Comparative Responsiveness of the PROMIS Pain Interference Short Forms With Legacy Pain Measures: Results From Three Randomized Clinical Trials

Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial

Importance

Although mindfulness-based interventions (MBIs) are evidence-based treatments for chronic pain and comorbid conditions, implementing them at scale poses many challenges, such as the need for dedicated space and trained instructors.

Objective

To examine group and self-paced, scalable, telehealth MBIs, for veterans with chronic pain, compared to usual care.

Design, Setting, and Participants

This was a randomized clinical trial of veterans with moderate to severe chronic pain, recruited from 3 Veterans Affairs facilities from November 2020 to May 2022. Follow-up was completed in August 2023.

Interventions

Two 8-week telehealth MBIs (group and self-paced) were compared to usual care (control). The group MBI was done via videoconference with prerecorded mindfulness education and skill training videos by an experienced instructor, accompanied by facilitated discussions. The self-paced MBI was similar but completed asynchronously and supplemented by 3 individual facilitator calls.

Main Outcomes and Measures

The primary outcome was pain-related function using the Brief Pain Inventory interference scale at 3 time points: 10 weeks, 6 months, and 1 year. Secondary outcomes included biopsychosocial outcomes: pain intensity, physical function, anxiety, fatigue, sleep disturbance, participation in social roles and activities, depression, patient ratings of improvement of pain, and posttraumatic stress disorder.

Results

Among 811 veterans randomized (mean [SD] age, 54.6 [12.9] years; 387 [47.7%] women), 694 participants (85.6%) completed the trial. Averaged across all 3 time points, pain interference scores were significantly lower for both MBIs compared to usual care (group MBI vs control difference: -0.4 [95% CI, -0.7 to -0.2]; self-paced vs control difference: -0.7 [95% CI, -1.0 to -0.4]). Additionally, both MBI arms had significantly better scores on the following secondary outcomes: pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and posttraumatic stress disorder. Both group and self-paced MBIs did not significantly differ from one another. The probability of 30% improvement from baseline compared to control was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI, at all 3 time points.

Conclusions and Relevance

In this randomized clinical trial, scalable telehealth MBIs improved pain-related function and biopsychosocial outcomes compared to usual care among veterans with chronic pain. Relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in health care systems.

Trial Registration

ClinicalTrials.gov Identifier: NCT04526158.

Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings

The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35-.37) while moderate-to-good relationships (r = .51-.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PERSPECTIVE: This study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.

Withdrawal interference scale: a novel measure of withdrawal-related life disruption in opioid use disorder and alcohol use disorder

Background: Hyperkatifeia describes amplified emotional and motivational withdrawal due to addiction-related sensitization of brain-stress-systems. Hyperkatifeia has been proposed as a target for addiction treatment development. However, translation of basic research in this area will require new tools designed to measure hyperkatifeia and related phenomena outside of laboratory settings.Objectives: We define a novel concept, withdrawal interference, and introduce a new tool - the Withdrawal Interference Scale (WIS) - which measures the impact of withdrawal on daily life among individuals with OUD or AUD.Methods: Described are the combined results of three separate cross-sectional studies. The structural validity, convergent validity, construct validity, trans-diagnostic (AUD/OUD) configural, metric, and scalar invariance, internal consistency, and composite reliability of WIS was tested among three independent samples of 1) treatment-seeking adults with OUD (n = 132), 2) treatment-seeking adults with AUD (n = 123), and 3) non-treatment-seeking adults with OUD (n = 140). Males numbered 218 and females were 163.Results: WIS exhibited structural validity (1 factor), convergent validity (average variance extracted .670-.676), construct validity, trans-diagnostic configural (χ2/df = 2.10), metric (Δχ2 = 5.70, p = .681), and scalar invariance (Δχ2 = 12.34, p = .338), internal consistency (α .882-928), and composite reliability (.924-.925).Conclusion: These results suggest WIS is a valid and reliable instrument for measuring withdrawal-related life disruption in AUD and OUD. Further, given our findings of transdiagnostic measurement invariance, WIS scores of individuals with AUD and OUD can be meaningfully compared in future statistical analyses.

Impact of pain and adverse health outcomes on long-term US testicular cancer survivors

BACKGROUND

No study has quantified the impact of pain and other adverse health outcomes on global physical and mental health in long-term US testicular cancer survivors or evaluated patient-reported functional impairment due to pain.

METHODS

Testicular cancer survivors given cisplatin-based chemotherapy completed validated surveys, including Patient-Reported Outcomes Measurement Information System v1.2 global physical and mental health, Patient-Reported Outcomes Measurement Information System pain questionnaires, and others. Multivariable linear regression examined relationships between 25 adverse health outcomes with global physical and mental health and pain-interference scores. Adverse health outcomes with a β^  of more than 2 are clinically important and reported below.

RESULTS

Among 358 testicular cancer survivors (median age = 46 years, interquartile range [IQR] = 38-53 years; median time since chemotherapy = 10.7 years, IQR = 7.2-16.0 years), median adverse health outcomes number was 5 (IQR = 3-7). A total of 12% testicular cancer survivors had 10 or more adverse health outcomes, and 19% reported chemotherapy-induced neuropathic pain. Increasing adverse health outcome numbers were associated with decreases in physical and mental health (P < .0001 each). In multivariable analyses, chemotherapy-induced neuropathic pain (β^ = -3.72; P = .001), diabetes (β^ = -4.41; P = .037), obesity (β^ = -2.01; P = .036), and fatigue (β^ = -8.58; P < .0001) were associated with worse global mental health, while being married or living as married benefited global mental health (β^ = 3.63; P = .0006). Risk factors for pain-related functional impairment included lower extremity location (β^ = 2.15; P = .04) and concomitant peripheral artery disease (β^ = 4.68; P < .001). Global physical health score reductions were associated with diabetes (β^ = -3.81; P = .012), balance or equilibrium problems (β^ = -3.82; P = .003), cognitive dysfunction (β^ = -4.43; P < .0001), obesity (β^ = -3.09; P < .0001), peripheral neuropathy score (β^ = -2.12; P < .0001), and depression (β^ = -3.17; P < .0001).

CONCLUSIONS

Testicular cancer survivors suffer adverse health outcomes that negatively impact long-term global mental health, global physical health, and pain-related functional status. Clinically important factors associated with worse physical and mental health identify testicular cancer survivors requiring closer monitoring, counseling, and interventions. Chemotherapy-induced neuropathic pain must be addressed, given its detrimental impact on patient-reported functional status and mental health 10 or more years after treatment.

Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain

Background

Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities.

Materials and Methods

This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures.

Results

Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities.

Conclusion

Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans.

Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Comparable Minimally Important Differences and Responsiveness of Brief Pain Inventory and PEG Pain Scales across 6 Trials

The 3-item pain intensity (P), interference with the enjoyment of life (E), and interference with general activity (G), or PEG, has become one of the most widely used measures of pain severity and interference. The minimally important differences (MID) and responsiveness of the PEG are essential metrics for solidifying its role in research and clinical care. The current study aims to establish the MID and responsiveness of the PEG by synthesizing data from 1,710 participants across 6 controlled trials. MIDs were estimated using absolute score changes among individuals reporting their pain was "a little better" on a retrospective global change anchor as well as distribution-based estimates using standard deviation thresholds and 1 and 2 standard errors of measurement. Responsiveness was assessed using standardized response means, area under the curve, and treatment effect sizes. MID estimates for the PEG ranged from 0.60 to 1.1 when using 0.35 SD, and 0.78 to 1.22 using 1 standard error of measurement. MID estimates using the global anchor had somewhat more variability but most estimates ranged from 1.0 to 1.75. Responsiveness effect sizes were generally large (>.80) for standardized response means and moderate (>.50) for treatment effect. Similarly, the most area under the curve values demonstrated an acceptable level of scale responsiveness (≥.70). Importantly, MID estimates and responsiveness of the PEG and BPI scales were largely comparable when aggregating data across trials. Our synthesis indicates that 1 point is a reasonable MID estimate on these 0- to 10-point pain scales, with 2 points being an upper bound. PERSPECTIVE: This article synthesizes data from 6 clinical trials to establish the minimally important difference (MID) and responsiveness of the 3-item PEG pain scale. The PEG demonstrated good responsiveness, and 1 to 2 points proved to be reasonable estimates for the lower and upper bounds of the MID.

