The Combined Influence of Sleep Disturbance and Depression on 12-month Outcomes after Lumbar Spine Surgery

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To examine the combined influence of preoperative sleep disturbance and depression on 12-month patient-reported outcomes after lumbar spine surgery (LSS).

SUMMARY OF BACKGROUND DATA

Psychological and behavioral factors are considered major risk factors of poor outcome after LSS. However, there is a need to explore the combined effects of preoperative factors such as sleep disturbance and depression. Understanding the influence of sleep disturbance and depression can inform evidence-based preoperative assessment and shared-decision making of preoperative and postoperative treatment.

METHODS

Data from 700 patients undergoing LSS were analyzed. Preoperative sleep disturbance and depression were assessed with PROMIS subscales. Established thresholds defined patients with moderate/severe symptoms. Outcomes for disability (Oswestry Disability Index) and back and leg pain (Numeric Rating Scales) were assessed preoperatively and at 12 months. Separate multivariable linear regressions examined the influence of each factor on 12-month outcomes with and without accounting for the other, and in combination as a 4-level variable: 1) moderate/severe sleep disturbance alone, 2) moderate/severe depression alone, 3) both moderate/severe sleep disturbance and depression, 4) no moderate/severe sleep disturbance or depression.

RESULTS

Preoperative sleep disturbance and depression were associated with 12-month disability and pain (P<0.05). After accounting for depression, preoperative sleep disturbance remained associated with disability, while preoperative depression adjusting for sleep disturbance remained associated with all outcomes (P<0.05). Patients reporting both moderate/severe sleep disturbance and moderate/severe depression had 12.6 points higher disability and 1.5 points higher back and leg pain compared to patients without moderate/severe sleep disturbance or depression.

CONCLUSION

The combination of sleep disturbance and depression impacts postoperative outcomes considerably. The high-risk group of patients with moderate/severe sleep disturbance and depression could benefit from targeted treatment strategies.

An overview of systematic reviews examining the quantitative sensory testing-derived hypoalgesic effects of manual therapy for musculoskeletal pain

BACKGROUND

Changes in quantitative sensory testing (QST) after manual therapy can provide insight into pain relief mechanisms. Prior systematic reviews have evaluated manual-therapy-induced QST change. This overview of systematic reviews aims to consolidate this body of literature and critically review evidence on the hypoalgesic effects of manual therapy in clinical populations.

METHODS

A comprehensive search was conducted on PubMed, CINAHL, PsycInfo, and Embase. Peer-reviewed systematic reviews with or without meta-analysis were eligible if the reviews examined the effect of manual therapy compared to non-manual therapy interventions on QST outcomes in clinical populations. Methodological quality was assessed with the AMSTAR 2 tool. Meta-analysis results and qualitative (non-meta-analysis) interpretations were summarized by type of manual therapy. Overlap of studies was examined with the corrected covered area (CCA) index.

RESULTS

Thirty systematic reviews, including 11 meta-analyses, met inclusion. There was a slight overlap in studies (CCA of 1.72% for all reviews and 1.69% for meta-analyses). Methodological quality was predominantly low to critically low. Eight (27%) reviews examined studies with a range of manual therapy types, 13 (43%) reviews focused on joint-biased manual therapy, 7 (23%) reviews focused on muscle-biased manual therapy, and 2 (7%) reviews focused on nerve-biased manual therapy. Twenty-nine (97%) reviews reported on pressure pain threshold (PPT). Meta-analytic results demonstrated conflicting evidence that manual therapy results in greater hypoalgesic effects compared to other interventions or controls.

CONCLUSION

Our overview of QST effects, which has relevance to mechanisms underlying hypoalgesia, shows conflicting evidence from mostly low to critically low systematic reviews.

Combining Wearable Technology and Telehealth Counseling for Rehabilitation After Lumbar Spine Surgery: Feasibility and Acceptability of a Physical Activity Intervention

OBJECTIVE

The purpose of this study was to examine the feasibility and acceptability of a wearable device and telehealth counseling physical activity intervention early after lumbar spine surgery.

METHODS

Sixteen patients were randomized to an 8-session physical activity intervention or to usual postoperative care after surgery. The intervention included a wearable device (ie, Fitbit) and telehealth counseling by a licensed physical therapist. The feasibility of study procedures was assessed through recruitment, randomization, retention, and participation rates. Acceptability was assessed through a satisfaction survey and median within-participant change in objective physical activity (steps per day and time spent in moderate-to-vigorous physical activity [MVPA]) and patient-reported outcomes.

RESULTS

Of 64 participants who were eligible, recruitment and randomization rates were 41 and 62%, respectively. Retention for objective physical activity and patient-reported outcomes was 94 and 100%, respectively, at 6-month follow-up. Seven (88%) participants in the intervention group completed all telehealth sessions, and 6 (75%) met step goals over the 8 sessions. All participants in the intervention group found the wearable device and telehealth counseling to be helpful and reported it much or somewhat more important than other postoperative services. Median within-participant change for steps per day improved from baseline (preoperative) to 6 months after surgery for both the intervention (1070) and usual care (679) groups, while MVPA only improved for the intervention group (2.2. minutes per day). Improvements in back and leg pain and disability were noted for both groups. No adverse events were reported in the study.

CONCLUSION

Combining wearable technology and telehealth counseling is a feasible approach to promote the physical activity during the early postoperative period after spine surgery. Future randomized controlled trials are needed to investigate the efficacy of leveraging wearables and telehealth during postoperative rehabilitation.

IMPACT

This study has implications for the clinical dissemination of physical activity strategies in the rehabilitation setting.

Impact of Racial/Ethnic Disparities on Patient Reported Outcomes Following Cervical Spine Surgery: QOD Analysis

STUDY DESIGN

Retrospective analysis of data from the cervical module of a national spine registry, the Quality Outcomes Database (QOD).

OBJECTIVE

To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at 1 year after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and prolonged length of stay after cervical spine surgery compared to Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic and other non-Hispanic groups (i.e., Asian) remains unclear.

METHODS

PROMs were used to assess disability (NDI) and neck/arm pain preoperatively and 1-year postoperative. Primary outcomes were disability and pain, and not being satisfied from pre-operative to 12-months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups (Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)) with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving MCID 1-year postoperatively.

RESULTS

Of the 14,429 participants, all had significant reductions in pain and disability, and 87% were satisfied at 1-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30% to 70%) compared to NHW. NHB had 50% higher odds of worse disability scores compared to NHW. NHA reported similar disability and neck pain outcomes compared to NHW.

CONCLUSIONS

Hispanic and non-Hispanic Black patients had worse patient-reported outcomes 1-year after cervical spine surgery compared to non-Hispanic White individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for non-Hispanic Asian patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

LEVEL OF EVIDENCE

3.

Are Formal and Informal Home Mindfulness Practice Quantities Associated With Outcomes? Results From a Pilot Study of a Four-Week Mindfulness Intervention for Chronic Pain Management

Background

The association between home mindfulness practice quantity in standard length mindfulness-based interventions (MBIs) and chronic pain outcomes is variable. Few studies focus on abbreviated MBIs (< 8 weeks) and distinguish between formal guided practices and informal practices in daily life.

Objectives

To characterize home mindfulness practice and explore associations between home practice quantity and pre-to-post-outcome changes after an MBI for chronic pain.

Methods

In this single-arm study, 21 adults with chronic pain (mean age = 54 years, 81% White, mean pain duration = 7 years) completed an MBI with four weekly group sessions. Pre and post self-report measures of pain intensity/interference, physical function, depression, anxiety, positive affect, sleep disturbance (all PROMIS measures), and pain acceptance, catastrophizing, perceived stress and mindfulness were completed, along with daily surveys of formal (mindfulness of breath, body scan) and informal (breathing space, mindfulness of daily activities) practice. Bivariate correlations and multivariable regression models were used to assess the association between days and minutes of practice and change in outcomes.

