Psychological distress among patients with musculoskeletal illness in general practice

Surgeons Receiving Information About Patient Language Reflecting Unhelpful Thoughts or Distress About Their Symptoms Identify Such Language More Often Than Those Who Do Not Receive This Information

BACKGROUND

Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient's symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience.

QUESTIONS/PURPOSES

In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon's identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters?

METHODS

Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as "priming") once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors.

RESULTS

After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement).

CONCLUSION

The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Effects of childhood adversity and cortisol levels on suicidal ideation and behaviour: Results from a general population study

Childhood trauma is known to increase the risk of suicidal ideation and behaviours, and has also been linked to hypothalamic pituitary adrenal (HPA) axis dysregulation measured in cortisol levels. Recent evidence has shown that adverse childhood experiences are associated with lower cortisol reactivity to stress and diminished cortisol levels upon awakening in individuals vulnerable to suicide. The present study aimed to investigate whether less traumatic long term difficulties during childhood produced a similar effect on suicidal ideation/behaviour and cortisol levels in a general population sample. Participants (N = 1094; mean age 53 years, 53.7% female) from a large cohort study completed retrospective measures of long-term difficulties during childhood and adolescent years and a measure of history of suicidal thoughts, plans and actions together with a measure of current psychological distress. 24-hour urinary free cortisol samples were collected over two days. The results showed that experiencing childhood long-term difficulties were associated with 21% higher odds of reporting suicidal thoughts or plans in adulthood. Early childhood and adolescent difficulties were equally important predictors of suicide thoughts and plans. However, childhood difficulties were not found to be associated with adult urinary free cortisol, nor were adulthood suicidal thoughts, plans and behaviour associated with adult urinary free cortisol levels. Future research should explore the extent to which childhood difficulties and stressors are related to other indicators of HPA axis functioning. The current findings have implications for clinicians and for the development of future suicide prevention interventions.

Subgroups of Long-Term Sick-Listed Based on Prognostic Return to Work Factors Across Diagnoses: A Cross-Sectional Latent Class Analysis

Comorbidity is common among long-term sick-listed and many prognostic factors for return to work (RTW) are shared across diagnoses. RTW interventions have small effects, possibly due to being averaged across heterogeneous samples. Identifying subgroups based on prognostic RTW factors independent of diagnoses might help stratify interventions. The aim of this study was to identify and describe subgroups of long-term sick-listed workers, independent of diagnoses, based on prognostic factors for RTW. Latent class analysis of 532 workers sick-listed for eight weeks was used to identify subgroups based on seven prognostic RTW factors (self-reported health, anxiety and depressive symptoms, pain, self-efficacy, work ability, RTW expectations) and four covariates (age, gender, education, physical work). Four classes were identified: Class 1 (45% of participants) was characterized by favorable scores on the prognostic factors; Class 2 (22%) by high anxiety and depressive symptoms, younger age and higher education; Class 3 (16%) by overall poor scores including high pain levels; Class 4 (17%) by physical work and lack of workplace adjustments. Class 2 included more individuals with a psychological diagnosis, while diagnoses were distributed more proportionate to the sample in the other classes. The identified classes illustrate common subgroups of RTW prognosis among long-term sick-listed individuals largely independent of diagnosis. These classes could in the future assist RTW services to provide appropriate type and extent of follow-up, however more research is needed to validate the class structure and examine how these classes predict outcomes and respond to interventions.

Psychological Distress among Patients Attending Physiotherapy: A Survey-Based Investigation of Irish Physiotherapists' Current Practice and Opinions

Purpose: The primary purpose of this study was to investigate the current practice and opinions of members of the Irish Society of Chartered Physiotherapists (ISCP) with respect to the care of patients in psychological distress. Method: This was a cross-sectional, survey-based investigation of Irish physiotherapists. An electronic survey was sent by email to the ISCP membership. It consisted of closed- and open-ended questions, as well as opinion questions with Likert scale responses. Results: More than 80% of the respondents reported that they encountered patients with psychological distress at least once a week. A lack of education in the area of mental health emerged as a predominant theme. Reflecting on current practice, many discussed the importance of addressing underlying psychological issues before or in tandem with physical issues. Respondents who had engaged in further education in mental health, psychology, or both rated their confidence in recognizing the signs and symptoms of psychological distress higher (p < 0.001). Moreover, a greater proportion of these respondents routinely assessed for psychological distress in their clinical practice (p < 0.001). Conclusion: Physiotherapists regularly encounter patients whom they perceive to have high levels of psychological distress. Irish physiotherapists displayed positive attitudes toward patients' psychological well-being. However, additional education in mental health was a recognized need in the profession.

