Minimal Clinically Important Differences in Hand Pain Intensity (Numerical Pain Rate Scale) and Related-Function (Boston Carpal Tunnel Questionnaire) in Women With Carpal Tunnel Syndrome.

OBJECTIVE: To calculate the minimal clinically important differences (MCIDs) for hand pain intensity and the Boston Carpal Tunnel Questionnaire (BCTQ) in a sample of women with carpal tunnel syndrome (CTS). DESIGN: Secondary analysis of a randomized controlled trial. SETTING: A Hospital Rehabilitation Unit. PARTICIPANTS: One hundred twenty women with clinical and electromyographic diagnosis of CTS who were randomly assigned into 2 groups (N=120). INTERVENTIONS: One group received 3 sessions of manual physical therapy (n=60) and the other group received surgery (n=60). MAIN OUTCOME MEASURES: Mean and the worst pain intensity (numerical pain rate scale, 0-10 points) and functional status and symptoms' severity subscales of the BCTQ questionnaire were assessed before and 1 month after treatment. The Global Rating of Change (GROC) was used as the anchor variable for determining the MCID. RESULTS: A change of 1.5 and 2.5 points in mean and the worst pain intensity represents the MCID for Numerical Pain Rating Scale, whereas a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for each subscale of the BCTQ. All variables showed acceptable discrimination between patients classified as "improved" and those classified as "stable/not improved" (area under the curve≥0.72). Mean pain intensity (Youden index, 0.53; sensitivity: 73.3%; specificity: 80%) and symptoms' severity (Youden index, 0.69; sensitivity: 90%; specificity: 77.8%) showed the best discriminative ability expressed as a percentage of prediction. Participants classified as "improved" had significantly greater improvements in pain intensity, functional status, and symptoms' severity compared with those classified as "stable/not improved". CONCLUSION: A change of 1.5 and 2.5 points in mean and the worst pain and a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for pain intensity and BCTQ in women with CTS 1 month after treatment.

Unaccounted for Pitch Volume Among Adolescent Baseball Pitchers During a Travel Baseball Season.

OBJECTIVE: The primary aim was to compare differences in live game pitch counts (LGPCs) with all pitch counts (APCs) over the course of a youth baseball season. DESIGN: Prospective longitudinal study. SETTING: Midwest youth travel baseball. PARTICIPANTS: Ten male baseball players part of a youth baseball travel team. VARIABLES: Demographic data, pitch counts (practice, game, warm-up, and bullpen), innings pitched, and recommended rest days. MAIN OUTCOME MEASURES: Live pitch counts compared with APCs and the relationship to recommended rest days. RESULTS: During the season, 7866 pitches were recorded among 9 pitchers. By using the LGPC method alone, 42.5% of the pitches were unaccounted for. When considering age-specific rest days suggested by Pitch Smart Guidelines (PSGs), there were 104 rest days unaccounted for by using the live game pitch method. CONCLUSION: There is a high number of unaccounted for pitches and an underestimation of rest days per outing when using live game methods. Revisions to the PSGs that include all pitches should be considered to accurately reflect pitching volume, which may be associated with the rising rate of injuries among these athletes.

Comparative accuracy of ChatGPT-4, Microsoft Copilot and Google Gemini in the Italian entrance test for healthcare sciences degrees: a cross-sectional study.