Results

On average, formal practice was completed on 4.3 days per week and 13.5 minutes per day. Informal practice was completed on 3.5 days per week and 8.6 minutes per day. Formal practice was not significantly correlated with outcomes (Spearman's ρ = |.01|-|.32|), whereas informal practice was correlated with multiple outcomes (ρ = |.04|-|.66|). Number of days practiced informally was associated with improved pain interference, physical function, sleep disturbance, and catastrophizing (p's ≤ .05). Number of minutes practiced informally was associated with improved pain interference, anxiety, positive affect, and catastrophizing (p's ≤ .05).

Conclusion

Informal home practice quantity, but not formal practice quantity, is associated with improved outcomes during an abbreviated MBI for chronic pain. For these MBIs, it is important to evaluate the distinct roles of formal and informal practice.

ClinicalTrialsgov Registration

NCT03495856.

Effect of Cervicothoracic Junction LIV Selection on Posterior Cervical Fusion Mechanical Failure: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and Meta-analysis.

OBJECTIVE

Analyze and summarize literature evaluating the role of C7, T1, and T2 lowest instrumented vertebra (LIV) selection in posterior cervical fusion (PCF) and if this affects the progression of mechanical failure and revision surgery.

SUMMARY OF BACKGROUND DATA

Literature evaluating mechanical failure and adjacent segment disease in the setting of PCF at or nearby the cervicothoracic junction (CTJ) remains limited with studies reporting conflicting results.

MATERIALS AND METHODS

Two reviewers conducted a detailed systematic review using EMBASE, PubMed, Web of Science, and Google Scholar on June 28, 2021, for primary research articles comparing revision and complication rates for posterior fusions ending in the lower cervical spine (C7) and upper thoracic spine (T1-T2). The initial systematic database yielded 391 studies, of which 10 met all inclusion criteria. Random effects meta-analyses compared revision and mechanical failure rates between patients with an LIV above the CTJ and patients with an LIV below the CTJ.

RESULTS

Data from 10 studies (total sample=2001, LIV above CTJ=1046, and LIV below CTJ=955) were meta-analyzed. No differences were found between the 2 cohorts for all-cause revision [odds ratio (OR)=0.75, 95% CI=0.42-1.34, P<0.0001] and construct-specific revision (OR=0.62, 95% CI=0.25-1.53, P<0.0001). The odds of total mechanical failure in the LIV below CTJ cohort compared with the LIV above CTJ cohort were significantly lower (OR=0.38, 95% CI=0.18-0.81, P<0.0001).

CONCLUSION

The results show patients with PCFs ending below the CTJ have a lower risk of undergoing total mechanical failure compared with fusions ending above the CTJ. This is important information for both physicians and patients to consider when planning for operative treatment.

LEVEL OF EVIDENCE

Level I.

Clinical measurement of functional dart thrower's motion in patients with unilateral wrist conditions undergoing nonoperative or postoperative hand therapy

STUDY DESIGN

Cross-sectional and descriptive study BACKGROUND: Functional dart thrower's motion (F-DTM) is an obliquely oriented wrist motion that occurs in activities such as throwing and drinking from a cup. There is limited data on clinical measurement of F-DTM.

PURPOSE OF THE STUDY

The purpose of this study was to 1) describe and establish reference scores for F-DTM measurement for nonoperative and postoperative wrist patients 2) compare F-DTM between the affected and nonaffected sides and 3) determine F-DTM score agreement across three consecutive trials.

METHODS

Two certified hand therapists evaluated F-DTM in consecutive adult patients with a unilateral wrist condition undergoing nonoperative or postoperative therapy. Three trials of goniometer measurements for radial extension (RE) and ulnar flexion (UF) were assessed on the nonaffected and affected wrists. A total arc F-DTM was computed. Mean, 95% confidence intervals (CI), and Cohen's d effect size described side-to-side differences in RE, UF, and total arc F-DTM. Agreement in scores across trials was assessed with an intraclass correlation coefficient (ICC).

RESULTS

Thirty-one nonoperative (mean ± SD age = 40.0 ± 13.9 years, 74% female, 94% right hand dominant) and 44 postoperative patients (mean ± SD age = 44.9 ± 14.9 years, 66% female, 84% right hand dominant) were enrolled. The average side-to-side difference, in degrees, in the nonoperative group was -6.4 (95% CI: -9.4 to -3.4, Cohen's d = 0.8) for RE, -10.4 (-16.7 to -4.0, d = 0.6) for UF, and -16.8 (-24.3 to -9.2, d = 0.8) for total arc F-DTM. The average side-to-side difference in the postoperative group was -33.6 (-38.8 to -28.3, d = 1.9) for RE, -34.7 (-40.6 to -28.7, d = 1.8) for UF, and -68.2 (-77.9 to -58.5, d = 2.1) for total arc F-DTM. The range of ICCs for F-DTM measurements was 0.82-0.96.

CONCLUSIONS

Goniometer measurement of F-DTM is a clinically feasible method to quantify functional motion loss in an injured wrist population, particularly patients with postoperatively managed wrist conditions.

Outcomes of Activity-Related Lower Extremity Muscle Tears After Application of the British Athletics Muscle Injury Classification: A Systematic Review

CONTEXT

Muscle injury classification and grading systems have been reported for >100 years; yet it offer limited evidence relating the clinical or radiological qualities of a muscle injury to the pathology or clinical outcome. The British Athletics Muscle Injury Classification (BAMIC) incorporates recent predictive features of muscle injuries and provides a precise radiographic framework for clinical prediction and management.

OBJECTIVE

To investigate clinical outcomes, particularly time to return to play (RTP), reinjury rate (RIR), and prognostic value of specific magnetic resonance imaging (MRI) findings, of activity-related muscle injuries (tears) in athletes after application of the BAMIC.

DATA SOURCES

A search of PubMed (NLM), EMBASE (Ovid), Web of Science (Clarivate), Cochrane Library (Wiley), and ClinicalTrials.gov from the inception date of each database through August 31, 2022, was conducted. Keywords included the BAMIC.

STUDY SELECTION

All English language studies evaluating clinical outcomes of RTP and RIR after activity-related muscle injuries and where BAMIC was applied were included. A total of 136 articles were identified, and 11 studies met inclusion criteria.

STUDY DESIGN

Systematic review (PROSPERO: CRD42022353801).

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Two reviewers independently screened studies for eligibility and extracted data. Methodological quality of included study was assessed independently by 2 reviewers with the Newcastle-Ottawa Quality Scale (NOS); 11 good quality studies (4 prospective cohort studies, 7 retrospective cohort studies) with 468 athletes (57 female) and 574 muscle injuries were included.

RESULTS

All studies reported a statistically significant relationship between BAMIC grade, BAMIC injury site, and/or combined BAMIC grade and injury site with RTP. A statistically significant increased RIR was reported by BAMIC grade and BAMIC injury site in 2 of 4 and 3 of 4 studies, respectively. The prognostic value of individual MRI criteria was limited.

CONCLUSION

Consistent evidence suggests that BAMIC offers prognostic and therapeutic guidance for clinical outcomes, particularly RTP and RIR, after activity-related muscle injuries in athletes that may be superior to previous muscle injury classification and grading systems.

A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction

STUDY DESIGN

Qualitative interview study.

OBJECTIVE

The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction.

SUMMARY OF BACKGROUND DATA

Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery.

MATERIALS AND METHODS

Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed.

RESULTS

A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences.

CONCLUSION

Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Comparing Calcaneus Fracture Radiographic Outcomes and Complications after Percutaneous Pin versus Screw Fixation

Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. Although screws are thought to provide greater stability, limited data exists directly comparing fixation success of these implants. Medical record data from 53 patients (62 total fractures) surgically treated with percutaneous screws (28 fractures) or K-wires (34 fractures) for joint-depression calcaneus fractures at a large tertiary hospital were retrospectively reviewed. Bohler's angle and calcaneal varus were assessed from available radiographs at time of injury, postoperatively, and at final follow-up, and joint congruity was assessed postoperatively and at final follow-up. Complications were also extracted. There were no statistical differences in patient characteristics between surgical groups although a higher proportion of patients treated with K-wires compared to screws had other associated injuries (79% vs 42%, p = .01). A higher proportion of fractures treated with screws compared to K-wires maintained joint congruity at the final follow-up (69% vs 32%, p = .005). However, there were no statistically detectable differences in other postoperative radiographic metrics (p > .05). In conclusion, joint congruity was more often maintained with screw fixation although there was no statistical difference in restoration and maintenance of Bohler's angle or varus alignment. The difference in radiographic metrics was not correlated with secondary procedures, namely subtalar arthrodesis, and may not be clinically significant. Neither group was completely effective in attaining and maintaining reduction, and additional fixation strategies should be considered if feasible based on patient, injury, and soft tissue characteristics.

