Impact of automated data flow and reminders on adherence and resource utilization for remotely monitoring physical activity in individuals with stroke or chronic obstructive pulmonary disease.

As rehabilitation advances into the era of digital health, remote monitoring of physical activity via wearable devices has the potential to change how we provide care. However, uncertainties about patient adherence and the significant resource requirements needed create challenges to adoption of remote monitoring into clinical care. Here we aim to determine the impact of a novel digital application to overcome these barriers. The Rehabilitation Remote Monitoring Application (RRMA) automatically extracts data about physical activity collected via a Fitbit device, screens the data for adherence, and contacts the participant if adherence is low. We compare adherence and estimate the resources required (i.e., time and financial) to perform remote monitoring of physical activity with and without the RRMA in two patient groups. Seventy-three individuals with stroke or chronic obstructive pulmonary disease completed 28 days of monitoring physical activity with the RRMA, while 62 individuals completed 28 days with the data flow processes being completed manually. Adherence (i.e., the average percentage of the day that the device was worn) was similar between groups (p=0.85). However, the RRMA saved an estimated 123.8 minutes or $50.24 per participant month when compared to manual processes. These results demonstrate that automated technologies like the RRMA can maintain patient adherence to remote monitoring of physical activity while reducing the time and financial resources needed. Applications like the RRMA can facilitate the adoption of remote monitoring in rehabilitation by reducing barriers related to adherence and resource requirements.

Psychological treatments for the management of pain after musculoskeletal injury: a systematic review and meta-analysis.

ABSTRACT: Musculoskeletal injury is a leading cause of pain and disability worldwide; 35% to 75% of people experience persistent pain for months and years after injury. Psychological treatments can reduce pain, functional impairment, and psychological distress but are not widely used after injury. This systematic review and meta-analysis (PROSPERO ID: CRD42021236807) aimed to synthesize the literature testing psychological treatments for pain after musculoskeletal injury. We searched EMBASE, MEDLINE, PubMed, PsycINFO, and CENTRAL from inception to May 2022. We extracted participant, treatment, and injury characteristics and primary (eg, pain intensity, functional impairment, depression, anxiety, and PTSD symptoms) and secondary (treatment feasibility and acceptability) outcomes. Twenty-four randomized controlled trials (N = 1966) were included. Immediately posttreatment, people who received psychological treatments (versus any control) reported lower pain intensity (standardized mean differences [SMD] = -0.25, 95% confidence interval [-0.49, -0.02]), functional impairment (SMD = -0.32 [-0.55, -0.09]), and symptoms of depression (SMD = -0.46 [-0.64, -0.29]), anxiety (SMD = -0.34 [-0.65, -0.04]), and PTSD (SMD = -0.43 [-0.70, -0.15]); at 6-month follow-up, only depression symptoms were significantly lower. Included trials varied widely in treatment and injury characteristics. The certainty of evidence was low or very low for most effects and heterogeneity moderate to substantial. Most studies had risk of bias domains judged to be high or unclear. Owing to very low certainty of results, we are unsure whether psychological therapies reduce pain and functional impairment after musculoskeletal injury; they may result in improved depression immediately posttreatment and at follow-up. More research is needed to identify treatments that result in enduring effects.

Examining the Relationship Between Individual Patient Factors and Substantial Clinical Benefit From Telerehabilitation Among Patients With Chronic Low Back Pain.

OBJECTIVE: The coronavirus disease-2019 pandemic has facilitated the emergence of telerehabilitation, but it is unclear which patients are most likely to respond to physical therapy provided this way. The purpose of this study was to examine the relationship between individual patient factors and substantial clinical benefit from telerehabilitation among a cohort of patients with chronic low back pain (LBP). METHODS: This is a secondary analysis of data collected during a prospective longitudinal cohort study. Patients with chronic LBP (N = 98) were provided with a standardized physical therapy protocol adapted for telerehabilitation. We examined the relationship between patient factors and substantial clinical benefit with telerehabilitation, defined as a ≥50% improvement in disability at 10 weeks, measured using the Oswestry Disability Index. RESULTS: Sixteen (16.3%) patients reported a substantial clinical benefit from telerehabilitation. Patients reporting substantial clinical benefit from telerehabilitation had lower initial pain intensity, lower psychosocial risk per the STarT Back Screening Tool, higher levels of pain self-efficacy, and reported higher therapeutic alliance with their physical therapist compared to other patients. CONCLUSION: Patients with lower psychosocial risk and higher pain-self efficacy experienced substantial clinical benefit from telerehabilitation for chronic LBP more often than other patients in our cohort. Therapeutic alliance was higher among patients who experienced a substantial clinical benefit compared to those who did not. IMPACT: This study indicates that psychosocial factors play an important role in the outcomes of patients receiving telerehabilitation for chronic LBP. Baseline psychosocial screening may serve as a method for identifying patients likely to benefit from this approach.

