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Ferhi M, Marwen N, Abdeljabbar A, Mannai J. Psychological Outcomes and Quality of Life After Hysterectomy for Benign Diseases: A Prospective Cohort Study. Cureus 2024; 16:e60871. [PMID: 38910628 PMCID: PMC11192439 DOI: 10.7759/cureus.60871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
Background Hysterectomy is a common surgical procedure performed for benign gynecological diseases. While the physical benefits have been extensively studied, less attention has been given to its impact on psychological well-being and overall quality of life (QoL). This study aimed to assess the psychological outcomes and QoL before and after hysterectomy for benign diseases. Methodology This prospective cohort study included women undergoing hysterectomy for benign diseases at Ibn El Jazzar Hospital in Kairouan, Tunisia. The study was conducted from January 2, 2020, to December 31, 2021. We used the Short-Form-36 Health Survey (SF-36) to evaluate the QoL and the Hospital Anxiety and Depression Scale (HADS) to assess psychological outcomes preoperatively and after six months. Data entry and analysis were performed using SPSS version 26 (IBM Corp., Armonk, NY, USA) with the significance level (p) set to 0.05. Results Of 84 assessed patients, 60 were included. Following the hysterectomy, there were improvements in QoL and psychological outcomes across all domains, regardless of whether total or subtotal hysterectomy was performed. The mean HADS score for anxiety decreased from 12.57 to 8.77 after hysterectomy and from 14.83 to 9.57 for depression. Moreover, the median SF-36 total score increased from 29.81 to 68.1. We found no statistically significant difference between the two groups in all assessed outcomes. Conclusions Hysterectomy for benign conditions, whether total or subtotal, positively impacted symptoms of depression and anxiety, as well as the overall QoL for patients. A thorough preoperative psychiatric assessment is recommended to address and support mental health outcomes in these patients. Future research should consider a larger multicenter approach for a broader application of findings.
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Affiliation(s)
- Mohamed Ferhi
- Psychiatry, Ibn El Jazzar University Hospital, Kairouan, TUN
- Psychiatry, Mohamed Taher Maamouri University Hospital, Nabeul, TUN
| | - Nadia Marwen
- Obstetrics and Gynecology, Ibn El Jazzar University Hospital, Kairouan, TUN
| | - Ameni Abdeljabbar
- Obstetrics and Gynecology, Ibn El Jazzar University Hospital, Kairouan, TUN
| | - Jihenne Mannai
- Psychiatry, Ibn El Jazzar University Hospital, Kairouan, TUN
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2
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Ma F, Zhu Y, Liu Y. The relationship between psychological distress and the nursing humanistic care demands in postoperative cancer inpatients: a cross-sectional study. BMC Nurs 2024; 23:26. [PMID: 38195547 PMCID: PMC10775573 DOI: 10.1186/s12912-024-01704-7] [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: 08/22/2023] [Accepted: 01/01/2024] [Indexed: 01/11/2024] Open
Abstract
PURPOSE We aimed to investigate cancer patients' experiences of psychological distress after surgery and the factors that influence it, and to analyze the relationship between this and the nursing humanistic care demands. METHODS This study used a convenience sampling method to survey 432 cancer patients undergoing surgical treatment in the specialized cancer hospital in Beijing. The survey used socio-demographic information, the Distress Management Screening Measures, and the Nursing Humanistic Care Demands questionnaire. Questionnaire Star was used to collect data online. SPSS24.0 software was used to test the relationship between psychological distress and nursing humanistic care demands. RESULTS The mean scores for psychological distress and nursing humanistic care demands were 3.95 ± 2.71 and 147.02 ± 19.88, respectively, and showed a moderately positive correlation. The main issues that caused psychological distress in patients were: worry, financial problems, surroundings, nervousness, sleep, and pain. Regression analysis showed that gender, financial burden, personality trait, and need for humanistic care in nursing explained 24.5% of the total variance in the model and were independent predictors of psychological distress. CONCLUSION Cancer inpatients have significant psychological distress after surgery and exhibit high levels of nursing humanistic care demands. This study fills the research gap on humanistic care for psychological distress management, nursing humanistic care demands positively predicted psychological distress. Nursing staff should pay attention to the psychological suffering of patients and develop individualized care measures to alleviate their psychological suffering by accurately identifying their nursing humanistic care demands.
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Affiliation(s)
- Fengyan Ma
- Department of Thoracic Surgery. National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yajing Zhu
- Department of Thoracic Surgery. National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yan Liu
- Department of Thoracic Surgery. National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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3
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Gaddis JM, de Souza R, Montanez B, Nakonezny PA, Laboret B, Bialaszewski R, Wells JE. Hip Preservation Surgery in Patients With Femoroacetabular Impingement Syndrome and Acetabular Dysplasia Improves Functional Measures and Pain Catastrophizing. Cureus 2024; 16:e52461. [PMID: 38371072 PMCID: PMC10873215 DOI: 10.7759/cureus.52461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
Background Chronic hip pain is a debilitating condition that severely reduces one's quality of life. Prior studies uncovered a link between hip pathologies and pain catastrophizing, anxiety, and depression. The purpose of this study was to investigate whether hip preservation surgery in patients with femoroacetabular impingement syndrome (FAIS) and acetabular dysplasia (AD) improves functional outcomes and pain catastrophizing. Methods Patients with FAIS and AD were requested to complete a hip questionnaire both preoperatively and postoperatively at a single academic center (University of Texas Southwestern Medical Center, Dallas, Texas, USA). Pain catastrophizing was evaluated using the pain catastrophizing scale, and pain level was assessed using the visual analog scale. Assessments of hip functional outcomes included the hip outcome score (HOS) and the hip disability and osteoarthritis outcome score (HOOS). Outcome measures before and after treatment were compared using the dependent samples t-test. A correlation analysis, using the Spearman partial correlation coefficient (rs), was conducted to evaluate the relationship between variables. Results The results indicated a clinically significant improvement in functional measures and pain catastrophizing in patients who underwent hip preservation surgery. The most significant discovery was an inverse relationship between both HOOS quality of life (rs=-0.293, p=0.0065, false discovery rate (FDR)=0.0210) and HOS activities of daily living (rs=-0.242, p=0.0254, FDR=0.0423) and pain catastrophizing; however, similar improvements were seen in pain catastrophizing with improvements in other functional outcomes. Conclusion Undergoing hip preservation surgery for patients with AD or FAIS improved their hip functional measures and decreased pain catastrophizing postoperatively. The improvement of hip function, quality of life, and pain catastrophizing reveals an intricate link between the functional outcomes of hip preservation surgery and pain catastrophizing.
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Affiliation(s)
- John M Gaddis
- Department of Orthopedic Surgery, University of Texas Rio Grande Valley School of Medicine, Edinburg, USA
| | - Rafael de Souza
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Benjamin Montanez
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Paul A Nakonezny
- Department of Population and Data Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, USA
| | - Bretton Laboret
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Ryan Bialaszewski
- Department of Orthopedic Surgery, University of Texas Rio Grande Valley School of Medicine, Edinburg, USA
| | - Joel E Wells
- Department of Orthopedic Surgery, Baylor Scott and White Health, McKinney, USA
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Feltri P, Monteleone AS, Audigé L, Marbach F, Filardo G, Candrian C. Patients with rotator cuff tears present a psychological impairment, not only a functional deficit: a systematic review. INTERNATIONAL ORTHOPAEDICS 2024; 48:169-181. [PMID: 37673844 DOI: 10.1007/s00264-023-05952-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/20/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Psychological factors impact patients with rotator cuff tears (RCT) in terms of pain level, shoulder function, sleep disturbance, and quality of life (QoL). The aim of this study was to quantify the prevalence of psychological factors in those patients, evaluate their influence on patient-reported outcomes (PROMs), and assess the possible improvement with surgical treatment. METHODS The literature search was performed on PubMed, Web of Science, Wiley Cochrane Library up to January, 2023. INCLUSION CRITERIA RCT treated with arthroscopic rotator cuff reconstruction (ARCR), description of psychological variables evaluated with validated questionnaires, descriptions of PROMs. RESULTS Thirty-nine studies included 7021 patients. Depression was found in eight studies (19.2%), anxiety in 6 (13.0%), sleep disturbance in seven (71.3%), and distress in three studies (26.4%). Studies evaluating the relationship between psychological impairment and pain documented more pain and impaired shoulder function before and after ARCR in patients with altered psychological status. DISCUSSION An impaired psychological status has an important impact on patients' perception of their disease. RCT patients with psychological alterations often experience more pain and reduced shoulder function, thus having worse QoL. CONCLUSION This study underlines that psychological impairment largely affects RCT patient condition and treatment outcome, which underlines the importance of a multidisciplinary biopsychosocial intervention to achieve better results.
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Affiliation(s)
- Pietro Feltri
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900, Lugano, Switzerland
| | | | - Laurent Audigé
- Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Basel, Switzerland
- Research and Development, Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Francesco Marbach
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900, Lugano, Switzerland
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Christian Candrian
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Abed V, Lemaster NG, Hawk GS, Thompson KL, Conley CEW, Mair SD, Jacobs CA. Patients With Depression and/or Anxiety Having Arthroscopic Rotator Cuff Repair Show Decreased Number of Prescriptions and Number of Psychotherapy Sessions in the Year After Surgery. Arthroscopy 2023; 39:2438-2442.e9. [PMID: 37355188 PMCID: PMC10741251 DOI: 10.1016/j.arthro.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To determine whether the utilization of psychological treatments changes after arthroscopic rotator cuff repair (RCR) for patients with preoperative depression and/or anxiety. METHODS The Truven Healthcare Marketscan database was used to identify patients who underwent arthroscopic RCR between January 2009 and December 2016. We included all patients with diagnosis codes associated with either depression or anxiety before RCR. Patients were excluded if they did not have complete insurance coverage for 1 year before or after surgery, or if they had arthroscopic RCR in the year before the index surgical procedure. We compared the proportion of patients with preoperative depression or anxiety who filled a prescription and had psychotherapy procedural codes in the year before and the year after arthroscopic RCR. RESULTS A total of 170,406 patients who underwent RCR were identified, of which depression and/or anxiety was found in 46,737 patients (43.7% male). Of the 46,737 patients, 19.6% filled a prescription for a depression/anxiety medication at least once in the year before surgery. Of this subset of patients, 41.5% did not fill a prescription for depression or anxiety medication after surgery, whereas 32.6% continued medication use but demonstrated a median 30-day reduction in the number of days' worth of medication. Similarly, 13.1% of patients were attending psychotherapy sessions preoperatively, but 76.6% of those patients either stopped or reduced the amount of psychotherapy sessions in the year following RCR. CONCLUSIONS The number of prescriptions and psychotherapy sessions decreased in the year after RCR for patients with preoperative diagnoses of depression and/or anxiety. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Varag Abed
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Nicole G Lemaster
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Gregory S Hawk
- Department of Statistics, University of Kentucky, Lexington, Kentucky, U.S.A
| | | | - Caitlin E W Conley
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Scott D Mair
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Cale A Jacobs
- Mass General Brigham Sports Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A..
