Factors associated with pain intensity and physical limitations after lateral ankle sprains

Preoperative depression screening using PHQ-2 is associated with worse outcomes after ACL reconstruction

Purpose

To determine how screening positive for depression preoperatively can affect patient reported outcomes after anterior cruciate ligament reconstruction (ACLR).

Methods

Primary ACLR patients between May 2020-September 2022 with a PHQ-2 score prior to their surgery were retrospectively reviewed. Patients older than 13 years of age and with minimum 6-months of follow-up were included for analysis. Patients were categorized as PHQ(+) (PHQ-2 ≥2) or PHQ2(-) (PHQ-2 < 2). Demographics, preoperative and postoperative Patient Reported Outcome Information System (PROMIS) -Physical Function (PF) and Pain Interference (PI) scores, Patient Acceptable Symptomatic State (PASS), surgical clinical outcomes, and complications were collected and compared. Chi-square tests and independent t-tests were used for categorical and continuous variables, respectively.

Results

A total of 127 patients were analyzed, with 32 PHQ2(+) and 95 PHQ2(-). The PHQ2(+) group had a lower proportion responding "yes" to PASS preoperatively (6.5 % vs. 25.3 %, p = 0.03), at 9 months (47.4 % vs. 72.4 %, p = 0.05), and 12 months postoperatively (42.9 % vs 79.5 %, p = 0.009). PHQ2(+) reported worse PROMIS-PI scores preoperatively, at 6 months, and at 9 months. The PHQ2(+) group reported worse PROMIS-PF preoperatively, at 6 months, at and 12 months. The PHQ2(+) group had worse IKDC scores preoperatively at 9 months and at 12 months. Those screening positive for depression also demonstrated a higher incidence of postoperative complications (34.4 % vs. 9.5 %, p = 0.001) and reoperation rates (21.9 % vs. 4.2 %; p = 0.002).

Conclusion

A brief preoperative survey, such as the PHQ-2, can provide prognostic value for patient outcomes after ACLR.

Level of evidence

III-Retrospective cohort study.

Revealing the Progression of Pain Pathways and Identifying Chronification of Pain Predictors After an Isolated Lateral Ankle Sprain: Project RECOIL

Persistent pain is a common complaint among civilians and military personnel after a lateral ankle sprain (LAS). Most individuals who experience pain after an LAS self-report a moderate pain intensity level that interferes with activity. This pain experience is mostly described through study designs and outcomes that limit the understanding of the acute to chronic pain transition after an LAS. The purpose of this prospective study is to quantify the prevalence rate of chronic ankle pain at 6-months post-injury and identify susceptibility and resiliency factors that contribute to pain chronification after an LAS. The objective of this study will be accomplished through a two-site prospective cohort study design with data collected at four timepoints (<7 days post-LAS, 3-, 6-, and 12-months post-LAS). A target sample size of 200 men or women (100 per site) between 18 and 45 years of age who sustain an acute LAS within the previous 7-days will be enrolled. Participants will complete a series of standardized electronic surveys at each timepoint to self-report the presence of chronic ankle pain, healthcare utilization patterns, subsequent musculoskeletal injury, and new co-morbid conditions. Additionally, participants will complete validated patient-reported outcomes (PROs) electronically to characterize the pain burden and undergo quantitative sensory testing to assess mechanical pain sensitivity via pressure pain thresholds, pain facilitation via temporal summation, and pain inhibition via a conditioned pain modulation response at all timepoints. Lastly, clinician-based outcomes will be completed at 3-, 6-, and 12-months post-LAS to examine dynamic postural control, functional performance, and walking mechanics. We hypothesize that 30% of participants will self-report chronic ankle pain at 6-months post-injury. In addition, chronic pain at 6-months will be predicted by a combination of healthcare utilization patterns, prolonged levels of peripheral sensitization and pain facilitation, and worse functional performance and PROs.

