Psychometric properties of the Turkish version of Central Sensitization Inventory-9 in patients with chronic musculoskeletal pain

The aim of the study was to assess the psychometric properties of the Turkish version of Central Sensitization Inventory-9 (CSI-9) in patients with chronic musculoskeletal pain. The methodological study included 92 patients with chronic musculoskeletal pain. The original version of the CSI-9 was translated and culturally adapted into Turkish. The internal consistency and test-retest reliability were evaluated with Cronbach's α and the intraclass correlation coefficient (ICC), respectively. The assessment of reproducibility was conducted with the standard error of measurement (SEM) and minimal detectable difference (MDD) values. Convergent validity was explored by correlation analysis between the CSI-9 and Central Sensitization Inventory (CSI-25), Brief Pain Inventory (BPI), and European Quality of Life Survey-5 Dimensions (EQ-5D). The structural validity was assessed with factor analysis. Floor and ceiling effects were also analyzed. We found a very good internal consistency (Cronbach's α of 0.83) and excellent test-retest reliability (ICC of 0.96) of the Turkish CSI-9. The SEM demonstrated a range between 0.19 and 1.12, and the MDD was observed to vary from 1.17 to 1.35. The CSI-9 correlated significantly with the CSI-25 ( r  = 0.77, P  < 0.001), the pain severity subscale of the BPI ( r  = 0.41 to 0.53, P  < 0.001), the pain interference subscale of the BPI ( r  = 0.21 to 0.58, P  = 0.02 to P  < 0.001), the EQ-5D ( r  = 0.24 to 0.48, P  < 0.05), and the EQ-5D visual analog scale ( r  = -0.41, P  < 0.001). One factor was identified within the CSI-9. Our data suggest that the Turkish CSI-9 is reliable and valid outcome measure for assessing CS in patients with chronic musculoskeletal pain.

Translation and adaptation of the Arabic version of the injustice experience questionnaire in patients with chronic musculoskeletal pain

OBJECTIVE

The objectives of this study were to (1) translate the short version of the Injustice Experience Questionnaire (IEQ-SF) from English to Arabic and (2) test the validity and reliability of the translated Arabic version of the IEQ-SF.

SUBJECTS AND METHODS

A cross-sectional study in which the original English version of the IEQ-SF was translated into Arabic was conducted in accordance with Beaton's translation process. Internal consistency, reproducibility (retest within 5 days), and validity of the translated Arabic version of the IEQ-SF were tested in Arabic-speaking participants (n = 20). Individuals with chronic pain (n = 99) completed the Arabic versions of the IEQ-SF and the Musculoskeletal Health Questionnaire (MSK-HQ) from June to August 2021. The main analyses included Cronbach's alpha (α), Intraclass Correlation Coefficients (ICC), and Spearman's rank correlations (ρ).

RESULTS

The internal consistency (α = 0.74) and test-retest reliability (ICC = 0.88, 0.83-0.92 95% CI) for the translated Arabic version of IEQ-SF were high. There was also a high correlation between the translated Arabic version of the IEQ-SF and different health-related questionnaires such as the MSK-HQ (ρ = -0.738; p < 0.001), Hospital Anxiety and Depression Scale (ρ = 0.701-0.791; all, p < 0.001), and Pain Catastrophizing Scale (ρ = 0.762; p < 0.001).

CONCLUSIONS

The Arabic version of the IEQ-SF demonstrated high reliability and validity and would be useful for clinicians and researchers studying Arabic-speaking individuals with chronic pain.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

Demographic and clinical factors associated with psychological wellbeing in people with chronic, non-specific musculoskeletal pain engaged in multimodal rehabilitation: -a cross-sectional study with a correlational design

OBJECTIVES

To investigate which demographic and clinical factors were associated with psychological wellbeing in working-aged people in multimodal rehabilitation for musculoskeletal disorders.

METHODS

116 participants met the criteria for inclusion: persistent or intermittent pain for at least three months; pain that adversely impacts daily life; potential for active change despite pain; no co-morbidity or condition that will hinder participation in the rehabilitation program. Primary outcome was psychological wellbeing and independent measures were general, physical and mental health, pain intensity, limitations in daily life, depression and sleep.

RESULTS

The results show decreased odds of psychological wellbeing for persons rating high on depression. The results remained significant after adjusting for sex and age. Being a woman increased the odds of high psychological wellbeing. Logistic regression showed that psychological wellbeing was not significantly associated with pain intensity; sleep; functional limitations; general, physical, or mental health. None of the other independent variables was significantly associated with high vs. low psychological wellbeing.

CONCLUSIONS

Depression turned out to be significantly related to psychological wellbeing, contrary to pain and limitations in daily life. If further studies with larger, random samples can confirm these results, this knowledge may be important both in clinical settings and in future research.

Understanding Discrepancies in a Person's Fear of Movement and Avoidance Behavior: A Guide for Musculoskeletal Rehabilitation Clinicians Who Support People With Chronic Musculoskeletal Pain

BACKGROUND: Generic self-report measures do not reflect the complexity of a person's pain-related behavior. Since variations in a person's fear of movement and avoidance behavior may arise from contextual and motivational factors, a person-centered evaluation is required-addressing the cognitions, emotions, motivation, and actual behavior of the person. CLINICAL QUESTION: Most musculoskeletal rehabilitation clinicians will recognize that different people with chronic pain have very different patterns of fear and avoidance behavior. However, an important remaining question for clinicians is "How can I identify and reconcile discrepancies in fear of movement and avoidance behavior observed in the same person, and adapt my management accordingly?" KEY RESULTS: We frame a clinical case of a patient with persistent low back pain to illustrate the key pieces of information that clinicians may consider in a person-centered evaluation (ie, patient interview, self-report measures, and behavioral assessment) when working with patients to manage fear of movement and avoidance behavior. CLINICAL APPLICATION: Understanding the discrepancies in a person's fear of movement and avoidance behavior is essential for musculoskeletal rehabilitation clinicians, as they work in partnership with patients to guide tailored approaches to changing behaviors. J Orthop Sports Phys Ther 2023;53(5):1-10. Epub: 9 March 2023. doi:10.2519/jospt.2023.11420.

The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain

OBJECTIVES

The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument assessing different constructs related to the fear-avoidance model of pain. The aim was to translate the original English FACS into Dutch (FACS-D) and assess its measurement properties in persons with chronic musculoskeletal pain.

METHODS

The original English FACS (20 item-scale, range: 0-100) was translated in Dutch through standard forward-backward translation methodology. The FACS-D's measurement properties were evaluated in 224 persons with chronic musculoskeletal pain. Internal consistency, test-retest reliability and measurement error were assessed with the Cronbach's alpha coefficient (α), intraclass correlation coefficient (ICC), and standard error of measurement (SEM). Construct validity was assessed through inter-item correlation analyses, exploratory factor analysis, association with other fear-avoidance-related constructs, and hypothesis testing.

RESULTS

Internal consistency, test-retest reliability and hypotheses testing were good (α=0.92; ICC=0.92, CI 0.80-0.96; 7/8 hypotheses confirmed). Similar to the original FACS and other translated versions, a two-factor model best fit the data. However, the item distribution differed from other versions. One factor represented "pain-related cognitions and emotions" and a second factor represented "avoidance behaviour." In contrast to the original FACS, low inter-item correlations for item 12 were found. The FACS-D was more strongly associated with fear-avoidance-related constructs of pain severity, perceived disability, feelings of injustice, and depressive/anxiety symptoms than the other fear-avoidance-related scales studied here.

CONCLUSIONS

The FACS-D demonstrated good reliability and construct validity, suggesting that it may be a useful measure for Dutch-speaking healthcare providers. Two clinically relevant factors, with a different item distribution than the original FACS, were identified: one covering items on pain-related cognitions and emotions, and one covering items on avoidance behaviour. The stronger association between FACS-D and fear-avoidance related constructs suggests that the FACS-D may be more effective in evaluating the cognitive, emotional and behavioural constructs of pain-related fear-avoidance than other similar measures.

The Portuguese version of the musculoskeletal pain intensity and interference questionnaire for musicians (MPIIQM-Pt): Translation, cultural adaptation, and multicenter validation study in professional orchestra musicians

OBJECTIVES

We aim to assess the validity and reliability of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM) and to add to its cross-cultural adaptation process by translating, culturally adapting, and validating the MPIIQM into European Portuguese language in the population of Portuguese musicians.

METHODS

A Portuguese version of the MPIIQM (MPIIQM-Pt) was created through a process of forward and back translation, pilot testing, and cultural adaptation by expert panel evaluation. The psychometric evaluation was performed in a validation sample of 134 musicians, at baseline and after 7 days.

RESULTS

The high degree of internal consistency and the substantial test-retest reliability coefficients were demonstrated for each subscale (α = 0.896 and ICC = 0.997 for "pain intensity," and α = 0.879 and ICC = 0.999 for "pain interference," respectively). Exploratory factor analysis indicated two-factor structure (pain intensity and interference) that explained 75.5% of the variance. Both convergent and divergent validity are well demonstrated, confirming more than 90% of the previously defined hypotheses regarding correlations with other measures.

DISCUSSION

MPIIQM-Pt is the first validated questionnaire to evaluate pain among Portuguese musicians. It showed excellent psychometric properties, both in terms of internal consistency, test-retest reliability, factor analysis, and construct validity. Therefore, it is a valid and reliable tool suitable for both research and clinical practice purposes. MPIIQM-Pt will allow the development of more robust studies on pain among musicians and the improved assessment and monitoring of pain in this population, filling an important gap in this field of Pain Medicine.

