Factors Associated With Long-Term Quadriceps Muscle Function After Surgical Fixation of Lower Extremity Fractures.

OBJECTIVE: The long-term performance of the quadriceps femoris muscle and physical function following surgical repair of a lower extremity fracture remains largely undefined. The purpose of this study was to investigate between-limb differences in quadriceps performance 12 months after surgical fixation of a lower extremity fracture. It was hypothesized that the injured limb would be significantly weaker, have a lower rate of torque development (RTD), and that there would be a reduced step-down performance compared to the uninjured limb 12 months after surgery. Additionally, this study sought to identify demographic, surgical, and psychological factors associated with poor quadriceps function 12 months after surgery. METHODS: Quadriceps performance was measured bilaterally in 95 participants (49 female), aged 42 (SD = 14.5) years, 12 months after surgical fixation of a lower extremity fracture. Isometric quadriceps strength and RTD were quantified using isometric dynamometry, and a timed step-down test was used to evaluate quadriceps performance. Independent predictor variables from the time of surgery were extracted from participants' medical records. Kinesiophobia was screened at the time of testing. Wilcoxon signed-rank tests and linear regression analyses were used to assess between-limb differences in quadriceps performance and to determine factors associated with quadriceps performance 12 months after surgery. RESULTS: Significant between-limb differences in each measure of quadriceps performance were identified (peak torque involved: 1.37 [0.71] Nm × kg-1; uninvolved: 1.87 [0.74] Nm × kg-1; RTD involved: 4.16 [2.75] Nm × kg-1 × s-1; uninvolved: 6.10 [3.02] Nm × kg-1 × × -1; and single-leg step-downs involved: 12.6 [5.0]; uninvolved: 21.7 [14.8]). Female biological sex, external fixation, and kinesiophobia at 12 months were associated with reduced after-surgery quadriceps performance outcomes. CONCLUSION: Quadriceps performance is impaired 12 months after surgical repair of a lower extremity fracture, particularly in female participants, in cases requiring external fixation, and in those with higher kinesiophobia 12 months after surgery. IMPACT: Because long-term quadriceps weakness negatively impacts functional mobility, targeted strengthening should be emphasized after surgical repair of lower extremity fracture.

Beyond yellow flags: The Big-Five personality traits and psychologically informed musculoskeletal rehabilitation.

BACKGROUND: Psychosocial variables are known to play an important role in musculoskeletal pain. Recent efforts incorporating psychological theory into rehabilitative medicine, as part of patient-centred care or psychologically informed physical therapy, have gained broader acceptance. The fear-avoidance model is the dominant psychosocial model and has introduced a variety of phenomena which assess psychological distress (i.e., yellow flags). Yellow flags, such as fear, anxiety and catastrophizing, are useful concepts for musculoskeletal providers but reflect a narrow range of psychological responses to pain. OBJECTIVE: Clinicians lack a more comprehensive framework to understand psychological profiles of each patient and provide individualised care. This narrative review presents the case for applying personality psychology and the Big-Five trait model (extraversion, agreeableness, conscientiousness, neuroticism and openness to experience) to musculoskeletal medicine. These traits have strong associations with various health outcomes and provide a robust framework to understand patient emotion, motivation, cognition and behaviour. KEY RESULTS: High conscientiousness is associated with positive health outcomes and health promoting behaviours. High neuroticism with low conscientiousness increases the odds of negative health outcomes. Extraversion, agreeableness and openness have less direct effects but have positive correlations with important health behaviours, including active coping, positive affect, rehabilitation compliance, social connection and education level. CLINICAL APPLICATION: The Big-Five model offers an evidence-based way for MSK providers to better understand the personality of their patients and how it relates to health. These traits offer the potential for additional prognostic factors, tailored treatments and psychological intervention.

Psychosocial Predictors of Chronic Pain 12 Months After Surgical Fixation for Lower Extremity Fracture: A Prospective Study.

