Optimal Screening for Prediction of Referral and Outcome (OSPRO) for Musculoskeletal Pain Conditions: Results From the Validation Cohort

Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings

The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35-.37) while moderate-to-good relationships (r = .51-.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PERSPECTIVE: This study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.

Interrater reliability of the modified prone instability test for lumbar segmental instability in individuals with mechanical low back pain

OBJECTIVE

The purpose of this study was to establish the interrater reliability of measures obtained with a novel Modified Prone Instability Test (mPIT), which, like the original Prone Instability Test (PIT), is proposed to identify lumbar segmental instability. The mPIT has clinical feasibility advantages to the PIT, but its psychometric properties are yet to be determined.

DESIGN

Repeated measures (test-retest) design, methods study.

METHODS

The mPIT was administered by two blinded testers, an orthopedic physical therapy resident with < 1 year experience and board-certified orthopedic specialist physical therapist with >25 years' experience. Procedures were administered at an outpatient physical therapy clinic of a tertiary Medical Center. Participants included 50 adults (≥18 years old) with mechanical low back pain and no radicular (below the knee) symptoms (mean age 50.7 years, 66% female, 76% reported previous episodes of low back pain). Interrater reliability was measured via Fleiss' kappa coefficient.

RESULTS

Assessments of the mPIT had moderate interrater agreement (κ = .579 [95% CI = .302 to .856], p < .001.).

CONCLUSION

Measures obtained using the mPIT demonstrated moderate interrater reliability between a new graduate and an experienced clinician, which aligns with several studies examining interrater reliability of the original PIT. Further study examining comparative validation of the mPIT with other lumbar instability measures is warranted.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study

BACKGROUND

Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear.

METHODS

Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool.

RESULTS

Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME.

CONCLUSIONS

Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

BACKGROUND

Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care.

QUESTIONS/PURPOSES

(1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors?

METHODS

We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores.

RESULTS

Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated.

CONCLUSION

This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions.

LEVEL OF EVIDENCE

Level III, prognostic study.

Transition from Acute to Chronic Low Back Pain in a Community-Based Cohort

The transition from acute to chronic low back pain (LBP) in community settings has yet to be well understood. We recruited n=131 participants with acute LBP from the community and followed them for 3 and 6-month outcomes. Acute LBP was defined by a duration of < 4 weeks, and participants must have reported a 30-day LBP-free period before the current acute episode. Chronic LBP was defined as pain most or every day over the past 3 months. Baseline psychological, social, and demographic factors were examined as predictors of transition to chronic LBP at 3 months or continuation of chronic LBP at 6 months. The transition from acute to chronic LBP at 3 months was 32.2% ( 38/118). At 6 months, 80.7% (25/111) of participants who transitioned at 3 months continued to have chronic LBP. At 6 months, participants who identified as Black or African American were more likely than white participants to transition to chronic LBP (RR=1.76, 95% CI 1.05, 2.95) and more likely to continue to have chronic LBP (RR=2.19, 95% CI 1.14, 4.21). Those classified at baseline by both LBP most or every day and intensity of at least 30/100 were more likely to transition to chronic LBP (RR=3.13, 95% CI 1.84, 5.30) and continue to have chronic LBP at 6 months (RR=2.58, 95% CI 1.43, 4.16). The STarT Back Screening Tool and the OSPRO-YF were associated with the transition to chronic LBP at 3 months and continuation at 6 months. Participants with higher PROMIS General Health and PROMIS Physical Health scores were less likely to transition to chronic LBP or continue to have chronic LBP at 6 months. These findings identify factors of acute LBP in the community that may predict the transition to chronic LBP. Larger studies are needed to confirm these findings and better understand the mechanisms driving the transition to chronic LBP.

Cortisol as a Marker of Pain and Distress After Acute Musculoskeletal Trauma

OBJECTIVES

The best available predictors of chronic pain development broadly encompass baseline metrics of cognition (ie, beliefs/expectations) about the trauma and resulting symptoms. In the context of musculoskeletal trauma, we have previously shown the Traumatic Injuries Distress Scale (TIDS) capable of risk-stratifying cohorts for chronic pain development. Here, we explore whether the physiological marker cortisol shows meaningful associations with cognitions predictive of pain outcomes.

METHODS

Data for these cross-sectional analyses were drawn from an observational study that recruited 130 participants presenting to the hospital with pain related to a recent noncatastrophic Musculoskeletal trauma. Cortisol was measured from the participant's hair, saliva, and blood. In addition to pain and distress questionnaires, metadata such as age, sex, body mass index (BMI), adverse childhood events, pretrauma stress levels, and pre-existing physical/psychological comorbidities were collected.

RESULTS

We found no significant associations between cortisol levels and pain or distress in isolation. When stratified by person-level variables, associations were revealed with distress (TIDS) in young age and low pretrauma stress subgroups (hair cortisol) and low BMI (blood cortisol). Through hierarchical regression analysis, we found the "cortisol X age" or "cortisol X stress" interaction terms significantly improved TIDS prediction beyond either variable in isolation (Age: ∆ R2 =15.1%; pretrauma stress: ∆ R2 =9.1%).

DISCUSSION

Our findings suggest that while linear correlations between pain-related distress and cortisol may be overly simplistic, certain person-level variables such as age, pretrauma stress, and BMI are worthy of consideration for experimental design or confounder characterization in future studies of pain and distress following musculoskeletal injuries especially when "trait" (hair) cortisol is the predictor variable.

Acute Intermittent Hypoxia Did Not Alter Pain Sensitivity or Pain Intensity Ratings for Individuals with Chronic Low Back Pain: A Pilot Study

Aims and Objective

The purpose of this pilot study was to explore whether AIH produces changes in pain sensitivity or in reports of self-reported pain intensity for individuals with low back pain.

Methods

In a quasi-experimental, cross-over design we compared participants (n = 9) exposed to normal room air and hypoxia using a commercially available gas blender. The treatment period consisted of 5 consecutive days of randomly assigned to AIH or room air. For the participants initially randomized to AIH there was cross-over to receive 5 more consecutive days of room air. Therefore, this design allowed for between group and within subject assessment of AIH effects. Pain sensitivity was assessed with quantitative sensory testing (QST) for posterior superior iliac spine pressure threshold, plantar thermal threshold, and peak pain ratings. Self-reported pain intensity for low back pain was assessed via the Brief Pain Inventory.

Results

There were no between group differences for AIH and room air in pain sensitivity or self-reported pain intensity. In the within subject analyses larger effect sizes favoring AIH were detected for plantar measures of pain sensitivity but not for self-reported pain intensity.

Conclusion

This study, while presenting null findings, describes an initial step in determining whether AIH can be used to increase pain relief. Based on this pilot study we offer guidance for future research including study design, AIH dosage, participant selection, and using AIH in combination with non-pharmacologic treatments.

Pain-Associated Psychological Distress Is of High Prevalence in Patients With Hip Pain: Characterizing Psychological Distress and Phenotypes

Purpose

To identify common pain-related psychological factors among patients seeking care for athletic hip pain, as well as characterize psychological distress phenotypes and compare hip-specific quality-of-life measures across those phenotypes.