Musculoskeletal surgeons have implicit bias towards the biomedical paradigm of human illness

BACKGROUND

Evidence is mounting that the biopsychosocial paradigm is more accurate and useful than the biomedical paradigm of care. Habits of thought can hinder the implementation of this knowledge into daily care strategies. To understand and lessen these potential barriers, we asked: 1) What is the relative implicit and explicit attitudes of musculoskeletal surgeons towards the biomedical or biopsychosocial paradigms of medicine? 2) What surgeon factors are associated with these attitudes?

METHODS

An online survey-based experiment was distributed to members of the Science of Variation Group (SOVG) with a total of 163 respondents. Implicit bias towards the biomedical or biopsychosocial paradigms was measured using an Implicit Association Test (IAT) designed by our team using open-source software; explicit preferences were measured using ordinal scales.

RESULTS

On average, surgeons demonstrated a moderate implicit bias towards the biomedical paradigm (d-score: -0.21; Interquartile range [IQR]: -0.56 to 0.19) and a moderate explicit preference towards the biopsychosocial paradigm (mean: 14; standard deviation: 14). A greater implicit bias towards the biomedical paradigm was associated with male surgeons (d-score: -0.30; IQR: -0.57 to 0.14; P = 0.005). A greater explicit preference towards the biomedical paradigm was independently associated with a European practice location (Regression coefficient: -9.1; 95% CI: -14 to -4.4; P <0.001) and trauma subspecialty (RC: -6.2; 95% CI: -11 to -1.0; P <0.001).

CONCLUSIONS

The observation that surgeons have an implicit bias favoring the biomedical paradigm might inform strategies for implementation of care strategies based on evidence favoring the biopsychosocial paradigm.

"I Feel Like I Have Lost Part Of My Identity" - A Qualitative Study Exploring The Impact Of Chronic Ankle Instability

Introduction

Lateral ankle sprain is the most common ankle injury and up to 40% of those who sustain a lateral ankle sprain will develop chronic ankle instability (CAI). The aim of this study was to explore the thoughts and expectations of CAI-patients concerning their condition and expectations of care in an orthopedic setting. .

Study Design

Qualitative study.

Methods

Nine semi-structured one-to-one interviews were conducted with CAI-patients who were referred to an orthopedic setting. Interviews were recorded, transcribed, and analyzed using systematic text condensation with an inductive goal free approach. .

Results

Seven themes emerged. The themes were Injury history and symptoms (Lateral ankle sprain during sport, pain and instability), Information from health professional (conflicting information about management and prognosis), Management (mental and physical challenges), Expectation and hope (explanation of symptoms, prognosis and imaging to provide clarification of condition), Activity and participation (restriction in sport and daily life and feelings of uncertainty), Support (support from family/friends) and Identity (low ability to participate in sport and social life result in loss of identity). .

Conclusion

The impact of CAI exceeds an experience of pain and instability. Patients experienced loss of identity, having to manage uncertainty regarding their diagnosis and prognosis and had hopes of being able to explain their condition. .

Level of Evidence

Not applicable.

Opioids for acute and chronic pain when receiving psychiatric medications

BACKGROUND

People with mental health disorders (MHD) like depression and anxiety are more likely to experience substance use disorders (SUDs) than those without MHD. This study assesses opioid prescription patterns for acute or chronic pain management in patients receiving medication for depression and/or anxiety.