Could Novel Radiographic Findings Help Identify Aseptic Tibial Loosening?

BACKGROUND

Aseptic loosening following total knee arthroplasty remains one of the leading causes of long-term failure. Radiographic identification of loose implants can be challenging with standard views. The purpose of this study was to compare the incidence of novel radiographic findings of anterior heterotopic bone formation and medial or lateral cyst formation in patients who have aseptic loosening to patients who have well-fixed implants.

METHODS

A retrospective radiographic review was performed on 48 patients' revised secondary to aseptic tibial loosening. This cohort was compared to two additional cohorts; 48 patients returning for routine postoperative follow-up (control 1), and 48 patients revised secondary to infection or instability who had well-fixed implants (control 2).

RESULTS

There were 41 of 48 (85%) patients who had implant loosening and were noted to have anterior heterotopic bone formation compared to 1 of 48 (2%) patients in control 1 and 3 of 48 (6%) patients in control 2 (P ≤ .0001). There were 43 of 48 (90%) patients who had implant loosening and had medial cyst formation compared to 3 of 48 (6%) patients in control 1 and 5 of 48 (10%) in control 2 (P ≤ .0001). There were 42 of 48 (88%) patients who had implant loosening and had lateral cyst formation compared to 2 of 48 (4%) patients in control 1 and 4 of 48 (8%) in control 2 (P ≤ .0001).

CONCLUSION

In this study, we describe novel radiographic findings of anterior heterotopic bone formation and cysts that develop in patients who have aseptic loosening following primary total knee arthroplasty. We believe that these radiographic features may lead to easier identification of aseptic loosening.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03083886.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery.

METHODS

In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression.

RESULTS

Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted.

CONCLUSIONS

Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning.

IMPACT

This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.

Return to Sports After Anterior Cruciate Ligament Reconstruction: Validity and Reliability of the SPORTS Score at 6 and 12 Months

Background:

The Subjective Patient Outcome for Return to Sports (SPORTS) score is a single-item scale that measures athletes' ability to return to their preinjury sport based on effort and performance.

Purpose/Hypothesis:

The purpose of this study was to examine the psychometric properties of the SPORTS score and a modified score within the first year after anterior cruciate ligament reconstruction (ACLR). The modified version replaced “same sport” with “any sport” in the answer choices. It was hypothesized that both versions of the SPORTS score would have acceptable floor and ceiling effects and internal responsiveness, moderate convergent validity, and excellent test-retest reliability.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Patients were recruited preoperatively from 2 academic medical centers. The authors collected responses to the 1-item SPORTS scores at 6 and 12 months after ACLR and the Tegner activity scale, Lysholm knee score, Knee injury and Osteoarthritis Outcome Score (KOOS)–sport/recreation subscale, and Marx activity rating scale preoperatively and 6 and 12 months after ACLR. Ceiling and floor effects and responsiveness were assessed using descriptive statistics and cross-tabulations, respectively, at both follow-up time points. Spearman correlations and intraclass correlation coefficients were used to examine convergent validity and test-retest reliability, respectively.

Results:

Follow-up rates at 6 and 12 months were 100% and 99%, respectively. Test-retest follow-up was 77%. Floor effects for the SPORTS scores were not observed, while ceiling effects at 12 months ranged from 38% to 40%. Cross-tabulation of the SPORTS scores showed that 64% to 66% of patients reported a change in their score from 6 to 12 months, with significant differences noted between the proportions that improved versus worsened for return to any sport. Convergent validity was observed at 6 and 12 months via moderate correlations with the Tegner, Lysholm, KOOS–sport/recreation, and Marx scores (r = 0.31 to 0.47). Fair to good test-retest reliability (intraclass correlation coefficient, 0.58 and 0.60) was found at 12 months after ACLR.

Conclusion:

The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.

Design of the Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure Trial (SPINE CARE) study: Methods and lessons from a multi-site pragmatic cluster randomized controlled trial

BACKGROUND

Low back and neck pain (together, spine pain) are among the leading causes of medical visits, lost productivity, and disability. For most people, episodes of spine pain are self-limited; nevertheless, healthcare spending for this condition is extremely high. Focusing care on individuals at high-risk of progressing from acute to chronic pain may improve efficiency. Alternatively, postural therapies, which are frequently used by patients, may prevent the overuse of high-cost interventions while delivering equivalent outcomes.

METHODS

The SPINE CARE (Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure) trial is a cluster-randomized multi-center pragmatic clinical trial designed to evaluate the clinical effectiveness and healthcare utilization of two interventions for primary care patients with acute and subacute spine pain. The study was conducted at 33 primary care clinics in geographically distinct regions of the United States. Individuals ≥18 years presenting to primary care with neck and/or back pain of ≤3 months' duration were randomized at the clinic-level to 1) usual care, 2) a risk-stratified, multidisciplinary approach called the Identify, Coordinate, and Enhance (ICE) care model, or 3) Individualized Postural Therapy (IPT), a standardized postural therapy method of care. The trial's two primary outcomes are change in function at 3 months and spine-related spending at one year. 2971 individuals were enrolled between June 2017 and March 2020. Follow-up was completed on March 31, 2021.

DISCUSSION

The SPINE CARE trial will determine the impact on clinical outcomes and healthcare costs of two interventions for patients with spine pain presenting to primary care.

TRIAL REGISTRATION NUMBER

NCT03083886.

Role of psychosocial factors on the effect of physical activity on physical function in patients after lumbar spine surgery

Background

The purpose of this study was to investigate the longitudinal postoperative relationship between physical activity, psychosocial factors, and physical function in patients undergoing lumbar spine surgery.

Methods

We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition. Physical activity was measured using a triaxial accelerometer (Actigraph GT3X) at 6-weeks (6wk), 6-months (6M), 12-months (12M) and 24-months (24M) following spine surgery. Physical function (computerized adaptive test domain version of Patient-Reported Outcomes Measurement Information System) and psychosocial factors (pain self-efficacy, depression and fear of movement) were assessed at preoperative visit and 6wk, 6M, 12M and 24M after surgery. Structural equation modeling (SEM) techniques were utilized to analyze data, and results are represented as standardized regression weights (SRW). Overall SRW were computed across five imputed datasets to account for missing data. The mediation effect of each psychosocial factor on the effect of physical activity on physical function were computed [(SRW for effect of activity on psychosocial factor X SRW for effect of psychosocial factor on function) ÷ SRW for effect of activity on function]. Each SEM model was tested for model fit by assessing established fit indexes.

Results

The overall effect of steps per day on physical function (SRW ranged from 0.08 to 0.19, p<0.05) was stronger compared to the overall effect of physical function on steps per day (SRW ranged from non-existent to 0.14, p<0.01 to 0.3). The effect of steps per day on physical function and function on steps per day remained consistent after accounting for psychosocial factors in each of the mediation models. Depression and fear of movement at 6M mediated 3.4% and 5.4% of the effect of steps per day at 6wk on physical function at 12M, respectively. Pain self-efficacy was not a statistically significant mediator.

Conclusions

The findings of this study suggest that the relationship between physical activity and physical function is stronger than the relationship of function to activity. However, future research is needed to examine whether promoting physical activity during the early postoperative period may result in improvement of long-term physical function. Since depression and fear of movement had a very small mediating effect, additional work is needed to investigate other potential mediating factors such as pain catastrophizing, resilience and exercise self-efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04622-w.

How Many Steps Per Day During the Early Postoperative Period are Associated With Patient-Reported Outcomes of Disability, Pain, and Opioid Use After Lumbar Spine Surgery?