Interdisciplinary Multimodal Pain Rehabilitation in Patients with Chronic Musculoskeletal Pain in Primary Care-A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Chronic pain is a major public health issue. Mounting evidence suggests that interdisciplinary multimodal pain rehabilitation programs (IMMRPs) performed in specialist pain care are an effective treatment for patients with chronic pain, but the effects of such treatment if performed in primary care settings have been less studied. The aims of this pragmatic study were to (1) describe characteristics of patients participating in IMMRPs in primary care; (2) examine whether IMMRPs in primary care improve pain, disability, quality of life, and sick leave 1-year post discharge in patients with chronic pain; and (3) investigate if outcomes differ between women and men. Data from 744 (645 women and 99 men, age range 18-65 years) patients with non-malignant chronic pain included in the Swedish Quality Registry for Pain Rehabilitation Primary Care were used to describe patient characteristics and changes in health and sick leave. At 1-year follow-up, the patients had improved significantly (p < 0.01) in all health outcome measures and had reduced sick leave except in men, where no significant change was shown in physical activity level. This study indicates that MMRPs in primary care improved pain and physical and emotional health and reduced sick leave, which was maintained at the 1-year follow-up.

Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial

Importance

Low back and neck pain are often self-limited, but health care spending remains high.

Objective

To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain.

Design, Setting, and Participants

Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021).

Interventions

Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150).

Main Outcomes and Measures

The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance.

Results

Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT.

Conclusions and Relevance

Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year.

Trial Registration

ClinicalTrials.gov Identifier: NCT03083886.

Psychosocial Predictors of Chronic Musculoskeletal Pain Outcomes and their Contextual Determinants Among Black Individuals: A Narrative Review

Black communities are disproportionally affected by Chronic Musculoskeletal Pain (CMP), but little is known about the psychological predictors of CMP outcomes and their contextual determinants among Black individuals. To address this gap, we conducted a narrative review of extant literature to (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We searched 4 databases (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar) using the following search terms: musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. We illustrate 3 relevant conceptual models - socioecological, cumulative stress, and biopsychosocial - related to contextual determinants and several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies, (3) pain-related perceived injustice and perceived racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care. The detailed clinical and research implications could serve as a blueprint for the providers and clinical researchers to address health disparities and improve care for Black individuals with CMP. PERSPECTIVE: This narrative review illustrates conceptual models explaining the link between contextual determinants and psychological responses to pain among Black individuals with chronic musculoskeletal pain. We discuss 3 relevant conceptual models - socioecological, cumulative stress, biopsychosocial -, and 4 psychological factors: disproportionate burden of mental health, distinct coping strategies, perceived injustice/discrimination, preferences/expectations.

Using the Parent Risk Screening Measure (PRISM) to Assess Pain-Related Risk Factors in Parents of Youth Seeking Treatment for Acute Musculoskeletal Pain

OBJECTIVES

The Parent Risk Screening Measure (PRISM) rapidly assesses parent distress, psychosocial function, and behaviors associated with child pain-related dysfunction in parents of youth with chronic pain. Recognizing the importance of parent pain-related cognitions and responses to pain during the acute pain period, the current study examined the utility of the PRISM in screening parents of youth with acute pain.

METHODS

Participants were 175 parent-youth dyads taking part in a larger study examining risk and resilience in youth with acute musculoskeletal pain. Parents completed the PRISM and a battery of measures reporting on their child's pain-related disability and cognitions and behaviors in response to their child's pain. Youth reported on their pain, pain-related disability, pain-related fear, catastrophizing, and pain self-efficacy.

RESULTS

PRISM total scores ( M =2.55, SD=2.77) were correlated with many parent and child report measures (eg, protectiveness, catastrophizing, and pain-related fear), with higher scores associated with greater symptoms. Using published PRISM cutoffs, 86.9% of parents were classified as low and 13.13% as elevated risk. t tests revealed significant differences between elevated and low-risk groups on several measures. Moreover, youth of parents in the elevated risk group were more likely to meet clinical cutoffs on pain catastrophizing and fear avoidance measures.

DISCUSSION

Findings suggest the PRISM is useful in screening for parent distress and behaviors associated with elevated pain symptomatology in a pediatric acute musculoskeletal pain sample. The important next steps are to identify the ideal time for administering the PRISM and to examine the associations among PRISM scores and pain outcomes over time.

Individuals' beliefs about the biopsychosocial factors that contribute to their chronic musculoskeletal pain: protocol for a qualitative study in the UK

INTRODUCTION

Chronic musculoskeletal pain (CMP) is described as pain that persists for longer than 3 months. At present, no research is available that understands why CMP develops and continues from the perspective of the individual. Research is needed to establish if there are any consistent biopsychosocial factors perceived as contributing to CMP and what informs such beliefs. Understanding individual beliefs will inform more effective communication between clinicians and patients about their CMP, as well as informing future research into the epidemiology of CMP. Interpretative phenomenological analysis will be used as a methodological framework as it explores how individuals make sense of their world through personal experiences and perceptions while preserving individual nuance. The aim of this study is to understand individuals' beliefs and perceptions about the biological, psychological and social factors, which contribute to the development and maintenance of their CMP.

METHODS AND ANALYSIS

A qualitative study informed by the Consolidated Criteria for Reporting Qualitative Research using interpretative phenomenological analysis and semistructured interviews. A maximum variation purposive sample of 6-12 adults with CMP will be recruited from the general public in the UK. One semistructured interview will be conducted with each participant via an online video platform with interviews transcribed verbatim. The interview schedule (codesigned with expert patients and informed by existing evidence) identifies three domains of important questions; (1) patient beliefs on why they developed and continue to experience CMP; (2) the relationship between their biopsychosocial experiences and CMP; and (3) the origin of their beliefs. Strategies such as 'member checking' will be employed to ensure trustworthiness.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Research Ethics Office at the University of Birmingham (reference ERN_21-0813). Informed consent will be obtained from all participants. The study findings will be submitted for publication in a peer-reviewed journal and for presentation at conferences.

The Influence of Race, Sex, and Social Disadvantage on Self-reported Health in Patients Presenting With Chronic Musculoskeletal Pain

OBJECTIVE

The aim of the study was to better address sociodemographic-related health disparities. This study examined which sociodemographic variables most strongly correlate with self-reported health in patients with chronic musculoskeletal pain.

DESIGN

This single-center, cross-sectional study examined adult patients, followed by a physiatrist for chronic (≥4 yrs) musculoskeletal pain. Sociodemographic variables considered were race, sex, and disparate social disadvantage (measured as residential address in the worst vs. best Area Deprivation Index national quartile). The primary comparison was the adjusted effect size of each variable on physical and behavioral health (measured by Patient-Reported Outcomes Measurement Information System [PROMIS]).

RESULTS

In 1193 patients (age = 56.3 ± 13.0 yrs), disparate social disadvantage was associated with worse health in all domains assessed (PROMIS Physical Function Β = -2.4 points [95% confidence interval = -3.8 to -1.0], Pain Interference = 3.3 [2.0 to 4.6], Anxiety = 4.0 [1.8 to 6.2], and Depression = 3.7 [1.7 to 5.6]). Black race was associated with greater anxiety than white race (3.2 [1.1 to 5.3]), and female sex was associated with worse physical function than male sex (-2.5 [-3.5 to -1.5]).

CONCLUSIONS

Compared with race and sex, social disadvantage is more consistently associated with worse physical and behavioral health in patients with chronic musculoskeletal pain. Investment to ameliorate disadvantage in geographically defined communities may improve health in sociodemographically at-risk populations.

Development of Reliable and Valid Negative Mood Screening Tools for Orthopaedic Patients with Musculoskeletal Pain

BACKGROUND

Negative mood is an important risk factor for poor clinical outcomes among individuals with musculoskeletal pain. Screening for negative mood can aid in identifying those who may need additional psychological interventions. Limitations of current negative mood screening tools include (1) high response burden, (2) a focus on single dimensions of negative mood, (3) poor precision for identifying individuals with low or high negative mood levels, and/or (4) design not specific for use in populations with orthopaedic conditions and musculoskeletal pain.

QUESTIONS/PURPOSES

(1) Can item response theory methods be used to construct screening tools for negative mood (such as depression, anxiety, and anger) in patients undergoing physical therapy for orthopaedic conditions? (2) Do these tools demonstrate reliability and construct validity when used in a clinical setting?

METHODS

This was a cross-sectional study involving outpatients having physical therapy in tertiary-care settings. A total of 431 outpatients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions were enrolled between December 2014 and December 2015, with 24% (103 of 431) seeking care after orthopaedic surgery. Participants completed three validated psychological questionnaires measuring negative mood, resulting in 39 candidate items for item response theory analysis. Factor analysis was used to identify the dimensions (factors) assessed by the candidate items and select items that loaded on the main factor of interest (negative mood), establishing a unidimensional item set. Unidimensionality of an item set suggests they are assessing one main factor or trait, allowing unbiased score estimates. The identified items were assessed for their fit to the graded item response theory model. This model allows for items to vary by the level of difficulty they represent and by their ability to discriminate between patients at different levels of the trait being assessed, in this case, negative mood. Finally, a hierarchical bifactor model where multiple subfactors are allowed to load on an overall factor was used to confirm that the items identified as representing a unidimensional item set explained the large majority of variance of the overall factor, providing additional support for essential unidimensionality. Using the final item bank, we constructed a computer adaptive test administration mode, and reduced item sets were selected to create short forms including items with the highest information (reliability) at targeted score levels of the trait being measured, while also considering clinical content.

RESULTS

We identified a 12-item bank for assessment of negative mood; eight-item and four-item short-form versions were developed to reduce administrative burden. Computer adaptive test administration used a mean ± SD of 8 ± 1 items. The item bank's reliability (0 = no reliability; 1 = perfect reliability) was 0.89 for the computer adaptive test administration, 0.86 for the eight-item short form, and 0.71 for the four-item short form. Reliability values equal to or greater than 0.7 are considered acceptable for group level measures. Construct validity sufficient for clinical practice was supported by more severe negative mood scores among individuals with a previous episode of pain in the involved anatomical region, pain and activity limitations during the past 3 months, a work-related injury, education less than a college degree, and income less than or equal to USD 50,000.