Experiential Avoidance, Pain, and Suicide Risk in a National Sample of Gulf War Veterans

OBJECTIVE

Pain confers risk for suicidal thoughts and behaviors. Experiential avoidance (EA), which is relevant to both pain and suicide risk, has not been studied as a potential mechanism for this relationship. The present study tested the hypothesis that pain indirectly impacts suicide risk through EA in a national sample of Gulf War veterans.

METHODS

Participants included a stratified random sample of United States veterans (N = 1,012, 78% male) who had served in the Gulf War region between August 1990 and July 1991. Validated scales were used to quantify levels of pain, EA, and suicide risk.

RESULTS

Regression analyses indicated independent associations between pain, EA, and suicide risk; moreover, the association between pain and suicide risk was no longer significant once EA was included in model. Bootstrapping analyses confirmed that EA partially accounted for the cross-sectional association between pain and suicide risk, independent of common co-occurring problems, such as depression, PTSD, and alcohol use disorder symptoms.

CONCLUSIONS

EA could be a key modifiable risk factor to target in people experiencing pain.

The design and baseline characteristics for the HOPE Consortium Trial to reduce pain and opioid use in hemodialysis

The HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis (HOPE Trial) is a multicenter randomized trial addressing chronic pain among patients receiving maintenance hemodialysis for end-stage kidney disease. The trial uses a sequential, multiple assignment design with a randomized component for all participants (Phase 1) and a non-randomized component for a subset of participants (Phase 2). During Phase 1, participants are randomized to Pain Coping Skills Training (PCST), an intervention designed to increase self-efficacy for managing pain, or Usual Care. PCST consists of weekly, live, coach-led cognitive behavioral therapy sessions delivered by video- or tele-conferencing for 12 weeks followed by daily interactive voice response sessions delivered by telephone for an additional 12 weeks. At 24 weeks (Phase 2), participants in both the PCST and Usual Care groups taking prescription opioid medications at an average dose of ≥20 morphine milligram equivalents per day are offered buprenorphine, a partial opioid agonist with a more favorable safety profile than full-agonist opioids. All participants are followed for 36 weeks. The primary outcome is pain interference ascertained, for the primary analysis, at 12 weeks. Secondary outcomes include additional patient-reported measures and clinical outcomes including falls, hospitalizations, and death. Exploratory outcomes include acceptability, tolerability, and efficacy of buprenorphine. The enrollment target of 640 participants was met 27 months after trial initiation. The findings of the trial will inform the management of chronic pain, a common and challenging issue for patients treated with maintenance hemodialysis. NCT04571619.

Country-specific reference values for PROMIS® pain, physical function and participation measures compared to US reference values

INTRODUCTION

Patient-Reported Outcomes Measurement Information System (PROMIS^®) is commonly used across medical conditions. To facilitate interpretation of scores across countries, we calculated Dutch reference values for PROMIS Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), Pain Behavior (PROMIS-PB), Ability to Participate in Social Roles and Activities (PROMIS-APSRA), and Satisfaction with Social Roles and Activities (PROMIS-SSRA), as compared to US reference values.

PATIENTS AND METHODS

A panel completed full PROMIS-PF (n=1310), PROMIS-PI and PROMIS-PB (n=1052), and PROMIS-APSRA and PROMIS-SSRA (n=1002) item banks and reported their level of health per domain (no, mild, moderate, severe limitations). T-scores were calculated by sample and subgroups (age, gender, self-reported level of domain). Distribution-based and anchor-based thresholds for mild, moderate, and severe scores were determined.

RESULTS

Mean T-scores were close to the US mean of 50 for PROMIS-PF (49.8) and PROMIS-APSRA (50.6), lower for PROMIS-SSRA (47.5) and higher for PROMIS-PI (54.9) and PROMIS-PB (52.0). Distribution-based thresholds for mild, moderate, and severe scores were comparable to US recommended cut-off values (except for PROMIS-PI) but participants reported limitations 'earlier' than suggested thresholds.

CONCLUSION

Dutch reference values were close to US reference values for some PROMIS domains but not all. We recommend country-specific reference values to facilitate worldwide PROMIS use.KEY MESSAGESPROMIS offers universally applicable IRT-based efficient and patient-friendly measures to assess commonly relevant patient-reported outcomes across medical conditions.To support the use of PROMIS in daily clinical practice and research across the world, country-specific general population reference values should be obtained.More research is necessary to obtain reliable and valid cut-off values for what constitutes mild, moderate and severe scores from the patients' perspective.

Chronic pain outcomes of patients receiving electroconvulsive therapy: A systematic review and case series

INTRODUCTION

The potential benefits of electroconvulsive therapy (ECT) in chronic pain and several theories for its mechanism have been reported in the past, but mixed findings have also been reported. In the current systematic review and case series, our primary aim was to assess whether pain and functional outcomes are improved after ECT in patients with chronic pain. Secondary objectives included examining whether psychiatric improvement, specific pain diagnoses, and demographic or medical characteristics were associated with differences in pain treatment response.

METHODS

We performed a retrospective chart review to identify patients with chronic pain diagnoses for more than 3 months prior to the initiation of ECT and a systematic literature search on electronic databases for studies on chronic pain outcomes after ECT.

RESULTS

Eleven patients with various chronic pain diagnoses and comorbid psychiatric conditions were identified in the case series. Six patients reported improvement in pain while 10 patients reported improvement in mood following ECT. Systematic review identified 22 articles reporting a total of 109 cases. Eighty-five (78%) of cases reported reduction in pain while 96.3% of the patients with a comorbid psychiatric diagnosis reported improvement in mood symptoms post-ECT. While there was an association between improvement in mood and pain in studies with numeric ratings in both outcomes (r = 0.61; p < 0.001), some patients reported pain improvement without improvement in mood in both the case series and the pooled analysis of cases in the review. Certain pain diagnoses such as CRPS, phantom limb pain, neuropathic pain, and low back pain have consistently reported benefits and should be further studied in future studies with matched case controls.

CONCLUSION

ECT may be offered to patients with certain pain conditions who have not responded sufficiently to conventional therapies, particularly when comorbid mood symptoms are present. Improved documentation practices on the outcomes in chronic pain patients receiving ECT will help generate more studies that are needed on this topic.

Text messaging intervention to support patients with chronic pain during prescription opioid tapering: protocol for a double-blind randomised controlled trial

INTRODUCTION

Increases in pain and interference with quality of life is a common concern among people with chronic non-cancer pain (CNCP) who are tapering opioid medications. Research indicates that access to social and psychological support for pain self-management may help people to reduce their opioid dose without increasing pain and interference. This study evaluates the efficacy of a text messaging intervention designed to provide people with CNCP with social and psychological support for pain self-management while tapering long-term opioid therapy (LTOT) under the guidance of their prescriber.

