Telephone-Based Intervention to Improve Rehabilitation Engagement After Spinal Stenosis Surgery: A Prospective Lagged Controlled Trial

Nurse-led web-based self-management program to improve patient activation and health outcomes in patients with chronic low back pain: an acceptability and feasibility pilot study

BACKGROUND

Patients with chronic low back (cLBP) pain report reduced physical function and ability to participate in social roles and are more likely to use opioid pain medications. While self-management interventions have been shown to support these patients, their effectiveness has been limited due to poor patient engagement. "Patient activation" encompasses the skills, knowledge, and motivation that a person has to manage their health. Supporting patient activation may improve the effectiveness of self-management for cLBP.

METHODS

In this single-masked pilot study of adults with cLBP, patients were randomized to receive either no intervention (control) or 6 weekly sessions of an evidence-based web-based self-management program (SMP) with or without health behavior change counseling (HBCC) using motivational interviewing. Participants were assessed at baseline and at 12 and 26 weeks using the Patient Activation Measure, Oswestry Disability Index and PROMIS physical function, social role participation, and pain interference. We assessed acceptability and feasibility based on recruitment, session attendance, and follow-up.

RESULTS

Of 187 individuals screened, 105 were eligible and 34 were randomized to control (n = 12), SMP (n = 4), or SMP + HBCC (n = 18). The population had 19 women, 22 patients married or living with significant other, 13 Black or African American patients, and 4 Hispanic or Latino patients. Participants had a mean (SD) Oswestry Disability Index score of 42 (12), moderate impairments in physical function (40 (6.6)) and social roles (45 (10)), and moderately severe pain interference (61 (6.7)). Of 22 participants receiving SMP sessions, 20 participated in at least 1, 15 participated in at least 3, and 7 participated in all 6 sessions. Loss to follow-up was 6 over the 26-week study. Participants in the SMP and SMP + HBCC groups had at least medium effect size improvements in Patient Activation Measures and small-to-medium effect size improvements in Oswestry Disability Index scores and physical function and large effect size improvement in social roles at 12 weeks. Improvements persisted in the SMP + HBCC group at 26 weeks.

CONCLUSIONS

A web-based SMP is acceptable and feasible in this population. Participants who received augmentation with HBCC had persistent improvements in health outcomes at 26 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT06236529 (2/1/2024 - retrospectively registered).

LEVEL OF EVIDENCE: 3

Associations of cognitive appraisal and patient activation on disability and mental health outcomes: a prospective cohort study of patients undergoing spine surgery

BACKGROUND

With the increased use of patient-reported outcomes measures (PROMs) to assess spine surgery outcomes, it is important to understand how patients interpret their health changes over time. The measurement of cognitive-appraisal processes enables the quantification of how individuals think about quality of life (QOL). This study examined how appraisal processes were associated with patients' views of their role in managing their health-patient activation.

METHODS

This longitudinal cohort study from August 2019 to January 2022 included 222 adults undergoing spine surgery for cervical (n = 107) and/or lumbar (n = 148) pathology at an academic medical center. PROMs assessed disability (Neck Disability Index for cervical or Oswestry Disability Index for lumbar) and mental health (PROMIS-29 v2.0), cognitive-appraisal processes (QOLAPv2-SF), and patient activation (Patient Activation Measure). ANOVA models were used to examine the relationships between QOL and cognitive appraisal processes before and after surgery, overall and stratified by patient-activation stage. Effect sizes facilitated interpretation.

RESULTS

There were significant improvements in pain-related disability and mental health following surgery. Cognitive appraisal processes explained substantial amounts of variance, particularly with changes in mental health (45% before surgery, 75% at three months, and 63%, at 12-months after surgery). With respect to physical disability, less disability was associated with a lesser focus on negative aspects of QOL. Appraisal explained the most variance before surgery for high-activation patients. At 12-months post-surgery, however, appraisal explained the most variance for the low-activation patients. Appraisal explained similar amounts of variance in mental health at baseline and three-months post-surgery for all activation groups, but substantially more variance in the low-activation group at 12-months post-surgery. There were differences in the direction of appraisal-outcome associations by activation group in selected appraisal items/domains.

