Turn Your AART into a HIT Using a Complete Range of Aesthetic Injectables: Methodology for Combining Products to Maximise Patient Outcomes.

Purpose: Optimizing outcomes of aesthetic treatments with injectable products usually requires a consideration of the entire face to ensure balance, along with combination treatments that align with the patient's goals. To help injectors, a method of assessing the patient and developing an individualized, holistic treatment plan was developed. This methodology is termed Assessment, Anatomy, Range, and Treatment (AART™) and Holistic Individualized Treatments (HITs™). This article aims to describe and evaluate the novel and systematic AART-HIT™ methodology. Methods: The AART-HIT™ methodology, including its associated diagnostic tool the Facial Assessment Scale (FAS™), were developed to aid injectors in completing a patient assessment in which the entire face is evaluated, the relevant anatomy is considered, the science behind the available range of products is understood, and the treatment plan is individualised for the patient. Specifically, the HITs™ are methodologic tools for practitioners to perform a standardized, full facial assessment and to create an individualized treatment approach to holistically address a patient's aesthetic concerns. The use of this methodology in clinical practice was assessed via a survey, deployed to twenty-eight clinicians. Results: Over 85% of participants agreed that the AART-HIT™ methodology was adequate for their needs. Additionally, 100% of participants agreed that the temporal sequencing of HITs™ and the FAS™ diagnostic tool was useful in clinical practice. Furthermore, over 70% of participants agreed that the anatomical locations identified in each HIT™ were sufficient, while over 80% responded that the HITs™ adequately represented the range of products. Finally, over 85% of participants agreed that the HITs™ covered different ethnic skin types and various patient ages and, over 80% of participants responded that they would not add additional elements to any of the 5 HITs™. Conclusion: The AART-HIT™ methodology, including the FAS™ were comprehensive enough for clinical use in providing a personalised treatment plan for individual patients.

Low back pain or injury before collegiate athletics, a potential risk factor for non-contact athletic injuries.

CONTEXT: Majority of research surrounding the predictive value of clinical measurements and assessments for future athletic injury does not differentiate between contact and non-contact injuries. OBJECTIVE: We assessed the association between clinical measures and questionnaire data collected prior to sport participation and the incidence of non-contact lower extremity (LE) injuries among Division III collegiate athletes. DESIGN: Prospective cohort study. SETTING: University setting, NCAA Division III. PARTICIPANTS: 488 Division III freshmen athletes were recruited to participate in the study during their preseason physical examinations. PATIENTS OR OTHER PARTICIPANTS: 10,983 public schools. MAIN OUTCOME MEASURE: Prospective incidence of non-contact Lower extremity Injury. METHODS: Athletes completed questionnaires to collect demographics and musculoskeletal pain history. Clinical tests, performed by trained examiners, included hip provocative tests, visual appraisal of a single leg squat to identify dynamic knee valgus, and hip range of motion (ROM). Injury surveillance for each athlete's collegiate career was performed. The athletic training department documented each athlete-reported, new onset injury and documented the injury location, type, and outcome (days lost, surgery performed). Univariable Generalized Estimating Equations (GEE) models were used to analyze the relationship between each clinical measure and the first occurrence of non-contact LE injury. An exchangeable correlation structure was used to account for repeated measurements within athletes (right and left limbs). RESULTS: Of the 488 athletes, 369 athletes (75%) were included in the final analysis. 69 non-contact LE injuries were reported. Responding "Yes" to "Have you ever had pain or an injury to your low back" was associated with an increased risk of non-contact LE, odds ratio = 1.59 (95%CI 1.03- 2.45, p=.04). No other clinical measures were associated with increased injury risk. CONCLUSION: A history of prior low back pain or injury was associated with an increased risk of sustaining a non-contact LE injury while participating in NCAA Division III athletics.

Provider-Perceived Value of Interprofessional Team Meetings as a Core Element of a Lifestyle Medicine Program: A Mixed-Methods Analysis of One Center's Experience.

