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Abstract
BACKGROUND/OBJECTIVE The aim of this study was to identify psychological factors that influence moderate-vigorous physical activity (MVPA) participation in patients with fibromyalgia. METHODS In this secondary data analysis, 170 patients received personalized exercise plans and completed baseline and follow-up assessments of self-reported physical activity at weeks 12, 24, and 36. Structural equation modeling was used to examine the predictive strengths of psychological factors (exercise self-efficacy, perceived barriers, and intention) on MVPA participation. RESULTS Using a threshold increase in MVPA of 10 or greater metabolic equivalent hours per week (MET h/wk), 3 groups were defined based on subjects who achieved a minimum increase of 10 MET h/wk that was sustained for at least 12 weeks (SUS-PA), achieved an increase of 10 MET h/wk that was not sustained for at least 12 weeks (UNSUS-PA), and did not achieve an increase of 10 MET h/wk (LO-PA). Increases in exercise self-efficacy and intention and reductions in perceived barriers were associated with increased volume of PA, showing the greatest change in the SUS-PA, followed by UNSUS-PA. For the LO-PA group, there was no change in exercise self-efficacy, a decrease in intention, and an increase in barriers. Using path analysis, exercise self-efficacy and perceived barriers were associated with higher volumes of physical activity via greater intention to engage in MVPA. CONCLUSIONS For patients with fibromyalgia, exercise self-efficacy, perceived barriers, and intention to exercise are important constructs for increasing physical activity. Our findings provide guidance for practitioners who seek to promote physical activity in fibromyalgia and suggestions for researchers aiming to improve prediction models.
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Affiliation(s)
- Anthony S Kaleth
- From the Department of Kinesiology, Indiana University-Purdue University, Indianapolis, IN
| | - Silvia M Bigatti
- Department of Social and Behavioral Sciences, IU Fairbanks School of Public Health at IUPUI
| | - James E Slaven
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Nicholas Kelly
- From the Department of Kinesiology, Indiana University-Purdue University, Indianapolis, IN
| | - Dennis C Ang
- Division of Rheumatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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Dumenci L, Kroenke K, Keefe FJ, Ang DC, Slover J, Perera RA, Riddle DL. Disentangling trait versus state characteristics of the Pain Catastrophizing Scale and the PHQ-8 Depression Scale. Eur J Pain 2020; 24:1624-1634. [PMID: 32538517 DOI: 10.1002/ejp.1619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/25/2020] [Accepted: 06/05/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Research on the role of trait versus state characteristics of a variety of measures among persons experiencing pain has been a focus for the past few decades. Studying the trait versus state nature of the Pain Catastrophizing Scale (PCS) and the Patient Health Questionnaire (PHQ-8) depression scale would be highly informative given both are commonly measured in pain populations and neither scale has been studied for trait/state contributions. METHODS The PHQ-8 and PCS were obtained on persons undergoing knee arthroplasty at baseline, 2-, 6- and 12-month post-surgery (N = 402). The multi-trait generalization of the latent trait-state model was used to partition trait and state variability in PCS and PHQ-8 item responses simultaneously. A set of variables were used to predict trait catastrophizing and trait depression. RESULTS For total scores, the latent traits and latent states explain 63.2% (trait = 43.2%; state = 20.0%) and 50.2% (trait = 29.4%; state = 20.8%) of the variability in PCS and PHQ-8, respectively. Patients with a high number of bodily pain sites, high levels of anxiety, young patients and African-American patients had high levels of trait catastrophizing and trait depression. The PCS and the PHQ-8 consist of both enduring trait and dynamic state characteristics, with trait characteristics dominating for both measures. CONCLUSION Clinicians and researchers using these scales should not assume the obtained measurements solely reflect either trait- or state-based characteristics. SIGNIFICANCE Clinicians and researchers using the PCS or PHQ-8 scales are measuring both state and trait characteristics and not just trait- or state-based characteristics.
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Affiliation(s)
- Levent Dumenci
- Department of Epidemiology and Biostatistics, Temple University, Philadelphia, PA, USA
| | - Kurt Kroenke
- Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, IN, USA
| | - Francis J Keefe
- Pain Prevention and Treatment Research, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Dennis C Ang
- Section of Rheumatology, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - James Slover
- Department of Orthopaedic Surgery, New York University Medical Center, New York, NY, USA
| | - Robert A Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Daniel L Riddle
- Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA
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Riddle DL, Slover J, Keefe FJ, Ang DC, Dumenci L, Perera RA. Racial Differences in Pain and Function Following Knee Arthroplasty: A Secondary Analysis From a Multicenter Randomized Clinical Trial. Arthritis Care Res (Hoboken) 2020; 73:810-817. [PMID: 32144884 DOI: 10.1002/acr.24177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/04/2020] [Accepted: 02/25/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The assessment of racial differences in pain and function outcome following knee arthroplasty (KA) has received little attention despite very substantial literature exploring a variety of other prognostic factors. The present study was undertaken to determine whether race was associated with KA outcome after accounting for potential confounding factors. METHODS We conducted a secondary analysis of a randomized clinical trial of 384 participants with moderate-to-high pain catastrophizing who underwent KA. Preoperative measures included race/ethnicity status as well as a variety of potential confounders, including socioeconomic status, comorbidity, and bodily pain. Outcome measures were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scales as well as performance measures. Linear mixed-effects models compared outcomes over a 1-year follow-up period for African American versus non-African American participants. RESULTS WOMAC pain scores differences for African American versus non-African American participants averaged ~2 points in unadjusted analyses and 1-1.5 points in adjusted analyses. In adjusted analyses, follow-up WOMAC function scores differed by 6 points for African Americans compared to non-African Americans (P = 0.002). CONCLUSION African Americans generally had worse pain, function, and performance prior to KA and worse scores after surgery, but differences were small and attenuated by ~25-50% after adjustment for potential confounding. Only WOMAC function scores showed clinically important postsurgical differences in adjusted analyses. Clinicians should be aware that after adjustment for potential confounders, African Americans have approximately equivalent outcomes compared to others, with the exception of WOMAC function score.