Predictors of participation in online self-management programs: A longitudinal observational study.

PURPOSE/OBJECTIVE: Lack of patient participation and engagement remains a barrier to implementing effective online self-management and behavioral health interventions. Identifying patient characteristics associated with engagement rates may lead to interventions that improve engagement in traditional and online self-management programs. In this study, two online self-management and recovery programs were evaluated to identify factors that predict patient engagement. RESEARCH METHOD/DESIGN: Predictors were collected in a questionnaire at baseline before 435 participants started either of the two interventions. One or two online lessons were completed per week with seven or eight total lessons to complete in each program, and each lesson took about 20-30 min to finish. Full patient engagement was defined as completing all lessons and assessments in the program and partial engagement as attempting at least one lesson or assessment. RESULTS: Predictors of full patient engagement were self-rated confidence in completing the program or being over 60 years of age. Predictors of at least partial patient engagement were experienced ordering online or being over 50 years of age. CONCLUSIONS/IMPLICATIONS: Identifying profiles of individuals who predict poor engagement may improve implementation and the health outcomes of intervention programs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Medium- and Long-Term Effects of Insomnia Severity and Circadian Preference on Pain and Emotional Distress Among Individuals With Chronic Pain.

Studies have identified insomnia as having significant influence on chronic pain. A rising body of research has also underscored the association between eveningness and chronic pain. However, co-assessment of insomnia and eveningness in the context of chronic pain adjustment has been limited. The present study sought to investigate the effects of insomnia and eveningness on pain severity, pain interference, and emotional distress (ie, depressive and anxiety symptoms) over nearly 2 years among adults with chronic pain in the U.S. Adults with chronic pain (N = 884) were surveyed 3 times via Amazon's MTurk online crowdsourcing platform: baseline, 9-month follow-up, and 21-month follow-up. Path analysis was conducted to examine the effects of baseline insomnia severity (Insomnia Severity Index) and eveningness (Morningness and Eveningness Questionnaire), as well as their moderating effects on outcomes. Controlling for select sociodemographic variables and baseline outcome levels, greater insomnia severity at baseline was associated with worsening of all of the pain-related outcomes at 9-month follow-up, and pain interreference and emotional distress at 21-month follow-up. We did not find evidence that evening types are at a higher risk of experiencing worsening pain-related outcomes over time compared to morning and intermediate types. There were also no significant insomnia severity and eveningness moderation effects on any outcome. Our findings suggest that insomnia is a more robust predictor of changes in pain-related outcomes as compared to eveningness. Treatment of insomnia can be important in chronic pain management. Future studies should evaluate the role of circadian misalignment on pain using more accurate biobehavioral makers. PERSPECTIVE: This study examined the effects of insomnia and eveningness on pain and emotional distress in a large sample of individuals with chronic pain. Insomnia severity is a stronger predictor of changes in pain and emotional distress than eveningness, highlighting insomnia as an important clinical target for chronic pain management.

Protocol for a Parallel Group Randomized Clinical Trial Comparing a Culturally Adapted Cognitive Behavioral Telerehabilitation Intervention to Usual Physical Therapy for Latino Patients With Chronic Spine Pain.

OBJECTIVE: Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral-based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral-based hybrid telerehabilitation intervention for Latino patients with chronic spine pain. METHODS: A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses. IMPACT: This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain.

Characterizing modifications to a comparative effectiveness research study: the OPTIMIZE trial-using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME).

