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Greenlee TA, Bullock G, Teyhen DS, Rhon DI. Can a Psychologic Profile Predict Successful Return to Full Duty After a Musculoskeletal Injury? Clin Orthop Relat Res 2024; 482:617-629. [PMID: 38112301 PMCID: PMC10936990 DOI: 10.1097/corr.0000000000002935] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/31/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Psychologic variables have been shown to have a strong relationship with recovery from injury and return to work or sports. The extent to which psychologic variables predict successful return to work in military settings is unknown. QUESTIONS/PURPOSES In a population of active duty soldiers, (1) can a psychologic profile determine the risk of injury after return to full duty? (2) Do psychologic profiles differ between soldiers sustaining injuries in the spine (thoracic or lumbar) and those with injuries to the lower extremities? METHODS Psychologic variables were assessed in soldiers returning to full, unrestricted duty after a recent musculoskeletal injury. Most of these were noncombat injuries from work-related physical activity. Between February 2016 and September 2017, 480 service members who were cleared to return to duty after musculoskeletal injuries (excluding those with high-velocity collisions, pregnancy, or amputation) were enrolled in a study that tracked subsequent injuries over the following year. Of those, we considered individuals with complete 12-month follow-up data as potentially eligible for analysis. Based on that, approximately 2% (8 of 480) were excluded because they did not complete baseline surveys, approximately 2% (11 of 480) were separated from the military during the follow-up period and had incomplete injury data, 1% (3 of 480) were excluded for not serving in the Army branch of the military, and approximately 2% (8 of 480) were excluded because they were not cleared to return to full duty. This resulted in 450 soldiers analyzed. Individuals were 86% (385 of 450) men; 74% (331 of 450) had lower extremity injuries and 26% (119 of 450) had spinal injuries, including soft tissue aches and pains (for example, strains and sprains), fractures, and disc herniations. Time-loss injury within 1 year was the primary outcome. While creating and validating a new prediction model using only psychological variables, 19 variables were assessed for nonlinearity, further factor selection was performed through elastic net, and models were internally validated through 2000 bootstrap iterations. Performance was deciphered through calibration, discrimination (area under the curve [AUC]), R 2 , and calibration in the large. Calibration assesses predicted versus actual risk by plotting the x and y intersection of these values; the more similar predicted risk values are to actual ones, the closer the slope of the line formed by the intersection points of all subjects is to equaling "1" (optimal calibration). Likewise, perfect discrimination (predicted injured versus actual injured) presents as an AUC of 1. Perfect calibration in the large would equal 0 because it represents the average predicted risk versus the actual outcome rate. Sensitivity analyses stratified groups by prior injury region (thoracic or lumbar spine and lower extremity) as well as the severity of injury by days of limited duty (moderate [7-27 days] and severe [28 + days]). RESULTS A model comprising primarily psychologic variables including depression, anxiety, kinesiophobia, fear avoidance beliefs, and mood did not adequately determine the risk of subsequent injury. The derived logistic prediction model had 18 variables: R 2 = 0.03, calibration = 0.63 (95% confidence interval [CI] 0.30 to 0.97), AUC = 0.62 (95% CI 0.52 to 0.72), and calibration in the large = -0.17. Baseline psychologic profiles between body regions differed only for depression severity (mean difference 1 [95% CI 0 to 1]; p = 0.04), with greater mean scores for spine injuries than for lower extremity injuries. Performance was poor for those with prior spine injuries compared with those with lower extremity injuries (AUC 0.50 [95% CI 0.42 to 0.58] and 0.63 [95% CI 0.57 to 0.69], respectively) and moderate versus severe injury during the 1-year follow-up (AUC 0.61 [95% CI 0.51 to 0.71] versus 0.64 [95% CI 0.64 to 0.74], respectively). CONCLUSION The psychologically based model poorly predicted subsequent injury. This study does not minimize the value of assessing the psychologic profiles of injured athletes, but rather suggests that models looking to identify injury risk should consider a multifactorial approach that also includes other nonpsychologic factors such as injury history. Future studies should refine the most important psychologic constructs that can add the most value and precision to multifactorial models aimed at identifying the risk of injury. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
| | - Garrett Bullock
- Department of Orthopaedics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Deydre S. Teyhen
- Army Medical Specialist Corps, Office of the Army Surgeon General, Bethesda, MD, USA
| | - Daniel I. Rhon
- Brooke Army Medical Center, San Antonio, TX, USA
- Department of Rehabilitation Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Rhon DI, George SZ, Greenlee TA, Farrokhi S, Lentz TA. General and Pain-Associated Psychological Distress Phenotypes Among Patients With Low Back Pain in the Military Health System. Arthritis Care Res (Hoboken) 2024. [PMID: 38383982 DOI: 10.1002/acr.25315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/17/2024] [Accepted: 02/20/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE The primary objective was to describe rates of general and pain-related psychological distress for individuals with low back pain (LBP) in the Military Health System (MHS). We identified common phenotypes defined by rates of general and pain-related psychological distress and compared phenotypes on their level of pain interference, physical function, anxiety, and depression. METHODS We created a cohort from two completed trials assessing nonpharmacological treatment for LBP in the MHS (n = 510 total). The Optimal Screening for Prediction of Referral and Outcome Yellow Flag assessment tool identified the presence of 11 different yellow flags. Latent class analysis (LCA) used yellow flag indicators to identify common psychological phenotypes. We then compared Patient-Reported Outcomes Measurement Information Systems measures of pain interference, physical function, sleep disturbance, depression, and anxiety across phenotypes. RESULTS LCA identified five phenotypes (percentage of the sample): low distress (32%), high distress (27%), poor pain coping and low self-efficacy (18%), low self-efficacy and acceptance (14%), and poor pain coping (10%). Highly distressed phenotypes reported higher levels of pain interference, sleep disturbance, depression, and anxiety than those with other phenotypes, whereas the low distress phenotype had significantly lower pain interference and higher physical function scores than those characterized by all other phenotypes. CONCLUSION These phenotypes provide opportunities for clinicians and researchers to develop novel LBP treatment pathways tailored to patients with different profiles of psychological distress. Future work is needed to validate their predictive capabilities for clinical outcomes.
