1
|
Joyce CT, Roseen EJ, Smith CN, Patterson CG, McDonough CM, Hurstak E, Morone NE, Beneciuk J, Stevans JM, Delitto A, Saper RB. A Cluster Analysis of Initial Primary Care Orders for Patients with Acute Low Back Pain. J Am Board Fam Med 2024; 36:986-995. [PMID: 38182423 DOI: 10.3122/jabfm.2023.230123r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE Primary care physicians (PCPs) often face a complex intersection of patient expectations, evidence, and policy that influences their care recommendations for acute low back pain (aLBP). The purpose of this study was to elucidate patterns of PCP orders for patients with aLBP, identify the most common patterns, and describe patient clinical and demographic characteristics associated with patterns of aLBP care. METHODS This prospective cohort study included 9574 aLBP patients presenting to 1 of 77 primary care practices in 4 geographic locations in the United States. We performed a cluster analysis of PCP orders extracted from electronic health records within the first 21 days of an initial visit for aLBP. RESULTS 1401 (15%) patients did not receive a PCP order related to back pain within the first 21 days of their initial visit. These patients predominantly had aLBP without leg pain, less back-related disability, and were at low-risk for persistent disability. Of the remaining 8146 patients, we found 4 distinct order patterns: combined nonpharmacologic and first-line medication (44%); second-line medication (39%); imaging (10%); and specialty referral (7%). Among all patients, 29% received solely 1 order from their PCP. PCPs more often combined different guideline concordant and discordant orders. Patients with higher self-reported disability and psychological distress were more likely to receive guideline discordant care. CONCLUSION Guideline discordant orders such as steroids and NSAIDS are often combined with guideline recommended orders such as physical therapy. Further defining patient, clinician, and health care setting characteristics associated with discordant care would inform targeted efforts for deimplementation initiatives.
Collapse
Affiliation(s)
- Christopher T Joyce
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS).
| | - Eric J Roseen
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Clair N Smith
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Charity G Patterson
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Christine M McDonough
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Emily Hurstak
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Natalia E Morone
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Jason Beneciuk
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Joel M Stevans
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Anthony Delitto
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| | - Robert B Saper
- From the School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA (CTJ); Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA (EJR, EH, NEM); School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA (CNS, CGP, CMM, JMS, AD); Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States (JB); Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL, United States (JB); Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA (RBS)
| |
Collapse
|
2
|
Griffith G, Lamotte G, Mehta N, Fan P, Nikolich J, Springman V, Suttman E, Joslin E, Balfany K, Dunlap M, Kohrt WM, Christiansen CL, Melanson EL, Josbeno D, Chahine LM, Patterson CG, Corcos DM. Chronotropic Incompetence During Exercise Testing as a Marker of Autonomic Dysfunction in Individuals with Early Parkinson's Disease. J Parkinsons Dis 2024; 14:121-133. [PMID: 38189712 PMCID: PMC10836543 DOI: 10.3233/jpd-230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND An attenuated heart rate response to exercise, termed chronotropic incompetence, has been reported in Parkinson's disease (PD). Chronotropic incompetence may be a marker of autonomic dysfunction and a cause of exercise intolerance in early stages of PD. OBJECTIVE To investigate the relationship between chronotropic incompetence, orthostatic blood pressure change (supine - standing), and exercise performance (maximal oxygen consumption, VO2peak) in individuals with early PD within 5 years of diagnosis not on dopaminergic medications. METHODS We performed secondary analyses of heart rate and blood pressure data from the Study in Parkinson's Disease of Exercise (SPARX). RESULTS 128 individuals were enrolled into SPARX (63.7±9.3 years; 57.0% male, 0.4 years since diagnosis [median]). 103 individuals were not taking chronotropic medications, of which 90 had a normal maximal heart rate response to exercise testing (155.3±14.0 bpm; PDnon-chrono) and 13 showed evidence of chronotropic incompetence (121.3±11.3 bpm; PDchrono, p < 0.05). PDchrono had decreased VO2peak compared to PDnon-chrono (19.7±4.5 mL/kg/min and 24.3±5.8 mL/kg/min, respectively, p = 0.027). There was a positive correlation between peak heart rate during exercise and the change in systolic blood pressure from supine to standing (r = 0.365, p < 0.001). CONCLUSIONS A subgroup of individuals with early PD not on dopaminergic medication had chronotropic incompetence and decreased VO2peak, which may be related to autonomic dysfunction. Evaluation of both heart rate responses to incremental exercise and orthostatic vital signs may serve as biomarkers of early autonomic impairment and guide treatment. Further studies should investigate whether cardiovascular autonomic dysfunction affects the ability to exercise and whether exercise training improves autonomic dysfunction.
Collapse
Affiliation(s)
- Garett Griffith
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Niyati Mehta
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Peng Fan
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Juliana Nikolich
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Victoria Springman
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Erin Suttman
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Elizabeth Joslin
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Katherine Balfany
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Wendy M. Kohrt
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Veterans Affairs Geriatric Research, Education, and Clinical Center, Denver, CO, USA
| | - Cory L. Christiansen
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Veterans Affairs Geriatric Research, Education, and Clinical Center, Denver, CO, USA
| | - Edward L. Melanson
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Veterans Affairs Geriatric Research, Education, and Clinical Center, Denver, CO, USA
| | - Deborah Josbeno
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lana M. Chahine
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Daniel M. Corcos
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| |
Collapse
|
3
|
Hicks GE, George SZ, Pugliese JM, Coyle PC, Sions JM, Piva S, Simon CB, Kakyomya J, Patterson CG. Hip-focused physical therapy versus spine-focused physical therapy for older adults with chronic low back pain at risk for mobility decline (MASH): a multicentre, single-masked, randomised controlled trial. Lancet Rheumatol 2024; 6:e10-e20. [PMID: 38258673 PMCID: PMC10806342 DOI: 10.1016/s2665-9913(23)00267-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Previously, we identified a population of older adults with chronic low back pain, hip pain, and hip muscle weakness who had worse 12-month low back pain and functional outcomes than age-matched adults with only low back pain, indicating an increased risk for future mobility decline. We sought to determine whether tailored, hip-focused physical therapy reduced pain and functional limitations in this high-risk population compared with non-tailored, spine-focused physical therapy. METHODS We did a multicentre, single-masked, randomised controlled trial at three research-based sites in the USA. We recruited older adults (aged 60-85 years) with hip pain and weakness who reported moderate low back pain intensity at least half the days in the last 6 months. Patients were randomly assigned to hip-focused physical therapy or spine-focused physical therapy using permuted blocks with random block size, stratified by site and sex (ie, male or female). The primary outcomes were self-reported disability using the Quebec Back Pain Disability Scale (QBPDS) and performance-based 10-Meter Walk Test (10MWT) at 8 weeks. All analyses were done in the intention-to-treat population. Adverse events were collected by study staff via a possible adverse event reporting form and then adjudicated by site investigators. This trial was registered with ClinicalTrials.gov, NCT04009837. FINDINGS Between Nov 1, 2019, and April 30, 2022, 184 participants were randomly assigned to receive hip-focused (n=91) or spine-focused physical therapy (n=93) interventions. The mean age was 70·7 (SD 6·2) years. 121 (66%) of 184 participants were women, 63 (34%) were men, and 149 (81%) were White. At 8 weeks, the mean between-group difference on the QBPDS was 4·0 (95% CI 0·5 to 7·5), favouring hip-focused physical therapy. Both groups had similar, clinically meaningful gait speed improvements (10MWT) at 8 weeks (mean difference 0·004 m/s [95% CI -0·044 to 0·052]). No serious adverse events were related to study participation. INTERPRETATION Tailored hip-focused physical therapy demonstrated greater improvements in low back pain-related disability at 8 weeks. However, both hip-focused physical therapy and spine-focused physical therapy produced clinically meaningful improvements in disability and function for this high-risk population at 6 months. These findings warrant further investigation before clinical implementation. FUNDING US National Institute on Aging of the National Institutes of Health.
Collapse
Affiliation(s)
- Gregory E Hicks
- Department of Physical Therapy, University of Delaware, Newark, DE, USA.
| | - Steven Z George
- Department of Orthopedic Surgery, Duke Clinical Research Institute, Duke School of Medicine, Durham, NC, USA
| | | | - Peter C Coyle
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - J Megan Sions
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Sara Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Corey B Simon
- Department of Orthopedic Surgery, Duke Clinical Research Institute, Duke School of Medicine, Durham, NC, USA
| | - Joseph Kakyomya
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charity G Patterson
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
4
|
Jones Berkeley SB, Johnson AM, Mormer ER, Ressel K, Pastva AM, Wen F, Patterson CG, Duncan PW, Bushnell CD, Zhang S, Freburger JK. Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010026. [PMID: 38189125 PMCID: PMC10997162 DOI: 10.1161/circoutcomes.123.010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/13/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral. METHODS We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10 702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral. RESULTS Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained. CONCLUSIONS One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
Collapse
Affiliation(s)
- Sara B Jones Berkeley
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Elizabeth R Mormer
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Kristin Ressel
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Amy M Pastva
- Department of Orthopaedic Surgery, Doctor of Physical Therapy Division and Center for the Study of Aging and Human Development, Duke University School of Medicine (A.M.P.)