BACKGROUND: Artificial intelligence (AI) chatbots are emerging educational tools for students in healthcare science. However, assessing their accuracy is essential prior to adoption in educational settings. This study aimed to assess the accuracy of predicting the correct answers from three AI chatbots (ChatGPT-4, Microsoft Copilot and Google Gemini) in the Italian entrance standardized examination test of healthcare science degrees (CINECA test). Secondarily, we assessed the narrative coherence of the AI chatbots' responses (i.e., text output) based on three qualitative metrics: the logical rationale behind the chosen answer, the presence of information internal to the question, and presence of information external to the question. METHODS: An observational cross-sectional design was performed in September of 2023. Accuracy of the three chatbots was evaluated for the CINECA test, where questions were formatted using a multiple-choice structure with a single best answer. The outcome is binary (correct or incorrect). Chi-squared test and a post hoc analysis with Bonferroni correction assessed differences among chatbots performance in accuracy. A p-value of < 0.05 was considered statistically significant. A sensitivity analysis was performed, excluding answers that were not applicable (e.g., images). Narrative coherence was analyzed by absolute and relative frequencies of correct answers and errors. RESULTS: Overall, of the 820 CINECA multiple-choice questions inputted into all chatbots, 20 questions were not imported in ChatGPT-4 (n = 808) and Google Gemini (n = 808) due to technical limitations. We found statistically significant differences in the ChatGPT-4 vs Google Gemini and Microsoft Copilot vs Google Gemini comparisons (p-value < 0.001). The narrative coherence of AI chatbots revealed "Logical reasoning" as the prevalent correct answer (n = 622, 81.5%) and "Logical error" as the prevalent incorrect answer (n = 40, 88.9%). CONCLUSIONS: Our main findings reveal that: (A) AI chatbots performed well; (B) ChatGPT-4 and Microsoft Copilot performed better than Google Gemini; and (C) their narrative coherence is primarily logical. Although AI chatbots showed promising accuracy in predicting the correct answer in the Italian entrance university standardized examination test, we encourage candidates to cautiously incorporate this new technology to supplement their learning rather than a primary resource. TRIAL REGISTRATION: Not required.

Cost analysis of one-time intravenous antibiotic doses in the emergency department.

BACKGROUND: Research shows that one-time doses of intravenous (IV) antibiotics do not improve resolution of infection. Providers, however, continue to use them - especially in the emergency department. Very few studies have aimed to quantify the cost of this practice. OBJECTIVES: The primary objective was to evaluate the difference in average total cost of emergency department (ED) stay between patients who received a one-time dose of intravenous antibiotics in the ED before discharging on oral antibiotics and patients who were just discharged on oral antibiotics. Secondary objectives were to evaluate the differences in durations of stay between the two groups, as well as the differences in adverse drug effects and need for healthcare contact after discharge. METHODS: Chart review was conducted to identify patients who received and did not receive a one-time dose of IV antibiotics in the ED between April 30, 2020, and April 30, 2022. A micro-costing approach was used to determine ED-associated costs per patient. Comparisons in primary and secondary outcomes were performed using statistical inferential tests. RESULTS: A total of 102 patients were analyzed in each group. Patients who received a one-time dose of intravenous antibiotics in the emergency department before being discharged on oral antibiotics had an average length of stay of 4.55 hours, as opposed to patients who did not receive a one-time dose of intravenous antibiotics before being discharged on oral antibiotics who had an average length of stay of 2.82 hours (absolute difference: 1.73 hours, p < 0.001). One-time dosing of intravenous antibiotics in the emergency department incurred an additional cost of approximately $556 per patient, totaling to over $56,000 in our study cohort. CONCLUSION: The use of one-time intravenous antibiotics in the emergency department did not confer any additional benefits to patients. Use of one-time doses resulted in significantly reduced throughput in the emergency department and significantly increased healthcare costs.

High-Impact Chronic Pain Transition in Lumbar Surgery Recipients.