METHODS AND ANALYSIS

A double-blind randomised controlled trial will be conducted. Patients with CNCP (n=74) who are tapering LTOT will be enrolled from across Australia. Participants will continue with their usual care while tapering LTOT under the supervision of their prescribing physician. They will randomly receive either a psychoeducational video and supportive text messaging (two Short Message Service (SMS) per day) for 12 weeks or the video only. The primary outcome is the pain intensity and interference assessed by the Pain, Enjoyment of Life and General Activity scale. Secondary outcomes include mood, self-efficacy, pain cognitions, opioid dose reduction, withdrawal symptoms, and acceptability, feasibility, and safety of the intervention. Participants will complete questionnaires at baseline and then every 4 weeks for 12 weeks and will be interviewed at week 12. This trial will provide evidence for the efficacy of a text messaging intervention to support patients with CNCP who are tapering LTOT. If proven to be efficacious and safe, this low-cost intervention can be implemented at scale.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBER

ACTRN12622001423707.

Biobehavioral Assessments in BACPAC: Recommendations, Rationale, and Methods

The Biobehavioral Working Group of BACPAC was charged to evaluate a range of psychosocial, psychophysical, and behavioral domains relevant to chronic low back pain, and recommend specific assessment tools and procedures to harmonize biobehavioral data collection across the consortium. Primary references and sources for measure selection were the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials, the Minimum Data Set from the National Institutes of Health (NIH) Research Task Force on Standards for Chronic Low Back Pain, the Patient-Reported Outcomes Measurement Information System, and NeuroQOL. The questionnaire's recommendations supplemented the NIH HEAL Common Data Elements and BACPAC Minimum Data Set. Five domains were identified for inclusion: Pain Characteristics and Qualities; Pain-Related Psychosocial/Behavioral Factors; General Psychosocial Factors; Lifestyle Choices; and Social Determinants of Health/Social Factors. The Working Group identified best practices for required and optional Quantitative Sensory Testing of psychophysical pain processing for use in BACPAC projects.

A multi-site pilot randomized clinical trial of the Treatment and Education Approach for Childhood-onset Lupus (TEACH) program: study design and COVID-19 adaptations

BACKGROUND

Childhood-onset Systemic Lupus Erythematosus (cSLE) is an autoimmune disease associated with fatigue, mood symptoms, and pain. Fortunately, these symptoms are potentially modifiable with psychological intervention such as cognitive-behavioral therapy (CBT). The Treatment and Education Approach for Childhood-onset Lupus (TEACH) program is a CBT intervention developed to target these symptoms for adolescents and young adults with cSLE. This pilot randomized controlled trial (RCT) aims to determine the feasibility and effect of TEACH for youth with cSLE. Adjustments to the study protocol following the COVID-19 pandemic are also described.

METHODS

This two-arm multisite RCT will explore the feasibility (primary outcome) and effect (secondary outcome) of a remotely delivered TEACH protocol. Participants will be randomized to a six-week remotely delivered TEACH program plus medical treatment as usual (TAU) or TAU alone. We will include patients ages 12-22 years presenting to rheumatology clinics from six sites. Validated measures of fatigue, depressive symptoms, and pain will be obtained at baseline and approximately eight and 20 weeks later. Protocol adjustments were also made due to the COVID-19 pandemic, in collaboration with the investigative team, which included patients and caregivers.

CONCLUSIONS

Findings from this multi-site RCT aim to document the feasibility of TEACH and provide an estimate of effect of a remotely delivered TEACH protocol on fatigue, depression, and pain symptoms in youth with cSLE as compared to standard medical treatment alone. This findings may positively impact clinical care for patients with cSLE.

CLINICAL TRIALS

gov registration: NCT04335643.

Pain interference and fatigue in limb-girdle muscular dystrophy R9

Pain is prevalent in individuals with limb-girdle muscular dystrophy (LGMD) R9, but impact on daily living and correlation with fatigue remain unknown. Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and fatigue short forms were completed annually by 23 children and 54 adults with biallelic fukutin-related protein (FKRP) variants for up to six years. Concurrent motor and pulmonary function were evaluated. Pain interference T-scores were near the normal mean of 50 by linear mixed model analysis (48.5 in children, 51.6 in adults). 58% of participants experienced pain interference levels greater than the general population on at least one assessment. Fatigue T-scores were elevated in adults but not children (49.0 in children, 55.1 in adults), and 75% had at least one elevated fatigue score. Of participants with at least two visits, serial scores were not consistent across visits, without a clear pattern. Pain interference and fatigue were positively correlated (r = 0.55). Both increased with older age (r = 0.21 and 0.41 respectively). Neither differed by sex or ambulation status. Motor (r=-0.32) and pulmonary (r=-0.25) function correlated with fatigue in adults, not children. Results suggest that pain in those with LGMDR9 is variable and episodic, limiting impact on daily life, while fatigue increases over time.

Group differences and associations between patient-reported outcomes and physical characteristics in chronic low back pain patients and healthy controls

BACKGROUND

Patients with chronic low back pain can exhibit altered slower gait, poor balance, and lower strength/power, and psychological dysfunctions such as pain catastrophizing and fear of movement. Few studies have investigated the relationships between physical and psychological dysfunctions. This study examined associations between patient-reported outcomes (pain interference, physical function, central sensitization, and kinesiophobia) and physical characteristics (gait, balance, and trunk sensorimotor characteristics).

METHODS

Laboratory testing included a 4-m walk, balance, and trunk sensorimotor testing with 18 patients and 15 controls. Gait and balance were collected with inertial measurement units. Isokinetic dynamometry measured trunk sensorimotor characteristics. Patient-reported outcomes included PROMIS Pain Interference / Physical Function, Central Sensitization Inventory, and Tampa Scale of Kinesiophobia. Independent t-tests or Mann-Whitney U tests were used to compare between groups. Additionally, Spearman's rank correlation coefficient (r_s) established associations between physical and psychological domains, and Fisher z-tests compared correlation coefficient values between groups (significance P < 0.05).

FINDINGS

The patient group had worse tandem balance and all patient-reported outcomes (P < 0.05) while no group differences were observed in gait and trunk sensorimotor characteristics. There were significant correlations between worse central sensitization and poor tandem balance (r_s = 0.446-0.619, P < 0.05) and lower peak force and rate of force development (r_s = -0.429-0.702, P < 0.05).

INTERPRETATION

Observed group differences in tandem balance agree with previous studies, indicating impaired proprioception. The current findings provide preliminary evidence that balance and trunk sensorimotor characteristics were significantly associated with patient-reported outcomes in patients. Early and period screening could help clinicians further categorize patients and develop objective treatment plans.

