Faculty Bibliography

INTRODUCTION:Musculoskeletal disorders (MSDs) are a primary cause of separation and long-term disability in active duty service members (ADSMs). Psychologically informed physical therapy (PiPT) is designed to identify and address modifiable psychological risk factors early in an MSD episode and has been proven effective in preventing chronicity in civilian populations. We developed a course to train military physical therapy (PT) personnel in PiPT for treating ADSM with MSD. This study tests the feasibility and effectiveness of our training. OBJECTIVE:Establish the feasibility of implementing PiPT and its effectiveness in the U.S. military. MATERIALS AND METHODS:An observational, prospective, comparative cohort study will test implementation and effectiveness. First, we will observe clinical outcomes in a cohort of ADSM with MSD receiving usual PT care at a military outpatient PT clinic. Next, we will train all PT staff in PiPT. Finally, PiPT will be implemented in a second cohort of ADSM. Data will be collected from each cohort at pre-treatment, fourth PT visit, 6 months post enrollment, and 12 months post enrollment. The primary outcomes are pain interference and psychological risk for chronicity. RESULTS AND CONCLUSIONS:Data collection is ongoing. Findings will identify the factors associated with PiPT outcomes in ADSM, inform the implementation of PiPT across health care settings, and allow us to document the prevalence of risk factors for chronicity in ADSM. Findings can help to prevent chronification from MSD, thereby reducing lost man-hours and enhancing military readiness, contribute to the development of a highly skilled workforce for the provision of health services to ADSM, and enhance the efficiency of health care delivery through optimal allocation of PT resources, resulting in significant cost savings for the military.

INTRODUCTION/UNASSIGNED:The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". RESEARCH QUESTION/UNASSIGNED:Not applicable. MATERIAL AND METHODS/UNASSIGNED:Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. RESULTS/UNASSIGNED:Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. DISCUSSION AND CONCLUSION/UNASSIGNED:SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

BACKGROUND:Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations. RESEARCH QUESTION/OBJECTIVE:Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease? MATERIALS AND METHODS/METHODS:Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses. RESULTS:). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all p<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs 17.6;p<0.001) and PCS (27.4 vs 19.3;p<0.001). DISCUSSION AND CONCLUSION/CONCLUSIONS:Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated. LEVEL OF EVIDENCE/METHODS:Level III.

PURPOSE/OBJECTIVE:Globally, spine disorders are the leading cause of disability, affecting more than half a billion individuals. However, less than 50% of G20 countries specifically identify spine health within their public policy priorities. Therefore, it is crucial to raise awareness among policy makers of the disabling effect of spine disorders and their impact on the economic welfare of G20 nations. In 2019, SPINE20 was established as the leading advocacy group to bring global attention to spine disorders. METHODS:Recommendations were developed through two Delphi methods with international and multi-professional panels. RESULTS:In 2022, seven recommendations were delivered to the leaders of G20 countries, urging them to: Develop action plans to provide universal access to evidence-based spine care that incorporates the needs of minorities and vulnerable populations. Invest in the development of sustainable human resource capacity, through multisectoral and inter-professional competency-based education and training to promote evidence-based approaches to spine care, and to build an appropriate healthcare working environment that optimizes the delivery of safe health services. Develop policies using the best available evidence to properly manage spine disorders and to prolong functional healthy life expectancy in the era of an aging population. Create a competent workforce and improve the healthcare infrastructure/facilities including equipment to provide evidence-based inter-professional rehabilitation services to patients with spinal cord injury throughout their continuum of care. Build collaborative and innovative translational research capacity within national, regional, and global healthcare systems for state-of-the-art and cost-effective spine care across the healthcare continuum ensuring equality, diversity, and inclusion of all stakeholders. Develop international consensus statements on patient outcomes and how they can be used to define and develop pathways for value-based care. Recognize that intervening on determinants of health including physical activity, nutrition, physical and psychosocial workplace environment, and smoking-free lifestyle can reduce the burden of spine disabilities and improve the health status and wellness of the population. At the third SPINE20 summit 2022 which took place in Bali, Indonesia, in August 2022, 17 associations endorsed its recommendations. CONCLUSION/CONCLUSIONS:SPINE20 advocacy efforts focus on developing public policy recommendations to improve the health, welfare, and wellness of all who suffer from spinal pain and disability. We propose that focusing on facilitating access to systems that prioritize value-based care delivered by a competent healthcare workforce will reduce disability and improve the productivity of the G20 nations.