OBJECTIVE: Pain is a common outcome after lower extremity fracture (LEF) requiring surgical fixation. Although psychosocial characteristics have meaningful associations with adverse outcomes, no studies have evaluated how psychosocial characteristics throughout recovery are associated with pain outcomes. The primary purpose of this study was to determine whether psychosocial characteristics are early risk factors for pain outcomes in patients following LEF who have no history of chronic pain. METHODS: Participants, 122 patients with a LEF, consented to this single-center, prospective cohort study. Measurements of depression, pain self-efficacy, pain catastrophizing, and fear of movement were completed at 1 week, 6 weeks, 3 months, 6 months, and 12 months after LEF. Chronic pain development and pain intensity were assessed at 12 months. Univariate analyses assessing the difference between means and corresponding effect sizes were evaluated between those individuals with and without chronic pain at 12 months. Separate logistic and linear regression models using psychosocial scores at each time point were used to determine the association with the development of chronic pain and pain intensity, respectively. RESULTS: Of 114 patients (93.4%) who completed the study, 51 (45%) reported chronic pain at 12 months. In the univariate analysis, all psychosocial variables at 6 weeks, 3 months, 6 months, and 12 months were significantly different between those with and those without chronic pain at 12 months (Cohen d range = 0.84 to 1.65). In the multivariate regression models, all psychosocial variables at 6 weeks, 3 months, and 6 months were associated with chronic pain development (odds ratio range = 1.04 to 1.22) and pain intensity (ß range = .05 to .14) at 12 months. CONCLUSION: Psychosocial scores as early as 6 weeks after surgery are associated with pain outcomes 12 months after LEF. IMPACT: Physical therapists should consider adding psychosocial screening throughout recovery after LEF to identify patients at increased risk for long-term pain outcomes.

Early Pain Catastrophizing Exacerbates Impaired Limb Loading and 6-Minute Walk Test Distance 12 Months After Lower Extremity Fracture.

OBJECTIVE: Disability is common after lower extremity fracture (LEF). Although psychosocial factors have been associated with patient-reported outcomes after LEF, they have not been associated with objective measures of function. Aberrant gait patterns are important markers of function, but are poorly defined after LEF. The primary purpose of this study was to explore whether pain catastrophizing and fear of movement 6 weeks after surgery were associated with injured limb loading outcomes and 6-minute walk test (6MWT) distance 12 months after femur or tibia fracture. The secondary purpose was to determine if limb loading characteristics differed between injured and uninjured limbs. METHODS: At 6 weeks after LEF, patients completed validated measures of pain catastrophizing, fear of movement, and depression. At 12 months, patients completed a 6MWT while wearing instrumented insoles that recorded the limb loading outcomes of stance time, impulse, and loading rate. Bivariate correlations assessed how patient and psychosocial characteristics at 6 weeks were associated with injured limb loading outcomes and 6MWT distance. Multivariable regression analyses were performed to determine if psychosocial variables were associated with each outcome after controlling for depression and patient demographic and clinical characteristics. Finally, paired t tests compared limb loading outcomes between limbs. RESULTS: Forty-seven participants completed the 6MWT at 12 months (65%), and 38 completed the 6MWT with the instrumented insoles. Fear of movement carried a poor relationship (r = 0.11-0.32) and pain catastrophizing a moderate relationship (r = 0.46-0.54) with 12-month outcomes. The regression results indicated that pain catastrophizing continued to be associated with all outcomes. Finally, the injured limb had significantly lower limb loading outcomes than the uninjured limb at 12 months (Cohen d = 0.54-0.69). CONCLUSION: Pain catastrophizing early after LEF was associated with impaired limb loading and 6MWT distance at 12 months. IMPACT: Impaired limb loading persists 12 months after LEF. Further research is needed to determine whether rehabilitative efforts focused on pain catastrophizing can restore limb loading after LEF.

STarT-Lower Extremity Screening Tool at Six-weeks Predicts Pain and Physical Function 12-months after Traumatic Lower Extremity Fracture.

