Insurance Status, Language, and Access to Care for Pediatric Anterior Cruciate Ligament Injury.

Background: Patients with public insurance (PUBs) face more difficulty obtaining orthopaedic appointments and have longer wait times than privately insured patients (PVTs). These delays are associated with greater injury severity at the time of surgery, which affects sports injuries such as anterior cruciate ligament tears where early surgical stabilization leads to better outcomes. Additionally, previous evidence showed that patients with limited English proficiency often must rely on informal translation services, such as family members or friends, to communicate with their orthopaedic surgeons, which may represent a disparity in the care provided. Hypothesis: It was hypothesized that PUBs would be less likely to obtain an appointment compared with PVTs and that most providers would not offer professional translation services to Spanish-speaking patients. Study Design: Cross-sectional study. Methods: The authors called 50 randomly selected orthopaedic surgeons' offices in California specializing in sports medicine to request an appointment. Each office was called 4 times in random order for the hypothetical patient having either private or public insurance and speaking either Spanish or English. Results: The hypothetical PUB had significantly decreased access to an appointment (19% of offices offered an appointment) when compared to the PVT (73.8% offered an appointment). Independent private practice (IPP) offices were less likely to accept public insurance (13.3%) compared with offices at academic medical centers (57.1%). There was no difference in access to an appointment for the Spanish- versus English-speaking patient. Translation services were offered at 73.8% of the orthopaedic offices. Conclusion: Overall, the data illustrated disparities in access to pediatric orthopaedic care for PUBs compared to those with private insurance. Disparities were most prominent in IPP settings, which were less likely than academic offices to accept public insurance. Additionally, it was found that 73.8% of the offices the authors contacted offered Spanish translation services. Interventions should focus on increasing acceptance of public insurance and translation services in IPP settings. Future studies should expand this analysis to other languages and investigate the potential impacts of language on the quality of care provided.

No Differences in 2-Year Reoperation Rates for Meniscus Allograft Transplant With Concomitant Cartilage Restoration or Osteotomy: A National Database Study.

PURPOSE: To investigate reoperation rates after meniscus allograft transplant (MAT), comparing rates with and without concomitant articular cartilage and osteotomy procedures using a national insurance claims database. METHODS: We performed a retrospective cohort study of patients who underwent MAT from 2010 to 2021 with a minimum 2-year follow-up using the PearlDiver database. Using Current Procedural Terminology and International Classification of Diseases codes, we identified patients who underwent concomitant procedures including chondroplasty or microfracture, cartilage restoration defined as osteochondral graft or autologous chondrocyte implantation (ACI), or osteotomy. Univariate logistic regressions identified risk factors for reoperation. Reoperations were classified as knee arthroplasty, interventional procedures, or diagnostic or debridement procedures. RESULTS: The study included 750 patients with an average age of 29.6 years (interquartile range: 21.0-36.8) and average follow-up time was 5.41 years (SD: 2.51). Ninety-day, 2-year, and all-time reoperation rates were 1.33%, 14.4%, and 27.6%, respectively. MAT with cartilage restoration was associated with increased reoperation rate at 90 days (odds ratio: 4.88; 95% confidence interval: 1.38-19.27; P = .015); however, there was no significant difference in reoperation rates at 2 years or to the end of follow-up. ACI had increased reoperation rates at 90 days (odds ratio: 6.95; 95% confidence interval: 1.45-25.96; P = .006), with no difference in reoperation rates 2 years postoperatively or to the end of follow-up. Osteochondral autograft and allograft were not associated with increased reoperation rates. CONCLUSIONS: In our cohort, 14.4% of patients had a reoperation within 2 years of MAT. Nearly 1 in 4 patients undergoing MAT had concomitant cartilage restoration, showing that it is commonly performed on patients with articular cartilage damage. Concomitant osteochondral autograft, osteochondral allograft, chondroplasty, microfracture, and osteotomy were not associated with any significant difference in reoperation rates. ACI was associated with increased reoperation rates at 90 days, but not later. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Mental Health and Involuntary Retirement from Sports Post-Musculoskeletal Injury in Adult Athletes: a Systematic Review.