PURPOSE/OBJECTIVE:The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS:On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS:In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS:SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

INTRODUCTION/BACKGROUND:This brief report describes the number and nature of cases of musculoskeletal pain and injury among sailors and marines presenting to the ship's physical therapist during recent, respective deployments of two U.S. Navy aircraft carriers. MATERIALS AND METHODS/METHODS:The case definition for this study was cases of work-limiting medical complaints involving the musculoskeletal system presenting, or referred, to the ship's physical therapy services for evaluation and treatment. The population for this study was drawn from ship's company from two Nimitz class carriers on their respective deployments. Potential subjects were recruited at their index visit for their complaint. Participants completed a survey of their symptoms while at the ship's medical department. Data for analysis consist of counts of cases, body part affected, self-reported mechanism of injury, age, and gender of the subject. Data were analyzed by generating descriptive tables. RESULTS:One hundred ninety-seven cases were captured across the two carriers. Injury to the low back was the most frequent (34%), followed by shoulder (25%) and knee (15%). Twenty one cases (11%) were reported to be exacerbation of previous injuries and the rest new injuries. Of the 176 new injury cases, 93 (53%) were of an insidious onset and the remainder had a specific, identifiable onset. Of the 82 cases with a specific identifiable onset, 38 cases (46%) occurred during participation in sport and exercise activity on board ship, and the remainder of the cases occurred during the performance of duty-related work. None of the cases required evacuation off of the ship. CONCLUSION/CONCLUSIONS:Care should be used interpreting the results since participants were volunteers and a small proportion of eligible subjects chose not to participate in the study. Nevertheless, our data are generally consistent with other studies of musculoskeletal injury on board U.S. Navy ships and are useful for health care planning purposes and for planning for future studies that may take place on board U.S. Navy vessels. The novel and important finding of this study suggests that sports and exercise activity on board ship may warrant a new area of attention for safety.

Reports an error in "Feasibility of training physical therapists to implement a psychologically informed physical therapy program for deployed U.S. sailors and marines with musculoskeletal injuries " by Sherri Weiser, Angela Lis, Gregg Ziemke, Rudi Hiebert, Danielle Faulkner, Tara Brennan, Brian Iveson and Marco Campello (Military Medicine, 2018[Mar-Apr], Vol 183[3-4, Suppl], 503-509). In the original article, on page 503, the author list includes "Gregg Ziemke, MSC, USN, (Ret.)" and "Brian Iveson, MSC, USN." These authors should instead be listed as Gregg Ziemke PT, MS, OCS and Brian Iveson PT, DsC, FAAOMPT. (The following abstract of the original article appeared in record 2019-60047-071). This study assesses the feasibility of training U.S. Navy Physical Therapy staff members (PT staff) aboard a U.S. Navy Aircraft Carrier in psychologically informed physical therapy (PiPT). Training was conducted prior to deployment over 3 d and included background information, skills development, and application in the form of role playing and case studies. During deployment, nine phone conferences were conducted to reinforce training, assess skills, and discuss implementation. PiPT knowledge was assessed by a written test and role-playing skills. The adoption of the training was determined by analysis of clinical notes and verbal responses of the PT staff during phone conferences. There were two PT staff members on the carrier. Both received passing knowledge test scores and demonstrated role-playing proficiency. Clinical note assessment and discussions during conference calls also indicated successful implementation. The feasibility of training Navy PT staff to implement PiPT was demonstrated. PT staff successfully translated training into practice. This is significant, since PiPT has the potential to limit attrition due to musculoskeletal injuries in Navy personnel. Factors believed to be associated with the success of the training include adoption of the PiPT model by PT staff and reinforcement of changes in clinical practice during deployment.