OBJECTIVE: High-impact chronic pain (HICP) is a term that characterizes the presence of a severe and troubling pain-related condition. To date, the prevalence of HICP in lumbar spine surgery recipients and their HICP transitions from before to after surgery are unexplored. The purpose was to define HICP prevalence, transition types, and outcomes in lumbar spine surgery recipients and to identify predictors of HICP outcomes. METHODS: In total, 43,536 lumbar surgery recipients were evaluated for HICP transition. Lumbar spine surgery recipients were categorized as having HICP preoperatively and at 3 months after surgery if they exhibited chronic and severe pain and at least one major activity limitation. Four HICP transition groups (Stable Low Pain, Transition from HICP, Transition to HICP, and Stable High Pain) were categorized and evaluated for outcomes. Multivariate multinomial modeling was used to predict HICP transition categorization. RESULTS: In this sample, 15.1% of individuals exhibited HICP preoperatively; this value declined to 5.1% at 3 months after surgery. Those with HICP at baseline and 3 months had more comorbidities and worse overall outcomes. Biological, psychological, and social factors predicted HICP transition or Stable High Pain; some of the strongest involved social factors of 2 or more to transition to HICP (OR = 1.43; 95% CI = 1.21-1.68), and baseline report of pain/disability (OR = 3.84; 95% CI = 3.20-4.61) and psychological comorbidity (OR = 1.78; 95% CI = 1.48-2.12) to Stable Stable High Pain. CONCLUSION: The percentage of individuals with HICP preoperatively (15.1%) was low, which further diminished over a 3-month period (5.1%). Postoperative HICP groups had higher levels of comorbidities and worse baseline outcomes scores. Transition to and maintenance of HICP status was predicted by biological, psychological, and social factors.

Creation and Validation of the Select Medical Patient Reported Experience Measure for Physical and Occupational Therapy Outpatient Clinics.

OBJECTIVE: This study describes the creation and examination of the internal consistency, content validity, construct/structural validity, and criterion/concurrent validity of the Select Medical Patient Reported Experience Measure (SM-PREM). DESIGN: Observational study design. SETTING: 1054 Outpatient physical and occupational therapy locations in North America. PARTICIPANTS: The study included 89,205 patients with various musculoskeletal disorders (N=89,205). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Content validity was described, and internal consistency, construct/structural validity (factor analysis), and criterion/concurrent validity were analyzed, with concurrent validity compared against patient reported outcomes (PROM), the Net Promoter Scale, and the Orebro Musculoskeletal Screening Questionnaire-12. RESULTS: Exploratory and confirmatory factor analysis of the SM-PREM yielded 3 dimensions, each with a very strong internal consistency (>.850). The SM-PREM yielded statistically significant results in all areas, with values that reflected minimal to fair association with PROMs. CONCLUSION: The SM-PREM appears to capture a unique construct compared to PROMs. The 11-item tool has 3 definitive dimensions and exhibits strong internal consistency. The tool may be useful in examining patient experience in patients with musculoskeletal injuries seen by physical and occupational therapists.

Tolerability and efficacy of chemoimmunotherapy when administered with a corticosteroid-free anti-emetic regimen.

BACKGROUND: The use of immune checkpoint inhibitors (ICIs) in combination with chemotherapy is commonplace. This study sought to determine whether the omission of corticosteroids from the antiemetic regimen in patients receiving chemoimmunotherapy changes control of nausea and time on ICI therapy. METHODS: This single-site, retrospective, observational study was conducted at Veteran Health Indiana, a level 1A Veterans Affairs tertiary care facility. All patients who received concurrent chemoimmunotherapy between January 1, 2018, and December 31, 2020, were included. The replacement of corticosteroids with olanzapine in chemoimmunotherapy regimens occurred on March 27, 2019. Outcomes were compared in patients who received corticosteroids as part of antiemetic prophylaxis versus patients in whom corticosteroids were omitted. Outcomes included the proportion of patients achieving an anti-nausea complete control response (CCR) or partial control response (PCR) with antiemetic prophylaxis, and the time on ICI therapy in months. RESULTS: Seventy-two patients received a chemotherapeutic agent with a concomitant ICI during the designated time frame and were included for anti-emetogenic and ICI efficacy analysis, 36 patients received corticosteroids with chemoimmunotherapy and 36 patients did not. CCR was achieved in 55.6% of patients who received corticosteroids and in 69.4% of patients who did not. PCR was 19.4% versus 25.0%, respectively. Removal of corticosteroids from chemoimmunotherapy regimens did not result in a significant difference in nausea control or time on ICI therapy. CONCLUSIONS: Results suggest corticosteroids may be safely continued, or removed and replaced by other novel agents for chemotherapy-induced nausea and vomiting when administered with ICIs.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial.