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Tanık F, Keskin M, Özer Kaya D. Pressure pain sensitivity, thermographic changes, function, life and sleep quality in patients with unilateral rotator cuff injury: A case-control study. Musculoskelet Sci Pract 2023; 67:102860. [PMID: 37741010 DOI: 10.1016/j.msksp.2023.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 09/14/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION-AIM This study aimed to assess pressure pain sensitivity, thermographic changes, functional status, quality of life, and sleep in individuals with unilateral shoulder pain due to rotator cuff tear and compare these parameters with the unaffected side and asymptomatic individuals. MATERIAL-METHOD Thirty-two patients with unilateral rotator cuff injury and 32 volunteers without shoulder problems were included. Pain was evaluated using a visual analogue scale, pressure pain sensitivity with a digital algometer, thermographic changes with a thermal camera, upper extremity function through the Disabilities of the Arm, Shoulder, and Hand Disability Questionnaire, sleep quality using the Pittsburgh Sleep Quality Index, and quality of life using SF-36. RESULTS Pressure pain sensitivity of the deltoideus, supraspinatus, and subscapularis muscles in the affected limb was lower than in the unaffected limb (p = 0.027, p = 0.005, p < 0.001). Conversely, pressure sensitivity of the deltoideus, biceps brachii, and subscapularis muscles was higher in the patient group (p = 0.008, p = 0.042, p < 0.001). Furthermore, a decrease in temperature was observed in all patients, except for the trapezius muscles of the affected side (p < 0.05). CONCLUSION This study sheds light on altered pressure pain sensitivity and thermographic changes in individuals with unilateral shoulder pain due to rotator cuff tear. Additionally, the study highlights impairments in functional status, quality of life, and sleep in these individuals, emphasizing the broader impact of such injuries. Targeted interventions based on these findings have the potential to enhance overall well-being and functional outcomes for affected individuals. LEVEL OF EVIDENCE Level III, Case-control study, prognosis study.
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Affiliation(s)
- Faruk Tanık
- Department of Physiotherapy and Rehabilitation, Health Sciences Institute, Izmir Katip Celebi University, Izmir, Turkey.
| | - Merve Keskin
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
| | - Derya Özer Kaya
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
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Freshman RD, Oeding JF, Anigwe C, Zhang AL, Feeley BT, Ma CB, Lansdown DA. Pre-existing Mental Health Diagnoses Are Associated With Higher Rates of Postoperative Complications, Readmissions, and Reoperations Following Arthroscopic Rotator Cuff Repair. Arthroscopy 2023; 39:185-195. [PMID: 35970453 DOI: 10.1016/j.arthro.2022.06.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/18/2022] [Accepted: 06/25/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE To investigate the association between preoperative mental health disorders and postoperative complications, readmissions, and ipsilateral revision procedures among patients undergoing arthroscopic rotator cuff repair (RCR). METHODS A retrospective cohort study from 2010 to 2020 was performed using the PearlDiver database. Current Procedural Terminology and International Classification of Diseases codes were used to compare patients with and without mental health disorders who underwent arthroscopic RCR. Mental health disorders evaluated in this study include depressive disorder, major depressive disorder, major depressive affective disorder, bipolar disorder, dysthymic disorder, adjustment disorder, separation anxiety disorder, and posttraumatic stress disorder. Patients were matched at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, body mass index, and tobacco use. Rates of complications and subsequent surgeries were compared between patients with and without a preoperative diagnosis of a mental health disorder. RESULTS The 1-year preoperative prevalence of a mental health disorder from 2010 to 2020 was 14.6%. After 1:1 matching, patients with a mental health disorder who underwent arthroscopic RCR were nearly twice as likely to undergo a revision procedure (odds ratio 1.94, 95% confidence interval 1.76-2.14, P < .001) and more than twice as likely to experience conversion to shoulder arthroplasty (odds ratio 2.29, 95% confidence interval 1.88-2.80, P < .001) within 2 years of initial arthroscopy when compared with patients without a mental disorder. Patients with a mental disorder also experienced increased risk for 90-day readmission (1.9% vs 0%, P < .001) as well as multiple postoperative medical complications. CONCLUSIONS Patients with pre-existing mental health diagnoses experience increased rates of 90-day postoperative complications and readmissions following arthroscopic RCR. In addition, patients with mental health diagnoses are more likely to undergo revision repair and conversion to shoulder arthroplasty within 2 years of the index procedure. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan D Freshman
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Jacob F Oeding
- NYU Grossman School of Medicine, New York, New York, U.S.A.
| | - Christopher Anigwe
- School of Medicine, University of California San Francisco, San Francisco, California, U.S.A
| | - Alan L Zhang
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Brian T Feeley
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - C Benjamin Ma
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Drew A Lansdown
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
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Hall A, Dandu N, Sonnier JH, Rao S, Holston K, Liu J, Freedman K, Tjoumakaris F. The Influence of Psychosocial Factors on Hip Surgical Disorders and Outcomes After Hip Arthroscopy: A Systematic Review. Arthroscopy 2022; 38:3194-3206. [PMID: 35660519 DOI: 10.1016/j.arthro.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/02/2022] [Accepted: 05/12/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the associations between mental health and preoperative or postoperative outcomes of hip arthroscopy for femoroacetabular impingement. METHODS The literature search was conducted using the PubMed, EMBASE and PsychINFO databases following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS Nine studies were identified that met the inclusion and exclusion criteria. All studies assessing patient-reported outcomes found significantly lower patient-reported outcomes (modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports-Specific Subscale, and International Hip Outcome Tool scores) related to worse mental health functioning before surgery. Specifically, preoperative Hip Outcome Score-Activities of Daily Living and Hip Outcome Score-Sports-Specific Subscale were significantly greater in control patients than patients in the mental health group by 11.6 points (mean difference; 95% confidence interval 7.58-15.79, P < .001) and 10 points (95% confidence interval 5.14-14.87, P < .001), without significant heterogeneity between studies (I2 = 28.59, P = .25; I2 = 0, P = .93), respectively. Patients with lower mental health status also had lower rates of achieving a minimal clinically important difference in 5 studies included in this review. CONCLUSIONS This systematic review finds consistent evidence supporting the association between negative psychological function and worse preoperative and postoperative outcomes for patients with hip disorders. Understanding both the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy. LEVEL OF EVIDENCE IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Anya Hall
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Navya Dandu
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Kayla Holston
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - James Liu
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Kevin Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
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Pain catastrophizing and pre-operative psychological state are predictive of chronic pain after joint arthroplasty of the hip, knee or shoulder: results of a prospective, comparative study at one year follow-up. INTERNATIONAL ORTHOPAEDICS 2022; 46:2461-2469. [PMID: 35999466 PMCID: PMC9556350 DOI: 10.1007/s00264-022-05542-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/03/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE To assess the relationship between pre-operative psychological state, postoperative pain and function one year after total shoulder, hip or knee arthroplasty. METHODS Patients undergoing shoulder, hip or knee arthroplasty between March 2014 and November 2015 were included. Pain catastrophizing score (PCS) was determined preoperatively, at six months and at one year follow-up. Joint pain at rest was quantified using a Visual Analogue Scale (0‒100). Depressive symptoms were measured using the Beck Depression Inventory or Geriatric Depression Score, situational anxiety and dispositional anxiety were measured using the State-Trait Inventory and joint function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index for the hip and knee and Oxford Shoulder Score for the shoulder. RESULTS A total of 266 patients were included (65% female; mean (± SD) age: 71.8 ± 10.3 years; mean body mass index: 27.5 ± 5.0 kg/m2). Pre-operative PCS was significantly correlated with pain > 30/100 at one year and with functional scores, for all joints. Multivariate analysis identified the following variables as risk factors for pain intensity > 30/100 at one year: pre-operative PCS > 20/52 (OR = 3.5 ± 1.1 [95% CI: 1.9‒6.6]; p = 0.0001), trait-anxiety score ≥ 46 (OR = 2.4 ± 0.9 [95% CI: 1.1‒5.2]; p = 0.03), pre-operative pain ≥ 60/100 (OR = 3.2 ± 1 [95% CI: 1.8‒6.1]; p = 0.0001) and pain for at least 3 years (OR = 1.8 ± 0.6 [95% CI: 1‒3.4]; p = 0.04). CONCLUSION Pre-operative pain catastrophizing and trait-anxiety are risk factors for post-operative pain after shoulder, hip and knee arthroplasty. TRIAL REGISTRATION NUMBER www. CLINICALTRIALS gov NCT02361359.
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Vogel M, Binneböse M, Wallis H, Lohmann CH, Junne F, Berth A, Riediger C. The Unhappy Shoulder: A Conceptual Review of the Psychosomatics of Shoulder Pain. J Clin Med 2022; 11:jcm11185490. [PMID: 36143137 PMCID: PMC9504378 DOI: 10.3390/jcm11185490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Chronic pain is a multifaceted disorder genuinely entangled with psychic and psychosomatic symptoms, which are typically involved in the processes of chronification. The impingement syndrome of the shoulder is no exception to this rule, but several studies have shown respective peculiarities among those with pain and impingement of the shoulder. Notably, chronic pain is a lateralized experience, and, similarly, its psychosomatic correlates may be attached to the hemispheres functionally. AIM The present review therefore gives an overview of the respective findings, with regard not only to psychopathology, but also to personality factors and psychologic trauma, since the latter are reportedly associated with chronic pain. Moreover, we acknowledge symmetry as a possible pathogenic factor. METHODS This narrative review followed the current standards for conducting narrative studies. Based on prior findings, our research strategy included the relevance of psychotraumatologic and symmetrical aspects, as well as comorbidity. We retrieved the relevant literature reporting on the impact of psychopathology as well as personality features on shoulder pain, as published up to January 2022 from the Medline database (1966-2022). Study selecton: We included numerous studies, and considered the contextual relevance of studies referring to the neuropsychosomatics of chronic pain. RESULTS Pain-specific fears, depression, and anxiety are important predictors of shoulder pain, and the latter is generally overrepresented in those with trauma and PTSD. Moreover, associations of shoulder pain with psychological variables are stronger as regards surgical therapies as compared to conservative ones. This may point to a specific and possibly trauma-related vulnerability for perioperative maladaptation. Additionally, functional hemispheric lateralization may explain some of those results given that limb pain is a naturally lateralized experience. Not least, psychosocial risk factors are shared between shoulder pain and its physical comorbidities (e.g., hypertension), and the incapacitated state of the shoulder is a massive threat to the function of the human body as a whole. CONCLUSIONS This review suggests the involvement of psychosomatic and psychotraumatologic factors in shoulder impingement-related chronic pain, but the inconclusiveness and heterogeneity of the literature in the field is possibly suggestive of other determinants such as laterality.