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Affiliation(s)
- Daniel I Rhon
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, Uniformed Services University, Bethesda, Maryland, and The Geneva Foundation, Tacoma, Washington
| | | | - Tina A Greenlee
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, Uniformed Services University, Bethesda, Maryland, and The Geneva Foundation, Tacoma, Washington
| | - Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, San Diego, California
| | - Trevor A Lentz
- Duke Clinical Research Institute, Durham, North Carolina
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Rhon DI, Plisky PJ, Kiesel K, Greenlee TA, Bullock GS, Shaffer SW, Goffar SL, Teyhen DS. Predicting Subsequent Injury after Being Cleared to Return to Work from Initial Lumbar or Lower Extremity Injury. Med Sci Sports Exerc 2023; 55:2115-2122. [PMID: 37486770 DOI: 10.1249/mss.0000000000003257] [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] [Indexed: 07/25/2023]
Abstract
PURPOSE The purpose of this study is to develop a model to predict re-injury after being cleared to return to full duty from an initial injury. METHODS This was a prediction model derivation cohort study. Military service members cleared for unrestricted full duty after sustaining a musculoskeletal injury were enrolled from three large military hospitals. Medical history, demographics, psychological profile, physical performance (Y-Balance Test™, Functional Movement Screen™, Selective Functional Movement Assessment, triple hop, closed chain ankle dorsiflexion, 2-mile run, 75% bodyweight carry time), and past injury history were assessed. Monthly text messages, medical records and limited duty databases were used to identify injuries resulting in time lost from work in the following year. RESULTS Four hundred fifty participants (65 females), ages 18 to 45 yr were analyzed. Fifteen variables were included in the final model. The area under the curve was 0.74 (95% confidence interval, 0.69-0.80), indicating good performance. The calibration score of the model was 1.05 (95% confidence interval, 0.80-1.30) indicating very good performance. With an injury incidence in our cohort of 38.0%, the treat all net benefit was 0.000, and the net benefit of our predictive model was 0.251. This means 25 additional soldiers out of every 100 were correctly identified as high risk for injury compared with not using a prediction model at all. CONCLUSIONS This multivariable model accurately predicted injury risk after returning for full duty and was better than not using a prediction model at all (an additional 25 of every 100 tactical athletes were correctly identified). This model provides guidance for proper decision making about when these individuals are not ready to return to full duty, with higher risk of a subsequent injury.
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Affiliation(s)
| | - Phillip J Plisky
- Department of Physical Therapy, University of Evansville, Evansville, IN
| | - Kyle Kiesel
- Department of Physical Therapy, University of Evansville, Evansville, IN
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX
| | | | - Scott W Shaffer
- School of Physical Therapy, University of Incarnate Word, San Antonio, TX
| | - Stephen L Goffar
- School of Physical Therapy, University of Incarnate Word, San Antonio, TX
| | - Deydre S Teyhen
- 20 Chief, Army Medical Specialist Corps, Fort Sam Houston, TX, USA
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Bullock GS, Dartt CE, Ricker EA, Fallowfield JL, Arden N, Clifton D, Danelson K, Fraser JJ, Gomez C, Greenlee TA, Gregory A, Gribbin T, Losciale J, Molloy JM, Nicholson KF, Polich JG, Räisänen A, Shah K, Smuda M, Teyhen DS, Allard RJ, Collins GS, de la Motte SJ, Rhon DI. Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review. Inj Prev 2023; 29:461-473. [PMID: 37620010 DOI: 10.1136/ip-2023-044905] [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: 03/22/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities. METHODS A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified. RESULTS From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions. CONCLUSION Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.
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Affiliation(s)
- Garrett S Bullock
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Centre for Sport, Exercise, and Osteoarthritis, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Carolyn E Dartt
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Emily A Ricker
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Joanne L Fallowfield
- Environmental Medicine and Sciences Division, Institute of Naval Medicine, Gosport, UK
| | - Nigel Arden
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
- University of Southampton MRC Lifecourse Epidemiology Centre, Southampton, UK
| | - Daniel Clifton
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Kerry Danelson
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - John J Fraser
- Directorate for Operational Readiness & Health, Naval Health Research Center, San Diego, California, USA
| | - Christina Gomez
- College of Health Sciences, Western University of Health Sciences, Pomona, California, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Alexandria Gregory
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Timothy Gribbin
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Justin Losciale
- Department of Rehabilitation, The University of British Columbia, Vancouver, British Columbia, Canada
- Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Joseph M Molloy
- Office of the Army Surgeon General, Falls Church, Virginia, USA
| | - Kristen F Nicholson
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Julia-Grace Polich
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anu Räisänen
- Department of Physical Therapy Education, Oregon, College of Health Sciences, Western University of Health Sciences, Lebanon, Oregon, USA
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Karishma Shah
- Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Michael Smuda
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Deydre S Teyhen
- Army Medical Specialist Corps Chief, Office of the Army Surgeon General, Falls Church, Virginia, USA
| | - Rhonda J Allard
- Learning Resource Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Sarah J de la Motte
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
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Rhon DI, Greenlee TA, Poehlein E, Beneciuk JM, Green CL, Hando BR, Childs JD, George SZ. Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2321929. [PMID: 37410465 DOI: 10.1001/jamanetworkopen.2023.21929] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
Importance Tailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems. Objective To assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP. Design, Setting, and Participants This parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022. Interventions Risk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants' general practitioners and may have included a referral to physiotherapy. Main Outcomes and Measures The primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group. Results Analysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, -0.75 points; 95% CI -2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, -1.66 to 1.76 points). Conclusions and Relevance In this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03127826.