Interprofessional care improves outcomes for medically complex patients and may be a valuable addition to standard lifestyle medicine practice, but implementation barriers exist. The purpose of this study was to explore the key features, perceived impact, and implementation considerations related to holding interprofessional team meetings as part of an intensive lifestyle medicine program. In this mixed-methods study, focus groups were conducted with 15 lifestyle medicine clinicians from various healthcare disciplines who had participated in interprofessional team meetings. Quantitative descriptive statistics of the meeting minutes were also calculated. Clinician-perceived benefits from participating in interprofessional team meetings included increased acquisition of knowledge, access to other clinicians, collaborative decision-making, patient satisfaction, and achievement of patient-centered goals. Participants described the importance of preparing an agenda for the interprofessional team meetings in advance, but a major implementation challenge was the time required to prepare for and conduct the meetings. Commitment and financial support by organization and program leadership were reported as key facilitators to implementing the meetings. Clinicians perceive significant value from incorporation of interprofessional team meetings into an intensive lifestyle medicine program, but successful implementation of meetings requires investment from all levels within a healthcare system.

Arthritis Foundation/HSS Workshop on Hip Osteoarthritis, Part 3: Rehabilitation and Exercise.

Far more publications are available for osteoarthritis of the knee than of the hip. Recognizing this research gap, the Arthritis Foundation (AF), in partnership with the Hospital for Special Surgery (HSS), convened an in-person meeting of thought leaders to review the state of the science of and clinical approaches to hip osteoarthritis. This article summarizes the recommendations gleaned from 5 presentations given on hip-related rehabilitation at the 2023 Hip Osteoarthritis Clinical Studies Conference, which took place on February 17 and 18, 2023, in New York City.

Relationship of Chronic Systemic Inflammation to Both Chronic Lifestyle-Related Diseases and Osteoarthritis: The Case for Lifestyle Medicine for Osteoarthritis.

Systemic inflammation is a root cause of lifestyle-related chronic diseases and may also play a role in the development and progression of osteoarthritis (OA). Lifestyle medicine seeks to treat, prevent, and reverse lifestyle-related chronic disease via 6 pillars: nutrition, sleep health, stress management, physical activity, social connections, and risky behavior avoidance/reduction. This article presents a review of the literature in which we assess the connections between the 6 pillars of lifestyle medicine, chronic systemic inflammation, and OA. We also discuss the whole-person approach that lifestyle medicine interventions can provide to reduce chronic systemic inflammation and affect the development or progression of OA.

Evaluation of sleep health documentation and sleep-related intervention by physiatrists treating musculoskeletal disorders: A retrospective investigation.

BACKGROUND: Sleep health is linked to pain, function, and global health. Unfortunately, sleep health may not be consistently addressed as a part of musculoskeletal care. OBJECTIVE: To describe the frequency of sleep health documentation and intervention by musculoskeletal physiatrists. Additionally, patient-reported outcome measures were compared between patients with and without sleep impairment. We hypothesized that sleep health is documented and addressed in less than half of initial patient encounters and that patients with a sleep impairment have worse patient-reported outcomes scores compared to those without sleep impairment. DESIGN: Retrospective study. SETTING: Tertiary orthopedic hospital. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Frequency of provider documentation of sleep health, frequency and characteristics of sleep health intervention provided, and Patient-Reported Outcome Measurement Information System (PROMIS)-10 mental health and physical health scores. RESULTS: Initial visits for a musculoskeletal condition of 39,452 patients from January 1, 2020 to October 1, 2022 were included. Documentation of sleep health was found in 33.0% (13,002/39,452) of patients. Of those with sleep health documentation, 59.2% (7697/13,002) were classified as having a sleep impairment. Only 19.0% of patients were provided with sleep-related education or other intervention. Patients with a sleep impairment had worse PROMIS-10 mental health and physical health scores (p < .001), as compared to those without a sleep impairment. CONCLUSIONS: Patients with sleep impairment had worse mental and physical health scores than those without sleep impairment, and only 19.0% received sleep health intervention. These data suggest that sleep impairment is common in patients presenting for evaluation of a musculoskeletal condition, and advanced provider education and tools to help patients improve their sleep health are needed.