METHODS AND FINDINGS

Cross-sectional data trend analysis of 24.5 million adult medical claims was conducted using medical and pharmacy data (2012-2019) for adults aged 21-64 from the IBM Watson MarketScan Medicaid Multi-State Database. Information on sex, age, race, provider type, acute or chronic pain, and prescriptions for opioids and antidepressant and/or antianxiety medication from outpatient encounters were analyzed. For those receiving opioid prescriptions within 14 days of a pain diagnosis, ICD-10-CM codes were used to categorize diagnoses as chronic pain (back pain, neck pain, joint pain, and headache); or acute pain (dental-, ENT-, and orthopedic-related pain). Nearly 8 million adults had at least one prescription for antidepressant or antianxiety medications (MHD), with 2.5 million of those (32%) also diagnosed with an acute or chronic pain condition (pain + MHD). Among the pain + MHD group, 34% (0.85 million) received an opioid prescription within 14 days of diagnosis. Individuals with chronic pain diagnoses received a higher proportion of opioid prescriptions than those with acute pain. Among individuals with pain + MHD, the majority were aged 50-64 (35%), female (72%), and non-Hispanic white (65.1%). Nearly half (48.2%) of the opioid prescriptions given to adults with an MHD were provided by physicians. Compared to other physician types, Health Care Providers (HCPs) in emergency departments were 50% more likely to prescribe an opioid for dental pain to those with an MHD, whereas dentists were only half as likely to prescribe an opioid for dental pain management. Although overall opioid prescriptions for pain management declined from 2012 to 2019, adults with an MHD received opioids for pain management at nearly twice the level as adults without an MHD.

CONCLUSIONS

Although HCPs have reduced opioids for acute or chronic pain to patients at high-risk for SUD, for example, those with MHD, the use of opioids for pain management has remained at consistently higher levels for this SUD high-risk group, suggesting the need to revisit pain management guidelines for those receiving antidepressant or antianxiety drugs.

Magnitude of Incapability and Pain Intensity are Associated More with Unhelpful Thoughts Than Stressful Life Events

Prior studies show that stressful life events are associated with greater magnitude of incapability and symptom intensity. We sought to understand the association of such events (i.e., both adverse childhood experiences and recent difficult life events [DLEs]) alongside feelings of worry or despair and unhelpful, on the magnitude of incapability and symptom intensity in musculoskeletal patients. One hundred and thirty-six patients presenting for musculoskeletal specialty care completed measures of incapability, pain intensity, adverse childhood experiences, DLEs in the last year, unhelpful thoughts, symptoms of anxiety and depression, and sociodemographic factors. Factors associated with the magnitude of incapability and pain intensity were sought in multivariable analysis. Accounting for potential confounders, greater incapability was associated with greater unhelpful thoughts (RC  =  -0.81; 95% CI  =  -1.2 to -0.42; P  ≤  .001), but not with stressful life events (either during childhood or more recently). Greater pain intensity was associated with greater unhelpful thoughts(RC  =  0.25; 95% CI  =  0.16 to 0.35; P  ≤  .001) and being divorced or widowed (RC  =  1.8; 96% CI  =  0.43 to 3.2; P  =  .011), but again, not with stressful life events. The strong association of unhelpful thoughts with magnitude of incapability and pain intensity can motivate musculoskeletal specialists to anticipate patients expressing negative pain thoughts and behaviors. Future studies might account for social and environmental context behind stressful life events and the influence of resiliency and pain-coping strategies on these interactions.

Level of Evidence

Level III, prognostic study.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective

To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit.

Methods

A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales.

Results

Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration.

Conclusion

Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration.

Innovation

Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness.

Level of evidence

N/a.

The Influence of Symptoms of Anger on Pain Intensity and Activity Intolerance

This study assessed the association of anger, anxiety, and depression, and cognitive bias with pain and activity tolerance among patients with a musculoskeletal illness or injury expected to last more than a month. 102 Patients completed emotional thermometers to quantify symptoms of anger, anxiety, depression; the abbreviated Pain Catastrophizing Scale; a pain intensity scale; Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computer Adaptive Test; the Spielberger State-Trait Anxiety Inventory and demographic questionnaires. Controlling for potential confounding in multivariable analysis we found greater activity intolerance was associated with retired work-status and greater depressive symptoms, but not with greater symptoms of anger. In addition, greater pain intensity was associated with greater symptoms of depression and greater catastrophic thinking, but not with greater symptoms of anger. Anger emotions do not contribute to symptom intensity and activity intolerance in musculoskeletal illness. Attention can be directed at addressing psychological distress and cognitive bias.

