Use of implementation strategies to promote the uptake of knee osteoarthritis practice guidelines and improve patient outcomes: A Systematic Review

OBJECTIVE

Translation of knee osteoarthritis (KOA) clinical practice guidelines (CPGs) to practice remains suboptimal. The primary purpose of this systematic review was to describe the use of implementation strategies to promote KOA CPG recommended care.

METHODS

MEDLINE (via PubMed), Embase, CINAHL, and Web of Science were searched from inception to February 23, 2023, and subsequently updated and expanded on January 16, 2024. Implementation strategies were mapped per the Expert Recommendations for Implementing Change taxonomy. Risk of bias (RoB) was assessed using the Cochrane Effective Practice and Organization of Care criteria. The review was registered prospectively (CRD42023402383).

RESULTS

Nineteen studies were included in the final review. All (100% (n=4) studies that included the domains of provide interactive assistance, train and educate stakeholders (89%(n=18)), engage consumers (87%(n=15)) and support clinicians (79%(n=14)) reported change to provider adherence. Studies that reported a change to disability included train and educate stakeholders, engage consumers and adapt and tailor to context. Studies that used train and educate stakeholders, engage consumers, and support clinicians reported a change in pain and quality of life. Most studies had a low to moderate RoB.

CONCLUSION

Implementation strategies have the potential to impact clinician uptake of CPG's and patient reported outcomes (PROs). The implementation context, using an active learning strategy with a patient partner, restructuring funding models, and integrating taxonomies to tailor multifaceted strategies should be prioritized. Further experimental research is recommended to determine which implementation strategies are most effective.

Developing a Computer Vision Model to Automate Quantitative Measurement of Hip-Knee-Ankle Angle in Total Hip and Knee Arthroplasty Patients

BACKGROUND

Increasing deformity of the lower extremities, as measured by the Hip-Knee-Ankle Angle (HKAA), is associated with poor patient outcomes after total hip and knee arthroplasty (THA, TKA). Automated calculation of HKAA is imperative to reduce the burden on orthopaedic surgeons. We proposed a detection-based deep learning (DL) model to calculate HKAA in THA and TKA patients and assessed the agreement between DL-derived HKAAs and manual measurement.

METHODS

We retrospectively identified 1,379 long-leg radiographs (LLR) from patients scheduled for THA or TKA within an academic medical center. There were 1,221 LLRs used to develop the model (randomly split into 70% training, 20% validation, and 10% held-out test sets); 158 LLRs were considered "difficult," as the femoral head was difficult to distinguish from surrounding tissue. There were two raters who annotated the HKAA of both lower extremities, and inter-rater reliability was calculated to compare the DL-derived HKAAs with manual measurement within the test set.

RESULTS

The DL model achieved a mean average precision of 0.985 on the test set. The average HKAA of the operative leg was 173.05 +/- 4.54°; the non-operative leg was 175.55 +/- 3.56°. The inter-rater reliability between manual and DL-derived HKAA measurements on the operative leg and non-operative leg indicated excellent reliability (Intraclass Correlation (ICC) (2,k) = 0.987 [0.96, 0.99], ICC (2,k) = 0.987 [0.98, 0.99, respectively]). The standard error of measurement for the DL-derived HKAA for the operative and non-operative legs was 0.515° and 0.403°, respectively.

CONCLUSION

A detection-based DL algorithm can calculate the HKAA in LLRs and is comparable to that calculated by manual measurement. The algorithm can detect the bilateral femoral head, knee, and ankle joints with high precision, even in patients where the femoral head is difficult to visualize.

Utility of PROMIS Measures in Predicting Shoulder Arthroplasty in Patients with Shoulder Osteoarthritis

BACKGROUND

The decision to treat shoulder osteoarthritis definitively with shoulder arthroplasty (SA) is multifactorial, considering objective findings, subjective information, and patient goals. The first goal of this study was to determine if Patient Reported Outcome Measurement Information System (PROMIS) measures correlated with patients with shoulder osteoarthritis (OA) who underwent SA within 1 year. The second goal of this study was to determine if score cut-offs in PROMIS domains could further discriminate which shoulder OA patients underwent SA within 1 year.

METHODS

This retrospective case-control study examined patients with a diagnosis of shoulder OA who consulted an orthopedic provider from November 1, 2020, to May 23, 2022, and recorded PROMIS measures in the domains of Physical Function (PF), Depression, and/or Pain Interference (PI). A surgical group was defined as patients who underwent SA within 1 year of the most recent PROMIS measures, and the non-surgical patients were defined as the control group. Mean PROMIS scores were compared between the surgical and control groups. Separate logistic regression models controlling for age, race, ethnicity, and comorbidity count were performed for each PROMIS domain as a 1) continuous variable, then as 2) binary variable defined by PROMIS score cut-off points to determine which scores correlated with undergoing SA to further characterize the potential clinical utility of PROMIS score cut-offs in relating to undergoing SA.

RESULTS

The surgical group of 478 patients was older (68.2 vs. 63.8 years), more often of White race (82.6% vs. 70.9%), and less often of Hispanic Ethnicity (1.5% vs. 2.9%) than the control group of 3343 patients. Using optimal cut-offs in PROMIS scores, PI ≥ 63 (Odds Ratio (OR) = 2.97 (2.41-3.64), p < 0.001), PF ≤ 39 (OR = 1.81 (95% CI, 1.48-2.22), p < 0.001), and Depression ≥ 49 (OR = 1.82 (95% CI, 1.50-2.22), p < 0.001) were all found to correlate with undergoing SA within 1 year in multivariable logistic regressions.

CONCLUSION

The results of this study demonstrate that cut-off scores for PROMIS measures differentiated patients undergoing SA within 1 year. These cut-off scores may have clinical utility in aiding in decision-making regarding surgical candidates for SA. Further research is needed to validate these cut-off scores and determine how they relate to patient outcomes after SA.

Does Medically Supervised Weight Loss Prior to Total Knee Arthroplasty Improve Patient-Reported Pain and Physical Function?

BACKGROUND

Weight loss is commonly recommended before total knee arthroplasty (TKA) despite inconsistent evidence for better outcomes. This study sought to examine the impacts of preoperative weight loss on patient-reported and adverse outcomes among TKA patients supervised by a medical weight management clinic.

METHODS

This study retrospectively analyzed patients who underwent medical weight management supervision within 18 months before TKA comparing patients who did and did not have clinically relevant weight loss. Preoperative body mass indices, demographics, Patient-Reported Outcomes Measurement Information System physical function and pain interference scores, pain intensity scores, and adverse outcomes were extracted. Multivariable linear regressions were performed to determine if preoperative weight loss correlated with patient-reported outcomes after controlling for confounders.

RESULTS

There were 90 patients, 75.6% women, who had a mean age of 65 years (range, 42-82) and were analyzed. There were 51 (56.7%) patients who underwent clinically relevant weight loss with a mean weight loss of 10.4% and experienced no difference in adverse outcomes. Preoperative weight loss predicted significantly improved 3-month postoperative physical function (β = 15.2 [13.0-17.3], P < .001), but not pain interference (β = -18.9 [-57.1-19.4], P = .215) or pain intensity (β = -1.8 [-4.9-1.2], P = .222) scores.

CONCLUSION

We found that medically supervised preoperative weight loss predicted improvement in physical function 3 months after TKA. This weight loss caused no major adverse effects. Further research is needed to understand the causal relationships between preoperative weight loss, medical supervision, and outcome after TKA and to elucidate potential longer-term benefits in a larger sample.

Acute Intermittent Hypoxia Did Not Alter Pain Sensitivity or Pain Intensity Ratings for Individuals with Chronic Low Back Pain: A Pilot Study

Aims and Objective

The purpose of this pilot study was to explore whether AIH produces changes in pain sensitivity or in reports of self-reported pain intensity for individuals with low back pain.