BACKGROUND: The OPTIMIZE trial is a multi-site, comparative effectiveness research (CER) study that uses a Sequential Multiple Assessment Randomized Trial (SMART) designed to examine the effectiveness of complex health interventions (cognitive behavioral therapy, physical therapy, and mindfulness) for adults with chronic low back pain. Modifications are anticipated when implementing complex interventions in CER. Disruptions due to COVID have created unanticipated challenges also requiring modifications. Recent methodologic standards for CER studies emphasize that fully characterizing modifications made is necessary to interpret and implement trial results. The purpose of this paper is to outline the modifications made to the OPTIMIZE trial using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) to characterize modifications to the OPTIMIZE trial in response to the COVID pandemic and other challenges encountered. METHODS: The FRAME outlines a strategy to identify and report modifications to evidence-based interventions or implementation strategies, whether planned or unplanned. We use the FRAME to characterize the process used to modify the aspects of the OPTIMIZE trial. Modifications were made to improve lower-than-anticipated rates of treatment initiation and COVID-related restrictions. Contextual modifications were made to permit telehealth delivery of treatments originally designed for in-person delivery. Training modifications were made with study personnel to provide more detailed information to potential participants, use motivational interviewing communication techniques to clarify potential participants' motivation and possible barriers to initiating treatment, and provide greater assistance with scheduling of assigned treatments. RESULTS: Modifications were developed with input from the trial's patient and stakeholder advisory panels. The goals of the modifications were to improve trial feasibility without compromising the interventions' core functions. Modifications were approved by the study funder and the trial steering committee. CONCLUSIONS: Full and transparent reporting of modifications to clinical trials, whether planned or unplanned, is critical for interpreting the trial's eventual results and considering future implementation efforts. TRIAL REGISTRATION: ClinicalTrials.gov NCT03859713. Registered on March 1, 2019.

A Learning Health System Infrastructure for Precision Rehabilitation After Stroke.

ABSTRACT: Functional recovery and the response to rehabilitation interventions after stroke are highly variable. Understanding this variability will promote precision rehabilitation for stroke, allowing us to deliver targeted interventions to the right person at the right time. Capitalizing on large, heterogeneous data sets, such as those generated through clinical care and housed within the electronic health record, can lead to understanding of poststroke variability. However, accessing data from the electronic health record can be challenging because of data quality, privacy concerns, and the resources required for data extraction. Therefore, creating infrastructure that overcomes these challenges and contributes to a learning health system is needed to achieve precision rehabilitation after stroke. We describe the creation of a Precision Rehabilitation Data Repository that facilitates access to systematically collected data from the electronic health record as part of a learning health system to drive precision rehabilitation. Specifically, we describe the process of (1) standardizing the documentation of functional assessments, (2) obtaining regulatory approval, (3) defining the patient cohort, and (4) extracting data for the Precision Rehabilitation Data Repository. The development of similar infrastructures at other institutions can help generate large, heterogeneous data sets to drive poststroke care toward precision rehabilitation, thereby maximizing poststroke function within an efficient healthcare system.

Determining Profiles of Pain-Specific and General Emotion Regulation Skills and Their Relation to 12-Month Outcomes Among People With Chronic Pain.

Difficulties with pain-specific emotion regulation (ER; eg, pain catastrophizing, pain acceptance) are associated with poor pain outcomes. Less is known about how general ER relates to pain outcomes, or the extent to which pain-specific and general ER interact. In a sample (N = 1,453) of adults with chronic pain, the current study used latent profile analysis to identify subgroups of people with distinct pain-specific and general ER profiles, and determined how subgroup membership at baseline related to pain severity, pain interference, depression and anxiety symptoms at 12-month follow-up. Four groups were identified: 1) general ER difficulties only (29.6%); 2) pain-specific and general ER difficulties (26.3%); 3) skillful pain-specific and general ER (24.6%); 4) pain-specific ER difficulties only (19.4%). Controlling for auto-correlation and demographic covariates, those with pain-specific and general ER difficulties had the worst outcomes in all domains. Membership to other groups did not differentiate between pain severity or interference outcomes; those skillful in pain-specific and general ER had the lowest depression and anxiety symptoms at 12 months. General ER difficulties are common among adults with chronic pain and raise relative risk when paired with pain-specific ER difficulties. Findings offer potential directions for individualizing pain psychology treatment. PERSPECTIVE: This article shows that people with chronic pain have different sets of strengths and difficulties when it comes to regulating emotions related and/or unrelated to the experience of pain itself. Understanding an individual's unique constellation of emotion regulation skills and difficulties might help personalize the psychological treatment of pain.

Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study.

OBJECTIVE: We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). METHODS: In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. RESULTS: We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively). CONCLUSIONS: We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. CLINICALTRIALS.GOV IDENTIFIER: NCT02647658.

A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction.