| | - Fang Wen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Charity G Patterson
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | | | - Shuqi Zhang
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| |
Collapse
|
5
|
Patterson PD, Hilditch CJ, Weaver MD, Roach DGL, Okerman TS, Martin SE, Patterson CG, Weiss LS. The effect of a night shift nap on post-night shift performance, sleepiness, mood, and first recovery sleep: A randomized crossover trial. Scand J Work Environ Health 2024; 50:22-27. [PMID: 37933729 PMCID: PMC10924715 DOI: 10.5271/sjweh.4129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVES This study aimed to test the effect of a 30-minute nap versus a 2-hour nap opportunity taken during a simulated night shift on performance, fatigue, sleepiness, mood, and sleep at the end of shift and during post-night shift recovery. METHODS We conducted a randomized crossover trial of three nap conditions (30-minute, 2-hour, and no-nap) during 12-hour simulated night shifts. We tested for differences in performance, fatigue, sleepiness, mood, and sleep during in-lab and at-home recovery. Performance was measured with the Brief Psychomotor Vigilance Test (PVT-B). Subjective ratings were assessed with single-item surveys. RESULTS Twenty-eight individuals consented to participate [mean age 24.4 (standard deviation 7.2) years; 53.6% female; 85.7% Emergency Medical Services clinicians]. PVT-B false starts at the end of the 12-hour night shift (at 07:00 hours) and at the start of in-lab recovery (08:00 hours) were lower following the 2-hour nap versus other conditions (P<0.05). PVT-B response time at +0 minutes post-recovery nap was poorer compared to pre-recovery nap for the no-nap condition (P=0.003), yet not detected for other nap conditions (P>0.05). Sleepiness, fatigue, and some mood states were lower at most hourly assessments during the in-lab recovery period following the 2-hour nap condition compared to the other conditions. Sleep during recovery did not differ by duration of night shift nap. CONCLUSIONS A 2-hour nap opportunity versus a 30-minute or no-nap opportunity is beneficial for performance, alertness, and mood post-night shift. No differences were detected in sleep during recovery.
Collapse
Affiliation(s)
- P Daniel Patterson
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, 3600 Forbes Ave., Iroquois Building, Suite 400A, Pittsburgh, PA 15261.
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Surkar SM, Willson JD, Cassidy JM, Kantak S, Patterson CG. Remote ischaemic conditioning combined with bimanual task training to enhance bimanual skill learning and corticospinal excitability in children with unilateral cerebral palsy: a study protocol of a single centre, phase II randomised controlled trial. BMJ Open 2023; 13:e076881. [PMID: 37770277 PMCID: PMC10546168 DOI: 10.1136/bmjopen-2023-076881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/22/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Children with unilateral cerebral palsy (UCP) have difficulty in bimanual coordination that restricts the child's independence in daily activities. Although several efficacious interventions to improve bimanual coordination exist, these interventions often require higher training doses and have modest effect sizes. Thus, there is a critical need to find an effective priming agent that, when paired with task-specific training, will facilitate neurobiological processes to enhance the magnitude of training effects and subsequently improve functional capabilities of children with UCP. The aim of this study is to determine the effects of a novel priming agent, remote ischaemic conditioning (RIC), combined with bimanual training on bimanual skill learning and corticospinal excitability in children with UCP. METHODS AND ANALYSES 46 children, aged 8-16 years, will be randomly assigned to receive RIC or sham conditioning combined with 5 days of bimanual skill (cup stacking) training (15 trials per session). RIC or sham conditioning will be performed with a standard conditioning protocol of five cycles of alternative inflation and deflation of a pressure cuff on the affected arm with the pressure of at least 20 mm Hg above systolic blood pressure for RIC and 25 mm Hg for sham conditioning. Primary outcomes will be movement time and corticospinal excitability measures determined with a single-pulse transcranial magnetic stimulation (TMS). Secondary outcomes include Assisting Hand Assessment, spatio-temporal kinematic variables and paired pulse TMS measures. All measures will be conducted before and immediately after the intervention. A mixed model analysis of variance will test the group×time interaction for all outcomes with group (RIC and sham) as between-subject and time (preintervention, postintervention) as within-subject factors. ETHICS AND DISSEMINATION The study has been approved by the University Medical Centre Institutional Review Board (UMCIRB #21-001913). We will disseminate the study findings via peer-reviewed publications and presentations at professional conferences. TRIAL REGISTRATION NUMBER NCT05777070.
Collapse
Affiliation(s)
- Swati M Surkar
- Physical Therapy, East Carolina University, Greenville, North Carolina, USA
| | - John D Willson
- Physical Therapy, East Carolina University, Greenville, North Carolina, USA
| | - Jessica M Cassidy
- Department of Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shailesh Kantak
- Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
- Department of Rehabilitation Medicine, Moss Rehabilitation Research Institute, Philadelphia, PA, USA
| | - Charity G Patterson
- Department of Physical Therapy and School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
7
|
Gardas SS, Lysaght C, McMillan AG, Kantak S, Willson JD, Patterson CG, Surkar SM. Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy. Behav Sci (Basel) 2023; 13:681. [PMID: 37622821 PMCID: PMC10451828 DOI: 10.3390/bs13080681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
The purpose of this study was to quantify characteristics of bimanual movement intensity during 30 h of hand-arm bimanual intensive therapy (HABIT) and bimanual performance (activities and participation) in real-world settings using accelerometers in children with unilateral cerebral palsy (UCP). Twenty-five children with UCP participated in a 30 h HABIT program. Data were collected from bilateral wrist-worn accelerometers during 30 h of HABIT to quantify the movement intensity and three days pre- and post-HABIT to assess real-world performance gains. Movement intensity and performance gains were measured using six standard accelerometer-derived variables. Bimanual capacity (body function and activities) was assessed using standardized hand function tests. We found that accelerometer variables increased significantly during HABIT, indicating increased bimanual symmetry and intensity. Post-HABIT, children demonstrated significant improvements in all accelerometer metrics, reflecting real-world performance gains. Children also achieved significant and clinically relevant changes in hand capacity following HABIT. Therefore, our findings suggest that accelerometers can objectively quantify bimanual movement intensity during HABIT. Moreover, HABIT enhances hand function as well as activities and participation in real-world situations in children with UCP.
Collapse
Affiliation(s)
- Shailesh S. Gardas
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Christine Lysaght
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Amy Gross McMillan
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Shailesh Kantak
- Moss Rehabilitation Research Institute, Elkins Park, PA 19027, USA
- Department of Physical Therapy, Arcadia University, Glenside, PA 19038, USA
| | - John D. Willson
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| | - Charity G. Patterson
- Department of Physical Therapy and School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Swati M. Surkar
- Department of Physical Therapy, East Carolina University, Greenville, NC 27834, USA; (S.S.G.); (C.L.); (A.G.M.); (J.D.W.)
| |
Collapse
|
8
|
Patterson PD, Okerman TS, Roach DGL, Hilditch CJ, Weaver MD, Patterson CG, Sheffield MA, Di Salvatore JS, Bernstein H, Georges G, Andreozzi A, Willson CM, Jain D, Martin SE, Weiss LS. Are Short Duration Naps Better than Long Duration Naps for Mitigating Sleep Inertia? Brief Report of a Randomized Crossover Trial of Simulated Night Shift Work. PREHOSP EMERG CARE 2023; 27:807-814. [PMID: 37347968 DOI: 10.1080/10903127.2023.2227696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/02/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE We sought to test the effects of different duration naps on post-nap cognitive performance during simulated night shifts. METHODS We used a randomized laboratory-based crossover trial design with simulated 12-hr night shifts and each participant completing three conditions of 72 hrs each (Clinicaltrials.gov; registration # NCT04469803). The three conditions tested included no-nap, a 30-min nap opportunity, and a 2-hr nap opportunity. Naps occurred at 02:00 hrs. Cognitive performance was assessed with the Brief 3-min Psychomotor Vigilance Test (PVT-B). Four PVT-B measures include: reaction time (RT in milliseconds (ms)), lapses (RT > 355 ms), false starts (reactions before stimulus or RT <100 ms), and speed (1,000/RT). The PVT-B was performed at the start of the simulated night shift (19:00), end of shift (07:00), pre-nap (02:00), and at 0 mins, 10 mins, 20 mins, and 30 mins following the 30-min and 2-hr nap conditions. Simultaneously, participants reported subjective ratings of fatigue and other constructs. RESULTS Twenty-eight (15 female), mostly certified emergency medical technicians or paramedics, consented to participate. For all three conditions, looking within condition, PVT-B lapse performance at the end of the 12-hr simulated night shift (at 07:00) was poorer compared to shift start (p < 0.05). Performance on PVT-B speed, RT, and false starts were poorer at shift end than shift start for the no-nap and 30-min nap conditions (p < 0.05), but not for the 2-hr nap condition (p > 0.05). Compared to pre-nap measures, performance on the PVT-B assessed at 0 mins post-nap showed significant performance declines for lapses and speed for both the 30-min and 2-hr nap conditions (p < 0.05), but not at 10, 20, or 30 mins post-nap. After waking from the 2-hr on-shift nap opportunity (at 0 mins), participants rated sleepiness, difficulty with concentration, and alertness poorer than pre-nap (p < 0.05). Participants in the 30-min nap condition rated alertness poorer immediately after the nap (at 0 mins) compared to pre-nap (p < 0.05). CONCLUSIONS While sleep inertia was detectable immediately following short 30-min and long 2-hr nap opportunities during simulated night shift work, deficits in cognitive performance and subjective ratings quickly dissipated and were not detectable at 10-30 mins post-nap.