CONCLUSIONS

Cognitive-appraisal processes demonstrate a significant relationship with QOL among spine surgery patients. These processes explain substantial variance in pain-related disability and mental health, especially among those high in activation before surgery and those low in activation at 12-months post-surgery. Our findings suggest that patients' ways of thinking about their health may be effective targets of motivational coaching, to help them become more engaged over the recovery trajectory.

Influence of motivational interviewing on postoperative mobilization in the enhanced recovery after surgery (ERAS®) pathway in elective colorectal surgery - a randomized patient-blinded pilot study

PURPOSE

Early mobilization is an essential component of the Enhanced Recovery after Surgery (ERAS®)-pathway. However, a large percentage of patients fail to achieve the ERAS® recommended goal (360 min out of bed from post-operative day 1/POD1). Motivational Interviewing (MI) is an evidence-based type of patient-centered consultation to promote intrinsic motivation. This study aims to evaluate if MI can improve postoperative mobilization.

METHODS

This two-arm, patient-blinded pilot randomized controlled trial included ERAS®-patients undergoing elective bowel resections. Conversations were validated by MI Treatment Integrity. Two validated motion sensors (movisens) and self-assessments were used to measure mobilization (POD1-POD3: Time out of bed, time on feet and step count).

RESULTS

97 patients were screened, 60 finally included and randomized. Cumulatively across POD1-3, the intervention group (IG) was longer out of bed than the control group (CG) (median: 685 vs. 420 min; p=0.022). The IG achieved the ERAS®-goal of 360 min/day more frequently across POD1-3 (27.4% vs. 10.61%; p=0.013). Time on feet was 131.5 min/day (median per POD) in IG vs. 95.8 min/day in the CG (p=0.212), step count was 1347 in IG vs. 754 steps/day in CG (p=0.298).

CONCLUSION

MI could be conducted low threshold and was well accepted by patients. MI can improve mobilization in the context of ERAS®. Despite better performance, it should be noted that only 27.4% of the IG reached the ERAS®-compliance goal of 360 min/day. The findings of this pilot study stipulate to further test the promising perioperative effects of MI within a multicenter superiority trial.

REGISTRATION

This study was registered prospectively in the German Clinical Trials Register on 25.02.2022. Trial registration number is "DRKS00027863".

Prehabilitation for spine surgery: A scoping review

We aimed to identify and describe the current interventions used in preoperative programs ("prehabilitation") for spine surgery. Knowledge gaps in approaches, feasibility, timing, patient experience, clinical outcomes, and health care costs were explored while describing their potential benefits on physical and psychological outcomes. An electronic search was conducted from January 2004 to February 2022 in Ovid Medline, Embase, EBSCO CINAHL, the Cochrane Database of Systematic Reviews, and PEDro to identify studies in English evaluating adults enrolled in prehabilitation before undergoing elective spine surgeries. Studies were uploaded into DistillerSR for systematic screening after removing duplicates. Four reviewers screened nested references for inclusion based on titles and abstracts, followed by their full-text review. Two reviewers subsequently extracted data and summarized the results. The results were reported using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Studies were rated for quality using National Health and Medical Research Council criteria. Out of 18,879 potential studies, a total of 23 studies (0.12%) met the eligibility criteria and were included in this scoping review. The prehabilitation programs included general education (n = 6, 26%), exercise (n = 6, 26%), cognitive behavioral therapy (n = 3, 13%), pain neuroscience education (n = 3, 13%), health behavior counseling (n = 3, 13%), and mindfulness (n = 2, 9%). Additional studies are needed to identify optimal patient characteristics, intervention dosage, and whether multimodal approaches using a combination of physical and psychological strategies lead to more favorable outcomes. Although studies on prehabilitation for spine surgery are limited, they seem to demonstrate that prehabilitation programs are feasible, reduce medical expenditures, and improve patients' postoperative pain, disability, self-efficacy, psychological behaviors, and satisfaction with surgical outcomes. The available literature suggests there is an opportunity to improve patient experience, clinical outcomes and reduce medical costs with the use of prehabilitation in spine surgery.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: Roles of psychological distress and patient activation

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Psychological distress compounds negative effects of COVID-19 on pain and HRQoL.