CONCLUSION

These newly derived tools include short-form and computer adaptive test options for reliable and valid negative mood assessment in outpatient orthopaedic populations. Future research should determine the responsiveness of these measures to change and establish score thresholds for clinical decision-making.

CLINICAL RELEVANCE

Orthopaedic providers can use these tools to inform prognosis, establish clinical benchmarks, and identify patients who may benefit from psychological and/or behavioral treatments.

How Should We Measure Social Deprivation in Orthopaedic Patients?

BACKGROUND

Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions.

QUESTIONS/PURPOSES

(1) Which measure of social deprivation, defined as "limited access to society's resources due to poverty, discrimination, or other disadvantage," is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture?

METHODS

Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful.

RESULTS

Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains.

CONCLUSION

To capture the most variability due to social deprivation in orthopaedic patients' self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider accounting for insurance classification and/or national Area Deprivation Index, both of which are freely available and can be obtained from data that are typically collected during routine clinical care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Are There Distinct Statistical Groupings of Mental Health Factors and Pathophysiology Severity Among People with Hip and Knee Osteoarthritis Presenting for Specialty Care?

BACKGROUND

There is mounting evidence that objective measures of pathophysiology do not correlate well with symptom intensity. A growing line of inquiry identifies statistical combinations (so-called "phenotypes") of various levels of distress and unhelpful thoughts that are associated with distinct levels of symptom intensity and magnitude of incapability. As a next step, it would be helpful to understand how distress and unhelpful thoughts interact with objective measures of pathologic conditions such as the radiologic severity of osteoarthritis. The ability to identify phenotypes of these factors that are associated with distinct levels of illness could contribute to improved personalized musculoskeletal care in a comprehensive, patient-centered model.

QUESTIONS/PURPOSES

(1) When measures of mental health are paired with radiologic osteoarthritis severity, are there distinct phenotypes among adult patients with hip and knee osteoarthritis? (2) Is there a difference in the degree of capability and pain self-efficacy among the identified mental health and radiologic phenotypes? (3) When capability (Patient-reported Outcomes Measurement Information System Physical Function [PROMIS PF]) is paired with radiographic osteoarthritis severity, are there distinct phenotypes among patients with hip and knee osteoarthritis? (4) Is there a difference in mental health among patients with the identified capability and radiologic phenotypes?

METHODS

We performed a secondary analysis of data from a study of 119 patients who presented for musculoskeletal specialty care for hip or knee osteoarthritis. Sixty-seven percent (80 of 119) of patients were women, with a mean age of 62 ± 10 years. Seventy-six percent (91 of 119) of patients had knee osteoarthritis, and 59% (70 of 119) had an advanced radiographic grade of osteoarthritis (Kellgren-Lawrence grade 3 or higher). This dataset is well-suited for our current experiment because the initial study had broad enrollment criteria, making these data applicable to a diverse population and because patients had sufficient variability in radiographic severity of osteoarthritis. All new and returning patients were screened for eligibility. We do not record the percentage of eligible patients who do not participate in cross-sectional surveys, but the rate is typically high (more than 80%). One hundred forty-eight eligible patients started the questionnaires, and 20% (29 of 148) of patients did not complete at least 60% of the questionnaires and were excluded, leaving 119 patients available for analysis. We measured psychologic distress (Patient Health Questionnaire-2 [PHQ-2] and Generalized Anxiety Disorder-2 questionnaire [GAD-2]), unhelpful thoughts about pain (Pain Catastrophizing Scale-4 [PCS-4]), self-efficacy when in pain (Pain Self-Efficacy Questionnaire-2), and capability (PROMIS PF). One of two arthroplasty fellowship-trained surgeons assigned the Kellgren-Lawrence grade of osteoarthritis based on radiographs in the original study. We used a cluster analysis to generate two sets of phenotypes: (1) measures of mental health (PHQ-2, GAD-2, PCS-4) paired with the Kellgren-Lawrence grade and (2) capability (PROMIS PF) paired with the Kellgren-Lawrence grade. We used one-way ANOVA and Kruskal-Wallis H tests to assess differences in capability and self-efficacy and mental health, respectively.

RESULTS

When pairing measures of psychologic distress (PHQ-2 and GAD-2) and unhelpful thoughts (catastrophic thinking) with the grade of radiographic osteoarthritis, six distinct phenotypes arose. These groups differed in terms of capability and pain self-efficacy (for example, mild pathology/low distress versus average pathology/high distress [PROMIS PF, mean ± standard deviation]: 43 ± 6.3 versus 33 ± 4.8; p = 0.003). When pairing the degree of capability (PROMIS PF) with the Kellgren-Lawrence grade, four distinct phenotypes arose. Patients in three of these did not differ in terms of disease severity but had notable variation in the degree of limitations. Patients with these radiologic and capability phenotypes differed in terms of distress and unhelpful thoughts (for example, moderate pathology/low capability versus mild pathology/high capability [PHQ-2, median and interquartile range]: 3 [1 to 5] versus 0 [0 to 0]; p < 0.001).

CONCLUSION

Statistical groupings ("phenotypes") that include both measures of pathology and mental health are associated with differences in symptom intensity and magnitude of incapability and have the potential to help musculoskeletal specialists discern mental and social health priorities. Future investigations may test whether illness phenotype-specific comprehensive biopsychosocial treatment strategies are more effective than treatment of pathology alone.

LEVEL OF EVIDENCE

Level III, prognostic study.

Do Unhelpful Thoughts or Confidence in Problem Solving Have Stronger Associations with Musculoskeletal Illness?

BACKGROUND

Measures of unhelpful thoughts and distress correlate with the intensity of pain and the magnitude of incapability among people seeking musculoskeletal specialty care. In this evolving knowledge area, we want to be sure we have not neglected other important mental health factors. This study addressed how measures of confidence in problem solving as well as past and current ability to achieve goals account for variation in symptoms and capability independent of unhelpful thoughts and distress.

QUESTIONS/PURPOSES

(1) Are measures of confidence in problem solving ability and past and current ability to achieve goals regarding future outcomes associated with variation in capability, independent of measures of symptoms of depression and anxiety (distress) and measures of unhelpful thoughts (worst-case thinking, negative pain thoughts)? (2) Are these measures independently associated with variation in pain intensity? (3) Are these measures associated with measures of symptoms of depression, symptoms of anxiety, and unhelpful thoughts?

METHODS

Over a 7-month period during the pandemic, we enrolled sporadically from the offices of four surgeons treating patients who sought care for various upper and lower extremity conditions. We invited approximately 200 adult new and returning patients to participate (the number of invitations was not formally tracked) and 187 accepted. Thirty-one were excluded due to markedly incomplete entries (related to a problematic attempt to use the patient's cell phone to complete questionnaires as a pandemic work around), leaving 156 for analysis. Patients completed an 11-point ordinal rating of pain intensity, two measures of unhelpful thoughts (the Pain Catastrophizing Scale and the Negative Pain Thoughts Questionnaire), the Adult Hope Scale to measure past and current ability to achieve goals, the Personal Optimism and Self-Efficacy Optimism Scale to measure confidence in problem solving ability, the Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive test to measure symptoms of anxiety, the PROMIS computer adaptive test to measure symptoms of depression, and the PROMIS physical function computer adaptive test to assess the magnitude of capability. All questionnaires were validated in previous studies. We used bivariate analyses to identify factors associated with magnitude of capability, pain intensity, confidence in problem solving ability, and past and current ability to achieve goals. All factors with a p value of less than 0.1 were included in multivariable analyses to seek associations between these measures accounting for confounders. We reported partial η2 as a measure of effect size for all multivariable regression models. The following rules of thumb are used to interpret values for partial η2: a value of 0.01 = small, 0.06 = medium, and values of 0.14 and higher show large effect size.

RESULTS

Greater capability was modestly associated with fewer negative pain thoughts (β = -0.63 [95% CI -1.0 to -0.22]; standard error = 0.20; partial η2 = 0.06; p = 0.003) and no self-reported comorbidities (β = 2.6 [95% CI 0.02 to 5.3]; standard error = 1.3; partial η2 = 0.03; p = 0.048) after controlling for education, symptoms of depression and anxiety, worst-case thinking, as well as past and current ability to achieve goals. In a similar multivariable model, greater pain intensity was modestly associated with greater worst-case thinking (β = 0.33 [95% CI 0.20 to 0.45]; standard error = 0.06; partial η2 = 0.16; p < 0.001) and established patients (β = -1.1 [95% CI -1.8 to -0.31]; standard error = 0.38; partial η2 = 0.05; p = 0.006). In another similar multivariable model, having more confidence in problem solving ability had a limited association with higher ratings of past and current ability to achieve goals (β = 0.15 [95% CI 0.09 to 0.21]; standard error = 0.03; partial η2 = 0.13; p < 0.001). In a final multivariable model, lower past and current ability to achieve goals was independently associated with having greater symptoms of depression (β = -0.45 [95% CI -0.67 to -0.23]; standard error = 0.11; partial η2 = 0.1; p < 0.001) and more negative pain thoughts (β = -0.49 [95% CI -0.89 to -0.09]; standard error = 0.20; partial η2 = 0.04; p = 0.02).

CONCLUSION

The observation that unhelpful thoughts about symptoms are more strongly associated with symptom intensity than past and current ability to achieve goals and confidence in problem solving ability add to the evidence that attentiveness to unhelpful thinking is an important aspect of musculoskeletal health. Musculoskeletal specialists can prioritize communication strategies such as relationship building and motivational interviewing that develop trust and facilitate reorientation of common unhelpful thoughts.

LEVEL OF EVIDENCE

Level II, prognostic study.