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Affiliation(s)
- Matthias Vogel
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
- Correspondence: ; Tel.: +49391-6714200; Fax: +49391-6714202
| | - Marius Binneböse
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Hannah Wallis
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Christoph H. Lohmann
- Department of Orthopedic Surgery, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Florian Junne
- Department of Psychosomatic Medicine and Psychotherapy, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Alexander Berth
- Department of Orthopedic Surgery, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
| | - Christian Riediger
- Department of Orthopedic Surgery, Otto-von Guericke-University of Magdeburg, 39120 Magdeburg, Germany
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11
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Skedros JG, Cronin JT, Finlinson ED, Langston TD, Adondakis MG. Manual wheelchair use leads to a series of failed shoulder replacements: A case report and literature review. Clin Case Rep 2022; 10:e06374. [PMID: 36188047 PMCID: PMC9508804 DOI: 10.1002/ccr3.6374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/12/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- John G. Skedros
- Department of Orthopaedic Surgery The University of Utah Salt Lake City Utah USA
- Utah Orthopaedic Specialists Salt Lake City Utah USA
- Intermountain Medical Center Salt Lake City Utah USA
| | | | | | - Tanner D. Langston
- Department of Radiology West Virginia University Morgantown West Virginia USA
| | - Micheal G. Adondakis
- Department of Radiology Beth Israel Deaconess Medical Center Boston Massachusetts USA
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Levin JM, Baker R, Goltz DE, Wickman J, Lentz TA, Cook C, George SZ, Klifto CS, Anakwenze OA. Heterogeneity of pain-related psychological distress in patients seeking care for shoulder pathology. J Shoulder Elbow Surg 2022; 31:681-687. [PMID: 34656777 DOI: 10.1016/j.jse.2021.09.009] [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: 06/27/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to (1) describe the prevalence of various subtypes of psychological distress; (2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function; and (3) determine differences in psychological distress profiles between patients receiving nonoperative vs. operative treatment. METHODS The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags (YFs) ranges from 0 to 11, with higher YF counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using χ2 test and Student t test. Linear regression was used to evaluate the association between pain, disability, and YFs, whereas Poisson regression evaluated the association between operative treatment and psychological distress. K-means cluster analysis was performed to propose potential psychological distress phenotypes. RESULTS Two hundred fifty-one patients (91%) had at least 1 YF on the OSPRO-YF tool, with a mean number of 6 ± 3.5 YFs. YFs in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (P < .001), Single Assessment Numeric Evaluation (P < .001), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) scores. Comparing operative and nonoperative cohorts, the operative cohort had a significantly higher mean number of YFs (6.5 vs. 5.6, P = .035), presence of any YF (94.3% vs. 85.7%, P = .015), and presence of YFs within the unhelpful coping domain (91.8% vs. 75.6%, P < .001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (P < .001), with females (P = .037) and smokers (P = .018) associated with higher psychological distress phenotypes. CONCLUSIONS YFs, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychological distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.
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Affiliation(s)
- Jay M Levin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Rafeal Baker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John Wickman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Chad Cook
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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13
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Baker M, Albelo F, Zhang T, Schneider MB, Foster MJ, Aneizi A, Hasan SA, Gilotra MN, Henn RF. PROMIS Depression and Anxiety in shoulder surgery patients. Bone Joint J 2022; 104-B:479-485. [PMID: 35360950 DOI: 10.1302/0301-620x.104b4.bjj-2021-1089.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The purpose of this study was to assess the prevalence of depression and anxiety symptoms in patients undergoing shoulder surgery using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety computer adaptive tests, and to determine the factors associated with more severe symptoms. Additionally, we sought to determine whether PROMIS Depression and Anxiety were associated with functional outcomes after shoulder surgery. METHODS This was a retrospective analysis of 293 patients from an urban population who underwent elective shoulder surgery from 2015 to 2018. Survey questionnaires included preoperative and two-year postoperative data. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. RESULTS Mean two-year PROMIS Depression and Anxiety scores significantly improved from preoperative scores, with a greater improvement observed in PROMIS Anxiety. Worse PROMIS Depression and Anxiety scores were also significantly correlated with worse PROMIS Physical Function (PF) and American Shoulder and Elbow Surgeons scores (ASES). After controlling for confounding variables, worse PROMIS Depression was an independent predictor of worse PROMIS PF, while worse PROMIS Anxiety was an independent predictor of worse PROMIS PF and ASES scores. CONCLUSION Mean two-year PROMIS Depression and Anxiety scores improved after elective shoulder surgery and several patient characteristics were associated with these scores. Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes. Cite this article: Bone Joint J 2022;104-B(4):479-485.
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Affiliation(s)
- Mitchell Baker
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Fernando Albelo
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Tina Zhang
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | | | - Michael J Foster
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Ali Aneizi
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | - S Ashfaq Hasan
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mohit N Gilotra
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
| | - R Frank Henn
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, Maryland, USA
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14
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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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15
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Lebe M, Burns SA, Falworth M, Higgs DS, Rudge WB, Majed A. Atraumatic shoulder instability: patient characteristics, comorbidities, and disability. JSES Int 2021; 5:955-959. [PMID: 34766069 PMCID: PMC8570950 DOI: 10.1016/j.jseint.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Atraumatic shoulder instability of the shoulder is well described, and numerous extrinsic factors have been identified as having a negative influence on long-term shoulder function, including age, sex, smoking, and workers' compensation status. Furthermore, physical factors such as acute or chronic pain, as well as psychological comorbidities such as depression and suicidal thoughts, are common in shoulder-related conditions. Methods Patients with atraumatic shoulder instability were recruited from a review of outpatient logbook and inpatient rehabilitation center admission records. Average and worst pain visual analogue scale rates were recorded for acute and chronic shoulder pain. Disability was measured using the “Disability of the Arm and Hand” score, as well as the Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Depression was assessed using Becks Depression Inventory II, and further single psychological items were selected from other psychological assessment questionnaires. Results We included 64 patients, of which 51 (79.7%) were female. Mean visual analogue scale pain scores were in average 5.11 (standard deviation 2.24) and 5.58 (standard deviation 2.34) for acute and chronic shoulder pain, respectively. A stepwise, multiple linear regression revealed that only chronic shoulder pain remained significantly related to disability (F(1,61) = 46.13, P < .001). A second linear regression analysis was performed and showed a significant association between the overall Disability of the Arm, Shoulder and Hand score and overall Becks Depression Inventory score (F(1,62) = 12.78, P < .001). A further stepwise, multiple linear regression analysis indicated that chronic pain and depression remain independent variables in the prediction of disability. Conclusion In addition to sociodemographic factors, pain and psychological comorbidities were found to have a negative impact on patient's functional outcome. This study further supports the need for an multidisciplinary team, holistic approach in the management of atraumatic shoulder instability patients with particular emphasis on chronic pain management and psychological support.
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Affiliation(s)
- Moritz Lebe
- Royal London Hospital Rotation, London, England, UK
| | | | - Mark Falworth
- Shoulder and Elbow Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Deborah S Higgs
- Shoulder and Elbow Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Will Bj Rudge
- Shoulder and Elbow Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Addie Majed
- Shoulder and Elbow Unit, Royal National Orthopaedic Hospital, Stanmore, UK
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16
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Gibson E, LeBlanc J, Sabo MT. Prior mood disorder diagnoses do not relate to current mood disorder symptoms or patient-reported disease severity in rotator cuff patients. Shoulder Elbow 2021; 13:683-690. [PMID: 34804218 PMCID: PMC8600670 DOI: 10.1177/1758573220947025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgery for rotator cuff syndrome does not always produce symptom improvement. Biological factors may explain some symptoms, but mood disorder symptoms may also contribute. The purpose of this study is to examine the interaction between disease severity, prevalence of mood disorder diagnoses, and current mood disorder symptoms in preoperative rotator cuff patients. METHODS A prospective cohort of patients aged 35-75 years with unilateral rotator cuff disease awaiting surgery participated. Demographics, psychiatric history, the Hospital Anxiety & Depression Scale, and the Western Ontario Rotator Cuff index were collected. Descriptive and univariate statistical testing was performed. RESULTS Of 140 participants (75M:65W) aged 55 ± 8 years, 34 reported a prior diagnosis of a mood disorder. There was a moderate positive relationship between disease severity and current depression and anxiety scores. Women were more likely to carry a diagnosis of a mood disorder, but there were no differences in current symptom levels between genders. No differences were found in patient-reported outcome measure scores between patients with and without a mood disorder diagnosis. DISCUSSION Current mood disorder symptoms were associated with greater disease severity, whereas the presence of a past mood disorder diagnosis was not. Awareness of this relationship may reduce bias about past mood disorder diagnoses during decision-making.
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Affiliation(s)
- Eric Gibson
- Sport Injury Prevention Research Centre,
University of Calgary, Calgary, Canada,South Campus Research Unit for Bone and
Soft Tissue, University of Calgary, Calgary, Canada,Eric Gibson, Sport Injury Prevention
Research Centre, 2500 University Drive NW, Calgary, Alberta, Canada T2N 1N4.
| | - Justin LeBlanc
- South Campus Research Unit for Bone and
Soft Tissue, University of Calgary, Calgary, Canada,Section of Orthopaedic Surgery, Cumming
School of Medicine, University of Calgary, Calgary, Canada
| | - Marlis T Sabo
- South Campus Research Unit for Bone and
Soft Tissue, University of Calgary, Calgary, Canada,Section of Orthopaedic Surgery, Cumming
School of Medicine, University of Calgary, Calgary, Canada
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17
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Multidimensional Perioperative Recovery Trajectories in a Mixed Surgical Cohort: A Longitudinal Cluster Analysis Utilizing National Institutes of Health Patient-Reported Outcome Measurement Information System Measures. Anesth Analg 2021; 134:279-290. [PMID: 34591809 DOI: 10.1213/ane.0000000000005758] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery. METHODS Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships. RESULTS Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters. CONCLUSIONS These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes.