Collapse
Affiliation(s)
- P Daniel Patterson
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Department of Rehabilitation Sciences and Technology, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tiffany S Okerman
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David G L Roach
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Graduate School of Public Health, Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cassie J Hilditch
- Fatigue Countermeasures Laboratory, San José State University, San José, California
| | - Matthew D Weaver
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Charity G Patterson
- School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark A Sheffield
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jillian S Di Salvatore
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Department of Rehabilitation Sciences and Technology, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Haley Bernstein
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - George Georges
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - April Andreozzi
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cameron M Willson
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Disha Jain
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah E Martin
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leonard S Weiss
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
9
|
Patterson PD, Okerman TS, Roach DGL, Weaver MD, Patterson CG, Martin SE, Okwiya N, Nong L, Eyiba C, Huff JR, Ruzicka A, Ruggieri J, McIlvaine Q, Weiss LS. Effect of Short versus Long Duration Naps on Blood Pressure during Simulated Night Shift Work: A Randomized Crossover Trial. PREHOSP EMERG CARE 2023; 27:815-824. [PMID: 37347964 DOI: 10.1080/10903127.2023.2227891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/02/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE Blunting of the sleep-related dip in blood pressure (BP) has been linked to numerous cardiovascular outcomes including myocardial infarction. Blunting of BP dipping occurs during night shift work and previous research suggest that a 60-min or longer on-shift nap is needed to restore normal/healthy BP dipping. We sought to determine the effect of different durations of napping on BP during and following simulated night shifts. We hypothesized that the greatest benefit in terms of restoration of normal BP dipping during night shift work would be observed during a longer duration nap versus a shorter nap opportunity. METHODS We used a randomized crossover laboratory-based study design. Participants consented to complete three separate 72-hr conditions that included a 12-hr simulated night shift. Nap conditions included a 30-min and 2-hr nap compared to a no-nap condition. Ambulatory BP monitoring was assessed hourly and every 10-30 mins during in-lab naps. Blunted BP dipping during in-lab naps was the primary outcome. Goal enrollment of 25 (35 with attrition) provided 80% power to detect a mean difference of 5 mmHg in BP between nap conditions. RESULTS Of the 58 screened, 28 were consented, and 26 completed all three 72-hr conditions. More than half (53.6%) were female. Mean age was 24.4 years (SD7.2). Most (85.7%) were certified as emergency medical technicians or paramedics. The mean percentage dip in systolic BP (SBP) and diastolic BP (DBP) did not differ between the 30-min and 2-hr nap conditions (p > 0.05), yet a greater proportion of participants experienced a 10-20% dip in SBP or DBP during the 2-hr nap versus the 30-min nap (p < 0.05). For every additional minute of total sleep during the 30-min nap, the percentage of SBP dip improved by 0.60%, and the percentage of DBP dip improved by 0.68% (p < 0.05). These improvements approximate to a 6% per minute relative advancement toward normal/healthy BP dipping. CONCLUSIONS Restoration of a normal/healthy dip in BP is achievable during short and long duration nap opportunities during simulated night shift work. Our findings support the hypothesis that BP dipping is more common during longer 2-hr versus shorter 30-min naps. TRIAL REGISTRATION ClinicalTrials.gov, NCT04469803. Registered on 9 July 2020.
Collapse
Affiliation(s)
- P Daniel Patterson
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tiffany S Okerman
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David G L Roach
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew D Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Charity G Patterson
- School of Health and Rehabilitation Sciences, SHRS Data Center, and Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah E Martin
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nicholas Okwiya
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lily Nong
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chinemeh Eyiba
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jordan R Huff
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anna Ruzicka
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julia Ruggieri
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Quentin McIlvaine
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- School of Health and Rehabilitation Sciences, Emergency Medicine Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leonard S Weiss
- School of Medicine, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
10
|
Elbin RJ, Trbovich A, Womble MN, Mucha A, Fedor S, Stephenson K, Holland C, Dollar C, Sparto P, Durfee K, Patterson CG, Smith CN, Huppert TJ, Okonkwo DO, Collins MW, Kontos AP. Targeted multidomain intervention for complex mTBI: protocol for a multisite randomized controlled trial in military-age civilians. Front Neurol 2023; 14:1085662. [PMID: 37456641 PMCID: PMC10349652 DOI: 10.3389/fneur.2023.1085662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Background Mild traumatic brain injury (mTBI) affects ~18,000 military personnel each year, and although most will recover in 3-4 weeks, many experience persisting symptoms and impairment lasting months or longer. Current standard of care for U.S. military personnel with complex mTBI involves initial (<48 h) prescribed rest, followed by behavioral (e.g., physical activity, sleep regulation, stress reduction, hydration, nutrition), and symptom-guided management. There is growing agreement that mTBI involves different clinical profiles or subtypes that require a comprehensive multidomain evaluation and adjudication process, as well as a targeted approach to treatment. However, there is a lack of research examining the effectiveness of this approach to assessing and treating mTBI. This multisite randomized controlled trial (RCT) will determine the effectiveness of a targeted multidomain (T-MD) intervention (anxiety/mood, cognitive, migraine, ocular, vestibular; and sleep, autonomic) compared to usual care (behavioral management) in military-aged civilians with complex mTBI. Methods This study employs a single-blinded, two-group repeated measures design. The RCT will enroll up to 250 military-aged civilians (18-49 yrs) with a diagnosed complex mTBI within 8 days to 6 months of injury from two concussion specialty clinics. The two study arms are a T-MD intervention and a usual care, behavioral management control group. All participants will complete a comprehensive, multidomain clinical evaluation at their first clinical visit. Information gathered from this evaluation will be used to adjudicate mTBI clinical profiles. Participants will then be randomized to either the 4-week T-MD or control arm. The T-MD group will receive targeted interventions that correspond to the patient's clinical profile (s) and the control group will receive behavioral management strategies. Primary outcomes for this study are changes from enrollment to post-intervention on the Neurobehavioral Symptom Inventory (NSI), Patient Global Impression of Change (PGIC), and functional near-infrared spectroscopy (fNIRS). Time to return to activity (RTA), and healthcare utilization costs will also be assessed. Discussion Study findings may inform a more effective approach to treat complex mTBI in military personnel and civilians, reduce morbidity, and accelerate safe return-to-duty/activity. Ethics and dissemination The study is approved by the University of Pittsburgh Institutional Review board and registered at clinicaltrials.gov. Dissemination plans include peer-reviewed publications and presentations at professional meetings. Clinical Trial Registration www.clinicaltrials.gov, identifier: NCT04549532.
Collapse
Affiliation(s)
- R. J. Elbin
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, United States
| | - Alicia Trbovich
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Melissa N. Womble
- Inova Sports Medicine Concussion Program, Fairfax, VA, United States
| | - Anne Mucha
- UPMC Centers for Rehab Services, Pittsburgh, PA, United States
| | - Sheri Fedor
- Inova Physical Therapy Center, Fairfax, VA, United States
| | - Katie Stephenson
- College of Osteopathic Medicine, University of New England, Biddeford, ME, United States
| | - Cyndi Holland
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Christina Dollar
- Inova Sports Medicine Concussion Program, Fairfax, VA, United States
| | - Patrick Sparto
- School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kori Durfee
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, United States
| | - Charity G. Patterson
- School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Clair N. Smith
- School of Health and Rehabilitation Sciences, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Theodore J. Huppert
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - David O. Okonkwo
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Michael W. Collins
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anthony P. Kontos
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| |
Collapse
|
11
|
Roseen EJ, Smith CN, Essien UR, Cozier YC, Joyce C, Morone NE, Phillips RS, Gergen Barnett K, Patterson CG, Wegener ST, Brennan GP, Delitto A, Saper RB, Beneciuk JM, Stevans JM. Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study. Pain Med 2023; 24:633-643. [PMID: 36534910 PMCID: PMC10233486 DOI: 10.1093/pm/pnac193] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/07/2022] [Accepted: 11/17/2022] [Indexed: 10/20/2023]
Abstract
OBJECTIVE We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). METHODS In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. RESULTS We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively). CONCLUSIONS We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. CLINICALTRIALS.GOV IDENTIFIER NCT02647658.
Collapse
Affiliation(s)
- Eric J Roseen
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Department of Rehabilitation Sciences, MGH Institute for Health Professions, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Clair N Smith
- University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, USA
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yvette C Cozier
- Slone Epidemiology Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Christopher Joyce
- School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts, USA
| | - Natalia E Morone
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Russell S Phillips
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Katherine Gergen Barnett
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Charity G Patterson
- University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gerard P Brennan
- Department of Physical Therapy, Intermountain Healthcare Rehabilitation Services, Murray, Utah, USA
| | - Anthony Delitto
- University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, USA
| | - Robert B Saper
- Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jason M Beneciuk
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville, Florida, USA
| | - Joel M Stevans
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville, Florida, USA
| |
Collapse
|
12
|
Jones SB, Johnson AM, Mormer ER, Ressel KE, Pastva AM, Wen M, Patterson CG, Duncan PW, Bushnell CD, Freburger JK. Abstract P471: Predictors of Referral to Community-Based Rehabilitation Following Stroke. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Background:
While several studies have examined care transitions following stroke, few have assessed use of rehabilitation. We explored factors predictive of referral to community-based rehabilitation following stroke.
Setting:
40 NC acute care hospitals that participated in the COMprehensive Post-Acute Stroke Services study from 2016-2019.
Participants:
Adults discharged home following stroke or TIA (N=11,195)
Methods:
Guided by an a priori conceptual framework, 41 predictors of referral to community-based rehabilitation were grouped into 3 patient-level domains: demographics, stroke severity, and medical history (e.g., prior stroke); 2 hospital-level domains: structural characteristics (e.g., bed size) and stroke-specific characteristics (e.g., stroke center status); and 1 community-level domain (county-level therapist supply). We estimated predictors of referral using a logistic mixed model with a hospital-specific random effect. We used a hierarchical backward selection approach, first performing domain-specific model selection, then entering retained variables into a complete model.