OBJECTIVE

To investigate whether early postoperative walking is associated with "best outcome" and no opioid use at 1 year after lumbar spine surgery and establish a threshold for steps/day to inform clinical practice.

DESIGN

Secondary analysis from randomized controlled trial.

SETTING

Two academic medical centers in the United States.

PARTICIPANTS

We enrolled 248 participants undergoing surgery for a degenerative lumbar spine condition (N=248). A total of 212 participants (mean age, 62.8±11.4y, 53.3% female) had valid walking data at baseline.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability (Oswestry Disability Index), back and leg pain (Brief Pain Inventory), and opioid use (yes vs no) were assessed at baseline and 1 year after surgery. "Best outcome" was defined as Oswestry Disability Index ≤20, back pain ≤2, and leg pain ≤2. Steps/day (walking) was assessed with an accelerometer worn for at least 3 days and 10 h/d at 6 weeks after spine surgery, which was considered as study baseline. Separate multivariable logistic regression analyses were conducted to determine the association between steps/day at 6 weeks and "best outcome" and no opioid use at 1-year. Receiver operating characteristic curves identified a steps/day threshold for achieving outcomes.

RESULTS

Each additional 1000 steps/d at 6 weeks after spine surgery was associated with 41% higher odds of achieving "best outcome" (95% confidence interval [CI], 1.15-1.74) and 38% higher odds of no opioid use (95% CI, 1.09-1.76) at 1 year. Walking ≥3500 steps/d was associated with 3.75 times the odds (95% CI, 1.56-9.02) of achieving "best outcome" and 2.37 times the odds (95% CI, 1.07-5.24) of not using opioids.

CONCLUSIONS

Walking early after surgery may optimize patient-reported outcomes after lumbar spine surgery. A 3500 steps/d threshold may serve as an initial recommendation during early postoperative counseling.

Composite psychosocial risk based on the fear avoidance model in patients undergoing anterior cruciate ligament reconstruction: Cluster-based analysis

OBJECTIVES

To examine associations between preoperative fear-avoidance model (FAM) risk subgroup status and patient expectation of surgical success with postoperative outcomes at 6 and 12 months after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cohort study.

SETTING

Academic medical center.

PARTICIPANTS

54 patients (25 females) undergoing unilateral ACLR.

MAIN OUTCOME MEASURES

Cluster analysis distinguished FAM risk subgroups based on preoperative fear of movement/reinjury, self-efficacy, and pain catastrophizing. Preoperative expectation for surgical success was assessed with a numeric rating scale. Six and 12-month outcomes included Subjective Patient Outcomes for Return to Sport, Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life, and International Knee Documentation Committee (IKDC) Subjective Knee Form.

RESULTS

Thirteen (24%) patients were "moderate-to-high FAM risk." Moderate-to-high FAM risk patients had lower odds of return to sport at 12 months (OR = 0.3, p = .05) and lower KOOS sports/recreation at 6 months (st. beta = -0.27, p = .05), KOOS quality of life at 12 months (st. beta = -0.42, p = .007), and IKDC at 6 (st. beta = -0.29, p = .04) and 12 months (st. beta = -0.47, p = .001). Higher expectation was associated with lower 6-month IKDC (st. beta = -0.36, p = .008) and 12-month KOOS quality of life (st. beta = -0.29, p = .05).

CONCLUSIONS

Preoperative FAM risk influences patient-reported outcomes and return to sport at 6 and 12 months.

Dart thrower's motion and the injured scapholunate interosseous ligament: A scoping review of studies examining motion, orthoses, and rehabilitation

STUDY DESIGN

Scoping review.

INTRODUCTION

Dart thrower's motion (DTM) of the wrist primarily arises from the midcarpal joint, and minimizes stress to the scapholunate interosseous ligament (SLIL). After SLIL injury or surgery, early controlled DTM may reduce the effects of prolonged immobilization, while protecting SLIL integrity.

PURPOSE OF THE STUDY

To summarize the literature on the effects of DTM on the injured and surgically repaired SLIL and the extent to which various DTM orthotic designs promote SLIL recovery.

METHODS

A systematic literature search was conducted within 6 databases for articles published between 2003 and March 2018. Eligible studies examined DTM in the context of SLIL injury or repair. Relevant data were extracted by 2 independent reviewers.

RESULTS

Of 425 identified articles, 15 were eligible for inclusion. Five biomechanical studies examined the influence of DTM on the injured SLIL, whereas 5 articles described DTM orthotic designs. Also included were five articles that reported outcomes when DTM was used in the rehabilitation protocol.

DISCUSSION

The included studies suggest limiting end ranges of DTM in the injured/repaired SLIL, while blocking orthogonal plane movements. Custom orthotic designs may accomplish this goal. DTM has been used in comprehensive therapy programs in small case studies reporting short-term and intermediate clinical outcomes.

CONCLUSIONS

Caution should be exercised with using DTM on the torn SLIL as gap increases, particularly at the end-range motion. Orthosis designs have potential to limit this motion to midrange, while allowing early movement. Further high-level research is needed to understand the influence of DTM on injured and postsurgical populations.

Pain-Reducing Effects of Physical Therapist-Delivered Interventions: A Systematic Review of Randomized Trials Among Older Adults With Dementia

BACKGROUND AND PURPOSE

Pain is common among older adults with dementia. There are nonpharmacological options for managing pain in this population. However, the effects of physical therapist-delivered interventions have not been summarized. The purpose of this systematic review was to summarize the literature on physical therapist-delivered interventions in randomized trials for reducing pain among older adults with dementia.

METHODS

A systematic search of MEDLINE/PubMed, CINAHL, PsycINFO, and Web of Science was conducted for randomized trials of pain management in individuals 60 years or older with medically diagnosed dementia of any severity. Included studies addressed the effects of nonpharmacological physical therapist-delivered interventions on pain outcomes. Pain outcomes included patient or caregiver self-report, observational or interactive measures. Independent reviewers extracted relevant data and assessed methodological quality using the PEDro scale.

RESULTS AND DISCUSSION

Three studies (total = 222 participants; mean age range = 82.2-84.0 years; 178 [80.2%] females) met inclusion criteria. PEDro scores ranged from 4 to 8/10. Interventions included passive movement and massage. Pain outcomes included the observational measures Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), Pain in Advanced Dementia (PAINAD), and Doloplus-2 Scale. Passive movement did not show better results when compared with no treatment, while massage showed pain-reducing effects in 1 study compared with no treatment.

CONCLUSIONS

The evidence supporting pain-reducing physical therapy interventions for patients with dementia is limited. There is a clear gap in knowledge related to evidence-based physical therapy for managing pain in this population. Future studies should examine active physical therapist-delivered interventions and utilize interactive pain measures.

Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery

BACKGROUND

The purpose of this prospective case series study was to compare changes in early postoperative physical activity and physical function between 6 weeks and 3 and 6 months after lumbar spine surgery.

METHODS

Fifty-three patients (mean [95% confidence interval; CI] age = 59.2 [56.2, 62.3] years, 64% female) who underwent spine surgery for a degenerative lumbar condition were assessed at 6 weeks and 3- and 6-months after surgery. The outcomes were objectively-measured physical activity (accelerometry) and patient-reported and objective physical function. Physical activity was assessed using mean steps/day and time spent in moderate to vigorous physical activity (MVPA) over a week. Physical function measures included Oswestry Disability Index (ODI), 12-item Short Form Health Survey (SF-12), Timed Up and Go (TUG), and 10-Meter Walk (10 MW). We compared changes over time in physical activity and function using generalized estimating equations with robust estimator and first-order autoregressive covariance structure. Proportion of patients who engaged in meaningful physical activity (e.g., walked at least 4400 and 6000 steps/day or engaged in at least 150 min/week in MVPA) and achieved clinically meaningful changes in physical function were compared at 3 and 6 months.

RESULTS

After surgery, 72% of patients initiated physical therapy (mean [95%CI] sessions =8.5 [6.6, 10.4]) between 6 weeks and 3 months. Compared to 6 weeks post-surgery, no change in steps/day or time in MVPA/week was observed at 3 or 6 months. From 21 to 23% and 9 to 11% of participants walked at least 4400 and 6000 steps/day at 3 and 6 months, respectively, while none of the participants spent at least 150 min/week in MVPA at these same time points. Significant improvements were observed on ODI, SF-12, TUG and 10 MW (p <  0.05), with over 43 to 68% and 62 to 87% achieving clinically meaningful improvements on these measures at 3 and 6 months, respectively.