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Affiliation(s)
| | - James Slover
- New York University Medical Center, New York, New York
| | | | - Dennis C Ang
- Wake Forest School of Medicine, Winston-Salem, North Carolina
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Hung A, Li Y, Keefe FJ, Ang DC, Slover J, Perera RA, Dumenci L, Reed SD, Riddle DL. Ninety-day and one-year healthcare utilization and costs after knee arthroplasty. Osteoarthritis Cartilage 2019; 27:1462-1469. [PMID: 31176805 PMCID: PMC6750955 DOI: 10.1016/j.joca.2019.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/06/2019] [Accepted: 05/29/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study examined ninety-day and one-year postoperative healthcare utilization and costs following total knee arthroplasty (TKA) from the health sector and patient perspectives. DESIGN This study relied on: 1) patient-reported medical resource utilization data from diaries in the Knee Arthroplasty Pain Coping Skills Training (KASTPain) trial; and 2) Medicare fee schedules. Medicare payments, patient cost-sharing, and patient time costs were estimated. Generalized linear mixed models were used to identify baseline predictors of costs. RESULTS In the first ninety days following TKA, patients had an average of 29.7 outpatient visits and 6% were hospitalized. Mean total costs during this period summed to $3,720, the majority attributed to outpatient visit costs (84%). Over the year following TKA, patients had an average of 48.9 outpatient visits, including 33.2 for physical therapy. About a quarter (24%) of patients were hospitalized. Medical costs were incurred at a decreasing rate, from $2,428 in the first six weeks to $648 in the last six weeks. Mean total medical costs across all patients over the year were $8,930, including $5,328 in outpatient costs. Total costs were positively associated with baseline Charlson comorbidity score (P < 0.01). Outpatient costs were positively associated with baseline Charlson comorbidity score (P = 0.03) and a bodily pain burden summary score (P < 0.01). Mean patient cost-sharing summed to $1,342 and time costs summed to $1,346. CONCLUSIONS Costs in the ninety days and year after TKA can be substantial for both healthcare payers and patients. These costs should be considered as payers continue to explore alternative payment models.
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Affiliation(s)
- A Hung
- Duke Clinical Research Institute, Durham, NC, USA
| | - Y Li
- Duke Clinical Research Institute, Durham, NC, USA
| | - F J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - D C Ang
- Department of Medicine, Section of Rheumatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Slover
- Department of Orthopaedic Surgery, New York University Medical Center, New York, NY, USA
| | - R A Perera
- Department of Biostatistics, VA Commonwealth University, Richmond VA, USA
| | - L Dumenci
- Department of Epidemiology and Biostatistics, Temple University, Philadelphia, PA, USA
| | - S D Reed
- Duke Clinical Research Institute, Durham, NC, USA.
| | - D L Riddle
- Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA
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Ross CL, Ang DC, Almeida-Porada G. Targeting Mesenchymal Stromal Cells/Pericytes (MSCs) With Pulsed Electromagnetic Field (PEMF) Has the Potential to Treat Rheumatoid Arthritis. Front Immunol 2019; 10:266. [PMID: 30886614 PMCID: PMC6409305 DOI: 10.3389/fimmu.2019.00266] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/31/2019] [Indexed: 01/14/2023] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation of synovium (synovitis), with inflammatory/immune cells and resident fibroblast-like synoviocytes (FLS) acting as major players in the pathogenesis of this disease. The resulting inflammatory response poses considerable risks as loss of bone and cartilage progresses, destroying the joint surface, causing joint damage, joint failure, articular dysfunction, and pre-mature death if left untreated. At the cellular level, early changes in RA synovium include inflammatory cell infiltration, synovial hyperplasia, and stimulation of angiogenesis to the site of injury. Different angiogenic factors promote this disease, making the role of anti-angiogenic therapy a focus of RA treatment. To control angiogenesis, mesenchymal stromal cells/pericytes (MSCs) in synovial tissue play a vital role in tissue repair. While recent evidence reports that MSCs found in joint tissues can differentiate to repair damaged tissue, this repair function can be repressed by the inflammatory milieu. Extremely-low frequency pulsed electromagnetic field (PEMF), a biophysical form of stimulation, has an anti-inflammatory effect by causing differentiation of MSCs. PEMF has also been reported to increase the functional activity of MSCs to improve differentiation to chondrocytes and osteocytes. Moreover, PEMF has been demonstrated to accelerate cell differentiation, increase deposition of collagen, and potentially return vascular dysfunction back to homeostasis. The aim of this report is to review the effects of PEMF on MSC modulation of cytokines, growth factors, and angiogenesis, and describe its effect on MSC regeneration of synovial tissue to further understand its potential role in the treatment of RA.