Golfing after Orthopaedic Surgery: A longitudinal follow-up (GOLF) study protocol.

Aims: The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. Methods: This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undertaken of arthroplasty patients at both sites. Conclusion: The results of this prospective study will provide clinicians with accurate data to deliver to patients with regard to the likelihood of return to golf and timing of when they can expect to return to golf following their hip, knee, ankle, or shoulder arthroplasty, as well as their joint-specific functional outcomes. This will help patients to manage their postoperative expectations and plan their postoperative recovery pathway.

The Women's Soccer Health Study: From Head to Toe.

OBJECTIVES: Women are under-represented in the sports literature despite increasing rates of sports participation. Our objective was to investigate the risks and benefits of an elite women's soccer career in five health domains: general, musculoskeletal, reproductive endocrinology, post-concussion, and mental. METHODS: An online survey was distributed to retired US college, semi-professional, professional, and national team soccer players using personal networks, email, and social media. Short validated questionnaires were used to evaluate the health domains, including the Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numerical Evaluation (SANE), Post-Concussion Symptom Scale (PCSS), and Patient Health Questionnaire (PHQ). RESULTS: A total of 560 eligible players responded to the survey over a 1-year period. The highest competitive levels were 73% college, 16% semi-professional, 8% professional, and 4% national team. The mean number of years since retirement was 12 (SD = 9), and 17.0% retired for involuntary reasons. The mean SANE scores (0-100 scale as percentage of normal) were knee = 75% (SD = 23), hip = 83% (SD = 23), and shoulder = 87% (SD = 21). The majority (63%) reported that their current activity level included participation in impact sports. A substantial proportion of players reported menstrual irregularities during their careers: 40% had fewer periods with increasing exercise and 22% had no periods for ≥ 3 months. The players (n = 44) who felt that post-concussion symptoms were due to soccer reported more time-loss concussions (F[2] = 6.80, p = 0.002) and symptom severity (F[2] = 30.26, p < 0.0001). Players who recently retired (0-5 years) reported the highest anxiety/depression scores and lowest satisfaction rates compared with those who retired 19+ years ago. CONCLUSION: Health concerns include musculoskeletal injuries, post-concussion symptoms, and lower mental health in the early years following retirement. This comprehensive survey provides initial results that will lay the foundation for further analyses and prioritize research studies that can help all female athletes.

What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.

Musculoskeletal exercise: Its role in promoting health and longevity.

Resistance training (RT) is an often ignored but essential component of physical health. The functioning of the musculoskeletal system declines with age, resulting in sarcopenia, loss of muscle strength and power, decrease in muscle flexibility and balance. Other pertinent age-related changes include decline in basal metabolic rate, increase in fat mass, and decrease in bone mineral density. Such primary aging can be accentuated by the concomitant presence of comorbid conditions, such as insulin resistance and diabetes, obesity, inflammatory conditions, and physical inactivity (PI). The latter is often promoted by the presence of musculoskeletal conditions, such as osteoarthritis, back pain, and osteoporosis, which are quite common in society. RT can diminish long-term joint stress, "resist" age-related physiological deterioration and improve health outcomes through its ability to increase muscle strength and mass, balance the distribution of forces within a joint, increase basal metabolic rate and bone density, reduce body fat and cardiac risk factors, enhance endothelial function, and promote cognitive function and psychological well-being. Accordingly, health providers should screen for PI, lack of RT, and mobility risks using short screening questions, and employ simple functional tests, when indicated, to evaluate patients for impairment in gait, muscle strength, flexibility, and balance. This review also provides general principles for initiating and conducting RT and provides general and specific examples of resistance training programs, which should be individualized for patients through the evaluation and guidance by appropriate health providers, physical therapists, and certified trainers.

Interpretation of PROMIS Depression and Anxiety Measures Compared with DSM-5 Diagnostic Criteria in Musculoskeletal Patients.