CONCLUSION

Limited improvement was observed in objectively-measured physical activity from 6 weeks to 6 months after spine surgery, despite moderate to large function gains. Early postoperative physical therapy interventions targeting physical activity may be needed.

Embedding pain neuroscience education in the physical therapy management of patients with chronic plantar fasciitis: a prospective case series

OBJECTIVES

The purpose of this case series was to describe the effects of a biopsychosocial approach that embeds pain neuroscience education (PNE) within physical therapy for improving foot and ankle function, pain, and psychosocial factors in patients with chronic plantar fasciitis.

METHODS

Seven female patients (mean [SD] age = 49.0 [11.4] years) receiving physical therapy for chronic plantar fasciitis were enrolled. Along with formal physical therapy, patients received six 15-minute PNE sessions. Knowledge of pain neuroscience was assessed before and after PNE with the Revised Neurophysiology of Pain Questionnaire. Patients completed questionnaires for foot and ankle function (Activities of Daily Living subscale of the Foot and Ankle Ability Measure), pain intensity (Numeric Rating Scale), pain catastrophizing (Pain Catastrophizing Scale), and fear of movement (Tampa Scale for Kinesiophobia) at baseline (before treatment) and 6 and 12 weeks. Local and remote pain sensitivity was assessed using a pressure algometer at baseline and 6 weeks.

RESULTS

Patients attended a mean (range) of 8.7 (7 to 12) physical therapy sessions over a mean (range) of 46.7 (42 to 56) days. After PNE, six (86%) patients demonstrated increased knowledge of pain neuroscience. At 12 weeks, six (86%) patients met or exceeded minimally clinically important difference (MCID) for foot and ankle function and pain. Five (71%) patients met or exceeded MCID for pain catastrophizing and fear of movement. Local pain sensitivity was reduced in six (86%) patients.

CONCLUSIONS

Physical therapy integrating PNE is potentially beneficial for patients with chronic plantar fasciitis. Future studies should examine the efficacy of PNE in randomized trials with larger representative samples.

Psychosocial Mechanisms of Cognitive-Behavioral-Based Physical Therapy Outcomes After Spine Surgery: Preliminary Findings From Mediation Analyses

OBJECTIVE

Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery.

METHODS

In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months.

RESULTS

Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1]).

CONCLUSIONS

This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism.

IMPACT

Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs.

Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: An open pilot study

OBJECTIVES

To describe feasibility, adherence, acceptability, and outcomes of a cognitive-behavioral-based physical therapy (CBPT-ACLR) intervention for improving postoperative recovery after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Pilot study.

SETTING

Academic medical center.

PARTICIPANTS

Eight patients (mean age [SD] = 20.1 [2.6] years, 6 females) participated in a 7-session telephone-based CBPT-ACLR intervention beginning preoperatively and lasting 8 weeks after surgery.

MAIN OUTCOME MEASURES

At 6 months, patients completed Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life (QOL) subscales, International Knee Documentation Committee (IKDC), Tampa Scale of Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), and Knee Self-Efficacy Scale (K-SES), return to sport (Subjective Patient Outcome for Return to Sports), and satisfaction. Minimal clinically important difference (MCID) was used for meaningful change.

RESULTS

Seven (88%) patients completed all sessions. Seven (88%) patients exceeded MCID on the TSK, 6 (75%) on the PCS, 5 (63%) on the KOOS sports/recreation subscale, 4 (50%) on the IKDC, and 3 (38%) on the KOOS QOL subscale. Three (38%) patients returned to their same sport at the same level of effort and performance. All patients were satisfied with their recovery.

CONCLUSIONS

A CBPT-ACLR program is feasible and acceptable for addressing psychological risk factors after ACLR.

Biopsychosocial Influences on Shoulder Pain: Analyzing the Temporal Ordering of Postoperative Recovery

Shoulder surgery is a primary intervention for shoulder pain, yet many individuals experience persistent postoperative pain. Previously, we found individuals categorized as having a high-risk phenotype (comprised of COMT variation and pain catastrophizing) had approximately double the chance of not reaching a 12-month pain recovery criterion. As a means to better understand the development of persistent postoperative shoulder pain, this study advanced our previous work by examining temporal ordering of postoperative shoulder recovery based on potential mediating factors, and expansion of outcomes to include movement-evoked pain and shoulder active range of motion. Before surgery, individuals were categorized as either high-risk (high pain catastrophizing, COMT-genotype linked to low enzyme activity [n = 41]) or low-risk (low pain catastrophizing, COMT-genotype linked to normal enzyme activity [n = 107]). We then compared potential mediating variables at 3, 6, and 12 months postoperatively 1) endogenous pain modulation defined by a conditioned pain modulation paradigm; and 2) and emotion factors such as anxiety, fear of movement, and depressive symptoms. At 3 months, the high-risk subgroup had higher fear and movement-evoked pain, and causal mediation analysis confirmed the direct effect of risk subgroup on 12-month movement evoked pain. However, baseline to 12-month change in depressive symptoms were found to mediate 53% of the total effect of risk subgroup on 12-month movement-evoked pain. This study introduces potential temporal components and relationships to the development of persistent postoperative shoulder pain, which future studies will confirm and assess for potential therapeutic targets. PERSPECTIVE: This study expands upon postoperative shoulder recovery measures to include movement-evoked pain and depressive symptoms, and provides preliminary indication of temporal ordering to postoperative shoulder recovery for a preidentified high-risk subgroup. Future studies will distinguish temporal components of shoulder surgery that may optimize treatment targets of postoperative recovery.

Safety and feasibility of an early telephone-supported home exercise program after anterior cervical discectomy and fusion: a case series

Objective: To describe the safety, feasibility, and preliminary outcomes of an early telephone-supported home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF) surgery.Methods: Eight patients (mean ± SD age = 53.4 ± 14.9 years, 5 females) were enrolled in this case series. Immediately after surgery, patients began a 6-week HEP including daily walking, deep breathing, distraction techniques, and cervical and upper body exercises. The HEP was supported by weekly telephone calls by a physical therapist. Safety for performing early exercise was examined with radiographic imaging at 6 months. Adverse events were assessed through weekly calls with a physical therapist. HEP adherence and acceptability data were obtained by patient self-report. Clinical measures were assessed preoperatively, at 6 weeks and at 6 months, and included the Neck Disability Index, Numeric Rating Scale for pain, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and accelerometry for physical activity.Results: Early radiographic imaging showed no signs of nonunion at 6 months. There were no reports of serious adverse events. At 6 months, all patients reported clinically significant changes in pain catastrophizing. Seven (88%) patients had clinically significant changes in disability and arm pain, six (75%) patients for neck pain and pain self-efficacy, and five (53%) patients for fear of movement. Only three (43%) of seven patients showed increased physical activity at 6 months.Conclusion: Based on this small case series, an early telephone-supported HEP appears safe for patients, feasible to implement, and promising for clinical benefits.

The Central Sensitization Inventory and Pain Sensitivity Questionnaire: An exploration of construct validity and associations with widespread pain sensitivity among individuals with shoulder pain

BACKGROUND

The Central Sensitization Inventory (CSI) and Pain Sensitivity Questionnaire (PSQ) are alternatives to quantitative sensory testing (QST) for inferring central sensitization.

OBJECTIVE

Explore 1) comparative validity of the CSI and PSQ with QST (construct validity) and pain-related psychological questionnaires (concurrent validity), and 2) associations with widespread pain sensitivity.

METHODS

Seventy-eight participants with unilateral shoulder pain less than 6 months (mean ± SD age = 39.0 ± 14.5 years, N (%) females = 36 (46.2%)) completed the CSI, PSQ, psychological questionnaires, and underwent QST for local and remote pressure pain thresholds (PPT), heat pain threshold, and suprathreshold heat pain ratings. Data from 25 age and sex-matched healthy participants (mean ± SD age = 35.2 ± 11.1 year, N (%) females = 13 (52.0%)) were used to determine a composite index for widespread pressure pain sensitivity in the shoulder pain group. Analyses included correlations between measures and between-group comparisons.