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
- Department of Rehabilitation Medicine, Uniformed Services University, Bethesda, Maryland
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Jason M Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville
- Brooks Rehabilitation Clinical Research Center, Jacksonville, Florida
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Ben R Hando
- Department of Orthopaedics and Rehabilitation, Wilford Hall Ambulatory Surgical Center, JBSA Lackland, Texas
| | | | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, School of Medicine, Durham, North Carolina
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Young JL, Sell TC, Boeth R, Foster K, Greenlee TA, Rhon DI. What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain? Clin Rehabil 2023:2692155231157177. [PMID: 36793225 DOI: 10.1177/02692155231157177] [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] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain. DESIGN Retrospective cohort study. SETTING Military Health System. PARTICIPANTS Individuals (n = 92,319) ages 17-60 diagnosed with patellofemoral pain between 2010-2011. INTERVENTIONS Therapeutic exercise. MAIN OUTCOME MEASURES Frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan-Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury. RESULTS After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76-0.81), hip (HR = 0.93, 95% CI 0.87-0.98) or ankle-foot (HR = 0.86, 95% CI 0.83-0.90) injury. CONCLUSION The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.
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Affiliation(s)
- Jodi L Young
- 15638Physical Therapy Department, Bellin College, Green Bay, WI, USA.,104849The Geneva Foundation, Tacoma, WA, USA
| | - Timothy C Sell
- 2351Department of Orthopedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Riley Boeth
- 104849The Geneva Foundation, Tacoma, WA, USA
| | - Kaitlyn Foster
- 104849The Geneva Foundation, Tacoma, WA, USA.,Department of Rehabilitation Medicine, 3998Brooke Army Medical Center, San Antonio, TX, USA
| | - Tina A Greenlee
- 104849The Geneva Foundation, Tacoma, WA, USA.,Department of Rehabilitation Medicine, 3998Brooke Army Medical Center, San Antonio, TX, USA
| | - Daniel I Rhon
- 104849The Geneva Foundation, Tacoma, WA, USA.,Department of Rehabilitation Medicine, 3998Brooke Army Medical Center, San Antonio, TX, USA.,Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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7
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Foster KS, Greenlee TA, Fraser JJ, Young JL, Rhon DI. The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury. Med Sci Sports Exerc 2023; 55:177-185. [PMID: 36084225 DOI: 10.1249/mss.0000000000003035] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE This study aimed to investigate the burden of knee, hip, and lumbar spine disorders occurring in the year after an ankle sprain and the influence therapeutic exercise (TE) has on this burden. METHODS A total of 33,361 individuals diagnosed with ankle sprain in the Military Health System between 2010 and 2011 were followed for 1 yr. The prevalence of knee, hip, and lumbar care-seeking injuries sustained after sprain was identified. Relationships between demographic groups, ankle sprain type, and use of TE with rate of proximal injuries were evaluated using Cox proportional hazard models to determine hazard rate effect modification by attribute. The observed effect of TE for ankle sprain on rate of injury to proximal joints was evaluated using Kaplan-Meier survival analyses. RESULTS Of the total cohort, 20.5% ( n = 6848) of patients sustained a proximal injury. Specifically, 10.1% of the cohort sustained a knee ( n = 3356), 2.9% a hip ( n = 973), and 10.3% a lumbar injury ( n = 3452). Less than half of the cohort received TE after initial sprain. Patients that did were less likely to have subsequent knee (HR = 0.87, 95% confidence interval [CI] = 0.80-0.94), hip (HR = 0.68, 95% CI = 0.58-0.79), or lumbar (HR = 0.82, 95% CI = 0.76-0.89) injuries. CONCLUSIONS One in five individuals that sought care for an ankle sprain experienced a proximal joint injury in the following year. TE for the management of the initial ankle sprain reduced the likelihood of proximal injury diagnosis and should be considered in treatment plans for return to work and sport protocols after ankle sprains.
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Affiliation(s)
- Kaitlyn S Foster
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, TX
| | - John J Fraser
- Directorate for Operational Readiness and Health, Naval Health Research Center, San Diego, CA
| | - Jodi L Young
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, WI
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Foster KS, Greenlee TA, Young JL, Janney CF, Rhon DI. How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury? J Knee Surg 2022; 35:1181-1191. [PMID: 35944572 DOI: 10.1055/s-0042-1751246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/07/2023]
Abstract
Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70-2.79), increasing age (OR 1.03, 95% CI 1.02-1.04), female sex (OR 1.58, 95% CI 1.28-1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03-1.09), female sex (OR 2.73, 95% CI 1.74-4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03-2.89), and active-duty status (OR 2.28, 95% CI 1.38-3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28-0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries.
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Affiliation(s)
- Kaitlyn S Foster
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Jodi L Young
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Cory F Janney
- Naval Medical Center San Diego, San Diego, California
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas.,Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Rhon DI, Greenlee TA, Carreño PK, Patzkowski JC, Highland KB. Pain Catastrophizing Predicts Opioid and Health-Care Utilization After Orthopaedic Surgery: A Secondary Analysis of Trial Participants with Spine and Lower-Extremity Disorders. J Bone Joint Surg Am 2022; 104:1447-1454. [PMID: 35700089 DOI: 10.2106/jbjs.22.00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/01/2023]
Abstract
BACKGROUND Most individuals undergoing elective surgery expect to discontinue opioid use after surgery, but many do not. Modifiable risk factors including psychosocial factors are associated with poor postsurgical outcomes. We wanted to know whether pain catastrophizing is specifically associated with postsurgical opioid and health-care use. METHODS This was a longitudinal cohort study of trial participants undergoing elective spine (lumbar or cervical) or lower-extremity (hip or knee osteoarthritis) surgery between 2015 and 2018. Primary and secondary outcomes were 12-month postsurgical days' supply of opioids and surgery-related health-care utilization, respectively. Self-reported and medical record data included presurgical Pain Catastrophizing Scale (PCS) scores, surgical success expectations, opioid use, and pain interference duration. RESULTS Complete outcomes were analyzed for 240 participants with a median age of 42 years (34% were female, and 56% were active-duty military service members). In the multivariable generalized additive model, greater presurgical days' supply of opioids (F = 17.23, p < 0.001), higher pain catastrophizing (F = 1.89, p = 0.004), spine versus lower-extremity surgery (coefficient estimate = 1.66 [95% confidence interval (CI), 0.50 to 2.82]; p = 0.005), and female relative to male sex (coefficient estimate = -1.25 [95% CI, -2.38 to -0.12]; p = 0.03) were associated with greater 12-month postsurgical days' supply of opioids. Presurgical opioid days' supply (chi-square = 111.95; p < 0.001), pain catastrophizing (chi-square = 96.06; p < 0.001), and lower extremity surgery (coefficient estimate = -0.17 [95% CI, -0.24 to -0.11]; p < 0.001), in addition to age (chi-square = 344.60; p < 0.001), expected recovery after surgery (chi-square = 54.44; p < 0.001), active-duty status (coefficient estimate = 0.58 [95% CI, 0.49 to 0.67]; p < 0.001), and pain interference duration (chi-square = 43.47; p < 0.001) were associated with greater health-care utilization. CONCLUSIONS Greater presurgical days' supply of opioids and pain catastrophizing accounted for greater postsurgical days' supply of opioids and health-care utilization. Consideration of several modifiable factors provides an opportunity to improve postsurgical outcomes. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.,Department of Rehabilitation Medicine, Uniformed Services University, Bethesda, Maryland
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Patricia K Carreño
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, Maryland
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10
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Rhon DI, Greenlee TA, Gill NW, Carlson AE, Hart AM, Larsen TH, McLelland A, Mayhew RJ, McCafferty RR, Koppenhaver SL. Does Engaging Patients with Relevant Education About Long-Term Opioid Use Before Spine Surgery Affect Long-term Opioid Use? A Randomized Controlled Trial. Spine (Phila Pa 1976) 2022; 47:5-12. [PMID: 34341321 DOI: 10.1097/brs.0000000000004186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Parallel-arm randomized controlled trial. OBJECTIVE To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine surgery. SUMMARY OF BACKGROUND DATA Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed. METHODS Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months. RESULTS A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ± 10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation [SD] 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization. CONCLUSION The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1.