Responsiveness and Minimal Important Change of the PROMIS Pain Interference Item Bank in Patients Presented in Musculoskeletal Practice

We evaluated the responsiveness of the Patient Reported Outcome Information System Pain Interference item bank in patients with musculoskeletal pain by testing predefined hypotheses about the relationship between the change scores on the item bank, change scores on legacy instruments and Global Ratings of Change (GRoC), and we estimated Minimal Important Change (MIC). Patients answered the full Dutch-Flemish V1.1 item bank. From the responses we derived scores for the standard 8-item short form (SF8a) and a CAT-score was simulated. Correlations between the change scores on the item bank, GRoC and legacy instruments were calculated, together with Effect Sizes, Standardized Response Means, and Area Under the Curve. GRoC were used as an anchor for estimating the MIC with (adjusted) predictive modeling. Of 1,677 patients answering baseline questionnaires 960 completed follow-up questionnaires at 3 months. The item bank correlated moderately high with the GRoC (Spearman's rho 0.63) and with the legacy instruments (Pearson's R ranging from .45 to .68). It showed a high ES (.97) and Standardized Response Means (.71), and could distinguish well between improved and not improved patients based on the GRoC (Area Under the Curve .77). Comparable results were found for the derived SF8a and CAT-scores. The MIC was estimated to be 3.2 (CI 2.6-3.7) T-score points. PERSPECTIVE: Our study supports the responsiveness of the PROMIS-PI item bank in patients with musculoskeletal complaints. Almost all predefined hypotheses were met (94%). The PROMIS-PI item bank correlated well with several legacy instruments which supports generic use of the item bank. MIC for PROMIS-PI was estimated to be 3.2 T-score points.

A cross-sectional study of patient-reported outcomes and symptom burden using PROMIS and PRO-CTCAE measures in light chain amyloidosis

BACKGROUND

We conducted a cross-sectional study to characterize health-related quality of life and symptom burden in individuals living with light chain (AL) amyloidosis.

METHODS

Members of the Amyloidosis Support Groups, Inc. with AL amyloidosis who consented to this IRB-approved survey provided information on their amyloidosis diagnosis, treatment, symptoms, and functioning. HRQL was measured using PROMIS and PRO-CTCAE questionnaires.

RESULTS

Among 297 participants who responded, the median age at diagnosis was 60 years (23-82) with 52% female and 90% white race. There were 69% AL (lambda) and 39% reported 3 or more organs involved with amyloidosis (58% cardiac, 58% renal, 30% neurological AL). Time from diagnosis was less than 2 years in 64 (22%), 2-5 years in 105 (36%), > 5 years in 126 (43%), and unknown in 2 (< 1%) individuals. Therapy included prior chemotherapy in 88% and stem cell transplant in 52%. Fifty percent of the cohort was on active treatment. Multiple domains were impaired in AL amyloidosis compared to the general population, including physical function, fatigue, and social roles. While highest among those within 2 years of diagnosis, high symptom burden was also seen in long-term survivors. A trend to decreased severity and number of impaired symptoms was seen with longer treatment-free interval but many symptoms remained persistent.

CONCLUSIONS

Significant and persistent symptom burden is seen in AL amyloidosis. Patient-reported outcomes should be routinely measured and used to provide best supportive care to all AL amyloidosis patients, including long-term survivors and those not on active therapy.

Comparative responsiveness and minimally important difference of Fatigue Symptom Inventory (FSI) scales and the FSI-3 in trials with cancer survivors

Background

Fatigue is a highly prevalent and disabling symptom in cancer survivors. Although many measures have been developed to assess survivors’ fatigue, their ability to accurately capture change following intervention has rarely been assessed in post-treatment survivors. Ultra-brief fatigue measures are preferable in clinical practice but have limited evidence supporting their use with cancer survivors. We examined the psychometric properties of four Fatigue Symptom Inventory (FSI) measures, including the new FSI-3, in cancer survivors. Examined properties included responsiveness to change and minimally important differences (MIDs).

Methods

We analyzed data from three randomized controlled trials with post-treatment cancer survivors (N = 328). Responsiveness to change was evaluated by comparing standardized response means for survivors who reported their fatigue as being better, the same, or worse at 2–3 months. Responsiveness to intervention was assessed via effect sizes, and MIDs were estimated by using several methods. We also computed area under the curve (AUC) values to assess FSI measures’ discriminative accuracy compared to an established cut-point.

Results

All FSI measures differentiated survivors who reported improvement at 2–3 months from those with stable fatigue, but did not uniformly differentiate worsening fatigue from stable fatigue. Measures showed similar levels of responsiveness to intervention, and MIDs ranged from 0.29 to 2.20 across FSI measures. AUC analyses supported the measures’ ability to detect significant fatigue.

Conclusions

Four FSI scales show similar responsiveness to change, and estimated MIDs can inform assessment of meaningful change in fatigue. The FSI-3 shows promise as an ultra-brief fatigue measure for survivors.

Measurement properties and interpretability of the PROMIS item banks in stroke patients: a systematic review

PURPOSE

Both the International Consortium for Health Outcomes Measurement and the National Institutes of Health recommend the use of Patient-Reported Outcomes Measurement Information System (PROMIS®) measures in clinical care and research for stroke patients. This study aimed to systematically review the literature on the measurement properties and interpretability of PROMIS measures in stroke patients.

METHODS

Nine databases were searched from January 1st, 2007 till April 12th, 2021 for studies concerning the measurement properties and interpretability of PROMIS measures in stroke patients. The findings of these studies were analyzed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of Patient-Reported Outcome Measures (PROMs).

RESULTS

Ten studies were included. The PROMIS Global Health was studied the most: its two subscales had sufficient structural validity in one study of very good quality, sufficient construct validity with > 75% of hypotheses tested confirmed (high GRADE rating), sufficient internal consistency, i.e. α ≥ 0.70 in two studies (high GRADE rating), sufficient reliability, i.e. ICC ≥ 0.70 in one study of doubtful quality, and indeterminate responsiveness in one study of inadequate quality. For other PROMIS measures, the measurement properties and interpretability were limitedly studied.

CONCLUSION

The PROMIS Global Health showed sufficient structural and construct validity and internal consistency in stroke patients. There is a need for further research on content validity, structural validity, and measurement invariance of PROMIS measures in stroke patients. Trial Registration Information: CRD42020203044 (PROSPERO).

Analyses of Cross-Sectional Data to Link the PEG With the Patient Reported Outcomes Measurement and Information System (PROMIS) Global Physical Health Scale

It is challenging to synthesize findings across studies of pain impact. This study develops a link to estimate the Patient-Reported Outcomes Measurement Information System (PROMIS) global health measure from the 3-item Pain intensity, interference with Enjoyment of life, interference with General activity (PEG) scale. The PROMIS and PEG items were administered to 795 adults (average age = 51; 54% female, 79% White). We estimated correlations among the PEG and PROMIS items and conducted factor analysis to identify the best subset of PROMIS items for linking to the PEG. An item response theory graded response model was estimated to link the PEG with the 4-item PROMIS global physical health scale. A categorical single-factor model and a bifactor model provided support for a single dimension for the PEG and PROMIS global physical health items. The product-moment correlation between estimated PROMIS global physical health scale from the PEG and the actual global physical health score was .74. The mean difference between estimated PROMIS global physical health scale score from the PEG and the observed global physical health score was less than a T-score point. This study makes it possible to estimate the average global physical health for group-level comparisons in research that includes the PEG. PERSPECTIVE: This article describes an empirical link of the PEG to the PROMIS global physical health scale that makes it possible to estimate the average global physical health in studies that include the PEG. This link can facilitate comparisons among studies that have not administered the PEG or the PROMIS global health scale.