Results:
The cohort was 49% female, 72% white, with a mean age of 66.8 (SD=14.0) years and overall low stroke severity [mean [SD] NIHSS 2.4 [3.8]). Thirty-six percent of patients were referred to rehabilitation. Referral varied across hospitals, ranging from 3-78%, with a median of 35%. In the final model, older age, female sex, non-white race, higher stroke severity, longer length of stay, previous stroke, current smoking, and heart failure were associated with higher odds of referral as was hospital-employed vs. external-contracted OT services (Table).
Discussion:
Approximately one-third of stroke survivors discharged home were referred to community-based rehabilitation. Women and non-white patients had higher odds of referral. Hospital and community factors were largely not independent predictors of referral. Unmeasured process measures may play a role in unexplained hospital variation.
Collapse
Affiliation(s)
| | | | | | | | | | - Molly Wen
- Univ of North Carolina, Chapel Hill, NC
| | | | - Pamela W Duncan
- Atrium Health Wake Forest Baptist Med Cntr, Winston Salem, NC
| | | | | |
Collapse
|
13
|
Patterson PD, Martin SE, Brassil BN, Hsiao WH, Weaver MD, Okerman TS, Seitz SN, Patterson CG, Robinson K. The Emergency Medical Services Sleep Health Study: A cluster-randomized trial. Sleep Health 2023; 9:64-76. [PMID: 36372657 DOI: 10.1016/j.sleh.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Greater than half of emergency medical services (EMS) clinician shift workers report poor sleep, fatigue, and inadequate recovery between shifts. We hypothesized that EMS clinicians randomized to receive tailored sleep health education would have improved sleep quality and less fatigue compared to wait-list controls after 3 months. METHODS We used a cluster-randomized, 2-arm, wait-list control study design (clinicaltrials.gov identifier: NCT04218279). Recruitment of EMS agencies (clusters) was nationwide. Our study was powered at 88% to detect a 0.4 standard deviation difference in sleep quality with 20 agencies per arm and a minimum of 10 individuals per agency. The primary outcome was measured using the Pittsburgh Sleep Quality Index (PSQI) at 3-month follow-up. Our intervention was accessible in an online, asynchronous format and comprised of 10 brief education modules that address fatigue mitigation topics prescribed by the American College of Occupational Environmental Medicine. RESULTS In total, 36 EMS agencies and 678 individuals enrolled. Attrition at 3 months did not differ by study group (Intervention = 17.4% vs. Wait-list control = 18.2%; p = .37). Intention-to-treat analyses detected no differences in PSQI and fatigue scores at 3 months. Per protocol analyses showed the greater the number of education modules viewed, the greater the improvement in sleep quality and the greater the reduction in fatigue (p < .05). CONCLUSIONS While intention-to-treat analyses revealed no differences in sleep quality or fatigue at 3 months, per protocol findings identified select groups of EMS clinician shift workers who may benefit from sleep health education. Our findings may inform fatigue risk management programs.
Collapse
Affiliation(s)
- P Daniel Patterson
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA; University of Pittsburgh, School of Health and Rehabilitation Sciences, Division of Community Health Services, Emergency Medicine Program, Pittsburgh, Pennsylvania, USA.
| | - Sarah E Martin
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Bridget N Brassil
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Wei-Hsin Hsiao
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew D Weaver
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Boston, Massachusetts, USA; Harvard Medical School, Division of Sleep Medicine, Boston, Massachusetts, USA
| | - Tiffany S Okerman
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Staci N Seitz
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Charity G Patterson
- University of Pittsburgh, School of Health and Rehabilitation Sciences, Department of Physical Therapy, Pittsburgh, Pennsylvania, USA
| | - Kathy Robinson
- National Association of State EMS Officials (NASEMSO), Falls Church, Virginia, USA
| |
Collapse
|
14
|
Batorsky A, Bowden AE, Darwin J, Fields AJ, Greco CM, Harris RE, Hue TF, Kakyomya J, Mehling W, O'Neill C, Patterson CG, Piva SR, Sollmann N, Toups V, Wasan AD, Wasserman R, Williams DA, Vo NV, Psioda MA, McCumber M. The BACPAC Research Program Data Harmonization: Rationale for Data Elements and Standards. Pain Med 2023:7017526. [PMID: 36721327 DOI: 10.1093/pm/pnad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE One aim of the Back Pain Consortium (BACPAC) Research Program is to develop an integrated model of chronic low back pain that is informed by combined data from translational research and clinical trials. We describe efforts to maximize data harmonization and accessibility to facilitate Consortium-wide analyses. METHODS Consortium-wide working groups established harmonized data elements to be collected in all studies and developed standards for tabular and non-tabular data (e.g., imaging and omics). The BACPAC Data Portal was developed to facilitate research collaboration across the Consortium. RESULTS Clinical experts developed the BACPAC Minimum Dataset with required domains and outcome measures to be collected using questionnaires across projects. Other non-required domain-specific measures are collected by multiple studies. To optimize cross-study analyses, a modified data standard was developed based on the Clinical Data Interchange Standards Consortium Study Data Tabulation Model to harmonize data structures and facilitate integration of baseline characteristics, participant-reported outcomes, chronic low back pain treatments, clinical exam, functional performance, psychosocial characteristics, quantitative sensory testing, imaging and biomechanical data. Standards to accommodate the unique features of chronic low back pain data were adopted. Research units submit standardized study data to the BACPAC Data Portal, developed as a secure cloud-based central data repository and computing infrastructure for researchers to access and conduct analyses on data collected by or acquired for BACPAC. CONCLUSIONS BACPAC harmonization efforts and data standards serve as an innovative model for data integration that could be used as a framework for other consortia with multiple, decentralized research programs.
Collapse
Affiliation(s)
- Anna Batorsky
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anton E Bowden
- Department of Mechanical Engineering, Brigham Young University, Provo, UT, USA
| | - Jessa Darwin
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aaron J Fields
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Trisha F Hue
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Joseph Kakyomya
- School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wolf Mehling
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Conor O'Neill
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Charity G Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA.,School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sara R Piva
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nico Sollmann
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA.,Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany.,Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vincent Toups
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ronald Wasserman
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Back and Pain Center, University of Michigan, Ann Arbor, MI, USA
| | - David A Williams
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Internal Medicine-Rheumatology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nam V Vo
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Ferguson Laboratory for Orthopaedic and Spine Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew A Psioda
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Micah McCumber
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
15
|
Vo NV, Piva SR, Patterson CG, McKernan GP, Zhou L, Bell KM, Anderst W, Greco CM, Schneider MJ, Delitto A, Dicianno BE, Darwin J, Sowa GA. Toward the Identification of Distinct Phenotypes: Research Protocol for the Low Back Pain Biological, Biomechanical, and Behavioral (LB3P) Cohort Study and the BACPAC Mechanistic Research Center at the University of Pittsburgh. Pain Med 2023:7009238. [PMID: 36715642 PMCID: PMC10403299 DOI: 10.1093/pm/pnad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/15/2022] [Accepted: 01/17/2023] [Indexed: 01/31/2023]
Abstract
As a member of the Back Pain Consortium (BACPAC), the University of Pittsburgh Mechanistic Research Center's research goal is to phenotype chronic low back pain using biological, biomechanical, and behavioral domains using a prospective, observational cohort study. Data will be collected from 1,000 participants with chronic low back pain according to BACPAC-wide harmonized and study-specific protocols. Participation lasts 12 months with one required in person baseline visit, an optional second in person visit for advanced biomechanical assessment, and electronic follow ups at months 1, 2, 3, 4, 5, 6, 9, and 12 to assess low back pain status and response to prescribed treatments. Behavioral data analysis includes a battery of patient-reported outcomes, social determinants of health, quantitative sensory testing, and physical activity. Biological data analysis includes omics generated from blood, saliva, and spine tissue. Biomechanical data analysis includes a physical examination, lumbopelvic kinematics, and intervertebral kinematics. The statistical analysis includes traditional unsupervised machine learning approaches to categorize participants into groups and determine the variables that differentiate patients. Additional analysis includes the creation of a series of decision rules based on baseline measures and treatment pathways as inputs to predict clinical outcomes. The characteristics identified will contribute to future studies to assist clinicians in designing a personalized, optimal treatment approach for each patient.
Collapse
Affiliation(s)
- Nam V Vo
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,Ferguson Laboratory for Orthopaedic and Spine Research, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sara R Piva
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Charity G Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Gina P McKernan
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Leming Zhou
- Department of Health Information Management, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Kevin M Bell
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - William Anderst
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Carol M Greco
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA.,Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael J Schneider
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Delitto
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Brad E Dicianno
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA.,Human Engineering Research Laboratories, Department of Veterans Affairs, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Rehabilitation and Technology, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Jessa Darwin
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gwendolyn A Sowa
- Ferguson Laboratory for Orthopaedic and Spine Research, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
16
|
Johari K, Kelley RM, Tjaden K, Patterson CG, Rohl AH, Berger JI, Corcos DM, Greenlee JDW. Human subthalamic nucleus neurons differentially encode speech and limb movement. Front Hum Neurosci 2023; 17:962909. [PMID: 36875233 PMCID: PMC9983637 DOI: 10.3389/fnhum.2023.962909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN), which consistently improves limb motor functions, shows mixed effects on speech functions in Parkinson's disease (PD). One possible explanation for this discrepancy is that STN neurons may differentially encode speech and limb movement. However, this hypothesis has not yet been tested. We examined how STN is modulated by limb movement and speech by recording 69 single- and multi-unit neuronal clusters in 12 intraoperative PD patients. Our findings indicated: (1) diverse patterns of modulation in neuronal firing rates in STN for speech and limb movement; (2) a higher number of STN neurons were modulated by speech vs. limb movement; (3) an overall increase in neuronal firing rates for speech vs. limb movement; and (4) participants with longer disease duration had higher firing rates. These data provide new insights into the role of STN neurons in speech and limb movement.