Priorities for Advancing Mental and Social Health Among People Presenting for Care of Musculoskeletal Symptoms : International Consortium for Mental and Social Health in Musculoskeletal Care

An international group of clinicians and researchers formed a consortium to advance mental and social health among people seeking musculoskeletal specialty care: The International Consortium for Mental and Social Health in Musculoskeletal Care (I-MESH). As a first step to organize the work of the consortium, we sought to identify important, appropriate, and feasible interventions to address mental and social health. Members of I-MESH responded to a list of 10 queries intended to elicit mental and social health priorities. Open text answers were analyzed by 2 researchers to elicit individual themes. A modified RAND/UCLA Delphi Appropriateness process was conducted of 32 candidate social and mental health priorities using a 15-person panel of I-MESH members, using 2 rounds of independent voting with intervening discussion via surveys and video teleconferences. Panelists rated each potential priority for importance, feasibility, and appropriateness on a 9-point Likert scale. Top level priorities scored both mean and median greater than 7 in all 3 categories. Second level priorities scored a median 7 or greater on the final scoring in all 3 categories. Candidate priorities were organized into 9 themes: viable business model, coordination of specialty and non-specialty care, actionable measurement, public health/cultural interventions, research, adequate and timely access, incorporating assessment in care, strategies to develop the patient-clinician relationship, communication strategies that can directly enhance health, and support for mental and social health. Twelve top level (met mean and median criteria) and 17 s level priorities (met median criterion) were identified. Implementing evidence-based strategies to efficiently diagnose, prioritize, and begin addressing mental and social health opportunities has the potential for notable impact on both musculoskeletal and overall health. It is our hope that the results of this Delphi panel will generate enthusiasm and collaboration for implementing the mounting evidence that social and mental health are integral to musculoskeletal health.

Psychological factors associated with foot and ankle pain: a mixed methods systematic review

BACKGROUND

Foot and ankle pain is common, and generally viewed through a biomedical lens rather than applying a biopsychosocial model. The objectives of this review were to evaluate: (1) the psychosocial characteristics of participants with foot/ankle pain compared to participants without foot/ankle pain; (2) the association between psychosocial factors with pain and function in people with foot/ankle pain; and (3) understand the psychosocial factors associated with the lived experience of foot/ankle pain.

METHODS

A mixed methods systematic review was conducted according to the PRISMA guidelines and guided by the Joanna Briggs Institute methodology for mixed methods systematic reviews. The databases MEDLINE, Embase, CINAHL, SPORTDiscus, PsychInfo, and Scopus were searched. The Mixed Methods Assessment Tool was used to evaluate study quality. A convergent segregated approach was used to synthesise and integrate quantitative and qualitative data.

RESULTS

Eighteen studies were included, consisting of 13 quantitative, 4 qualitative and 1 mixed methods study. The overall quality of the studies was considered high. Integration of the quantitative and qualitative data were not possible due to the disparate nature of the included studies. A narrative synthesis of the quantitative data revealed that negative emotional and cognitive factors were more common in people with foot/ankle pain compared to those without foot/ankle pain. A significant association was also found between emotional distress with foot pain and foot function in some people with plantar heel pain. In addition, kinesiophobia and pain catastrophising were significantly associated with impaired foot function, and pain catastrophising was significantly associated with first step pain in people with plantar heel pain. The qualitative data revealed emotional impacts, physical challenges, and a loss of self which was individual and unpredictable.

CONCLUSIONS

This review provides evidence that negative psychological constructs are greater in participants with foot/ankle pain compared to those without foot/ankle pain, although the cross-sectional nature of the study designs included in this review reduces the certainty of the evidence. These findings indicate that psychological constructs are associated with foot/ankle pain. Further research should evaluate the predictive ability of multidimensional screening tools to identify patients at risk of developing persistent foot/ankle pain.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, prognostic study.