Methods

In a quasi-experimental, cross-over design we compared participants (n = 9) exposed to normal room air and hypoxia using a commercially available gas blender. The treatment period consisted of 5 consecutive days of randomly assigned to AIH or room air. For the participants initially randomized to AIH there was cross-over to receive 5 more consecutive days of room air. Therefore, this design allowed for between group and within subject assessment of AIH effects. Pain sensitivity was assessed with quantitative sensory testing (QST) for posterior superior iliac spine pressure threshold, plantar thermal threshold, and peak pain ratings. Self-reported pain intensity for low back pain was assessed via the Brief Pain Inventory.

Results

There were no between group differences for AIH and room air in pain sensitivity or self-reported pain intensity. In the within subject analyses larger effect sizes favoring AIH were detected for plantar measures of pain sensitivity but not for self-reported pain intensity.

Conclusion

This study, while presenting null findings, describes an initial step in determining whether AIH can be used to increase pain relief. Based on this pilot study we offer guidance for future research including study design, AIH dosage, participant selection, and using AIH in combination with non-pharmacologic treatments.

Does Preoperative Weight Loss Within 6 Months or 1 Year Change the Risk of Adverse Outcomes in Total Knee Arthroplasty by Initial Body Mass Index Classification?

BACKGROUND

High body mass index (BMI) is associated with adverse outcomes after total knee arthroplasty (TKA). Thus, many patients are advised to lose weight before TKA. This study examined how weight loss before TKA is associated with adverse outcomes depending on patients' initial BMI.

METHODS

This was a retrospective study of 2,110 primary TKAs at a single academic center. Data on preoperative BMIs, demographics, comorbidities, and incidences of revision or prosthetic joint infection (PJI) were obtained. Multivariable logistic regressions segmented by patients' initial (1-year preoperative) BMI classifications were performed to determine if a > 5% BMI decrease from 1 year or 6 months preoperatively predicted PJI and revision controlling for patient age, race, sex, and Elixhauser comorbidity index.

RESULTS

Preoperative weight loss did not predict adverse outcomes for patients who had Obesity Class II or III. 6-month weight loss had greater odds of adverse outcomes than 1-year weight loss and most significantly predicted the occurrence of 1-year PJI (adjusted odds ratio: 6.55, P < .001) for patients who had Obesity Class 1 or lower.

CONCLUSION

This study does not show a statistically significant effect to patients who had Obesity Class II and III losing weight preoperatively with respect to PJI or revision. For patients who have Obesity Class I or lower pursuing TKA, future research should consider potential risks associated with weight loss. Further study is needed to determine if weight loss can be implemented as a safe and effective risk reduction strategy for specific BMI classes of TKA patients.

Patient-reported outcome measures in physical therapy practice for neck pain: an overview of reviews

BACKGROUND

Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy.

METHODS

An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2.

RESULTS

Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies).

CONCLUSION

This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

Do You PROMIS (Patient Reported Outcomes Measurement Information System)? Physical Function and Pain Interference Scores After Total Knee and Hip Arthroplasty

Background

Physical function and pain outcomes vary after arthroplasty. We investigated differences in postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores for patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to identify preoperative factors that predict postoperative PROMIS scores.

Methods

Patients who underwent TKA and THA from 2014-2020 were eligible. Preoperative variables including demographics, comorbidities, and pain scores were obtained from the medical record. Patients completed surveys measuring postoperative PF and PI. Descriptive statistics and separate linear regression models for each anatomical location were performed to examine factors predicting postoperative PROMIS PF and PI scores.

Results

Surveys were completed by 2411 patients (19.5% response rate). Unadjusted mean PF postoperative scores were 47.2 for TKA and 48.8 for THA. Preoperative predictors of lower PF included female sex; body mass index and comorbidities for TKA and THA; and age, tobacco use, and non-White race for THA. Mean PI scores were 47.9 for THA and 49.0 for TKA. Preoperative predictors of increased PI included non-White race and increased body mass index for TKA and THA; higher preoperative pain for TKA; and female sex and increased comorbidity for THA.

Conclusions

Postoperative PROMIS scores were similar for TKA and THA, with THA having slightly higher PF and lower PI scores. Regression models using preoperative variables showed similar performance for TKA compared with THA. These findings suggest areas for future development of clinical decision support tools.

Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain

Objective

To determine associations between post-emergency department (ED) management pathways and downstream opioid prescriptions in patients seeking care for incident neck and/or back pain.

Patients and Methods

We identified patients seeking first-time ED care for neck and/or back pain from January 1, 2013, through November 6, 2017. We reported demographic characteristics and opioid prescriptions across management pathways using descriptive statistics and assessed the relative risk of any opioid prescription 12 months post-ED visit among 5 different post-ED management pathways using Poisson regression adjusted for patient demographic characteristics.

Results

Within 12 months after the index ED visit, 58.0% (n=10,949) were prescribed an opioid, with most patients prescribed an opioid within the first week (average daily morphine milligram equivalents of 6.8 mg (SD 9.6 mg). The morphine milligram equivalents decreased to 0.7 mg (SD 8.2 mg) by week 4 and remained consistently less than 1 mg between week 4 and 12 months. Compared with the ED to primary care provider pathway, the relative risk of opioid prescription between 7 days and 12 months after the index ED visit was similar for the ED to physical therapy pathway, higher for both the ED to hospital admission or repeat ED visit pathway (30% increase; relative risk (RR), 1.3; 95% CI, 1.17-1.44) and the ED to specialist pathway (19% increase; RR, 1.19; 95% CI, 1.07-1.33), and lower in the ED with no follow-up visits pathway (41% decrease; RR, 0.59; 95% CI, 0.54-0.65).

Conclusion

In general, more conservative care was associated with lower opioid prescription rates, and escalated care was associated with higher opioid prescription rates.

Can PROMIS Measures Estimate High Impact Chronic Pain After Total Joint Arthroplasty?

BACKGROUND

High impact chronic pain (HICP) is not typically measured following orthopaedic surgeries, but has a substantial negative impact on post-operative quality of life. This analysis determined which Patient-Reported Outcome Measurement Information System (PROMIS) measures accurately estimate HICP status following total joint arthroplasty (TJA).

METHODS

This was a secondary analysis of a hip and knee TJA cohort. HICP status was determined by two items from the Graded Chronic Pain Scale-Revised. The cohort (n = 2,400) consisted of 47.5% hip (n = 1,142) and 52.5% knee TJA (n = 1,258). For total hip arthroplasty (THA), 53.7% were women (n = 615), 48.6% were 65 years or older (n = 557), 72.5% completed the survey more than 24 months after first surgery (n = 831), and 9.9% had HICP (n = 114). For total knee arthroplasty (TKA), 54.3% were women (n = 687), 59.3% were 65 years or older (n = 750), 72.3% survey completed the survey more than 24 months after first surgery (n = 915), and 11.5% had HICP (n = 145). Included PROMIS measures were pain interference, physical function, anxiety, and sleep disturbance. First, discriminant function analysis determined PROMIS measure contribution to HICP status. Then, area under the curve (AUC) calculated the accuracy of PROMIS measures to estimate HICP status. Influences of sociodemographic and surgical characteristics on AUC were explored in sensitivity analyses.

RESULTS

Results for TKA and THA were similar so they are presented collectively for the sake of brevity. Mean differences were identified for all PROMIS measures for those with HICP (All P values < 0.01). Pain interference (β = 0.934) and sleep disturbance (β = 0.154) were independently correlated with HICP status in discriminant function analyses. The AUC (95% Confidence Intervals) for HICP were as follows: pain interference (.952-.973), physical function (.921-.949), sleep (.780-.838), and anxiety (.687-.757). Sensitivity analyses revealed little change in AUC and HICP cut-off scores for PROMIS pain interference and physical function.

CONCLUSION

Two PROMIS measures commonly administered as standard of care for orthopaedics, pain interference and physical function, can be used to estimate HICP status for THA and TKA; thereby refining assessment of TJA outcomes.