Methods

A total of 721 patients were recruited from hip preservation clinics. The Optimal Screening for Prediction of Referral and Outcome-Yellow Flag Assessment Tool (OSPRO-YF) was used to identify the presence or absence of 11 different pain-associated psychological distress characteristics (yellow flags), while the International Hip Outcome Tool-12 (iHOT-12) was used to assess hip-related quality of life. Latent class analysis identified patient subgroups (phenotypes) based on naturally occurring combinations of distress characteristics. An analysis of variance was used to compare demographics, number of yellow flags, and iHOT-12 scores across phenotypes.

Results

The median (interquartile range) number of yellow flags was 6 (3-9), with 13.5% of the sample reporting 11 yellow flags. Latent class analysis (L2 = 543.3, classification errors = 0.082) resulted in 4 phenotypes: high distress (n = 299, 41.5%), low distress (n = 172, 23.9%), low self-efficacy and acceptance (n = 74, 10.3%), and negative pain coping (n = 276, 24.4%). Significant differences in mean yellow flags existed between all phenotypes except low self-efficacy and negative pain coping. There were no differences in demographics between phenotypes. The high distress class had the lowest mean iHOT-12 score (mean [SD], 23.5 [17.6]), with significant differences found between each phenotypic class.

Conclusions

There was a high prevalence of pain-associated psychological distress in patients presenting to tertiary hip arthroscopy clinics with hip pain. Furthermore, hip quality-of-life outcome scores were uniformly lower in patients with higher levels of psychological distress.

Level of Evidence

Level III, retrospective cohort study.

Beyond yellow flags: The Big-Five personality traits and psychologically informed musculoskeletal rehabilitation

BACKGROUND

Psychosocial variables are known to play an important role in musculoskeletal pain. Recent efforts incorporating psychological theory into rehabilitative medicine, as part of patient-centred care or psychologically informed physical therapy, have gained broader acceptance. The fear-avoidance model is the dominant psychosocial model and has introduced a variety of phenomena which assess psychological distress (i.e., yellow flags). Yellow flags, such as fear, anxiety and catastrophizing, are useful concepts for musculoskeletal providers but reflect a narrow range of psychological responses to pain.

OBJECTIVE

Clinicians lack a more comprehensive framework to understand psychological profiles of each patient and provide individualised care. This narrative review presents the case for applying personality psychology and the Big-Five trait model (extraversion, agreeableness, conscientiousness, neuroticism and openness to experience) to musculoskeletal medicine. These traits have strong associations with various health outcomes and provide a robust framework to understand patient emotion, motivation, cognition and behaviour.

KEY RESULTS

High conscientiousness is associated with positive health outcomes and health promoting behaviours. High neuroticism with low conscientiousness increases the odds of negative health outcomes. Extraversion, agreeableness and openness have less direct effects but have positive correlations with important health behaviours, including active coping, positive affect, rehabilitation compliance, social connection and education level.

CLINICAL APPLICATION

The Big-Five model offers an evidence-based way for MSK providers to better understand the personality of their patients and how it relates to health. These traits offer the potential for additional prognostic factors, tailored treatments and psychological intervention.

The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study

INTRODUCTION

The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice.

OBJECTIVE

To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge.

DESIGN

Retrospective cohort study.

SETTING

Hospital-based outpatient physical therapy.

PARTICIPANTS

Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis.

MAIN OUTCOME MEASURES

Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge.

RESULTS

A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region.

CONCLUSION

These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.

Characterizing Acute Low Back Pain in a Community-Based Cohort

Acute low back pain (LBP) is a common experience, however, the associated pain severity, pain frequency, and characteristics of individuals with acute LBP in community settings have yet to be well understood. The purpose of this manuscript is to categorize and compare acute LBP groups for differences in the following characteristics: 1) sociodemographic, 2) general and physical health, and 3) psychological. This cross-sectional study used baseline data from 131 community-based participants with acute LBP (<4 weeks duration before screening and > 30 pain-free days before acute LBP onset). Two LBP categorization definitions were used based on LBP frequency combined with either: 1) pain interference frequency (impact-based) or 2) pain intensity (intensity-based). Descriptive associations were calculated as prevalence ratios for categorical variables and Hedges' g for continuous variables. Our analyses identified several large associations for impact-based and intensity-based categories for pain interference with activity and with enjoyment in life, global mental health, STarT Back Screening Tool risk category, general health, and Fear Avoidance Beliefs Questionnaire-Physical Activity subscale. Larger associations were found with social constructs (racially and ethnically minoritized, performance of social roles, and isolation) when using the intensity-based versus impact-based categorization. This study adds to the literature by providing standard ways to characterize community-based individuals experiencing acute LBP. The robust differences observed between these categorization approaches suggest they may be used to improve the early identification of factors potentially contributing to the development of chronic LBP.

Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study

INTRODUCTION

The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization.

OBJECTIVE

The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach.

METHODS

A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management.

RESULTS

The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management.

CONCLUSION

DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.

The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain

BACKGROUND

Musculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities.

OBJECTIVE

Explore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP.

METHODS

A longitudinal assessment of individuals 18-90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain.

RESULTS

532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (β) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((β = 0.6; 95%CI: 0.1, 1.1), and prior surgery (β = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (β = -0.2, 95%CI: -0.3, -0.02).

CONCLUSIONS

Depression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.

Working Alliance Inventory (WAI) and its relationship to patient-reported outcomes in painful musculoskeletal conditions

PURPOSE

Therapeutic alliance (TA) has been positively correlated to improvements in patient outcomes. This study examined the Working Alliance Inventory (WAI) relationship with changes in disability and pain intensity for patients receiving physical therapy (PT) treatment for acute and chronic musculoskeletal pain conditions.

METHODS

Fifty participants were dichotomized into success or failure by the minimal clinically important difference (MCID) on region-specific patient-reported outcome measures (PROM) and Numeric Pain Rating Scale (NPRS). Regression and correlation statistics examined the relationship between WAI with change scores and quantity of PT. Independent t-tests compared WAI scores across categorical variables.

RESULTS

WAI scores were higher for those meeting MCIDs on PROM and NPRS compared to those who did not. WAI scores were significantly correlated with improvement on region-specific outcome measures and NPRS. Regression analysis found the patient rating of the TA to be a positive predictor for improvement on regions specific outcome measures and NPRS.

CONCLUSIONS

Patients who rated the TA higher were more likely to meet the MCID for region-specific disability and pain intensity. Patient ratings of the TA were associated with improved change scores on pain rating and standardized outcome measures during a course of treatment for musculoskeletal pain conditions.Implications for rehabilitationPatients' early rating of the therapeutic alliance (TA) is associated with improvements seen on pain and functional outcomes.Physical therapists should assess the TA and use strategies to enhance the alliance to optimize patient's experiences with physical therapy.

Pain and Disability Following Exercise-Induced Injury in Prognostic and Intervention Studies: The Why May Be More Important Than the How

OBJECTIVES

In preclinical prognostic studies, the description of expected outcomes during an informed consent process indicates that the extent of pain and disability experienced and recovery time is unknown. In intervention studies, the consent process suggests that pain and disability will definitely occur and a treatment provided. Our objective was to determine whether study design (prognosis or intervention) was associated with the severity of pain intensity and disability reports from a preclinical model.

MATERIALS AND METHODS

We pooled pain and disability outcomes from prognostic and intervention studies using an exercise-induced muscle injury model of pain. Pain intensity, disability, and fear of pain were collected by validated self-report measures. Pain and disability data were z-transformed for pooled analyses and compared across the study design.