Comprehensive Rehabilitation of the Athlete: A Specific and Purposeful Approach

There is a need to improve the quality of rehabilitation in sports medicine to return athletes to optimal function safely and quickly, reducing the risk of reinjury. This paper describes a planning paradigm to guide clinical reasoning during individual treatment sessions and a model for planning the rehabilitation program from acute injury to return to play. The design of a rehabilitation program should be a collaborative, team effort, and accounting for the specific needs of the athlete. As the athlete progresses from acute injury management all the way back to full competition, the rehabilitation professional emphasizes the components of pain management, motion, motor control, and force production in varying degrees based upon phases of tissue healing and the athlete's response. Utilizing high-value, evidence-based treatments maximize both the effectiveness and efficiency of rehabilitation to restore and improve upon preinjury levels of physical performance.

Living With Both a Total Ankle Replacement and an Ankle Fusion: A Qualitative Study From the Patients' Perspective

BACKGROUND

Total ankle replacement (TAR) and ankle fusion are effective treatments for end-stage ankle arthritis. Comparative studies elucidate differences in treatment outcomes; however, the literature lacks evidence demonstrating what outcomes are important to patients. The purpose of this study was to investigate patients' experiences of living with both a TAR and ankle fusion.

METHODS

This research study used qualitative description. Individuals were selected from a cohort of patients with TAR and/or ankle fusion (n = 1254). Eligible patients were English speaking with a TAR and contralateral ankle fusion, and a minimum of 1 year since their most recent ankle reconstruction. Surgeries were performed by a single experienced surgeon, and semistructured interviews were conducted by a single researcher in a private hospital setting or by telephone. Ankle Osteoarthritis Scale (AOS) scores, radiographs, and ancillary surgical procedures were collected to characterize patients. Themes were derived through qualitative data analysis.

RESULTS

Ten adults (8 men, 2 women), ages 59 to 90 years, were included. Average AOS pain and disability scores were similar for both surgeries for most patients. Participants discussed perceptions of each reconstructed ankle. Ankle fusions were considered stable and strong, but also stiff and compromising balance. TARs were considered flexible and more like a "normal ankle," though patients expressed concerns about their TAR "turning" on uneven ground. Individuals applied this knowledge to facilitate movement, particularly during a first step and transitioning between positions. They described the need for careful foot placement and attention to the environment to avoid potential challenges.

CONCLUSION

This study provides insight into the experiences of individuals living with a TAR and ankle fusion. In this unusual but limited group of patients, we found that each ankle reconstruction was generally perceived to have different characteristics, advantages, and disadvantages. Most participants articulated a preference for their TAR. These findings can help clinicians better counsel patients on expectations after TAR and ankle fusion, and improve patient-reported outcome measures by better capturing meaningful outcomes for patients.

LEVEL OF EVIDENCE

Level IV, case series.

Pain during physical examination of a healing upper extremity fracture

The evidence that symptom intensity and magnitude of limitations correlate with thoughts and emotions means that subjective signs, such as pain with physical examination, reflect both physical and mental health. During a 1-month evaluation of a rapidly healing upper extremity fracture with no risk of nonunion, 117 people completed measures of adaptiveness to pain and pain during the physical examination. Greater pain during examination correlated with less adaptive responses to pain and older age. This finding raises questions about using tenderness to assess fracture union.Level of evidence: II.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Predictive Factors of Recovery after an Acute Lateral Ankle Sprain: A Longitudinal Study