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18
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Debeer P, Commeyne O, De Cupere I, Tijskens D, Verhaegen F, Dankaerts W, Claes L, Kiekens G. The outcome of hydrodilation in frozen shoulder patients and the relationship with kinesiophobia, depression, and anxiety. J Exp Orthop 2021; 8:85. [PMID: 34591188 PMCID: PMC8484410 DOI: 10.1186/s40634-021-00394-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/19/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose The aims of this study were to (1) investigate the effect of hydrodilatation in frozen shoulder patients on objective indices of shoulder functionality and subjective outcomes of pain, mobility, kinesiophobia, depression, and anxiety, and (2) progress knowledge about the reciprocal temporal relationship between psychological parameters at baseline and objective and subjective outcomes at 3-month follow-up. Methods We evaluated the clinical and psychological status of 72 patients with a frozen shoulder before and after hydrodilatation, using the Constant Murley score, the Visual Analogue score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, and the Shoulder Pain And Disability Index. Results We noted a significant improvement in functionality, pain and disability (p < .001). Depression and anxiety improved significantly (p < .001) between baseline and 3-month follow-up. Prospective analyses demonstrated that psychological factors are more likely to predict outcomes of hydrodilatation than vice versa. Conclusion Hydrodilatation followed by physiotherapy is an excellent way to treat patients with recalcitrant frozen shoulder, resulting in a continuous improvement of ROM and pain. Physiotherapists and physicians should be aware that psychological factors might have an impact on the treatment outcome.
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Affiliation(s)
- Philippe Debeer
- Orthopedics, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven, Leuven, Belgium. .,Institute for Orthopaedic Research and Training, Leuven, Belgium.
| | - Olivia Commeyne
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Ianthe De Cupere
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Dorien Tijskens
- Orthopedics, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Institute for Orthopaedic Research and Training, Leuven, Belgium
| | - Filip Verhaegen
- Orthopedics, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Institute for Orthopaedic Research and Training, Leuven, Belgium
| | - Wim Dankaerts
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Laurence Claes
- Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium.,Faculty of Medicine and Health Sciences, University Antwerp, Antwerp, Belgium
| | - Glenn Kiekens
- Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium.,Department of Neurosciences, Center for Contextual Psychiatry, KU Leuven, Leuven, Belgium
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19
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Sheikhzadeh A, Wertli MM, Weiner SS, Rasmussen-Barr E, Weiser S. Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review. BMC Musculoskelet Disord 2021; 22:560. [PMID: 34147071 PMCID: PMC8214793 DOI: 10.1186/s12891-021-04359-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 05/12/2021] [Indexed: 01/28/2023] Open
Abstract
Background Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention. Methods This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against. Results Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome. Conclusions Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.
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Affiliation(s)
- Ali Sheikhzadeh
- Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center (OIOC), NYU Langone Orthopedic Hospital, 63 Downing Street, New York, NY, 10014, USA. .,Graduate Program in Ergonomics and Biomechanics (ERBI), Graduate School of Arts and Sciences, New York University, New York, USA.
| | - Maria M Wertli
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland.,Horten Centre for Patient Oriented Research and Knowledge Transfer, University Hospital Zurich, Pestalozzistrasse, Zurich, Switzerland
| | - Shira Schecter Weiner
- Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center (OIOC), NYU Langone Orthopedic Hospital, 63 Downing Street, New York, NY, 10014, USA.,Graduate Program in Ergonomics and Biomechanics (ERBI), Graduate School of Arts and Sciences, New York University, New York, USA.,School of Health Sciences, Touro College, New York, NY, USA
| | - Eva Rasmussen-Barr
- Department of Neurobiology, Karolinska Institutet, Care Sciences and Society, Division of Physiotherapy, Huddinge, Sweden
| | - Sherri Weiser
- Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center (OIOC), NYU Langone Orthopedic Hospital, 63 Downing Street, New York, NY, 10014, USA.,Graduate Program in Ergonomics and Biomechanics (ERBI), Graduate School of Arts and Sciences, New York University, New York, USA
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20
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Innocenti T, Ristori D, Galantini P, Testa M, Di Bari M. The influence of central pain modulation on postoperative outcomes after shoulder surgery: A systematic review. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2021; 55:227-234. [PMID: 34100363 PMCID: PMC10566350 DOI: 10.5152/j.aott.2021.20125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 12/28/2020] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review whether the altered central pain modulation has a significant influence on post-surgical outcomes in patients undergoing shoulder surgery due to musculoskeletal disorders. METHODS A systematic search of MEDLINE, PEDro, and EMBASE was conducted without time restriction, including observational prognostic studies. Quality in Prognostic Studies Tool was adopted for critical appraisal, and a qualitative synthesis was undertaken. Two authors independently performed study selection, data extraction, and risk of bias assessment; any disagreement was resolved by a third author. A review protocol is published in the PROSPERO registry (CRD42019122303). The data regarding the potential predictors and outcome measures were obtained from the studies. RESULTS 11 prospective cohort studies were appraised. Overall, 952 patients were included with a sample size that ranged from 20 to 314. Studies included both arthroscopy and open surgery and presented low to moderate ROB. The prognostic factors investigated were depression, psychological distress, anxiety, catastrophizing, fear avoidance beliefs, self-efficacy and quantitative sensory testing. Only avoidance behaviors and self-efficacy were significantly related to post-surgical pain and function at 12 months after surgery. CONCLUSION Fear avoidance beliefs and inadequate coping strategies seem to be the most correlated factors with the worst pain and function scores. Surgeons and physical therapists should look for patients with signs of altered central pain modulation before surgery as they might be at risk of unfavorable outcome. LEVEL OF EVIDENCE Level II, Therapeutic Study.
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Affiliation(s)
- Tiziano Innocenti
- Department of Health Science, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The
Netherlands
| | - Diego Ristori
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona,
Italy
| | - Patrizia Galantini
- University of FlorenceScuola di Scienze della Salute Umana, Florence,
Italy
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Genova,
Italy
| | - Mauro Di Bari
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence,
Italy
- Unit of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence,
Italy
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21
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Henstenburg JM, Larwa JA, Williams CS, Shah MP, Harding SP. Risk factors for complications following pelvic ring and acetabular fractures: A retrospective analysis at an urban level 1 trauma center. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2021. [DOI: 10.1177/22104917211006890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Pelvic ring and acetabular fractures are some of the most morbid in orthopedic trauma. They commonly require large exposures for fixation and are associated with significant morbidity and mortality. This study attempts to identify risk factors for complications following operative fixation of pelvic injuries. Methods: 126 patients treated for pelvic injuries were reviewed retrospectively. Demographics, procedure characteristics, and outcomes were recorded. Variables associated with complications were analyzed using logistic regression analysis. Results: Complications occurred in 12 patients. Higher BMI, longer length of stay, and ilioinguinal approach were significantly associated with increased infection risk. Co-morbid heart disease and concurrent smoking status showed a trend for increased infection risk. Higher BMI and ilioinguinal approach were significantly associated with an increased likelihood of re-operation. Positive psychiatric history and Medicaid payer status showed a trend toward higher reoperation risk. Conclusion: Knowledge of these risk factors can help guide management and predict outcomes following pelvic fracture fixation.
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Affiliation(s)
- Jeffrey M Henstenburg
- Rothman Orthopaedic Institute at Jefferson Health Department of Orthopaedic Surgery, Philadelphia, PA, USA
| | - Joseph A Larwa
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | | | - Susan P Harding
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Brown A, Alas H, Bortz C, Pierce KE, Vasquez-Montes D, Ihejirika RC, Segreto FA, Haskel J, Kaplan DJ, Segar AH, Diebo BG, Hockley A, Gerling MC, Passias PG. Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery. J Clin Neurosci 2020; 84:42-45. [PMID: 33485597 DOI: 10.1016/j.jocn.2020.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 10/28/2020] [Accepted: 11/28/2020] [Indexed: 11/29/2022]
Abstract
Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).
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Affiliation(s)
- Avery Brown
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Haddy Alas
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Cole Bortz
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Dennis Vasquez-Montes
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Rivka C Ihejirika
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank A Segreto
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Jonathan Haskel
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Daniel James Kaplan
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Anand H Segar
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Aaron Hockley
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Michael C Gerling
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA.
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Surgical Stabilization of Shoulder Instability in Patients With or Without a History of Seizure: A Comparative Analysis. Arthroscopy 2020; 36:2664-2673.e3. [PMID: 32540371 PMCID: PMC7751058 DOI: 10.1016/j.arthro.2020.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patients from a large multicenter cohort with a history of seizure and those without a history of seizure regarding preoperative and intraoperative findings and surgical procedures performed. METHODS Patients undergoing shoulder stabilization from 2011 to 2018 at 11 orthopaedic centers were prospectively enrolled. Those with a history of seizure were identified and compared with non-seizure controls. Preoperative demographic, history, physical examination, and imaging findings were collected. Intraoperative findings and surgical procedures performed were recorded. The Mann-Whitney test, χ2 test, and logistic regression analysis were used to examine differences between the groups and define independent risk factors. Owing to the number of statistical tests performed, the false discovery method was used to determine adjusted P values to achieve α < .05. RESULTS During enrollment, 25 of 1,298 shoulder stabilization patients (1.9%) had a history of seizure. The sex ratio and age were similar between groups, as was posterior instability incidence (23.2% in control group vs 28.0% in seizure group). Seizure patients more frequently had more than 5 dislocations in the year preceding surgery (P = .016) and had increased preoperative radiographic evidence of bone loss (P < .001). Intraoperatively, seizure patients had a higher prevalence of reverse Hill-Sachs lesions (P < .001) and large (>30% of glenoid fossa) bony Bankart lesions (P < .001). Arthroscopic Bankart repair was the most common procedure in both groups. However, open procedures were performed in 15.6% of controls and 40.0% of seizure patients (P = .001). These procedures were most commonly bony procedures. CONCLUSIONS Seizure patients had more prior dislocations, had more preoperative bone loss, and underwent more open stabilization procedures than controls because of bone loss. Studies examining recurrence after stabilization will help establish appropriate management practices in this population. LEVEL OF EVIDENCE Level III, retrospective review of prospectively collected cohort.