Unhelpful Thoughts and Distress Regarding Symptoms Limit Accommodation of Musculoskeletal Pain

BACKGROUND

Among people with musculoskeletal disorders, much of the variation in magnitude of incapability and pain intensity is accounted for by mental and social health opportunities rather than severity of pathology. Current questionnaires seem to combine distinct aspects of mental health such as unhelpful thoughts and distress regarding symptoms, and they can be long and burdensome. To identify personalized health strategies, it would be helpful to measure unhelpful thoughts and distress regarding symptoms at the point of care with just a few questions in a way that feels relevant to a person's health.

QUESTIONS/PURPOSES

(1) Do questions that address unhelpful thoughts and distress regarding symptoms independently account for variation in accommodation of pain? (2) Which questions best measure unhelpful thoughts and distress regarding symptoms?

METHODS

This is a cross-sectional questionnaire study of people seeking care regarding upper and lower extremity conditions from one of eight specialist clinicians (one upper extremity, one arthroplasty, and one sports surgeon and their three nurse practitioners and two physician assistants) in one urban office. Between June 2020 and September 2020, 171 new and returning patients were approached and agreed to participate, and 89% (153) of patients completed all questionnaires. The most common reason for noncompletion was the use of a pandemic strategy allowing people to use their phone to finish the questionnaire, with more people leaving before completion. Women and divorced, separated, or widowed people were more likely to not complete the survey, and we specifically account for sex and marital status as potential confounders in our multivariable analysis. Forty-eight percent (73 of 153) of participants were women, with a mean age 48 ± 16 years. Participants completed demographics and the validated questionnaires: Pain Catastrophizing Scale, Negative Pain Thoughts Questionnaire, Tampa Scale of Kinesiophobia, Intolerance of Uncertainty Scale, and Pain Self-Efficacy Questionnaire (a measure of accommodation to pain). In an exploratory factor analysis, we found that questions group together on four topics: (1) distress about symptoms (unhelpful feelings of worry and despair), (2) unhelpful thoughts about symptoms (such as worst-case thinking and pain indicating harm), (3) being able to plan, and (4) discomfort with uncertainty. We used a multivariable analysis, accounting for potential confounding demographics, to determine whether the identified question groupings account for variation in accommodation of pain-and thus are clinically relevant. Then, we used a confirmatory factor analysis to determine which questions best represent clinically relevant groupings of questions.

RESULTS

After accounting for sex, marital status, work, and income, we found that distress and unhelpful thoughts about symptoms were independently associated with accommodation of pain, and together, they explained 60% of its variation (compared with 52% for distress alone and 40% for unhelpful thoughts alone). Variation in symptoms of distress was best measured by the question "I feel I can't stand it anymore" (76%). Variation in unhelpful thoughts was best addressed by the question "I wouldn't have this much pain if there wasn't something potentially dangerous going on in my body" (64%).

CONCLUSION

We found that distress (unhelpful feelings) and unhelpful thoughts about symptoms are separate factors with important and comparable associations with accommodation to pain. It also appears that these two factors can be measured with just a few questions. Being attentive to the language people use and the language of influential questions might improve clinician identification of mental health opportunities in the form of distress and unhelpful thoughts about symptoms, which in turn might contribute to better accommodation and alleviation of symptoms.

LEVEL OF EVIDENCE

Level II, prognostic study.

Effectiveness of rehabilitation on pain and function in people affected by hemophilia

INTRODUCTION

Literature provides unclear evidence of the effectiveness of many physiotherapy interventions on pain intensity, quality of life, and functional ability in hemophilic patients, and suggests that rehabilitation programs should be focused on functional goals and the disability of patients.

AIM

The aim of the present study is to present the outcome of a case series of patients with hemophilia in which a rehabilitation program has been carried out on the basis of a specific individual patient's functional impairment.

METHODS

Fifty-one patients were enrolled: 32 patients (Rehab Group) received a rehabilitative treatment, 19 patients for different reasons (living far from the hospital, family problems) did not receive rehabilitation (Control Group). The rehabilitation program was planned with respect to the emergent problems: musculoskeletal pain, joint range of motion limitation, muscle flexibility, walking difficulties, the appearance of hematomas/hemartro, and postural problems. All the patients were assessed at baseline (T0), after 1 month (T1), and after 3 months (T2) through visual analogic scale for musculoskeletal pain, the Hemophilia Joint Health Score for joint range of motion, the Functional Independence Score in Hemophilia for disability, and postural assessment by visual inspection.

RESULTS

A significant reduction of pain and improvement of Hemophilia Joint Health Score and Functional Independence Score in Hemophilia score was found in the Rehab Group along with the follow-up. Pain in the Control Group was lower with respect to the other group at baseline and significantly decreased after 1 month.

CONCLUSION

A rehabilitation program focused on individual impairment of patients with hemophylia determined satisfying results in terms of pain control, functional, and disability improvement in 3 months follow-up.

Clinician Facial Expression of Emotion Corresponds with Patient Mindset

BACKGROUND

Mental health has a notable and perhaps underappreciated relationship with symptom intensity related to musculoskeletal pathophysiology. Tools for increasing awareness of mental health opportunities may help musculoskeletal specialists identify and address psychological distress and unhealthy misconceptions with greater confidence. One such type of technology-software that identifies emotions by analyzing facial expressions-could be developed as a clinician-awareness tool. A first step in this endeavor is to conduct a pilot study to assess the ability to measure patient mental health through specialist facial expressions.

QUESTIONS/PURPOSES

(1) Does quantification of clinician emotion using facial recognition software correlate with patient psychological distress and unhealthy misconceptions? (2) Is there a correlation between clinician facial expressions of emotions and a validated measure of the quality of the patient-clinician relationship?

METHODS

In a cross-sectional pilot study, between April 2019 and July 2019, we made video recordings of the clinician's face during 34 initial musculoskeletal specialist outpatient evaluations. There were 16 men and 18 women, all fluent and literate in English, with a mean age of 43 ± 15 years. Enrollment was performed according to available personnel, equipment, and room availability. We did not track declines, but there were only a few. Video recordings were analyzed using facial-emotional recognition software, measuring the proportion of time spent by clinicians expressing measured emotions during a consultation. After the visit, patients completed a demographic questionnaire and measures of health anxiety (the Short Health Anxiety Inventory), fear of painful movement (the Tampa Scale for Kinesiophobia), catastrophic or worst-case thinking about pain (the Pain Catastrophizing Scale), symptoms of depression (the Patient Health Questionnaire), and the patient's perception of the quality of their relationship with the clinician (Patient-Doctor Relationship Questionnaire).

RESULTS

Clinician facial expressions consistent with happiness were associated with less patient health anxiety (r = -0.59; p < 0.001) and less catastrophic thinking (r = -0.37; p = 0.03). Lower levels of clinician expressions consistent with sadness were associated with less health anxiety (r = 0.36; p = 0.04), fewer symptoms of generalized anxiety (r = 0.36; p = 0.03), and less catastrophic thinking (r = 0.33; p = 0.05). Less time expressing anger was associated with greater health anxiety (r = -0.37; p = 0.03), greater symptoms of anxiety (r = -0.46; p < 0.01), more catastrophic thinking (r = -0.38; p = 0.03), and greater symptoms of depression (r = -0.42; p = 0.01). More time expressing surprise was associated with less health anxiety (r = -0.44; p < 0.01) and symptoms of depression (r = -0.52; p < 0.01). More time expressing fear was associated with less kinesiophobia (r = -0.35; p = 0.04). More time expressing disgust was associated with less catastrophic thinking (r = -0.37; p = 0.03) and less health anxiety (GAD-2; r = -0.42; p = 0.02) and symptoms of depression (r = -0.44; p < 0.01). There was no association between a clinicians' facial expression of emotions and patient experience with patient-clinician interactions.

CONCLUSION

The ability to measure a patient's mindset on the clinician's face confirms that clinicians are registering the psychological aspects of illness, whether they are consciously aware of them or not. Future research involving larger cohorts of patients, mapping clinician-patient interactions during consultation, and more sophisticated capture of nonverbal and verbal cues, including a broader range of emotional expressions, may help translate this innovation from the research setting to clinical practice.

CLINICAL RELEVANCE

Tools for measuring emotion through facial recognition could be used to train clinicians to become aware of the psychological aspects of health and to coach clinicians on effective communication strategies both for gentle reorientation of common misconceptions as well as for appropriate and timely diagnosis and treatment of psychological distress.

Identifying the content and context of pain within paediatric rheumatology healthcare professional curricula in the UK: a summative content analysis

BACKGROUND

The curriculum for professionals working in paediatric rheumatology should include pain but it is unclear to what extent this currently occurs. The aim of this study was to identify pain-related curriculum content and the context in which pain is presented in educational and training documentation for healthcare professionals in this clinical speciality.

METHODS

Core curricula documents from UK based professional organisations were identified in partnership with healthcare professionals. Documents were analysed using a summative content analysis approach. Key pain terms were quantified and weighted frequencies were used to explore narrative pain themes. Latent content was interpreted qualitatively to explore the context within which pain terms were positioned.

RESULTS

Nine curriculum documents were identified and analysed from doctors, nurses, physiotherapists and occupational therapists specialising in paediatric rheumatology. Pain themes represented a mean percentage of 1.51% of text across all documents. Pain was rarely presented in the context of both inflammatory and non-inflammatory condition types despite being a common feature of each. Musculoskeletal pain was portrayed simply as a 'somatic' symptom, rather than as a complex phenomenon involving biological and psychosocial processes. Content around the assessment and management of pain was vague and inexplicit.

CONCLUSION

Current educational and training documentation in paediatric rheumatology do not include core pain topics. Curricula for these healthcare professionals would benefit from updates in contemporary pain theories and examples of in-context, evidence-based pain practices. This should be a priority starting point for optimising patient pain care in paediatric musculoskeletal healthcare.