There is growing awareness among orthopaedic clinicians that mental health directly impacts clinical musculoskeletal outcomes. The Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly used for mental health screening in this context, but proper interpretation of patient scores remains unclear. The purpose of the present study was to compare musculoskeletal patients' PROMIS Depression and Anxiety scores with a board-certified clinical psychologist's assessment of their depression and/or anxiety diagnoses, as defined by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Methods: In this cross-sectional analysis, existing medical records were reviewed for 50 patients who presented to an interdisciplinary program within a tertiary care orthopaedic department for the treatment of ≥1 musculoskeletal condition. All patients completed PROMIS Depression and Anxiety measures and were evaluated by a board-certified clinical psychologist. Receiver operating characteristic (ROC) curve analyses were performed to assess the diagnostic accuracy of PROMIS Depression and Anxiety scores as compared with the psychologist's diagnosis of a DSM-5 depressive or anxiety disorder. Results: Twenty-eight patients (56%) were diagnosed by the psychologist with a DSM-5 depressive disorder, and 15 (30%) were diagnosed with a DSM-5 anxiety disorder. The ROC analysis for PROMIS Depression had an area under the curve (AUC) of 0.82. The optimal score cutoff to predict a diagnosis of a DSM-5 depressive disorder was ≥53 (sensitivity, 79% [95% CI, 63% to 94%]; specificity, 86% [72% to 100%]; positive predictive value [PPV], 88% [75% to 100%]; negative predictive value [NPV], 76% [59% to 93%]). The ROC analysis for PROMIS Anxiety had an AUC of 0.67. The optimal score cutoff to predict a diagnosis of a DSM-5 anxiety disorder was ≥59 (sensitivity, 60% [95% CI, 35% to 85%]; specificity, 74% [60% to 89%]; PPV, 50% [27% to 73%]; and NPV, 81% [68% to 95%]). Conclusions: Modestly elevated PROMIS Depression scores were suggestive of the presence of a DSM-5 depressive disorder, whereas elevations in PROMIS Anxiety scores seemed to have less association with DSM-5 anxiety disorders. Nevertheless, neither PROMIS measure demonstrated adequate discriminant ability to definitively identify patients who met DSM-5 criteria. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions in the setting of lifestyle-related chronic disease.

BACKGROUND: Lifestyle factors are associated with musculoskeletal pain and metabolic chronic diseases. To date, intensive lifestyle medicine programs have predominantly targeted metabolic rather than musculoskeletal conditions. OBJECTIVE: To assess the feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions. DESIGN: Prospective observational feasibility study. SETTING: Tertiary academic medical center. PATIENTS: Adults diagnosed with musculoskeletal condition(s) and lifestyle-related chronic disease(s) who previously completed standard-of-care musculoskeletal treatments, enrolled from 2018 to 2020. INTERVENTIONS: Patients enrolled in an intensive interprofessional lifestyle medicine program led by a physiatrist, with options to interface with an acupuncturist, dietician, massage therapist, psychologist, physical therapist, and smoking cessation specialist. The physiatrist engaged in shared decision making with patients to establish program goals related to function, overall health, and required lifestyle changes. Bimonthly interprofessional team conferences facilitated communication between treatment team and patients. MAIN OUTCOME MEASURES: Feasibility was measured by patient participation and goal attainment. Secondary outcomes included changes from program enrollment to discharge in patient anthropometric, metabolic lab, sleep apnea risk, and Patient-Reported Outcomes Measurement Information System (PROMIS) function, pain, and behavioral health measures. RESULTS: Twenty-six patients enrolled in the program (18 [69%] female, mean age 59 [SD 14.5] years, baseline hemoglobin A1c 6.0% [0.8%], high-sensitivity C-reactive protein 7.7 [12.1] mg/dL, 25-hydroxy vitamin D 32.0 [14.2] ng/mL). Of 21 (81%) patients who completed the program, 13/21 (62%) met their goal. On average, program completers presented for 26.2 (10.6) total visits over 191 (88) days. By discharge, program completers achieved clinically meaningful improvement in PROMIS Anxiety (mean difference -3.5 points, 95% confidence interval [-6.5 to 0.5], p = .035), whereas noncompleters did not (p > .05). CONCLUSIONS: An intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions is feasible. With training in lifestyle intervention, physiatrists are well suited to lead interprofessional teams aimed at assisting patients in making lifestyle changes to achieve personalized function- and health-related goals.