BACKGROUND: Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT. METHODS: The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes). RESULTS: The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82). CONCLUSIONS: In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function. TRIAL REGISTRATION: The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

Association between radiographic soft-tissue thickness and increased length of stay, operative time, and infection rate after reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a widely performed surgical procedure to address various shoulder pathologies. Several studies have suggested that radiographic soft-tissue thickness may play a role in predicting complications after orthopedic surgery, but there have been limited studies determining the use of radiographic soft-tissue thickness in RSA. The purpose of this study was to evaluate whether radiographic soft-tissue thickness could predict clinical outcomes after RSA and compare the predictive capabilities against body mass index (BMI). We hypothesized that increased radiographic shoulder soft-tissue thickness would be a strong predictor of operative time, length of stay (LOS), and infection in elective RSA. MATERIAL AND METHODS: A retrospective review of patients undergoing RSA at an academic institution was conducted. Preoperative radiographic images were evaluated including measurements of the radius from the humeral head center to the skin (HS), deltoid radius-to-humeral head radius ratio (DHR), deltoid size, and subcutaneous tissue size. Different correlation coefficients were used to analyze various types of relationships, and the strength of these associations was classified based on predefined boundaries. Subsequently, multivariable linear and logistic regressions were performed to determine whether HS, DHR, deltoid size, and subcutaneous tissue size could predict LOS, operative time, or infection while controlling for patient factors. RESULTS: HS was the most influential factor in predicting both operative time and LOS after RSA, with strong associations indicated by standardized ß coefficients of 0.234 for operative time and 0.432 for LOS. Subcutaneous tissue size, deltoid size, and DHR also showed stronger predictive values than BMI for both outcomes. In terms of prosthetic joint infection, HS, deltoid size, and DHR were significant predictors, with HS demonstrating the highest predictive power (Nagelkerke R2 = 0.44), whereas BMI did not show a statistically significant association with infection. Low event counts resulted in wide confidence intervals for odds ratios in the infection analysis. CONCLUSION: Greater shoulder soft-tissue thickness as measured with concentric circles on radiographs is a strong predictor of operative time, LOS, and postoperative infection in elective primary RSA patients.

The probiotic Lacticaseibacillus paracasei strain Shirota (LcS) in a fermented milk beverage survives the gastrointestinal tract of generally healthy U.S. Adults.

The probiotic strain Lacticaseibacillus paracasei (previously Lactobacillus casei) strain Shirota (LcS) has demonstrated its survivability in the gastrointestinal tract across populations in different countries. The objective of this study was to validate this survivability in the United States, where evidence is lacking. Faecal samples were collected from 26 healthy individuals (age: 32.0 ± 5.9 years) at baseline, after 7 and 14 days of daily consumption of 80 mL fermented milk containing 108 colony forming units (CFU) LcS/mL, and after a subsequent 14-days of no product consumption. Live LcS counts significantly (p < 0.001) increased after 7 and 14 days of product consumption (6.37 ± 1.18 and 5.24 ± 1.81 log10 CFU/g faeces, respectively) and returned to baseline in 87% of participants. These results indicate LcS survives passage through the gastrointestinal tract of generally healthy U.S. adults, providing support for its uniquely accumulated evidence of universal survival capacity in the gastrointestinal tract.

Association of Burden and Prevalence of Arthritis With Disparities in Social Risk Factors, Findings From 17 US States.