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Affiliation(s)
- Christina L Ross
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, United States.,Wake Forest Center for Integrative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Dennis C Ang
- Department of Rheumatology and Immunology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Graça Almeida-Porada
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, United States
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Riddle DL, Keefe FJ, Ang DC, Slover J, Jensen MP, Bair MJ, Kroenke K, Perera RA, Reed SD, McKee D, Dumenci L. Pain Coping Skills Training for Patients Who Catastrophize About Pain Prior to Knee Arthroplasty: A Multisite Randomized Clinical Trial. J Bone Joint Surg Am 2019; 101:218-227. [PMID: 30730481 PMCID: PMC6791506 DOI: 10.2106/jbjs.18.00621] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education. METHODS A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure. RESULTS Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), -0.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, -0.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups. CONCLUSIONS Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel L. Riddle
- Department of Physical Therapy, Orthopaedic Surgery and Rheumatology, West Hospital (D.L.R.), and Department of Biostatistics (R.A.P.), Virginia Commonwealth University, Richmond, Virginia
| | - Francis J. Keefe
- Pain Prevention and Treatment Research, Department of Psychiatry and Behavioral Sciences (F.J.K. and D.M.), and Duke Clinical Research Institute (S.D.R.), Duke University, Durham, North Carolina
| | - Dennis C. Ang
- Section of Rheumatology, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Slover
- Department of Orthopaedic Surgery, New York University Medical Center, New York, NY
| | - Mark P. Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Indiana University School of Medicine, Indianapolis, Indiana,Regenstrief Institute, Indianapolis, Indiana
| | - Kurt Kroenke
- VA Center for Health Information and Communication, Indiana University School of Medicine, Indianapolis, Indiana,Regenstrief Institute, Indianapolis, Indiana
| | - Robert A. Perera
- Department of Physical Therapy, Orthopaedic Surgery and Rheumatology, West Hospital (D.L.R.), and Department of Biostatistics (R.A.P.), Virginia Commonwealth University, Richmond, Virginia
| | - Shelby D. Reed
- Pain Prevention and Treatment Research, Department of Psychiatry and Behavioral Sciences (F.J.K. and D.M.), and Duke Clinical Research Institute (S.D.R.), Duke University, Durham, North Carolina
| | - Daphne McKee
- Pain Prevention and Treatment Research, Department of Psychiatry and Behavioral Sciences (F.J.K. and D.M.), and Duke Clinical Research Institute (S.D.R.), Duke University, Durham, North Carolina
| | - Levent Dumenci
- Department of Epidemiology and Biostatistics, Temple University, Philadelphia, Pennsylvania
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Riddle DL, Slover JD, Ang DC, Bair MJ, Kroenke K, Perera RA, Dumenci L. Opioid use prior to knee arthroplasty in patients who catastrophize about their pain: preoperative data from a multisite randomized clinical trial. J Pain Res 2018; 11:1549-1557. [PMID: 30174454 PMCID: PMC6109658 DOI: 10.2147/jpr.s168251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Opioid use rates prior to knee arthroplasty (KA) among people who catastrophize about their pain are unknown. We determined prevalence of opioid use and compared patterns of preoperative opioid use and oral morphine equivalent (OME), a measure of daily opioid dose, across varied geographic sites. We also determined which baseline variables were associated with opioid use and OME. Patients and methods Preoperative opioid use data described type of opioid, dosage, and frequency among 397 patients scheduled for KA. Demographic, knee-related pain, and psychological distress dimensions were examined to identify variables associated with opioid use and opioid dose (OME). Opioid use prevalence and OME were compared across the four sites. A three-level censored regression determined variables associated with opioid use and OME. Results The overall opioid use prevalence was 31.7% (95% confidence interval [CI] = 27.0, 36.3) and varied across sites from 15.9% (95% CI = 9.0, 22.8) to 51.2% (95% CI = 40.5, 61.9). After adjustment, patients using opioids were more likely to be younger, African American, and have higher self-efficacy and comorbidity scores (P < 0.05). The only variable independently associated with OME was lower depressive symptoms (P < 0.05). Conclusion People who catastrophized prior to KA did not demonstrate increased preoperative opioid use based on current evidence, but variation in the prevalence of opioid use across study sites was substantial. Variables associated with opioid use were non-modifiable demographic and comorbidity variables.
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Affiliation(s)
- Daniel L Riddle
- Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA,
| | - James D Slover
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Dennis C Ang
- Department of Rheumatology, Wake Forest University School of Medicine, Raleigh, NC, USA
| | - Matthew J Bair
- Department of Medicine, VA Center for Health Information and Communication, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert A Perera
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Levent Dumenci
- College of Public Health, Temple University, Philadelphia, PA, USA
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Abstract
OBJECTIVE Obesity is a common comorbid condition among patients with fibromyalgia (FM). Our objective was to assess if obesity moderates the treatment benefits of exercise-based motivational interviewing (MI) for FM. MATERIALS AND METHODS This is a secondary data analysis of a completed clinical trial of 198 FM patients who were randomized to receive either MI or attention control (AC). Using body mass index (BMI) to divide participants into obese (BMI≥30 kg/m) and nonobese (BMI<30 kg m) groups, mixed linear models were used to determine interaction between treatment arms and obesity status with regards to the primary outcome of global FM symptom severity (Fibromyalgia Impact Questionnaire, FIQ). Secondary measures included pain intensity (Brief Pain Inventory), 6-Minute Walk Test, and self-reported physical activity (Community Health Activities Model Program for Seniors). RESULTS Of the 198 participants, 91 (46%) were nonobese and 107 (54%) were obese. On global FM symptom severity (FIQ), the interaction between treatment arms and obesity status was significant (P=0.02). In the nonobese group, MI was associated with a greater improvement in FIQ than AC. In the obese group, MI participants reported less improvement in FIQ compared with AC. The interaction analysis was also significant for Brief Pain Inventory pain intensity (P=0.01), but not for the walk test and self-reported physical activity. DISCUSSION This is the first study to show that obesity negatively affects the treatment efficacy of MI in patients with FM. Our findings suggest that exercise-based MI may be more effective if initiated after weight loss is achieved.
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Affiliation(s)
| | - James E Slaven
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Dennis C Ang
- Department of Medicine, Division of Rheumatology, Wake Forest University School of Medicine, Winston-Salem, NC
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Steiner JL, Bigatti SM, Slaven JE, Ang DC. The Complex Relationship between Pain Intensity and Physical Functioning in Fibromyalgia: The Mediating Role of Depression. J Appl Biobehav Res 2017; 22:e12079. [PMID: 29527113 PMCID: PMC5839337 DOI: 10.1111/jabr.12079] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Fibromyalgia (FM) is typically associated with the experience of diffuse pain and physical impairment. Depression also commonly co-exists in patients with FM, and has been correlated with pain intensity and physical functioning. Previous research suggests an association between pain intensity and physical functioning; however, the direct causal relationship between improvements in pain intensity and in functioning is not observed in many FM patients. This may suggest that another factor such as depression is mediating this relationship. The present work examined mediating role of depression. METHODS 216 patients with FM completed measures of pain intensity, depression, and physical function as part of a larger longitudinal study. Assessments were completed at baseline, 12, 24, and 36 weeks. RESULTS Longitudinal mediational analyses indicated that depression is a partial mediator of the relationship between pain intensity and physical functioning at all four assessment points. Beta coefficients for the path from pain to physical functioning ranged from 0.18 - 0.36, with attenuated path coefficients ranging from 0.03 - 0.08, still showing significant but decreased associations when depression was added as a mediator. CONCLUSIONS Clinical implication includes the importance of treating co-morbid depression in patients with fibromyalgia early in the course of treatment to prevent engagement in the cycle of disability.