RESULTS

Data from 310 people were included. The primary findings were that self-reported pain intensity and disability were: (1) higher in prognostic studies than in the intervention studies and (2) associated with fear of pain. A secondary finding was that fear of pain was lower in the intervention compared with the prognostic studies.

DISCUSSION

Although there are other possible explanations, we speculate that these results could be related to the uncertainty inherent to providing informed consent for a prognostic study. In light of these findings, we recommend that informed consent language be more carefully considered when pain is induced in a controlled manner. Incorporating informed consent language commonly used in prognostic studies could result in higher pain intensity and disability ratings in studies that use preclinical models to test the efficacy of pain interventions.

Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED.

METHODS AND ANALYSIS

This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04290741.

Willingness to use nonpharmacologic treatments for musculoskeletal pain in the emergency department: a cross-sectional study

Supplemental Digital Content is Available in the Text.

Patients in emergency department with musculoskeletal pain report high willingness to try nonpharmacologic treatments, and health care provider encouragement correlated with greater nonpharmacologic treatment use.

Objectives:

Pain is an individual experience that should incorporate patient-centered care. This study seeks to incorporate patient perspectives toward expanding nonpharmacologic treatment options for pain from the emergency department (ED).

Methods:

In this cross-sectional study of adult patients in ED with musculoskeletal neck, back, or extremity pain, patient-reported outcomes were collected including willingness to try and prior use of various nonpharmacologic pain treatments, sociodemographics, clinical characteristics, functional outcomes, psychological distress, and nonmusculoskeletal symptoms. Least absolute shrinkage and selection operator regression identified variables associated with (1) willingness to try and (2) having previously tried nonpharmacologic treatments.

Results:

Responses were analyzed from 206 adults, with a mean age of 45.4 (SD 16.4) years. The majority (90.3%) of patients in ED were willing to try at least one form of nonpharmacologic pain treatment, with 70.4%, 81.6%, and 70.9% willing to try respective subcategories of active (eg, exercise), passive (eg, heat), and psychosocial (eg, prayer) modalities. Only 56.3% of patients had previously tried any, with 35.0%, 52.4%, and 41.3% having tried active, passive, and psychosocial modalities, respectively. Patient-level factors associated with willingness included pain in upper back, more severe pain-related symptoms, and functional impairments. The factor most consistently associated with treatment use was health care provider encouragement to do so.

Conclusions:

Patients in ED report high willingness to try nonpharmacologic treatments for pain. Higher pain severity and interference may indicate greater willingness, while health care provider encouragement correlated with treatment use. These findings may inform future strategies to increase the introduction of nonpharmacologic treatments from the ED.

Blood Flow Restriction Training for Subacromial Pain: Two Case Reports

BACKGROUND

Blood flow restriction training (BFRT) appears to promote the strengthening of shoulder muscles, but primary clinical applications are limited to the lower extremity.

CASE PRESENTATION

Two female recreational athletes (Case A: 27 years old; Case B: 28 years old) with subacromial pain were treated with BFRT (50% occlusion) during 3 isotonic strengthening exercises of the upper extremity against 20% of the maximal isometric strength. At the beginning of each treatment week, we measured strength with a handheld dynamometer to ensure appropriate load progression.

OUTCOME AND FOLLOW-UP

Case A completed 16 visits and Case B completed 22 visits of BFRT with no adverse events. At discharge, we found meaningful improvement for patient-reported function, clinical measures of shoulder flexion and external-rotation range of motion and isometric strength, supraspinatus and infraspinatus cross-sectional area, and upper extremity performance.

DISCUSSION

BFRT may be a valuable adjunct to standard rehabilitation for the conservative management of subacromial pain. Despite the inherent limitations of our design, we believe these preliminary findings are compelling to warrant future investigations.

Heterogeneity of pain-related psychological distress in patients seeking care for shoulder pathology

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.

Injury-related psychological distress and the association with perceived running ability in injured runners

OBJECTIVE

Examine injury-related psychological distress and association with perceived running ability in injured runners.

DESIGN

Prospective longitudinal study.

PARTICIPANTS

Forty-three patients with a running-related injury.

MAIN OUTCOME MEASURES

Data collection at initial physical therapy visit and 12-16 weeks later included Optimal Screening for Prediction of Referral and Outcome - Yellow Flag (OSPRO-YF) and Athlete Fear Avoidance Questionnaire (AFAQ) for injury-related psychological distress, and University of Wisconsin Running and Recovery Index (UWRI) for perceived running ability. OSPRO-YF composite score, total yellow flags, and yellow flags in each domain (negative mood, fear-avoidance, positive affect/coping) were calculated.

RESULTS

UWRI score and OSPRO-YF composite score and yellow flags significantly improved over time, while AFAQ score and yellow flags in OSPRO-YF negative mood domain did not. AFAQ scores were significantly correlated with UWRI score at baseline, follow-up and change over time, while OSPRO-YF composite score and yellow flags were not. Baseline OSPRO-YF composite score and AFAQ score were not correlated with follow-up UWRI score.

CONCLUSIONS

Injury-related psychological distress is elevated when injured runners start rehabilitation, and generally improves; however, negative mood and athletic fear-avoidance may persist. Higher athletic fear-avoidance is associated with lower perceived running ability at the same time point or interval.

The Effect of Mobile Care Delivery on Clinically Meaningful Outcomes, Satisfaction, and Engagement Among Physical Therapy Patients: Observational Retrospective Study

Background

Musculoskeletal care is now delivered via mobile apps as a health care benefit. Although preliminary evidence shows that the clinical outcomes of mobile musculoskeletal care are comparable with those of in-person care, no research has examined the features of app-based care that secure these outcomes.

Objective

Drawing on the literature around in-person physical therapy, this study examines how patient-provider relationships and program engagement in app-based physical therapy affect clinically meaningful improvements in pain, function, and patient satisfaction. It then evaluates the effects of patient-provider relationships forged through in-app messages or video visits and timely, direct access to care on patients’ engagement in their recovery.

Methods

We conducted an observational, retrospective study of 814 pre- and postsurveyed participants enrolled in a mobile app physical therapy program where physical therapists prescribed workouts, education, and therapeutic activities after a video evaluation from February 2019 to December 2020. We estimated generalized linear models with logit functions to evaluate the effect of program engagement on clinical outcomes, minimal clinically important differences (MCIDs) in pain (ΔVisual Analogue Scale ≤−1.5) and function (ΔPatient Specific Functional Scale ≥1.3), and the effects of patient-provider relationships and clinical outcomes on patient satisfaction—participant reported likelihood to recommend the program (Net Promoter Scores of 9-10). We estimated Poisson generalized linear models to evaluate the effects of stronger patient-provider relationships and timely access to physical therapy within 24 hours on engagement including the number of weekly workouts and weeks in the program.

Results

The odds that participants (N=814) had a pain MCID increased by 13% (odds ratio [OR] 1.13, 95% CI 1.04-1.23; P=.003) with each weekly workout and the odds of a function MCID by 4% (OR 1.04, 95% CI 1.00-1.08; P=.03) with each week in the program. Participants with MCIDs in function and large changes in pain (Δ Visual Analogue Scale ≤−3.5) were 1.85 (95% CI 1.17-2.93; P=.01) and 2.84 times (95% CI 1.68-4.78; P<.001) more satisfied, respectively. Those with video follow-up visits were 2 to 3 times (P=.01) more satisfied. Each physical therapist’s message increased weekly workouts by 11% (OR 1.11, 95% CI 1.07-1.16; P<.001). Video follow-up visits increased weekly workouts by at least 16% (OR 1.16, 95% CI 1.04-1.29; P=.01) and weeks in the program at least 8% (OR 1.08, 95% CI 1.01-1.14; P=.02). Access was associated with a 14% increase (OR 1.14, 95% CI 1.05-1.24; P=.003) in weekly workouts.