Sleep disturbance, dyspnea, and anxiety following total joint arthroplasty: an observational study

Background

Patient-Reported Outcomes Measurement Information System (PROMIS) domains for sleep disturbance, anxiety, and dyspnea have been under-reported for total joint arthroplasty (TJA). The aims of this study were to report postoperative differences for these domains based on TJA location and chronic pain state. We also investigated whether these domains were associated with physical function and pain interference outcomes.

Methods

This was a retrospective, observational study of patients who underwent hip, knee, or shoulder TJA (primary and revision surgeries) at a single academic tertiary referral center. A subset of these patients completed an email-based survey for chronic pain grade (Chronic Pain Grade Scale-Revised) and sleep disturbance, anxiety, dyspnea, physical function, and pain interference (PROMIS short forms). Pre-operative and operative data were extracted from the electronic health record. Data analysis investigated PROMIS domains for differences in TJA location and chronic pain grade. Hierarchical linear regression determined associations of these domains with physical function and pain interference.

Results

A total of 2638 individuals provided informed consent and completed the email survey. In the ANOVA models for sleep disturbance, anxiety, and dyspnea, there was no location by chronic pain grade interaction (p > 0.05) and no difference based on TJA location (p > 0.05). There were differences for chronic pain grade (p < 0.01). The poorest postoperative outcome score for each domain was associated with high impact chronic pain. Furthermore, sleep disturbance and dyspnea had the strongest associations with physical function and pain interference (p < 0.01).

Conclusions

Sleep disturbance, anxiety, and dyspnea did not vary based on TJA location, but were associated with postoperative chronic pain grade. Sleep disturbance and dyspnea were strongly associated with commonly reported outcomes of physical function and pain interference. These findings provide guidance for those interested in expanding TJA outcome assessment to include sleep disturbance, anxiety, and/or dyspnea.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03288-x.

The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study

Background

Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS.

Methods

This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation.

Discussion

This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05598-x.

Does the implementation of clinical practice guidelines for low back and neck pain by physical therapists improve patient outcomes? A systematic review

BACKGROUND

Physical therapy for neck and low back pain is highly variable despite the availability of clinical practice guidelines (CPG). This review aimed to determine the impact of CPG implementation on patient-level outcomes for spinal pain. Implementation strategies were also examined to determine prevalence and potential impact.

METHODS

Multiple databases were searched through April 2021 for studies assessing CPG implementation in physical therapy for neck and low back pain. Articles were screened for eligibility. The Modified Downs and Black checklist was utilized to determine study quality. Due to the heterogeneity between studies, a meta-analysis was not performed.

RESULTS

Twenty-one studies were included in this review. Implementation strategies were significantly varied between studies. Outcomes pertaining to healthcare utilization, pain, and physical functioning were assessed in relation to the implementation of CPGs. Multiple implementation strategies were identified, with Managing Quality as the most frequently utilized key implementation process. Findings indicate CPG implementation decreased healthcare utilization, but inconsistent results were found with physical functioning and pain outcomes.

CONCLUSIONS

CPG implementation appears to have a beneficial effect on healthcare utilization outcomes, but may not impact pain and physical functioning outcomes. Effective CPG implementation strategies remain unknown, though utilizing implementation framework may improve outcomes. More research is needed to determine the most effective implementation strategies and effects on pain and physical function outcomes.

Chronic Pain Prevalence and Factors Associated With High Impact Chronic Pain following Total Joint Arthroplasty: An Observational Study

Hip, knee, and shoulder arthroplasty are among the most frequently performed orthopaedic procedures in the United States. High impact and bothersome chronic pain rates following total joint arthroplasty (TJA) are unknown; as are factors that predict these chronic pain outcomes. This retrospective observational study included individuals that had a TJA from January 2014 to January 2020 (n = 2,638). Pre-operative and clinical encounter information was extracted from the electronic health record and chronic pain state was determined by email survey. Predictor variables included TJA location, number of surgeries, comorbidities, tobacco use, BMI, and pre-operative pain intensity. Primary outcomes were high impact and bothersome chronic pain. Rates of high impact pain (95% CI) were comparable for knee (9.8-13.3%), hip (8.3-11.8%) and shoulder (7.6-16.3%). Increased risk of high impact pain included non-white race, two or more comorbidities, age less than 65 years, pre-operative pain scores 5/10 or higher, knee arthroplasty, and post-operative survey completion 24 months or less. Rates of bothersome chronic pain (95% CI) were also comparable for knee (24.9-29.9%) and hip (21.3-26.3%) arthroplasty; but higher for shoulder (26.9-39.6%). Increased risk of bothersome chronic pain included non-white race, shoulder arthroplasty, knee arthroplasty, current or past tobacco use, and being female. PERSPECTIVE: In this cohort more than 1/3rd of individuals reported high impact or bothersome chronic pain following TJA. Non-white race and knee arthroplasty were the only two variables associated with both chronic pain outcomes.

Use of Patient-Reported Outcomes Measurement Information System (PROMIS) measures to characterise health status for patients seeking care from an orthopaedic provider: a retrospective cohort study

OBJECTIVES

Characterise the health status of patients newly consulting an orthopaedic specialist across eight clinical subspecialties.

DESIGN

Retrospective cohort.

SETTING

18 orthopaedic clinics, including 8 subspecialties (14 ambulatory and 4 hospital based) within an academic health system.

PARTICIPANTS

14 910 patients consulting an orthopaedic specialist for a new patient consultation who completed baseline Patient-Reported Outcomes Measurement Information System (PROMIS) measures associated with their appointment from 17 November 2017 to 13 May 2019. Patients were aged 55.72±5.8 years old, and 61.3% were female and 79.3% were Caucasian and 13.4% were black or African American. Patients who did not complete PROMIS measures or cancelled their appointment were excluded from the study.

PRIMARY OUTCOME

PROMIS domains of physical function, pain interference, pain intensity, depression, anxiety, fatigue, sleep disturbance and the ability to participate in social roles.

RESULTS

Mean PROMIS scores for physical function were (38.1±9.2), pain interference (58.9±8.1), pain intensity (4.6±2.5), depression (47.9±8.9), anxiety (49.9±9.5), fatigue (50.5±10.3), sleep disturbance (51.1±9.8) and ability to participate in social roles (49.1±10.3) for the entire cohort. Across the clinical subspecialties, neurosurgery, spine and trauma patients were most profoundly affected across almost all domains and patients consulting with a hand specialist reported the least limitations or symptoms across domains. There was a moderate, negative correlation between pain interference and physical functioning (r=-0.59) and low correlations between pain interference with anxiety (r=0.36), depression (r=0.39) as well as physical function and anxiety (r=-0.32) and depression(r=-0.30) and sleep (r=-0.31).

CONCLUSIONS

We directly compared clinically meaningful PROMIS domains across eight orthopaedic subspecialties, which would not have been possible with legacy measures alone. These results support PROMIS's utility as a common metric to assess and compare patient health status across multiple orthopaedic subspecialties.

Can PROMIS measures be used to create subgroups for patients seeking orthopaedic care?

Aims

Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care.

Methods

This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance.

Results

Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits.

Conclusion

These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity.

Cite this article: Bone Jt Open 2021;2(7):493–502.

Electronic health record-integrated approach for collection of patient-reported outcome measures: a retrospective evaluation

Background

The integration of Patient Reported Outcome Measures (PROMs) into clinical care presents many challenges for health systems. PROMs provide quantitative data regarding patient-reported health status. However, the most effective model for collecting PROMs has not been established. Therefore the purpose of this study is to report the development and preliminary evaluation of the standardized collection of PROMs within a department of orthopedic surgery at a large academic health center.

Methods

We utilized the Users’ Guide to Integrating Patient-Reported Outcomes in Electronic Health Records by Gensheimer et al., 2018 as a framework to describe the development of PROMs collection initiative. We framed our initiative by operationalizing the three aspects of PROM collection development: Planning, Selection, and Engagement. Next, we performed a preliminary evaluation of our initiative by assessing the response rate of patients completing PROMs (no. of PROMs completed/no. of PROMs administered) across the entire department (18 clinics), ambulatory clinics only (14 clinics), and hospital-based clinics only (4 clinics). Lastly, we reported on the mean response rates for the top 5 and bottom 5 orthopaedic providers to describe the variability across providers.