STUDY DESIGN: Qualitative interview study. OBJECTIVE: The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction. SUMMARY OF BACKGROUND DATA: Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery. MATERIALS AND METHODS: Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed. RESULTS: A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences. CONCLUSION: Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Orthopedic surgeons and physical therapists differ regarding rehabilitative needs after lower extremity fracture repair.

BACKGROUND: Little evidence is available to guide physical therapy (PT) following lower extremity fracture repair distal to the hip. As such, variability has been reported in the way PT is utilized post-operatively. Examination of current practice by orthopedic surgeons (OS) and physical therapists is needed to inform clinical practice guidelines in this area. OBJECTIVE: To describe current PT referral practices among OS, identify patient and clinical factors that affect PT referral, and examine differences between OS and physical therapists with regard to visit frequency, duration, and use of specific PT interventions. METHODS: Provider surveys. RESULTS: Surveys were completed by 100 OS and 347 physical therapists. Over half (54%) of OS reported referring "most patients" to PT and identified joint stiffness and strength limitations as top reasons for PT referral. Over 80% of OS and physical therapists indicated that joint stiffness, strength limitations, and patients' functional goals affected their recommendations for PT visit frequency. More physical therapists than OS reported that pain severity (55% vs 25%, p < .001), maladaptive pain behaviors (64% vs. 33%, p < .001), and patient self-efficacy (70% vs. 49%, p = .003) affected their visit frequency recommendations. While OS recommended more frequent PT for patients with peri-articular fractures, fracture type had minimal impact on the visit frequencies recommended by physical therapists. CONCLUSION: OS and physical therapists consider similar physical impairments when determining the need for PT and visit frequencies, however, physical therapists consider pain and psychosocial factors more often, with OS focusing more on injury type.

Treatment effect modifiers for individuals with acute low back pain: secondary analysis of the TARGET trial.

ABSTRACT: Treatment effect modifiers identify patient characteristics associated with treatment responses. The purpose of this secondary analysis was to identify potential treatment effect modifiers for disability from the TARGET trial that compared usual care (control) with usual care + psychologically informed physical therapy (PIPT). The sample consisted of a STarT Back tool identified high-risk patients with acute low back pain that completed Oswestry Disability Index (ODI) data at index visit and 6 months later (n = 1250). Candidate treatment effect modifiers were identified a priori and informed by the literature. Linear mixed models tested for treatment effect modification through tests of statistical interaction. All statistical interactions ( P ≤ 0.20) were stratified by modifier to inspect for specific effects ( P ≤ 0.05). Smoking was identified as a potential effect modifier (treatment * smoking interaction, P = 0.08). In participants who were smokers, the effect of PIPT was (ODI = 5.5; 95% CI: 0.6-10.4; P = 0.03) compared with usual care. In participants who were nonsmokers, the effect of PIPT was (ODI = 1.5; 95% CI: -1.4 to 4.4; P = 0.31) compared with usual care. Pain medication was also identified as a potential effect modifier (treatment × pain medication interaction, P = 0.10). In participants prescribed ≥3 pain medications, the effect of PIPT was (ODI = 7.1; 95% CI: -0.1 to 14.2; P = 0.05) compared with usual care. The PIPT effect for participants prescribed no pain medication was (ODI = 3.5; 95% CI: -0.4 to 7.4; P = 0.08) and for participants prescribed 1 to 2 pain medications was (ODI = 0.6; 95% CI: -2.5 to 3.7; P = 0.70) when compared with usual care. These findings may be used for generating hypotheses and planning future clinical trials investigating the effectiveness of tailored application of PIPT.

Are Surgeons' Tendencies to Avoid Discomfort Associated with Attitudes and Beliefs Toward Patient Psychosocial Factors?

Background: Orthopedic surgeons are sometimes hesitant to assess and address psychosocial factors. Surgeon-specific modifiable factors may contribute to surgeon attitudes and beliefs regarding the mental and social aspects of illness. A better understanding of these factors could help inform interventions to support surgeons and improve patient outcomes. We aimed to investigate whether orthopedic surgeons' self-reported compassion, perceived stress, and experiential avoidance are independently associated with various surgeon attitudes and beliefs regarding psychosocial aspects of health. Methods: This is a cross-sectional study of 165 members of the Science of Variation Group (SOVG). Surgeons completed measures of compassion, stress, experiential avoidance, and demographics. They answered questions addressing attitudes and beliefs regarding psychosocial aspects of care, which were condensed to the following 6 dimensions through factor analysis: (1) confidence, (2) perceived resource availability, (3) blame towards patients, (4) fear of offending patients, (5) professional role resistance, and (6) fear of negative patient reactions. We performed 6 multivariable hierarchical regression analyses to determine whether self-reported compassion, perceived stress, and experiential avoidance were associated with aspects of surgeons' attitudes and beliefs regarding psychosocial care. Results: After accounting for the influence of relevant covariates, experiential avoidance explained 2.9-6.6% of the variance (P-values .002 to .031) in all aspects of surgeon attitudes and beliefs regarding psychosocial care, except for perceived resource availability. Perceived stress and compassion toward others were not associated with any outcome variable. Conclusion: Targeting orthopedic surgeons' tendency to avoid discomfort (i.e., experiential avoidance) via supportive/educational programs may decrease barriers and increase their abilities to address psychosocial factors, resulting in improved patient outcomes.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial.