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Patient activation is protective from COVID-19 effects on pain and HRQoL.

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Providers should screen for psychological distress and patient activation.

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Enhanced patient supports to manage pain are needed for at-risk patients.

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Enhanced patient supports to maintain HRQoL are needed for at-risk patients.

Background

Public health measures during the COVID-19 pandemic have disrupted access to basic resources (income, food, housing, healthcare). The effects may impact patients differently based on socioeconomic status (SES), pre-existing psychological distress, and patient activation (knowledge, skills, and motivation to manage healthcare). We examined changes in access to basic resources and in pain and health-related quality of life (HRQoL) during the pandemic and determined how pre-existing psychological distress and patient activation are associated with exacerbation or mitigation of effects on pain and HRQoL.

Methods

This cross-sectional study assessed 431 patients in a longitudinal-outcomes registry who underwent or scheduled spine surgery at our institution and were surveyed about COVID-19 effects on accessing basic resources. We assessed pain (numeric rating scale) and HRQoL (PROMIS 29-Item Profile). Information on preoperative SES, psychological distress, patient activation, pain, and HRQoL was collected previously. We compared access to basic resources by SES. We compared changes from pre-COVID-19 to COVID-19 assessments of pain and HRQoL and proportions of patients reporting worsened pain and HRQoL stratified by psychological distress. We analyzed associations between patient activation and negative effects on HRQoL using multivariable linear regression. Alpha=0.05.

Results

Respondents reported minor disruptions in accessing basic resources (no difference by SES) but significant worsening of back (p=.027) and leg pain (p=.013) and HRQoL (physical function, fatigue, p<0.001; satisfaction with participation in social roles, p=0.048) during COVID-19. Psychological distress was associated with clinically relevant worsening of back, pain, leg pain, and physical function all, (p<0.05). High patient activation was associated with less impairment of physical function (p=0.03).

Conclusion

Patients with pre-existing psychological distress experienced greater worsening of pain and HRQoL. High patient activation appeared to mitigate worsening of physical function. Providers should screen for psychological distress and patient activation and enhance supports to manage pain and maintain HRQoL in at-risk patients.

Level of Evidence: III

Patient-centeredness in Physiotherapy - A literature mapping review

Background and purpose: Research on patient-centeredness within physiotherapy points to a need for clarification about what the concept entails in science and practice and how research positions itself within health care. Thus, the aim is to systematically map the characteristics of research on patient-centeredness in physiotherapy and critically discuss the dominant understandings within. Methods: A systematic research mapping was carried out, based on searches in leading bibliographic databases. Four categories were selected in order to characterize the research field: focus, design, theoretical approach and inherent logic. Findings: Of 5,324 studies, 101 were included in the final mapping, pointing to a limited amount of research. The papers included were published in 47 different journals. Two major research foci emerges: one testing or developing technologies (tools) to promote patient-centeredness and one exploring patients' or professionals' experiences related to physiotherapy practice. Most papers reported on empirical research and there seems to be a dearth of conceptual papers. The theoretical approaches applied were mainly psychological, pedagogical and biomedical. The papers included were divided into equal amounts of studies carried out within inherent logics of causality and complexity. Conclusion: The mapping suggests an incipient awareness of patient-centeredness within the research field of physiotherapy. Empirical studies dominate the field, whereas conceptual and critical papers seem in need of wider acknowledgment. The research field is divided into two mutually disconnected trends: one concerned with understanding the complexity of clinical practice and patients' experiences of treatment and illness, and another trend concerned with solving "the problem" of patient involvement.