BACKGROUND: Patients with lower extremity fracture requiring surgical fixation often have poor long-term pain and disability outcomes. This indicates the need for a risk stratification tool that can inform patient prognosis early in recovery. The purpose of this study was to determine the predictive validity of the STarT-Lower Extremity Screening Tool (STarT-LE) in patients with lower extremity fracture requiring surgical fixation. MATERIALS AND METHODS: One-hundred and twenty-two patients (41.7 ± 14.7 years, 54% male) with lower extremity fracture and no history of chronic pain were enrolled in this prospective cohort study. Patients completed the STarT-LE Screening Tool six-weeks after definitive fixation. Validated measures of chronic pain development, pain interference, and physical function were collected at 12-months. STarT-LE low, medium, and high risk subgroups were compared against each outcome measure with chi-square, one-way analysis of variance, and sensitivity and specificity analyses. Multivariable linear regression analyses determined if STarT-LE risk subgroups at six weeks were associated with each outcome at 12 months when controlling for important baseline demographics. RESULTS: Twelve-month follow-up was completed by 114 patients (93.4%). Increase in STarT-LE risk subgroup at six-weeks was associated with higher frequency of chronic pain (Low: 14.7%, Medium: 48.3%, High: 85.0%), worse pain interference (Low: 48.6 ± 8.88, Medium: 56.33 ± 8.79, High: 61.65 ± 7.74), and worse physical function (Low: 50.77 ± 9.89, Medium: 42.52 ± 6.47, High: 37.44 ± 7.46) at 12-months. The low risk subgroup had high sensitivity (range: 84.9%-93.9%) and the high risk subgroup had high specificity (range: 87.7%-95.2%) for dichotomized 12-month outcomes. The multivariable results showed that medium and high STarT-LE risk categories were associated with chronic pain development (Medium odds ratio: 3.90, 95%CI: 1.11 to 13.66; High odds ratio: 13.14, 95%CI: 2.25 to 76.86), worse pain interference (Medium: ß:4.37, 95%CI: 0.17 to 8.58; High: ß:7.01, 95%CI: 1.21 to 12.81), and worse physical function (Medium: ß:-3.76, 95%CI: -7.41 to -0.11; ß:-7.44, 95%CI:-12.47 to -2.41), respectively, when controlling for important baseline variables. CONCLUSION: The STarT-LE has the potential to identify patients at-risk for poor pain and functional outcomes, and may help inform the post-surgical management of patients with traumatic LE injury.

Quadriceps Strength and Kinesiophobia Predict Long-Term Function After ACL Reconstruction: A Cross-Sectional Pilot Study.

BACKGROUND: Many patients live with long-term deficits in knee function after an anterior cruciate ligament reconstruction (ACLR). However, research is inconclusive as to which physical performance measure is most strongly related to long-term patient-reported outcomes after ACLR. HYPOTHESIS: Quadriceps strength would be most strongly associated with patient-reported long-term outcomes after ACLR. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 40 patients (29 female) consented and participated an average of 10.9 years post-ACLR (range, 5-20 years). Patients completed the Lower Extremity Functional Scale (LEFS), the International Knee Documentation Committee (IKDC) Scale, Knee injury and Osteoarthritis Outcome Score Quality of Life (KOOS QoL) and Sport (KOOS Sport) subscales, and the Tampa Scale of Kinesiophobia (TSK-17). Each patient subsequently performed maximal isometric quadriceps contraction, a 60-second single-leg step-down test, and the single-leg single hop and triple hop for distance tests. Multivariate linear and logistic regression models determined how performance testing was associated with each patient-reported outcome when controlling for time since surgery, age, and TSK-17. RESULTS: When controlling for time since surgery, age at the time of consent, and TSK-17 score, maximal isometric quadriceps strength normalized to body weight was the sole physical performance measure associated with IKDC (P < 0.001), KOOS Sport (P = 0.006), KOOS QoL (P = 0.001), and LEFS scores (P < 0.001). Single-leg step-down, single hop, and triple hop did not enter any of the linear regression models (P > 0.20). Additionally, TSK-17 was associated with all patient-reported outcomes (P ≤ 0.01) while time since surgery was not associated with any outcomes (P > 0.05). CONCLUSION: Isometric quadriceps strength and kinesiophobia are significantly associated with long-term patient-reported outcomes after ACLR. CLINICAL RELEVANCE: These results suggest that training to improve quadriceps strength and addressing kinesiophobia in the late stages of recovery from ACLR may improve long-term self-reported function.

Reliability and Validity Evidence of the STarT-Lower Extremity Screening Tool for Patients With Lower Extremity Fracture: A Prospective Study.