PURPOSE OF REVIEW: The psychological aspects of musculoskeletal injury are often overlooked in the rehabilitation process. This review examines the effects of musculoskeletal injury on mental health in adult athletes and identifies themes to guide further research. RECENT FINDINGS: Athletes are at risk for mental health struggles due to high athletic identity and identity foreclosure. Injured athletes have specifically been shown to have higher rates of anxiety and depression when compared to the general population. There is a lack of intervention-based research on the psychological well-being of athletes, and there are no systematic reviews synthesizing the impact of musculoskeletal injury on the mental health of adult athletes across a variety of sports. Across professional, college-level, and amateur athletes, musculoskeletal injury is associated with worse mental health scores, including higher distress, higher anxiety and depression, lower social functioning, and lower health-related quality of life. For adults, involuntary retirement from sports due to musculoskeletal injury is a common theme associated with increased psychological distress, anxiety, and depression. In the reviewed literature, 22 unique mental health and 12 distinct physical health screening tools were used. Two articles studied interventions addressing mental health post-injury. Further research using an integrated physical and psychological approach to recovery is warranted and may improve mental and physical outcomes for injured athletes.

Stronger Athlete Identity Is a Risk Factor for More Severe Depressive Symptoms After Musculoskeletal Injury in Pediatric Athletes: a Systematic Review.

PURPOSE OF REVIEW: Treatment for musculoskeletal sports injuries often neglects the psychological components of health and recovery. Pediatric patients require particular consideration of their psychosocial and cognitive development. This systematic review investigates the effects of musculoskeletal injury on mental health in pediatric athletes. RECENT FINDINGS: Athlete identity may increase in adolescence and is associated with worse mental health post-injury. Psychological models suggest loss of identity, uncertainty, and fear mediate the association between injury and symptoms of anxiety, depression, post-traumatic stress disorder, and obsessive-compulsive disorder. Fear, identity, and uncertainty also influence return to sport. In the reviewed literature, there were 19 psychological screening tools and 8 different physical health measures with various adaptations to athlete developmental level. In pediatric patients, no interventions were studied to reduce the psychosocial impacts of injury. Musculoskeletal injury is associated with worse mental health in pediatric athletes, and stronger athlete identity is a risk factor for the development of depressive symptoms. Psychological interventions that reduce uncertainty and address fear may help mitigate these risks. More research is needed on screening and interventions to improve mental health post-injury.

Chronic Pain in Young Athletes: The Impact of Athletic Identity on Pain-related Distress and Functioning.

BACKGROUND: It is common for youth to engage in sport and unfortunately also common for chronic pain to emerge in childhood. The convergence of chronic pain and sports participation in youth has not been extensively studied. OBJECTIVE: The goal of this study was to examine the association between athletic identity (AI) and pain-related distress and functioning in youth with chronic pain. PARTICIPANTS: Our cohort consisted of 305 youth ages 8 to 21, 83.6% of whom reported being currently engaged or previously involved in sport. Correlation and regression analyses were completed to evaluate the relationship between AI and pain-related distress and functioning in our cohort of chronic pain patients. RESULTS: Children currently involved in sport had higher total AI and social AI, lower fear of pain, and lower functional disability. Greater negative affectivity-AI had the strongest relationship with pain-related distress, including pain catastrophizing, fear and avoidance of pain, and anxiety. Stronger social AI was associated with lower levels of depression and pain-related avoidance of activities. Functional disability was not significantly associated with AI, but was lowest in individuals currently involved in sport. CONCLUSION: Our study provides evidence that focusing on continued sports engagement in the context of chronic pain is associated with less pain-related distress and functional limitations when compared with those who discontinue sports involvement, thus may serve as a buffer in the context of chronic pain. The association of AI with pain-related distress suggests that there is emotional significance in the degree to which youth identify as an athlete. This may be beneficial to clinically assess in youth with chronic pain.

Pain neuroscience education on YouTube.