Results

We described the development of a fully-integrated, population health based implementation strategy leveraging the existing resources of our local EHR to maximize clinical utility of PROMs and routine collection. We collected a large volume of PROMs over a 13 month period (n = 10,951) across 18 clinical sites, 7 clinical specialties and over 100 providers. The response rates varied across the department, ranging from 29 to 42%, depending on active status for the portal to the electronic health record (MyChart). The highest single provider mean response rate was 52%, and the lowest provider rate was 13%. Rates were similar between hospital-based (26%) and ambulatory clinics (29%).

Conclusions

We found that our standardized PROMs collection initiative, informed by Gensheimer et al., achieved scope and scale, but faced challenges in achieving a high response rate commensurate with existing literature. However, most studies reported a targeted recruitment strategy within a narrow clinical population. Further research is needed to elucidate the trade-off between scalability and response rates in PROM collection initiatives.

Derivation of a Risk Assessment Tool for Prediction of Long-Term Pain Intensity Reduction After Physical Therapy

Rationale

Risk assessment tools can improve clinical decision-making for individuals with musculoskeletal pain, but do not currently exist for predicting reduction of pain intensity as an outcome from physical therapy.

Aims and Objective

The objective of this study was to develop a tool that predicts failure to achieve a 50% pain intensity reduction by 1) determining the appropriate statistical model to inform the tool and 2) select the model that considers the tradeoff between clinical feasibility and statistical accuracy.

Methods

This was a retrospective, secondary data analysis of the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort. Two hundred and seventy-nine individuals seeking physical therapy for neck, shoulder, back, or knee pain who completed 12-month follow-up were included. Two modeling approaches were taken: a longitudinal model included demographics, presence of previous episodes of pain, and regions of pain in addition to baseline and change in OSPRO Yellow Flag scores to 12 months; two comparison models included the same predictors but assessed only baseline and early change (4 weeks) scores. The primary outcome was failure to achieve a 50% reduction in pain intensity score at 12 months. We compared the area under the curve (AUC) to assess the performance of each candidate model and to determine which to inform the Personalized Pain Prediction (P3) risk assessment tool.

Results

The baseline only and early change models demonstrated lower accuracy (AUC=0.68 and 0.71, respectively) than the longitudinal model (0.79) but were within an acceptable predictive range. Therefore, both baseline and early change models were used to inform the P3 risk assessment tool.

Conclusion

The P3 tool provides physical therapists with a data-driven approach to identify patients who may be at risk for not achieving improvements in pain intensity following physical therapy.

Trends in Comorbidities and Complications Using ICD-9 and ICD-10 in Total Hip and Knee Arthroplasties

BACKGROUND

The transition to the new ICD-10 (International Classification of Diseases, Tenth Revision) coding system in the U.S. poses challenges to the ability to consistently and accurately measure trends in comorbidities and complications. We examined the prevalence of comorbidities and postoperative medical complications before and after the transition from ICD-9 to ICD-10 among patients who underwent primary total hip or knee arthroplasty (THA or TKA). We hypothesized that the transition to ICD-10 codes was associated with discontinuity and slope change in comorbidities and medical complications.

METHODS

The Elixhauser comorbidities and medical complications were identified using the Premier Healthcare database from fiscal year (FY)2011 to FY2018. Using multivariable segmented regression models, we examined the changes in the levels and slopes after the transition from ICD-9 to ICD-10 coding. Odds ratios (ORs) of <1 and >1 indicate decreases and increases, respectively, in levels and slopes.

RESULTS

Overall, 2,006,581 patients who underwent primary THA or TKA were identified. The mean age was 65.9 ± 10.5 years, and the median length of the hospital stay was 2 days (interquartile range [IQR], 2 to 3 days). Of the comorbidities studied, congestive heart failure, hypertension, and obesity had a statistically significant but clinically small discontinuity after the transition from ICD-9 to ICD-10 coding. Of the complications, pneumonia (OR = 0.66, 95% confidence interval [CI] = 0.48 to 0.90), acute respiratory failure (OR = 1.88, 95% CI = 1.52 to 2.33), sepsis (OR = 2.54, 95% CI = 1.45 to 4.44), and urinary tract infection (OR = 1.79, 95% CI = 1.32 to 2.42) demonstrated statistically significant discontinuity. Alcohol abuse and paralysis had an increasing prevalence before the ICD transition, followed by a decreasing prevalence after the transition. In contrast, metastatic cancer, weight loss, and acquired immunodeficiency syndrome (AIDS) showed a decreasing prevalence before the ICD transition followed by an increasing prevalence after the transition. Generally, complications showed a decreasing prevalence over time.

CONCLUSIONS

The discontinuities after the transition from ICD-9 to ICD-10 coding were relatively small for most comorbidities. Medical complications generally showed a decreasing trend over the quarters studied. These findings support caution when conducting joint replacement studies that rely on ICD coding and include the ICD coding transition period.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

Background

The Patient-Reported Outcomes Measurement Information System^Ⓡ (PROMIS^Ⓡ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

Methods

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

Results

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

Conclusion

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

Registration

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02068-9.

Using a behavioral model to identify factors associated with choice of provider for neck and low back pain: A systematic review

BACKGROUND

It remains unclear as to what factors influence a patient's choice to seek care from a specific healthcare provider for low back and neck pain.

OBJECTIVE

Utilize Andersen's Behavioral Model of Health Service Utilization as a conceptual framework to identify the predisposing, enabling and need factors associated with choice of healthcare provider for back and/or neck pain.

METHODS

PubMed, CINAHL, EMBASE, and SCOPUS databases were searched for studies that included 1) patients seeking care for acute or chronic low back or neck pain; 2) patients at least 18 years of age; 3) reported any healthcare provider type chosen to be seen. Significant factors addressing a patient's choice of provider seen for back pain, neck pain, or both were extracted from studies and analyzed under the Behavioral Model of Health Service Utilization.

RESULTS

20 studies were included in this review: 17 quantitative studies and 3 qualitative studies. Provider types identified were medical physicians, chiropractors, physical therapists, acupuncturists and CAM providers. Age and sex were the most commonly reported predisposing factors; financial and personal factors were the most common enabling factors; patients' duration of pain and self-reported level of functioning were the most commonly reported need factors.

CONCLUSIONS

While predisposing and need factors are important, enabling factors also have an influence in choice of healthcare provider for back and/or neck pain.

Longitudinal Monitoring of Pain Associated Distress With the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Tool: Predicting Reduction in Pain Intensity and Disability

OBJECTIVE

To investigate the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool for longitudinal monitoring of pain associated distress with the goal of improving prediction of 50% reduction in pain intensity and disability outcomes.

DESIGN

Cohort study with 12-month follow-up after initial care episode.

SETTING

Ambulatory care, participants seeking care from outpatient physical therapy clinics.

PARTICIPANTS

Participants (N=440) were seeking care for primary complaint of neck, low back, knee, or shoulder pain. This secondary analysis included 440 subjects (62.5% female; mean age, 45.1±17y) at baseline with n=279 (63.4%) providing follow-up data at 12 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A 50% reduction (baseline to 12-mo follow-up) in pain intensity and self-reported disability.

RESULTS

Trends for prediction accuracy were similar for all versions of the OSPRO-YF. For predicting 50% reduction in pain intensity, model fit met the statistical criterion for improvement (P<.05) with each additional time point added from baseline. Model discrimination improved statistically when the 6-month to 12-month change was added to the model (area under the curve=0.849, P=.003). For predicting 50% reduction in disability, there was no evidence of improvement in model fit or discrimination from baseline with the addition of 4-week, 6-month, or 12-month changes (P>.05).