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Affiliation(s)
- Daniel I Rhon
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX
- US Army-Baylor Doctoral Program in Physical Therapy, JBSA Fort Sam Houston, TX
| | | | - Norman W Gill
- Army Medical Department (AMEDD) Center & School, JBSA Fort Sam Houston, TX
| | - Andrew E Carlson
- US Army-Baylor Doctoral Program in Physical Therapy, JBSA Fort Sam Houston, TX
| | - Allison M Hart
- US Army-Baylor Doctoral Program in Physical Therapy, JBSA Fort Sam Houston, TX
| | - Trent H Larsen
- US Army-Baylor Doctoral Program in Physical Therapy, JBSA Fort Sam Houston, TX
| | - Alex McLelland
- US Army-Baylor Doctoral Program in Physical Therapy, JBSA Fort Sam Houston, TX
| | - Rachel J Mayhew
- US Army-Baylor Doctoral Program in Physical Therapy, JBSA Fort Sam Houston, TX
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11
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Rhon DI, Teyhen DS, Kiesel K, Shaffer SW, Goffar SL, Greenlee TA, Plisky PJ. Recovery, Rehabilitation, and Return to Full Duty in a Military Population After a Recent Injury: Differences Between Lower-Extremity and Spine Injuries. Arthrosc Sports Med Rehabil 2022; 4:e17-e27. [PMID: 35141533 PMCID: PMC8811499 DOI: 10.1016/j.asmr.2021.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/25/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To compare readiness to return to duty in soldiers following recent lower-extremity versus spine injury. The secondary purposes were to provide normative data for the Selective Functional Movement Assessment Top Tier movements (SFMA-TTM) and assess the association between SFMA-TTM scores and future injury occurrence, comparing injuries of the lower extremity and thoracic/lumbar spine. Methods SFMA was rated by trained assessors on 480 U.S. Army soldiers within 2 weeks of being cleared to return to duty after recent lower-extremity or lumbar/thoracic injury. Participants were followed for 1 year to determine incidence of subsequent time-loss injury. Results Only 74.4% of soldiers felt 100% mission capable when returning to full duty (73.6% lower-extremity; 76.5% spine). After 1 year, 37.9% had sustained a time-loss injury, and pain with movement at baseline was associated with higher odds for having an injury (odd ratio 1.53 95% confidence interval 1.04-2.24; P = .032). Almost all (99.8%) had at least 1 dysfunctional pattern, and 44.1% had pain with at least 1 movement (40.3% with previous lower-extremity injury; 54.6% with previous spine injury) after being cleared to return to duty. Conclusions One in four patients did not feel 100% mission capable upon being cleared for full duty. Pain with movement was also associated with future injury. Regardless of recent injury type, 99.8% of soldiers returned to full unrestricted duty with at least 1dysfunctional movement pattern and 44.1% had pain with at least 1 of the SFMA-TTM movements. Level of Evidence Level III, retrospective comparative cohort study.
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Rhon DI, Greenlee TA, Dickens JF, Wright AA. Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review. Orthop J Sports Med 2021; 9:23259671211053034. [PMID: 34805422 PMCID: PMC8600561 DOI: 10.1177/23259671211053034] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Female servicemembers sustain higher rates of lower extremity injuries as
compared with their male counterparts. This can include intra-articular
pathology in the hip. Female patients are considered to have worse outcomes
after hip arthroscopy for femoroacetabular impingement and for hip labral
repair. Purpose: To (1) compare published rates of hip arthroscopy between male and female
military servicemembers and (2) determine if there are any sex-based
differences in outcomes after hip arthroscopy in the military. Study Design: Systematic review; Level of evidence, 3. Methods: We reviewed the literature published from January 1, 2000, through December
31, 2020, to identify studies in which hip arthroscopy was performed in
military personnel. Clinical trials and cohort studies were included. The
proportion of women within each cohort was identified, and results of any
between-sex analyses were reported. Results: Identified were 11 studies that met established criteria. Studies included
2481 patients, 970 (39.1%) of whom were women. Surgery occurred between
January 1998 and March 2018. Despite women accounting for approximately 15%
of the active-duty military force, they represented 39.1% (range,
25.7%-57.6%) of patients undergoing hip arthroscopy. In most cases, there
were no differences in self-reported outcomes (pain, disability, and
physical function), return to duty, or medical disability status based on
sex. Conclusion: Women account for approximately 15% of the military, but they made up 40% of
patients undergoing hip arthroscopy. Outcomes were not different between the
sexes; however, definitive conclusions were limited by the heterogeneity of
outcomes, missing data, lack of sex-specific subgroup analyses, and zero
studies with sex differences as the primary outcome. A proper understanding
of sex-specific outcomes after hip arthroscopy will require a paradigm shift
in the design and reporting of trials in the military health system.