Rate and Timing of Return to Golf After Hip, Knee, or Shoulder Arthroplasty: A Systematic Review and Meta-analysis.

BACKGROUND: The physical and mental health benefits of golf are well recognized, and as a moderate-intensity activity, it is an ideal sport for patients after joint arthroplasty. PURPOSE: To assess the rate and timing of returning to golf and the factors associated with these after hip, knee, or shoulder arthroplasty. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A search of PubMed and Medline was performed in March 2021 in line with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Search terms included sport, golf, and arthroplasty. The criterion for inclusion was any published research article studying return to golf after arthroplasty. Random-effects modeling was used to measure rates of returning to golf for each type of arthroplasty. RESULTS: A total of 23 studies were included for review. All studies were retrospective in their methodology. The mean age of patients was 66.8 years (SD, 3.37). Four studies reported on hip arthroplasty, 6 on knee arthroplasty, and 13 on shoulder arthroplasty. Among 13 studies, the mean rate of returning to golf was 80% (95% CI, 70%-89.9%). Hip, knee, and shoulder arthroplasty had mean return rates of 90% (95% CI, 82%-98%), 70% (95% CI, 39%-100%), and 80% (95% CI, 68%-92%), respectively. Among 9 studies, the mean time to return to golf was 4.4 months (95% CI, 3.2-6). Change in handicap was reported in 8 studies (35%) with a mean change of -0.1 (95% CI, -2.4 to +2.2). There were no studies presenting factors associated with return to golf. CONCLUSION: This is the first meta-analysis of returning to golf after joint arthroplasty. The study reports a high rate of returning to golf, which was greatest after hip arthroplasty. However, the study highlights the paucity of prospective data on demographic, surgical, and golf-specific outcomes after arthroplasty. Future prospective studies are required to eliminate response bias and accurately capture golf and patient-specific outcomes.

An audit of structure-based medical acupuncture by a single provider in patients with musculoskeletal pain using PROMIS scores as the outcome.

BACKGROUND: To assess whether structure-based medical acupuncture (SMA) can improve Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients presenting with musculoskeletal pain. METHODS: An audit was conducted of all patients presenting with musculoskeletal pain treated by a single provider with SMA in 2017. Inclusion criteria included a pre-treatment and at least one post-treatment PROMIS score. Patient demographics and previous treatments tried were recorded. Documented events other than acupuncture that were thought to interfere with PROMIS scores were recorded, and no further scores were used after these events. A maximum of nine visits after the initial visit were used. The PROMIS domains assessed included anxiety, depression, pain interference and physical function. RESULTS: Seventy-two patients who had been treated with SMA met the inclusion criteria. Sixty-five of the patients (90%) had chronic pain. For their presenting complaint, 59 (82%) had previously sought treatment from another non-operative provider, 60 (83%) had tried physical therapy, and 20 (28%) had even had surgery. Despite this, SMA appeared to be able to significantly improve PROMIS anxiety at visits 1-3 and PROMIS depression at visit 3. After just one treatment, minimal clinically important differences (MCID) were reached in 32%-44% of patients for PROMIS anxiety, 17%-36% for PROMIS depression, 28%-29% for PROMIS physical function, and 21%-36% for PROMIS pain interference, based on low and high cut-offs of a range of quoted MCID values. CONCLUSION: In a difficult patient population with musculoskeletal pain, SMA is a technique that can likely be used to improve PROMIS anxiety and depression, although no firm conclusions can be drawn from this uncontrolled clinical audit. Of note, MCIDs were sometimes obtained even after just one treatment.

Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain.

INTRODUCTION: Factors that motivate musculoskeletal patients to pursue an intensive, lifestyle medicine-based approach to care are poorly understood. OBJECTIVE: To determine whether, compared to patients seeking musculoskeletal care through traditional pathways, patients who choose an intensive lifestyle medicine program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and/or more biopsychosocial comorbidities. DESIGN: Cross-sectional analysis of existing medical records from 2018 to 2021. SETTING: Orthopedic department of one academic medical center. PATIENTS: Fifty consecutive patients who enrolled in an intensive lifestyle medicine program to address a musculoskeletal condition. Comparison groups were the following: (1) 100 patients who presented for standard nonoperative musculoskeletal care, and (2) 100 patients who presented for operative evaluation by an orthopedic surgeon and qualified for joint arthroplasty. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Primary outcomes were age-adjusted, between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS) physical and psychological health measures. Secondary outcomes were between-group differences in sociodemographic and medical history characteristics. RESULTS: Patients who enrolled in the intensive lifestyle medicine program were more racially diverse (non-White race: lifestyle cohort 34% vs. comparison cohorts 16%-18%, p ≤ .029) and had a higher prevalence of obesity and diabetes than both comparison groups (mean body mass index: lifestyle cohort 37.6 kg/m2 vs. comparison cohorts 29.3-32.0, p < .001; diabetes prevalence: lifestyle cohort 32% vs. comparison cohorts 12%-16%, p ≤ .024). Compared to standard nonoperative patients, there were no clear between-group differences in PROMIS physical or psychological health scores. Compared to standard operative evaluation patients, patients in the lifestyle program reported worse anxiety but less pain interference (PROMIS Anxiety: B = 3.8 points [95% confidence interval, 0.1 to 7.4], p = .041; Pain interference: B = -3.6 [-6.0 to -1.2], p = .004). CONCLUSIONS: Compared to musculoskeletal patients who sought care through traditional pathways, patients who chose an intensive lifestyle medicine pathway had a higher prevalence of metabolic comorbidities, but there was substantial overlap in patients' physical, psychological, and sociodemographic characteristics.

Rate of continued conservative management versus progression to surgery at minimum 1-year follow-up in patients with pre-arthritic hip pain.

BACKGROUND: Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. OBJECTIVE: To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum 1-year follow-up. DESIGN: Retrospective cohort study. SETTING: Single tertiary care academic medical center. PATIENTS: Patients ages 13 to 40 years who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n = 713 patients, 830 hips). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The primary outcome was the rate of progression to surgery at minimum 1-year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. RESULTS: In a cohort with a mean age of 25.4 (SD 8.1) years, 72.7% female, and mean follow-up of 2.6 (range 1.0-4.8) years, 429 of 830 hips (51.7%, 95% confidence interval [CI] 48.2% to 55.1%) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year, 95% CI 0.93 to 0.98), pain duration longer than 6 months (ORs 1.87-2.03, p ≤ .027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System [PROMIS] point, 0.92 to 0.99), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47, 2.05 to 5.89), acetabular dysplasia (OR 2.75, 1.73 to 4.35), and/or labral tear (OR 10.71, 6.98 to 16.47). Radiographic dysplasia (lateral center edge angle <20 degrees) increased the likelihood of surgery in all subgroups (ORs 2.05-8.47, p ≤ .008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α > 63 degrees) (OR 1.03/degree, 1.00 to 1.06). CONCLUSION: Almost half of patients with pre-arthritic hip pain did not progress to surgery at a minimum 1-year follow-up. A trial of conservative management is likely worthwhile in most patients.

How Should We Measure Social Deprivation in Orthopaedic Patients?