CONCLUSIONS

These results suggested that longitudinal monitoring improved prediction accuracy for reduction in pain intensity but not for disability reduction. Differences in OSPRO-YF item sets (10 vs 17 items) or scoring methods (simple summary score vs yellow flag count) did not affect predictive accuracy for pain intensity, providing flexibility for implementing this tool in practice settings.

Predicting Patient-Centered Outcomes from Spine Surgery Using Risk Assessment Tools: a Systematic Review

PURPOSE OF REVIEW

The purpose of this systematic review is to evaluate the current literature in patients undergoing spine surgery in the cervical, thoracic, and lumbar spine to determine the available risk assessment tools to predict the patient-centered outcomes of pain, disability, physical function, quality of life, psychological disposition, and return to work after surgery.

RECENT FINDINGS

Risk assessment tools can assist surgeons and other healthcare providers in identifying the benefit-risk ratio of surgical candidates. These tools gather demographic, medical history, and other pertinent patient-reported measures to calculate a probability utilizing regression or machine learning statistical foundations. Currently, much is still unknown about the use of these tools to predict quality of life, disability, and other factors following spine surgery. A systematic review was conducted using PRISMA guidelines that identified risk assessment tools that utilized patient-reported outcome measures as part of the calculation. From 8128 identified studies, 13 articles met inclusion criteria and were accepted into this review. The range of c-index values reported in the studies was between 0.63 and 0.84, indicating fair to excellent model performance. Post-surgical patient-reported outcomes were identified in the following categories (n = total number of predictive models): return to work (n = 3), pain (n = 9), physical functioning and disability (n = 5), quality of life (QOL) (n = 6), and psychosocial disposition (n = 2). Our review has synthesized the available evidence on risk assessment tools for predicting patient-centered outcomes in patients undergoing spine surgery and described their findings and clinical utility.

Timing of physical therapy consultation on 1-year healthcare utilization and costs in patients seeking care for neck pain: a retrospective cohort

BACKGROUND

Patients seek care from physical therapists for neck pain but it is unclear what the association of the timing of physical therapy (PT) consultation is on 1-year healthcare utilization and costs. The purpose of this study was to compare the 1-year healthcare utilization and costs between three PT timing groups: patients who consulted a physical therapist (PT) for neck pain within 14 days (early PT consultation), between 15 and 90 days (delayed PT consultation) or between 91 and 364 days (late PT consultation).

METHODS

A retrospective cohort of 308 patients (69.2% female, ages 48.7[±14.5] years) were categorized into PT timing groups. Descriptive statistics were calculated for each group. In adjusted regression models, 1-year healthcare utilization of injections, imaging, opioids and costs were compared between groups.

RESULTS

Compared to early PT consultation, the odds of receiving an opioid prescription (aOR = 2.79, 95%CI: 1.35-5.79), spinal injection (aOR = 4.36, 95%CI:2.26-8.45), undergoing an MRI (aOR = 4.68, 95%CI:2.25-9.74), X-ray (aOR = 2.97, 95%CI:1.61-5.47) or CT scan (aOR = 3.36, 95%CI: 1.14-9.97) were increased in patients in the late PT consultation group. Similar increases in risk were found in the delayed group (except CT and Opioids). Compared to the early PT consultation group, mean costs were $2172 ($557, $3786) higher in the late PT contact group and $1063 (95%CI: $ 138 - $1988) higher in the delayed PT consultation group.

DISCUSSION

There was an association with the timing of physical therapy consultation on healthcare utilization and costs, where later consultation was associated with increases costs and healthcare utilization. This study examined the association of timing of physical therapy consultation on costs and healthcare utilization, but not the association of increased access to physical therapy consultation. Therefore, the findings warrant further investigation to explore the effects of increased access to physical therapy consultation on healthcare utilization and costs in a prospective study.

Comparison of 2 Lumbar Manual Therapies on Temporal Summation of Pain in Healthy Volunteers

The purpose of this study was to compare the immediate change in temporal summation of heat pain (TSP) between spinal manipulation (SMT) and spinal mobilization (MOB) in healthy volunteers. Ninety-two volunteers (24 male; 23.8 ± 5.3 years) were randomized to receive SMT, MOB, or no treatment (REST) for 1 session. Primary outcomes were changes in TSP, measured at the hand and foot, immediately after the session. A planned subgroup analysis investigated effects across empirically derived TSP clusters. For the primary outcome there were no differences in the immediate change in TSP measured at the foot between SMT and MOB, however, both treatments were superior to the REST condition. In the subgroup analysis the response to a standard TSP protocol was best characterized by 3 clusters: 52% no change (n = 48, 52%); facilitatory response (n = 24, 26%), and inhibitory response (n = 20, 22%). There was a significant Time × Treatment group × Cluster interaction for TSP measured at the foot. The inhibitory cluster showed the greatest attenuation of TSP after SMT and MOB compared with REST. These data suggest lumbar manual therapies of different velocities produce a similar localized attenuation of TSP, compared with no treatment. Attenuation of localized pain facilitatory processes by manual therapies was greatest in pain-free individuals who show an inhibitory TSP response.

PERSPECTIVE

The attenuation of pain facilitatory measures may serve an important underlying role in the therapeutic response to manual therapies. Identifying patients in pain who still have an inhibitory capacity (ie, an inhibitory response subgroup) may be useful clinically in identifying the elusive "manual therapy" responder.

Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain

Objective

To examine patients seeking care for neck pain to determine associations between the type of provider initially consulted and 1-year health care utilization.

Patients and Methods

A retrospective cohort of 1702 patients (69.25% women, average age, 45.32±14.75 years) with a new episode of neck pain who consulted a primary care provider, physical therapist (PT), chiropractor (DC), or specialist from January 1, 2012, to June 30, 2013, was analyzed. Descriptive statistics were calculated for each group, and subsequent 1-year health care utilization of imaging, opioids, surgery, and injections was compared between groups.

Results

Compared with initial primary care provider consultation, patients consulting with a DC or PT had decreased odds of being prescribed opioids within 1 year from the index visit (DC: adjusted odds ratio [aOR], 0.54; 95% CI, 0.39-0.76; PT: aOR, 0.59; 95% CI, 0.44-0.78). Patients consulting with a DC additionally demonstrated decreased odds of advanced imaging (aOR, 0.43; 95% CI, 0.15-0.76) and injections (aOR, 0.34; 95% CI, 0.19-0.56). Initiating care with a specialist or PT increased the odds of advanced imaging (specialist: aOR, 2.96; 95% CI, 2.01-4.38; PT: aOR, 1.57; 95% CI, 1.01-2.46), but only initiating care with a specialist increased the odds of injections (aOR, 3.21; 95% CI, 2.31-4.47).

Conclusion

Initially consulting with a nonpharmacological provider may decrease opioid exposure (PT and DC) over the next year and also decrease advanced imaging and injections (DC only). These data provide an initial indication of how following recent practice guidelines may influence health care utilization in patients with a new episode of neck pain.

A value proposition for early physical therapist management of neck pain: a retrospective cohort analysis

BACKGROUND

Neck pain is one of the most common reasons for entry into the healthcare system. Recent increases in healthcare utilization and medical costs have not correlated with improvements in health. Therefore there is a need to identify management strategies for neck pain that are effective for the patient, cost efficient for the payer and provided at the optimal time during an episode of neck pain.

METHODS

One thousand five hundred thirty-one patients who underwent physical therapist management with a primary complaint of non-specific neck pain from January 1, 2008 to December 31, 2012 were identified from the Rehabilitation Outcomes Management System (ROMS) database at Intermountain Healthcare. Patients reporting duration of symptoms less than 4 weeks were designated as undergoing "early" management and patients with duration of symptoms greater than 4 weeks were designated as receiving "delayed" management. These groups were compared using binary logistic regression to examine odds of achieving Minimal Clinically Important Difference (MCID) on the Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS). Separate generalized linear modeling examined the effect of timing of physical therapist management on the metrics of value and efficiency.