BACKGROUND CONTEXT: Negative beliefs are known to influence treatment outcome in patients with spine pain (SP). The impact of positive beliefs is less clear. PURPOSE: Assess the influence of positive and negative beliefs on baseline and treatment responses in patients with SP. STUDY DESIGN/SETTING: Retrospective cross-sectional and longitudinal analysis of prospectively collected data of outpatient physical therapy patients with SP. Questionnaires administered before and during treatment included the STarT Back distress scale (negative beliefs), and expectation and self-efficacy questions (positive beliefs). PATIENT SAMPLE: Patients with SP with a baseline assessment and follow-up assessment. OUTCOME MEASURE: Perceived disability (oswestry disability index (ODI) or neck disability index (NDI). A clinical meaningful change (MCID) was defined as decrease in ODI / NDI of >/=30%. METHODS: We used the Akaike Information Criterion (AIC) from the first imputed dataset of the prediction model to select predictor variables. Prediction models were fitted to the outcome variables. This study was not funded and the authors have no conflict of interest to declare. RESULTS: In the cross-sectional analysis 1,695 low back pain (LBP) episodes and 487 neck pain (NP) episodes were analyzed . SBST-distress was positively associated with perceived disability in both LBP and NP; LBP (Beta 2.31, 95% CI 1.75 - 2.88) and NP (Beta 2.57, 95% CI 1.47 - 3.67). Lower self-efficacy was negatively associated with more perceived disability for LBP (Beta 0.50, 0.29 - 0.72) but not for NP while less positive expectations was associated with more perceived disability in NP (Beta 0.57, 0.02 - 1.12) but not in LBP. In the longitudinal analysis 607 LBP episodes (36%) and 176 (36%) NP episodes were included. SBST-distress did not predict treatment outcome in spine patients. In LBP, patients with a lower positive expectation were less likely to experience a MCID in perceived disability (OR per point increase 0.89, 95% CI 0.83 - 0.96) and there was a similar trend in NP (0.90, 0.79 - 1.03). In patients with LBP, lower self-efficacy at baseline was associated with a higher likelihood that an MCID was achieved (OR per point increase 1.09, 1.01 - 1.19). In NP, self-efficacy was not included in the final model. CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability however, in this study only positive beliefs were associated with treatment outcome.

This study assesses the feasibility of training U.S. Navy Physical Therapy staff members (PT staff) aboard a U.S. Navy Aircraft Carrier in psychologically informed physical therapy (PiPT). Training was conducted prior to deployment over 3 d and included background information, skills development, and application in the form of role playing and case studies. During deployment, nine phone conferences were conducted to reinforce training, assess skills, and discuss implementation. PiPT knowledge was assessed by a written test and role-playing skills. The adoption of the training was determined by analysis of clinical notes and verbal responses of the PT staff during phone conferences. There were two PT staff members on the carrier. Both received passing knowledge test scores and demonstrated role-playing proficiency. Clinical note assessment and discussions during conference calls also indicated successful implementation. The feasibility of training Navy PT staff to implement PiPT was demonstrated. PT staff successfully translated training into practice. This is significant, since PiPT has the potential to limit attrition due to musculoskeletal injuries in Navy personnel. Factors believed to be associated with the success of the training include adoption of the PiPT model by PT staff and reinforcement of changes in clinical practice during deployment.

Background: Psychologically informed physical therapy (PIPT) requires physical therapy (PT) staff to address common psychological risk factors, such as patients' understanding and beliefs about spine pain (SP), to reduce the risk of disability. However, the effect of this treatment on patients' perceptions of their SP has not been studied. We developed a training program for physical therapists aboard a United States Navy Aircraft Carrier aimed at modifying psychological risk factors in active duty services members (ADSM) with SP, and queried subjects about what they learned from PT to determine the effect of PIPT on their SP beliefs. Purpose: To determine what patients with SP learn from PIPT. Methods: This is a qualitative analysis of data obtained from a larger controlled study on two US Navy Aircraft Carriers, testing the effectiveness of PIPT for all musculoskeletal injuries (MSIs) in ADSM. Physical therapists and PT technicians in the intervention arm participated in a 3-day PIPT course that was reinforced during deployment. Four weeks post-enrollment, subjects completed an open-ended question: "please list the most important thing(s) you learned in physical therapy", to determine if messages that subjects received from PT staff differed between study groups. Concepts consistent with PIPT messages were established a priori and used to guide the qualitative analysis of the responses (e.g. I understand the mind/body connection, pain is not damage). Three blinded raters independently assessed subjects' responses. Subjects were considered to have understood the PIPT based message when all raters agreed that a response reflected PIPT concepts or when consensus was reached. PIPT concepts were considered absent from all other responses. Results: Of the 47 SP intervention subjects, two (4.3%) did not answer the study question, compared to six (26.1%) of the 23 SP control subjects. Among patients with SP, 20 (42.6%) of the responses reflected PIPT concepts in the intervention carrier compared to zero in the control carrier. Only nine (23.7%) of the intervention subjects with all other MSIs listed statements reflecting PIPT concepts. Conclusion: This is the first study to examine the transfer of PIPT knowledge from PT staff to the patient. Effectiveness of PIPT requires that specific messages are communicated by the PT staff and absorbed by the patient. Almost half of the subjects with SP exposed to PIPT listed statements reflective of PIPT concepts among the most important things learned during physical therapy. In contrast, no subjects in the control arm did so. Subjects with SP also had a higher percentage of responses reflecting PIPT concepts than subjects with other MSIs, suggesting that this approach may be particularly helpful for patients with SP Further studies to assess the impact of PIPT on patient beliefs and functional outcomes are ongoing