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA.,Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA
| | - Jonathan F Dickens
- Uniformed Services University of Health Sciences, Bethesda, Maryland, USA.,Department of Sports Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,John A. Feagin Jr Sports Medicine Fellowship, Keller Army Community Hospital, West Point, New York, USA
| | - Alexis A Wright
- School of Medicine, Tufts University, Boston, Massachusetts, USA
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13
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Rhon DI, Mayhew RJ, Greenlee TA, Fritz JM. The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial. BMC Fam Pract 2021; 22:200. [PMID: 34627152 PMCID: PMC8502287 DOI: 10.1186/s12875-021-01549-y] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks. OBJECTIVE Assess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups. METHODS This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs. RESULTS Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention. CONCLUSION Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process. TRIAL REGISTRATION clinicaltrials.gov NCT02777983 .
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Health Sciences , Bethesda, MD, USA.
| | - Rachel J Mayhew
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
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Rhon DI, Greenlee TA, Cook CE, Westrick RB, Umlauf JA, Fraser JJ. Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System. Int J Sports Phys Ther 2021; 16:1313-1322. [PMID: 34631252 PMCID: PMC8486414 DOI: 10.26603/001c.27912] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/05/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Whereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System. METHODS This was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed. RESULTS Of 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs. CONCLUSION Fractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity. LEVEL OF EVIDENCE 3b.
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Affiliation(s)
- Daniel I Rhon
- Military Performance Division, United States Army Research Institute of Environmental Medicine; Department of Rehabilitation Medicine, Brooke Army Medical Center
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15
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Rhon DI, Fritz JM, Greenlee TA, Dry KE, Mayhew RJ, Laugesen MC, Dragusin E, Teyhen DS. Move to health-a holistic approach to the management of chronic low back pain: an intervention and implementation protocol developed for a pragmatic clinical trial. J Transl Med 2021; 19:357. [PMID: 34407840 PMCID: PMC8371880 DOI: 10.1186/s12967-021-03013-y] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/25/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The prevalence of chronic pain conditions is growing. Low back pain was the primary cause of disability worldwide out of 156 conditions assessed between 1990 and 2016, according to the Global Burden of Disease Study. Conventional medical approaches have failed to identify effective and long-lasting approaches for the management of chronic pain, and often fail to consider the multiple domains that influence overall health and can contribute to the pain experience. Leading international organizations that focus on pain research have stated the importance of considering these other domains within holistic and multidisciplinary frameworks for treating pain. While the research behind the theoretical link between these domains and chronic pain outcomes has expanded greatly over the last decade, there have been few practical and feasible methods to implement this type of care in normal clinical practice. METHODS The purpose of this manuscript is to describe an implementation protocol that is being used to deliver a complex holistic health intervention at multiple sites within a large government health system, as part of a larger multisite trial for patients with chronic low back pain. The Move to Health program developed by the US Army Medical Command was tailored for specific application to patients with low back pain and begins by providing an empirical link between eight different health domains (that include physical, emotional, social, and psychological constructs) and chronic low back pain. Through a six-step process, a health coach leverages motivational interviewing and information from a personal health inventory to guide the patient through a series of conversations about behavioral lifestyle choices. The patient chooses which domains they want to prioritize, and the health coach helps implement the plan with the use of SMART (Specific, Measurable, Attainable, Realistic, Time-bound) goals and a series of resources for every domain, triaged from self-management to specialist referral. DISCUSSION Complex interventions described in clinical trials are often challenging to implement because they lack sufficient details. Implementation protocols can improve the ability to properly deliver trial interventions into regular clinical practice with increased fidelity. TRIAL REGISTRATION Implementation of this intervention protocol was developed for a clinical trial that was registered a priori (clinicaltrials.gov #NCT04172038).
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Affiliation(s)
- Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA.
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, MD, USA.
| | | | - Tina A Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Katie E Dry
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Rachel J Mayhew
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Mary C Laugesen
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Edita Dragusin
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Deydre S Teyhen
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Carrignan JA, Simmet RT, Coddington M, Gill NW, Greenlee TA, McCafferty R, Rhon DI. Are Exercise and Physical Therapy Common Forms of Conservative Management in the Year Before Lumbar Spine Surgery? Arch Phys Med Rehabil 2020; 101:1389-1395. [DOI: 10.1016/j.apmr.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/13/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
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Rhon DI, Greenlee TA, Fritz JM. The Influence of a Guideline-Concordant Stepped Care Approach on Downstream Health Care Utilization in Patients with Spine and Shoulder Pain. Pain Med 2019; 20:476-485. [PMID: 30412232 DOI: 10.1093/pm/pny212] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories. OBJECTIVE To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT. DESIGN Retrospective observational cohort. METHODS Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data. RESULTS From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001). CONCLUSIONS MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.