RESULTS

Patients who received early physical therapist management had increased odds of achieving MCID on the NDI (aOR = 2.01, 95 % CI 1.57, 2.56) and MCID on the NPRS (aOR = 1.82, 95 % CI 1.42, 2.38), when compared to patients receiving delayed management. Patients who received early management demonstrated the greatest value in decreasing disability with a 2.27 percentage point change in NDI score per 100 dollars, best value in decreasing pain with a 0.38 point change on the NPRS per 100 dollars. Finally, patients receiving early management were managed more efficiently with a 3.44 percentage point change in NDI score per visit and 0.57 point change in NPRS score per visit.

CONCLUSIONS

These findings suggest that healthcare systems that provide pathways for patients to receive early physical therapist management of neck pain may realize improved patient outcomes, greater value and higher efficiency in decreasing disability and pain compared to delayed management. Further research is needed to confirm this assertion.

Clinical Outcomes, Utilization, and Charges in Persons With Neck Pain Receiving Guideline Adherent Physical Therapy

In efforts to decrease practice variation, clinical practice guidelines for neck pain have been published. The purpose of this study was to determine the effect of receiving guideline adherent physical therapy (PT) on clinical outcomes, health care utilization, and charges for health care services in patients with neck pain. A retrospective review of 298 patients with neck pain receiving PT from 2008 to 2011 was performed. Clinical outcomes, utilization, and charges were compared between patients who received guideline adherent care and nonadherent care. Patients in the adherent care group experienced a lower percentage improvement in pain score compared to nonadherent care group ( p = .01), but groups did not significantly differ on percentage improvement in disability ( p = .32). However, patients receiving adherent care had an average 3.6 fewer PT visits ( p < .001) and less charges for PT ( p < .001). Additionally, patients receiving adherent care had 7.3 fewer visits to other health care providers ( p < .001), one less prescription medication ( p = .02) and 43% fewer diagnostic images ( p = .02) but did not differ in their charges to other health care providers ( p = .68) during the calendar year of undergoing PT. Although receiving guideline adherent care demonstrated positive effects on health care utilization and financial outcomes, there appears to be a trade-off with clinical outcomes.

Description of Common Clinical Presentations and Associated Short-Term Physical Therapy Clinical Outcomes in Patients With Neck Pain

OBJECTIVE

To determine the effect of clinical presentations of neck pain on short-term physical therapy outcomes.

DESIGN

Retrospective analysis of pair-matched groups from a clinical cohort.

SETTING

Thirteen outpatient physical therapy clinics in 1 health care system.

PARTICIPANTS

Patients (N=1069) grouped by common clinical presentations of neck pain: nonspecific neck pain (NSNP) with duration <4 weeks; NSNP with duration >4 weeks; neck pain with arm pain; neck pain with headache; and neck pain from whiplash.

INTERVENTION

Conservative interventions provided by physical therapists.

MAIN OUTCOME MEASURES

Neck Disability Index (NDI) and numerical pain rating scale (NPRS) recorded at the initial and last visits. The main outcome of interest was achieving recovery status on the NDI. Changes in NDI and NPRS were compared between clinical presentation groups.

RESULTS

Compared with patients presenting with NSNP >4 weeks, patients with NSNP <4 weeks had increased odds of achieving recovery status on the NDI (P<.0001) and demonstrated the greatest changes in clinical outcomes of pain (P≤.0001) and disability (P≤.0001). Patients with neck pain and arm pain demonstrated an increased odds of achieving recovery status on the NDI (P=.04) compared with patients presenting with NSNP >4 weeks.

CONCLUSIONS

Treating patients with NSNP within <4 weeks of onset of symptoms may lead to improved clinical outcomes from physical therapy compared with other common clinical presentations.

Spinal manipulative therapy-specific changes in pain sensitivity in individuals with low back pain (NCT01168999)

Spinal manipulative therapy (SMT) is effective for some individuals experiencing low back pain; however, the mechanisms are not established regarding the role of placebo. SMT is associated with changes in pain sensitivity, suggesting related altered central nervous system response or processing of afferent nociceptive input. Placebo is also associated with changes in pain sensitivity, and the efficacy of SMT for changes in pain sensitivity beyond placebo has not been adequately considered. We randomly assigned 110 participants with low back pain to receive SMT, placebo SMT, placebo SMT with the instructional set "The manual therapy technique you will receive has been shown to significantly reduce low back pain in some people," or no intervention. Participants receiving the SMT and placebo SMT received their assigned intervention 6 times over 2 weeks. Pain sensitivity was assessed prior to and immediately following the assigned intervention during the first session. Clinical outcomes were assessed at baseline and following 2 weeks of participation in the study. Immediate attenuation of suprathreshold heat response was greatest following SMT (P = .05, partial η(2) = .07). Group-dependent differences were not observed for changes in pain intensity and disability at 2 weeks. Participant satisfaction was greatest following the enhanced placebo SMT. This study was registered at www.clinicaltrials.gov under the identifier NCT01168999.

PERSPECTIVE

The results of this study indicate attenuation of pain sensitivity is greater in response to SMT than the expectation of receiving an SMT. These findings suggest a potential mechanism of SMT related to lessening of central sensitization and may indicate a preclinical effect beyond the expectations of receiving SMT.

Effect of a single session of muscle-biased therapy on pain sensitivity: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Muscle-biased therapies (MBT) are commonly used to treat pain, yet several reviews suggest evidence for the clinical effectiveness of these therapies is lacking. Inadequate treatment parameters have been suggested to account for inconsistent effects across studies. Pain sensitivity may serve as an intermediate physiologic endpoint helping to establish optimal MBT treatment parameters. The purpose of this review was to summarize the current literature investigating the short-term effect of a single dose of MBT on pain sensitivity in both healthy and clinical populations, with particular attention to specific MBT parameters of intensity and duration.

METHODS

A systematic search for articles meeting our prespecified criteria was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE from the inception of each database until July 2012, in accordance with guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analysis. Relevant characteristics from studies included type, intensity, and duration of MBT and whether short-term changes in pain sensitivity and clinical pain were noted with MBT application. Study results were pooled using a random-effects model to estimate the overall effect size of a single dose of MBT on pain sensitivity as well as the effect of MBT, dependent on comparison group and population type.

RESULTS

Reports from 24 randomized controlled trials (23 articles) were included, representing 36 MBT treatment arms and 29 comparative groups, where 10 groups received active agents, 11 received sham/inert treatments, and eight received no treatment. MBT demonstrated a favorable and consistent ability to modulate pain sensitivity. Short-term modulation of pain sensitivity was associated with short-term beneficial effects on clinical pain. Intensity of MBT, but not duration, was linked with change in pain sensitivity. A meta-analysis was conducted on 17 studies that assessed the effect of MBT on pressure pain thresholds. The results suggest that MBT had a favorable effect on pressure pain thresholds when compared with no-treatment and sham/inert groups, and effects comparable with those of other active treatments.

CONCLUSION

The evidence supports the use of pain sensitivity measures by future research to help elucidate optimal therapeutic parameters for MBT as an intermediate physiologic marker.

Exercise-induced pain intensity predicted by pre-exercise fear of pain and pain sensitivity

OBJECTIVES

Our primary goals were to determine whether preexisting fear of pain and pain sensitivity contributed to post-exercise pain intensity.

METHODS

Delayed-onset muscle pain was induced in the trunk extensors of 60 healthy volunteers using an exercise paradigm. Levels of fear of pain and experimental pain sensitivity were measured before exercise. Pain intensity in the low back was collected at 24 and 48 hours post-exercise. Participants were grouped based on pain intensity. Group membership was used as the dependent variable in separate regression models for 24 and 48 hours. Predictor variables included fear, pain sensitivity, torque lost during the exercise protocol, and demographic variables.