OBJECTIVES: To determine whether a modified version of the STarT Back Screening Tool in its current structure has adequate properties for use in patients with lower extremity fracture. DESIGN: Single-center, prospective study. SETTING: Level I trauma center. PARTICIPANTS: Patients with lower extremity fracture without a history of chronic pain (N=114), with 93% follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six weeks after surgical fixation, individuals completed the Subgroups for Targeted Treatment of Lower Extremity Screening Tool (STarT-LE). A subsample completed the STarT-LE again 1 week later. The following questionnaires were completed at 6 weeks and 6 months: Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Brief Pain Inventory pain intensity subscale, and PROMIS Depression and Pain Interference computer adaptive testing modules. Reliability was evaluated using intraclass correlation coefficients (ICC) and Cronbach's alpha (α). Convergent validity evidence was measured concurrently using the Spearman ρ correlation between the 6-week STarT-LE and established questionnaires. Predictive validity evidence was evaluated by area under the curve analysis (AUC) using the 6-week STarT-LE total and psychosocial scores and 6-month criterion physical and psychosocial reference standards. RESULTS: The STarT-LE has good test-retest reliability (ICC, 0.85; 95% confidence interval, 0.78-0.91) and acceptable internal consistency (α=0.74). The convergent validity evidence was fair to moderate (ρ, 0.53-0.68; P<.001) and the predictive validity evidence was acceptable to excellent (AUC, 0.73-0.84). CONCLUSIONS: The STarT-LE has adequate properties for use in patients with lower extremity fracture. Future larger scale studies are needed to validate risk cutoffs.

Abdominal aortic aneurysm in a patient with low back pain.

STUDY DESIGN: Resident's case problem. BACKGROUND: The purpose of this report was to describe (1) the clinical reasoning that led a clinician to identify an abdominal aortic aneurysm (AAA) in a patient with low back pain requiring immediate medical referral, and (2) an evidence-based approach to clinical evaluation of patients with suspected AAA. DIAGNOSIS: The patient was unable to identify a specific mechanism of injury for his low back pain, lacked aggravating/easing factors for his symptoms, and complained of night pain and an inability to ease his symptoms with position changes. While the patient's symptoms remained unchanged during physical examination of the lumbar spine and hip, abdominal palpation revealed a strong, nontender pulsation over the midline of the upper and lower abdominal quadrants. Due to concern for an AAA, the patient was immediately referred to his physician. Subsequent computed tomography imaging revealed a prominent AAA, which measured up to 5.5 cm in greatest dimension and extended from below the renal arteries to the bifurcation of the iliac arteries. The patient initially deferred surgical intervention but eventually consented 6 months later, after repeat computed tomography imaging revealed that the AAA had progressed to 6.7 cm in greatest dimension. DISCUSSION: It is essential for physical therapists to be familiar with a diagnostic pathway to help identify AAA in patients presenting with apparent musculoskeletal complaints. Knowledge of the risk factors for AAA, understanding how to screen for nonmusculoskeletal symptoms, and a basic competence in abdominal palpation and how to interpret findings will help with the clinician's clinical decision making. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2014;44(7):500-507. Epub 25 April 2014. doi:10.2519/jospt.2014.4935.

Predictors of web-based follow-up response in the Prevention Of Low Back Pain In The Military Trial (POLM).

BACKGROUND: Achieving adequate follow-up in clinical trials is essential to establish the validity of the findings. Achieving adequate response rates reduces bias and increases probability that the findings can be generalized to the population of interest. Therefore, the purpose of this study was to determine the influence of attention, demographic, psychological, and health status factors on web-based response rates in the ongoing Prevention of Low Back Pain in the Military (POLM) trial. METHODS: Twenty companies of Soldiers (n = 4,325) were cluster randomized to complete a traditional exercise program including sit-ups (TEP) with or without a psychosocial educational program (PSEP) or a core stabilization exercise program (CSEP) with or without PSEP. A subgroup of Soldiers (n = 371) was randomized to receive an additional physical and ultrasound imaging (USI) examination of key trunk musculature. As part of the surveillance program, all Soldiers were encouraged to complete monthly surveys via email during the first year. Descriptive statistics of the predictor variables were obtained and compared between responders and non-responders using two sample t-tests or chi-square test, as appropriate. Generalized linear mixed models were subsequently fitted for the dichotomous outcomes to estimate the effects of the predictor variables. The significance level was set at .05 a priori. RESULTS: The overall response rate was 18.9% (811 subjects) for the first year. Responders were more likely to be older, Caucasian, have higher levels of education and income, reservist military status, non smoker, lower BMI, and have received individualized attention via the physical/USI examination (p < .05). Age, race/ethnicity, education, military status, smoking history, BMI, and whether a Soldier received the physical/USI examination remained statistically significant (p < .05) when considered in a full multivariate model. CONCLUSION: The overall web based response rate during the first year of the POLM trial was consistent with studies that used similar methodology, but lower when compared to rates expected for standard clinical trials. One year response rate was significantly associated with demographic characteristics, health status, and individualized attention via additional testing. These data may assist for planning of future trials that use web based response systems. TRIAL REGISTRATION: This study has been registered at reports at http://clinicaltrials.gov (NCT00373009).