Conclusions

Similar to in-person care, program engagement positively affects clinical outcomes, and strong patient-provider relationships positively affect satisfaction. In app-based physical therapy, clinical outcomes positively affect patient satisfaction. Timely access to care and strong patient-provider relationships, particularly those forged through video visits, affect engagement.

American Physical Therapy Association Clinical Practice Guideline Implementation for Neck and Low Back Pain in Outpatient Physical Therapy: A Nonrandomized, Cross-sectional Stepped-Wedge Pilot Study

OBJECTIVE

To determine whether a multifaceted implementation strategy for American Physical Therapy Association neck and low back pain clinical practice guidelines (CPGs) was associated with changes in clinician and patient outcomes.

DESIGN

Cross-sectional stepped-wedge pilot study.

METHODS

Physical therapy clinics (n = 9) were allocated to 1 of 4 clusters that varied by CPG implementation timing. Clinics crossed over from usual care (control) to CPG implementation (intervention) every 8 weeks and ended with a 24-week follow-up period. Implementation outcomes were measured at the clinician (perspectives and behaviors) and patient (pain and disability outcomes) levels. Descriptive statistics were used to summarize clinician perspectives and behaviors. Generalized linear mixed models were used to analyze patient-level outcomes data (pain and disability) and total number of physical therapy visits.

RESULTS

Improvements in several clinician perspectives about CPGs were observed 8 weeks after training and sustained at 16 weeks (P<.05), although it is unclear whether these changes were meaningful. Training on CPGs was relevant to physical therapists and more acceptable at 16 weeks (P<.05). In a random sample (n = 764/1994, 38.3%), the overall rate of CPG classification was 65.0% (n = 497/764), and CPG intervention concordance was 71.2% (n = 354/497). Implementation of a CPG was not associated with final pain and disability scores (P>.05) but was associated with an approximate increase of 8% in total visits.

CONCLUSION

Our multifaceted implementation strategy was associated with statistical changes in clinician perspectives and behaviors, but not in patient outcomes. J Orthop Sports Phys Ther 2022;52(2):113-123. doi:10.2519/jospt.2022.10545.

Can Physical Therapy Deliver Clinically Meaningful Improvements in Pain and Function through a Mobile App?: An Observational Retrospective Study

Objective

To examine the effect of digital physical therapy (PT) delivered by mobile application (app) on reducing pain and improving function for people with a variety of musculoskeletal conditions.

Design

An observational, longitudinal, retrospective study using survey data collected pre- and postdigital PT to estimate multilevel models with random intercepts for patient episodes.

Setting

Privately insured employees participating in app-based PT as an employer health care benefit.

Participants

The study sample included 814 participants (N=814) 18 years or older who completed their digital PT program with reported final clinical outcomes between February 2019 (program launch) through December 2020. Mean age of the sample at baseline was 40.9±11.89 years, 47.5% were female, 21% sought care for lower back pain, 16% for shoulders, 15% for knees, and 13% for neck.

Interventions

Digital PT consisted of a synchronous video evaluation with a physical therapist followed by a course of PT delivered through a mobile app.

Main Outcome Measures

Pain was measured by the visual analog scale from 0 “no pain” to 10 “worst pain imaginable” and physical function by the Patient-Specific Functional Scale on a scale from 0 “completely unable to perform” to 10 “able to perform normally.”

Results

After controlling for significant demographics, comorbid conditions, adverse symptoms, chronicity, and severity, the results from multilevel random intercept models showed decreased pain (−2.69 points; 95% CI, −2.86 to −2.53; P<.001) and increased physical function (+2.67 points; 95% CI, 2.45-2.89; P<.001) after treatment.

Conclusions

Digital PT was associated with clinically meaningful improvements in pain and function among a diverse set of participants. These early data are an encouraging indicator of the clinical benefit of digital PT.

Efficient Screening for Fear of Movement in Outpatient Settings: Short Form and Computer Adaptive Tests for Fear Avoidance and Negative Pain Coping

OBJECTIVE

The purpose of this study was to develop screening measures using item response theory (IRT) for 2 factors highly relevant to fear of movement (FoM): fear avoidance and negative pain coping.

METHODS

A total of 431 patients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions seeking physical therapy completed 8 validated psychological questionnaires measuring fear avoidance and negative pain coping, resulting in 97 candidate items for IRT analysis. Unidimensionality and local independence were assessed using exploratory factor analyses followed by confirmatory factor analyses. Items were assessed for model fit to the graded response model for ordinal items. Using the final item bank, a computer adaptive test (CAT) administration mode was constructed, and reduced item sets were selected to create short forms (SFs), including items with highest information (reliability) at the different levels of the trait being measured while also considering clinical content.

RESULTS

The results supported a 28-item bank for fear avoidance and 16-item bank for negative pain coping. A 10-item and 8-item SF were developed for fear avoidance and negative pain coping, respectively. Additionally, 4-item form versions were created to provide options with lower administrative burden. CAT administration used a mean (median) of 7.7 (8) and 7.0 (7) items for fear avoidance and negative pain coping, respectively. All factors demonstrated construct validity by discriminating patient groups in expected clinical patterns.

CONCLUSION

These newly derived SFs and CAT administration modes provide reliable, valid, and efficient options to screen for fear avoidance and negative pain coping in populations with musculoskeletal pain.

IMPACT

These tools, collectively referred to as the Screening for Pain Vulnerability and Resilience tools, address a critical need for standard FoM screening processes that aid in clinical decision-making to identify who might benefit from psychologically informed approaches.

Moving toward patient-centered care in the emergency department: Patient-reported expectations, definitions of success, and importance of improvement in pain-related outcomes

OBJECTIVES

Musculoskeletal pain is a common emergency department (ED) presentation, and patient-centered care may improve quality of life, treatment satisfaction, and outcomes. Our objective was to investigate the expectations, definitions of success, and priorities of ED patients with musculoskeletal pain.

METHODS

We conducted a cross-sectional survey of the demographic, clinical, and psychosocial characteristics of adult ED patients (n = 210) with musculoskeletal pain. Patients completed the Patient-Centered Outcomes Questionnaire to quantify usual, desired, expected, and successful levels of pain and interference with daily activities, fatigue, and emotion from 0 (none) to 100 (worst imaginable). They also reported the importance of improvement in each domain. Cluster analysis identified subgroups by importance ratings. Patients were asked their willingness to try various pharmacologic and nonpharmacologic treatments. Fully completed surveys were analyzed (n = 174).

RESULTS

Most patients desired 100% resolution in each domain and defined treatment success as substantial (median = 63.2%-76.5%) reductions but expected only moderate (median = 45%-53.7%) improvements across all domains. Patients with previous pain episodes had similar desired levels but less stringent definitions of success and expectations for improvement. Cluster analysis identified three patient subgroups by importance ratings of each domain: (1) multiple domains important (n = 118) with high importance attached to all four domains, (2) pain and function important (n = 34) with high importance primarily for pain and interference with daily activities, and (3) only pain important (n = 22). Regardless of subgroup, there was a high willingness to use a variety of pharmacologic and nonpharmacologic treatments.