Sensory Versus Affective Pain Descriptors Predicting Functional Versus Psychosocial Disability

In the lexical assessment of pain, an offshoot of the McGill Pain Questionnaire is the Pain Descriptor System (PDS) which assesses sensory, affective, and overall intensity of pain. To determine if sensory versus affective pain components might be selectively related to different aspects of disability, PDS scores were examined in relation to functional status and psychosocial impairment on the Pain Disability Questionnaire (PDQ). A sample of 629 chronic pain patients rated the degree to which each of 36 PDS words described their pain and also rated 15 items of the PDQ. Three regression models (including Group Lasso) were applied to the data. Results showed that as hypothesized, PDS sensory scores significantly predicted PDQ functional status, accounting for about 13% of the variance; PDS affective scores significantly predicted PDQ psychosocial impairment, accounting for 17% of the variance; PDS total scores significantly predicted PDQ total scores, accounting for approximately 24% of the variance. This supports the overall predictive validity of pain descriptors, while confirming more specific links between components of pain and facets of disability. Clinically, the patient's description of pain sensation may hold valuable clues to physical impairment, whereas the communication of affect/suffering is more likely to connote psychosocial difficulties in functioning. PERSPECTIVE: Regression models (including Group Lasso) were applied to data on pain and disability from 629 patients. Findings support the Pain Descriptor System in assessing pain but further suggest that sensory descriptors are predictive of physical impairment from chronic pain, whereas affective descriptors are more predictive of psychologically-related disability.

Stratification of spine patients based on self-reported clinical symptom classes

BACKGROUND CONTEXT

Improving prognostic stratification for patients with low back pain (LBP) outside of a primary care setting has been identified as an important area for further research.

PURPOSE

Our study aimed to identify clinical symptom classes of patients presenting to a spine clinic based on 4 Patient Reported Outcome Measurement Information System (PROMIS) domains and evaluate demographic and clinical differences across classes.

STUDY DESIGN

An observational cross-sectional study of patients seen in spine centers at a large health system.

PATIENT SAMPLE

Adult patients with LBP seen in a spine center between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes as part of routine care.

OUTCOME MEASURES

PROMIS physical function, pain interference, satisfaction with social roles and activities, and fatigue.

METHODS

Latent class analysis identified symptom classes based on PROMIS domain scores ≥1 standard deviation worse (meaningfully worse) than the general population. A multivariable multinomial logistic regression model was constructed to evaluate differences in symptom classes based on demographics and socioeconomic characteristics. Lastly, the ability of the profiles to discriminate across levels of disability, based on the modified Oswestry Disability Questionnaire (ODI), was evaluated.

RESULTS

There were 7,144 adult patients included in the study who visited spine clinics for a primary complaint of LBP and completed all 4 PROMIS domains (age 58.7±15.9, 54% female). Three distinct classes were identified. Class 1 ("Significant Symptoms," n=3238) had PROMIS scores that were meaningfully worse than the population average for all domains. Class 2 ("Mixed Symptoms," n=1366) had meaningfully worse scores on physical function and pain interference but average scores on other domains. Class 3 ("Mild Symptoms," n=2540) had average scores across all domains. Compared to patients in Class 3, those in Class 2 were more likely older, and those in Classes 1 and 2 were more likely to be divorced, have lower household income, and no employment. Level of disability was significantly different across each class (average (SD) ODI for Classes 1-3: 53.4 (14.3), 39.9 (12.5), 22.9 (12.1), p<.01).

CONCLUSIONS

Patients presenting to specialty clinics for LBP demonstrate distinct clinical symptom classes which could be utilized to inform specific symptom-based treatment. Future research should evaluate the ability of these classes to predict long-term disability.

Agreement between older adult patient and caregiver proxy symptom reports

BACKGROUND

Proxy report is essential for patients unable to complete patient-reported outcome (PRO) measures themselves and potentially beneficial when the caregiver perspective can complement patient report. In this study, we examine agreement between self-report by older adults and proxy report by their caregivers when completing PROs for pain, anxiety, depression, and other symptoms/impairments.

METHODS

Four PROs were administered by telephone to older adults and their caregivers followed by re-administration within 24 h in a random subgroup. The PROs included the PHQ-9 depression, GAD-7 anxiety, PEG pain, and SymTrak multi-dimensional symptom and functional status scales.

RESULTS

The sample consisted of 576 older adult and caregiver participants (188 patient-caregiver dyads, 200 patients without identified caregiver). The four measures had good internal (Cronbach's alpha, 0.76 to 0.92) and test-retest (ICC, 0.63 to 0.92) reliability whether completed by patients or caregivers. Total score and item-level means were relatively similar for both patient and caregiver reports. Agreement for total score as measured by intraclass correlation coefficient (ICC) was better for SymTrak-23 (0.48) and pain (0.58) than for anxiety (0.28) and depression (0.25). Multinomial modeling showed higher (worse) patient-reported scale scores were associated with caregiver underreporting, whereas higher caregiver task difficulty was associated with overreporting.

CONCLUSION

When averaged over individuals at the group level, proxy reports of PRO scores by caregivers tend to approximate patient reports. For individual patients, proxy report should be interpreted more cautiously for psychological symptoms as well as when patient-reported symptoms are more severe, or caregiver task difficulty is high.

Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence-Enabled App (Wysa): Protocol for a Prospective Pilot Study

BACKGROUND

Patients with chronic pain often suffer from coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial Intelligence Supported Cognitive Behavioral Therapy or AI-CBT interventions could offer cost-effective, accessible, and potentially effective resources to tackle this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain.

OBJECTIVE

This prospective cohort study aims to examine the efficacy and usage of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app), using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text-based conversational agent (CA).

METHODS

Participants with self-reported chronic pain (N = 500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is taken from the participants within the app and the Wysa intervention is delivered remotely for 8 weeks. Outcome measures including NPRS (Numeric Pain Rating Scale), PROMIS PI (Patient-Reported Outcomes Measurement Information System Pain Interference), GAD-7 (Generalized Anxiety Disorder), and PHQ-9 (Patient Health Questionnaire) questionnaires will be administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the WAI-SR (Working Alliance Inventory-Short Revised). Retention and usage statistics will be observed for adherence and engagement.

RESULTS

The study will open for recruitment in April 2022 and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late-2022.

CONCLUSIONS

Mental health conversational agents driven by artificial intelligence (AI) could be effective in helping patients with chronic pain learn to self-manage their pain and deal with common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions with a human therapist in loop. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain.

CLINICALTRIAL

The use of PROMIS measures in clinical research in stroke patients, a systematic literature review

Objective

To systematically describe the use and outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) measures in clinical studies in populations with stroke.

Data Sources

A systematic search on the use of PROMIS measures in clinical stroke studies in 9 electronic databases.

Study Selection

Studies had to be original, reporting on outcome data using PROMIS measures in populations with stroke (ischemic and/or hemorrhagic), from January 1st, 2007. Initially, 174 unique studies met the inclusion criteria. In 2 steps, titles, abstracts and full-text articles were screened for eligibility (2 authors independently).

Data Extraction

From the selected articles, study characteristics, type of PROMIS measures, and its outcomes were extracted by 2 authors independently. The authors discussed their views to achieve consensus. A third author was consulted if necessary.

Data Synthesis

In total, 27 studies (24,366 patients) were included, predominantly from the United States (22); most study populations were hospital-based (20); the number of patients ranged from 30-3283. In general, patients had no or mild symptoms (median modified Rankin scale 1). Two different generic PROMIS measures were reported (PROMIS Global Health, PROMIS 29) and 9 PROMIS measures focusing on specific domains (sleep, pain, physical functioning, self-efficacy, satisfaction with social roles, depression, anxiety, cognition, fatigue). These match the International Classification of Functioning, Disability, and Health (ICF) domains mentioned in the Core Set for Stroke. The measures were administered 1-55 months after stroke. Outcome data are provided. Pooling of data was not achieved because of a large variety in study characteristics (inclusion criteria, follow-up moments, data processing).