Collapse
Affiliation(s)
- Karim Johari
- Human Neurophysiology and Neuromodulation Lab, Department of Communication Science and Disorders, Louisiana State University, Baton Rouge, LA, United States.,Department of Neurosurgery, The University of Iowa, Iowa City, IA, United States
| | - Ryan M Kelley
- Medical Scientist Training Program, The University of Iowa, Iowa City, IA, United States.,Program in Neuroscience, The University of Iowa, Iowa City, IA, United States
| | - Kris Tjaden
- Department of Communicative Disorders and Sciences, University at Buffalo, Buffalo, NY, United States
| | - Charity G Patterson
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Andrea H Rohl
- Department of Neurosurgery, The University of Iowa, Iowa City, IA, United States
| | - Joel I Berger
- Department of Neurosurgery, The University of Iowa, Iowa City, IA, United States
| | - Daniel M Corcos
- Department of Physical Therapy & Human Movement Sciences, Northwestern University, Chicago, IL, United States
| | - Jeremy D W Greenlee
- Department of Neurosurgery, The University of Iowa, Iowa City, IA, United States.,Program in Neuroscience, The University of Iowa, Iowa City, IA, United States.,Iowa Neuroscience Institute, Iowa City, IA, United States
| |
Collapse
|
17
|
Thomas DG, Erpenbach H, Hickey RW, Waltzman D, Haarbauer-Krupa J, Nelson LD, Patterson CG, McCrea MA, Collins MW, Kontos AP. Implementation of active injury management (AIM) in youth with acute concussion: A randomized controlled trial. Contemp Clin Trials 2022; 123:106965. [PMID: 36252936 PMCID: PMC10924688 DOI: 10.1016/j.cct.2022.106965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/10/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents. OBJECTIVE To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response. METHODS This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days. CONCLUSION Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.
Collapse
Affiliation(s)
- D G Thomas
- Medical College of Wisconsin, Department of Pediatrics, United States of America.
| | - H Erpenbach
- Medical College of Wisconsin, Department of Pediatrics, United States of America
| | - R W Hickey
- University of Pittsburgh, Department of Pediatrics, United States of America
| | - D Waltzman
- Centers for Disease Control and Prevention, United States of America
| | - J Haarbauer-Krupa
- Centers for Disease Control and Prevention, United States of America
| | - L D Nelson
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - C G Patterson
- University of Pittsburgh, Department of Physical Therapy, United States of America
| | - M A McCrea
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - M W Collins
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
| | - A P Kontos
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
| |
Collapse
|
18
|
Ludden T, O’Hare K, Shade L, Reeves K, Patterson CG, Tapp H. Implementation of Coach McLungsSM into primary care using a cluster randomized stepped wedge trial design. BMC Med Inform Decis Mak 2022; 22:285. [PMID: 36333727 PMCID: PMC9636750 DOI: 10.1186/s12911-022-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background Asthma is a prevalent chronic disease that is difficult to manage and associated with marked disparities in outcomes. One promising approach to addressing disparities is shared decision making (SDM), a method by which the patient and provider cooperatively make a decision about asthma care. SDM is associated with improved outcomes for patients; however, time constraints and staff availability are noted implementation barriers. Use of health information technology (IT) solutions may facilitate the utilization of SDM. Coach McLungsSM is a collaborative web-based application that involves pediatric patients, their caregivers, and providers in a personalized experience while gathering patient-reported data. Background logic provides decision support so both audiences can develop a well-informed treatment plan together. The goal of this study is to evaluate the implementation of the Coach McLungsSM intervention into primary care. Methods Implementation will be evaluated using a stepped wedge randomized control study design at 21 pediatric and family medicine practices within a large, integrated, nonprofit healthcare system. We will measure changes in emergency department visits, hospitalizations, and oral steroid use, which serve as surrogate measures for patient-centered asthma outcomes. We will use a generalized linear mixed models with logit link to test the hypothesis for the reduction in exacerbation rates specifying the fixed effects of intervention and time and random effects for practice and practice*time. This design achieves 84% power to detect the hypothesized effect size difference of 10% in overall exacerbation between control (40%) and intervention (30%) periods (two-sided, p = 0.05). Implementation will be guided using the Expert Recommendations for Implementing Change (ERIC), a compilation of implementation strategies, and evaluated using the CFIR (Consolidated Framework for Implementation Research) and RE-AIM (Reach Effectiveness, Adoption, Implementation, Maintenance). Discussion We anticipate that a tailored implementation of Coach McLungsSM across diverse primary care practices will lead to a decrease in emergency department visits, hospitalizations, and oral steroid use for patients in the intervention group as compared to the control condition. Trial Registration: Clincaltrials.gov, NCT05059210. Registered 28 September 2021, https://www.clinicaltrials.gov/ct2/show/NCT05059210 Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-02030-1.
Collapse
|
19
|
Patterson CG, Joslin E, Gil AB, Spigle W, Nemet T, Chahine L, Christiansen CL, Melanson E, Kohrt WM, Mancini M, Josbeno D, Balfany K, Griffith G, Dunlap MK, Lamotte G, Suttman E, Larson D, Branson C, McKee KE, Goelz L, Poon C, Tilley B, Kang UJ, Tansey MG, Luthra N, Tanner CM, Haus JM, Fantuzzi G, McFarland NR, Gonzalez-Latapi P, Foroud T, Motl R, Schwarzschild MA, Simuni T, Marek K, Naito A, Lungu C, Corcos DM. Study in Parkinson's disease of exercise phase 3 (SPARX3): study protocol for a randomized controlled trial. Trials 2022; 23:855. [PMID: 36203214 PMCID: PMC9535216 DOI: 10.1186/s13063-022-06703-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To date, no medication has slowed the progression of Parkinson's disease (PD). Preclinical, epidemiological, and experimental data on humans all support many benefits of endurance exercise among persons with PD. The key question is whether there is a definitive additional benefit of exercising at high intensity, in terms of slowing disease progression, beyond the well-documented benefit of endurance training on a treadmill for fitness, gait, and functional mobility. This study will determine the efficacy of high-intensity endurance exercise as first-line therapy for persons diagnosed with PD within 3 years, and untreated with symptomatic therapy at baseline. METHODS This is a multicenter, randomized, evaluator-blinded study of endurance exercise training. The exercise intervention will be delivered by treadmill at 2 doses over 18 months: moderate intensity (4 days/week for 30 min per session at 60-65% maximum heart rate) and high intensity (4 days/week for 30 min per session at 80-85% maximum heart rate). We will randomize 370 participants and follow them at multiple time points for 24 months. The primary outcome is the Movement Disorders Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) motor score (Part III) with the primary analysis assessing the change in MDS-UPDRS motor score (Part III) over 12 months, or until initiation of symptomatic antiparkinsonian treatment if before 12 months. Secondary outcomes are striatal dopamine transporter binding, 6-min walk distance, number of daily steps, cognitive function, physical fitness, quality of life, time to initiate dopaminergic medication, circulating levels of C-reactive protein (CRP), and brain-derived neurotrophic factor (BDNF). Tertiary outcomes are walking stride length and turning velocity. DISCUSSION SPARX3 is a Phase 3 clinical trial designed to determine the efficacy of high-intensity, endurance treadmill exercise to slow the progression of PD as measured by the MDS-UPDRS motor score. Establishing whether high-intensity endurance treadmill exercise can slow the progression of PD would mark a significant breakthrough in treating PD. It would have a meaningful impact on the quality of life of people with PD, their caregivers and public health. TRIAL REGISTRATION ClinicalTrials.gov NCT04284436 . Registered on February 25, 2020.