RESULTS

The final models predicting whether a participant reported clinically meaningful pain intensity at 24 hours only included baseline fear of pain at each level of pain intensity tested. The final model at 48 hours included average baseline pain sensitivity and the loss of muscle performance during the exercise protocol for 1 level of pain intensity tested (greater than 35 mm of 100 mm).

DISCUSSION

Combined, these findings suggest that the initial reports of pain after injury may be more strongly influenced by fear whereas the inflammatory process and pain sensitivity may play a larger role for later pain intensity reports.

Self-reported pain and disability outcomes from an endogenous model of muscular back pain

Background

Our purpose was to develop an induced musculoskeletal pain model of acute low back pain and examine the relationship among pain, disability and fear in this model.

Methods

Delayed onset muscle soreness was induced in 52 healthy volunteers (23 women, 17 men; average age 22.4 years; average BMI 24.3) using fatiguing trunk extension exercise. Measures of pain intensity, unpleasantness, and location, and disability, were tracked for one week after exercise.

Results

Pain intensity ranged from 0 to 68 with 57.5% of participants reporting peak pain at 24 hours and 32.5% reporting this at 48 hours. The majority of participants reported pain in the low back with 33% also reporting pain in the legs. The ratio of unpleasantness to intensity indicated that the sensation was considered more unpleasant than intense. Statistical differences were noted in levels of reported disability between participants with and without leg pain.

Pain intensity at 24 hours was correlated with pain unpleasantness, pain area and disability. Also, fear of pain was associated with pain intensity and unpleasantness. Disability was predicted by sex, presence of leg pain, and pain intensity; however, the largest amount of variance was explained by pain intensity (27% of a total 40%). The second model, predicting pain intensity only included fear of pain and explained less than 10% of the variance in pain intensity.

Conclusions

Our results demonstrate a significant association between pain and disability in this model in young adults. However, the model is most applicable to patients with lower levels of pain and disability. Future work should include older adults to improve the external validity of this model.

Relationship of intersession variation in negative pain-related affect and responses to thermally-evoked pain

The purpose of this study was to determine whether session-specific measures of negative pain-related affect would account for longitudinal variability in the ratings of the evoked thermal pain. Pain-free subjects rated pain evoked on the posterior leg using thermal stimuli of 45 degrees , 47 degrees , 49 degrees , and 51 degrees C on 3 occasions, each separated by 2 weeks. Session-specific negative pain-related affect measures were also collected. Ratings of pain decreased significantly with repeated testing, demonstrating a systematic change in rating from the first to second sessions that ranged from a mean of 5.3 at 47 degrees C to 9.1 at 49 degrees C. In addition, large random variation occurred across all sessions, resulting in minimal detectable change ranging from 14 to 27. The least variability occurred when a mean rating of the 4 temperatures was used. Session-specific measures of pain-related affect decreased with repeated testing; however, the significant between-subject variability in both rating of pain and pain-related affect were not related to each other. No associations were identified between psychological measures and variability in rating of evoked pain. Future studies of the variability in ratings should consider other factors such as attentional focus.

PERSPECTIVE

The individual variability in thermal rating was not explained by individual variation in session-specific measures of negative pain-related affect. The results of this study support the use of repeated baseline measures of thermal stimuli when feasible. When this is not possible, the variability in ratings of thermal stimuli over multiple sessions is reduced when the mean of multiple temperatures is used.

Neonatal screening for haemoglobin variants using filter paper-dried blood specimens

Neonatal screening for haemoglobinopathies utilizing cord blood samples is well established, although it has a high miss rate and has the inherent problem of possible misdiagnosis from maternal contamination of the sample. The use of dried Guthrie card samples which are taken at six days of age avoids these problems and has the advantage of using an established system of sample collection. Controversy exists as to the method of choice for analysis of dried samples, this study of 2406 samples found that Iso-electric focusing (IEF) analysis of dried specimens gives excellent correlation when compared with cellulose acetate/citrate agar electrophoresis of liquid cord blood samples. The IEF results were clear and relatively simple to interpret even when the samples had been stored at room temperature for 4 weeks. The commercial enzyme linked immunosorbent assay (ELISA) screening test JOSHUA reliably determines the presence or absence of haemoglobin S in dried specimens. It could therefore be used as a relatively cheap and simple method for the confirmation of sickle cell trait in neonatal screening programmes based on dried specimens.

Plant molecular farming: systems and products

Plant molecular farming is a new and promising industry involving plant biotechnology. In this review, we describe several diverse plant systems that have been developed to produce commercially useful proteins for pharmaceutical and industrial uses. The advantages and disadvantages of each system are discussed. The first plant-derived molecular farming products have reached the marketplace and other products are poised to join them during the next few years. We explain the rationale for using plants as biofactories. We also describe the products currently on the market, and those that appear likely to join them in the near future. Lastly, we discuss the issue of public acceptance of molecular farming products.

Improved recovery of active recombinant laccase from maize seed

Lignolytic enzymes such as laccase have been difficult to over-express in an active form. This paper describes the expression, characterization, and application of a fungal laccase in maize seed. The transgenic seed contains immobilized and extractable laccase. Fifty ppm dry weight of aqueously extractable laccase was obtained, and the remaining solids contained a significant amount of immobilized laccase that was active. Although a portion of the extractable laccase was produced as inactive apoenzyme, laccase activity was recovered by treatment with copper and chloride. In addition to allowing the apoenzyme to regain activity, treatment with copper also provided a partial purification step by precipitating other endogenous corn proteins while leaving >90% of the laccase in solution. The data also demonstrate the application of maize-produced laccase as a polymerization agent. The apparent concentration of laccase in ground, defatted corn germ is approximately 0.20% of dry weight.

Plant-based vaccines: unique advantages

Numerous studies have shown that viral epitopes and subunits of bacterial toxins can be expressed and correctly processed in transgenic plants. The recombinant proteins induce immune responses and have several benefits over current vaccine technologies, including increased safety, economy, stability, versatility and efficacy. Antigens expressed in corn are particularly advantageous since the seed can be produced in vast quantities and shipped over long distances at ambient temperature, potentially allowing global vaccination. We have expressed the B-subunit of Escherichia coli heat-labile enterotoxin and the spike protein of swine transmissible gastroenteritis virus at high levels in corn, and demonstrate that these antigens delivered in the seed elicit protective immune responses.

Transgenic plants of Orchardgrass (Dactylis glomerata L.) from protoplasts

We have demonstrated the transfer and expression of a foreign chimeric gene in the grass species, Dactylis glomerata L. This species is a member of the Gramineae sub-family Pooideae, which includes the small grain cereals, from which transformed plants have not yet been obtained. A chimeric hygromycin-resistance gene was introduced into protoplasts isolated from an embryogenic suspension culture, using heat shock followed by electroporation or polyethylene glycol treatment. Cell colonies resistant to 20 μg/ml hygromycin were selected in liquid medium using an agarose bead type culture system. Transformed calli were identified by Southern hybridization. Embryogenic callus was induced to regenerate plants and transformed plants were shown to contain the hygromycin resistance gene.

Plant regeneration from protoplasts of embryogenic suspension cultures of orchardgrass (Dactylis glomerata L.)

An embryogenic suspension culture of orchardgrass (Dactylis glomerata L.) consisting of small, embryogenic cell clusters was obtained from callus formed on basal sections of young leaves through a process of selective enrichment. These suspensions were used as a source of protoplasts. The isolated protoplasts divided at a frequency of 0.5-10% when plated in an agarose solidified culture medium. Conditioned medium, in which embryogenic Dactylis suspension cultures had been grown, was found to increase the rate of cell colony formation. Protoplast-derived colonies grew rapidly in a bead-type culture system of floating agarose slabs in liquid medium. New suspension cultures formed as the colonies grew out of the agarose. These cultures were embryogenic and formed green plantlets when plated on a solid medium lacking auxin. The plantlets were established in soil and grown to mature plants.