Large Propulsion Demands Increase Locomotor Adaptation at the Expense of Step Length Symmetry

There is an interest to identify factors facilitating locomotor adaptation induced by split-belt walking (i.e., legs moving at different speeds) because of its clinical potential. We hypothesized that augmenting braking forces, rather than propulsion forces, experienced at the feet would increase locomotor adaptation during and after split-belt walking. To test this, forces were modulated during split-belt walking with distinct slopes: incline (larger propulsion than braking), decline (larger braking than propulsion), and flat (similar propulsion and braking). Step length asymmetry was compared between groups because it is a clinically relevant measure robustly adapted on split-belt treadmills. Unexpectedly, the group with larger propulsion demands (i.e., the incline group) changed their gait the most during adaptation, reached their final adapted state more quickly, and had larger after-effects when the split-belt perturbation was removed. We also found that subjects who experienced larger disruptions of propulsion forces in early adaptation exhibited greater after-effects, which further highlights the catalytic role of propulsion forces on locomotor adaptation. The relevance of mechanical demands on shaping our movements was also indicated by the steady state split-belt behavior, during which each group recovered their baseline leg orientation to meet leg-specific force demands at the expense of step length symmetry. Notably, the flat group was nearly symmetric, whereas the incline and decline group overshot and undershot step length symmetry, respectively. Taken together, our results indicate that forces propelling the body facilitate gait changes during and after split-belt walking. Therefore, the particular propulsion demands to walk on a split-belt treadmill might explain the gait symmetry improvements in hemiparetic gait following split-belt training.

Validation of the Long-term Difficulties Inventory (LDI) and the List of Threatening Experiences (LTE) as measures of stress in epidemiological population-based cohort studies

BACKGROUND

Stress questionnaires are included in many epidemiological cohort studies but the psychometric characteristics of these questionnaires are largely unknown. The aim of this study was to describe these characteristics for two short questionnaires measuring the lifetime and past year occurrence of stress: the List of Threatening Events (LTE) as a measure of acute stress and the Long-term Difficulties Inventory (LDI) as a measure of chronic stress.

METHOD

This study was performed in a general population cohort consisting of 588 females (53.7%) and 506 males (46.3%), with a mean age of 53.5 years (s.d.=11.3 years). Respondents completed the LTE and the LDI for the past year, and for the age categories of 0-12, 13-18, 19-39, 40-60, and >60 years. They also completed questionnaires on perceived stress, psychological distress (the General Health Questionnaire, GHQ-12), anxiety and depression (the Symptom Checklist, SCL-8) and neuroticism (the Eysenck Personality Questionnaire - Revised Short Scale, EPQ-RSS-N). Approximately 2 years later, 976 respondents (89%) completed these questionnaires for a second time.

RESULTS

The stability of the retrospective reporting of long-term difficulties and life events was satisfactory: 0.7 for the lifetime LDI and 0.6 for the lifetime LTE scores. The construct validity of these lists is indicated by their positive associations with psychological distress, mental health problems and neuroticism.

CONCLUSIONS

This study in a large population-based sample shows that the LDI and LTE have sufficient validity and stability to include them in major epidemiological cohort studies.

Psychological Stress Measure (PSM-9): integration of an evidence-based approach to assessment, monitoring, and evaluation of stress in physical therapy practice

Stress can be a primary or secondary contributor to ill health via excessive and sustained sympathetic arousal leading to ischemic heart disease, hypertension, stroke, obesity, and mental ill health, or through related behaviors such as smoking, substance abuse, and over or inappropriate eating; or as a contextual variable in terms of risk factor and lifestyle outcome. In addition, psychosocial stress can impair recovery from any pathological insult or injury. Most assessments of stress relate to life events, and both past and current life stressors, acute and chronic, play a major role. However, beyond the impact of stressors, it is the reported state of feeling stressed that is the critical predictor of ill health. This article describes stress and its correlates, discusses models of stress, and presents the nine-item Psychological Stress Measure (PSM-9). This tool is aimed directly at the state of feeling stressed, is suited for assessing stress clinically in the general population and serving as an outcome measure. The tool is valid and reliable and easy to administer in health care settings; it has a normal distribution, which makes it a very sensitive-to-change instrument in repeated measures to document progress.