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Affiliation(s)
- Daniel I Rhon
- Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio - Fort Sam, Houston, Texas.,Doctoral Programs in Physical Therapy, Baylor University, San Antonio, Texas
| | - Tina A Greenlee
- Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio - Fort Sam, Houston, Texas
| | - Julie M Fritz
- College of Health, University of Utah, Salt Lake City, Utah, USA
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18
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Rhon DI, Greenlee TA, Sissel CD, Reiman MP. The two-year incidence of hip osteoarthritis after arthroscopic hip surgery for femoroacetabular impingement syndrome. BMC Musculoskelet Disord 2019; 20:266. [PMID: 31153368 PMCID: PMC6545211 DOI: 10.1186/s12891-019-2646-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 01/28/2019] [Accepted: 05/20/2019] [Indexed: 12/30/2022] Open
Abstract
Background One of the reported goals of hip preservation surgery is to prevent or delay the onset of osteoarthritis. This includes arthroscopic surgery to manage Femoroacetabular Impingement (FAI) Syndrome. The purpose of this study was to describe the prevalence of clinically-diagnosed hip OA within 2 years after hip arthroscopy for FAI syndrome, and 2) determine which variables predict a clinical diagnosis of OA after arthroscopy. Methods Observational analysis of patients undergoing hip arthroscopy between 2004 and 2013, utilizing the Military Health System Data Repository. Individuals with prior cases of osteoarthritis were excluded. Presence of osteoarthritis was based on diagnostic codes rendered by a medical provider in patient medical records. Adjusted odds ratios (95% CI) for an osteoarthritis diagnosis were reported for relevant clinical and demographic variables. Results Of 1870 participants in this young cohort (mean age 32.2 years), 21.9% (N = 409) had a postoperative clinical diagnosis of hip osteoarthritis within 2 years. The 3 significant predictors in the final model were older age (OR = 1.04; 95%CI = 1.02, 1.05), male sex (OR = 1.31; 95%CI = 1.04, 1.65), and having undergone an additional hip surgery (OR = 2.33; 95% CI = 1.72, 3.16). Military status and post-surgical complications were not risk factors. Conclusion A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy in as little as 2 years. These rates may differ when using alternate criteria to define OA, such as radiographs, and likely underestimate the prevalence. A more comprehensive approach, considering various criteria to detect OA will likely be necessary to accurately identify the true rates. Females were at lower risk, while increasing age and multiple surgeries increased the risk for an OA diagnosis. OA onset still occurs after “hip preservation” surgery in a substantial number of individuals within 2 years. This should be considered when estimating rates of disease prevention after surgery. Prospective trials with sound methodology are needed to determine accurate rates and robust predictors of osteoarthritis onset after hip preservation surgery.
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Affiliation(s)
- Daniel I Rhon
- Physical Performance Service Line, G 3/5/7, US Army Office of the Surgeon General, Falls Church, VA, USA. .,Baylor University, Road, Bldg 2841, Suite 1301; JBSA Fort Sam Houston, Stanley, TX, 3630, USA.
| | - Tina A Greenlee
- Center for the Intrepid, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, USA
| | | | - Michael P Reiman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Rhon DI, Greenlee TA, Marchant BG, Sissel CD, Cook CE. Comorbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions. Br J Sports Med 2018; 53:547-553. [DOI: 10.1136/bjsports-2018-099294] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 02/05/2023]
Abstract
ObjectivesWe aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2 years after hip arthroscopy.MethodsData from individuals (ages 18–50 years) undergoing arthroscopic hip surgery between 2004 and 2013 were collected from the Military Health System (MHS) Data Repository (MDR). The MDR captures all healthcare encounters in all settings and locations for individuals within the MHS. Person-level data over 36 months were pulled and aggregated. Seven comorbidities related to poor outcomes from musculoskeletal disorders (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) were examined 12 months prior and 24 months after surgery. Changes in frequencies were calculated as were differences in proportions between presurgery and postsurgery.Results1870 subjects were identified (mean age 32.24 years; 55.5% men) and analysed. There were statistically significant increases (p<0.001) proportionally for all comorbidities after surgery. Relative to baseline, cases of mental health disorders rose 84%, chronic pain diagnoses increased 166%, substance abuse disorders rose 57%, cardiovascular disorders rose by 71%, metabolic syndrome cases rose 85.9%, systemic arthropathy rose 132% and sleep disorders rose 111%.ConclusionsMajor (potentially ‘hidden’) clinical comorbidities increased substantially after elective arthroscopic hip surgery when compared with preoperative status. These comorbidities appear to have been overlooked in major studies evaluating the benefits and risks of arthroscopic hip surgery.Level of evidencePrognostic, level III.
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Greenlee TA, Greene DR, Kaim RM, Chizewski A, Rougeau KM, Horn GP, Petruzzello SJ. Firefighting Influences Cognitive Performance. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000538432.67287.f8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Rhon DI, Snodgrass SJ, Cleland JA, Greenlee TA, Sissel CD, Cook CE. Comparison of Downstream Health Care Utilization, Costs, and Long-Term Opioid Use: Physical Therapist Management Versus Opioid Therapy Management After Arthroscopic Hip Surgery. Phys Ther 2018; 98:348-356. [PMID: 29669080 DOI: 10.1093/ptj/pzy019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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] [Received: 05/06/2017] [Accepted: 02/06/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used. OBJECTIVE The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids. DESIGN The design of this study was an observational cohort. METHODS Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions. RESULTS Of 1870 total patients, 76.8% (n = 1437) received physical therapy, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed the final timing-of-care analysis. Adjusted hip-related mean costs were the same in both groups receiving isolated treatments (${\$}$11,628 vs ${\$}$11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs (${\$}$18,185 vs ${\$}$23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first (${\$}$18,806 vs ${\$}$16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days' supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69.5% vs 53.2%). LIMITATIONS Claims data were limited by the accuracy of coding, and observational data limit inferences of causality. CONCLUSIONS Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.