INTRODUCTION: Social risks previously have been associated with arthritis prevalence and costs. Although social risks often cluster among individuals, no studies have examined associations between multiple social risks within the same individual. Our objective was to determine the association between individual and multiple social risks and the prevalence and burden of arthritis by using a representative sample of adults in 17 US states. METHODS: Data are from the 2017 Behavioral Risk Factor Surveillance System. Respondents were 136,432 adults. Social risk factors were food insecurity, housing insecurity, financial insecurity, unsafe neighborhoods, and health care access hardship. Weighted χ2 and logistic regression analyses, controlling for demographic characteristics, measures of socioeconomic position, and other health conditions examined differences in arthritis prevalence and burden by social risk factor and by a social risk index created by summing the social risk factors. RESULTS: We observed a gradient in the prevalence and burden of arthritis. Compared with those reporting 0 social risk factors, respondents reporting 4 or more social risk factors were more likely to have arthritis (adjusted odds ratio [AOR], 1.92; 95% CI, 1.57-2.36) and report limited usual activities (AOR, 2.97; 95% CI, 2.20-4.02), limited work (AOR, 2.72; 95% CI, 2.06-3.60), limited social activities (AOR, 3.10; 95% CI, 2.26-4.26), and severe joint pain (AOR, 1.86; 95% CI, 1.44-2.41). CONCLUSION: Incremental increases in the number of social risk factors were independently associated with higher odds of arthritis and its burden. Intervention efforts should address the social context of US adults to improve health outcomes.

Heterogeneity of pain-related psychological distress in patients seeking care for shoulder pathology.

BACKGROUND: Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to (1) describe the prevalence of various subtypes of psychological distress; (2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function; and (3) determine differences in psychological distress profiles between patients receiving nonoperative vs. operative treatment. METHODS: The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags (YFs) ranges from 0 to 11, with higher YF counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using χ2 test and Student t test. Linear regression was used to evaluate the association between pain, disability, and YFs, whereas Poisson regression evaluated the association between operative treatment and psychological distress. K-means cluster analysis was performed to propose potential psychological distress phenotypes. RESULTS: Two hundred fifty-one patients (91%) had at least 1 YF on the OSPRO-YF tool, with a mean number of 6 ± 3.5 YFs. YFs in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (P < .001), Single Assessment Numeric Evaluation (P < .001), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) scores. Comparing operative and nonoperative cohorts, the operative cohort had a significantly higher mean number of YFs (6.5 vs. 5.6, P = .035), presence of any YF (94.3% vs. 85.7%, P = .015), and presence of YFs within the unhelpful coping domain (91.8% vs. 75.6%, P < .001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (P < .001), with females (P = .037) and smokers (P = .018) associated with higher psychological distress phenotypes. CONCLUSIONS: YFs, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychological distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.

Precise Analgesic Instructions Improve Narcotic Usage: A Randomized Trial.

BACKGROUND: Given the ongoing battle with opioid abuse and overuse in the United States, new strategies are consistently being implemented to reduce opioid utilization and overprescribing. OBJECTIVES: The purpose of this study was to determine if a more regulated explicit pain management instruction plan could reduce the number of opioids taken. METHODS: Blinded randomized prospective study comparing a total of 110 (Group A = 55, Group B = 55) women who underwent elective outpatient bilateral breast reduction surgery by 2 different plastic surgeons. Patients were randomly divided into either Group A (control) that received general pain management instructions or Group B (experimental) that received explicit pain management instructions from the surgeons and nurses. Participants were asked to record the number of times they treated their pain with each separate modality. They were also asked to record their average daily pain scale for the days that they were treating their pain. RESULTS: Patients in Group B took on average 1.5 oxycodone (5 mg) and patients in Group A took on average 5.7 oxycodone (5 mg) (P < 0.01). Thirty-four patients in Group B took no oxycodone. Patients in Group B also had statistically significant lower subjective pain scores. CONCLUSIONS: Based on these results, it appears that standardizing how patients are instructed to treat their pain postoperatively may reduce the number of narcotics needed, thus reducing the number of narcotics prescribed without compromising pain control.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination.

Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial.

BACKGROUND: Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery. METHODS: We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care. DISCUSSION: Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications. TRIAL REGISTRATION: This study is registered as NCT03353272 at ClincialTrials.gov.

Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology.

HYPOTHESIS/BACKGROUND: In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE. METHODS: The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test. RESULTS: We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87). CONCLUSION: This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 1: A synthesis of recommendation.

BACKGROUND: Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs. OBJECTIVES: The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice. METHODS: We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process. RESULTS: We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP. CONCLUSIONS: We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.

Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial.

BACKGROUND: Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown. DESIGN: The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures. SUMMARY: AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.

Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis.

PURPOSE: To update evidence of diagnostic potential for identification of lumbar spinal stenosis (LSS) based on demographic and patient history, clinical findings, and physical tests, and report posttest probabilities associated with test findings. METHODS: An electronic search of PubMed, CINAHL and Embase was conducted combining terms related to low back pain, stenosis and diagnostic accuracy. Prospective or retrospective studies investigating diagnostic accuracy of LSS using patient history, clinical findings and/or physical tests were included. The risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Diagnostic accuracy including sensitivities (SN), specificities (SP), likelihood ratios (+LR and -LR) and posttest probabilities (+PTP and -PTP) with 95% confidence intervals were summarized. RESULTS: Nine studies were included (pooled n = 36,228 participants) investigating 49 different index tests (30 demographic and patient history and 19 clinical findings/physical tests). Of the nine studies included, only two exhibited a low risk of bias and seven exhibited good applicability according to QUADAS 2. The demographic and patient history measures (self-reported history questionnaire, no pain when seated, numbness of perineal region) and the clinical findings/physical tests (two-stage treadmill test, symptoms after a March test and abnormal Romberg test) highly improved positive posttest probability by > 25% to diagnose LSS. CONCLUSION: Outside of one study that was able to completely rule out LSS with no functional neurological changes none of the stand-alone findings were strong enough to rule in or rule out LSS. These slides can be retrieved under Electronic Supplementary Material.

Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review.

BACKGROUND: Consequences of prescription opioid use involve harms, addiction, tolerance and death. Despite routine prescription, opioids are not recommended for initial intervention by any major multidisciplinary low back pain (LBP) guideline. OBJECTIVE: Our primary purpose was to improve overall understanding of the harms and benefits associated with oral opioid interventions prescribed for treatment of acute or chronic back pain. Our second goal was to evaluate pain intensity and to compare and contrast these data with the harms. Our last objective was to evaluate conflicts of interest among the study authors and the findings. DESIGN/DATA/ELIGIBILITY CRITERIA: Studies incorporating oral prescription opioid management of non-surgical LBP were evaluated. After systematic assessment, no studies that met inclusion included participants with specifically acute LBP. Therefore, extracted data reflects only populations with subacute and chronic LBP. Data on reported harms, severe harms, pain outcomes and withdrawal rates were extracted and meta-analyses were completed for opioid versus placebo trials and opioids versus non-opioid trials. RESULTS: Fourteen studies met inclusion/exclusion requirements. All trials involved short-term management with limited follow-up. A high percentage of harms were identified across most studies. Opioids were not shown to be superior to other medications, and only showed superiority to placebo comparators (at cost of additional harms). CONCLUSION: This review identified trends of higher harms rates and higher percentages of severe harms in opioid arms for the management of subacute and chronic LBP. The majority of trials that demonstrated benefits with opioids also had potential conflicts of interest. Lastly, non-opioid medications demonstrated statistically significant pain improvement compared with opioids. We feel that the results of the trial are supportive of current LBP guidelines and do not condone the initial use of opioids in management of subacute or chronic LBP. TRIAL REGISTRATION NUMBER: CRD42017070914.