Conclusions

The PROMIS measures in this review could be relevant from a patient's perspective, covering ICF core set domains for patients with stroke. The large variety in study characteristics hampers comparisons across populations. Many different outcome measures are used to report results of stroke rehabilitation studies.

The effect of a Life Care Specialist on pain management and opioid-related outcomes among patients with orthopedic trauma: study protocol for a randomized controlled trial

BACKGROUND

Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma.

METHODS

In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education.

DISCUSSION

There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04154384 . Registered on 11/6/2019 (last updated on 6/10/2021).

A Quality-of-Life Evaluation Study Assessing Health-Related Quality of Life in Patients Receiving Medicinal Cannabis (the QUEST Initiative): Protocol for a Longitudinal Observational Study

Background

Evidence supports several countries introducing legislation to allow cannabis-based medicine as an adjunctive treatment for the symptomatic relief of chronic pain, chemotherapy-induced nausea, spasticity in multiple sclerosis (MS), epileptic seizures, depression, and anxiety. However, clinical trial participants do not represent the entire spectrum of disease and health status seen in patients currently accessing medicinal cannabis in practice.

Objective

This study aims to collect real-world data to evaluate health-related quality of life in patients prescribed medicinal cannabis oil and describe any differences over time, from before starting therapy to after 3 and 12 months of therapy.

Methods

Adult patients newly prescribed medicinal cannabis oil by authorized prescribers and under the Special Access Schemes across Australia will be screened for eligibility and invited to participate. A sample size of 2142 is required, with a 3-month follow-up. All participants will complete the EuroQol 5-Dimension; European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30; Depression, Anxiety, and Stress Scale-21; Patients’ Global Impression of Change; Patient-Reported Outcomes Measurement Information System (PROMIS) Short Form (SF) version 1.0: Sleep Disturbance 8b; and PROMIS SF Fatigue 13a questionnaires. Patients with chronic pain conditions will also complete the PROMIS SF version 1.0: Pain Intensity 3a and PROMIS SF version 1.0: Pain Interference 8a. Patients with movement disorders will also complete Quality of Life in Neurological Disorders (Neuro-QoL) SF version 1.0: Upper Extremity Function (Fine Motor and Activities of Daily Living) and if chorea is indicated, the Neuro-QoL SF version 2.0: Huntington’s Disease health-related Quality of LIFE-Chorea 6a. All questionnaires will be administered at baseline, 2 weeks (titration), monthly up to 3 months, and then every 2 months up to 1 year.

Results

Recruitment commenced in November 2020. By June 2021, 1095 patients were screened for the study by 69 physicians in centers across 6 Australian states: Australian Capital Territory, New South Wales, Queensland, South Australia, Victoria, and Western Australia. Of the patients screened, 833 (39% of the target sample size) provided consent and completed baseline questionnaires. Results are expected to be published in 2022. Results of this study will show whether patient-reported outcomes improve in patients accessing prescribed medicinal cannabis from baseline to 3 months and whether any changes are maintained over a 12-month period. This study will also identify differences in improvements in patient-reported outcomes among patients with different chronic conditions (eg, chronic pain, MS, epilepsy, Parkinson disease, or cancer).

Conclusions

This protocol contains detailed methods that will be used across multiple sites in Australia. The findings from this study have the potential to be integral to treatment assessment and recommendations for patients with chronic pain and other health indicators for accessing medicinal cannabis.

Trial Registration

Australian New Zealand Clinical Trials Registry: ANZCTRN12621000063819; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380807&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/32327

Implementation of the Uniformed Services University Pain Registry Biobank: A Military and Veteran Population Focused Biobank and Registry

OBJECTIVE

The objective of this overview is to discuss the development, implementation, data content, and structure of the Uniformed Services University Pain Registry Biobank. Additionally, procedures and policies for accessing samples for pain-related research purposes are detailed.

DESIGN

Cross-sectional overview.

SETTING

Multiple military treatment facilities.

SUBJECTS

Adult beneficiaries seeking care within the Military Health System.

METHODS

Participants complete a baseline battery of biopsychosocial survey measures, including PROMIS® measures, provide biologic samples (e.g. blood and saliva), and relevant health history, including medications and surgical history, is extracted from medical records. During the course of the next year, enrolled participants complete surveys and provide biologic samples at 3-months, 6-months, and 12-months. Thereafter, participants are contacted once annually to complete self-reported assessments and provide biologic samples.

RESULTS

In the first year alone 86 subjects have participated in the Uniformed Services University Pain Registry Biobank and provided 390 observations (e.g. biological samples and biopsychosocial patient-reported outcomes). The Uniformed Services University Pain Registry Biobank's integration of biological samples, patient-reported outcomes, and health record data over a longitudinal period across a diverse sample recruited from multiple military facilities addresses many of the limitations faced by other pain-related registries or biorepositories.

CONCLUSIONS

The Uniformed Services University Pain Registry Biobank will serve as a platform for conducting research closely aligned with the Federal Pain Research Strategy. The inclusion of active duty service members, beneficiaries, and civilians living with and without acute or chronic pain provides a unique data repository for all investigators interested in advancing pain science.

Meaningful Change Thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) Fatigue and Pain Interference Scores in Patients With Rheumatoid Arthritis

OBJECTIVE

We estimated meaningful change thresholds (MCTs) for Patient-Reported Outcomes Measurement Information System (PROMIS) Fatigue and Pain Interference in rheumatoid arthritis (RA).

METHODS

The responsiveness of several patient-reported outcomes (PROs) was assessed among 521 patients with RA in the Arthritis, Rheumatism, and Aging Medical Information Systems (ARAMIS) cohort. PROMIS Fatigue (7-item) and Pain Interference (6-item) short form instruments were administered at baseline, 6 months, and 12 months. Self-reported retrospective changes over the previous 6 months (a lot better/worse, a little better/worse, stayed the same) were obtained at 6 and 12 months' follow-up. We estimated MCTs using the mean change in PROMIS scores for patients who rated their change "a little better" or "a little worse."

RESULTS

Baseline fatigue and pain interference scores were near normal (median 54 and 56, respectively). At 6 months, 7.9% of patients reported their fatigue was a little better compared to baseline (mean change [SD]: -2.6 [4.8]) and 22.8% a little worse (1.7 [5.6]). Pain was a little better for 11.5% of patients (-1.9 [6.1]) and a little worse for 24.2% of patients (0.6 [5.7]). At 12 months, results were similar. Thus, the MCT range was 1-2 points for both fatigue and pain interference. Correlations between change scores and retrospective ratings were low (0.13-0.29), indicating possible underestimation of MCT.

CONCLUSION

The group-level MCT for PROMIS Fatigue and Pain Interference is roughly 2-3 points and corresponds to a small effect size, which is consistent with earlier work demonstrating an MCT of 2 points for PROMIS Physical Functioning.