Interaction between occupational physical burdens and low job control on musculoskeletal pain: Analysis of the 5th Korean Working Environment Survey

OBJECTIVE

This study aimed to investigate the interactive impacts between occupational physical burdens and psychological job demand or control on musculoskeletal pain (MSP) using nationally representative data for Korean workers.

METHODS

Using 5th Korean Working Conditions Survey (KWCS), we explored the interaction between occupational physical burdens and levels of psychological job demand or control on risk of MSP in 49 572 eligible participants. For quantitative evaluation of the interaction, relative excess risk due to interaction (RERI) was calculated.

RESULTS

In a group with low job control and at least one occupational physical burden, odds ratio (OR) for neck and upper extremity pain was 2.44 (95% CI, 2.24-2.66) compared with a group with high job control and no physical burden (a reference group: lowest risk), which was the highest value among the four groups, and the RERI was 0.35 (95% CI, 0.19-0.51). Similarly, OR for lower extremity pain was 2.15 (95% CI, 1.95-2.37) and RERI was 0.26 (95% CI, 0.07-0.45). However, the RERI was not significant in the case of psychological job demand.

CONCLUSION

This study revealed significant interactions between occupational physical burdens and low job control on MSP.

The Association Between Physiological Sources of Pain and Sleep Quality in Older Adults With and Without Dementia

The association of musculoskeletal pain, respiratory distress, gastrointestinal discomfort, and genitourinary pain to sleep quality in 89 persons with and without dementia was examined in the current exploratory, cross-sectional, observational quantitative design. Sources of pain were recorded, with 37.1% of the sample reporting urinary retention, 30.3% reporting genitourinary discomfort, and 53.9% reporting gastrointestinal discomfort. Mild scores of musculoskeletal pain and respiratory discomfort were elicited in >75% of the sample. An actigraph was used to measure sleep variables. Findings from this research illustrated dementia, gender, pillow use, respiratory distress, and urinary retention were statistically significantly associated with nighttime sleep quality. Results suggest comprehensive assessments of pain and sleep for older adults with and without dementia are needed. Developing and testing interventions that address factors contributing to sleep quality may improve outcomes. [Research in Gerontological Nursing, 13(6), 297-308.].

Chronic pain in people with HIV: a common comorbidity and threat to quality of life

Evidence indicates that over half of all people with HIV (PWH) will experience nonmalignant chronic pain throughout their lifetimes, with increasing prevalence as they age. Peripheral neuropathy resulting from the neurotoxic effects of HIV itself and the medications used to treat HIV were widely considered the primary cause of acute and chronic pain early on in the antiretroviral treatment era. However, recent studies suggest a predominance of non-neuropathic (e.g., musculoskeletal) pain in PWH with uncertain etiology. Chronic pain is often widespread in PWH, affecting multiple body locations. Additional research is needed to better understand contributors to chronic pain in PWH, which is likely to include biological (e.g., immune dysregulation), psychological (e.g., substance abuse) and social (e.g., stigma) factors.

Measurement properties of the musculoskeletal health questionnaire (MSK-HQ): a between country comparison

BACKGROUND

The Musculoskeletal Health Questionnaire (MSK-HQ) has been developed to measure musculoskeletal health status across musculoskeletal conditions and settings. However, the MSK-HQ needs to be further evaluated across settings and different languages.

OBJECTIVE

The objective of the study was to evaluate and compare measurement properties of the MSK-HQ across Danish (DK) and English (UK) cohorts of patients from primary care physiotherapy services with musculoskeletal pain.

METHODS

MSK-HQ was translated into Danish according to international guidelines. Measurement invariance was assessed by differential item functioning (DIF) analyses. Test-retest reliability, measurement error, responsiveness and minimal clinically important change (MCIC) were evaluated and compared between DK (n = 153) and UK (n = 166) cohorts.

RESULTS

The Danish version demonstrated acceptable face and construct validity. Out of the 14 MSK-HQ items, three items showed DIF for language (pain/stiffness at night, understanding condition and confidence in managing symptoms) and three items showed DIF for pain location (walking, washing/dressing and physical activity levels). Intraclass Correlation Coefficients for test-retest were 0.86 (95% CI 0.81 to 0.91) for DK cohort and 0.77 (95% CI 0.49 to 0.90) for the UK cohort. The systematic measurement error was 1.6 and 3.9 points for the DK and UK cohorts respectively, with random measurement error being 8.6 and 9.9 points. Receiver operating characteristic (ROC) curves of the change scores against patients' own judgment at 12 weeks exceeded 0.70 in both cohorts. Absolute and relative MCIC estimates were 8-10 points and 26% for the DK cohort and 6-8 points and 29% for the UK cohort.

CONCLUSIONS

The measurement properties of MSK-HQ were acceptable across countries, but seem more suited for group than individual level evaluation. Researchers and clinicians should be aware that some discrepancy exits and should take the observed measurement error into account when evaluating change in scores over time.

Workers Age 55 and over Working with Pain. A Descriptive Interpretive Study

Purpose In most industrialized countries, the share of workers in the age 55+ age group is increasing while there is a shortage of young workers. Although data suggest that at least one in five older workers suffers from chronic musculoskeletal pain, most will continue working despite pain. The objective of this study is to explore factors associated with staying at work for workers with musculoskeletal pain. Methods An interpretive descriptive method was used. Semi-structured individual interviews were conducted. Inclusion criteria were: manual/mixed occupations, persistent musculoskeletal pain, and working 28 h weekly or more. Analysis was performed using themes from the conceptual model created. Results Fourteen participants were included, ages 55-70. They ranged from self-employed individuals to employees of large organizations. For most, the perception of being useful, having peer recognition and feeling that work contributes to health were essential drivers for staying at work. Flexibility at work was deemed essential by all but took various forms. Individual cost of staying at work varied from low to high. Conclusion This study identified both personal and work-related factors associated with working in the presence of pain. New concept of cost of staying at work appears promising.

"It's just like a needle going into my hip, basically all of the time". The experiences and perceptions of patients with Greater Trochanteric Pain syndrome in the UK National Health Service

BACKGROUND

Greater Trochanteric Pain syndrome (GTPS) is a condition causing lateral hip pain, which can be both persistent and debilitating. Data suggests that NHS patients with GTPS often have complex presentations with greater risk of developing persistent pain. No research to date has looked to understand the lived experience of patients with GTPS.

OBJECTIVES

This data may help inform a programme of intervention development for testing in a future randomised controlled trial. Hence, this qualitative study aimed to provide insight into the experiences and perceptions of patients suffering with GTPS.

DESIGN

Qualitative study using semi-structured interviews.

METHODS

Ten patients diagnosed with GTPS in consultant-led clinic at one NHS Hospital. Patients were identified from the physiotherapy waiting list and approached via a postal letter. Once informed consent was gained, semi-structured telephone interviews were conducted, transcribed verbatim and analysed using the Framework Method.

RESULTS

Data were analysed with reference to five pre-determined themes (1) living with persistent pain; (2) understanding the problem and pain; (3) experiences of previous treatment; (4) beliefs about activity and exercise; (5) the future.

CONCLUSION

The participants with GTPS, interviewed in this study commonly suffered from debilitating pain, affecting them during activity and at rest. They were confused about the diagnoses they were given and the meaning of their pain in relation to activity. Furthermore, participants were often either uncertain or pessimistic about their potential to recover.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov Identifier: NCT03720587.

Using vignettes to assess the contribution of goal adjustment in the adaptation to chronic musculoskeletal pain

PURPOSE

The quality of life of individuals with chronic musculoskeletal pain partly depends on their capacity to adjust their personal goals. Vignettes have been rarely used to assess this ability. Therefore, this study aimed to test the relationships between vignettes assessing different goal strategies and chronic pain adaptation (i.e., daily functioning, pain-related impairment, and psychological well-being).

METHODS

The sample comprised 258 individuals with chronic musculoskeletal pain who completed a series of questionnaires and vignettes. The vignettes presented a short description of a situation in which a person with chronic pain experienced a threat to a valued domain-specific goal and had to choose a possible goal management solution (i.e., goal persistence, flexibility reengagement, and disengagement). Hierarchical regression analyses were used to predict chronic pain adaptation using the selected vignette strategies as predictors.

RESULTS

After controlling for age, sex, pain intensity, and the responses to the dispositional goal management scales, persistence, reengagement, and disengagement goal strategies presented in the case scenarios predicted daily functioning (p < .001). Persistence, flexibility, disengagement (p < .001), and reengagement (p < .05) predicted pain-related impairment. Persistence, disengagement (p < .001), and flexibility (p < .05) predicted psychological well-being scores.

CONCLUSION

The use of vignettes could be useful to assess goal adjustment because this methodology enables respondents to provide more context-specific responses. The results of this approach could be used to improve clinical practice aimed at helping people with chronic musculoskeletal pain to better cope with this health condition.

Cross-cultural adaptation and validity of the Spanish fear-avoidance components scale and clinical implications in primary care

BACKGROUND

Pain-related fear-avoidance (FA) is a common problem affecting many patients with painful medical conditions. As there is great interest in the clinical importance of the relationship between FA and disability, several questionnaires have been developed to measure FA. The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument that addresses critical issues not previously considered in previous FA-related questionnaires. The original English version of the FACS demonstrated good reliability, internal consistency, and construct, criterion, and predictive validity. Two factors were determined: General Fear Avoidance and Types of Activities That are Avoided. The aim of this study was to to translate the FACS into European-style Spanish (FACS-Sp), and validate its psychometric properties.

METHODS

This two-stage psychometric study included 330 subjects with various chronic musculoskeletal pain disorders. An initial translation and cross-cultural adaptation of the FACS, from English to Spanish, was performed. Then, critical psychometric properties were analysed, including internal consistency by Cronbach's α coefficients, structural validity from the Maximum Likelihood Extraction (MLE), and convergent validity by Pearson correlation with the Central Sensitization Inventory (CSI).