Contact Tracing for COVID-19: The Use of Motivational Interviewing and the Role of Social Work

One method in mitigating the impact of COVID-19 is that of contact tracing. It is estimated that in the US, 35,000-100,000 contact tracers will be hired (and trained) to talk to recently-infected individuals, understand who they have exposed to the virus, and encourage those exposed to self-quarantine. The Center for Disease Control recommends the use of motivational interviewing (MI) by contact tracers to encourage compliance with contact tracing/quarantine. Contact tracers need to sensitively communicate with COVID-19-exposed individuals who may also be experiencing other issues caused by the pandemic, such as anxiety, depression, grief, anger, intimate partner violence, health problems, food insecurity, and/or unemployment. Social workers are particularly prepared to address the mental health and other psychosocial problems that may be encountered in the tracing process. This article describes contact tracing, its use in other diseases, the role of MI, psychosocial issues that contact tracers may encounter, and how social work can respond to these needs. A sample dialogue of contact tracing using MI is presented with a discussion of the content and skills used in the process.

Current Prehabilitation Programs Do Not Improve the Postoperative Outcomes of Patients Scheduled for Lumbar Spine Surgery: A Systematic Review With Meta-analysis

OBJECTIVE

To assess the effectiveness of prehabilitation in patients with degenerative disorders of the lumbar spine who are scheduled for spine surgery.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

Seven electronic databases were systematically searched for randomized controlled trials or propensity-matched cohorts.

STUDY SELECTION CRITERIA

Studies that measured the effect of prehabilitation interventions (ie, exercise therapy and cognitive behavioral therapy [CBT]) on physical functioning, pain, complications, adverse events related to prehabilitation, health-related quality of life, psychological outcomes, length of hospital stay, use of analgesics, and return to work were included.

DATA SYNTHESIS

Data were extracted at baseline (preoperatively) and at short-term (6 weeks or less), medium-term (greater than 6 weeks and up to 6 months), and long-term (greater than 6 months) follow-ups. Pooled effects were analyzed as mean differences and 95% confidence intervals (CIs). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS

Cognitive behavioral therapy interventions were no more effective than usual care for all outcomes. Pooled effect sizes were -2.0 (95% CI: -4.4, 0.4) for physical functioning, -1.9 (95% CI: -5.2, 1.4) for back pain, and -0.4 (95% CI: -4.1, 0.4) for leg pain. Certainty of evidence for CBT ranged from very low to low. Only 1 study focused on exercise therapy and found a positive effect on short-term outcomes.

CONCLUSION

There was very low-certainty to low-certainty evidence of no additional effect of CBT interventions on outcomes in patients scheduled for lumbar surgery. Existing evidence was too limited to draw conclusions about the effects of exercise therapy. J Orthop Sports Phys Ther 2021;51(3):103-114. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9748.

The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders

OBJECTIVE

Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.

METHODS

Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).

RESULTS

While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8-5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5-5.3).

CONCLUSIONS

Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

The Role of Engagement in Teleneurorehabilitation: A Systematic Review

The growing understanding of the importance of involving patients with neurological diseases in their healthcare routine either for at-home management of their chronic conditions or after the hospitalization period has opened the research for new rehabilitation strategies to enhance patient engagement in neurorehabilitation. In addition, the use of new digital technologies in the neurorehabilitation field enables the implementation of telerehabilitation systems such as virtual reality interventions, video games, web-based interventions, mobile applications, web-based or telephonic telecoach programs, in order to facilitate the relationship between clinicians and patients, and to motivate and activate patients to continue with the rehabilitation process at home. Here we present a systematic review that aims at reviewing the effectiveness of different engagement strategies and the different engagement assessments while using telerehabilitation systems in patients with neurological disorders. We used PICO's format to define the question of the review, and the systematic review protocol was designed following the Preferred Reported Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Bibliographical data was collected by using the following bibliographic databases: PubMed, EMBASE, Scopus, and Web of Science. Eighteen studies were included in this systematic review for full-text analyses. Overall, the reviewed studies using engagement strategies through telerehabilitation systems in patients with neurological disorders were mainly focused on patient self-management and self-awareness, patient motivation, and patient adherence subcomponents of engagement, that are involved in by the behavioral, cognitive, and emotional dimensions of engagement. Conclusion: The studies commented throughout this systematic review pave the way for the design of new telerehabilitation protocols, not only focusing on measuring quantitative or qualitative measures but measuring both of them through a mixed model intervention design (1). The future clinical studies with a mixed model design will provide more abundant data regarding the role of engagement in telerehabilitation, leading to a possibly greater understanding of its underlying components.