Kritische Überprüfung der Faktorenstruktur und Konstruktvalidität des Whiteley-Index - einem etablierten Screening-Instrument zur Erfassung von Hypochondrie

Zusammenfassung. Theoretischer Hintergrund: Der Whiteley-Index (WI) ist ein international etabliertes Screening-Instrument zur Erfassung von Hypochondrie. Trotz großer Verbreitung herrscht Unklarheit über die faktorielle Struktur und Konstruktvalidität. Fragestellung: Kritische Überprüfung der Faktorenstruktur des WI. Methode: An einer umfangreichen Stichprobe von Studierenden (N = 1302) wurden sechs konkurrierende Modelle zur Faktorenstruktur des WI mittels konfirmatorischer Faktorenanalyse überprüft. Ergebnisse: Eine gute Modellpassung erzielte lediglich eine 2-faktorielle Lösung mit radikal reduzierter Itemanzahl. Auf Grund explorativer Analysen wurde ein alternatives 2-faktorielles Modell mit 10 Items realisiert und an einer zweiten Stichprobe (N = 804) konfirmatorisch repliziert. Zusammenhänge mit konvergenten und diskriminanten Außenkriterien belegen insbesondere die Konstruktvalidität des ersten Faktors “Krankheitsangst“, während der zweite Faktor “Krankheitsüberzeugung und Beschwerden“ abbildet. Schlussfolgerungen: Implikationen der Ergebnisse für die Anwendung des WI werden diskutiert.

The organisation of the stress response, and its relevance to chiropractors: a commentary

The stress response is a natural reaction by the body, against potentially harmful stimuli to enhance the chance for survival. Persistent activation of the stress response can cause changes to homeostatic mechanisms. The study of stress neurophysiology, in the evaluation of the manifestation of disease in the body, suggests that these chronic changes have detrimental effects on sub cortical structures. Furthermore, there is much scientific support for the notion that chronic activation of supraspinal systems will lead to maladaptation of homeostatic mechanisms, causing the impairment of processes within the body, and ultimately leading to visceral disorders. The chiropractic profession for many years has alluded to chronic change of neurophysiological pathways as a potential explanation of visceral disorders, but the profession has typically described these in terms of somatovisceral or viscerosomatic reflex activity. Change in supraspinal neurophysiological efferent activity is increasingly being used to explain "stress" related disease. The chiropractic profession should consider investigating such stress responses by conducting spinal manipulative therapy trials that evaluate supraspinal effects of manipulation. Such research may help elucidate key mechanisms associated with the change of visceral disorders noted by some chiropractors following manipulative therapy.

Kinesiophobia among patients with musculoskeletal pain in primary healthcare

OBJECTIVES

To describe the occurrence of kinesiophobia and to investigate the association between kinesiphobia and pain variables, physical exercise measures and psychological characteristics in patients with musculoskeletal pain.

DESIGN

A prospective descriptive study involving 2 selected physiotherapy departments within a primary healthcare setting in the south-west of Sweden.

PATIENTS

Included were 140 of 369 (38%) consecutive patients (aged between 18 and 65 years) with musculoskeletal pain.

METHODS

Questionnaires including background data, pain variables, physical exercise measures and psychological characteristics were sent to the patients prior to their appointment with the physiotherapist. A simple and a multiple logistic regression model were performed to identify associations among the variables where kinesiophobia was defined as the dependent variable.

RESULTS

A high degree of kinesiophobia and psychological distress were observed in approximately 50% of the responders. According to the simple logistic regression analysis the factors that seemed to be associated with kinesiophobia were interference, disability, pain severity, pain intensity, life control, affective distress, depressed mood and solicitous response. The multiple logistic regression analysis showed no significant associations.

CONCLUSION

Kinesiophobia is a commonly seen factor among patients with musculoskeletal pain, which ought to be taken into consideration when designing and performing rehabilitation programmes.

Marriage and family therapists and psychotropic medications: practice patterns from a national study

A national sample of marriage and family therapists (MFTs) was used to describe practice patterns of MFTs whose clients use psychotropics and to compare medicated and nonmedicated clients. Marriage and Family Therapists (n=283) reported on 195 medicated and 483 nonmedicated adult clients. Clients (n=375) rated their improvement and satisfaction with treatment. Results showed that 91% of MFTs treat medicated clients, and these clients accounted for 25% of MFT cases. Medicated clients were most often seen in individual therapy, had more serious medical problems, and showed greater cumulative improvement in relational functioning. Therapists from MFT educational backgrounds had fewer medicated clients than MFTs from other educational backgrounds.