RESULTS

This study reports for the first time the psychometric properties of the Spanish version of the FACS. Total scores ranged from 0 to 88 points, with a mean of 30.49 (±17.18). The FACS-Sp showed a high internal consistency for factor 1 (α = 0.902) and factor 2 (α = 0.88). Factor structure was two-dimensional and supported structural validity, accounting for 48.75% of the total variance. Convergent validity analysis found a significant Pearson correlation r = 0.414.

CONCLUSION

This study reports for the first time the psychometric properties of the Spanish version of the FACS-Sp. Psychometric properties supported the validation of FACS-Sp and ensured the conceptual equivalence with the original English version. In primary care and chronic pain rehabilitation, FA assessment is crucial for clinical decision-making and treatment guidance. The FACS-Sp offers a new measure of FA in Spanish speaking populations. Future research on the FACS-Sp should evaluate test-retest reliability, treatment responsiveness and psychometric comparisons with other translated versions.

Internet-delivered attentional bias modification training (iABMT) for the management of chronic musculoskeletal pain: a protocol for a randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain is a complex medical condition that can significantly impact quality of life. Patients with chronic pain demonstrate attentional biases towards pain-related information. The therapeutic benefits of modifying attentional biases by implicitly training attention away from pain-related information towards neutral information have been supported in a small number of published studies. Limited research however has explored the efficacy of modifying pain-related biases via the internet. This protocol describes a randomised, double-blind, internet-delivered attentional bias modification intervention, aimed to evaluate the efficacy of the intervention on reducing pain interference. Secondary outcomes are pain intensity, state and trait anxiety, depression, pain-related fear, and sleep impairment. This study will also explore the effects of training intensity on these outcomes, along with participants' perceptions about the therapy.

METHODS AND ANALYSIS

The study is a double-blind, randomised controlled trial with four arms exploring the efficacy of online attentional bias modification training versus placebo training theorised to offer no specific therapeutic benefit. Participants with chronic musculoskeletal pain will be randomised to one of four groups: (1) 10-session attentional modification group; (2) 10-session placebo training group; (3) 18-session attentional modification group; or (4) 18-session placebo training group. In the attentional modification groups, the probe-classification version of the visual-probe task will be used to implicitly train attention away from threatening information towards neutral information. Following the intervention, participants will complete a short interview exploring their perceptions about the online training. In addition, a subgroup analysis for participants aged 16-24 and 25-60 will be undertaken.

ETHICS AND DISSEMINATION

This study has been approved by the University of Southampton Research Ethics Committee. Results will be published in peer-reviewed journals, academic conferences, and in lay reports for pain charities and patient support groups.

TRIAL REGISTRATION NUMBER

NCT02232100; Pre-results.

Quantitative sensory testing and predicting outcomes for musculoskeletal pain, disability, and negative affect: a systematic review and meta-analysis

Hypersensitivity due to central pain mechanisms can influence recovery and lead to worse clinical outcomes, but the ability of quantitative sensory testing (QST), an index of sensitisation, to predict outcomes in chronic musculoskeletal disorders remains unclear. We systematically reviewed the evidence for ability of QST to predict pain, disability, and negative affect using searches of CENTRAL, MEDLINE, EMBASE, AMED, CINAHL, and PubMed databases up to April 2018. Title screening, data extraction, and methodological quality assessments were performed independently by 2 reviewers. Associations were reported between baseline QST and outcomes using adjusted (β) and unadjusted (r) correlations. Of the 37 eligible studies (n = 3860 participants), 32 were prospective cohort studies and 5 randomised controlled trials. Pain was an outcome in 30 studies, disability in 11, and negative affect in 3. Meta-analysis revealed that baseline QST predicted musculoskeletal pain (mean r = 0.31, 95% confidence interval [CI]: 0.23-0.38, n = 1057 participants) and disability (mean r = 0.30, 95% CI: 0.19-0.40, n = 290 participants). Baseline modalities quantifying central mechanisms such as temporal summation and conditioned pain modulation were associated with follow-up pain (temporal summation: mean r = 0.37, 95% CI: 0.17-0.54; conditioned pain modulation: mean r = 0.36, 95% CI: 0.20-0.50), whereas baseline mechanical threshold modalities were predictive of follow-up disability (mean r = 0.25, 95% CI: 0.03-0.45). Quantitative sensory testing indices of pain hypersensitivity might help develop targeted interventions aiming to improve outcomes across a range of musculoskeletal conditions.

The important role of central sensitization in chronic musculoskeletal pain seen in different rheumatic diseases

OBJECTIVE

This study explored the role of central sensitization (CS) pain in patients with various rheumatic diseases using the CS inventory (CSI).

METHODS

A total of 193 patients of mean age 50.72 ± 9.65 years were included; they were divided into four different groups in terms of their rheumatic diseases. Patients with rheumatoid arthritis (RA), spondyloarthropathy (SpA), osteoarthritis (OA), and fibromyalgia syndrome (FMS) were evaluated in tertiary care rheumatology/pain medicine settings. Disease duration and activity, the Bath Ankylosing Spondylitis Disease Activity Index, the Disease Activity Score-28, and pain severity (evaluated using a visual analog scale) were assessed, and the Turkish version of the CSI administered.

RESULTS

CS syndromes were present in almost half the patients (45% of SpA, 41% of RA, 62% of OA, and 94% of FMS patients). We found no significant relationship between disease activity and the CSI-A scores in SpA or RA patients (p = 0.731 and p = 0.390, respectively). As expected, the CSI-A scores were highest in the FMS group (p = 0.000), but were similar in the other groups (p < 0.05). CS-related syndromes (CSI-B conditions) were present at similar frequencies in the RA, SpA, and OA groups, but were less common in the FMS group (p = 0.000).

CONCLUSIONS

The CSI usefully detects CS pain in patients with rheumatic diseases. Treatment of such pain can enhance the quality of daily life in patients with rheumatic diseases.Key Point• Central sensitization pain is common in patients with rheumatic diseases including rheumatoid arthritis, spondyloarthropathies, and osteoarthritis.

Job-related self-efficacy in musculoskeletal disorders - a questionnaire

BACKGROUND

The Return-To-Work Self-Efficacy Scale questionnaire maps self-efficacy upon return to work following acute lower back pain. We wished to translate and validate the questionnaire, as well as to assess the concordance between the translated form and two other forms.

MATERIAL AND METHOD

The questionnaire was translated into Norwegian according to recommended guidelines. Employees in the health and care service with musculoskeletal symptoms were recruited for the study. Cross-cultural validity was assessed by principal component analysis and internal consistency by Cronbach's alpha. Conceptual validity was assessed by correlation between the translated form and simultaneous measurements from two questionnaires that focus on closely related characteristics: the Tampa scale for kinesiophobia and the Demand-ControlSupport model.

RESULTS

The Norwegian questionnaire is called 'Job-related self-efficacy'. Of a sample of 229 persons, 206 (89.9 %) were included in the analyses. Principal component analysis supported cross-cultural validity through findings of a three-factor structure in accordance with the original questionnaire. Internal consistency was high for all questions in the questionnaire (0.95), as well as for each of the three factors: meet job requirements (0.99), communicate needs to others (0.97) and adapt work duties (0.96), after adjusting for the number of questions. There were low correlations (< 0.40) between Job-Related Self-Efficacy and the Tampa scale for kinesiophobia, and the various factors in the Demand-Control-Support questionnaire, respectively.

INTERPRETATION

The 'Job-Related Self-Efficacy' questionnaire has satisfactory cross-cultural validity after it was translated, and satisfactory internal consistency.

The Development and Content of the Vocational Advice Intervention and Training Package for the Study of Work and Pain (SWAP) Trial (ISRCTN 52269669)

Purpose There are substantial costs associated with sickness absence and struggling at work however existing services in the UK are largely restricted to those absent from work for greater than 6 months. This paper details the development of an early Vocational Advice Intervention (VAI) for adult primary care consulters who were struggling at work or absent due to musculoskeletal pain, and the structure and content of the training and mentoring package developed to equip the Vocational Advisors (VAs) to deliver the VAI, as part of the Study of Work and Pain (SWAP) cluster randomised trial. Methods In order to develop the intervention, we conducted a best-evidence literature review, summarised evidence from developmental studies and consulted with stakeholders. Results A novel early access, brief VAI was developed consisting of case management and stepped care (three steps), using the Psychosocial Flags Framework to identify and overcome obstacles associated with the health-work interface. Four healthcare practitioners were recruited to deliver the VAI; three physiotherapists and one nurse (all vocational advice was actually delivered by the three physiotherapists). They received training in the VA role during a 4-day course, with a refresher day 3 months later, along with monthly group mentoring sessions. Conclusions The process of development was sufficient to develop the VAI and associated training package. The evidence underpinning the VAI was drawn from an international perspective and key components of the VAI have the potential to be applied to other settings or countries, although this has yet to be tested.

Multidisciplinary Biopsychosocial Program for Chronic Musculoskeletal Pain at the Dead Sea

BACKGROUND

Multidisciplinary biopsychosocial rehabilitation for patients presenting with rheumatic diseases has been shown to produce better results in a warm climate. Dead Sea Climatotherapy (DSC) has been successfully used for decades to treat many patients with rheumatic diseases.

OBJECTIVES

To evaluate the short-term improvement of Norwegian patients who presented with chronic pain following a multidisciplinary biopsychosocial approach to treatment combined with DSC. Both objective and subjective clinical parameters were evaluated.

METHODS

This retrospective study included a statistical analysis of 938 patients presenting with rheumatoid arthritis and ankylosing spondylitis (n=105), osteoarthritis (n=342), fibromyalgia (n=374), and other orthopedic conditions (n=117). Clinical assessments were conducted before and after a 3 week treatment program at the Dead Sea.