DISCUSSION

ED patients with musculoskeletal pain have expectations and goals that include addressing impairments in function, improving quality of life, and reducing pain.

CONCLUSIONS

Our findings indicate that: (1) patient subgroups by outcome priorities may exist that could inform multimodal, personalized approaches from the ED and (2) patients are flexible in which treatments they are willing to try to meet their individual goals.

Predicting the number of physical therapy visits and patient satisfaction in individuals with temporomandibular disorder: A cohort study

BACKGROUND

Temporomandibular disorders (TMD) can be challenging to manage for clinicians and patients alike. It is unclear which factors are associated with prolonging conservative care and patient dissatisfaction with treatment outcomes.

OBJECTIVES

To examine factors collected during a physical therapy (PT) evaluation in a cohort of individuals with TMD to determine factors associated with an increased number of PT visits and reduced patient satisfaction.

METHODS

Records of 511 patients referred to PT over 18 months were reviewed to extract 27 variables to develop a predictive model. Outcomes were patient satisfaction following PT and number of PT visits. Linear and zero inflated negative binomial regressions were used, and a multivariate regression model was built for both outcomes.

RESULTS

Two factors were associated with both lower patient satisfaction and an increased number of PT visits: higher patient rated functional neck disability and a greater number of healthcare professionals seen. Other factors associated with patient satisfaction were duration of symptoms, subluxation, and referral from an oral surgeon. Only patient rated functional neck disability score was a significant predictive factor in the multivariate model. Factors associated with number of PT visits were gender, educational level, time between initial visit and discharge, number of pain areas, bruxism, biopsychosocial factors, dizziness, pain rating, and presence of neck pain. In the multivariate model, gender, number of healthcare professionals seen, and resting pain rating were significant predictors of number of PT visits.

CONCLUSION

Considering key factors on initial evaluation, specifically functional neck disability and the number of prior healthcare professionals seen before starting PT, can help to predict a higher number of PT visits and reduced patient satisfaction with outcomes.

Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework

BACKGROUND

Psychological factors influence or are associated with physical function, pain, and health care costs among individuals with musculoskeletal pain conditions. Recent clinical practice guidelines recommend screening for psychological factors (also referred to as "yellow flags") in physical therapy practice to help understand prognosis and inform shared decision making for treatment.

CLINICAL QUESTION

Despite the urgings of clinical practice guidelines and evidence of the influence of psychological factors on clinical outcomes, screening for yellow flags is uncommon in clinical practice. Clinicians may feel uncertain about how to integrate screening tools into clinical practice, and how screening results might inform decision making and care coordination.

KEY RESULTS

We outline a 3-step framework for routine yellow flag screening in physical therapy practice: (1) establish a standard first-line screening instrument and process, (2) interpret the results to inform shared decision making, and (3) monitor treatment progress. Four case examples illustrate how yellow flag screening can help clinicians and patients decide whether the patient might benefit most from standard physical therapy, psychologically informed physical therapy, psychologically informed physical therapy with referral to another health care provider, or immediate referral.

CLINICAL APPLICATION

Consider incorporating a standard yellow flag screening process into usual musculoskeletal health care. We present a framework to guide yellow flag screening in practice (1) to help inform treatment pathway selection and (2) to enhance interdisciplinary communication. J Orthop Sports Phys Ther 2021;51(9):459-469. doi:10.2519/jospt.2021.10570.

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BACKGROUND

Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.

QUESTION/PURPOSE

After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?

METHODS

Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.

RESULTS

This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001).

CONCLUSION

Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.

LEVEL OF EVIDENCE

Level II, prognostic study.

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial

BACKGROUND

Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery.

METHODS

We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care.

DISCUSSION

Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications.

TRIAL REGISTRATION

This study is registered as NCT03353272 at ClincialTrials.gov.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

Patient-centered outcomes: Domain importance predicts health care use following physical therapy

INTRODUCTION

Identifying patients with musculoskeletal pain who are at risk for additional health care use is important for improving the value of physical therapists' services. We previously identified three subgroups based on the importance attached by patients to improvements in outcome domains including a (1) Pain and Function Outcomes Important subgroup; (2) Pain Important subgroup; and (3) Multiple Outcome Domains Important subgroup.

OBJECTIVE

The primary aim was to determine whether subgroups based on patient-determined outcomes of importance predicted any additional pain-related health care use after an episode of physical therapy. A secondary aim was to determine if subgroup membership predicted use of specific services.

DESIGN

Secondary analysis of a longitudinal cohort.

SETTING

Ambulatory outpatient physical therapy clinics.

PATIENTS

Two hundred forty-six patients seeking physical therapy recruited from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort study.

INTERVENTIONS

Patients completed a demographic and health history questionnaire, numeric pain rating scale, region-specific disability measure, and Charlson Comorbidity Index. Subgroup membership was determined based on responses to the Patient Centered Outcome Questionnaire. At 1 year, patients reported use of health care since discharge from physical therapy. Separate logistic regression models determined whether subgroup membership predicted additional health care use.

RESULTS

Compared to the Pain and Function Outcomes Important subgroup, the Pain Important subgroup had higher adjusted odds (95% confidence interval [CI]) for the primary outcome of any additional health care use (adjusted odds ratio [aOR] 2.47, 95% CI 1.01-6.00) and secondary outcomes of opioid use (aOR 9.45, 95% CI 2.87-31.17), injection (aOR 4.09, 95% CI 1.25-13.41), and surgery (aOR 5.10, 95% CI 1.15-22.67). There were no significant differences in health care utilization between the Pain and Function Outcomes Important and Multiple Outcome Domains Important subgroups.

CONCLUSION

In this cohort, patients with a singular focus on pain improvements were at higher risk for additional health care, including opioid use, injection, and surgery. These findings are exploratory and need to be confirmed in other cohorts.

Sensory and Psychological Factors Predict Exercise-Induced Shoulder Injury Responses in a High-Risk Phenotype Cohort

Our prior studies identified a high-risk phenotype (ie, high pain sensitivity variant of the catechol-O-methyltransferase gene (Single Nucleotide Polymorphism [SNP] rs6269) and pain catastrophizing scores) for shoulder pain. The current study identified sensory and psychological predictors of heightened pain responses following exercise-induced shoulder injury. Healthy participants (N = 131) with the SNP rs6269 catechol-O-methyltransferase gene and Pain Catastrophizing Scale scores ≥5 underwent baseline sensory and psychological testing followed by an established shoulder fatigue protocol, to induce muscle injury. Movement-evoked pain, pain intensity, disability, and strength were assessed 24 hours postinjury. Demographic, sensory, and psychological variables were included as predictors in full and parsimonious models for each outcome. The highest variance explained was for the shoulder disability outcome (full model R2 = .20, parsimonious R2 = .13). In parsimonious models, the individual predictors identified were: 1) 1st pulse heat pain sensitivity for isometric shoulder movement-evoked pain and pain intensity; 2) pressure pain threshold for shoulder disability; 3) fear of pain for active shoulder movement-evoked pain and shoulder disability; and 4) depressive symptoms for shoulder strength. Findings indicate specific pain sensitivity and psychological measures may have additional prognostic value for self-reported disability within a high-risk phenotype. These findings should be tested in a clinical cohort for validation. PERSPECTIVE: The current study extends previous work by providing insight regarding how poor shoulder outcomes may develop within a high-risk phenotype. Specifically, 1st pulse heat pain sensitivity and pressure pain threshold were sensory measures, and fear of pain and depressive symptoms were psychological measures, that improved prediction of different shoulder outcomes.