A prominent feature of ankle sprains is their variable clinical course. The difficulty of providing a reliable early prognosis may be responsible for the substantial rate of poor outcomes after an ankle sprain. The aim of the present study was to evaluate the prognostic value of objective clinical measures, pain, and functional scores for ankle sprain recovery. Fifty-two participants suffering from lateral ankle sprain were included. Sprain status was assessed four weeks following injury and included evaluations of ankle range of motion, strength, function, and pain. Seven months following injury, a second assessment classified the patients into recovered and non-recovered groups using ankle ability measures. Following a predictor pre-selection procedure, logistic regressions evaluated the association between the four-week predictors and the seven-month recovery status. Twenty-seven participants (52%) fully recovered and 25 did not (48%). The results of the logistic regressions showed that walking pain was negatively associated with the probability of recovering at seven months (odds ratio: 0.71, 95% CI: 0.53–0.95). Pain four weeks after ankle sprain had relevant predictive value for long-term recovery. Special attention should be paid to patients reporting persistent pain while walking four weeks following sprain to reduce the risk of chronicity.

Criteria-Based Return to Sport Decision-Making Following Lateral Ankle Sprain Injury: a Systematic Review and Narrative Synthesis

OBJECTIVE

The aim of this systematic review was to identify prospective studies that used a criteria-based return to sport (RTS) decision-making process for patients with lateral ankle sprain (LAS) injury.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched to 23 November 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they prospectively applied a criteria-based RTS decision-making process for patients with LAS injury, but were excluded if they merely gathered outcome measures at the RTS time point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury.

RESULTS

No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, therefore we provide a narrative synthesis of relevant questionnaires, as well as clinical and functional assessments commonly used in studies retrieved in the search.

CONCLUSION

There are currently no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. Based on our narrative synthesis, we propose a number of variables that could be used to develop a criteria-based RTS decision paradigm. Future research should aim to reach consensus on these variables and apply them to actual RTS decisions within prospective study designs. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to inform the development of an RTS decision-making paradigm for athletes with LAS injury.

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis

BACKGROUND

There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery.

METHODS

This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization.

RESULTS

Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured.

CONCLUSIONS

Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied.

LEVEL OF EVIDENCE

Level III, comparative study.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Ankle fractures: What role does level of insurance play in recovery and outcomes?

Introduction

A number of factors including socioeconomic status have been correlated with post-operative outcomes in orthopedic trauma. The objective of this study is to compare post-operative courses and patient-reported outcomes following operatively managed ankle fractures taking into account a patient's level of insurance coverage.

Methods

A retrospective cohort study was performed at a single level I trauma center. Patients were identified by billing code for operative intervention of ankle fractures (OTA 44) from January 2014 to January 2015. Study outcomes included narcotic refills, compliance with follow-up visits, visual analog scale (VAS) pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) survey data, and perioperative complication rates. Statistical analysis included mean comparison between insurance groups and multivariate regression modeling.

Results

From January 2014 to January 2015, 209 patients met the inclusion criteria (45 patients under/uninsured vs. 164 fully insured). No differences were found amongst demographic data or fracture characteristics. The underinsured group had a higher average number of narcotic prescriptions (2.6 refills vs. 1.5 refills, p < 0.05). The underinsured group also demonstrated a significantly greater number of missed post-operative clinic visits (0.8 vs. 0.3 visits p < 0.05); the total number of post-operative visits were similar (6.4 vs. 6.9, p = 0.38). At one-year follow-up, the underinsured group had higher pain scores (VAS 3.8 vs. 2.1, p < 0.05), and significantly worse PROMIS scores with respect to mood (54 vs. 49.1, p < 0.05), pain (59.6 vs. 55.5, p < 0.05), and functional outcomes (38 vs. 44.7, p < 0.05). There was no difference in perioperative complication rates. Multivariate regression modeling found insurance (p < 0.05), age (p < 0.05), and smoking (p < 0.05) to be significant determinants of post-operative outcomes.

Conclusion

Despite similar demographic and fracture characteristics, patients with decreased insurance coverage demonstrated higher narcotic requirements and missed more appointments. They had worse subjective and objective outcomes. As physician reimbursement becomes increasingly dependent on outcomes, further understanding of the psychosocial factors of this subset of patients is needed to establish realistic expectations and identify avenues for further intervention.