Collapse
Affiliation(s)
- Charity G. Patterson
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Elizabeth Joslin
- Department of Physical Therapy and Human Science, Northwestern University, Feinberg School of Medicine, Suite 1100, 645 North Michigan Avenue, Chicago, IL 60305 USA
| | - Alexandra B. Gil
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Wendy Spigle
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Todd Nemet
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Lana Chahine
- Department of Neurology, University of Pittsburgh, School of Medicine, 3471 Fifth Avenue, Pittsburgh, PA 15213 USA
| | - Cory L. Christiansen
- Department of Physical Medicine & Rehabilitation, University of Colorado, School of Medicine, Aurora, CO 80217 USA
| | - Ed Melanson
- Division of Endocrinology, Metabolism and Diabetes, and Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- Eastern Colorado VA Health Care System, Geriatric Research Education and Clinical Center (GRECC), Denver, CO USA
| | - Wendy M. Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- Eastern Colorado Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional VAMC, Aurora, USA
| | - Martina Mancini
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Road, Portland, OR 97219 USA
| | - Deborah Josbeno
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences, 100 Technology Drive, Suite 500, Pittsburgh, PA 15219 USA
| | - Katherine Balfany
- Department of Physical Medicine & Rehabilitation, University of Colorado, School of Medicine, Aurora, CO 80217 USA
| | - Garett Griffith
- Department of Physical Therapy and Human Science, Northwestern University, Feinberg School of Medicine, Suite 1100, 645 North Michigan Avenue, Chicago, IL 60305 USA
| | - Mac Kenzie Dunlap
- Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 USA
| | - Guillaume Lamotte
- Movement Disorders Division, Department of Neurology, University of Utah, 175 Medical Dr N, Salt Lake City, UT 84132 USA
| | - Erin Suttman
- Department of Physical Therapy & Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT 84115 USA
| | - Danielle Larson
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Suite 115, 710 N Lake Shore Drive, Chicago, IL 60611 USA
| | - Chantale Branson
- Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310 USA
| | - Kathleen E. McKee
- Neurosciences Clinical Program, Intermountain Healthcare, 5171 S Cottonwood Street, Suite 810, Murray, UT 84107 USA
| | - Li Goelz
- Department of Kinesiology and Nutrition, UIC College of Applied Health Sciences, 919 W Taylor Street, Chicago, IL 60612 USA
| | - Cynthia Poon
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Suite 115, 710 N Lake Shore Drive, Chicago, IL 60611 USA
| | - Barbara Tilley
- Department of Biostatistics and Data Science, University of Texas Health Science Center School of Public Health, 1200 Pressler Street E835, Houston, TX 77030 USA
| | - Un Jung Kang
- NYU Langone Health, NYU Grossman School of Medicine, 435 E 30th Street, Science Building 1305, New York, NY 10016 USA
| | - Malú Gámez Tansey
- Department of Neuroscience and Neurology, Normal Fixel Institute for Neurological Diseases and College of Medicine, University of Florida, 4911 Newell Road, Gainesville, FL 32610 USA
| | - Nijee Luthra
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, San Francisco, CA 94158 USA
| | - Caroline M. Tanner
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, San Francisco, CA 94158 USA
| | - Jacob M. Haus
- School of Kinesiology, University of Michigan, 830 N. University Ave, Ann Arbor, MI 48109 USA
| | - Giamila Fantuzzi
- Department of Kinesiology and Nutrition, UIC College of Applied Health Sciences, 919 W Taylor Street, Chicago, IL 60612 USA
| | - Nikolaus R. McFarland
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, College of Medicine, University of Florida, Gainesville, FL 32608 USA
| | - Paulina Gonzalez-Latapi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Suite 115, 710 N Lake Shore Drive, Chicago, IL 60611 USA
| | - Tatiana Foroud
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 410 W. 10th Street, Indianapolis, IN 46220 USA
| | - Robert Motl
- Department of Kinesiology and Nutrition, UIC College of Applied Health Sciences, 919 W Taylor Street, Chicago, IL 60612 USA
| | - Michael A. Schwarzschild
- Mass General Institute for Neurodegenerative Disease, Massachusetts General Hospital, Rm 3002, 114 16th Street, Boston, MA 02129 USA
| | - Tanya Simuni
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Suite 115, 710 N Lake Shore Drive, Chicago, IL 60611 USA
| | - Kenneth Marek
- Institute for Neurodegenerative Disorders, 60 Temple St, New Haven, CT 06510 USA
| | - Anna Naito
- Parkinson’s Foundation 200 SE 1st Street Suite 800, Miami, FL 33131 USA
| | - Codrin Lungu
- National Institute of Neurological Disorders and Stroke, NIH, 6001 Executive Blvd, #2188, Rockville, MD 20852 USA
| | - Daniel M. Corcos
- Department of Physical Therapy and Human Science, Northwestern University, Feinberg School of Medicine, Suite 1100, 645 North Michigan Avenue, Chicago, IL 60305 USA
| |
Collapse
|
20
|
Patterson CG, Leland NE, Mormer E, Palmer CV. Alternative Designs for Testing Speech, Language, and Hearing Interventions: Cluster-Randomized Trials and Stepped-Wedge Designs. J Speech Lang Hear Res 2022; 65:2677-2690. [PMID: 35858257 DOI: 10.1044/2022_jslhr-21-00522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Individual-randomized trials are the gold standard for testing the efficacy and effectiveness of drugs, devices, and behavioral interventions. Health care delivery, educational, and programmatic interventions are often complex, involving multiple levels of change and measurement precluding individual randomization for testing. Cluster-randomized trials and cluster-randomized stepped-wedge trials are alternatives where the intervention is allocated at the group level, such as a clinic or a school, and the outcomes are measured at the person level. These designs are introduced along with the statistical implications of similarities among individuals within the same cluster. We also illustrate the parameters that have the most impact on the likelihood of detecting intervention effects, which must be considered when planning these trials. CONCLUSION Cluster-randomized and stepped-wedge designs should be considered by researchers as experimental alternatives to individual-randomized trials when testing speech, language, and hearing care interventions in real-world settings.
Collapse
Affiliation(s)
- Charity G Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
- School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, PA
| | - Natalie E Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
| | - Elaine Mormer
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
| | - Catherine V Palmer
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, PA
| |
Collapse
|
21
|
Pugliese JM, Coyle PC, Knox PJ, Sions JM, Patterson CG, Pohlig RT, Simon CB, Weiner DK, George SZ, Piva S, Hicks GE. The Manual Therapy and Strengthening for the Hip (MASH) Trial: Protocol for a Multisite Randomized Trial of a Subgroup of Older Adults With Chronic Back and Hip Pain. Phys Ther 2021; 102:6420898. [PMID: 34751784 PMCID: PMC8831280 DOI: 10.1093/ptj/pzab255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/14/2021] [Accepted: 10/11/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment. METHODS This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively. IMPACT This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP.
Collapse
Affiliation(s)
- Jenifer M Pugliese
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Peter C Coyle
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Patrick J Knox
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - J Megan Sions
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Charity G Patterson
- Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania USA
| | - Ryan T Pohlig
- Department of Epidemiology, University of Delaware, Newark, Delaware, USA
| | - Corey B Simon
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Debra K Weiner
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA,Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA,Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven Z George
- Department of Orthopedic Surgery, Duke School of Medicine, Durham, North Carolina, USA
| | - Sara Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
22
|
Tosin MHS, Stebbins GT, Comella C, Patterson CG, Hall DA. Does MDS-UPDRS Provide Greater Sensitivity to Mild Disease than UPDRS in De Novo Parkinson's Disease? Mov Disord Clin Pract 2021; 8:1092-1099. [PMID: 34631945 DOI: 10.1002/mdc3.13329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/22/2021] [Accepted: 08/08/2021] [Indexed: 11/08/2022] Open
Abstract
Background The Movement Disorder Society revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) was designed to be more sensitive to mild motor severity than the Unified Parkinson's Disease Rating Scale (UPDRS). Objective To test whether MDS-UPDRS Part III items provide increased sensitivity to mild motor severity when compared to the same items of the UPDRS in de novo PD patients. Method Using a sample of 129 de novo PD patients assessed at one time point simultaneously with both scales, we compared the scale's scores on the 17 items measuring the same motor function. The scaling anchors for the MDS-UPDRS were Slight, Mild, Moderate and Severe, and for the UPDRS were Mild, Moderate, Severe and Marked. Using Classical Test Theory (CTT) we compared the distributions of the scaling anchors from the individual items. Using Item Response Theory (IRT), we examined the sensitivity of the scaling anchors from each scale to the latent-trait measurement of overall parkinsonian motor severity. Results There was 2193 observations of individual scaling anchors from the 17 items in both scales. The CTT approach revealed frequent floor effects with only the item assessing Gait demonstrating a significance difference in the scaling distribution between the scales (P = 0.005). The IRT analyses revealed similar levels of sensitivity to the latent trait of PD motor function. Conclusion These results do not support increased sensitivity of MDS-UPDRS over the UPDRS for assessing mild motor severity in de novo PD patients, with significant difference in the scaling only for the item assessing gait.
Collapse
Affiliation(s)
- Michelle H S Tosin
- Department of Nursing Fluminense Federal University Niteroi Brazil.,Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
| | - Glenn T Stebbins
- Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
| | - Cynthia Comella
- Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
| | - Charity G Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences Data Center University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Deborah A Hall
- Department of Neurological Sciences Rush University Medical Center Chicago Illinois USA
| | | |
Collapse
|
23
|
Wawrose RA, Howington FE, LeVasseur CM, Smith CN, Couch BK, Shaw JD, Donaldson WF, Lee JY, Patterson CG, Anderst WJ, Bell KM. Assessing the biofidelity of in vitro biomechanical testing of the human cervical spine. J Orthop Res 2021; 39:1217-1226. [PMID: 32333606 PMCID: PMC7606317 DOI: 10.1002/jor.24702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 12/10/2019] [Accepted: 01/06/2020] [Indexed: 02/06/2023]
Abstract
In vitro biomechanical studies of the osteoligamentous spine are widely used to characterize normal biomechanics, identify injury mechanisms, and assess the effects of degeneration and surgical instrumentation on spine mechanics. The objective of this study was to determine how well four standards in vitro loading paradigms replicate in vivo kinematics with regards to the instantaneous center of rotation and arthrokinematics in relation to disc deformation. In vivo data were previously collected from 20 asymptomatic participants (45.5 ± 5.8 years) who performed full range of motion neck flexion-extension (FE) within a biplane x-ray system. Intervertebral kinematics were determined with sub-millimeter precision using a validated model-based tracking process. Ten cadaveric spines (51.8 ± 7.3 years) were tested in FE within a robotic testing system. Each specimen was tested under four loading conditions: pure moment, axial loading, follower loading, and combined loading. The in vivo and in vitro bone motion data were directly compared. The average in vitro instant center of rotation was significantly more anterior in all four loading paradigms for all levels. In general, the anterior and posterior disc heights were larger in the in vitro models than in vivo. However, after adjusting for gender, the observed differences in disc height were not statistically significant. This data suggests that in vitro biomechanical testing alone may fail to replicate in vivo conditions, with significant implications for novel motion preservation devices such as cervical disc arthroplasty implants.