Graded chronic pain scale revised: mild, bothersome, and high-impact chronic pain

Drawing on advances in chronic pain metrics, a simplified Graded Chronic Pain Scale-Revised was developed to differentiate mild, bothersome, and high-impact chronic pain. Graded Chronic Pain Scale-Revised was validated among adult enrollees of 2 health plans (N = 2021). In this population, the prevalence of chronic pain (pain present most or every day, prior 3 months) was 40.5%: 15.4% with mild chronic pain (lower pain intensity and interference); 10.1% bothersome chronic pain (moderate to severe pain intensity with lower interference with life activities); and 15.0% high-impact chronic pain (sustained pain-related activity limitations). Persons with mild chronic pain vs those without chronic pain showed small differences on 10 health status indicators (unfavorable health perceptions, activity limitations, and receiving long-term opioid therapy), with nonsignificant differences for 7 of 10 indicators. Persons with bothersome vs mild chronic pain differed significantly on 6 of 10 indicators (eg, negative pain coping beliefs, psychological distress, unfavorable health perceptions, and pain-related interference with overall activities). Persons with high-impact chronic pain differed significantly from those with mild chronic pain on all 10 indicators. Persons with high-impact chronic pain, relative to those with bothersome chronic pain, were more likely to have substantial activity limitations (significant differences for 4 of 5 disability indicators) and more often received long-term opioid therapy. Graded Chronic Pain Scale-Revised strongly predicted 5 activity-limitation indicators with area under receiver operating characteristic curve coefficients of 0.76 to 0.89. We conclude that the 5-item Graded Chronic Pain Scale-Revised and its scoring rules provide a brief, simple, and valid method for assessing chronic pain.

Responsiveness of PROMIS and Patient Health Questionnaire (PHQ) Depression Scales in three clinical trials

BACKGROUND

The PROMIS depression scales are reliable and valid measures that have extensive normative data in general population samples. However, less is known about how responsive they are to detect change in clinical settings and how their responsiveness compares to legacy measures. The purpose of this study was to assess and compare the responsiveness of the PROMIS and Patient Health Questionnaire (PHQ) depression scales in three separate samples.

METHODS

We used data from three clinical trials (two in patients with chronic pain and one in stroke survivors) totaling 651 participants. At both baseline and follow-up, participants completed four PROMIS depression fixed-length scales as well as legacy measures: Patient Health Questionnaire 9-item and 2-item scales (PHQ-9 and PHQ-2) and the SF-36 Mental Health scale. We measured global ratings of depression change, both prospectively and retrospectively, as anchors to classify patients as improved, unchanged, or worsened. Responsiveness was assessed with standardized response means, statistical tests comparing change groups, and area-under-curve analysis.

RESULTS

The PROMIS depression and legacy scales had generally comparable responsiveness. Moreover, the four PROMIS depression scales of varying lengths were similarly responsive. In general, measures performed better in detecting depression improvement than depression worsening. For all measures, responsiveness varied based on the study sample and on whether depression improved or worsened.

CONCLUSIONS

Both PROMIS and PHQ depression scales are brief public domain measures that are responsive (i.e., sensitive to change) and thus appropriate as outcome measures in research as well as for monitoring treatment in clinical practice. Trial registration ClinicalTrials.gov ID: NCT01236521, NCT01583985, NCT01507688.

The Cancer Rehabilitation Medicine Metrics Consortium: A Path to Enhanced, Multi-Site Outcome Assessment to Enhance Care and Demonstrate Value

Purpose

A primary objective stated at the Cancer Rehabilitation Symposium at the National Institutes of Health was to improve outcome measurement. The purpose of this project was for the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) to develop an assessment tool to evaluate function in cancer patients via a data-driven and methodologically sound process. There is no agreed-upon measure of physical and cognitive function for cancer patients, making it difficult to demonstrate the value of rehabilitation interventions. Cancer patients are a particularly challenging population, with many tumor- and treatment-related variables impacting function.

Methods

Investigators from nine different cancer rehabilitation programs participated in a modified-Delphi process to delineate necessary aspects of an ideal patient assessment tool, including instrument type, domains evaluated, applicability across a range of patient traits, clinical feasibility, and item response characteristics. This involved numerous meetings, data review, and analysis of items involved in patient assessment.

Results

The CRMMC developed a 21-item patient-reported outcome measure based on item response theory. The process by which the short form was developed was documented and provides a framework for other clinicians to follow.

Conclusion

This document provides a framework for rehabilitation providers to follow when developing an assessment tool. This process is described in a stepwise fashion for reproducibility even in different, non-cancer populations.

Changes in patient-reported outcomes in light chain amyloidosis in the first year after diagnosis and relationship to NT-proBNP change

We conducted a prospective cohort study in newly diagnosed systemic light chain (AL) amyloidosis patients (N = 59) to study patient-reported outcomes (PROs) through the first year. The median age was 68 years with 42% female, 8% Black, and 78% lambda subtype. Organ involvement was cardiac in 66%, renal in 58%, with 25% having 3 or greater organs involved. Between baseline and 3 months, all PROMIS^®-29 domain scores worsened by 0.4–4.1 points except anxiety which improved by 2.1 points. By 1 year, scores improved compared to the greatest decline at 3 months, most statistically significant for global physical health, physical function, and fatigue. On stage-adjusted survival analysis, in addition to baseline global physical and mental health, domains measuring physical function, fatigue, anxiety, depression, and social roles were associated with 1-year survival. At 1 year, PROMIS measures were associated with NT-proBNP changes and hematologic response. Among patients with an NT-proBNP response, the improvement was seen in physical function, social roles, global mental health, and anxiety. Among patients with an NT-proBNP progression, worsening was seen with anxiety, depression, sleep, and global mental health. Measuring and tracking PROs in patients with AL amyloidosis is important and these important outcomes can be used as correlative endpoints in clinical care/research.

Clinical outcome assessment in clinical trials of chronic pain treatments

Clinical outcome assessments (COAs) measure outcomes that are meaningful to patients in clinical trials and are critical for determining whether a treatment is effective. The objectives of this study are to (1) describe the different types of COAs and provide an overview of key considerations for evaluating COAs, (2) review COAs and other outcome measures for chronic pain treatments that are recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) or other expert groups, and (3) review advances in understanding pain-related COAs that are relevant to clinical trials. The authors reviewed relevant articles, chapters, and guidance documents from the European Medicines Agency and U.S. Food and Drug Administration. Since the original core set of outcome measures were recommended by IMMPACT 14 years ago, several new advancements and publications relevant to the measurement or interpretation of COAs for chronic pain trials have emerged, presenting new research opportunities. Despite progress in the quality of measurement of several outcome domains for clinical trials of chronic pain, there remain some measurement challenges that require further methodological investigation.

A Sequential Multiple-Assignment Randomized Trial (SMART) for Stepped Care Management of Low Back Pain in the Military Health System: A Trial Protocol

BACKGROUND

The Defense Health Agency has prioritized system-level pain management initiatives within the Military Health System (MHS), with low back pain as one of the key focus areas. A stepped care model focused on nonpharmacologic treatment to promote self-management is recommended. Implementation of stepped care is complicated by lack of information on the most effective nonpharmacologic strategies and how to sequence and tailor the various available options. The Sequential Multiple-Assignment Randomization Trial for Low Back Pain (SMART LBP) is a multisite pragmatic trial using a SMART design to assess the effectiveness of nonpharmacologic treatments for chronic low back pain.

DESIGN

This SMART trial has two treatment phases. Participants from three military treatment facilities are randomized to 6 weeks of phase I treatment, receiving either physical therapy (PT) or Army Medicine's holistic Move2Health (M2H) program in a package specific to low back pain. Nonresponders to treatment in phase I are again randomized to phase II treatment of combined M2H + PT or mindfulness-based treatment using the Mindfulness-Oriented Recovery Enhancement (MORE) program. The primary outcome is the Patient-Reported Outcomes Measurement Information System pain interference computer-adapted test score.

SUMMARY

This trial is part of an initiative funded by the National Institutes of Health, Veterans Affairs, and the Department of Defense to establish a national infrastructure for effective system-level management of chronic pain with a focus on nonpharmacologic treatments. The results of this study will provide important information on nonpharmacologic care for chronic LBP in the MHS embedded within a stepped care framework.

