Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review
BACKGROUND:Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention. METHODS:This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against. RESULTS:Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome. CONCLUSIONS:Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.
Incidence and Mechanisms of Musculoskeletal Injuries in Deployed Navy Active Duty Service Members Aboard Two U.S. Navy Air Craft Carriers
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.
"Feasibility of training physical therapists to implement a psychologically informed physical therapy program for deployed U.S. sailors and marines with musculoskeletal injuries": Corrigendum
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.
Team Approach: Perioperative Optimization for Total Joint Arthroplasty
Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry
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.
Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries
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.
A comparison between different outcome measures based on "meaningful important differences" in patients with lumbar spinal stenosis
PURPOSE: Patient-reported outcome measures (PROM) are used to measure treatment efficacy in clinical trials. The impact of the choice of a PROM and the cut-off values for 'meaningful important differences' (MID) on the study results in patients with lumbar spinal stenosis (LSS) is unclear. OBJECTIVE: The objective is to study the consequences of applying different PROMs and values for MID for pain and disability on the proportions of patients with improvement. DESIGN: Prospective multi-center cohort study. METHODS: Proportions of patients with improvement using established MID cut-off values were calculated and compared for PROMs for pain and disability. RESULTS: 466 patients with LSS completed a baseline and 6-month follow-up assessment and were analyzed. Treatment modalities included surgery (65 %), epidural steroid injections (15 %), or conservative care (20 %). The prevalence of patients fulfilling the criteria for MID ranged from 40 to 70 % across all outcome measures and cut-offs. The agreement of the spinal stenosis outcome measure (SSM) symptom subscale with other pain scales, and the SSM function subscale with other function scales was fair to moderate (Cohen's kappa value between 0.24 and 0.5). Disagreement in the assessment of MID (MID reported by patients in one scale but not the other) was found in at least one-third of the patients. CONCLUSION: The MID in outcome scores for this population varied from 40 to 70 %, depending on the measure or cut-off score used. Further, the disagreement between domain specific measures indicates that differences between studies may be also related to the choice of an outcome measures. An international consensus on the use and reporting of outcome measures in studies on lumbar spinal stenosis is needed.
What do patients with spine pain learn from psychologically informed physical therapy? [Meeting Abstract]
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
Validity of lumbar spinal stenosis outcome measures used in clinical studies: A systematic analysis of randomized and observational clinical trials [Meeting Abstract]
Background: Questionnaires are used to assess the outcome of clinical studies. Validation studies in a specific patient population assures that patient relevant complaints are assessed. Compared to low back pain, patients with lumbar spinal stenosis express different clinical signs and symptoms. Therefore, outcome measures validated in low back pain populations may not assess the relevant complaints in patients with LSS. The aim of the current study was to analyze outcome measures used in studies on LSS patients and whether they were validated for this population. Methods: Based on systematic reviews and meta-analysis published between 2006 and January 2016, all randomized (RCT) and observational studies (OS) on patients with LSS were analyzed. All information on outcome measures was extracted. Referenced validation studies were retained in full text analyzed. We assessed the quality of each validation study based on previously published quality criteria: minimal number of patients, construct validity, internal consistency, criterion validity, reproducibility, responsiveness, floor and ceiling effect, and interpretability. Results: Overall, 97 studies were analyzed (46 RCT, 50 OS, 1 combined) that used 33 different outcome measures (8 pain measures, 25 functional outcome measures). The most frequently used pain measure was the Visual Analogue Scale (VAS), the most frequently used disability measures were the Oswestry Disability Index (ODI) and the Spinal Stenosis Measure. One-fifth of the measures were validated in LSS patients. Out of the 97 studies, 30 studies (31%) used no validated outcome measure and 67 (69%) used at least one validated outcome measure. For most validation studies (n = 7), we found poor methodological quality (Table 1). Conclusion: The systematic analysis of RCT and OS showed that one-third of the studies used no validated outcome measure to assess clinical outcomes. Further, the methodological quality of many validation studies was poor. (Table Presented)
The start back screening tool in secondary care: Do psychological subscale scores differ among patients with acute, subacute and chronic spine pain [Meeting Abstract]
BACKGROUND CONTEXT: The STarT Back Screening Tool (SBST) provides a method of identifying obstacles to recovery in patients with spine pain and has been validated in primary care. Although primary care populations include patients with acute, subacute, and chronic pain, differences in SBST profiles among these groups are not known. Such differences may have implications for targeted interventions. For example, anxiety may be higher in the acute stage when the injury is new, while depression may be higher in the chronic stage due to failed treatment. This study reports on differences in SBST psychological subscale scores in patients with acute (<4 weeks), subacute (4-12 weeks) and chronic (>12 weeks) spine pain seeking outpatient Physical Therapy (PT). This study is a first step in determining the usefulness of the SBST in different spine pain groups. PURPOSE: To compare SBST psychological profiles in patients with acute, subacute and chronic spine pain. STUDY DESIGN/SETTING: Cross-sectional/Outpatient Physical Therapy Clinic. PATIENT SAMPLE: Patients with spine pain seeking PT from January to December 2013. OUTCOME MEASURES: Data was extracted from a clinical database. The 5 SBST psychological subscale scores and age, gender and pain duration were collected for this study. METHODS: MANOVA analysis was used to compare the 5 items of the SBST across study groups. Because the sample sizes of the 3 groups were unbalanced, and did not have normal distributions, a univariate analysis was conducted to confirm if significant findings by MANOVA reflected a true difference by group. As cut-off scores have not been established for patients in secondary care, we analyzed the items of the SBST psychological subscale as both continuous and categorical variables (using previously validated cutoff scores). A Non-parametric Kruskal Wallis-H test was used for continuous SBST scores and Chi-square test were used for dichotomized scores. Statistical analysis was done using SPSS v.23. RESULTS: The sample included 384 patients; 10% acute (n=38), 25% subacute (n=97) and 65% chronic (n=249). Fifty-five percent were female and 45% male; mean age was 51 years (SD=16). No significant group differences were found on demographic variables. MANOVAshowed that the SBST subscale significantly differed between patients groups (p<.0005). The Kruskal Wallis-H test showed a statistically significant difference in catastrophyzing (p<.005) among study groups, with acute patients showing less catastrophyzing (mean=0.92, 95% CI: 0.29-1.54) than the other two groups (Subacute mean=2.71, 95% CI: 2.06-3.36 and Chronic mean=3.11, 95%CI: 2.71- 3.51). The Chi-square analysis showed that catastrophyzing and anxiety were different among study groups (p<.05). In both cases, the acute patients had lower scores than the other two groups. CONCLUSIONS: SBST psychological profiles were similar among patients with acute, subacute and chronic pain. However, catastrophyzing was higher in the subacute and chronic groups than in the acute group in both analyses. This suggests that interventions aimed at reducing catastrophyzing thoughts should be initiated in acute care prophylactically. Although anxiety showed the same pattern as catastrophyzing in the Chi-square analysis, cutoff scores that have not yet been validated for this population were used, limiting the validity of this finding. The SBST may be useful for identifying risk factors in the study groups. However, future prospective studies are needed to validate existing cut-off scores in all groups before conclusions can be drawn