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Affiliation(s)
| | - Silvia M Bigatti
- Indiana University, Richard M. Fairbanks School of Public Health, Indianapolis
| | - James E Slaven
- Indiana University School of Medicine, Department of Biostatistics, Indianapolis
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Kaleth AS, Slaven JE, Ang DC. Obesity Moderates the Effects of Motivational Interviewing Treatment Outcomes in Fibromyalgia. Med Sci Sports Exerc 2017. [DOI: 10.1249/01.mss.0000517766.74610.2e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Biologic therapy continues to revolutionize the treatment of autoimmune disease, especially in rheumatology as the pathophysiology of both inflammation and autoimmune disease becomes better understood. These therapies are designed to dampen the response of the inflammatory cascades. Although the first biologic therapies were approved many years ago, expanding indications and new agents continue to challenge the traditional treatment strategies for rheumatic diseases. This article reviews the data supporting the current use of biologic therapies, including off-label indications, in a subset of rheumatic diseases including rheumatoid arthritis, lupus, inflammatory myositis, ankylosing spondylitis, psoriatic arthritis, vasculitis, and gout.
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Affiliation(s)
- Rachel M Wolfe
- Section on Rheumatology and Immunology, Wake Forest Baptist Health, Medical Center Boulevard, Winston Salem, NC 27157, USA
| | - Dennis C Ang
- Section on Rheumatology and Immunology, Wake Forest Baptist Health, Medical Center Boulevard, Winston Salem, NC 27157, USA.
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Kim S, Slaven JE, Ang DC. Sustained Benefits of Exercise-based Motivational Interviewing, but Only among Nonusers of Opioids in Patients with Fibromyalgia. J Rheumatol 2016; 44:505-511. [PMID: 27909084 DOI: 10.3899/jrheum.161003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Given the known side effects of opioids and their potential effects on cognition, we sought to evaluate the benefits of motivational interviewing (MI) to promote physical activity on 2 subsets of participants with fibromyalgia (FM): nonusers and users of opioids. METHODS This was a secondary data analysis of a 36-week randomized controlled trial to assess the efficacy of MI to promote physical activity among participants with FM. Participants were randomized to 1 of 2 treatment arms: 6 phone-based MI sessions (n = 107) or 6 sessions of FM self-management instructions [attention control (AC), n = 109]. The primary outcomes were changes in physical function (Medical Outcomes Study Short Form-36), pain severity (Brief Pain Inventory), global FM symptom severity (Fibromyalgia Impact Questionnaire), and the amount of light to moderate physical activity (LMPA) from baseline to each followup visit. At study entry, subjects were categorized as opioid nonusers versus users. Repeated measures ANOVA was used to assess treatment effects adjusting for potential confounders. RESULTS Of the 216 participants, 145 (67%) were nonusers and 71 (33%) were opioid users. Among nonusers, MI was associated with improved physical function, reduced pain severity, and global FM severity, and increased LMPA at 6-month followup. Among opioid users, there were no significant differences in any outcome measures between the MI and AC groups. CONCLUSION Exercise-based MI was associated with sustained clinical benefits 6 months after completion of therapy, but only for those who were not taking opioids.
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Affiliation(s)
- Sunghye Kim
- From the Department of Medicine, Division of General Internal Medicine, and Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Biostatistics, Indiana University, Indianapolis, Indiana, USA.,S. Kim, MD, MMSc, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Wake Forest School of Medicine; J.E. Slaven, MS, Biostatistician, Division of Biostatistics, Indiana University; D.C. Ang, MD, MS, Associate Professor, Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine
| | - James E Slaven
- From the Department of Medicine, Division of General Internal Medicine, and Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Biostatistics, Indiana University, Indianapolis, Indiana, USA.,S. Kim, MD, MMSc, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Wake Forest School of Medicine; J.E. Slaven, MS, Biostatistician, Division of Biostatistics, Indiana University; D.C. Ang, MD, MS, Associate Professor, Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine
| | - Dennis C Ang
- From the Department of Medicine, Division of General Internal Medicine, and Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Biostatistics, Indiana University, Indianapolis, Indiana, USA. .,S. Kim, MD, MMSc, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Wake Forest School of Medicine; J.E. Slaven, MS, Biostatistician, Division of Biostatistics, Indiana University; D.C. Ang, MD, MS, Associate Professor, Department of Medicine, Division of Rheumatology, Wake Forest School of Medicine.
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Kaleth AS, Slaven JE, Ang DC. Determining the Minimal Clinically Important Difference for Six-Minute Walk Distance in Fibromyalgia. Med Sci Sports Exerc 2016. [DOI: 10.1249/01.mss.0000487052.90485.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Kaleth AS, Slaven JE, Ang DC. Does increasing steps per day predict improvement in physical function and pain interference in adults with fibromyalgia? Arthritis Care Res (Hoboken) 2015; 66:1887-94. [PMID: 25049001 DOI: 10.1002/acr.22398] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/01/2014] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To examine the concurrent and predictive associations between the number of steps taken per day and clinical outcomes in patients with fibromyalgia (FM). METHODS A total of 199 adults with FM (mean age 46.1 years, 95% women) who were enrolled in a randomized clinical trial wore a hip-mounted accelerometer for 1 week and completed self-report measures of physical function (Fibromyalgia Impact Questionnaire-Physical Impairment [FIQ-PI], Short Form 36 [SF-36] health survey physical component score [PCS], pain intensity and interference (Brief Pain Inventory [BPI]), and depressive symptoms (Patient Health Questionnaire-8 [PHQ-8]) as part of their baseline and followup assessments. Associations of steps per day with self-report clinical measures were evaluated from baseline to week 12 using multivariate regression models adjusted for demographic and baseline covariates. RESULTS Study participants were primarily sedentary, averaging 4,019 ± 1,530 steps per day. Our findings demonstrate a linear relationship between the change in steps per day and improvement in health outcomes for FM. Incremental increases on the order of 1,000 steps per day were significantly associated with (and predictive of) improvements in FIQ-PI, SF-36 PCS, BPI pain interference, and PHQ-8 (all P < 0.05). Although higher step counts were associated with lower FIQ and BPI pain intensity scores, these were not statistically significant. CONCLUSION Step count is an easily obtained and understood objective measure of daily physical activity. An exercise prescription that includes recommendations to gradually accumulate at least 5,000 additional steps per day may result in clinically significant improvements in outcomes relevant to patients with FM. Future studies are needed to elucidate the dose-response relationship between steps per day and patient outcomes in FM.
