Clinical conversations in the management of chronic musculoskeletal pain in vulnerable patient populations: a meta-ethnography

PURPOSE

The purpose of this meta-ethnography was to synthesize the research exploring patient/provider perceptions of clinical conversations (CC) centered on chronic musculoskeletal pain (CMP) in vulnerable adult populations.

MATERIALS AND METHODS

A systematic search for qualitative/mixed method studies in CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used PRIMSA-P guidelines. Data synthesis used eMERGe guidelines; findings were presented in nested hierarchal theoretical frameworks.

RESULTS

The included studies explored patients' (n = 18), providers' (n = 2), or patients' and providers' perspectives (n = 5) with diversity in patient participants represented (n = 415): immigrants, indigenous people, women, and veterans. Themes for each level of the nested hierarchal models revealed greater complexity in patients' perceptions about the CC in CMP relative to clinicians' perceptions. A unique finding was sociopolitical/historical factors can influence CC for vulnerable populations.

CONCLUSION

The combined nested hierarchical models provided insight into the need for clinicians to be aware of the broader array of influences on the CC. Key themes indicated that improving continuity of care and cultural training are needed to improve the CC. Additionally, due to patients' perception of how healthcare systems' policies influence the CC, patients should be consulted to guide the change needed to improve inequitable outcomes.IMPLICATIONS FOR REHABILITATIONHealthcare providers wishing to improve the clinical conversation in chronic musculoskeletal pain can more broadly explore potential factors influencing patients' experiences and perceptions.Screening during the clinical conversation can include assessing for sociopolitical and historical influences on patients' experiences with chronic musculoskeletal pain.Healthcare providers can explore how to minimize disjointed care in an effort to improve the clinical conversation and outcomes in chronic musculoskeletal pain.Healthcare providers and patients can work together to improve inequitable outcomes for vulnerable adults with chronic musculoskeletal pain.This may include cultural training for healthcare providers that is informed by patients.

Patient and Provider Attitudes, Beliefs, and Biases That Contribute to a Marginalized Process of Care and Outcomes in Chronic Musculoskeletal Pain. A Systematic Review. Part I: Clinical Care

OBJECTIVE

Chronic musculoskeletal pain (CMP) outcomes are affected by numerous variables including the clinical conversation. When good therapeutic/working alliances are formed, congruent clinical conversations can lead to improved CMP outcomes. Identifying patient/provider attitudes, beliefs, and biases in CMP that can influence the clinical conversation, and thus clinical management decisions, is foundationally important.

DESIGN

The aims of this systematic review were to 1) summarize the evidence of the attitudes and beliefs of patients and healthcare providers (HCPs) involved in the clinical conversation of CMP; 2) examine if/how these perceptions impacted the process of care.

METHODS

A systematic search of CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used PRISMA guidelines. Included studies: vulnerable adult populations with chronic pain. Study bias was examined using the Downs and Black tool.

RESULTS

Seven retrospective studies were included. HCPs demonstrated negative implicit biases toward minorities and women when making pharmaceutical management decisions. HCPs demonstrated negative implicit biases toward lower educated women when making referrals to multidisciplinary care. Unmet patient expectations resulted in higher drop-out rates at multidisciplinary pain management programs. Patients' trust was influenced by healthcare setting and patients often had limited options secondary to health insurance type/status.

CONCLUSION

These findings suggest that patients with CMP may experience a marginalized process of care due to HCPs' negative implicit biases, unmet patient expectations, and healthcare setting. Results suggest several factors may contribute to inequitable care and the recalcitrant nature of CMP, particularly in vulnerable populations with limited healthcare choices.

The role of sleep dysfunction in temporomandibular onset and progression: A systematic review and meta-analyses

BACKGROUND

Painful temporomandibular (TM) disorders result in 4.3 billion dollars spent annually in the United States. The complex interplay of physiological processes in persistent pain and dysfunctional sleep has been established. Recently, dysfunctional sleep has been identified as a potential pathway to the onset of painful TM disorder.

OBJECTIVES

The aims were to (1) identify self-report outcome measures (SROMs) of sleep quality that are clinimetrically sound in patients with painful TM disorders and (2) determine whether sleep dysfunction has any diagnostic or prognostic value for this population.

METHODS

A systematic search following PRISMA guidelines was run in six databases: CINAHL, Dental, PsychALL, PubMed, Scopus and Web of Science. Any study involving minors was excluded. Risks of biases were examined in all studies. Diagnostic pooled findings were reported.

RESULTS

Of the identified articles (n = 681), 18 were included in this systematic review (n = 1 clinimetric studies, n = 11 diagnostic studies, n = 6 prognostic studies). Nine different assessment tools were used; only the Pittsburg Sleep Quality Index (PSQI) has been validated in patients with painful TM disorders. Overall, sleep dysfunction was diagnostic for painful TM disorders. The pooled relative risk of sleep dysfunction was 1.71 (95% CI 1.30. 2.26). When PSQI scores were greater than 5/21, the unadjusted hazard ratio for development of painful TM disorders was reported to be 2.1.