BACKGROUND: Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions. QUESTIONS/PURPOSES: (1) Which measure of social deprivation, defined as "limited access to society's resources due to poverty, discrimination, or other disadvantage," is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture? METHODS: Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful. RESULTS: Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains. CONCLUSION: To capture the most variability due to social deprivation in orthopaedic patients' self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider accounting for insurance classification and/or national Area Deprivation Index, both of which are freely available and can be obtained from data that are typically collected during routine clinical care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Opioid use and social disadvantage in patients with chronic musculoskeletal pain.

BACKGROUND: Historically, marginalized patients were prescribed less opioid medication than affluent, white patients. However, because of persistent differential access to nonopioid pain treatments, this direction of disparity in opioid prescribing may have reversed. OBJECTIVE: To compare social disadvantage and health in patients with chronic pain who were managed with versus without chronic opioid therapy. It was hypothesized that patients routinely prescribed opioids would be more likely to live in socially disadvantaged communities and report worse health. DESIGN: Cross-sectional analysis of a retrospective cohort defined from medical records from 2000 to 2019. SETTING: Single tertiary safety net medical center. PATIENTS: Adult patients with chronic musculoskeletal pain who were managed longitudinally by a physiatric group practice from at least 2011 to 2015 (n = 1173), subgrouped by chronic (≥4 years) adherent opioid usage (n = 356) versus no chronic opioid usage (n = 817). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The primary outcome was the unadjusted between-group difference in social disadvantage, defined by living in the worst national quartile of the Area Deprivation Index (ADI). An adjusted effect size was also calculated using logistic regression, with age, sex, race, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Physical Function scores as covariates. Secondary outcomes included adjusted differences in health by chronic opioid use (measured by PROMIS). RESULTS: Patients managed with chronic opioid therapy were more likely to live in a zip code within the most socially disadvantaged national quartile (34.9%; 95% confidence interval [CI] 29.9-39.9%; vs. 24.9%; 95% CI 21.9-28.0%; P < .001), and social disadvantage was independently associated with chronic opioid use (odds ratio [OR] 1.01 per ADI percentile [1.01-1.02]). Opioid use was also associated with meaningfully worse PROMIS Depression (3.8 points [2.4-5.1]), Anxiety (3.0 [1.4-4.5]), and Pain Interference (2.6 [1.7-3.5]) scores. CONCLUSIONS: Patients prescribed chronic opioid treatment were more likely to live in socially disadvantaged neighborhoods, and chronic opioid use was independently associated with worse behavioral health. Improving access to multidisciplinary, nonopioid treatments for chronic pain may be key to successfully overcoming the opioid crisis.

The Influence of Race, Sex, and Social Disadvantage on Self-reported Health in Patients Presenting With Chronic Musculoskeletal Pain.

OBJECTIVE: The aim of the study was to better address sociodemographic-related health disparities. This study examined which sociodemographic variables most strongly correlate with self-reported health in patients with chronic musculoskeletal pain. DESIGN: This single-center, cross-sectional study examined adult patients, followed by a physiatrist for chronic (≥4 yrs) musculoskeletal pain. Sociodemographic variables considered were race, sex, and disparate social disadvantage (measured as residential address in the worst vs. best Area Deprivation Index national quartile). The primary comparison was the adjusted effect size of each variable on physical and behavioral health (measured by Patient-Reported Outcomes Measurement Information System [PROMIS]). RESULTS: In 1193 patients (age = 56.3 ± 13.0 yrs), disparate social disadvantage was associated with worse health in all domains assessed (PROMIS Physical Function Β = -2.4 points [95% confidence interval = -3.8 to -1.0], Pain Interference = 3.3 [2.0 to 4.6], Anxiety = 4.0 [1.8 to 6.2], and Depression = 3.7 [1.7 to 5.6]). Black race was associated with greater anxiety than white race (3.2 [1.1 to 5.3]), and female sex was associated with worse physical function than male sex (-2.5 [-3.5 to -1.5]). CONCLUSIONS: Compared with race and sex, social disadvantage is more consistently associated with worse physical and behavioral health in patients with chronic musculoskeletal pain. Investment to ameliorate disadvantage in geographically defined communities may improve health in sociodemographically at-risk populations.