OBJECTIVE: The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery. METHODS: In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression. RESULTS: Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted. CONCLUSIONS: Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning. IMPACT: This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.

Identifying Perceptions, Experiences, and Recommendations of Telehealth Physical Therapy for Patients With Chronic Low Back Pain: A Mixed Methods Survey.

OBJECTIVE: To describe concerns, advantages, and disadvantages encountered in an evidence-based physical therapy (PT) program for persons with chronic low back pain (CLBP) delivered by telehealth. DESIGN: Mixed methods survey and semistructured interview of persons with CLBP. SETTING: Prospective observational cohort study of persons with CLBP from 3 health care systems receiving 8 sessions of evidence-based telehealth PT. PARTICIPANTS: Participants were selected after completing week 10 (from baseline) assessment from an ongoing cohort study. We enrolled 31 of 126 participants (mean age, 42.4 years; 71.0% female) from the cohort study (N=31). INTERVENTIONS: Participants had completed 8 sessions of evidence-based telehealth PT and participated in semistructured interviews. MAIN OUTCOME MEASURES: Baseline and week 10 and 26 assessments assessed psychosocial risk (StarTBack Screening Tool), working alliance (Working Alliance Inventory-Short Form), pain (Oswestry Disability Index), and health-related quality of life (Patient-Reported Outcomes Measurement Information System-29 profile, version 2). Semistructured interviews were conducted by telephone and consisted of open-ended questions assessing perception, satisfaction, and likelihood of recommending telehealth PT. Participants identified advantages and disadvantages to telehealth PT. Interviews were recorded, transcribed, and coded using an iterative qualitative process. Statistical comparisons by experience were made using analysis of variance (continuous) and Fisher exact test (categorical). RESULTS: Compared with the negative experience group (n=5), participants in positive (n=16) and neutral (n=10) experience groups endorsed higher bond working alliance with their therapist. Participants with a positive experience were more likely to view telehealth PT as cost-saving (n=10, 62.5%) compared with those with a neutral (n=1, 10.0%) or negative (n=1, 20.0%) experience and less likely to view telehealth PT as lower quality (n=0, 0.0%; n=1, 10.0%; n=2, 40.0%, respectively). Prior to starting telehealth, based on semistructured interviews, 18 participants (58.1%) had concerns and these persisted after starting in half of this group. Concerns regarded telehealth being different from or inferior to in-person PT, lack of physical correction, and worries of not using technology appropriately. Convenience, time savings, and personalization were seen as advantages. Difficulty making a personal connection with the therapist, lack of physical correction, and problems with technology were seen as disadvantages. Many participants endorsed a hybrid approach that included in-person and telehealth PT. Providing necessary equipment and technology assistance was seen as ways to improve telehealth PT experience. CONCLUSIONS: Telehealth is an acceptable modality to deliver PT for patients with CLBP with most having a positive experience and reporting advantages. Improvements could include offering a hybrid approach (in-person and telehealth combined) and providing necessary equipment and technical support. More research is needed to optimize the most effective strategies for providing telehealth PT for patients with CLBP.

Outcomes of Telehealth Physical Therapy Provided Using Real-Time, Videoconferencing for Patients With Chronic Low Back Pain: A Longitudinal Observational Study.