Comparison of patient-reported outcomes measurement information system and legacy instruments in multiple domains among older veterans with chronic back pain

BACKGROUND

Chronic low back pain (cLBP) results in significant physical, psycho-social and socioeconomic burden. Identifying efficient and reliable patient reported outcome measures is critical for research and clinical purposes. The NIH's Patient Reported Outcomes Measurement Information System (PROMIS) instruments have not been compared to validated "legacy" instruments in older adults with cLBP. This study evaluates construct (convergent and discriminant) validity and time to complete (TTC) PROMIS as compared to legacy instruments.

METHODS

We enrolled older Veterans (age 60+) with cLBP with/without leg pain scheduled for lumbar epidural steroid injections. Subjects completed PROMIS computer adaptive test item banks and corresponding legacy instruments in the following domains: pain intensity, interference, and behavior; functional status; depression and anxiety; fatigue; sleep and social functioning. Convergent and discriminant validity between PROMIS and legacy instruments was evaluated using Spearman rank order correlations; Mann-Whitney U tests compared TTC.

RESULTS

Of the 71 Veterans recruited, the median (IQR) age was 67 (63-71) years old, 94% were men, 76% were White, 17% Black, and 96% were Non-Hispanic. Spearman correlations between PROMIS and legacy instruments showed moderate to very strong convergent validity in all domains (r = 0.4-1.0), except for social functioning and pain behavior (PROMIS Pain Behavior with Fear Avoidance Belief Questionnaire). The total median TTC for all PROMIS items was significantly shorter than legacy items, 8 min 50 s vs 29 min 14 s respectively, p < 0.001.

CONCLUSIONS

Given time efficiency of using PROMIS, along with strong construct validity, PROMIS instruments are a practical choice for measuring multidimensional PROs in older Veterans with cLBP for both research and clinical purposes.

Relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing and legacy instruments in patients undergoing isolated biceps tenodesis

HYPOTHESIS

The purpose of this study was to correlate the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) domains with commonly used legacy patient-reported outcome measures (PROMs) preoperatively in a population of patients presenting to a tertiary care orthopedic center for biceps and labral pathology.

METHODS

Prospective data were collected on 175 patients scheduled to undergo isolated biceps tenodesis at a tertiary center. Enrollees completed legacy scores (Veterans RAND 12-Item Health Survey, Short Form 12, American Shoulder and Elbow Surgeons [ASES] Assessment Form, Single Assessment Numeric Evaluation, and Constant-Murley score) and PROMIS CAT questionnaires (Upper Extremity [UE], Pain Interference [PIF], and Depression). In addition, patients were asked to provide an assessment of the strength, function, and pain of the affected shoulder using a custom visual analog scale (VAS) questionnaire. Spearman rank correlations of the PROMIS CAT with legacy measures and the custom VAS were calculated. Floor and ceiling effects were assessed.

RESULTS

The UE CAT yielded moderate correlations with the ASES score (r = 0.57) and the custom VAS strength score (r = 0.50-0.57). The PIF CAT demonstrated moderate correlations with the VAS pain score (r = 0.45) and high-moderate correlations with the ASES score, VR6D score, and UE CAT (r = 0.61-0.66). The Depression CAT demonstrated high-moderate correlations with the mental health legacy measures (r = -0.64 to -0.61). There was a significant relative floor effect for the Depression CAT at a score of 34.2 (19%).

CONCLUSION

The PIF CAT was comparable to the ASES score, the current gold standard. Compared with legacy measures, both the UE CAT and PIF CAT are less burdensome and have few floor or ceiling effects. The PIF CAT may be a viable alternative to describe the physical and psychosocial impact of pain in biceps tenodesis patients.

The use of PROMIS patient-reported outcomes (PROs) to inform light chain (AL) amyloid disease severity at diagnosis

We sought to evaluate how PROMIS patient-reported outcome (PRO) measures correlated with disease characteristics in systemic light chain (AL) amyloidosis patients at diagnosis. Newly diagnosed AL patients were recruited at two centres (N = 61). Patients completed the PROMIS Global Health v1.2, PROMIS-29 Profile v2.0 and Fatigue 8a v1.0. We assigned disease severity based on stage, presence of cardiac AL, and number of organs involved. We evaluated a) known groups validity by comparing PROMIS T-scores by disease severity, b) internal consistency using Cronbach's alpha and c) convergent/discriminant validity based on correlations across the domains and summary scores. Using receiver operating characteristic (ROC) curve analysis, NT-proBNP cut-off level corresponding to normal/mild vs moderate/severe PRO scores was determined. The median age was 68 (48-83) years with 58% males. Sixty-six percent had cardiac involvement and 25% had 3 or more organs involved with AL amyloidosis; 14% had stage 1, 28% stage 2, 36% stage 3 and 16% stage 4 disease. PROMIS measures had acceptable to excellent internal consistency and expected patterns of correlations. PROMIS Global Physical Health score was worse than the Global Mental Health Score at diagnosis; Physical function, fatigue and anxiety were the most impaired domains. PROMIS Global Health summary scores discriminated across AL amyloidosis stage and number of organs involved. Physical Function showed the strongest effects across known groups by stage, cardiac involvement and number of organs involved followed by Ability to Participate in Social Roles and Activities. A diagnostic NT-proBNP cut-off of 4200 pg/ml identified patients with moderate/severe PRO scores for these domains. Our results provide evidence for reliability and validity of select PROMIS short form measures in AL amyloidosis at diagnosis.

Validation of PROMIS CATs and PROMIS Global Health in an Interdisciplinary Pain Program for Patients With Chronic Low Back Pain

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To (1) confirm validity of Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference computer-adaptive tests (CATs) and (2) assess the validity of PROMIS Global Health (GH) and five additional PROMIS CATs: social role satisfaction, fatigue, anxiety, depression, and sleep disturbance in a population of patients with chronic low back pain (cLBP) who completed a 3-month Interdisciplinary Pain Program (IPP).

SUMMARY OF BACKGROUND DATA

Recent recommendations for assessing outcomes in patients with cLBP have included PROMIS scales; however, there is a need for further evaluation, and PROMIS GH has not been studied in this population.

METHODS

The study cohort included patients with cLBP who completed the entirety of a 3-month IPP between August 2016 and December 2018. Patient-reported outcome measures (PROMs) were analyzed before the start of the IPP and at graduation. Convergent and discriminant validity were evaluated using Pearson correlation coefficients. Known groups' validity assessed the change in PROMIS scores stratified by improvement on the Modified LBP Disability Questionnaire. Responsiveness was evaluated with standardized response means based on global impression of change.

RESULTS

IPP was completed by 217 patients (67.7% women, age 53.8 ± 12.8). Convergent validity was supported (P < 0.01 for all pairwise PROMs comparisons). All PROMs improved significantly by graduation, with the largest improvement for PROMIS pain interference, physical function, social role satisfaction, and Modified LBP Disability Questionnaire. Known groups' validity demonstrated the greatest change on PROMIS physical function, social role satisfaction, pain interference, and depression. Responsiveness was supported for all PROMs in 170 (78.3%) patients who indicated at least minimal improvement (standardized response means 0.43-1.06).

CONCLUSION

Our study provides support of PROMIS CATs, highlights the importance of including other meaningful outcome measures, such as social role satisfaction, and provides the first validation of PROMIS GH, in patients with cLBP. PROMs collection can be streamlined through the use of PROMIS CATs which offer advantages over legacy measures.

LEVEL OF EVIDENCE

3.