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Emotions of Orthopaedic Arthroplasty Patients: A European Survey. Orthop Nurs 2020; 39:315-323. [PMID: 32956273 DOI: 10.1097/nor.0000000000000696] [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] [Indexed: 11/26/2022] Open
Abstract
METHODS This was a pre/post-observational study examining patients' emotions before and during elective knee or hip replacement surgery for osteoarthritis in seven European Union countries to identify factors related to better emotional status at discharge. INSTRUMENTS In addition to demographic data, information was collected on quality of life (EuroQoL five-dimension questionnaire), hospital expectations (Knowledge Expectations of Hospital Patients Scale), symptoms, and experienced emotions. ANALYSIS Total negative emotions scores at baseline and discharge were transformed into median values. Multivariate analysis identified the baseline factors related to better emotional status at discharge. RESULTS Patients (n = 1,590), mean age 66.7 years (SD = 10.6), had a significant reduction in the frequency of total negative emotions at discharge as compared with baseline. The multivariate model showed better health status (odds ratio [OR] = 1.012; p = .004), better emotional status at baseline (≥24 points), and shorter duration of hospital stay (OR = 0.960; p = .011) as independent factors associated with better emotional status at discharge (OR = 4.297; p = .001). CONCLUSIONS Patients undergoing elective knee or hip replacement surgery for osteoarthritis improve their emotional status during hospitalization, with fewer negative emotions at discharge. Good emotional status, feeling of higher health status at baseline, and shorter hospitalization were independently associated with better emotional status at discharge.
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Weekes DG, Campbell RE, Shi WJ, Giunta N, Freedman KB, Pepe MD, Tucker BS, Tjoumakaris FP. Prevalence of Clinical Depression Among Patients After Shoulder Stabilization: A Prospective Study. J Bone Joint Surg Am 2019; 101:1628-1635. [PMID: 31567799 DOI: 10.2106/jbjs.18.01460] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Depression is a potential risk factor for poor postoperative outcomes. This study aimed to identify the prevalence of clinical depression symptoms before and after shoulder stabilization, as well as the relationship between depression and functional outcomes. METHODS Patients undergoing arthroscopic primary glenohumeral stabilization for recurrent instability were eligible for enrollment. Participants completed the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) and the Western Ontario Shoulder Instability Index (WOSI) questionnaire preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patients with a preoperative QIDS-SR score of ≥6 were assigned to the clinical depression group. RESULTS Seventy-six patients were enrolled and were prospectively followed during this study. Thirty-nine patients were stratified into the clinical depression group. Preoperatively, the clinical depression cohort had worse WOSI scores than the cohort without clinical depression (mean difference, 8.3% [95% confidence interval (CI), 0.5% to 16.1%]; p = 0.04). Both the clinical depression cohort and the cohort without clinical depression displayed an improvement in WOSI scores at 1 year postoperatively (p < 0.01 for both cohorts). Both the clinical depression cohort and the cohort without clinical depression displayed an improvement in QIDS-SR scores at 1 year postoperatively (p < 0.01 for both cohorts). At 1 year postoperatively, the clinical depression cohort continued to have worse WOSI scores than the cohort without clinical depression (mean difference, 12.2% [95% CI, 5.9% to 18.5%]; p < 0.01) and worse QIDS-SR scores; the median QIDS-SR score was 5.0 points (interquartile range [IQR], 2.0 to 8.0 points) for the clinical depression group and 0.0 points (IQR, 0.0 to 3.0 points) for the group without clinical depression (p < 0.01). The postoperative prevalence of clinical depression (24%) was lower than the preoperative prevalence (51%) (p < 0.01). Increasing patient age was associated with preoperative depression symptoms (odds ratio, 3.1; p = 0.03). CONCLUSIONS Fifty-one percent of patients with shoulder instability reported depression symptoms before the surgical procedure. Surgical intervention improved shoulder function and depression symptoms over time; however, the clinical depression cohort had worse postoperative shoulder and depression outcomes. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Weilong J Shi
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | | | | | - Matthew D Pepe
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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Pensak MJ, Carry PM, Entin JM, Lalka A, Shourbaji NA, Scott FA. Depression and Anxiety among Patients with Atraumatic Lateral Epicondylitis and Ulnar-Sided Wrist Pain. J Wrist Surg 2019; 8:295-299. [PMID: 31402994 PMCID: PMC6685784 DOI: 10.1055/s-0039-1685451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
Background Ulnar-sided wrist pain (UWP) and lateral epicondylitis (LE) are common disorders that can be difficult to treat. Depression and anxiety have been shown to modify patient symptoms, disability and pain. Questions/Purposes The purpose of our study was to quantify the prevalence of depression and anxiety among patients with LE or UWP. A secondary aim was to determine if these patients report higher levels of pain upon presentation and if they are more likely to require occupational therapy. Patients and Methods A retrospective chart review was conducted, and patients included those with LE or UWP, atraumatic in origin, ages 18 and over, and ongoing use of noninvasive treatment of LE or UWP. Results Our final analysis included 97 patients of which 57 had LE, 34 had UWP, and 6 had both. The prevalence of a mood disorder was 34.0%. Anxiety and/or depression was more prevalent in patients with LE compared to UWP. The most common medication was alprazolam. Pain scores averaged 1.2 points higher in subjects with a history of a mental health disorder. After adjusting for age and sex, there was no significant association between prevalence of depression and/or anxiety and utilization of physical or occupational therapy. Conclusions Patients with either LE, UWP or both along with depression and/or anxiety may be less likely to improve with traditional treatments. Future investigations are warranted focusing on the value of a multidisciplinary team consisting of a hand surgeon, behavioral therapist, or psychologist to optimize treatment response. Level of Evidence This is a Level IV, case series study.
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Affiliation(s)
- Michael J. Pensak
- Department of Orthopedics, University of Colorado School of Medicine; University of Colorado Hospital, Aurora, Colorado
| | - Patrick M. Carry
- Children's Hospital Colorado, Musculoskeletal Research Center, Department of Orthopedic Surgery, Aurora, Colorado
| | - Jacob M. Entin
- Department of Orthopedics, University of Colorado School of Medicine; University of Colorado Hospital, Aurora, Colorado
| | - Andy Lalka
- Children's Hospital Colorado, Musculoskeletal Research Center, Department of Orthopedic Surgery, Aurora, Colorado
- Department of Orthopedics, University of Colorado School of Medicine Aurora, Colorado
| | - Nader A. Shourbaji
- Department of Orthopedics, University of Colorado School of Medicine; University of Colorado Hospital, Aurora, Colorado
| | - Frank A. Scott
- Department of Orthopedics, University of Colorado School of Medicine; University of Colorado Hospital, Aurora, Colorado
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Abstract
BACKGROUND The complex interrelationship among physical health, mental health, and social health has gained the attention of the medical community in recent years. Poor social health, also called social deprivation, has been linked to more disease and a more-negative impact from disease across a wide variety of health conditions. However, it remains unknown how social deprivation is related to physical and mental health in patients presenting for orthopaedic care. QUESTIONS/PURPOSES (1) Do patients living in zip codes with higher social deprivation report lower levels of physical function and higher levels of pain interference, depression, and anxiety as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) at initial presentation to an orthopaedic provider than those from less deprived areas; and if so, is this relationship independent of other potentially confounding factors such as age, sex, and race? (2) Does the relationship between the level of social deprivation of a patient's community and that patient's physical function, pain interference, depression, and anxiety, as measured by PROMIS remain consistent across all orthopaedic subspecialties? (3) Are there differences in the proportion of individuals from areas of high and low levels of social deprivation seen by the various orthopaedic subspecialties at one large, tertiary orthopaedic referral center? METHODS This cross-sectional evaluation analyzed 7500 new adult patients presenting to an orthopaedic center between August 1, 2016 and December 15, 2016. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index, a composite measure of community-level social deprivation, based on multiple census metrics such as income, education level, and housing type for a given nine-digit zip code was used to estimate individual social deprivation. Statistical analysis determined the effect of disparate area deprivation (based on most- and least-deprived national quartiles) for the entire sample as well as for patients categorized by the orthopaedic subspecialty providing care. Comparisons of PROMIS scores among these groups were based on an MCID of 5 points for each PROMIS domain (Effect size 0.5). RESULTS Patients living in zip codes with the highest levels of social deprivation had worse mean scores across all four PROMIS domains when compared with those living in the least-deprived quartile (physical function 38 +/- 9 versus 43 +/- 9, mean difference 4, 95% CI, 3.7-5.0; p < 0.001; pain interference 64 +/- 8 versus 60+/-8, mean difference -4, 95% CI, -4.8 to -3.7; p < 0.001; depression 50+/-11 versus 45+/-8, mean difference -5, 95% CI, -6.0 to -4.5; p < 0.001; anxiety 56+/-11 versus 50 +/-10, mean difference -6, 95% CI, -6.9 to -5.4; p < 0.001). There were no differences in physical function, pain interference, depression, or anxiety PROMIS scores between patients from the most- and least-deprived quartiles who presented to the subspecialties of spine (physical function, mean 35+/-7 versus 35+/-7; p = 0.872; pain interference, 67+/-7 versus 66+/-7; p = 0.562; depression, 54+/-12 versus 51 +/-10; p = 0.085; and anxiety, 60+/-11 versus 58 +/-9; p = 0.163), oncology (physical function, mean 33+/-9 versus 38 +/-13; p = 0.105; pain interference, 68+/-9 versus 64+/-10; p = 0.144; depression, 51+/-10 versus 52+/-13; p = 0.832; anxiety, 59+/-11 versus 59+/-10 p = 0.947); and trauma (physical function, 35+/-11 versus 32+/-10; p = 0.268; pain interference, 66+/-7 versus 67+/-6; p = 0.566; depression, 52+/-12 versus 53+/-11; p = 0.637; and anxiety, 59+/-12 versus 60+/-9 versus; p = 0.800). The social deprivation-based differences in all PROMIS domains remained for the subspecialties of foot/ankle, where mean differences ranged from 3 to 6 points on the PROMIS domains (p < 0.001 for all four domains), joint reconstruction where mean differences ranged from 4 to 7 points on the PROMIS domains (p < 0.001 for all four domains), sports medicine where mean differences in PROMIS scores ranged from 3 to 5 between quartiles (p < 0.001 for all four domains), and finally upper extremity where mean differences in PROMIS scores between the most- and least-deprived quartiles were five points for each PROMIS domain (p < 0.001 for all four domains). The proportion of individuals from the most- and least-deprived quartiles was distinct when looking across all seven subspecialty categories; only 11% of patients presenting to sports medicine providers and 17% of patients presenting to upper extremity providers were from the most-deprived quartile, while 39% of trauma patients were from the most-deprived quartile (p < 0.001). CONCLUSIONS Orthopaedic patients must be considered within the context of their social environment because it influences patient-reported physical and mental health as well as has potential implications for treatment and prognosis. Social deprivation may need to be considered when using patient-reported outcomes to judge the value of care delivered between practices or across specialties. Further studies should examine potential interventions to improve the perceived health of patients residing in communities with greater social deprivation and to determine how social health influences ultimate orthopaedic treatment outcomes. LEVEL OF EVIDENCE Level II, prognostic study.