Derivation of a Risk Assessment Tool for Prediction of Long-Term Pain Intensity Reduction After Physical Therapy

Rationale

Risk assessment tools can improve clinical decision-making for individuals with musculoskeletal pain, but do not currently exist for predicting reduction of pain intensity as an outcome from physical therapy.

Aims and Objective

The objective of this study was to develop a tool that predicts failure to achieve a 50% pain intensity reduction by 1) determining the appropriate statistical model to inform the tool and 2) select the model that considers the tradeoff between clinical feasibility and statistical accuracy.

Methods

This was a retrospective, secondary data analysis of the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort. Two hundred and seventy-nine individuals seeking physical therapy for neck, shoulder, back, or knee pain who completed 12-month follow-up were included. Two modeling approaches were taken: a longitudinal model included demographics, presence of previous episodes of pain, and regions of pain in addition to baseline and change in OSPRO Yellow Flag scores to 12 months; two comparison models included the same predictors but assessed only baseline and early change (4 weeks) scores. The primary outcome was failure to achieve a 50% reduction in pain intensity score at 12 months. We compared the area under the curve (AUC) to assess the performance of each candidate model and to determine which to inform the Personalized Pain Prediction (P3) risk assessment tool.

Results

The baseline only and early change models demonstrated lower accuracy (AUC=0.68 and 0.71, respectively) than the longitudinal model (0.79) but were within an acceptable predictive range. Therefore, both baseline and early change models were used to inform the P3 risk assessment tool.

Conclusion

The P3 tool provides physical therapists with a data-driven approach to identify patients who may be at risk for not achieving improvements in pain intensity following physical therapy.

Identification of clinically-useful cut scores of the Traumatic Injuries Distress Scale (TIDS) for predicting rate of recovery following musculoskeletal trauma

Objective

The Traumatic Injuries Distress Scale (TIDS) is a 12-item self-report tool intended for prognostic risk phenotyping in people with acute musculoskeletal (MSK) trauma. The initial validation study showed good associations with outcomes 12 weeks later in a cohort of 72 acutely injured patients from one region in Canada. This study aims to provide further clinical utility through identification of meaningful cut scores in a larger, mixed geography sample, and expands the prediction window from 12 to 52 weeks.

Methods

Data were drawn from databanks in London, Canada and Chicago, United States. Participants were recruited within 3 weeks of non-catastrophic MSK trauma and followed for 12 months. Using outcomes trajectories, the TIDS underwent linear regression-based analysis to predict 52-week outcomes, and area under the receiver operating characteristic curves to identify discriminative accuracy and meaningful cut scores.

Results

N = 224 participants with acute trauma were followed and both %Interference and Pain Severity were captured at intake and 3 follow-ups to establish curvilinear recovery trajectories. The TIDS explained significant variance in both the interference and severity outcomes after controlling for sex, region of injury, and baseline scores. ROC analysis revealed significant discriminative accuracy for predicting both the trajectories and the distal outcomes over 52 weeks. The TIDS was more accurate for identifying the low-risk than high-risk patients.

Conclusion

The TIDS is a useful tool for ‘ruling out’ high risk of poor outcome in a mixed sample of participants from two different countries.

Impact statement

The TIDS will be a useful tool for clinicians to predict the rate of recovery by displaying meaningful cut-scores for their patients after an acute musculoskeletal injury. This could lead to reduced burden of care for low risk patients and more informed treatment options for higher risk patients.

An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

BACKGROUND

Shoulder pain (SP) may originate from both musculoskeletal and visceral conditions. Physiotherapists (PT) may encounter patients with life-threatening pathologies that mimic musculoskeletal pain such as Acute Myocardial Infarction (AMI). A trained PT should be able to distinguish between signs and symptoms of musculoskeletal or visceral origin aimed at performing proper medical referral.

CASE PRESENTATION

A 46-y-old male with acute SP lasting from a week was diagnosed with right painful musculoskeletal shoulder syndrome, in two successive examinations by the emergency department physicians. However, after having experienced a shift of the pain on the left side, the patient presented to a PT. The PT recognized the signs and symptoms of visceral pain and referred him to the general practitioner, which identified a cardiac disease. The final diagnosis was acute myocardial infarction.

CONCLUSION

This case report highlights the importance of a thorough patient screening examination, especially for patients treated in an outpatient setting, which allow distinguishing between signs and symptoms of musculoskeletal from visceral diseases.

Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology

Purpose: The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) is a screening tool that incorporates many important psychosocial domains into one questionnaire to reduce the burden of completing multiple questionnaires. The objectives of this study were to examine the reliability and validity of the 10-item version of the OSPRO-YF with patients with shoulder conditions. Method: The study group consisted of injured workers with an active compensation claim for a shoulder injury. The control group consisted of patients with a complaint of shoulder pain but without a work-related shoulder injury. We examined reliability (internal consistency, test-retest) and validity (factorial, convergent, known groups). The Hospital Anxiety and Depression Scale; the Quick Disabilities of Arm, Shoulder and Hand; and the short Örebro Musculoskeletal Pain Screening Questionnaire were used for comparison. Results: Eighty patients had an active compensation claim, and 160 were in the control group. The intra-class correlation coefficient values for two observations of the domain scores varied from 0.91 to 0.94. The test-retest reliability of the dichotomous constructs was moderate to perfect for 8 of 11 constructs. The 10-item OSPRO-YF questionnaire had three distinct domains, as conceptualized by the developers: mood, fear avoidance, and positive affect-coping. The Cronbach's a coefficients for these domains were 0.88, 0.94, and 0.94, respectively. The associations between the psychological constructs and domains and the similar theoretically derived scales were moderate to high and in the expected direction. Of the 11 constructs of the OSPRO-YF, 10 differentiated between patients with and without a work-related injury (p-values ranging from 0.028 to < 0.001). Conclusions: The 10-item OSPRO-YF reduces the burden of using multiple questionnaires and has acceptable test-retest and internal consistency reliability and factorial, convergent, and known-groups validity.

What General and Pain-associated Psychological Distress Phenotypes Exist Among Patients with Hip and Knee Osteoarthritis?

BACKGROUND

Psychological distress can negatively influence disability, quality of life, and treatment outcomes for individuals with hip and knee osteoarthritis (OA). Clinical practice guidelines recommend a comprehensive disease management approach to OA that includes the identification, evaluation, and management of psychological distress. However, uncertainty around the best psychological screening and assessment methods, a poor understanding of the heterogeneity of psychological distress in those with OA, and lack of guidance on how to scale treatment have limited the growth of OA care models that effectively address individual psychological needs.

QUESTIONS/PURPOSES

(1) Across which general and pain-related psychological distress constructs do individuals seeking conservative care for hip or knee OA report higher scores than the general population of individuals seeking conservative care for musculoskeletal pain conditions? (2) What common psychological phenotypes exist among nonsurgical care-seeking individuals with hip or knee OA?