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Kaleth AS, DeSabatine S, Ang DC. Effects of Whole-body Vibration Exercise on Physical Function and Pain Severity in Patients with Fibromyalgia. Med Sci Sports Exerc 2014. [DOI: 10.1249/01.mss.0000495123.67131.0a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Outcalt SD, Ang DC, Wu J, Sargent C, Yu Z, Bair MJ. Pain experience of Iraq and Afghanistan Veterans with comorbid chronic pain and posttraumatic stress. ACTA ACUST UNITED AC 2014; 51:559-70. [DOI: 10.1682/jrrd.2013.06.0134] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Samantha D. Outcalt
- Department of Veterans Affairs (VA) Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Dennis C. Ang
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jingwei Wu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Christy Sargent
- Department of Veterans Affairs (VA) Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Zhangsheng Yu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Matthew J. Bair
- Department of Veterans Affairs (VA) Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical Center, Indianapolis, IN;Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; and Regenstrief Institute, Inc, Indianapolis, IN
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Steiner JL, Bigatti SM, Ang DC. Trajectory of change in pain, depression, and physical functioning after physical activity adoption in fibromyalgia. J Health Psychol 2013; 20:931-41. [DOI: 10.1177/1359105313504234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fibromyalgia is associated with widespread pain, depression, and declines in physical functioning. The purpose of this study was to examine the trajectory of these symptoms over time related to physical activity adoption and maintenance via motivational interviewing versus education, to increase physical activity. There were no treatment group differences; we divided the sample ( n = 184) based on changes in physical activity. Repeated measures analyses demonstrated differential patterns in depression, pain, and physical functioning at 24 and 36 weeks. Findings suggest increased physical activity may serve as a multiple-target intervention that provides moderate to large, long-lasting benefits for individuals with fibromyalgia.
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Kaleth AS, Saha CK, Jensen MP, Slaven JE, Ang DC. Effect of moderate to vigorous physical activity on long-term clinical outcomes and pain severity in fibromyalgia. Arthritis Care Res (Hoboken) 2013; 65:1211-8. [PMID: 23401486 DOI: 10.1002/acr.21980] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 01/26/2013] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the relationship between long-term maintenance of moderate to vigorous physical activity (MVPA) and clinical outcomes in fibromyalgia (FM). METHODS Patients with FM (n = 170) received individualized exercise prescriptions and completed baseline and followup physical activity assessments using the Community Health Activities Model Program for Seniors questionnaire at weeks 12, 24, and 36. The primary outcome was the change in the Fibromyalgia Impact Questionnaire-Physical Impairment (FIQ-PI) score. The secondary outcomes included improvements in overall well-being (FIQ total score), pain severity ratings, and depression. RESULTS Using a threshold increase in MVPA of ≥10 metabolic equivalent hours/week above usual activities, 27 subjects (15.9%) increased and sustained (SUS-PA), 68 (40%) increased but then declined (UNSUS-PA), and 75 (44.1%) did not achieve (LO-PA) this benchmark. Compared to LO-PA subjects, both SUS-PA and UNSUS-PA subjects reported greater improvement in FIQ-PI (P < 0.01) and FIQ total score (P < 0.05). Additionally, the SUS-PA group reported greater improvement in pain severity compared to the LO-PA group (P < 0.05). However, there were no significant group differences between SUS-PA and UNSUS-PA for any primary or secondary outcome measure. CONCLUSION Increased participation in MVPA for at least 12 weeks improved physical function and overall well-being in patients with FM. Although sustained physical activity was not associated with greater clinical benefit compared with unsustained physical activity, these findings also suggest that performing greater volumes of physical activity is not associated with worsening pain in FM. Future research is needed to determine the relationship between sustained MVPA participation and subsequent improvement in patient outcomes.
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Affiliation(s)
- Anthony S Kaleth
- Department of Kinesiology, Indiana University-Purdue University Indianapolis, 901 West New York Street, Indianapolis, IN 46202-5193, USA.
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Muthalaly AS, Bradish J, Sampson R, Hugenberg ST, Ang DC, Warren S, Muthalaly A. Prurigo pigmentosa as an atypical persistent plaque-like skin rash in adult-onset Still’s disease: case report and literature review. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ijr.13.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ang DC, Chakr R, France CR, Mazzuca SA, Stump TE, Hilligoss J, Lengerich A. Association of Nociceptive Responsivity With Clinical Pain and the Moderating Effect of Depression. The Journal of Pain 2011; 12:384-9. [DOI: 10.1016/j.jpain.2010.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
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Kaleth AS, Ang DC, Chakr R, Tong Y. Validity and reliability of community health activities model program for seniors and short-form international physical activity questionnaire as physical activity assessment tools in patients with fibromyalgia. Disabil Rehabil 2010; 32:353-9. [PMID: 20001609 DOI: 10.3109/09638280903166352] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE There currently is a paucity of well-validated instruments to quantitatively measure physical activity (PA) levels in patients with fibromyalgia syndrome (FMS). This study aims to determine the construct validity and test-retest reliability of two self-report physical activity questionnaires [short-form international physical activity questionnaire (s-IPAQ) and community health activities model program for seniors (CHAMPS)] in a fibromyalgia population. METHODS Thirty subjects (mean age 49.1 +/- 9.6 years; 90% females) who met the American College of Rheumatology criteria for FMS were invited to participate in the study. Two-week test-retest reliability was evaluated for the CHAMPS and s-IPAQ. Construct validity was evaluated by comparing PA reported from these questionnaires with data obtained from accelerometry (steps/week, counts/week) and the 6-minute walk test (6-MWT). RESULTS CHAMPS showed greater test-retest reliability (r = 0.58; p < 0.001) compared with s-IPAQ (r = 0.18; p = 0.15). No significant correlations were observed between the self-report PA questionnaires and the 6-MWT or accelerometry data (p > 0.05). CONCLUSIONS In a fibromyalgia population, the s-IPAQ does not appear to be a reliable and valid PA assessment tool. CHAMPS displayed moderate test-retest reliability; however, no associations were found between CHAMPS and objectives measures of PA. In view of the known benefits of exercise in patients with FMS, there is a need to develop new measures or validate other existing well-established PA questionnaires.
