Irving Medical Center, New York, New York, USA
| | - Sameer R Oak
- Cleveland Clinic Sports Medicine, Cleveland, Ohio, USA
| | | | | | - Alexander Zajichek
- Cleveland Clinic Department of Quantitative Health Sciences, Cleveland, Ohio, USA
| | - Ryan Goodwin
- Cleveland Clinic Sports Medicine, Cleveland, Ohio, USA
| | | | | | - James Rosneck
- Cleveland Clinic Sports Medicine, Cleveland, Ohio, USA
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Domb BG, Rosinsky PJ. Editorial Commentary: Predicting Satisfaction After Hip Arthroscopy Using Machine Learning: What Do Treadmills and Black Boxes Have to Do With Arthroscopy? Arthroscopy 2021; 37:1152-1154. [PMID: 33812519 DOI: 10.1016/j.arthro.2020.12.231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 02/02/2023]
Abstract
The use of advanced statistical methods and artificial intelligence including machine learning enables researchers to identify preoperative characteristics predictive of patients achieving minimal clinically important differences in health outcomes after interventions including surgery. Machine learning uses algorithms to recognize patterns in data sets to predict outcomes. The advantages are the ability, using "big data" registries, to infer relations that otherwise would not be readily understood and the ability to continuously improve the model as new data are added. However, machine learning has limitations. Models are only as good as the data incorporated, and data may be misapplied owing to huge data sets and strong computing capabilities, in which spurious correlations may be suggested based on significant P values. Hence, common sense must be applied. The future of outcome prediction studies will most definitely rely on machine learning and artificial intelligence methods.
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Baron JE, Khazi ZM, Duchman KR, Wolf BR, Westermann RW. Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures. Arthroscopy 2021; 37:686-693.e1. [PMID: 33239183 DOI: 10.1016/j.arthro.2020.10.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures. METHODS Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016. RESULTS In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001). CONCLUSIONS The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures. LEVEL OF EVIDENCE Level III; retrospective comparative study.
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Affiliation(s)
| | - Zain M Khazi
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Kyle R Duchman
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Brian R Wolf
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
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Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review. Knee Surg Sports Traumatol Arthrosc 2021; 29:2408-2416. [PMID: 33341914 PMCID: PMC8298339 DOI: 10.1007/s00167-020-06354-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/26/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE Recent advances in diagnostic imaging techniques and soft tissue endoscopy now allow for precise diagnosis and management of extra-articular hip pathology. The aim of this scoping review is to present an evidence-based update of the relevant literature focussing only on the pathoanatomy, clinical assessment and the diagnosis of pathology in the peritrochanteric space. METHODS A literature search was performed on PubMed to include articles which reported on the anatomy and diagnosis of greater trochanteric pain syndrome, trochanteric bursitis, gluteus medius tears and external snapping hip syndrome. RESULTS A total of 542 studies were identified, of which 49 articles were included for full text analysis for the scoping review. Peritrochanteric space pathology can be broadly classified into (1) greater trochanteric pain syndrome (GTPS), (2) abductor tears and (3) external snapping hip syndrome. Anatomically, gluteus medius, gluteus minimus and tensor fascia lata work in conjunction to abduct and internally rotate the hip. The anterolateral part of the gluteus medius tendon is more prone to tears due to a thin tendinous portion. Increased acetabular anteversion has also been shown to be associated with gluteal and trochanteric bursitis. In terms of clinical examination, tests which were found to be most useful for assisting in the diagnoses of lateral hip pain were the single-leg stance, resisted external derotation of the hip, hip lag sign and the Trendelenburg's test. Dynamic ultrasound along with guided injections and MRI scan do assist in differentiating the pathology and confirming the diagnosis in patients presenting with lateral hip pain. Finally, the assessment of baseline psychological impairment is essential in this group of patients to ensure outcomes are optimised. CONCLUSION Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. A thorough appreciation of the anatomy of the abductor musculature, specific clinical signs and imaging findings will lead to an appropriate diagnosis being made and management plan instituted. LEVEL OF EVIDENCE IV.
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Collis RW, McCullough AB, Ng C, Prather H, Colditz GA, Clohisy JC, Cheng AL. Rate of Surgery and Baseline Characteristics Associated With Surgery Progression in Young Athletes With Prearthritic Hip Disorders. Orthop J Sports Med 2020; 8:2325967120969863. [PMID: 33294476 PMCID: PMC7705795 DOI: 10.1177/2325967120969863] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 05/08/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement
(FAI), acetabular dysplasia, and acetabular labral tears, are a common cause
of pain and dysfunction in adolescent and young adult athletes, and optimal
patient-specific treatment has not been defined. Operative management is
often recommended, but conservative management may be a reasonable approach
for some athletes. Purpose: To identify (1) the relative rate of progression to surgery in self-reported
competitive athletes versus nonathletes with PAHD and (2) baseline
demographic, pain, and functional differences between athletes who proceeded
versus those who did not proceed to surgery within 1 year of evaluation. Study Design: Cohort study; Level of evidence, 3. Methods: An electronic medical record review was performed of middle school, high
school, and college patients who were evaluated for PAHD at a single
tertiary-care academic medical center between June 22, 2015, and May 1,
2018. Extracted variables included patients’ self-reported athlete status,
decision to choose surgery within 1 year of evaluation, and baseline
self-reported pain and functional scores on Patient-Reported Outcomes
Measurement Information System (PROMIS) domains, the Hip disability and
Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score. Results: Of 260 eligible patients (289 hips), 203 patients (78%; 227 hips) were
athletes. Athletes were no more likely to choose surgery than nonathletes
(130/227 hips [57%] vs 36/62 hips [58%]; relative risk [RR], 0.99 [95% CI,
0.78-1.25]). Among athletes, those who proceeded to surgery over
conservative care were more likely to be female (81% vs 69%; RR, 1.34 [95%
CI, 0.98-1.83]) and had more known imaging abnormalities (FAI: 82% vs 69%,
RR, 1.47 [95% CI, 1.09-1.99]; dysplasia: 48% vs 27%, RR, 1.44 [95% CI,
1.16-1.79]; mixed deformity: 30% vs 10%, RR, 2.91 [95% CI, 1.53-5.54]; known
labral tear: 84% vs 40%, RR, 2.79 [95% CI, 2.06-3.76]). Athletes who chose
surgery also reported worse baseline hip-specific symptoms on all HOOS
subscales (mean difference, 10.8-17.7; P < .01 for
all). Conclusion: Similar to nonathletes, just over half of athletes with PAHD chose surgical
management within 1 year of evaluation. Many competitive athletes with PAHD
continued with conservative management and deferred surgery, but more
structural hip pathology and worse hip-related baseline physical impairment
were associated with the choice to pursue surgery.
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Affiliation(s)
- Reid W Collis
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrea B McCullough
- Division of Physical Medicine and Rehabilitation, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Chris Ng
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Heidi Prather
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John C Clohisy
- Division of Adult Reconstruction and Hip Preservation, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Abby L Cheng
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Low Self-Efficacy and High Kinesiophobia Are Associated With Worse Function in Patients With Femoroacetabular Impingement Syndrome. J Sport Rehabil 2020; 30:445-451. [PMID: 33027764 DOI: 10.1123/jsr.2019-0498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 07/11/2020] [Accepted: 08/01/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS. OBJECTIVE (1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety. DESIGN Cross-sectional. SETTING University health center. PARTICIPANTS Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2). MAIN OUTCOME MEASURES Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function. RESULTS The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01). CONCLUSION Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.
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