Collapse
Affiliation(s)
- Richard A. Wawrose
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - Forbes E. Howington
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - Clarissa M. LeVasseur
- Department of Orthopaedic Surgery, Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, PA 15203
| | - Clair N. Smith
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - Brandon K. Couch
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - Jeremy D. Shaw
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - William F. Donaldson
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - Joon Y. Lee
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - Charity G. Patterson
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| | - William J. Anderst
- Department of Orthopaedic Surgery, Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, PA 15203
| | - Kevin M. Bell
- School of Medicine, Department of Orthopaedic Surgery, Ferguson Lab for Orthopaedic Research, University of Pittsburgh, Pittsburgh, PA 15213
| |
Collapse
|
24
|
Delitto A, Patterson CG, Stevans JM, Freburger JK, Khoja SS, Schneider MJ, Greco CM, Freel JA, Sowa GA, Wasan AD, Brennan GP, Hunter SJ, Minick KI, Wegener ST, Ephraim PL, Beneciuk JM, George SZ, Saper RB. Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. EClinicalMedicine 2021; 34:100795. [PMID: 33870150 PMCID: PMC8040279 DOI: 10.1016/j.eclinm.2021.100795] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability. METHODS We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: ClinicalTrials.gov NCT02647658. FINDINGS Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6; p = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups. INTERPRETATION There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines. FUNDING Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867.
Collapse
Affiliation(s)
- Anthony Delitto
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 4029 Forbes Tower, Pittsburgh, PA 15260 USA
- Corresponding author.
| | - Charity G. Patterson
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Joel M. Stevans
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Janet K. Freburger
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Samannaaz S. Khoja
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Michael J. Schneider
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Carol M. Greco
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Jennifer A. Freel
- Physician Network and Quality, St. Clair Hospital, 1000 Bower Hill Road, Pittsburgh, PA 15243 USA
| | - Gwendolyn A. Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Gerard P. Brennan
- 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA
| | - Stephen J. Hunter
- 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA
| | - Kate I. Minick
- 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA
| | - Stephen T. Wegener
- 600 N. Wolfe Street, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287 USA
| | - Patti L. Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Jason M. Beneciuk
- Department of Physical Therapy, Box 100154, University of Florida College of Public Health and Health Professions, Gainesville, Florida, 32610 USA
| | - Steven Z. George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, 200 Morris Street, Duke University, Durham, North Carolina, 27701 USA
| | - Robert B. Saper
- Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118 USA
| |
Collapse
|
25
|
Stevans JM, Delitto A, Khoja SS, Patterson CG, Smith CN, Schneider MJ, Freburger JK, Greco CM, Freel JA, Sowa GA, Wasan AD, Brennan GP, Hunter SJ, Minick KI, Wegener ST, Ephraim PL, Friedman M, Beneciuk JM, George SZ, Saper RB. Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open 2021; 4:e2037371. [PMID: 33591367 PMCID: PMC7887659 DOI: 10.1001/jamanetworkopen.2020.37371] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP. OBJECTIVE To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. DESIGN, SETTING, AND PARTICIPANTS This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. EXPOSURES SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). MAIN OUTCOMES AND MEASURES Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. RESULTS Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.
Collapse
Affiliation(s)
- Joel M. Stevans
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony Delitto
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samannaaz S. Khoja
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Charity G. Patterson
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Clair N. Smith
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J. Schneider
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Janet K. Freburger
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carol M. Greco
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer A. Freel
- Physician Network and Quality, St Clair Hospital, Pittsburgh, Pennsylvania
| | - Gwendolyn A. Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Kate I. Minick
- Intermountain Healthcare Rehabilitation Services, Murray, Utah
| | | | - Patti L. Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Jason M. Beneciuk
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville
| | - Steven Z. George
- Duke Clinical Research Institute, Department of Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Robert B. Saper
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
26
|
Irrgang JJ, Tashman S, Patterson CG, Musahl V, West R, Oostdyk A, Galvin B, Poploski K, Fu FH.. Anatomic single vs. double-bundle ACL reconstruction: a randomized clinical trial-Part 1: clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2021; 29:2665-2675. [PMID: 33970295 PMCID: PMC8298248 DOI: 10.1007/s00167-021-06585-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Compare clinical outcomes of anatomic single-bundle (SB) to anatomic double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). It was hypothesized that anatomic DB ACLR would result in better International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores and reduced anterior and rotatory laxity compared to SB ACLR. METHODS Active individuals between 14 and 50 years of age that presented within 12 months of injury were eligible to participate. Individuals with prior injury or surgery of either knee, greater than a grade 1 concomitant knee ligament injury, or ACL insertion sites less than 14 mm or greater than 18 mm were excluded. Subjects were randomized to undergo SB or DB ACLR with a 10 mm-wide quadriceps tendon autograft harvested with a patellar bone block and were followed for 24 months. The primary outcome measures included the IKDC-SKF and KT-1000 (side to side difference) and pivot shift tests. Other secondary outcomes included measures of sports activity and participation, range of motion (ROM) and re-injury. RESULTS Enrollment in the study was suspended due to patellar fractures related to harvest of the patellar bone plug. At that time, 57 subjects had been randomized (29 DB) and two-year follow-up was attained from 51 (89.5%). At 24-month follow-up there were no between-group differences detected for the primary outcomes. Twenty-one (77.8%) DB's and 20 (83.3%) SB's reported returning to pre-injury sports 2 years after surgery (n.s) Three subjects (2 DB's, 5.3% of total) sustained a graft rupture and 5 individuals (4 SB's, 8.8% of total) had a subsequent meniscus injury. CONCLUSIONS Due to the early termination of the study, there were no detectable differences in clinical outcome between anatomic SB and DB ACLR when performed with a quadriceps tendon autograft with a bone block in individuals with ACL insertion sites that range from 14 to 18 mm. LEVEL OF EVIDENCE Level 2.
Collapse
Affiliation(s)
- James J. Irrgang
- grid.21925.3d0000 0004 1936 9000Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Suite 210, Bridgeside Point 1, 100 Technology Drive, Pittsburgh, PA 15203 USA ,grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Scott Tashman
- grid.419649.70000 0001 0367 5968Steadman Philippon Research Institute, Vail, CO USA
| | - Charity G. Patterson
- grid.21925.3d0000 0004 1936 9000Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Suite 210, Bridgeside Point 1, 100 Technology Drive, Pittsburgh, PA 15203 USA
| | - Volker Musahl
- grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.412689.00000 0001 0650 7433UPMC Freddie Fu Sports Medicine, Center, Pittsburgh, PA USA
| | | | - Alicia Oostdyk
- grid.412689.00000 0001 0650 7433UPMC Freddie Fu Sports Medicine, Center, Pittsburgh, PA USA
| | - Bryan Galvin
- grid.412689.00000 0001 0650 7433UPMC Freddie Fu Sports Medicine, Center, Pittsburgh, PA USA
| | - Kathleen Poploski
- grid.21925.3d0000 0004 1936 9000Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Suite 210, Bridgeside Point 1, 100 Technology Drive, Pittsburgh, PA 15203 USA
| | - Freddie H . Fu
- grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.412689.00000 0001 0650 7433UPMC Freddie Fu Sports Medicine, Center, Pittsburgh, PA USA
| |
Collapse
|
27
|
Farrokhi S, Russell Esposito E, McPherson D, Mazzone B, Condon R, Patterson CG, Schneider M, Greco CM, Delitto A, Highsmith MJ, Hendershot BD, Maikos J, Dearth CL. Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial. Pain Med 2020; 21:S45-S52. [PMID: 33313735 DOI: 10.1093/pm/pnaa367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems. DESIGN The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss). SUMMARY The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.
Collapse
Affiliation(s)
- Shawn Farrokhi
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Naval Medical Center San Diego, San Diego, California
| | - Elizabeth Russell Esposito
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Danielle McPherson
- Naval Medical Center San Diego, San Diego, California.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Brittney Mazzone
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Naval Medical Center San Diego, San Diego, California
| | - Rachel Condon
- Naval Medical Center San Diego, San Diego, California
| | | | | | | | | | - M Jason Highsmith
- US Department of Veterans Affairs, Tampa, Florida.,University of South Florida, Tampa, Florida
| | - Brad D Hendershot
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jason Maikos
- US Department of Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Christopher L Dearth
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| |
Collapse
|
28
|
Alomar JA, Catelani MBC, Smith CN, Patterson CG, Artman TM, Piva SR. Validity and Responsiveness of Floor Sitting-Rising Test in Post–Total Knee Arthroplasty: A Cohort Study. Arch Phys Med Rehabil 2020; 101:1338-1346. [DOI: 10.1016/j.apmr.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/21/2019] [Accepted: 03/12/2020] [Indexed: 10/24/2022]
|
29
|
Khoja SS, Patterson CG, Goodpaster BH, Delitto A, Piva SR. Skeletal muscle fat in individuals with rheumatoid arthritis compared to healthy adults. Exp Gerontol 2019; 129:110768. [PMID: 31678218 PMCID: PMC10119702 DOI: 10.1016/j.exger.2019.110768] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/18/2019] [Accepted: 10/29/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To compare skeletal muscle fat (SMF), intermuscular adipose tissue (IMAT) and subcutaneous adipose tissue (SAT) between individuals with rheumatoid arthritis (RA), and healthy individuals of the same age, and healthy individuals at least 10 years older than those with RA. METHODS Two cross-sectional studies. In the first study, RA subjects were matched by age, sex, and BMI with healthy adults. In the second, RA subjects were matched by sex and BMI to adults 10-20 years older. SMF, IMAT and SAT were measured with Computed Tomography images of the mid-thigh region. We used parametric or non-parametric related-sample tests to compare fat accumulation between RA subjects and healthy adults. RESULTS In the first study SMF was significantly higher in the RA cohort compared to their age-matched healthy counterparts (mean difference = -3.5 HU (95% -6.2, -0.9), p = 0.011), but IMAT and SAT were similar between cohorts. In the second study, SMF, IMAT and SAT were not significantly different between the RA and matched older healthy cohorts. In both studies, there were no significant differences in mid-thigh muscle area between RA subjects and healthy adults. CONCLUSION SMF accumulation in RA was higher than in healthy individuals of similar age, sex, BMI. Accumulation of fat within and around the muscles in RA was not different compared to the matched healthy older individuals, indicating that muscle fat accumulation in RA might mimic a pattern not different from healthy aging.