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Affiliation(s)
- Anthony S Kaleth
- Department of Physical Education, Indiana University-Purdue University Indianapolis, Indianapolis, 46202-5193, USA.
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Ang DC, Kaleth AS, Bigatti S, Mazzuca S, Saha C, Hilligoss J, Lengerich M, Bandy R. Research to Encourage Exercise for Fibromyalgia (REEF): use of motivational interviewing design and method. Contemp Clin Trials 2010; 32:59-68. [PMID: 20828634 DOI: 10.1016/j.cct.2010.08.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 08/17/2010] [Accepted: 08/31/2010] [Indexed: 10/19/2022]
Abstract
Fibromyalgia (FM), defined as the presence of both chronic widespread pain and the finding of 11/18 tender points on examination, is an illness associated with major personal and societal burden. Supervised aerobic exercise is an important treatment modality to improve patient symptoms. Unfortunately, adherence to an exercise regimen after a structured supervised program is disappointingly low. Since FM is a chronic illness, studies are needed to test strategies that would enhance exercise adherence in these individuals. Individuals who are able to adhere to exercise almost always maintain the symptomatic benefits of exercise. The objective of this paper was to describe the protocol of the Research to Encourage Exercise for Fibromyalgia (REEF). REEF is a randomized attention-controlled trial that seeks to test the efficacy of 6 sessions of telephone delivered motivational interviewing (MI) that targets exercise adherence to improve FM-relevant clinical outcomes (i.e., physical function and pain severity). The trial has recently completed enrolling 216 subjects, and randomization has resulted in well-balanced groups. Details on the study design, MI program, and treatment fidelity are provided in the paper. Outcome assessments at week 12, week 24 and week 36 will test the immediate, intermediate and long-term effects of exercise-based MI on adherence (as measured by the Community Health Activities Model Program for Seniors/CHAMPS and accelerometer) and clinical outcomes. When completed, REEF will determine whether exercise-based MI could be utilized as a management strategy to sustain the clinical benefits of exercise for FM.
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Affiliation(s)
- Dennis C Ang
- Division of Rheumatology, Department of Medicine, Indiana University, Indianapolis, IN 46202,, United States.
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Ang DC, Bair MJ, Damush TM, Wu J, Tu W, Kroenke K. Predictors of Pain Outcomes in Patients with Chronic Musculoskeletal Pain Co-morbid with Depression: Results from a Randomized Controlled Trial. Pain Med 2010; 11:482-91. [DOI: 10.1111/j.1526-4637.2009.00759.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ang DC, Chakr R, Mazzuca S, France CR, Steiner J, Stump T. Cognitive-behavioral therapy attenuates nociceptive responding in patients with fibromyalgia: A pilot study. Arthritis Care Res (Hoboken) 2010; 62:618-23. [DOI: 10.1002/acr.20119] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
OBJECTIVE To understand the reasons behind racial disparities in the use of total joint arthroplasty (TJA), we sought to examine the predictors of time to referral to orthopedic surgery for consideration of joint replacement. METHODS In this prospective, longitudinal study of 676 primary care clinic patients with at least a moderately severe degree of hip or knee osteoarthritis (OA), we examined the effects of race, health beliefs (i.e., perceived benefits and risks) of TJA, and clinical appropriateness of TJA on referral to orthopedic surgery. RESULTS The sample included 255 African Americans (38%) and 421 whites (62%); 523 patients had knee OA (78%) and 153 had hip OA (22%). Subjects were 60% male, with a mean +/- SD age of 64 +/- 9 years, a mean +/- SD body mass index of 33.6 +/- 8 kg/m(2), and a mean +/- SD summary Western Ontario and McMaster Universities Osteoarthritis Index score of 56 +/- 14, suggesting moderately severe OA. At baseline, African Americans perceived fewer benefits and greater risk from TJA than whites. There were no significant racial group differences in the proportions of cases deemed clinically appropriate for TJA. After controlling for potential confounders, clinical appropriateness (hazard ratio [HR] 1.95, 95% confidence interval [95% CI] 1.15-3.32; P = 0.01) predicted referral to orthopedic surgery. Neither race (HR 1.30, 95% CI 0.94-2.05; P = 0.1) nor health beliefs (HR 1.0, P = 0.5) were associated with referral status. CONCLUSION In this sample of primary care clinic patients, African Americans and whites were equally likely to be referred by their physicians to orthopedic surgery. Clinical appropriateness predicted future referral to orthopedic surgery, and not race or TJA-specific health beliefs.