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Influence of Anxiety and Depression, Self-Rated Return-to-Work Problems, and Unemployment on the Outcome of Outpatient Rehabilitation After Shoulder Arthroscopy. Am J Phys Med Rehabil 2019; 98:1118-1124. [PMID: 31261254 DOI: 10.1097/phm.0000000000001260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to research the influence of psychosocial confounders on outpatient rehabilitation after arthroscopic shoulder surgery. DESIGN This retrospective study included patients who underwent such rehabilitation in a single center between January 2014 and October 2016. Shoulder function (Constant Shoulder Score) and pain (visual analog scale), improvements in these scores, and patient satisfaction were evaluated with regard to anxiety and depression (Hospital Anxiety and Depression Scale), self-rated return-to-work problems (Würzburg screening), and employment status. RESULTS The analysis included 176 patients. The mean (SD) Constant Shoulder Score and visual analog scale improved from 53.9 (18) to 75.4 (16.5) and 4.6 (2.1) to 2.9 (2.4) cm, respectively. A total of 84.1% of the patients were satisfied with the outcome. Unemployed patients (P = 0.001) and Hospital Anxiety and Depression Scale-positive ones (P = 0.014) were less satisfied than their counterparts. Patients with a Würzburg screening-positive screening showed less improvement in pain (P = 0.015), function (P = 0.016), and satisfaction (P = 0.002) than those without. Unemployed reported more pain (P = 0.008) than employed patients when starting rehabilitation. At the end of rehabilitation, all psychosocial scores (Hospital Anxiety and Depression Scale, P = 0.002; Würzburg screening, P = 0.001; unemployment, P < 0.001) negatively influenced pain, Würzburg screening (P = 0.007), and unemployment (P = 0.008) function. CONCLUSIONS Because we identified psychosocial factors that influence the success of outpatient shoulder rehabilitation, rehabilitation setup should be adjusted in patients with such problems.
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De Baets L, Matheve T, Meeus M, Struyf F, Timmermans A. The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review. Clin Rehabil 2019; 33:980-991. [DOI: 10.1177/0269215519831056] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: To examine the predictive, moderating and mediating role of cognitive, emotional and behavioral factors on pain and disability following shoulder treatment. Data sources: Electronic databases (PubMed, Web of Science, Embase and PsycINFO) were searched until 14 January 2019. Study selection: Studies including persons with musculoskeletal shoulder pain that describe the predictive, moderating or mediating role of baseline cognitive, emotional or behavioral factors on pain or disability following treatment were selected. Results: A total of 23 articles, describing 21 studies and involving 3769 participants, were included. Three studies had a high risk of bias. There was no predictive role of baseline depression, anxiety, coping, somatization or distress on pain or disability across types of shoulder treatment. No predictive role of fear-avoidance beliefs was identified in patients receiving physiotherapy, which contrasted to the results found when surgical treatment was applied. Baseline catastrophizing was also not predictive for pain or disability in patients receiving physiotherapy. After conservative medical treatments, results on the predictive role of catastrophizing were inconclusive. Treatment expectations and baseline self-efficacy predicted pain and disability in patients receiving physiotherapy, which was not the case in patients receiving conservative medical treatment. Finally, there was a moderating role for optimism in the relationship between pain catastrophizing and disability in patients receiving physiotherapy. Conclusion: There is evidence that expectations of recovery and self-efficacy have a predictive role and optimism a moderating role on pain and/or disability following physiotherapy for musculoskeletal shoulder pain. After surgical treatment, fear-avoidance is a predictor of pain and disability.
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Affiliation(s)
- Liesbet De Baets
- Rehabilitation Research Center (REVAL), Biomedical Research Institute (BIOMED), Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Thomas Matheve
- Rehabilitation Research Center (REVAL), Biomedical Research Institute (BIOMED), Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Mira Meeus
- Department of Rehabilitation Sciences & Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Group, Belgium
| | - Filip Struyf
- Department of Rehabilitation Sciences & Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Annick Timmermans
- Rehabilitation Research Center (REVAL), Biomedical Research Institute (BIOMED), Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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Francescutti VA, Maciver AH, Stewart E, Clark N, Marrara B, Saad-Harfouche FG, Rodriguez EM. Characterizing the Patient Experience of CS/HIPEC Through In-Depth Interviews with Patients: Identification of Key Concepts in the Development of a Patient-Centered Program. Ann Surg Oncol 2019; 26:1063-1070. [PMID: 30603814 DOI: 10.1245/s10434-018-07120-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) procedure is complex, involving lengthy preparation and recovery in a heterogeneous patient group. Understanding the patient experience is essential to improving interactions with health professionals that is critical to recovery. OBJECTIVE This study sought to characterize the early recovery and return to quality of life (at 3 and 6-12 months post-surgery, respectively) in patients having undergone CS/HIPEC, through structured interviews. METHODS Two sets of interviews were conducted among 20 CS/HIPEC patients. Interviews were uploaded into QSR NVivo 10 qualitative software (QSR International, Australia) and coded by two study personnel. Interview 1 focused on initial treatment decision making and postoperative hospitalization, while interview 2 focused on recovery, supports, and return to quality of life. RESULTS Among the participants, 60% were female and the mean age was 57 years (range 31-71). Diagnoses included disseminated peritoneal adenomucinosis (n = 6), appendiceal adenocarcinoma (n = 4), colorectal adenocarcinoma (n = 6), goblet cell (n = 2), and mesothelioma (n = 2). The first interview identified common themes of perioperative psychosocial isolation, lack of direction, and the importance of an established support system. Patients requested printed and audiovisual materials focused on addressing expectations. The main findings from the second interview captured patient experiences with longer-term complications, as well as surveillance. CONCLUSION Focused interviews with patients recently having undergone CS/HIPEC identified key issues that may be addressed in programs to improve the patient experience. These issues were distinctly different in relation to phase of recovery, and patient-centered programs designed with these factors in mind have the potential to enhance the recovery process.
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Affiliation(s)
- Valerie A Francescutti
- Department of Surgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
| | - Allison H Maciver
- Department of Surgery, London Regional Cancer Program, Western University, London, ON, Canada
| | - Erika Stewart
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Nikia Clark
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Bianca Marrara
- School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | - Frances G Saad-Harfouche
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Elisa M Rodriguez
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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31
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Thigpen CA, Floyd SB, Chapman C, Tokish JM, Kissenberth MJ, Hawkins RJ, Brooks JM. Comparison of Surgeon Performance of Rotator Cuff Repair: Risk Adjustment Toward a More Accurate Performance Measure. J Bone Joint Surg Am 2018; 100:2110-2117. [PMID: 30562291 DOI: 10.2106/jbjs.18.00211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Movement toward a value-based health-care system necessitates the development of performance measures to compare physicians, hospitals, and health-care systems. Patient-reported outcomes (PROs) are a potential metric. However, valid use of PROs hinges on the ability to risk-adjust for baseline patient differences across a surgeon's panel of patients. The purpose of this study was to propose an approach for baseline risk adjustment and evaluate the importance of risk adjustment when comparing surgeons' performance of rotator cuff repair. METHODS Patients (n = 995) treated with arthroscopic rotator cuff repair by 34 surgeons from 2010 to 2017 were identified from a large sports medicine clinical data registry. A linear regression model was used to adjust for baseline PROs, patient demographics, and clinical characteristics to predict American Shoulder and Elbow Surgeons (ASES) change scores for each surgeon. A risk-adjusted performance measure was calculated as the difference between the average unadjusted ASES change scores and the risk-adjusted predicted ASES change scores across all patients treated by a surgeon. RESULTS The differences between unadjusted and risk-adjusted performance scores varied widely across surgeons (range, -13.8 to 10.3 ASES points). Use of the risk-adjusted performance scores resulted in a dramatic change in the relative ranking of surgeons, compared with the ranking based on the observed ASES change scores, with 31 of the 34 surgeons' rank changing following risk adjustment. On average, the observed ASES scores improved from 49.5 ± 17.5 at baseline to 78.0 ± 22.5 at 6 months across all surgeons. In the risk-adjustment model (R = 0.44), male sex, Workers' Compensation status, higher scores on the Veterans RAND 12-item Health Survey (VR-12), lower baseline ASES scores, fair and poor tendon quality, and night pain all had a significant effect on the predicted ASES change scores (p < 0.05). CONCLUSIONS Our results show wide variation of nearly 25 points in the risk-adjusted 6-month ASES performance difference from the highest to the lowest-performing surgeons. Additionally, 91% of surgeons' rank changed following risk adjustment. This suggests that performance measurement that does not account for baseline patient characteristics would likely result in incorrect conclusions about a surgeon's relative performance based on PROs. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Charles A Thigpen
- ATI Physical Therapy, Greenville, South Carolina.,Center for Effectiveness Research in Orthopaedics, Greenville, South Carolina
| | - Sarah B Floyd
- Center for Effectiveness Research in Orthopaedics, Greenville, South Carolina.,Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina
| | - Cole Chapman
- Center for Effectiveness Research in Orthopaedics, Greenville, South Carolina.,Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina
| | | | | | - Richard J Hawkins
- Center for Effectiveness Research in Orthopaedics, Greenville, South Carolina.,Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina
| | - John M Brooks
- Center for Effectiveness Research in Orthopaedics, Greenville, South Carolina.,Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina
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The Impact of Comorbid Mental Health Disorders on Complications Following Cervical Spine Surgery With Minimum 2-Year Surveillance. Spine (Phila Pa 1976) 2018; 43:1455-1462. [PMID: 29579013 DOI: 10.1097/brs.0000000000002651] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To improve understanding of the impact of comorbid mental health disorders (MHDs) on long-term outcomes following cervical spinal fusion in cervical radiculopathy (CR) or cervical myelopathy (CM) patients. SUMMARY OF BACKGROUND DATA Subsets of patients with CR and CM have MHDs, and their impact on surgical complications is poorly understood. METHODS Patients admitted from 2009 to 2013 with CR or CM diagnoses who underwent cervical surgery with minimum 2-year surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. Patients with a comorbid MHD were compared against those without (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between MHD and no-MHD cohorts. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: age, sex, Charlson/Deyo score, and surgical approach). RESULTS A total of 20,342 patients (MHD: n = 4819; no-MHD: n = 15,523) were included. MHDs identified: depressive (57.8%), anxiety (28.1%), sleep (25.2%), and stress (2.9%). CR patients had greater prevalence of comorbid MHD than CM patients (P = 0.015). Two years postoperatively, all patients with MHD had significantly higher rates of complications (specifically: device-related, infection), readmission for any indication, and revision surgery (all P < 0.05); regression modeling corroborated these findings and revealed combined surgical approach as the strongest predictor for any complication (CR, odds ratio [OR]: 3.945, P < 0.001; CM, OR: 2.828, P < 0.001) and MHD as the strongest predictor for future revision (CR, OR: 1.269, P = 0.001; CM, OR: 1.248, P = 0.008) in both CR and CM cohorts. CONCLUSION Nearly 25% of patients admitted for CR and CM carried comorbid MHD and experienced greater rates of any complication, readmission, or revision, at minimum, 2 years after cervical spine surgery. Results must be confirmed with retrospective studies utilizing larger national databases and with prospective cohort studies. Patient counseling and psychological screening/support are recommended to complement surgical treatment. LEVEL OF EVIDENCE 3.