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Affiliation(s)
- Daniel I Rhon
- Baylor University Doctoral Physical Therapy Program, 3630 Stanley Road, Bldg 2841, Suite 2301, San Antonio, TX 78234. Dr Rhon is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopedic Manual Therapists
| | - Suzanne J Snodgrass
- Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Joshua A Cleland
- Physical Therapy Department, Franklin Pierce College, Concord, New Hampshire. Dr Cleland is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopedic Manual Therapists
| | - Tina A Greenlee
- US Army Brooke Army Medical Center, Center for the Intrepid, Fort Sam Houston, Texas
| | | | - Chad E Cook
- Doctor of Physical Therapy Division, Duke University, Durham, North Carolina. Dr Cook is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopedic Manual Physical Therapists
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Greenlee TA, Greene DR, Ward NJ, Reeser GE, Allen CM, Baumgartner NW, Cohen NJ, Kramer AF, Hillman CH, Barbey AK. Effectiveness of a 16-Week High-Intensity Cardioresistance Training Program in Adults. J Strength Cond Res 2018; 31:2528-2541. [PMID: 28820847 PMCID: PMC5566168 DOI: 10.1519/jsc.0000000000001976] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Greenlee, TA, Greene, DR, Ward, NJ, Reeser, GE, Allen, CM, Baumgartner, NW, Cohen, NJ, Kramer, AF, Hillman, CH, and Barbey, AK. Effectiveness of a 16-week high-intensity cardioresistance training program in adults. J Strength Cond Res 31(9): 2528–2541, 2017—The purpose of this study was to determine the efficacy of a novel, 16-week high-intensity cardioresistance training (HICRT) program on measures of aerobic fitness, agility, aerobic power, muscular endurance, lower-body explosive power, and self-reported activity level. The intervention group (N = 129; 63 f, 24.65 ± 5.55 years) had a baseline V̇o2max of 39.83 ± 9.13. These individuals participated in 26, 70-minute exercise sessions, and 4 fitness testing sessions. Participants were matched with a nonexercise control group, paired by sex, age, and baseline V̇o2max. Matched controls (N = 129, 63 f, 24.26 ± 5.59 years) had a baseline V̇o2max of 39.86 ± 8.59 and completed preintervention and postintervention V̇o2max testing only. The results demonstrate that participants in the fitness intervention group significantly increased their V̇o2max (2.72 ± 0.31, Mdiff ± SE; p < 0.001) and reported being more physically active (0.42 ± 0.11, Mdiff ± SE; p < 0.001) after the intervention. The matched control group showed no significant pre–post intervention changes. Participants in the fitness intervention showed a significant improvement in 3 of 5 components of the fitness field tests. Specifically, significant improvements were observed for the 1-minute rower (5.32 ± 0.505, Mdiff ± SE; p < 0.001), 1-minute push-up (8.168 ± 0.709, Mdiff ± SE; p < 0.001), and 1.5-mile run tests (1.79 ± 0.169, Mdiff ± SE; p < 0.001). No significant improvements were observed for the shuttle run (p = 0.173) or standing long jump (p = 0.137). These findings demonstrate the efficacy of a novel, HICRT intervention across multiple dimensions of fitness for young- and middle-aged adults. High-intensity cardioresistance training affords flexibility for tailoring to meet desired health and fitness outcomes and makes perceivably daunting high-intensity functional training and multimodal sports training more accessible to general, traditionally nonathletic, populations.
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Affiliation(s)
- Tina A Greenlee
- 1Beckman Institute for Advanced Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois; 2Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois; 3Department of Psychology, Tufts University, Medford, Massachusetts; 4Department of Psychology, University of Illinois at Urbana-Champaign, Urbana, Illinois; 5Department of Psychology, Northeastern University, Boston, Massachusetts; 6Department of Mechanical and Industrial Engineering, Northeastern University, Boston, Massachusetts; and 7Department of Health Sciences, Northeastern University, Boston, Massachusetts
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Chizewski A, Greenlee TA, Greene DR, Rougeau K, Smith DL, Petruzzello SJ. Improved Fitness Trends In Firefighter Recruits Over A 12-year Span. Med Sci Sports Exerc 2017. [DOI: 10.1249/01.mss.0000518590.65922.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Amjod R, Greene DR, Greenlee TA, Rougeau K, Chizewski A, Petruzzello SJ. Predicting Affective Responses To, And Enjoyment Of, High-intensity Interval Exercise. Med Sci Sports Exerc 2017. [DOI: 10.1249/01.mss.0000518448.63921.cd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Rougeau K, Chizewski A, Greenlee TA, Greene DR, Smith DL, Petruzzello SJ. Improvements In Recruit Fitness During A 6-week Firefighter Training Academy. Med Sci Sports Exerc 2017. [DOI: 10.1249/01.mss.0000519924.90681.c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Petruzzello SJ, Poh PYS, Greenlee TA, Goldstein E, Horn GP, Smith DL. Physiological, Perceptual and Psychological Responses of Career versus Volunteer Firefighters to Live-fire Training Drills. Stress Health 2016; 32:328-336. [PMID: 25393336 DOI: 10.1002/smi.2620] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 04/09/2014] [Revised: 09/10/2014] [Accepted: 10/20/2014] [Indexed: 11/10/2022]
Abstract
A primary objective of the present study was to examine the effect of short-term live-fire firefighting activities on key physiological, perceptual and psychological variables and whether occupational status influenced these responses. It was also of interest to examine whether individual difference factors differentiated the occupational status groups and if so, whether such individual difference factors influenced perceptual and psychological responses to firefighting activities. Male firefighters (n = 52 career, n = 53 volunteer firefighters) participated in 18 min of simulated firefighting activity in a training structure that contained live fires. Measures of heart rate (HR) and Tcore were obtained before and after firefighting activities along with perceptions of thermal sensations, exertion, respiratory distress and affect. Firefighting activities resulted in significant elevations in HR and Tcore , whereas thermal sensations, respiratory distress, exertion and affect all showed significant and sizable changes reflecting greater distress and dysphoria. Occupational status and individual difference factors accounted for some of this negative change. The findings replicate and extend previous work by demonstrating the influence of occupational status and individual difference factors in the psychological responses to firefighting activity. Copyright © 2014 John Wiley & Sons, Ltd.
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Affiliation(s)
- Steven J Petruzzello
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Urbana, IL, USA. .,University of Illinois Fire Service Institute, Champaign, IL, USA.