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Affiliation(s)
- Dennis C Ang
- Indiana University School of Medicine, Indianapolis, IN 46202, USA. dang@
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Kaleth AS, Ang DC, Schaffter A, Trotter A, Tong Y. Validity of Two Self-Report Physical Activity Questionnaires in Patients with Fibromyalgia Syndrome. Med Sci Sports Exerc 2008. [DOI: 10.1249/01.mss.0000322315.79190.b4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ang DC, Monahan PO, Cronan TA. Understanding ethnic disparities in the use of total joint arthroplasty: Application of the health belief model. ACTA ACUST UNITED AC 2007; 59:102-8. [DOI: 10.1002/art.23243] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND For patients to experience the benefits of total joint arthroplasty (TJA), primary care physicians (PCPs) ought to know when to refer a patient for TJA and/or optimize nonsurgical treatment options for osteoarthritis (OA). OBJECTIVE To evaluate the ability of physicians to make clinical treatment decisions. DESIGN AND PARTICIPANTS A survey, using ten clinical vignettes, of PCPs in Indiana. MEASUREMENTS A test score (range 0 to 10) was computed based on the number of correct answers consistent with published explicit appropriateness criteria for TJA. We also collected demographic characteristics and physicians' perceived success rate of TJA in terms of pain relief and functional improvement. RESULTS There were 149 PCPs (response rate = 61%) who participated. The mean test score was 6.5 +/- 1.5. Only 17% correctly identified the published success rate of TJA (i.e., > or =90%). In multivariate analysis, the only physician-related variables associated with test score were ethnicity, board status, and perceived success rate of TJA. Physicians who were white (P = .001), board-certified (P = .04), and perceived a higher success rate of TJA (P = .004) had higher test scores. CONCLUSIONS PCP knowledge with respect to guideline-concordant care for OA could be improved, specifically in deciding when to consider TJA versus optimizing nonsurgical options. Moreover, the perception of the success rate of TJA may influence a clinician's decision making.
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Affiliation(s)
- Dennis C Ang
- Division of Rheumatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Abstract
OBJECTIVE We sought to determine the predictors of incident chronic widespread pain (CWP), specifically, the effect of preexisting symptoms, stress, and psychosocial factors in the subsequent development of CWP among veterans from the first Gulf War (GW). METHODS We conducted a structured telephone survey (baseline) of military personnel originally from Iowa who were either eligible for or deployed to Operation Desert Shield/Desert Storm, approximately 5 years postconflict. We conducted a follow-up, clinical, in-person study of those who met a priori-defined outcomes of symptoms of cognitive dysfunction, depression, or CWP, and also a sample of those who did not meet any of the outcomes of interest. RESULTS A total of 370 of 602 evaluated GW veterans were free of CWP 5 years postconflict. At follow-up, 69 (19%) of these had developed CWP. A positive family history of medically unexplained persistent symptoms [odds ratio (OR)=4.8 (2.3, 13.2)] was strongly associated with CWP. At baseline, individuals who reported preexisting symptoms of bronchitis [OR=4.9 (1.9, 12.3)] and cognitive dysfunction [OR=2.1 (1.1, 4.2)] were more likely to develop CWP. Alcohol use [OR=0.2 (0.1, 0.7)] was protective against CWP. Rather than combat-related exposure per se, the perception of stress at the time of the GW [OR=1.6 (1.1, 2.3)] correlated with CWP. DISCUSSION Among the GW veterans evaluated longitudinally in this study, family history, predeployment symptoms, and the level of perceived stress during the GW were associated with subsequent development of CWP.
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Affiliation(s)
- Dennis C Ang
- Division of Rheumatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Ang DC, Paulus HE, Louie JS. Patient's ethnicity does not influence utilization of effective therapies in rheumatoid arthritis. J Rheumatol 2006; 33:870-8. [PMID: 16652419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Biological agents have revolutionized the treatment of rheumatoid arthritis (RA). Given the previously documented ethnic disparity in the health service literature, we sought to determine if ethnic difference exists in the lag time between the diagnosis of RA and use of first biological agent. METHODS RADIUS 1 and 2 are observational studies designed to document how rheumatologists treat RA across the United States. The sample analyzed here included early patients with RA who entered RADIUS with the initiation of the first biological agent. Ethnic status was categorized as White (W), African American (AA), and Hispanic (H). Lag time (months from RA diagnosis to initiation of the first biological agent) was the principal outcome variable. RESULTS Compared to W (n=1616), AA (n=147) and H (n=116) were more likely to be female, younger, and have less than a high school education. Despite similar swollen and tender joint counts, AA and H had more active disease on the basis of Health Assessment Questionnaire and patient global assessments. Almost 97% of patients had some type of insurance coverage. On multivariable analysis, ethnic affiliation was not associated with lag time (14.5 months W vs 14.9 AA vs 14.3 H; p=NS). Similarly, there were also no significant ethnic differences in time to first DMARD (e.g., methotrexate) initiation. CONCLUSION In a national sample of patients with RA, most of whom were insured, the length of time from diagnosis of RA to initiation of the first biological agent was not significantly different among Whites, African Americans, and Hispanics.
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Affiliation(s)
- Dennis C Ang
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202-5100, USA.
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Ang DC, Kroenke K, McHorney CA. Impact of pain severity and location on health-related quality of life. Rheumatol Int 2005; 26:567-72. [PMID: 16096793 DOI: 10.1007/s00296-005-0025-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 06/22/2005] [Indexed: 11/26/2022]
Abstract
Despite evidence that persistent pain affects well-being, little is known about the relationship of the location of pain to psychological and functional well-being. To determine whether patients with musculoskeletal disorders (MSD) are more likely to be depressed and functionally disabled compared to patients with pain at other sites, we conducted a secondary data analysis of the Medical Outcome Study--an observational study of adult outpatients with chronic medical conditions. Of the 3,360 patients who completed the baseline assessment, 1,237 (36.8%) had MSD and 2,123 (63.2%) had no MSD. Among patients in the MSD group, 84.5% reported > or = mild pain as compared to 70% in the no MSD. In multivariate analyses, MSD patients were more likely than non-MSD patients to be depressed (beta coefficient=-1.9, p=0.008) and functionally disabled (beta coefficient=-4.4, p<0.0001). However, the impact of MSD was eliminated after controlling for pain severity. Regardless of the location of pain, pain severity appears to be an important correlate of functional status, both mental and physical.
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Affiliation(s)
- Dennis C Ang
- Division of Rheumatology, Indiana University School of Medicine, 1110 West Michigan Street, Indianapolis, IN 46202-5100, USA.