RESULTS

Six parameters improved significantly in the rheumatoid arthritis and ankylosing spondylitis group as well as in the osteoarthritis group. Five parameters in the fibromyalgia group improved, while two improved in the orthopedic conditions group. Overall, major significant changes occurred in the pain self-assessment, joint motility, and daily activities scores.

CONCLUSIONS

A 3-week multidisciplinary biopsychosocial program combined with DSC induced positive changes in the clinical parameters of Norwegian patients presenting with chronic musculoskeletal pain.

Factors Influencing Cognitive Impairment in Neuropathic and Musculoskeletal Pain and Fibromyalgia

Objective

To assess cognitive performance of chronic pain (CP) patients diagnosed with three types of pain-neuropathic pain (NP), musculoskeletal (MSK), and fibromyalgia (FM)-and to analyze the factors influencing cognitive difficulties in each group.

Methods

Two hundred fifty-four CP patients-104 NP, 99 MSK, 51 FM-and 72 pain-free subjects were included in the study. The "Test Your Memory" (TYM) scale was used to assess cognitive performance. Pain intensity was measured by means of the visual analog scale (VAS); the Hospital Anxiety and Depression scale was used to assess mental status, and the Medical Outcome Study (MOS) sleep scale to assess sleep quality. The relationships between cognitive performance and these factors were analyzed using linear regression models.

Results

The mean score in the TYM was significantly lower (worse cognitive function) in CP patients than controls (40.5 vs 43.9, P < 0.001). In the separate analysis of each group, depression was observed to have a negative impact on MSK pain patients (ß = -0.37, 95% confidence interval [CI] = -0.53 to -0.2, P < 0.001) and on FM subjects (ß =-1.01, 95% CI = -1.05 to -2.38, P = 0.022). A significant interaction between pain intensity and depression was observed in the FM patients. In addition, a U-shaped association was found between the duration of pain and cognitive performance in the NP patients. Neither anxiety nor sleep impairment affected cognitive performance in any of the CP patients.

Conclusions

These results highlight the importance of taking into account the type of pain when assessing cognitive performance in CP patients and demonstrate the influence of the emotional state of the patient, especially if depression is present.

Opioid Prescribing and Polypharmacy in Children with Chronic Musculoskeletal Pain

OBJECTIVE

Thirty percent of adults with fibromyalgia receive an opioid, but the prevalence of opioid prescribing in pediatric chronic musculoskeletal pain is unknown. The aims of this study were to determine the prevalence of and factors associated with opioid exposure and polypharmacy among children with chronic musculoskeletal pain.

METHODS

In this retrospective cohort study using health care claims data from 2000 to 2013, the index date was the first ICD-9 code 729.1. Included subjects were ≥ 2 and < 18 years old at the index date with two or more codes within 12 months and 18 months of continuous enrollment. Subjects with burns, sickle cell disease, or malignancy were excluded. Opioid exposure was defined as one or more prescriptions within six months before or any time after the index date. Polypharmacy was considered minor (2-4 medications) or major (≥5 medications).

RESULTS

Of 25,321 included subjects, 20% received an opioid and 26% experienced minor polypharmacy. Opioid exposure was associated with female sex (odds ratio [OR] = 1.27, P < 0.01), Caucasian race (OR = 1.27, P < 0.01), hospitalization (OR = 1.20, P < 0.01), and visit with anesthesiology (OR = 1.97, P < 0.01) or orthopedics (OR = 1.09, P < 0.05). Mental health codes were associated with decreased odds of opioid exposure (all P < 0.05). Children seen by a chiropractor or physiatrist had a reduced odds of receipt of an opioid (OR = 0.42 and 0.84, respectively, both P < 0.01).

CONCLUSIONS

Twenty percent of children with chronic musculoskeletal pain received an opioid. Twenty-six percent experienced polypharmacy, with the majority receiving 2-4 medications. Increased availability of psychological and nonpharmacologic services are potential strategies to reduce opioid exposure.

Can the STarT Back Tool predict health-related quality of life and work ability after an acute/subacute episode with back or neck pain? A psychometric validation study in primary care

OBJECTIVES

The predictive ability of the STarT Back Tool (SBT) has not yet been examined among acute/subacute back and/or neck pain in a primary care setting in respect to health-related quality of life (HRQoL) and work ability outcomes. The aim of this study was to evaluate the SBT's predictive validity for HRQoL and work ability outcomes at long-term follow-up in a population with acute/subacute back and/or neck pain.

SETTING

Prospective data from 35 primary care centres in south Sweden during 2013.

PARTICIPANTS

Patients (n=329) with acute/subacute back and/or neck pain, aged 18-67 years, not on sick leave or <60 days of sick leave completed the SBT when applying for physiotherapy treatment. Long-term follow-up measures (median 13 months, range 11-27 months) of HRQoL (EQ-5D) and work ability (Work Ability Score) was completed by 238 patients (72%).

OUTCOMES

The predictive ability of the SBT for HRQoL and work ability outcomes was examined using Kruskal-Wallis test, logistic regression and area under the curve (AUC).

RESULTS

Based on SBT risk group stratification, 103 (43%), 107 (45%) and 28 (12%) patients were considered as low, medium and at high risk, respectively. There were statistically significant differences in HRQoL (p<0.001) and work ability (p<0.001) at follow-up between all three SBT risk groups. Patients in the high risk group had a significantly increased risk of having poor HRQoL (OR 6.16, 95% CI 1.50 to 25.26) and poor work ability (OR 5.08, 95% CI 1.75 to 14.71) vs the low risk group at follow-up. The AUC was 0.73 (95% CI 0.61 to 0.84) for HRQoL and 0.68 (95% CI 0.61 to 0.76) for work ability.

CONCLUSIONS

The SBT is an appropriate tool for identifying patients with a poor long-term HRQoL and/or work ability outcome in a population with acute/subacute back and/or neck pain, and maybe a useful adjunct to primary care physiotherapy assessment and practice.

TRIAL REGISTRATION NUMBER

NCT02609750; Results.

Pain could negatively affect school grades - Swedish middle school students with low school grades most affected

Recurrent headache, abdominal and musculoskeletal pain are common in adolescents and it is therefore important to understand their impact on the transitional period from childhood to adulthood. However, studies of the prevalence over time and implications on educational outcomes are still limited, especially regarding multiple pain symptoms. The present study material consists of questionnaire surveys, completed in 2000 and 2008, including two study populations of 9th grade adolescents aged 15 living in West Sweden (n = 20 877). Pain symptoms and demographic variables were based on self-reports from the questionnaires, and school grades were obtained from Statistics Sweden after the student had finished their 9th grade. Between 2000 and 2008, the prevalence of abdominal pain increased among Swedish adolescents (largest increase in girls); the prevalence of headache increased only in girls; the prevalence of pain in upper body decreased only in boys. School grades were significantly lower among those with headache or abdominal pain. Among students with low school grades (10th percentile) the estimated difference between those having any of the symptoms or none were -27 school grade units (95% confidence interval for girls (-27.8; -26.0), for boys (-27.6; -25.5). Both symptoms being present pronounced the association. Low parental education increased the negative effect of symptoms on school grades, most pronounced in the group with the lowest grades. In conclusion, identification of pain symptoms may improve academic achievements, especially in students with multiple symptoms and with parents having low education. Further intervention studies are need.

Association between sleep duration and musculoskeletal pain: The Korea National Health and Nutrition Examination Survey 2010-2015

Both extremely long and short sleep durations have been associated with increased risk of numerous health problems. This study examined the association between self-reported sleep duration and reporting of musculoskeletal pain in the adult Korean population.This study included data from 17,108 adults aged ≥50 years, obtained from the Korea National Health and Nutrition Examination Survey 2010-2012 and 2013-2015. Self-reported daily hours slept and the presence of musculoskeletal pain in knee joint, hip joint, or low back were examined. Patients were stratified into 5 groups by their sleep duration: ≤5, 6, 7, 8, or ≥9 h. Multivariate logistic regression analysis was performed, adjusting for covariates including age, sex, marital status, smoking, alcohol use, family income level, education, physical exercise, body mass index (BMI), and stress level.A U-shaped relationship was observed between the length of sleep duration and the presence of musculoskeletal pain. After adjusting for covariates, sleep duration of ≤5 h or ≥9 h was significantly associated with musculoskeletal pain experienced for more than 30 days over a 3-month period. We also found that the presence of multi-site musculoskeletal pain was significantly higher among those who slept for ≤5 h or ≥9 h than in those who slept for 7 h.These findings suggest that either short or long sleep duration is associated with musculoskeletal pain among Korean adults.

Musculoskeletal Pelvic Pain and Sexual Function in the First Year After Childbirth

OBJECTIVE

To characterize sexual function in women with and without musculoskeletal pelvic pain during the first year after childbirth.

DESIGN

Cross-sectional descriptive study.

SETTING

Outpatient women's health clinic in a Midwestern U.S. academic medical center.

PARTICIPANTS

Women who gave birth to singleton infants within the past year.

METHODS

Women were recruited from various outpatient settings. We obtained baseline demographic variables and used selected components from the Wilson and Cleary Health-Related Quality of Life model. Participants completed questionnaires related to sexual health, pain symptoms, and general quality of life. They were asked to indicate their pain on a pain diagram and to quantify it with the use of a numeric rating scale (NRS). Examiners used validated examination techniques to assess pelvic floor muscle tenderness, strength, and pelvic girdle pain. Participants who reported pelvic pain and had at least one positive physical examination finding were classified in the pain group.

RESULTS

Forty-five participants completed the study, and 20 participants were in the pain group. Most participants with pain had pelvic girdle pain (n = 15) and pelvic floor myofascial pain (n = 20). Participants with pain reported less sexual satisfaction (t[43] = 2.84, p = .007) and reduced quality of life (t[36] = 5.25, p < .001) compared with participants without pain.