| | - Paula Y S Poh
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Tina A Greenlee
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Eric Goldstein
- University of Illinois Fire Service Institute, Champaign, IL, USA
| | - Gavin P Horn
- University of Illinois Fire Service Institute, Champaign, IL, USA
| | - Denise L Smith
- University of Illinois Fire Service Institute, Champaign, IL, USA.,Department of Health and Exercise Science, Skidmore College, Saratoga Springs, NY, USA
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Greene DR, Chizewski A, Greenlee TA, Petruzzello SJ. That Feeling I Get. Med Sci Sports Exerc 2016. [DOI: 10.1249/01.mss.0000486270.11048.d7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Greenlee TA, Greene DR, Ward NJ, Reeser GE, Allen CM, Baumgartner NW, Cohen NJ, Kramer AF, Barbey AK, Hillman CH. Effectiveness Of A 16-week High-Intensity Cardio-Resistance Training (HICRT) Program In Adults. Med Sci Sports Exerc 2016. [DOI: 10.1249/01.mss.0000487579.57760.59] [Citation(s) in RCA: 2] [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] [Indexed: 11/21/2022]
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Ensari I, Greenlee TA, Motl RW, Petruzzello SJ. META-ANALYSIS OF ACUTE EXERCISE EFFECTS ON STATE ANXIETY: AN UPDATE OF RANDOMIZED CONTROLLED TRIALS OVER THE PAST 25 YEARS. Depress Anxiety 2015; 32:624-34. [PMID: 25899389 DOI: 10.1002/da.22370] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [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: 11/15/2014] [Revised: 02/28/2015] [Accepted: 03/18/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND One prominent and well-cited meta-analysis published nearly 25 years ago reported that an acute or single bout of exercise reduced state anxiety by approximately ¼ standard deviation. We conducted a meta-analysis of randomized controlled trials (RCTs) published after that meta-analysis for updating our understanding of the acute effects of exercise on state anxiety. METHODS We searched PubMed, EBSCOHost, Medline, PsycINFO, ERIC, and ScienceDirect for RCTs of acute exercise and state anxiety as an outcome. There were 36 RCTs that met inclusion criteria and yielded data for effect size (ES) generation (Cohen's d). An overall ES was calculated using a random effects model and expressed as Hedge's g. RESULTS The weighted mean ES was small (Hedge's g = 0.16, standard error (SE) = 0.06), but statistically significant (P < 0.05), and indicated that a single bout of exercise resulted in an improvement in state anxiety compared with control. The overall ES was heterogeneous and post hoc, exploratory analyses using both random- and fixed-effects models identified several variables as moderators including sample age, sex and health status, baseline activity levels, exercise intensity, modality and control condition, randomization, overall study quality, and the anxiety measure (P < 0.05). CONCLUSION The cumulative evidence from high quality studies indicates that acute bouts of exercise can yield a small reduction in state anxiety. The research is still plagued by floor effects associated with recruiting persons with normal or lower levels of state anxiety, and this should be overcome in subsequent trials.
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Affiliation(s)
- Ipek Ensari
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois
| | - Tina A Greenlee
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois
| | - Robert W Motl
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois
| | - Steven J Petruzzello
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois
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Greenlee TA, Greene DR, Fremarek NA, Petruzzello SJ. Keeping Anxiety At Bay. Med Sci Sports Exerc 2015. [DOI: 10.1249/01.mss.0000476869.75818.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Greene DR, Greenlee TA, Bone B, Petruzzello SJ. Fighting Fire With Resilience. Med Sci Sports Exerc 2015. [DOI: 10.1249/01.mss.0000478958.17716.ac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Greenlee TA, Greene DR, Rougeau KM, Chizewski A, Horn GP, Bone B, Petruzzello SJ. Cognitive Performance In Recruit Firefighters After An Intense Night-burn Drill. Med Sci Sports Exerc 2015. [DOI: 10.1249/01.mss.0000478959.55833.6a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Greenlee TA, Greene DR, Chizewski A, Petruzzello SJ. Working Memory And Cognitive Inhibitory Performance Of (new-recruit/academy ) Firefighters Immediately Following A Night-burn Drill (live-fire). Med Sci Sports Exerc 2014. [DOI: 10.1249/01.mss.0000496138.92917.1d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Greenlee TA, Horn G, Smith DL, Fahey G, Goldstein E, Petruzzello SJ. The influence of short-term firefighting activity on information processing performance. Ergonomics 2014; 57:764-773. [PMID: 24670047 DOI: 10.1080/00140139.2014.897375] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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] [Indexed: 06/03/2023]
Abstract
This study examined the following: effects of simulated firefighting (FF) activities under heat stress on sustained attention; whether incident rehabilitation (IR) influences performance; and relationships between performance, affect and personality. Firefighters performed ~18 min of FF. Attention, physiological, perceptual and psychological assessments were made before and after FF, IR and recovery. IR had no effects. Self-rated Energy increased, Tiredness decreased and Anxiety increased immediately post-FF; all returned to baseline 120 min post. The immediate effect of FF was faster reaction time (RT) followed by slowing after recovery. Perceived Energy at baseline was associated (p-values < 0.05) with faster and Tiredness with slower post-FF RTs; Accuracy was unaffected. Conscientiousness was negatively associated with RT before and 120 min following FF. RTs were faster following FF, accuracy was unchanged. Higher baseline Energy/lower Tiredness were associated with faster, less variable RTs at baseline and post-FF. Those with higher Conscientiousness had faster RTs. Research should further investigate higher-level cognitive processing following, or ideally during, FF.
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Affiliation(s)
- Tina A Greenlee
- a Department of Kinesiology and Community Health , University of Illinois at Urbana-Champaign , Urbana , IL , USA
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Abstract
OBJECTIVE To provide a quantitative synthesis of randomized controlled trials examining the effect of exercise training on symptomatic fatigue in persons with multiple sclerosis (MS). METHODS Electronic databases (Web of Science, PubMed, PsycInfo, and Google Scholar) were searched for articles published between 1960 and October 2012 by using the key words "fatigue," OR "tiredness," OR "energy," OR "mood," OR "lassitude," AND "exercise," OR "physical activity," OR "rehabilitation," OR "fitness" WITH "multiple sclerosis." The initial search resulted in 311 articles, of which 74 were reviewed in detail and 17 met the inclusion criteria and provided enough data to compute effect sizes (ESs; Cohen d). The meta-analysis was conducted using a meta-analysis software program, and a random-effects model was used to calculate the overall ES, expressed as Hedge g. RESULTS The weighted mean ES from 17 randomized controlled trials with 568 participants with MS was 0.45 (standard error = 0.12, 95% confidence interval = 0.22-0.68, z = 3.88, p ≤ .001). The weighted mean ES was slightly heterogeneous (Q = 29.9, df = 16, p = .019). CONCLUSIONS The cumulative evidence supports that exercise training is associated with a significant small reduction in fatigue among persons with MS.
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Affiliation(s)
- Lara A Pilutti
- Department of Kinesiology and Community Health, University of Illinois, Urbana, IL 61801, USA
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