CONCLUSION

At present, the only SROM that has diagnostic and prognostic value in evaluating and managing patients with painful TM disorders is the PSQI.

Non-Small Cell Lung Carcinoma: Clinical Reasoning in the Management of a Patient Referred to Physical Therapy for Costochondritis

BACKGROUND AND PURPOSE

Chest pain, a frequent complaint for seeking medical care, is often attributed to musculoskeletal pathology. Costochondritis is a common disorder presenting as chest pain. Initial physical therapist examination emphasizes red flag screening. Reexamination throughout the episode of care is critical, particularly when patients are not progressing and/or in the presence of complex pain presentations. The purpose of this case report is to describe the clinical reasoning process in the management of a patient referred to physical therapy with a medical diagnosis of costochondritis.

CASE DESCRIPTION

A 59-year-old woman presented with a 5-month history of left-sided chest pain that had progressed to include the cervical and shoulder regions. She reported multiple psychosocial stressors; a depression screen was positive. She reported a history of asthma and smoking and improvement in recent fatigue, coughing, dyspnea, and sweating. At the initial visit, shoulder, cervical, and thoracic active and passive range of motion and joint mobility testing reproduced her pain. Allodynia was present throughout the painful areas in the left upper quarter.

OUTCOMES

The patient demonstrated improvement over 30 days (4 visits). On her fifth visit (day 35), she reported an exacerbation of her chest and upper extremity pain and noted increased fatigue, sweating, dyspnea, and loss of appetite. Even though her pain was again reproduced with musculoskeletal testing, the physical therapist contacted the patient's physician regarding the change in presentation. A subsequent chest computed tomography scan revealed a non-small cell lung adenocarcinoma.

DISCUSSION

Cancer can masquerade as a musculoskeletal condition. This case highlights the importance of screening, clinical reasoning, and communication throughout the episode of care, particularly in the presence of chronic pain and psychosocial stressors.

Stress induces rapid changes in serotonergic activity: restraint and exertion

Rapid activation of central serotonergic systems occurs in response to the social stress of aggression in dominant lizards. The most rapid expression of serotonergic activity occurs in nucleus accumbens, hippocampus and brainstem. To compare previously measured responses induced by social stressors with those provoked by physical stress, serotonergic activity was examined following restraint stress (handling) and forced physical exertion. After handling, some male Anolis carolinensis were placed on a race track and either run until there was no movement following 1 min of prodding, or half that time. Controls were killed without treatment. Lizards stressed by handling showed rapid (25 s) increases in serotonergic activity (5-HIAA/5-HT) in striatum, dorsal cortex, locus ceruleus, and nucleus accumbens. Other changes in serotonergic systems caused by stress occurred in raphe and hippocampus. Serotonergic changes induced by handling stress were reversed by exercise (to 50% maximal exertion time) in subiculum, striatum and nucleus accumbens. The serotonergic profile of lizards run until they would no longer respond to prodding (maximal exertion time) was significantly different from that for more acute exertion in hippocampus, subiculum, striatum, medial amygdala, locus ceruleus, area postrema, and raphe. Physical stress (handling) mimicked social stress by producing rapid serotonergic changes in hippocampus, subiculum, nucleus accumbens and locus ceruleus. In contrast, the medial amygdala, which has previously been demonstrated to respond serotonergically to social stress only after a temporal delay, did not show a rapid response to restraint stress.

Serotonergic responses to corticosterone and testosterone in the limbic system

Glucocorticoids secreted peripherally during stressful events act on central monoaminergic systems. In particular, serotonergic mediation of social behavior, such as aggression and reproduction, may be affected by glucocorticoids. This study was undertaken to determine if systemically administered corticosterone would rapidly affect central monoaminergic activity. Male Anolis carolinensis (N = 8 each group) were injected intraperitoneally with 10 or 100 micrograms corticosterone, 10 micrograms testosterone, or saline. Twenty minutes after treatment, brains were rapidly dissected and frozen and then microdissected (punch diameter 300 microm) and analyzed by high-performance liquid chromatography. Serotonergic turnover (estimated by 5-hydroxyindoleacetic acid/serotonin) in the hippocampus and medial amygdala was significantly enhanced by systemic corticosterone. Both of these regions of the brain have been associated with social stress. Testosterone also enhanced turnover in the hippocampus. The effect of corticosterone and testosterone may be to modulate socially induced differences in serotonergic response. Rapid, but short-lived, glucocorticoid stimulation of serotonin release suggests a possible mechanism for mediation of changing social behavioral events.