CONCLUSION

Participants who experienced musculoskeletal pelvic pain in the first year after childbirth were significantly more likely to report problems with sexual function compared with their counterparts without pain.

Are Pain Beliefs, Cognitions, and Behaviors Influenced by Race, Ethnicity, and Culture in Patients with Chronic Musculoskeletal Pain: A Systematic Review

BACKGROUND

Chronic pain has been considered as a biopsychosocial condition in which cognitive and emotional factors as well as biological factors significantly affect perception of pain. Race, ethnicity and culture have a crucial impact on illness beliefs, health care preferences, help-seeking behaviors, and acceptance of medical interventions.

OBJECTIVES

The aim of the present study was to systematically review the current evidence regarding the racial, ethnic and cultural alterations and differences in pain beliefs, cognitions, and behaviors in patients with chronic musculoskeletal pain (MSKP).

STUDY DESIGN

Systematic review.

METHODS

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines (PRISMA). PubMed and Web of Science were searched. A first screening was conducted based on title and abstract of the articles. In the second screening, full-texts of the remaining articles were evaluated for the fulfilment of the inclusion criteria. The risk of bias was assessed with the modified Newcastle-Ottawa Scale.

RESULTS

A total of 11 articles were included. The methodological quality of the included studies ranged from low to moderate. There is moderate evidence that African-Americans use more praying, hoping, and emotion-focused coping strategies than Caucasians. There is also preliminary evidence regarding the differences in some coping strategies such as distraction, catastrophizing, and problem-focused solving between African-Americans and Caucasians. Preliminary evidence exists regarding the differences in pain coping strategies between the US and Portugal; the US and Singapore; and among 4 French-speaking countries. It is found that Spanish patients with fibromyalgia (FM) have more negative illness perceptions than Dutch patients. There is preliminary evidence that Caucasians have higher self-efficacy than African-Americans. There is also preliminary evidence that New Zealanders have more internal health expectancies than patients from the US. Preliminary evidence is demonstrated that Caucasians with rheumatoid arthritis (RA) have more positive control beliefs than African-Americans. Lastly, there is preliminary evidence that patients from the US believe that they are more disabled, while Singaporeans interpret the pain more by a traditional biomedical perspective.

LIMITATIONS

Only 11 articles were included. The small number of articles, wide range of assessment methods, and substantial risk of bias in the included studies led the investigator to draw conclusions cautiously.

CONCLUSION

Preliminary to moderate evidence shows the differences in coping strategies, illness perceptions, self-efficacy, fear avoidance beliefs, locus of control, and pain attitudes in different populations. Further prospective and longitudinal studies using standard definitions for race, ethnicity or culture and valid questionnaires for each population are warranted to explore the racial, ethnic and cultural discrepancies in pain beliefs, cognitions, and behaviours.

KEY WORDS

Chronic pain, musculoskeletal pain, pain beliefs, pain cognitions, pain behaviors, race, ethnicity, culture.

Risk factors associated with self-reported musculoskeletal pain among short and long distance industrial gas delivery truck drivers

AIM

This study investigated and compared the associations between self-reported exposures to individual as well as work-related physical and psychosocial risk factors for musculoskeletal (MS) disorders and the prevalence of MS symptoms in different body areas among short- (P&D) and long-distance (Bulk delivery) truck drivers working for the same large gas delivery company in Canada.

METHODS

123 truck drivers nationwide participated in this questionnaire-based cross-sectional study. Univariate and multivariate logistic regression analyses were performed.

RESULTS

43.1% of drivers reported MS pain in at least one body area over the past 12 months and 26.8% over the past 7 days. Bulk drivers had a significantly higher prevalence of MS pain than P&D drivers for both periods. When P&D and Bulk drivers were pooled together, belonging to the Bulk subgroup emerged as the strongest factor for low back pain (OR = 8.45, p = 0.002), for shoulder pain (OR = 3.70, p = 0.027) and for MS pain in any body area (OR = 4.05, p = 0.006). In Bulk drivers "High effort-reward imbalance" was strongly associated with MS pain in any body area (OR = 6.47, p = 0.01), with shoulder pain (OR = 4.95, p = 0.016), and with low back pain (OR = 4.51, p = 0.02). In P&D drivers MS pain in any body area was strongly associated with "Working with hands above shoulders" (OR = 6.58, p = 0.009) and "Whole-body vibration" (OR = 5.48, p = 0.018), while shoulder pain was strongly associated with "Hand-arm vibration" (OR = 7.27, p = 0.041).

CONCLUSIONS

Prevalence of MS pain was higher among industrial gas delivery truck drivers than in the general Quebec male worker population, and higher for Bulk drivers compared to P&D drivers. MS pain in Bulk drivers was mainly associated with psychosocial risk factors and lifestyle; MS pain in P&D drivers was mainly associated with physical risk factors.

Psychometric validation of the Serbian version of the Fear Avoidance Component Scale (FACS)

OBJECTIVE

The Fear Avoidance Components Scale (FACS) is a new patient-reported outcome (PRO) questionnaire designed to comprehensively evaluate fear avoidance (FA) beliefs and attitudes in persons with painful medical conditions. The original English version has demonstrated acceptable psychometric properties, including concurrent and predictive validity. Two factors have been identified: 1. general fear avoidance; and 2. types of activities that are avoided.

METHODS

The FACS was first translated into Serbian, and then psychometrically validated. A cohort of 322 chronic musculoskeletal pain subjects completed the FACS-Serb and additional FA-related patient-reported outcome (PRO) measures. Their FACS-Serb scores were then compared to a cohort of 68 acute pain subjects.

RESULTS

Test-retest reliability (ICC2,1 = 0.928) and internal consistency for both Factors (Cronbach α 0.904 and 0,880 respectively) were very good. An acceptable fit was found with a confirmatory factor analysis of the 2-factor model found with the original English version of the FACS. Strong associations were found among FACS-Serb scores and other PRO measures of pain catastrophizing, depressive/anxiety symptoms, perceived disability, and pain intensity (p<0.001 for all analyses). FACS-Serb total scores, separate Factor scores, and subjective pain ratings were significantly higher in the chronic vs. acute pain cohorts (p<0.001 for all analyses).

CONCLUSIONS

The FACS-Serb demonstrated strong psychometric properties, including strong reliability and internal consistency, criterion validity (through associations with other FA-related PRO measures), and discriminant validity (through comparisons with a separate acute pain cohort). The FACS-Serb appears to be a potentially useful pain-related assessment tool.

Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses

Background

Three main activity patterns have been distinguished in describing chronic pain (avoidance, pacing and persistence). However, their influence on patient outcomes remains a question of debate. This observational study aimed to measure the associations between the avoidance, pacing, and persistence (labelled overdoing) scales of the Patterns of Activity Measure–Pain (POAM-P), self-reported outcomes (pain-interference, depression, functional ability), and observational outcomes (walking, lifting test, physical fitness).

Methods

We conducted an observational study with cross-sectional and longitudinal analyses. The data were collected prospectively before and after treatment, which was a 5-week functional rehabilitation including vocational aspects. In addition to self-reported and observational outcomes, patients were asked if they thought they would be able to return to work at 6 months. Analyses were conducted with treatment effect sizes, correlations, and multiple regression models.

Results

In this sample (891 patients), we found on average small to moderate improvements for pain-interference and observational outcomes (Cohen’s d: 0.37 to 0.64). According to the multivariable models, overdoing was associated with most of the beneficial psychosocial and observational outcomes (β -0.13 to 0.17; all p<0.01). Avoidance was related to negative psychosocial outcomes before treatment (β -0.09 to 0.17; all p<0.015). Pacing, which had moderate correlation with avoidance (r = 0.46), was not associated with most of the outcomes. The feeling that the goal of returning to work was attainable was associated with lower avoidance scores (adjusted OR 0.97; p = 0.024).

Conclusions

The overdoing POAM-P scale probably measures a task-contingent persistence, which appears appropriate in the setting of this study. Persistent behavior was indeed related to small or moderate positive biopsychosocial outcomes, before and after treatment. Moreover feeling able to return to work was related to lower avoidance. Further studies should test the efficacy of motivational strategies that may promote functional task-contingent persistence and reduce avoidance of painful tasks.

Work Outcomes in Patients Who Stay at Work Despite Musculoskeletal Pain

Purpose To assess self-reported work impacts and associations between psychosocial risk factors and work impairment amongst workers seeking care for musculoskeletal pain while continuing to work. Methods Patients were recruited from Musculoskeletal Assessment Clinics at 5 hospitals across Ireland. Participants completed questionnaires including assessments of work impairment (Work Productivity and Activity Impairment Questionnaire), work ability (single item from the Work Ability Index) and work performance (Work Role Functioning Questionnaire; WRFQ). Logistic and hierarchical regressions were conducted to analyse the relation between psychosocial variables and work outcomes. Results 155 participants (53.5% female; mean age = 46.50 years) who were working at the time of assessment completed the questionnaires. Absenteeism was low, yet 62.6% were classified as functioning poorly according to the WRFQ; 52.3% reported having poor work ability. Logistic regression analyses indicated that higher work role functioning was associated with higher pain self-efficacy (OR 1.51); better work ability was associated with older age (OR 1.063) and lower functional restriction (OR 0.93); greater absenteeism was associated with lower pain self-efficacy (OR 0.65) and poorer work expectancy (OR 1.18). Multiple regression analysis indicated that greater presenteeism was associated with higher pain intensity (β = 0.259) and lower pain self-efficacy (β = - 0.385). Conclusions While individuals continue to work with musculoskeletal pain, their work performance can be adversely affected. Interventions that target mutable factors, such as pain self-efficacy, may help reduce the likelihood of work impairment.