RESULTS

Only the PSQ was associated with remote PPT (rho range = -0.25 to -0.27). Both the CSI and PSQ were associated with resilience (rho range = -0.29 to -0.39), anxiety (rho range = 0.25 to 0.66), and negative affect (rho range = 0.27 to 0.67). Neither the CSI nor PSQ were associated with widespread pain sensitivity (p > 0.05). Resilience (adjusted OR = 0.41, 95% CI = 0.18; 0.94) was a distinctive feature for widespread pain sensitivity.

CONCLUSIONS

These preliminary findings challenge the exclusive use of the CSI or PSQ for inferring central sensitization among individuals with shoulder pain.

The association of discharge destination with 30-day rehospitalization rates among older adults receiving lumbar spinal fusion surgery

BACKGROUND

As defined by Medicare (United States), post-acute rehabilitation services include care provided in inpatient rehabilitation units and facilities, skilled nursing facilities, long-term acute hospitals, and by home health services.

METHODS

We retrospectively evaluated the use of rehabilitation-based post-acute services among Medicare beneficiaries who were hospitalized for lumbar spinal fusion (ICD-9-CM procedure codes 81.04-81.08) in 2012-2014, examined the case-mix for those discharged to rehabilitation- and non-rehabilitation based services, and determined the association between these categories of discharge disposition and 30-day rehospitalization. The independent effect of rehabilitation-based discharge destination on 30-day readmissions was examined with a generalized linear mixed model, first adjusting for patient characteristics and then stratified by clusters that delineated more homogenous clinical profiles.

RESULTS

Among 261,558 Medicare beneficiaries with lumbar spinal fusion surgery, 50.8% were discharged to a rehabilitation-based post-acute services. Patients discharged to rehabilitation-based services were older and had more comorbidities, and had longer hospital lengths of stays. After adjusting for patient and hospital characteristics, patients discharged to rehabilitation-based post-acute care had increased odds of 30-day rehospitalization than those without discharge to other destinations (OR 1.36; 95%CI = 1.31, 1.40). Analysis of patients by clinical profile clusters found similar results.

CONCLUSIONS

Clinical profiles of Medicare beneficiaries who had lumbar spinal fusion surgery and were discharged to rehabilitation-based post-acute services included more comorbidities than those discharged to non-rehabilitation based settings. Controlling for these differences did not mediate the negative association between use of rehabilitation-based post-acute services and 30-day readmission.

Changes in psychosocial well-being after mindfulness-based stress reduction: a prospective cohort study

Objectives: The primary purpose of the current study was to assess the effects of a mindfulness-based stress reduction (MBSR) program, facilitated by non-psychologist clinicians, for improving psychosocial well-being. A secondary purpose of the current study was to explore the role of self-compassion as a potential underlying factor for improvements in emotional distress. Application of these findings to a physical therapy setting is provided. Methods: One hundred and thirty participants with a variety of medical complaints completed an eight-week MBSR program at Vanderbilt University's Osher Center for Integrative Medicine. Prior to the intervention and at the eight-week time point, participants completed measures for emotional distress (Brief Symptom Inventory), stress (Perceived Stress Scale-10), mindfulness (Mindfulness Attention and Awareness Scale), and self-compassion (Self-Compassion Scale). Wilcoxon signed-rank test was used to evaluate changes in outcomes after MBSR. Linear model estimation using ordinary least squares was used to evaluate the association between changes in self-compassion with changes in emotional distress. Results: Following MBSR, participants reported significant reductions in emotional distress (p < 0.001). Additionally, participants reported improvements in mindfulness and self-compassion (p < 0.001). Linear regression model revealed that changes in self-compassion were significantly associated with changes in emotional distress (p < 0.001). Discussion: An MBSR program conducted by non-psychologist clinicians was associated with improvements in emotional distress, stress, and self-compassion. MBSR is a promising adjunct intervention in which principles can be integrated within a physical therapy approach for chronic conditions. Level of Evidence: 3B.

Preoperative physical therapy treatment did not influence postoperative pain and disability outcomes in patients undergoing shoulder arthroscopy: a prospective study

Background

There is limited literature investigating preoperative physical therapy (pre-op PT) treatment on pain intensity and disability after musculoskeletal surgery. The purposes of the present cohort study were to describe patient characteristics for those who had and did not have pre-op PT treatment and determine whether pre-op PT influenced the length of postoperative physical therapy (post-op PT) treatment (number of sessions) and 3-month and 6-month postsurgical outcomes, such as pain intensity and disability.

Patients and methods

A total of 124 patients (mean age =43 years, 81 males) with shoulder pain were observed before and after shoulder arthroscopic surgery. Demographic data, medical history, and validated self-report questionnaires were collected preoperatively and at 3 months and 6 months after surgery. Analysis of variance models were performed to identify differences across measures for patients who had pre-op PT treatment and those who did not and to examine outcome differences at 3 months and 6 months. Alpha was set at the 0.05 level for statistical significance.

Results

Males had less participation in pre-op PT than females (P=0.01). In contrast, age, pain intensity, disability, and pain-associated psychological factors did not differ between pre-op PT treatment groups (P>0.05). Subacromial bursectomies were more commonly performed in patients having pre-op PT treatment (P<0.05). Pre-op PT treatment did not influence length of post-op PT treatment and did not affect 3-month and 6-month pain intensity and disability outcomes. Differences in distribution of pre-op PT for males and females and subacromial bursectomy did not influence 3-month or 6-month postsurgical outcomes.

Conclusion

Receiving pre-op PT treatment did not influence post-op PT treatment or pain and disability outcomes at 3 months and 6 months. This prospective cohort study provides no evidence of benefit for pre-op PT on post-op PT treatment or postsurgical outcomes. Females or patients receiving certain surgical procedures are more likely to undergo pre-op PT treatment. However, these differences did not influence postoperative outcomes in this cohort.

Thalamic Functional Connectivity in Mild Traumatic Brain Injury: Longitudinal Associations With Patient-Reported Outcomes and Neuropsychological Tests

OBJECTIVES

(1) To examine differences in patient-reported outcomes, neuropsychological tests, and thalamic functional connectivity (FC) between patients with mild traumatic brain injury (mTBI) and individuals without mTBI and (2) to determine longitudinal associations between changes in these measures.

DESIGN

Prospective observational case-control study.

SETTING

Academic medical center.

PARTICIPANTS

A sample (N=24) of 13 patients with mTBI (mean age, 39.3±14.0y; 4 women [31%]) and 11 age- and sex-matched controls without mTBI (mean age, 37.6±13.3y; 4 women [36%]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Resting state FC (3T magnetic resonance imaging scanner) was examined between the thalamus and the default mode network, dorsal attention network, and frontoparietal control network. Patient-reported outcomes included pain (Brief Pain Inventory), depressive symptoms (Patient Health Questionnaire-9), posttraumatic stress disorder ([PTSD] Checklist - Civilian Version), and postconcussive symptoms (Rivermead Post-Concussion Symptoms Questionnaire). Neuropsychological tests included the Delis-Kaplan Executive Function System Tower test, Trails B, and Hotel Task. Assessments occurred at 6 weeks and 4 months after hospitalization in patients with mTBI and at a single visit for controls.

RESULTS

Student t tests found increased pain, depressive symptoms, PTSD symptoms, and postconcussive symptoms; decreased performance on Trails B; increased FC between the thalamus and the default mode network; and decreased FC between the thalamus and the dorsal attention network and between the thalamus and the frontoparietal control network in patients with mTBI as compared with controls. The Spearman correlation coefficient indicated that increased FC between the thalamus and the dorsal attention network from baseline to 4 months was associated with decreased pain and postconcussive symptoms (corrected P<.05).

CONCLUSIONS

Findings suggest that alterations in thalamic FC occur after mTBI, and improvements in pain and postconcussive symptoms are correlated with normalization of thalamic FC over time.

Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy

BACKGROUND

Shoulder pain and surgery are common among older adults. However, the extent to which older age affects recovery after shoulder surgery is not well understood.

OBJECTIVE

To assess influence of older age on postoperative recovery factors 3 and 6 months after shoulder arthroscopy.

DESIGN

Prospective cohort study.

SETTING

University-affiliated outpatient orthopedic surgical center.

PATIENTS

A convenience sample of 139 persons between 20 and 79 years of age who experienced shoulder pain, had musculoskeletal dysfunction based on imaging and physician assessment, and were scheduled for an arthroscopic shoulder procedure.

MAIN OUTCOME MEASURES

Postoperative outcomes were compared among younger, middle-aged, and older adults before surgery and at 3 and 6 months after surgery using analysis of variance modeling. Movement-evoked pain and an experimental laboratory correlate of pain processing were assessed at each time point. The influence of older age on 3- and 6-month pain outcomes were determined via multivariate regression analyses after accounting for preoperative, intraoperative, and postoperative prognostic factors.

RESULTS

Older adults had higher movement-evoked pain intensity (F2,108 = 5.18, P = .007) and experimental pain response (F2,111 = 7.24, P = .001) at 3 months compared with young and middle-aged adults. After controlling for key prognostic factors, older age remained a positive predictor of 3-month movement-evoked pain (R(2) = 0.05; standardized [St.] β = 0.263, P = .031) and experimental pain response (R(2) = 0.07; St. β = 0.295, P = .014). Further, older age remained a positive predictor of movement-evoked pain at 6 months (R(2) = 0.04; St. β = 0.231, P = .004), despite no age group differences in outcome. Older age was found to be the strongest predictor of 3- and 6-month movement-evoked pain.

CONCLUSION

Older adults may experience more pain related to movement, as well as endogenous pain excitation, in the first few months after shoulder arthroscopy. Future age-related research should consider use of movement-evoked pain intensity and experimental pain response as pain outcomes, as well as the utility of such measures in clinical care.

Pain Sensitivity and Pain Catastrophizing Are Associated With Persistent Pain and Disability After Lumbar Spine Surgery

OBJECTIVE

To examine whether pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery.

DESIGN

Prospective observational cohort study.

SETTING

Academic medical center.

PARTICIPANTS

Patients (N=68; mean age, 57.9±13.1y; 40 women [58.8%]) undergoing spine surgery for a degenerative condition from March 1, 2012 to April 30, 2013 were assessed 6 weeks, 3 months, and 6 months after surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The main outcome measures were persistent back pain intensity, pain interference, and disability. Patients with persistent back pain intensity, pain interference, or disability were identified as those patients reporting Brief Pain Inventory scores ≥4 and Oswestry Disability Index scores ≥21 at all postoperative time points.

RESULTS

From 6 weeks to 6 months after surgery, approximately 12.9%, 24.2%, and 46.8% of patients reported persistent back pain intensity, pain interference, or disability, respectively. Increased pain sensitivity at 6 weeks was associated with having persistent back pain intensity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.1) after surgery. Increased pain catastrophizing at 6 weeks was associated with having persistent back pain intensity (OR, 1.1; 95% CI, 1.0-1.2), pain interference (OR, 1.1; 95% CI, 1.0-1.2), and disability (OR, 1.3; 95% CI, 1.1-1.4). An interaction effect was not found between pain sensitivity and pain catastrophizing on persistent outcomes (P>.05).

CONCLUSIONS

The findings suggest the importance of early postoperative screening for pain sensitivity and pain catastrophizing to identify patients at risk for poor postoperative pain intensity, pain interference, and/or disability outcomes. Future research should consider the benefit of targeted therapeutic strategies for patients with these postoperative prognostic factors.

Telephone-based goal management training for adults with mild traumatic brain injury: study protocol for a randomized controlled trial

BACKGROUND

Approximately 1 million individuals experience a mild traumatic brain injury (TBI) and cost the United States nearly $17 billion each year. Many trauma survivors with mild TBI have debilitating and long-term physical, emotional, and cognitive impairments that are unrecognized at trauma centers. Early intervention studies are needed to address these impairments, especially cognitive deficits in executive functioning. Goal management training (GMT) is a structured cognitive rehabilitation program that has been found to improve executive functioning in patients with moderate to severe TBI. The current study adapted the GMT program for telephone delivery in order to improve the accessibility of rehabilitation services in a patient population with multiple barriers to care and significant yet unrecognized cognitive impairment. The primary objective of this study is to examine the efficacy of telephone-based GMT for improving executive functioning, functional status, and psychological health in trauma survivors with mild TBI.

METHODS/DESIGN

This study is a three-group randomized controlled trial being conducted at a Level I trauma center. Ninety trauma survivors with mild TBI and cognitive deficits in executive functioning will be randomized to receive telephone-based GMT, telephone-based education, or usual care. GMT and education programs will be delivered by a physical therapist. The first in-person session is 1 h and the remaining six telephone sessions are 30 min. A battery of well-established cognitive tests will be conducted and validated questionnaires will be collected that measure executive functioning, functional status, and depressive and posttraumatic stress disorder symptoms at 6 weeks, 4 months, and 7 months following hospital discharge.

DISCUSSION

This study supports a telephone-delivery approach to rehabilitation services in order to broaden the availability of evidence-based cognitive strategies.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov on 10 October 2012, registration number: NCT01714531.

Content and bibliometric analyses of the Journal of Manual & Manipulative Therapy

BACKGROUND

Article characteristics and trends have been elucidated for other physical therapy-focused journals using content and bibliometric analysis. These findings are important for assessing the current state of a journal and for guiding future publication of research. To date, these analyses have not been performed for the Journal of Manual & Manipulative Therapy (JMMT).

OBJECTIVE

To describe content and trends for articles published in JMMT over a 20-year period (1993-2012).

METHODS

Journal articles were coded using previously-established domains (article type, participant type, research design, study purpose, and clinical condition). Total publications and proportion of publications based on domain were described. Articles specific to manual therapy intervention were examined and compared to data from other physical therapy-focused journals. Impact by citation and author was examined using bibliometric software.

RESULTS

Journal of Manual & Manipulative Therapy was found to have a recent acceleration in the number of articles published annually. Over time, topical reviews have decreased in favor of research reports. However, rigorous study designs have represented only a small portion of total journal content, and case reports have maintained a consistent publication presence. Manual therapy intervention articles in JMMT are predominantly case designs, however are similar in characteristics to manual therapy intervention articles published in other physical therapy-focused journals. For JMMT articles overall and manual therapy intervention articles across journals, young to middle-aged symptomatic adults with low back and/or neck pain were the most common study participants.

DISCUSSION

Increases in the number of papers and a move toward research reports were observed in JMMT over the 20-year period. Considerations for the future were outlined, including the publication of articles with more rigorous research designs. Manual therapy research for adolescents and older adults and for upper and lower extremity conditions should also be considered as priorities for the future.

A comparative effectiveness trial of postoperative management for lumbar spine surgery: changing behavior through physical therapy (CBPT) study protocol

Background

The United States has the highest rate of lumbar spine surgery in the world, with rates increasing over 200% since 1990. Medicare spends over $1 billion annually on lumbar spine surgery. Despite surgical advances, up to 40% of patients report chronic pain and disability following surgery. Our work has demonstrated that fear of movement is a risk factor for increased pain and disability and decreased physical function in patients following lumbar spine surgery for degenerative conditions. Cognitive-behavioral therapy and self-management treatments have the potential to address psychosocial risk factors and improve outcomes after spine surgery, but are unavailable or insufficiently adapted for postoperative care. Our research team developed a cognitive-behavioral based self-management approach to postoperative rehabilitation (Changing Behavior through Physical Therapy (CBPT)). Pilot testing of the CBPT program demonstrated greater improvement in pain, disability, physical and mental health, and physical performance compared to education. The current study compares which of two treatments provided by telephone – a CBPT Program or an Education Program about postoperative recovery - are more effective for improving patient-centered outcomes in adults following lumbar spine surgery for degenerative conditions.