OBJECTIVES: The Internet in general, and YouTube in particular, is now one of the most popular sources of health-related information. Pain neuroscience education has become a primary tool for managing persistent pain, based in part on the discovery that information about pain can change pain. Our objective was to examine the availability, characteristics, and content of YouTube videos that address the neuroscience of pain. METHODS: We conducted a systematic review of videos on YouTube using the search terms "pain education", "what is pain", and "pain brain" in January 2018. Videos were included if they were in English, were under 10 minutes long, and included information on the neuroscience of pain. Videos were coded for (i) descriptive characteristics (e.g., number of views, duration on YouTube), (ii) source and style, (iii) whether or not they addressed seven pre-determined target concepts of pain neuroscience education (e.g., 'Pain is not an accurate marker of tissue state'), and (iv) how engaging they were. RESULTS: We found 106 unique videos that met the inclusion criteria. The videos ranged from having four views to over five million views (Mdn = 1,163 views), with the three most highly viewed videos accounting for 75% of the total views. Animated videos were much more highly viewed than non-animated videos. Only a small number of videos had been posted by a clearly-identifiable reputable source such as an academic or medical institution (10%), although a number of videos were posted by healthcare professionals and professional medical societies. For a small number of videos (7%), the source was unclear. We found 17 videos that addressed at least one target concept of pain neuroscience science education, only nine of which were considered to be at least somewhat engaging. The target concept 'Pain is a brain output' was considered to be well addressed by the most videos (N = 11), followed by 'Pain is a protector' (N = 10). We found only one video that adequately addressed all seven target concepts of pain neuroscience education. DISCUSSION: YouTube contains a variety of videos that practitioners, patients, and families may view to access pain neuroscience education information. A small portion of these videos addressed one or more target concepts of pain neuroscience education in an engaging manner. It is yet to be determined to what extent patients are able to learn information from these videos, to what extent the videos promote behavior change, and thus to what extent the videos may be useful for clinical practice.

Is Empathy for Pain Unique in Its Neural Correlates? A Meta-Analysis of Neuroimaging Studies of Empathy.

Empathy is an essential component of our social lives, allowing us to understand and share other people's affective and sensory states, including pain. Evidence suggests a core neural network-including anterior insula (AI) and mid-cingulate cortex (MCC)-is involved in empathy for pain. However, a similar network is associated to empathy for non-pain affective states, raising the question whether empathy for pain is unique in its neural correlates. Furthermore, it is yet unclear whether neural correlates converge across different stimuli and paradigms that evoke pain-empathy. We performed a coordinate-based activation likelihood estimation (ALE) meta-analysis to identify neural correlates of empathy, assess commonalities and differences between empathy for pain and for non-pain negative affective states, and differences between pain-empathy evoking stimuli (i.e., facial pain expressions vs. acute pain inflictions) and paradigms (i.e., perceptual/affective vs. cognitive/evaluative paradigms). Following a systematic search, data from 128 functional brain imaging studies presenting whole-brain results of an empathy condition vs. baseline/neutral condition were extracted. Synthesizing neural correlates of empathy confirmed a core network comprising AI, MCC, postcentral gyrus, inferior parietal lobe, thalamus, amygdala, and brainstem. There was considerable overlap in networks for empathy for pain and empathy for non-pain negative affective states. Important differences also arose: empathy for pain uniquely activated bilateral mid-insula and more extensive MCC. Regarding stimuli, painful faces and acute pain inflictions both evoked the core empathy regions, although acute pain inflictions activated additional regions including medial frontal and parietal cortex. Regarding paradigms, both perceptual/affective and cognitive/evaluative paradigms recruited similar neural circuitry, although cognitive/evaluative paradigms activated more left MCC regions while perceptual/affective paradigms activated more right AI. Taken together, our findings reveal that empathy for pain and empathy for non-pain negative affective states share considerable neural correlates, particularly in core empathy regions AI and MCC. Beyond these regions, important differences emerged, limiting generalizability of findings across different affective/sensory states. Within pain-empathy studies, the core regions were recruited robustly irrespective of stimuli or instructions, allowing one to tailor designs according to specific needs to some extent, while ensuring activation of core regions.