Integrated care programmes for sport and work participation, performance of physical activities and quality of life among orthopaedic surgery patients: a systematic review with meta-analysis

Objectives

Orthopaedic surgery is primarily aimed at improving function and pain reduction. Additional integrated care may enhance patient’s participation in sports and work, possibly improving performance of physical activities and quality of life (QoL). We aimed to assess the effectiveness of integrated care among orthopaedic surgery patients.

Design

Systematic review with meta-analysis.

Data source

Medline, EMBASE and CINAHL (until 17 June 2019).

Eligibility for selecting studies

We searched for controlled studies on integrated care interventions consisting of active referral to case managers, rehabilitation with participation-based goals and/or e/mHealth, with outcomes of sports and work participation, performance of physical activities and/or QoL. Outcomes were normalised to 0–100 scales and statistically pooled.

Results

Seventeen articles (n=2494) of moderate quality were included reporting on patients receiving back, upper limb, knee or hip surgery. Only one study reported on return to sports and found no significant benefit. For return to work, one study did (90% vs 82%) and one did not (relative risk=1.18 (0.80 to 1.70)) observe significant benefits. Integrated care showed small effects for improving performance of physical activities (2.69 (–0.20 to 5.58); eight studies, n=1267) and QoL (2.62 (1.16 to 5.05); nine studies, n=1158) compared with usual care.

Summary/Conclusion

We found insufficient and inconsistent evidence for the effectiveness of integrated care for orthopaedic surgery patients regarding sport and work participation. Small effects were found for performance of physical activities and QoL. High quality research on integrated care focusing on sports and work participation is needed before integrated care can be implemented for orthopaedic surgery patients.

Patient-Reported Outcome Measures and Patient Activation: What Are Their Roles in Orthopedic Trauma?

The rise of patient-reported outcome (PRO) measurement across medicine has been swift and now extends to the world of orthopedic trauma. However, PRO measures (PROMs) applied to trauma patients pose special considerations; measuring "episodes of care" is less straightforward, injuries are heterogeneous in their severity, and the patient's initial visit is "postinjury." Obtaining baseline scores and assessing the impact of a traumatic event on mental health are key considerations. Currently, few, if any, trauma registries include PROs; though general and condition-specific PROMs plus the patient empowerment measure of Patient Activation represent meaningful inputs for the clinical decision-making process. To be useful in trauma care, PROMs should be psychometrically sound and validated, be used for capturing function, screen for mental state and substance use, and give the clinician a sense of the patient's "activation" (engagement in their own health). Although the implementation of routine PRO collection can seem daunting, clinicians can use a multitude of electronic resources to access validated measures and simplify the implementation process. Computer-adaptive testing has evolved to help minimize patient burden, and PROM collection must maximize efficiency. Once established as part of your practice, PROs become an important tool to track recovery, identify mental health issues, engage in the prevention of future injury, and enable care of the whole patient.

A Multidimensional Exercise Program in the Home for Older Adults Designed to Improve Function

The purpose of this study was to determine whether there was difference in the OASIS (Outcome and Assessment Information Set) activities of daily living (ADL) items scores between the Safe Strides program and Safe Strides plus Zōntago program. Eight home care offices were selected for this prospective randomized quality improvement study where Safe Strides versus Safe Strides plus Zōntago were compared. Rehabilitation outcome OASIS ADL change scores were analyzed for 112 total patient care episodes. The Safe Strides + Zōntago mean total ADL score change and ADL change per visit were higher than the Safe Strides group. Differences in ADL outcomes in older adults undergoing home care provided by physical therapists and physical therapist assistants in the Safe Strides exercise program versus the Safe Strides plus Zōntago program were noted. The Safe Strides + Zōntago compared with Safe Strides alone improved patient functional outcomes as measured by the OASIS.