Methods/design

A multi-center, comparative effectiveness trial will be conducted. Two hundred and sixty patients undergoing lumbar spine surgery for degenerative conditions will be recruited from two medical centers and community surgical practices. Participants will be randomly assigned to CBPT or Education at 6 weeks following surgery. Treatments consist of six weekly telephone sessions with a trained physical therapist. The primary outcome will be disability and secondary outcomes include pain, general health, and physical activity. Outcomes will be assessed preoperatively and at 6 weeks, 6 months and 12 months after surgery by an assessor masked to group allocation.

Discussion

Effective rehabilitation treatments that can guide clinicians in their recommendations, and patients in their actions will have the potential to effect change in current clinical practice.

Trial registration

NCT02184143.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-325) contains supplementary material, which is available to authorized users.

Experimental pain responses support peripheral and central sensitization in patients with unilateral shoulder pain

OBJECTIVE

The aims of this study were to (1) examine the pattern of experimental pain responses in the affected and nonaffected extremities in patients with shoulder pain and (2) explore the intraindividual association between sensitization states derived from experimental pain testing.

METHODS

Experimental pain responses from 58 patients with shoulder pain (17 women, aged 18 to 52 y) were compared with those from 56 age-matched and sex-matched pain-free volunteers (16 women, aged 21 to 58 y). Experimental pain responses included pressure pain threshold (PPT), thermal pain threshold and tolerance, and suprathreshold heat pain response. Comparisons were made between the affected and nonaffected extremities of clinical participants and the average response of extremities in control participants. Peripheral and central sensitization indexes were computed for clinical participants using standardized scores and percentile cutoffs on the basis of the data from the control sample. Experimental pain responses in clinical participants observed beyond the 25th and 75th percentile of control sample responses were used for investigation of intraindividual association of sensitization states.

RESULTS

PPT at the acromion and masseter on the affected side of clinical participants were diminished compared with that on their nonaffected side (P<0.015). Bilateral sensitivity in clinical participants was noted for PPT at the acromion and suprathreshold heat pain response (P<0.015). Peripheral and central sensitization indexes demonstrated that individuals with shoulder pain present with variable patterns of peripheral and central sensitization.

CONCLUSIONS

Collectively, experimental pain responses supported peripheral and central sensitization in response to pressure and thermal stimuli. No clear association was made between individuals exhibiting peripheral or central sensitization, thus suggesting heterogeneity in pain processing in this clinical population.

The effects of whole body vibration on mobility and balance in Parkinson disease: a systematic review

Whole body vibration (WBV) is a contemporary treatment modality that holds promise as an exercise training method in health-compromised individuals. A growing number of studies on individuals with Parkinson Disease are examining whether WBV improves balance and functional mobility. However, interpreting WBV studies is challenging since there is variability in the manner in which WBV intervention is conducted. The primary goal of this systematic review was to investigate the effect of WBV on improving mobility and balance as measured by a battery of clinical tests, in patients with Parkinson disease. Studies based on WBV parameters were characterized and a systematic search of peer-reviewed literature in five major databases was conducted. Randomized-controlled trials investigating the effects of WBV in patients with a Parkinson diagnosis and no cognitive impairment were included. A total of six publications met the inclusion criteria. Overall, studies demonstrated mixed results in favor of WBV for improving balance or mobility. The majority of studies seem to suggest a favorable benefit following WBV for mobility and balance, but not when compared to other active intervention or placebo. There was variability in the manner in which WBV intervention was applied. Variations among the six studies included: duration of intervention and rest, follow-up period, type of control groups, frequency of vibration, number of treatment sessions and sex distribution of subjects. Future research is needed to investigate the effects of different types of equipment and treatment dosage in individuals with Parkinson disease.

The relative effectiveness of segment specific level and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis

STUDY DESIGN

Systematic literature review and meta-analysis.

OBJECTIVE

IN SYMPTOMATIC SUBJECTS TO: (1) examine the effects of a single session of joint mobilization on pain at rest and with most painful movement, and (2) compare the effects when joint mobilization is provided to a specific or non-specific spinal level.

BACKGROUND

Joint mobilization is routinely used for treating spinal pain in conjunction with other interventions, but its unique effect is not well understood. Further, there is controversy about the role of 'specific level' techniques in producing benefit.

METHODS

Searches were performed for randomized controlled trials (RCTs) using electronic databases (MEDLINE, CINAHL, and PEDro) from 1966 through November 2010. Methodological quality was assessed using previously detailed criteria. Meta-analysis and meta-regression were conducted on eligible studies.

RESULTS

Eight RCTs with a mean methodological score of 10/12 were included. Significant heterogeneity (P = 0.075) was found in the overall meta-analysis estimate. When stratified by body location, no significant individual effect was found for pain at rest. However, there was a statistical mean difference [0.71 (95% confidence interval: 0.13-1.28)] between pain at rest for the cervical and lumbar individual means.

CONCLUSIONS

We found multiple studies which provided evidence that a single session of joint mobilization can lead to a reduction of pain at rest and with most painful movement. When using joint mobilization, the need for specific versus non-specific level mobilization may be influenced by anatomical region; the direction of effect in the cervical spine was toward specific mobilization and in the lumbar spine towards non-specific mobilization.

Effect of a single session of muscle-biased therapy on pain sensitivity: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Muscle-biased therapies (MBT) are commonly used to treat pain, yet several reviews suggest evidence for the clinical effectiveness of these therapies is lacking. Inadequate treatment parameters have been suggested to account for inconsistent effects across studies. Pain sensitivity may serve as an intermediate physiologic endpoint helping to establish optimal MBT treatment parameters. The purpose of this review was to summarize the current literature investigating the short-term effect of a single dose of MBT on pain sensitivity in both healthy and clinical populations, with particular attention to specific MBT parameters of intensity and duration.

METHODS

A systematic search for articles meeting our prespecified criteria was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE from the inception of each database until July 2012, in accordance with guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analysis. Relevant characteristics from studies included type, intensity, and duration of MBT and whether short-term changes in pain sensitivity and clinical pain were noted with MBT application. Study results were pooled using a random-effects model to estimate the overall effect size of a single dose of MBT on pain sensitivity as well as the effect of MBT, dependent on comparison group and population type.

RESULTS

Reports from 24 randomized controlled trials (23 articles) were included, representing 36 MBT treatment arms and 29 comparative groups, where 10 groups received active agents, 11 received sham/inert treatments, and eight received no treatment. MBT demonstrated a favorable and consistent ability to modulate pain sensitivity. Short-term modulation of pain sensitivity was associated with short-term beneficial effects on clinical pain. Intensity of MBT, but not duration, was linked with change in pain sensitivity. A meta-analysis was conducted on 17 studies that assessed the effect of MBT on pressure pain thresholds. The results suggest that MBT had a favorable effect on pressure pain thresholds when compared with no-treatment and sham/inert groups, and effects comparable with those of other active treatments.

CONCLUSION

The evidence supports the use of pain sensitivity measures by future research to help elucidate optimal therapeutic parameters for MBT as an intermediate physiologic marker.

Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis

Spinal manipulation (SMT) is commonly used for treating individuals experiencing musculoskeletal pain. The mechanisms of SMT remain unclear; however, pain sensitivity testing may provide insight into these mechanisms. The purpose of this systematic review is to examine the literature on the hypoalgesic effects of SMT on pain sensitivity measures and to quantify these effects using meta-analysis. We performed a systematic search of articles using CINAHL, MEDLINE, PsycINFO, and SPORTDiscus from each databases' inception until May 2011. We examined methodological quality of each study and generated pooled effect size estimates using meta-analysis software. Of 997 articles identified, 20 met inclusion criteria for this review. Pain sensitivity testing used in these studies included chemical, electrical, mechanical, and thermal stimuli applied to various anatomical locations. Meta-analysis was appropriate for studies examining the immediate effect of SMT on mechanical pressure pain threshold (PPT). SMT demonstrated a favorable effect over other interventions on increasing PPT. Subgroup analysis showed a significant effect of SMT on increasing PPT at the remote sites of stimulus application supporting a potential central nervous system mechanism. Future studies of SMT related hypoalgesia should include multiple experimental stimuli and test at multiple anatomical sites.