Gall stones in sickle cell disease in the United Kingdom

The prevalence of gall stones was studied prospectively by abdominal ultrasound examination in 131 patients with sickle cell disease aged 10-65 years. Of 95 patients with homozygous sickle cell disease, 55 (58%) had gall stones or had had a cholecystectomy. Gall stones were present in four out of 24 (17%) patients with haemoglobin S + C disease and two out of 12 (17%) with haemoglobin S beta thalassaemia. The presence of gall stones was not related to sex, geographical origin, or haematological variables and was not associated with abnormal results of liver function tests. Symptoms typical of biliary colic were reported by 32 out of 47 adult patients with gall stones, and cholecystitis or cholestasis was diagnosed in 18. Cholecystectomy was performed in 29 patients with good relief of symptoms in most cases. Postoperative complications were common, occurring in 10 of the 28 patients who could be evaluated, but not generally serious; they were considerably lessened by a preoperative exchange transfusion that reduced the haemoglobin S concentration to below 40%. It is suggested that all patients with sickle cell disease should be screened for gall stones and that elective cholecystectomy should be performed in those with symptoms or complications.

Neonatal screening for sickle cell diseases in Camberwell: results and recommendations of a two year pilot study

The sickle cell diseases are a major health problem for Afro-Caribbean peoples. Neonatal detection and prophylactic management can reduce mortality and morbidity in childhood. A study was therefore conducted analysing the results of the first two years of cord blood screening in the Camberwell health area. Thirteen cases of sickle cell disease and two of haemoglobin (Hb)C disease were identified among 2202 non-white infants screened. The carrier state, sickle cell trait (HbAS), was present in 11.9% and HbC trait (HbAC) in 4.1% of Afro-Caribbean infants. The incidence of disease and of carrier states was much higher in West Africans than in Caribbeans. The wider implications of screening and the need for a comprehensive plan of care are emphasised.

Photoautotrophic growth of soybean cells in suspension culture: I. Establishment of photoautotrophic cultures

Highly chlorophyllous photomixotrophic callus was visually selected from callus originating from soybean (Glycine max (L.) Merr. var. Corsoy) cotyledon. Suspension cultures initiated from this callus became photoautotrophic under continuous light with an atmosphere of 5% CO(2) (balance air). Dry weight increases of 1000 to 1400% in the 2-week subculture period have been observed. The cellular Chl content ranged from 4.4 to 5.9 micrograms per milligram dry weight which is about 75 to 90% of the Chl content in soybean leaves under equivalent illumination (300 micro-Einsteins per square meter per second).No growth can be observed in the dark in sucrose-lacking medium or in the presence of 0.5 micromolar 3-(3,4-dichlorophenyl)-1,1-dimethylurea, a concentration which does not inhibit heterotrophic growth (on sucrose). Photoautotrophic growth has an absolute requirement for elevated CO(2) concentrations (>1%). During the 14-day subculture period, growth (fresh weight and dry weight) is logarithmic. Photosynthesis quickly increases after day 4, reaching a peak of 83 micromoles CO(2) incorporated per milligram Chl per hour while dark respiration decreases 90% from day 2 to day 6. The pH of the growth medium quickly drops from 7.0 to 4.5 before slowly increasing to 5.0 by day 14. At this pH range and light intensity (200-300 microEinsteins per square meter per second), no O(2) evolution could be detected although at high pH and light intensity O(2) evolution was recorded.

Cyanide-Resistant Respiration in Suspension Cultured Cells of Nicotiana glutinosa L

The respiration of dark-grown Nicotiana glutinosa L. cells in liquid suspension culture was found to be highly cyanide resistant and salicylhydroxamic acid (SHAM) sensitive, indicative of an active alternative respiratory pathway. This was especially true during the lag and logarithmic phases of the 14-day growth cycle. Mitochondria isolated from logarithmically growing cells exhibited active oxidation of malate, succinate, and exogenous NADH. Oxidation of all three substrates had an optimum pH of 6.5 and all were highly resistant to inhibited by cyanide and sensitive to SHAM. Respiratory control was exhibited by all three substrates but only if SHAM was present to block the alternative pathway and divert electrons to the phosphorylating cytochrome pathway. The cyanide-resistant oxidation of exogenous NADH has previously only been associated with Arum spadix mitochondria. Coemergence during evolution of the alternative respiratory pathway and the exogenous NADH dehydrogenase in plant mitochondria as a possible mechanism for removal of cytoplasmic NADH is proposed. Evidence is presented which suggests that mitochondrial assays should be performed at pH 6.5.

Genetic factors in childhood asthma

The prevalences of asthma and atopy were examined in the families of 77 asthmatic and 87 control children attending a London general practice. The prevalence of asthma in first degree relatives of asthmatic children was found to be significantly higher than in relatives of control children, and this difference was more pronounced for relatives of atopic probands than for relatives of non-atopic probands. Among the relatives of asthmatics, atopic asthma was more common than non-atopic asthma, irrespective of the atopic status of the proband. However, among the relatives of control children, neither the prevalence of asthma nor the atopic status of the asthmatic relatives was influenced by the atopic status of the proband. These findings support the hypothesis that asthma and atopy are inherited independently. Although atopy itself does not predispose to asthma, it may enhance a genetic susceptibility to the condition, thus increasing the likelihood that the latter will be expressed.

A family study of the genetic basis of asthma and wheezy bronchitis

The family histories relating to asthma and wheezy bronchitis were examined in 77 asthmatic, 78 wheezy bronchitic, and 87 control children, aged between 1 and 12 years. The percentage of children with at least one asthmatic relative was significantly greater in the asthmatic and wheezy bronchitic probands than in the controls; and asthma was more prevalent in the relatives of both groups of wheezy probands than in the relatives of controls. Similarly, the percentage of children with at least one wheezy bronchitic relative tended to be greater in asthmatic and wheezy bronchitic probands than in the controls; and wheezy bronchitis tended to be more prevalent in the relatives of both groups of wheezy probands than in the relatives of controls. However these differences did not reach significance. The strong similarities between asthmatic and wheezy bronchitic children in their family histories of asthma and wheezy bronchitis suggest that these two forms of wheezy illness share a common genetic defect.

Role of viruses and bacteria in acute wheezy bronchitis in childhood: a study of sputum

Sputum, nasal swabs, and throat swabs were obtained from 22 children aged between 5 and 15 years during 72 attacks of wheezy bronchitis. A virus, most commonly a rhinovirus, was isolated in 49% of all episodes and in 64% of 22 severe episodes requiring treatment with corticosteroids; the isolation rate was higher early in the illness than later. Virus was recovered more often from sputum than from the nose or throat, suggesting that viral replication occurs freely in the lower respiratory tract: the cytological findings in sputum were compatible with an inflammatory response to viral infection. Pathogenic bacteria appeared to play a minor role compared with viruses, and routine antibiotic treatment was probably of little value in moost cases. The significance of the results is discussed in relation to the pathogenesis of childhood wheezy bronchitis.

Respiratory viral infection and wheezy bronchitis in childhood

The role of respiratory viral infection in wheezy bronchitis was studied in 163 children, aged 0-12 years, in a London general practice. Virological investigations were also performed when these same children had acute upper respiratory illness without wheeze. A virus was isolated in 146 (26.4%) of 554 episodes of wheezy bronchitis, rhinoviruses accounting for almost half of the isolations. The relative frequency with which individual viruses were isolated in wheezy bronchitis was similar to that in acute upper respiratory illness in 180 other children who had never had wheezy bronchitis. The large number of isolations of rhinoviruses in wheezy bronchitis is probably due to their numerous serotypes and the absence of cross-immunity between them. Our findings have confirmed that infection by respiratory viruses can provoke wheezy bronchitis in certain children, in whom host factors are an important predeterminant. In children with a previous history of wheezy bronchitis infection by rhinoviruses was associated significantly more often with such an episode than with upper respiratory illness. The maturation of protective mechanisms, including the acquisition of specific immunity to a progressively larger number of viruses, could explain the fall in the age-incidence of wheezy bronchitis.