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Koorevaar RCT, Kleinlugtenbelt YV, Landman EBM, van 't Riet E, Bulstra SK. Psychological symptoms and the MCID of the DASH score in shoulder surgery. J Orthop Surg Res 2018; 13:246. [PMID: 30286775 PMCID: PMC6172756 DOI: 10.1186/s13018-018-0949-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 09/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychological symptoms are frequently present in patients scheduled for shoulder surgery. The perception of functional disability, activity level and pain in the shoulder is negatively influenced by psychological symptoms, which leads to higher scores of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The aim of this study was to determine the influence of psychological symptoms on the minimal clinically important difference (MCID) of the DASH score in patients after shoulder surgery. METHODS In this prospective longitudinal cohort study, 176 patients were included. Group 1 (32 patients) had symptoms of psychological disorders before and after surgery; group 2 had no symptoms of psychological disorders (110 patients). In the remaining patients (34 patients), psychological disorders changed after surgery. Clinical outcome was measured with the change of DASH score and anchor questions for perceived improvement of pain and function after surgery. Symptoms of psychological disorders were identified with the Four-Dimensional Symptom Questionnaire. An anchor-based mean change score technique was used to determine the MCID of the DASH score. RESULTS DASH scores before and 12 months after shoulder surgery were significantly higher in patients with symptoms of psychological disorders; change of DASH score was not different between the two groups. The MCID of the DASH score was 13.0 [SD 20.7] in the group with symptoms of psychological disorders and 12.7 [SD 17.6] in the group with no symptoms of psychological disorders. We observed no difference (p = 0.559) in the MCID between the group with and the group without symptoms of psychological disorders. CONCLUSION Symptoms of psychological disorders had a negative effect on the DASH score but no influence on the MCID of the DASH score. The DASH score could be used in future studies to assess the influence of psychological factors on the clinical outcome of treatment.
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Affiliation(s)
- Rinco C T Koorevaar
- Department of Orthopedics, Deventer Hospital, N. Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands.
| | - Ydo V Kleinlugtenbelt
- Department of Orthopedics, Deventer Hospital, N. Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Ellie B M Landman
- Department of Orthopedics, Deventer Hospital, N. Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Esther van 't Riet
- Teaching Hospital/Research Department, Deventer Hospital, N. Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, PO box 30.001, 9700 GB, Groningen, The Netherlands
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Abstract
BACKGROUND Psychologic factors are associated with pain and disability in patients with chronic shoulder pain. Recent research regarding the association of affective psychologic factors (emotions) with patients' pain and disability outcome after surgery disagrees; and the relationship between cognitive psychologic factors (thoughts and beliefs) and outcome after surgery is unknown. QUESTIONS/PURPOSES (1) Are there identifiable clusters (based on psychologic functioning measures) in patients undergoing shoulder surgery? (2) Is poorer psychologic functioning associated with worse outcome (American Shoulder and Elbow Surgeons [ASES] score) after shoulder surgery? METHODS This prospective cohort study investigated patients undergoing shoulder surgery for rotator cuff-related shoulder pain or rotator cuff tear by one of six surgeons between January 2014 and July 2015. Inclusion criteria were patients undergoing surgery for rotator cuff repair with or without subacromial decompression and arthroscopic subacromial decompression only. Of 153 patients who were recruited and consented to participate in the study, 16 withdrew before data collection, leaving 137 who underwent surgery and were included in analyses. Of these, 124 (46 of 124 [37%] female; median age, 54 years [range, 21-79 years]) had a complete set of four psychologic measures before surgery: Depression, Anxiety and Stress Scale; Pain Catastrophizing Scale; Pain Self-Efficacy Questionnaire; and Tampa Scale for Kinesiophobia. The existence of clusters of people with different profiles of affective and cognitive factors was investigated using latent class analysis, which grouped people according to their pattern of scores on the four psychologic measures. Resultant clusters were profiled on potential confounding variables. The ASES score was measured before surgery and 3 and 12 months after surgery. Linear mixed models assessed the association between psychologic cluster membership before surgery and trajectories of ASES score over time adjusting for potential confounding variables. RESULTS Two clusters were identified: one cluster (84 of 124 [68%]) had lower scores indicating better psychologic functioning and a second cluster (40 of 124 [32%]) had higher scores indicating poorer psychologic functioning. Accounting for all variables, the cluster with poorer psychologic functioning was found to be independently associated with worse ASES score at all time points (regression coefficient for ASES: before surgery -9 [95% confidence interval {CI}, -16 to -2], p = 0.011); 3 months after surgery -15 [95% CI, -23 to -8], p < 0.001); and 12 months after surgery -9 [95% CI, -17 to -1], p = 0.023). However, both clusters showed improvement in ASES score from before to 12 months after surgery, and there was no difference in the amount of improvement between clusters (regression coefficient for ASES: cluster with poorer psychologic function 31 [95% CI, 26-36], p < 0.001); cluster with better psychologic function 31 [95% CI, 23-39], p < 0.001). CONCLUSIONS Patients who scored poorly on a range of psychologic measures before shoulder surgery displayed worse ASES scores at 3 and 12 months after surgery. Screening of psychologic factors before surgery is recommended to identify patients with poor psychologic function. Such patients may warrant additional behavioral or psychologic management before proceeding to surgery. However, further research is needed to determine the optimal management for patients with poorer psychologic function to improve pain and disability levels before and after surgery. LEVEL OF EVIDENCE Level II, therapeutic study.
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Rhon DI, Greenlee TA, Marchant BG, Sissel CD, Cook CE. Comorbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions. Br J Sports Med 2018; 53:547-553. [DOI: 10.1136/bjsports-2018-099294] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 02/05/2023]
Abstract
ObjectivesWe aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2 years after hip arthroscopy.MethodsData from individuals (ages 18–50 years) undergoing arthroscopic hip surgery between 2004 and 2013 were collected from the Military Health System (MHS) Data Repository (MDR). The MDR captures all healthcare encounters in all settings and locations for individuals within the MHS. Person-level data over 36 months were pulled and aggregated. Seven comorbidities related to poor outcomes from musculoskeletal disorders (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) were examined 12 months prior and 24 months after surgery. Changes in frequencies were calculated as were differences in proportions between presurgery and postsurgery.Results1870 subjects were identified (mean age 32.24 years; 55.5% men) and analysed. There were statistically significant increases (p<0.001) proportionally for all comorbidities after surgery. Relative to baseline, cases of mental health disorders rose 84%, chronic pain diagnoses increased 166%, substance abuse disorders rose 57%, cardiovascular disorders rose by 71%, metabolic syndrome cases rose 85.9%, systemic arthropathy rose 132% and sleep disorders rose 111%.ConclusionsMajor (potentially ‘hidden’) clinical comorbidities increased substantially after elective arthroscopic hip surgery when compared with preoperative status. These comorbidities appear to have been overlooked in major studies evaluating the benefits and risks of arthroscopic hip surgery.Level of evidencePrognostic, level III.
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Beleckas CM, Wright M, Prather H, Chamberlain A, Guattery J, Calfee RP. Relative Prevalence of Anxiety and Depression in Patients With Upper Extremity Conditions. J Hand Surg Am 2018; 43:571.e1-571.e8. [PMID: 29395589 PMCID: PMC5986590 DOI: 10.1016/j.jhsa.2017.12.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/29/2017] [Accepted: 12/04/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Prior research regarding the impact of mental health on upper extremity musculoskeletal function and recovery has frequently grouped catastrophizing, anxiety, and depression. This study was designed to define the relative prevalence of heightened anxiety versus depressive symptoms among a patient population seeking upper extremity care and to determine if those prevalences varied according to the symptomatic condition. METHODS All adult patients presenting to a tertiary upper extremity orthopedic center between June 1, 2016 and November 30, 2016 (n = 3,315) completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety and Depression Computer Adaptive Tests. Descriptive statistics and multivariable linear regression assessed differences in average PROMIS scores between demographic and diagnostic groups. Patients were also analyzed according to crossing thresholds for heightened anxiety and depression scores based on established linkage tables with the Generalized Anxiety Disorder 7 and Patient Health Questionnaire-9 Depression scales, respectively. Pearson chi-square analysis and binary logistic regression were performed to determine if the proportion of patients crossing these thresholds varied according to the primary symptomatic condition while accounting for patient age, sex, and race. RESULTS African American patients and those with carpal tunnel syndrome, trapeziometacarpal arthritis, or shoulder conditions reported significantly higher PROMIS Anxiety scores. Higher PROMIS Depression scores varied only by diagnosis. Seventeen percent of patients exceeded the Anxiety symptoms score threshold and 10% of patients exceeded the Depression symptom threshold. In logistic regression modeling, the likelihood of exceeding the Anxiety threshold varied by diagnosis and was increased in African American patients and females. African American race was associated with exceeding the Depression threshold while accounting for sex and diagnosis. CONCLUSIONS Patients with upper extremity conditions more frequently report heightened anxiety than heightened depression. Patient race and diagnosis are independent predictors of anxiety among patients seeking care for upper extremity conditions. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Casey M. Beleckas
- Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110
| | - Melissa Wright
- Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110
| | - Heidi Prather
- Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110
| | - Aaron Chamberlain
- Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110
| | - Jason Guattery
- Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110
| | - Ryan P. Calfee
- Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110
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Anxiety in the orthopedic patient: using PROMIS to assess mental health. Qual Life Res 2018; 27:2275-2282. [PMID: 29740783 DOI: 10.1007/s11136-018-1867-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE This study explored the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety assessment relative to the Depression assessment in orthopedic patients, the relationship between Anxiety with self-reported Physical Function and Pain Interference, and to determine if Anxiety levels varied according to the location of orthopedic conditions. METHODS This cross-sectional evaluation analyzed 14,962 consecutive adult new-patient visits to a tertiary orthopedic practice between 4/1/2016 and 12/31/2016. All patients completed PROMIS Anxiety, Depression, Physical Function, and Pain Interference computer adaptive tests (CATs) as routine clinical intake. Patients were grouped by the orthopedic service providing care and categorized as either affected with Anxiety if scoring > 62 based on linkage to the Generalized Anxiety Disorder-7 survey. Spearman correlations between the PROMIS scores were calculated. Bivariate statistics assessed differences in Anxiety and Depression scores between patients of different orthopedic services. RESULTS 20% of patients scored above the threshold to be considered affected by Anxiety. PROMIS Anxiety scores demonstrated a stronger correlation than Depression scores with Physical Function and Pain Interference scores. Patients with spine conditions reported the highest median Anxiety scores and were more likely to exceed the Anxiety threshold than patients presenting to sports or upper extremity surgeons. CONCLUSIONS One in five new orthopedic patients reports Anxiety levels that may warrant intervention. This rate is heightened in patients needing spine care. Patient-reported Physical Function more strongly correlates with PROMIS Anxiety than Depression suggesting that the Anxiety CAT is a valuable addition to assess mental health among orthopedic patients. LEVEL OF EVIDENCE Diagnostic level III.
