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Protocol for the Implementation of Psychologically Informed Physical Therapy to Prevent Chronification in Service Members With Musculoskeletal Disorders

Campello, Marco; Ziemke, Gregg; Hair, Leslie C; Oh, Cheongeun; Mowery, Hope; Hope, Timothy; Weiser, Sherri
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.
PMID: 37948222
ISSN: 1930-613x
CID: 5609962

The Psychological Burden of Disease Among Patients Undergoing Cervical Spine Surgery: Are We Underestimating Our Patients' Inherent Disability?

Passias, Peter; Naessig, Sara; Williamson, Tyler K; Tretiakov, Peter S; Imbo, Bailey; Joujon-Roche, Rachel; Ahmad, Salman; Passfall, Lara; Owusu-Sarpong, Stephane; Krol, Oscar; Ahmad, Waleed; Pierce, Katherine; O'Connell, Brooke; Schoenfeld, Andrew J; Vira, Shaleen; Diebo, Bassel G; Lafage, Renaud; Lafage, Virginie; Cheongeun, Oh; Gerling, Michael; Dinizo, Michael; Protopsaltis, Themistocles; Campello, Marco; Weiser, Sherri
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.
PMID: 36502878
ISSN: 1773-0619
CID: 5381802

Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review

Sheikhzadeh, Ali; Wertli, Maria M; Weiner, Shira Schecter; Rasmussen-Barr, Eva; Weiser, Sherri
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.
PMCID:8214793
PMID: 34147071
ISSN: 1471-2474
CID: 4917972

Incidence and Mechanisms of Musculoskeletal Injuries in Deployed Navy Active Duty Service Members Aboard Two U.S. Navy Air Craft Carriers

Hiebert, Rudi; Brennan, Tara; Campello, Marco; Lis, Angela; Ziemke, Gregg; Faulkner, Danielle; Weiser, Sherri
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.
PMID: 32852526
ISSN: 1930-613x
CID: 4586942

"Feasibility of training physical therapists to implement a psychologically informed physical therapy program for deployed U.S. sailors and marines with musculoskeletal injuries": Corrigendum

Weiser, Sherri; Lis, Angela; Ziemke, Gregg; Hiebert, Rudi; Faulkner, Danielle; Brennan, Tara; Iveson, Brian; Campello, Marco
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.
PSYCH:2019-58839-011
ISSN: 1930-613x
CID: 4231302

Team Approach: Perioperative Optimization for Total Joint Arthroplasty

Feng, James E; Novikov, David; Anoushiravani, Afshin A; Wasterlain, Amy S; Lofton, Holly F; Oswald, William; Nazemzadeh, Milad; Weiser, Sherri; Berger, Jeffery S; Iorio, Richard
PMID: 30300250
ISSN: 2329-9185
CID: 3334902

Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry

Wertli, Maria M; Held, Ulrike; Lis, Angela; Campello, Marco; Weiser, Sherri
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.
PMID: 28756302
ISSN: 1878-1632
CID: 2655442

Feasibility of Training Physical Therapists to Implement a Psychologically Informed Physical Therapy Program for Deployed U.S. Sailors and Marines with Musculoskeletal Injuries

Weiser, Sherri; Lis, Angela; Ziemke, Gregg; Hiebert, Rudi; Faulkner, Danielle; Brennan, Tara; Iveson, Brian; Campello, Marco
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.
PMID: 29635612
ISSN: 1930-613x
CID: 3036832

A comparison between different outcome measures based on "meaningful important differences" in patients with lumbar spinal stenosis

Wertli, Maria M; Buletti, Franziska Christina; Held, Ulrike; Rasmussen-Barr, Eva; Weiser, Sherri; Burgstaller, Jakob M; Steurer, Johann
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.
PMID: 27177468
ISSN: 1432-0932
CID: 2435052

What do patients with spine pain learn from psychologically informed physical therapy? [Meeting Abstract]

Weiser, S; Lis, A; Brennan, T; Ziemke, G; Hiebert, R; Faulkner, D; Iveson, B; Southerst, D; Campello, M
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
EMBASE:618721951
ISSN: 1432-0932
CID: 2751132