OBJECTIVE: To describe the feasibility of an evidence-based physical therapy (PT) program for persons with chronic low back pain (LBP) originally designed for in-person delivery, adapted for telehealth using videoconferencing. DESIGN: Prospective, longitudinal cohort. SETTING: Three health care systems in the United States. PARTICIPANTS: Adults, aged 18-64 years (N=126), with chronic LBP recruited from August through December 2020. INTERVENTION: Up to 8 weekly sessions of telehealth PT. MAIN OUTCOME MEASURES: Follow-up assessments were 10 and 26 weeks after baseline. Participant outcomes collected were the Oswestry Disability Index, Patient-Reported Outcomes Measurement Information System-29 health domains, and pain self-efficacy. Implementation outcomes included acceptability, adoption, feasibility, and fidelity assessed using participant surveys and compliance with session attendance. RESULTS: We enrolled 126 participants (mean age, 51.5 years; 62.7% female). Baseline perceptions about telehealth were generally positive. Eighty-eight participants (69.8%) initiated telehealth PT, with a median of 5 sessions attended. Participants in telehealth PT were generally satisfied (76.3%), although only 39.5% perceived the quality equal to in-person PT. Telehealth PT participants reported significant improvement in LBP-related disability, pain intensity, pain interference, physical function, and sleep disturbance at 10- and 26-week follow-ups. CONCLUSIONS: The findings generally support the feasibility of telehealth PT using videoconferencing. Implementation and participant outcomes were similar to in-person PT as delivered in the participating health care systems. We identified barriers that may detract from the patient experience and likelihood of benefitting from telehealth PT. More research is needed to optimize and evaluate the most effective strategies for providing telehealth PT for patients with chronic LBP.

Trajectories and Individual Differences in Pain, Emotional Distress, and Prescription Opioid Misuse During the COVID-19 Pandemic: A One-Year Longitudinal Study.

Recent studies suggest that the COVID-19 pandemic can serve as a unique psychosocial stressor that can negatively impact individuals with chronic pain. Using a large online sample in the U.S., the present study sought to investigate the impact of the pandemic on the trajectories of pain severity and interference, emotional distress (ie, anxiety and depressive symptoms), and opioid misuse behaviors across one year. Potential moderating effects of socio-demographic factors and individual differences in pain catastrophizing, pain acceptance, and sleep disturbance on outcome trajectories were also examined. Adults with chronic pain were surveyed three times across 1 year (April/May 2020 [N = 1,453]; June/July 2020 [N = 878], and May 2021 [N = 813]) via Amazon's Mechanical Turk online crowdsourcing platform. Mixed-effects growth models revealed that pain severity and interference, emotional distress, and opioid misuse behaviors did not significantly deteriorate across one year during the pandemic. None of the socio-demographic factors, pain catastrophizing, or sleep disturbance moderated outcome trajectories. However, individuals with higher pain acceptance reported greater improvement in pain severity (P< .008, 95% CI: -.0002, -.00004) and depressive symptoms (P< .001, 95% CI: -.001, -.0004) over time. Our findings suggest that the negative impact of the pandemic on pain, emotional distress, and opioid misuse behaviors is quite small overall. The outcome trajectories were also stable across different socio-demographic factors, as well as individual differences in pain catastrophizing and sleep disturbance. Nevertheless, interventions that target improvement of pain acceptance may help individuals with chronic pain be resilient during the pandemic. PERSPECTIVE: Individuals with chronic pain overall did not experience significant exacerbation of pain, emotional distress, and opioid misuse across one year during the COVID-19 pandemic. Individuals with higher pain acceptance showed greater improvement in pain severity and depressive symptoms over time during the pandemic.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After Traumatic Orthopaedic Lower Extremity Injury (CBPT-Trauma).

SUMMARY: Physical and psychological impairment resulting from traumatic injuries is often significant and affects employment and functional independence. Extremity trauma has been shown to negatively affect long-term self-reported physical function, the ability to work, and participation in recreational activities and contributes to increased rates of anxiety and/or depression. High pain levels early in the recovery process and psychosocial factors play a prominent role in recovery after traumatic lower extremity injury. Cognitive-behavioral therapy pain programs have been shown to mitigate these effects. However, patient access issues related to financial and transportation constraints and the competing demands of treatment focused on the physical sequelae of traumatic injury limit patient participation in this treatment modality. This article describes a telephone-delivered cognitive-behavioral-based physical therapy (CBPT-Trauma) program and design of a multicenter trial to determine its effectiveness after lower extremity trauma. Three hundred twenty-five patients from 7 Level 1 trauma centers were randomized to CBPT-Trauma or an education program after hospital discharge. The primary hypothesis is that compared with patients who receive an education program, patients who receive the CBPT-Trauma program will have improved physical function, pain, and physical and mental health at 12 months after hospital discharge.