Collapse
Affiliation(s)
- Samannaaz S Khoja
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Charity G Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bret H Goodpaster
- Translational Research Institute for Metabolism and Diabetes, Orlando, FL, United States
| | - Anthony Delitto
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sara R Piva
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
30
|
Delitto A, Patterson CG, Stevans JM, Brennan GP, Wegener ST, Morrisette DC, Beneciuk JM, Freel JA, Minick KI, Hunter SJ, Ephraim PL, Friedman M, Simpson KN, George SZ, Daley KN, Albert MC, Tamasy M, Cash J, Lake DS, Freburger JK, Greco CM, Hough LJ, Jeong JH, Khoja SS, Schneider MJ, Sowa GA, Spigle WA, Wasan AD, Adams WG, Lemaster CM, Mishuris RG, Plumb DL, Williams CT, Saper RB. Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial). Contemp Clin Trials 2019; 82:66-76. [PMID: 31136834 DOI: 10.1016/j.cct.2019.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP. METHODS AND STUDY DESIGN The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently. DISCUSSION The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT. TRIAL REGISTRATION ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.
Collapse
Affiliation(s)
- Anthony Delitto
- School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 4028 Forbes Tower, Pittsburgh, PA 15260, USA.
| | - Charity G Patterson
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Joel M Stevans
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gerard P Brennan
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - David C Morrisette
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Jason M Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Box 100154, UFHSC, Gainesville, FL 32610, USA
| | - Jennifer A Freel
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Kate I Minick
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen J Hunter
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Patti L Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27705, USA
| | - Kelly N Daley
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Michael C Albert
- Johns Hopkins Community Physicians, 6225 Smith Avenue, Baltimore, MD 21209, USA
| | - Marie Tamasy
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jewel Cash
- Boston Medical Center, Boston, MA 02118, USA
| | - D Scott Lake
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Janet K Freburger
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Linda J Hough
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA 15261, USA
| | - Samannaaz S Khoja
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Michael J Schneider
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gwendolyn A Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA
| | - Wendy A Spigle
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - William G Adams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Chelsey M Lemaster
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Rebecca G Mishuris
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Dorothy L Plumb
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Charles T Williams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| |
Collapse
|
31
|
Brosnahan GM, Abebe KZ, Rahbari-Oskoui FF, Patterson CG, Bae KT, Schrier RW, Braun WE, Chapman AB, Flessner MF, Harris PC, Perrone RD, Steinman TI, Torres VE. Effect of Statin Therapy on the Progression of Autosomal Dominant Polycystic Kidney Disease. A Secondary Analysis of the HALT PKD Trials. Curr Hypertens Rev 2019; 13:109-120. [PMID: 28460625 DOI: 10.2174/1573402113666170427142815] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 03/30/2017] [Accepted: 04/18/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) commonly results in end-stage renal disease (ESRD), yet a long-term treatment that is well tolerated is still lacking. In a small randomized trial in children and adolescents pravastatin administration for 3 years was associated with reduced renal cyst growth, but no large trial has tested the effect of statins in adults. METHODS We performed a post-hoc analysis of the HALT PKD trials to compare outcomes of participants who never used statins with those who used statin for at least 3 years. Because statins were not randomly allocated, we used propensity score models with inverse probability of treatment weighting to account for imbalances between the groups. For subjects in Study A (preserved renal function, n=438) relevant outcomes were percent change in total kidney and liver volume and the rate of decline in estimated glomerular filtration rate (eGFR); for those in Study B (reduced renal function, n=352) we compared time to the composite endpoint of death, ESRD or 50% decline in eGFR. Follow-up was 5-8 years. RESULTS There was no difference in any outcome between the 2 groups. However, limitations of this analysis are the small number of statin users in Study A, different statin drugs and doses used, non-randomized allocation and advanced disease stage in Study B. CONCLUSION Although this post-hoc analysis of the HALT PKD trials does not demonstrate a benefit of statin therapy, conclusions remain preliminary. A larger randomized trial in young people with ADPKD is necessary to answer the question whether statins can slow renal cyst growth and preserve kidney function.
Collapse
Affiliation(s)
| | - Kaleab Z Abebe
- University of Pittsburgh, Pittsburgh, Pennsylvania PA. United States
| | | | | | - Kyongtae T Bae
- University of Pittsburgh, Pittsburgh, Pennsylvania PA. United States
| | | | | | | | | | | | | | - Theodore I Steinman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts MA. United States
| | | | | |
Collapse
|
32
|
Long AS, Niemeier JP, McWilliams A, Patterson CG, Perrin P, Templin M, Price DE. Comparison of Neurocognitive Changes Over One Competitive Season in Adolescent Contact and Non-contact Athletes. ACTA ACUST UNITED AC 2019. [DOI: 10.3928/19425864-20180430-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
33
|
Schneider MJ, Ammendolia C, Murphy DR, Glick RM, Hile E, Tudorascu DL, Morton SC, Smith C, Patterson CG, Piva SR. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e186828. [PMID: 30646197 PMCID: PMC6324321 DOI: 10.1001/jamanetworkopen.2018.6828] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
IMPORTANCE Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older US adults. There is an evidence gap about nonsurgical LSS treatment options. OBJECTIVE To explore the comparative clinical effectiveness of 3 nonsurgical interventions for patients with LSS. DESIGN, SETTING, AND PARTICIPANTS Three-arm randomized clinical trial of 3 years' duration (November 2013 to June 2016). Analysis began in August 2016. All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat. INTERVENTIONS Medical care, group exercise, and manual therapy/individualized exercise. Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors in senior community centers. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists. MAIN OUTCOMES AND MEASURES Primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes). RESULTS A total of 259 participants (mean [SD] age, 72.4 [7.8] years; 137 women [52.9%]) were allocated to medical care (88 [34.0%]), group exercise (84 [32.4%]), or manual therapy/individualized exercise (87 [33.6%]). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care (-2.0; 95% CI, -3.6 to -0.4) or group exercise (-2.4; 95% CI, -4.1 to -0.8). Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates. CONCLUSIONS AND RELEVANCE A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01943435.
Collapse
Affiliation(s)
- Michael J. Schneider
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Donald R. Murphy
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ronald M. Glick
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Physical Medicine Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth Hile
- College of Allied Health, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Dana L. Tudorascu
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally C. Morton
- Department of Statistics, College of Science, Virginia Polytechnic Institute and State University, Blacksburg
| | - Clair Smith
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Charity G. Patterson
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sara R. Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
34
|
Braun WE, Abebe KZ, Brosnahan G, Patterson CG, Chapman AB, Harris PC, Hogan MC, Perrone RD, Torres VE, Miskulin DC, Steinman TI, Winklhofer FT, Rahbari-Oskoui FF, Czarnecki PG, Bae KT, Grantham JJ, Flessner MF, Schrier RW. ADPKD Progression in Patients With No Apparent Family History and No Mutation Detected by Sanger Sequencing. Am J Kidney Dis 2017; 71:294-296. [PMID: 29203126 DOI: 10.1053/j.ajkd.2017.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/07/2017] [Indexed: 12/22/2022]
Affiliation(s)
- William E Braun
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Kaleab Z Abebe
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Charity G Patterson
- University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania
| | | | | | - Marie C Hogan
- Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | | | | | | | | | | | | | - Kyongtae T Bae
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | |
Collapse
|
35
|
Long PW, Larkins RG, Patterson CG, Hyde J. Facilitating best practice: transferring the lessons of the Clinical Support Systems Program. J Qual Clin Pract 2001; 21:157-9. [PMID: 11856415 DOI: 10.1046/j.1440-1762.2001.00439.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Clinical Support Systems Program (CSSP) includes the management of clinical practice using clinical and consumer pathways, outcome and performance indicators, clinical measurement and review in a continuous improvement cycle using the best available extant evidence. The Royal Australasian College of Physicians is testing the CSSP model through four consortia around Australia. There are 17 project sites in three States. The funded projects address major clinical problems including congestive heart failure and acute coronary syndromes, acute stroke management, and colorectal cancer care. There is some early evidence of the CSSP influencing change in areas beyond the bounds of the project settings and the College has developed a plan to promote wider adoption of best practice. This approach recognises the College's role in providing Fellows with the practical tools of quality improvement, the means to collect data and compare their practice to other clinicians, while traversing the appropriate educational framework.
Collapse
Affiliation(s)
- P W Long
- The Royal Australasian College of Physicians, 145 Macquarie Street, Sydney, NSW 2000, Australia.
| | | | | | | |
Collapse
|
36
|
Affiliation(s)
- R G Larkins
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.
| | | | | |
Collapse
|
37
|
Affiliation(s)
- P A Komesaroff
- Eleanor Shaw Centre for the Study of Medicine, Society and Law, Baker Medical Research Institute, Melbourne, Vic.
| | | |
Collapse
|
38
|
Patterson CG. Health policy--taking physicians' views to Canberra. Aust N Z J Med 2000; 30:81-2. [PMID: 10800885 DOI: 10.1111/j.1445-5994.2000.tb01061.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Affiliation(s)
- C G Patterson
- Health Policy Unit, The Royal Australasian College of Physicians, Sydney
| |
Collapse
|