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Martinez-Calderon J, Meeus M, Struyf F, Miguel Morales-Asencio J, Gijon-Nogueron G, Luque-Suarez A. The role of psychological factors in the perpetuation of pain intensity and disability in people with chronic shoulder pain: a systematic review. BMJ Open 2018; 8:e020703. [PMID: 29654040 PMCID: PMC5905738 DOI: 10.1136/bmjopen-2017-020703] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/13/2018] [Accepted: 03/15/2018] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Chronic shoulder pain is a very complex syndrome, and the mechanisms involved in its perpetuation remain unclear. Psychological factors appear to play a role in the perpetuation of symptoms in people with shoulder chronicity. The purpose of this systematic review is to examine the role of psychological factors in the perpetuation of symptoms (pain intensity and disability) in people with chronic shoulder pain. METHODS AND ANALYSIS A systematic search was performed on PubMed, AMED, CINAHL, PubPsych and EMBASE from inception to July 2017. Longitudinal studies with quantitative designs analysing the role of psychological factors on pain intensity, disability or both were included. The methodological quality of the included studies was evaluated with an adapted version of the Newcastle Ottawa Scale. The level of evidence per outcome was examined using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS A total of 27 articles were included with a sample of 11 176 people with chronic shoulder pain. The risk of bias ranges from 7/21 to 13/21 across the studies. The quality of the evidence was very low. High levels of self-efficacy, resilience and expectations of recovery were significantly associated with low levels of pain intensity and disability. Inversely, high levels of emotional distress, depressive symptoms, anxiety, preoperative concerns, fear-avoidance beliefs, somatisation and pain catastrophising were significantly associated with high levels of pain intensity and disability. DISCUSSION Our results suggest that psychological factors may influence the perpetuation of pain intensity and disability, with very low evidence. A meta-analysis was not carried out due to the heterogeneity of the included studies so results should be interpreted with caution. PROSPERO TRIAL REGISTRATION NUMBER CRD42016036366.
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Affiliation(s)
- Javier Martinez-Calderon
- Department of Physiotherapy, University of Malaga, Malaga, Spain
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
| | - Mira Meeus
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
- Rehabilitation Sciences and Physiotherapy Department, Ghent University, Ghent, Belgium
- Pain in Motion International Research Group
| | - Filip Struyf
- Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
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Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? A Systematic Review. Clin Orthop Relat Res 2018; 476:810-829. [PMID: 29481342 PMCID: PMC6260082 DOI: 10.1007/s11999.0000000000000087] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Psychosocial factors are key determinants of health and can influence patient-reported outcomes after rotator cuff tears. However, to our knowledge, a systematic review of published studies has not been conducted to determine the degree of consistency and strength of the relationship between psychosocial factors and patient-reported outcomes in this patient population. QUESTIONS/PURPOSES (1) Are psychosocial factors associated with patient-reported measures at initial clinical presentation in patients with rotator cuff tears? (2) Are psychosocial factors associated with patient-reported outcomes after treatment in patients with rotator cuff tears? METHODS A systematic review of cross-sectional and prospective observational studies was performed in MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science from each database's inception to June 2016. We included studies examining associations between psychosocial factors and patient-reported measures in patients with rotator cuff tears. We excluded studies not reporting on this relationship, involving patients with nonspecific shoulder pain, and written in a language other than English. Two independent reviewers performed the search, extracted information, and assessed methodological quality. Study quality was assessed using the Methodological Items for Non-Randomized Studies (MINORS) criteria. The primary outcomes for the review were associations between each psychosocial factor and patient-reported measures of function or disability, pain, or quality of life. Associations were interpreted based on significance, strength, and direction of the relationship. A total of 10 studies (five cross-sectional and five prospective) in 1410 patients (age range, 46-62 years, 60% [571 of 958] men) were included in the review. Pooling of results for meta-analyses was not possible as a result of study heterogeneity. RESULTS Weak to moderate cross-sectional associations were found for emotional or mental health with function or disability and pain in multiple studies. Lower emotional or mental health function was associated with greater pain or disability or lower physical function at initial evaluation. Only one psychosocial factor (patient expectation) was weak to moderately associated with patient-reported outcomes after treatment in more than one study. In the two studies that examined expectations, the higher the expectation of benefit, the greater the perceived benefit after surgical intervention. CONCLUSIONS At the initial evaluation of patients with rotator cuff tear, there was an association between self-reported function and pain and emotional or mental health. However, these factors were not associated with patient-reported outcomes after intervention. This finding could be attributed to the lack of large prospective studies in this area or complex phenotypes within this patient population. Preoperative patient expectation is an important predictor of patient-reported outcomes in patients after rotator cuff surgery and may be a modifiable target for enhancing recovery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Diebo BG, Cherkalin D, Jalai CM, Shah NV, Poorman GW, Beyer GA, Segreto FA, Lafage V, Naziri Q, Newman JM, Urban WP, Errico TJ, Schwab FJ, Paulino CB, Passias PG. Comparing psychological burden of orthopaedic diseases against medical conditions: Investigation on hospital course of hip, knee, and spine surgery patients. J Orthop 2018; 15:297-301. [PMID: 29556113 DOI: 10.1016/j.jor.2018.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/18/2018] [Indexed: 10/18/2022] Open
Abstract
Retrospective review of National Inpatient Sample (2000-2012) revealed that 31.28% of musculoskeletal (MSK) patients were found to have in-hospital psychological burdens (PBs). Adult spinal deformity (ASD), degenerative disc disease (DDD) and lung cancer patients had highest PB-prevalence. MSK patients with PB were more often young, white females with increased Deyo index compared to no-PB patients. Patients who underwent spinal revision procedures had higher PB rates than with primary procedures; a converse trend was observed for total hip/knee arthroplasty. Psychological disorders were identified as significant predictors of increased total-hospital charges. Augmenting counseling with psychological screening/support is recommended to complement MSK management.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States
| | - Denis Cherkalin
- State University of New York, Downstate College of Medicine, 450 Clarkson Ave., Brooklyn, NY, United States
| | - Cyrus M Jalai
- Division of Spinal Surgery, NYU Hospital for Joint Diseases, 301 E. 17th St., New York, NY, United States
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States
| | - Greg W Poorman
- Division of Spinal Surgery, NYU Hospital for Joint Diseases, 301 E. 17th St., New York, NY, United States
| | - George A Beyer
- State University of New York, Downstate College of Medicine, 450 Clarkson Ave., Brooklyn, NY, United States
| | - Frank A Segreto
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States.,Division of Spinal Surgery, NYU Hospital for Joint Diseases, 301 E. 17th St., New York, NY, United States
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, 525 E. 71st St., 4th Floor, New, York, NY, United States
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States
| | - Jared M Newman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States
| | - William P Urban
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States
| | - Thomas J Errico
- Division of Spinal Surgery, NYU Hospital for Joint Diseases, 301 E. 17th St., New York, NY, United States
| | - Frank J Schwab
- Spine Service, Hospital for Special Surgery, 525 E. 71st St., 4th Floor, New, York, NY, United States
| | - Carl B Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Ave., MSC 30, Brooklyn, NY, United States
| | - Peter G Passias
- Division of Spinal Surgery, NYU Hospital for Joint Diseases, 301 E. 17th St., New York, NY, United States
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Abstract
Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between patients, surgeon, and anesthetist. A multimodal approach with preemptive medication, regional blockade, local anesthetics, and a combination of acetaminophen, nonsteroidal antiinflammatory drugs, tramadol, and gabapentinoids postoperatively leads to pain control and patient satisfaction. Assessment of patients' expectations constitutes a vital aspect of the preoperative patient evaluation. Educating and psychologically preparing patients reduces postoperative pain. Patients with anxiety and depression, preoperative narcotic use, and medical comorbidities are at an increased risk for suboptimal pain control. Minimizing narcotic use decreases opioid-related adverse effects and facilitates productive rehabilitation efforts.
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Affiliation(s)
- Jason L Codding
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA.
| | - Charles L Getz
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA
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Performance of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Versus Physical Function (PF) Computer Adaptive Tests (CATs) in Upper Extremity Clinics. J Hand Surg Am 2017; 42:867-874. [PMID: 28709794 PMCID: PMC5671895 DOI: 10.1016/j.jhsa.2017.06.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/12/2017] [Accepted: 06/10/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the performance of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Function Computer Adaptive Test (CAT) relative to the PROMIS Physical Function (PF) CAT in patients seeking specialty care for upper extremity conditions. METHODS This observational trial analyzed prospectively collected PROMIS UE and PF CAT scores from 5,202 adult patients with 10,344 outpatient clinic visits presenting to a tertiary orthopedic clinic. Pearson correlation coefficient was utilized to evaluate the association between initial PF and UE scores as well as the association between changes in PF and UE scores between visits. Differences in scores between populations presenting with hand conditions versus shoulder and elbow conditions were evaluated via Student t test, as were differences in scores between new and return patient visits. RESULTS The PROMIS UE CAT scores were strongly correlated with PROMIS PF CAT scores. However, patients averaged 8 points lower scoring on UE CAT testing than on PF CAT scores. The UE CAT demonstrated a ceiling effect at a score of 56 that affected 7% of patients with a secondary ceiling at 50. Changes in PF and UE scores between visits were moderately correlated with a mean difference of less than 1 point. Patients presenting for hand conditions achieved better PF and UE scores than patients presenting for shoulder and elbow conditions. CONCLUSIONS The PROMIS UE module appears responsive to changes over time. However, the current UE CAT has a ceiling score of 56, which does not allow for improvement of scores 0.6 SD higher than the presumptive normative population mean of 50. Although a specific assessment of upper extremity function is desirable, continued refinement of the PROMIS UE CAT is required to better assess patients with higher levels of function. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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