METHODS

The sample included participants from the Duke Joint Health Program (n = 1239), a comprehensive hip and knee OA care program, and the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort studies (n = 871) comprising individuals seeking conservative care for knee, shoulder, low back, or neck pain. At the initial evaluation, patients completed the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool, which assesses 11 general and pain-related psychological distress constructs (depression, anxiety, fear of movement, self-efficacy for managing one's own pain). We used OSPRO-YF scores to compare levels of psychological distress between the cohorts. Cohen's d effect sizes were calculated to determine the magnitude of differences between the groups, with d = 0.20, d = 0.50, and d = 0.80 indicating small, medium, and large effect sizes, respectively. We used a latent class analysis to derive psychological distress phenotypes in people with OA based on the 11 OSPRO-YF psychological distress indicators. Psychological distress phenotypes are characterized by specific mood, belief, and behavioral factors that differentiate subgroups within a population. Phenotyping can help providers develop scalable treatment pathways that are better tailored to the common needs of patients.

RESULTS

Patients with OA demonstrated higher levels of general and pain-related psychological distress across all psychological constructs except for trait anxiety (that is, anxiety level as a personal characteristic rather than as a response to a stressful situation, like surgery) with small-to-moderate effect sizes. Characteristics with the largest effect sizes in the OA and overall OSPRO cohort were (Cohen's d) general anxiety (-0.66, lower in the OA cohort), pain catastrophizing (the tendency to ruminate over, maginfiy, or feel helpless about a pain experience, 0.47), kinesiophobia (pain-related fear of movement, 0.46), pain self-efficacy (confidence in one's own ability to manage his or her pain, -0.46, lower in the OA cohort), and self-efficacy for rehabilitation (confidence in one's own ability to perform their rehabilitation treatments, -0.44, lower in the OA cohort). The latent class analysis yielded four phenotypes (% sample): high distress (52%, 647 of 1239), low distress (26%, 322 of 1239), low self-efficacy and acceptance (low confidence in managing and willingness to accept pain) (15%, 186 of 1239), and negative pain coping (exhibiting poor pain coping skills) (7%, 84 of 1239). The classification error rate was near zero (2%), and the median of posterior probabilities used to assign subgroup membership was 0.99 (interquartile range 0.98 to 1.00), both indicating excellent model performance. The high-distress group had the lowest mean age (61 ± 11 years) and highest levels of pain intensity (6 ± 2) and disability (HOOS JR: 50 ± 15; KOOS JR: 47 ± 15), whereas the low-distress group had the highest mean age (63 ± 10 years) and lowest levels of pain (4 ± 2) and disability (HOOS JR: 63 ± 15; KOOS JR: 60 ± 12). However, none of these differences met or exceeded anchor-based minimal clinically important difference thresholds.

CONCLUSIONS

General and pain-related psychological distress are common among individuals seeking comprehensive care for hip or knee OA. Predominant existing OA care models that focus on biomedical interventions, such as corticosteroid injection or joint replacement that are designed to directly address underlying joint pathology and inflammation, may be inadequate to fully meet the care-related needs of many patients with OA due to their underlying psychological distress. We believe this because biomedical interventions do not often address psychological characteristics, which are known to influence OA-related pain and disability independent of joint pathology. Healthcare providers can develop new comprehensive hip and knee OA treatment pathways tailored to these phenotypes where services such as pain coping skills training, relaxation training, and psychological therapies are delivered to patients who exhibit phenotypes characterized by high distress or negative pain coping. Future studies should evaluate whether tailoring treatment to specific psychological phenotypes yields better clinical outcomes than nontailored treatments, or treatments that have a more biomedical focus.

LEVEL OF EVIDENCE

Level III, diagnostic study.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System

Introduction

Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense’s Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care.

Materials and Methods

MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management.

Results

This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report.

Conclusions

MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency’s Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Longitudinal Monitoring of Pain Associated Distress With the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Tool: Predicting Reduction in Pain Intensity and Disability

OBJECTIVE

To investigate the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool for longitudinal monitoring of pain associated distress with the goal of improving prediction of 50% reduction in pain intensity and disability outcomes.

DESIGN

Cohort study with 12-month follow-up after initial care episode.

SETTING

Ambulatory care, participants seeking care from outpatient physical therapy clinics.

PARTICIPANTS

Participants (N=440) were seeking care for primary complaint of neck, low back, knee, or shoulder pain. This secondary analysis included 440 subjects (62.5% female; mean age, 45.1±17y) at baseline with n=279 (63.4%) providing follow-up data at 12 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A 50% reduction (baseline to 12-mo follow-up) in pain intensity and self-reported disability.

RESULTS

Trends for prediction accuracy were similar for all versions of the OSPRO-YF. For predicting 50% reduction in pain intensity, model fit met the statistical criterion for improvement (P<.05) with each additional time point added from baseline. Model discrimination improved statistically when the 6-month to 12-month change was added to the model (area under the curve=0.849, P=.003). For predicting 50% reduction in disability, there was no evidence of improvement in model fit or discrimination from baseline with the addition of 4-week, 6-month, or 12-month changes (P>.05).

CONCLUSIONS

These results suggested that longitudinal monitoring improved prediction accuracy for reduction in pain intensity but not for disability reduction. Differences in OSPRO-YF item sets (10 vs 17 items) or scoring methods (simple summary score vs yellow flag count) did not affect predictive accuracy for pain intensity, providing flexibility for implementing this tool in practice settings.

Which Psychological Factors Are Involved in the Onset and/or Persistence of Musculoskeletal Pain? An Umbrella Review of Systematic Reviews and Meta-Analyses of Prospective Cohort Studies

OBJECTIVE

The objective of this study was to summarize the current status of knowledge about the longitudinal association between vulnerability or protective psychological factors and the onset and/or persistence of musculoskeletal (MSK) pain.

METHODS

PubMed, CINAHL, PsycINFO, PubPsych, Scopus, Web of Science, gray literature, and manual screening of references were searched from inception to June 15, 2019. Systematic reviews with or without meta-analysis that explored the longitudinal association between psychological factors and the onset and/or persistence of MSK pain were identified. The AMSTAR-2 tool was used to assess the risk of bias.

RESULTS

Fifty-nine systematic reviews that included 286 original research studies were included, with a total of 249,657 participants (127,370 with MSK pain and 122,287 without MSK pain at baseline). Overall, our results found that exposure to many psychological vulnerability factors such as depression, anxiety, psychological distress, and fear, among others, may increase the risk of the onset and persistence of MSK pain across time. In addition, our results also showed that a range of psychological factors considered to be "protective" such as self-efficacy beliefs, better mental health, active coping strategies, or favorable expectations of recovery may reduce the risk of the onset and persistence of MSK pain. However, all these systematic reviews were evaluated to have critically low confidence based on the AMSTAR-2 tool, indicating that findings from these reviews may be informative, but should be interpreted with caution.

DISCUSSION

The large number of methodological flaws found across reviews gives rise to a call to action to develop high-quality systematic reviews in this field.