A brief diagnostic screening instrument for mental disturbances in general medical wards

OBJECTIVE

Mental illness is prevalent among general hospital ward patients but often goes unrecognised. The aim of this study was to validate the SCL-8d as a brief questionnaire for mental disturbances for use in general hospitals.

METHODS

The study included 2040 patients, 18 years or older, consecutively admitted to 11 general internal medicine wards in seven European countries. All patients were screened on admission by means of the SCL-8d questionnaire. The psychometric performance (i.e., the internal validity) of the SCL-8d scale was tested using modern item response theory (IRT) in the form of the Rasch model.

RESULTS

Differences between sample characteristics were considerable. Even so, the SCL-8d scale showed a remarkable, statistically significant fit in terms of internal homogeneity (P>.01) in all individual settings, except in Spain and Germany where the item "Everything is an effort" had to be excluded to obtain a fit. When pooling data from all centres, an excellent statistical significance of fit (P>.05) was obtained by exclusion of the "Effort" item. The scale was homogeneous as to gender (P>.05), but not age as it performed better among young patients than among patients older than 60 years (P<.01). In these two patient groups both internal and external homogeneity (gender, median age) was achieved. The SCL-8d sum score showed a marked correlation with current and previous treatment for mental illness.

CONCLUSION

Apart from the "Effort" item ranking differently on the latent severity dimension as to age, the SCL-8d seems very robust from a psychometric point of view. Besides being short, the SCL-8d scale contains only emotional symptoms. It would therefore seem to be an excellent diagnostic tool for use in medical settings.

Hypochondrie in der Allgemeinbevölkerung:

Zusammenfassung. Der Whiteley-Index ist ein Instrument zur Erfassung von Hypochondrie. Für diesen Fragebogen wurde eine Normierungs- und Validierungsstudie anhand einer bevölkerungsrepräsentativen Stichprobe (n = 1996) durchgeführt. Hypochondrie zeigt eine etwa lineare Altersabhängigkeit (r = .24). Frauen haben in allen Altersstufen höhere Hypochondrie-Ausprägungen als Männer. Für verschiedene Alters- und Geschlechtsgruppen werden Normwerte bereit gestellt. Die in der Literatur beschriebene dreidimensionale Struktur des Whiteley-Index (Krankheitsängste, somatische Beschwerden und Krankheitsüberzeugung) konnte mit gewissen Einschränkungen bestätigt werden. Validierungsuntersuchungen mit anderen Instrumenten (Hospital Anxiety and Depression Scale, Multidimensional Fatigue Inventory, Gießener Beschwerdebogen, Screening für Somatoforme Störungen und Nottingham Health Profile) zeigten, dass eine auf sieben Items reduzierte Kurzskala der Gesamtskala mit 14 Items ebenbürtig ist. Für differenzierte Analysen wird jedoch die Originalskala empfohlen. Durch die angegebenen Normwerte ist es künftig besser möglich, Patientengruppen verschiedener Alters- und Geschlechtsverteilungen untereinander oder auch mit Stichproben der Normalbevölkerung zu vergleichen.

Psychological correlates of pain behavior in patients with chronic low back pain

Pain behaviors that are excessive for the degree of known physical disease are common in patients with chronic low back pain and are frequently assumed to arise from a comorbid depressive illness. Although some studies have confirmed an association between depression and excessive pain behavior, methodologic problems (such as the use of depression ratings that also recorded symptoms attributable to physical disease) make interpretation of this finding difficult. We recruited 54 consecutive patients with chronic (>6 months) low back pain from a hospital clinic. Subjects completed self-rated assessments of anxiety and depression (Hospital Anxiety and Depression Scale) designed to be minimally affected by physical symptoms, along with assessments of disability (ODQ), pain (visual analogue scale), pain behavior (Waddell checklist), and physical impairment. Seventeen subjects (31%) exhibited excessive pain behavior. Overall, they were no more depressed or anxious than the remainder, although men with excessive pain behavior showed a trend toward being more depressed. Patients with excessive pain behavior were more disabled (self-rated and observer-rated), reported greater pain, and were more likely to be female and to have pain of shorter duration. Pain behavior did not correlate with anxiety or depression, but correlated with measures of disability and pain intensity. Factor analysis revealed that physical disability, pain intensity, and pain behavior loaded heavily on the first factor. Anxiety and depression loaded together on a separate factor. We conclude that pain behaviors were not related to anxiety or depression in our group, although gender differences between groups could have contributed to our negative findings. Pain behaviors may influence other physical measures. Further studies are required to investigate the relation between depression and pain behavior while controlling for gender differences.