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Ang DC, Choi H, Kroenke K, Wolfe F. Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis. J Rheumatol 2005; 32:1013-9. [PMID: 15940760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE Whether comorbid depression increases mortality in patients with rheumatoid arthritis (RA) is unknown. Our objective was to determine whether the presence of depression predicted mortality in patients with RA. METHODS We followed 1290 consecutive outpatients with RA who met our stringent inclusion criteria during an 18-year observation period. Since 1981, demographic, clinic, and self-report data were collected and entered into a computer database at the time of each clinic visit. The comorbidity data were consistently recorded beginning in 1991. Our primary independent variable was the mean of the Arthritis Impact Measurement Scales (AIMS) depression scores during the first 4 years of entry into the clinic cohort (average 4-year depression). Data were analyzed using Cox proportional hazard models. RESULTS After adjusting for covariates, the hazard ratio (HR) for each unit increase in the average 4-year depression score on mortality was 1.14 (p < 0.0001). Using only the data obtained from 1991 to 2003, the mortality risk was slightly increased (HR 1.35, p < 0.0001). To reduce residual confounding due to RA disease activity and/or comorbid medical conditions, we then excluded deaths during the first 2 years after study onset. With this method, the HR for the average 4-year depression remained significant (HR 1.35, p < 0.0001). Because an AIMS depression score > or = 4 is consistent with clinical depression, we analyzed the dataset using the average 4-year depression score as a dichotomous variable (score < 4 or > or = 4). The HR of clinical depression on mortality was 2.2 (95% CI 1.2- 3.9, p = 0.01). CONCLUSION Depression increases the risk of mortality in RA. Our study highlights the importance of comorbid depression in patients with RA.
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Affiliation(s)
- Dennis C Ang
- Division of Rheumatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Ang DC, Ibrahim SA, Burant CJ, Kwoh CK. Is there a difference in the perception of symptoms between african americans and whites with osteoarthritis? J Rheumatol 2003; 30:1305-10. [PMID: 12784407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To determine if there is a difference in the perception of pain and functional disability between African Americans and Whites at any given radiographic severity of osteoarthritis (OA). Ethnic differences in utilization of joint replacement may reflect differences in the perception of symptoms of OA. METHODS A cross-sectional survey included 596 male veterans (44% African Americans and 56% Whites) with chronic moderate to severe knee and/or hip pain at the General Medicine Clinics. The average age of the total cohort was 65.63 +/- 9.5 years. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain and function were the primary outcome measures of interest. All knee and or hip radiographs were graded using the Kellgren-Lawrence (K/L) grading system. RESULTS African Americans and Whites were comparable with respect to age (65 +/- 9.5 vs 66 +/- 9, respectively); body mass index > or = 30 kg/m2 (53.9% vs 58.8%); Lequesne severity score (11 +/- 4 vs 11 +/- 4); geriatric depression score (4.5 +/- 3.3 vs 5.0 +/- 3.8) and Charlson Comorbidity Index (2.3 +/- 2 vs 2.5 +/- 2). African Americans had lower socioeconomic status with fewer high school graduates (57% vs 71%, p = 0.001), lower employment rate (8.4% vs 14.7%, p = 0.017), and lower total household incomes (41.4% vs 20.4% reported income < $10,000, p = 0.000). African Americans and Whites were not different in mean scores for WOMAC pain and WOMAC function when stratified by joint space narrowing, osteophyte and Kellgren Lawrence grades. After controlling for important covariates, ethnicity was not a significant predictor of WOMAC pain and function. CONCLUSION In this sample of male veterans, African Americans and Whites perceived the same degree of pain and functional difficulties at any given radiographic severity of OA. Differences in the perception of symptoms cannot explain the observed ethnic disparity in utilization of joint replacement.
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Affiliation(s)
- Dennis C Ang
- Department of Medicine, Division of Rheumatology, Indiana University, Indianapolis 46202, USA.
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Abstract
CONTEXT Ethnic differences in utilization of arthroplasty may reflect differences in health-related attitudes and beliefs. OBJECTIVE To examine ethnic differences in the perception and use of prayer in the treatment of arthritis and its role in patients' decision making toward surgery. DESIGN A cross-sectional survey. SETTING VA Primary Care Clinics. PATIENTS Patients older than 50 years with chronic moderate-to-severe knee pain, hip pain, or both. MEASURES The "helpfulness of prayer" in the treatment of arthritis and patients' attitude toward joint arthroplasty. RESULTS Five hundred ninety-six veterans; 44% black patients, 56% white patients. Groups were comparable with respect to age (65 +/- 9.5 vs. 66 +/- 9), disease severity as assessed by WOMAC (47 +/- 17 vs. 45 +/- 17). Black patients scored higher than white patients on the religiosity scale (77 +/- 17 vs. 70 +/- 21). In multivariate analysis, black patients were more likely than white patients to perceive prayer as helpful in the management of their arthritis (OR, 2.1; 95% CI, 1.19, 3.72). Black patients were also less likely than white patients to consider surgery for severe hip/knee pain (OR, 0.58; 95% CI 0.34, 0.99); this relationship between ethnicity and consideration of surgery is mediated by perceptions of "helpfulness of prayer." The odds ratio for this relationship changes to 0.70 (P = 0.215). CONCLUSION In this sample, black patients were more likely than white patients to perceive prayer as helpful and to have actually used prayer for their arthritis. Perception of helpfulness of prayer may be an important explanatory variable in the relationship between ethnicity and patients' decision in considering arthroplasty.
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Affiliation(s)
- Dennis C Ang
- Louis Stokes Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
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Abstract
Since chronic fatigue is so common, long-lasting, and fraught with functional and emotional consequences, early intervention can limit overuse of health care resources and forestall disability. To help patients, we must intervene before chronicity is established or iatrogenic harm has occurred. Care that integrates medical and psychologic concepts, together with symptom management, can prevent significant secondary impairment in most cases.
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Affiliation(s)
- D C Ang
- Department of Rheumatic and Immunologic Disease, Cleveland Clinic Foundation, OH 44195, USA
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