Psychometric Evaluation of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) Tool: Factor Structure, Reliability, and Validity

Psychological characteristics consistently predict clinical outcomes for musculoskeletal pain conditions. The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool assesses negative mood, fear-avoidance, and positive affect/coping. Psychometric testing of the tool is needed to guide clinical use. The purpose of this secondary analysis was to determine the OSPRO-YF factor structure (17- and 10-item versions) and test factor reliability and concurrent validity. Data from 2 musculoskeletal pain cohorts (n1 = 428; n2 = 440) were used. An exploratory factor analysis (EFA) identified the factor structure in the first cohort; a confirmatory factor analysis (CFA) validated the factor structure in the second cohort. EFA yielded 4 factors for the 17-item version (catastrophizing, positive coping, negative mood, fear-avoidance) and 3 factors for the 10-item version (negative coping, negative mood positive affect/coping). CFA indicated good fit for the10-item and 17-item models. Factors from both versions demonstrated moderate to good test-retest reliability. Regression results revealed that factors from both versions contributed significantly to variance in pain intensity, disability, and quality of life. Results indicate the OSPRO-YF is a reliable and valid multidimensional psychological assessment tool for individuals with musculoskeletal pain. Future studies are needed to establish the OSPRO-YF as a prognostic and treatment monitoring tool. PERSPECTIVE: This article presents the psychometric properties of the OSPRO-YF tool. Findings indicate the OSPRO-YF is a reliable and valid multidimensional psychological assessment tool for individuals with musculoskeletal pain. Implementation of the OSPRO-YF tool may better guide clinical decision making and may lead to improved musculoskeletal pain management strategies.

Framework for improving outcome prediction for acute to chronic low back pain transitions

Clinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.

Importance of Outcome Domain for Patients With Musculoskeletal Pain: Characterizing Subgroups and Their Response to Treatment

BACKGROUND

Patient-centered care models allow for the ability to tailor treatment to outcomes of importance to patients.

OBJECTIVE

The purposes of this study were to (1) define patient subgroups based on outcomes of importance; (2) determine whether patient subgroups based on outcomes of importance differed in demographic, clinical, and psychological measures; and (3) determine whether outcome domain subgroups differed in treatment responses.

DESIGN

This was a prospective, longitudinal observational study.

METHODS

This was a secondary analysis of the Optimal Screening for Prediction of Referral and Outcome study. Patients in the development phase completed the Patient Centered Outcome Questionnaire (PCOQ) and questionnaires related to negative mood, fear avoidance, and positive coping, as well as region-specific questionnaires. Patients in the validation cohort completed the PCOQ, measures of treatment satisfaction and region-specific questionnaires at 4 weeks, 6 months, and 1 year. A hierarchical agglomerative cluster analysis identified profiles based on importance outcomes as determined by the PCOQ. Analysis of variance and chi-squared assessed baseline subgroup differences in demographics, psychological factors, and clinical outcomes. Repeated-measure analysis of variance considered subgroup differences in outcomes longitudinally.

RESULTS

Cluster analysis identified 3 subgroups: (1) "Multiple Outcome Domains Important" subgroup characterized by high importance attached to improvement in all domains, (2) "Pain and Function Outcomes Important" subgroup characterized by high importance attached to improvement in pain and interference, and (3) "Pain Important" subgroup characterized by greatest importance attached to improvement in pain.

LIMITATIONS

Our sample included patients from outpatient physical therapy and may not be representative of patients in other settings.

CONCLUSION

Patients can be characterized by the importance attached to improvement in outcome domains. The identified subgroups differed in baseline measures as well as response to treatment.

Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. PERSPECTIVE: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.

Patient-defined outcomes for pain, fatigue, emotional distress, and interference with activities did not differ by age for individuals with musculoskeletal pain

Introduction:

Age impacts the prevalence and experience of musculoskeletal pain; however, it is unknown whether this factor impacts patient's anticipated outcomes after treatment.

Objective:

Using the Patient-Centered Outcomes Questionnaire (PCOQ), the primary purpose was to determine whether there are age-related differences in desired, successful, expected levels, and importance of improvement in pain, fatigue, emotional distress, and interference with daily activities. As a secondary purpose, anatomical location and sex were then included in the model to examine for interaction effects.

Methods:

A secondary analysis of the Optimal Screening for Prediction of Referral and Outcome cross-sectional and longitudinal cohorts was conducted. Included in this analysis were 572 individuals seeking physical therapy for nonsurgical neck, low back, shoulder, and knee pain who completed the PCOQ at the initial evaluation. A three-way analysis of variance examined PCOQ domains by age categories, sex, and anatomical location.

Results:

Interaction effects were not observed for any of the domains of interest (P > 0.01). Significant main effects were also not observed for age, sex, and anatomical location (P > 0.01).

Conclusion:

Musculoskeletal pain prevalence may differ across age categories but, in this cohort, neither age, nor sex, nor anatomical location impacted patient-defined outcomes for intensity, fatigue, emotional distress, and interference with daily activities.

Longitudinal Analysis Supports a Fear-Avoidance Model That Incorporates Pain Resilience Alongside Pain Catastrophizing

Background

The fear-avoidance model of chronic pain holds that individuals who catastrophize in response to injury are at risk for pain-related fear and avoidance behavior, and ultimately prolonged pain and disability.

Purpose

Based on the hypothesis that the predictive power of the fear-avoidance model would be enhanced by consideration of positive psychological constructs, the present study examined inclusion of pain resilience and self-efficacy in the model.

Methods

Men and women (N = 343) who experienced a recent episode of back pain were recruited in a longitudinal online survey study. Over a 3-month interval, participants repeated the Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, the McGill Pain Questionnaire, and NIH-recommended measures of pain, depressive symptoms, and physical dysfunction. Structural equation modeling assessed the combined contribution of pain resilience and pain catastrophizing to 3-month outcomes through the simultaneous combination of kinesiophobia and self-efficacy.

Results

An expanded fear-avoidance model that incorporated pain resilience and self-efficacy provided a good fit to the data, Χ2 (df = 14, N = 343) = 42.09, p = .0001, RMSEA = 0.076 (90% CI: 0.05, 0.10), CFI = 0.97, SRMR = 0.03, with higher levels of pain resilience associated with improved 3-month outcomes on measures of pain intensity, physical dysfunction, and depression symptoms.

Conclusions

This study supports the notion that the predictive power of the fear-avoidance model of pain is enhanced when individual differences in both pain-related vulnerability (e.g., catastrophizing) and pain-related protective resources (e.g., resilience) are considered.

Multidimensional screening for predicting pain problems in adults: a systematic review of screening tools and validation studies

Screening tools allowing to predict poor pain outcomes are widely used. Often these screening tools contain psychosocial risk factors. This review (1) identifies multidimensional screening tools that include psychosocial risk factors for the development or maintenance of pain, pain-related distress, and pain-related disability across pain problems in adults, (2) evaluates the quality of the validation studies using Prediction model Risk Of Bias ASsessment Tool (PROBAST), and (3) synthesizes methodological concerns. We identified 32 articles, across 42 study samples, validating 7 screening tools. All tools were developed in the context of musculoskeletal pain, most often back pain, and aimed to predict the maintenance of pain or pain-related disability, not pain-related distress. Although more recent studies design, conduct, analyze, and report according to best practices in prognosis research, risk of bias was most often moderate. Common methodological concerns were identified, related to participant selection (eg, mixed populations), predictors (eg, predictors were administered differently to predictors in the development study), outcomes (eg, overlap between predictors and outcomes), sample size and participant flow (eg, unknown or inappropriate handling of missing data), and analysis (eg, wide variety of performance measures). Recommendations for future research are provided.