Leveraging web-based prediction calculators to set patient expectations for elective spine surgery: a qualitative study to inform implementation.

BACKGROUND: Prediction calculators can help set outcomes expectations following orthopaedic surgery, however effective implementation strategies for these tools are unknown. This study evaluated provider and patient perspectives on clinical implementation of web-based prediction calculators developed using national prospective spine surgery registry data from the Quality Outcomes Database. METHODS: We conducted semi-structured interviews in two health systems, Vanderbilt University Medical Center (VUMC) and Duke University Health System (DUHS) of orthopedic and neurosurgery health care providers (VUMC: n = 19; DUHS: n = 6), health care administrators (VUMC: n = 9; DUHS: n = 9), and patients undergoing elective spine surgery (VUMC: n = 16). Qualitative template analysis was used to analyze interview data, with a focus on end-user perspectives regarding clinical implementation of web-based prediction tools. RESULTS: Health care providers, administrators and patients overwhelmingly supported the use of the calculators to help set realistic expectations for surgical outcomes. Some clinicians had questions about the validity and applicability of the calculators in their patient population. A consensus was that the calculators needed seamless integration into clinical workflows, but there was little agreement on best methods for selecting which patients to complete the calculators, timing, and mode of completion. Many interviewees expressed concerns that calculator results could influence payers, or expose risk of liability. Few patients expressed concerns over additional survey burden if they understood that the information would directly inform their care. CONCLUSIONS: Interviewees had a largely positive opinion of the calculators, believing they could aid in discussions about expectations for pain and functional recovery after spine surgery. No single implementation strategy is likely to be successful, and strategies vary, even within the same healthcare system. Patients should be well-informed of how responses will be used to deliver better care, and concerns over how the calculators could impact payment and liability should be addressed prior to use. Future research is necessary to determine whether use of calculators improves management and outcomes for people seeking a surgical consult for spine pain.

Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial.

Importance: Low back and neck pain are often self-limited, but health care spending remains high. Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance. Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT. Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT03083886.

Acute Effects of Interrupting Prolonged Sitting With Intermittent Physical Activity on Blood Pressure in Preadolescent Children.

PURPOSE: To compare the acute effects of intermittent physical activity (PA) across 4 different intensities on blood pressure. METHODS: Thirty children (12 males and 18 females; aged 7-11 y; 33% overweight/obese; 53% nonwhite) completed 4 experimental conditions in random order: 8 hours sitting interrupted with 20, 2-minute low-, moderate-, high-intensity PA breaks, or sedentary screen-time breaks. PA intensity corresponded with 25%, 50%, and 75% of heart rate reserve. Blood pressure was measured during each condition in the morning (0800 h), noon (1200 h), and afternoon (1600 h). RESULTS: There were no significant differences across conditions for systolic blood pressure (SBP; all Ps > .05). There was a significant effect of time with SBP decreasing throughout the day for all conditions (average morning SBP: 106 [1] mm Hg, average noon SBP: 101 [2] mm Hg, average afternoon SBP: 103 [1] mm Hg; P = .01). There were no significant effects of condition or time on diastolic blood pressure (all Ps > .05). CONCLUSION: While sedentary behavior is known to be associated with hypertension in both adults and children, a single bout of prolonged sitting may be insufficient to produce hypertensive effects in otherwise healthy children. Future research should examine the appropriate dose of intermittent PA to accrue hypotensive responses in preadolescent children.

Acute Compensatory Responses to Interrupting Prolonged Sitting With Intermittent Activity in Preadolescent Children.

PURPOSE: The purpose of this study was to compare the effects of intermittent activity performed at varying intensities and of prolonged sitting on physical activity compensation. METHODS: A total of 33 children (14 boys and 19 girls; age 7-11 y; 24% overweight/obese; 61% nonwhite) completed 4 experimental conditions in random order: 8 hours of sitting interrupted with 20 two-minute low-, moderate-, or high-intensity activity breaks or 20 two-minute sedentary computer game breaks. Physical activity energy expenditure (PAEE) was assessed via accelerometry to establish baseline PAEE and throughout each condition day (8-h in-lab PAEE, out-of-lab PAEE, and 3-d postcondition). RESULTS: Compared with baseline PAEE, total daily PAEE was significantly higher during the high-intensity condition day (153 ± 43 kcal, P = .03), unchanged during the low-intensity (-40 ± 23 kcal, P > .05) and moderate-intensity condition days (-11 ± 18 kcal, P > .05), and decreased in response to prolonged sitting (-79 ± 22 kcal, P = .03). There were no significant differences in PAEE 3-day postcondition across conditions (P > .05). CONCLUSION: Despite the varying levels of PAEE accumulated during the 8-hour laboratory conditions, out-of-lab PAEE during each condition day and 3-day postcondition did not change from the baseline. These findings provide preliminary evidence that spontaneous physical activity in children does not change in response to intermittent activity or prolonged sitting.

Acute Effect of Intermittent Exercise and Action-Based Video Game Breaks on Math Performance in Preadolescent Children.

PURPOSE: The purpose of this study was to compare the acute effects of video game breaks and intermittent exercise breaks, performed at varying intensities, on math performance in preadolescent children. METHODS: A total of 39 children (18 males and 21 females; aged 7-11 y) completed 4 experimental conditions in random order: 8 hours of sitting interrupted with 20 two-minute low-, moderate-, or high-intensity exercise breaks or 20 two-minute sedentary computer game breaks. The intensity of exercise breaks for the low-, moderate-, and high-intensity conditions corresponded with 25%, 50%, and 75% of heart rate reserve, respectively. Math performance was assessed 3 times throughout each condition day using a 90-second math test consisting of 40 single-digit addition and subtraction questions. RESULTS: There were no significant differences in percent change in math scores (correct answers out of attempted) by condition [low: -1.3 (0.8), moderate: 0.1 (1.3), high: -1.8 (0.7), and computer: -2.5 (0.8); P > .05]. There were significant differences in percent change in math scores over the course of the condition days with lower math scores reported at end-of-day test compared with midday test [-2.4 (0.5) vs -0.4 (0.3); P = .01]. There were no significant condition × time, time × age, condition × age, or condition × time × age interactions (all Ps > .05). CONCLUSION: Action-based video game and exercise breaks elicit the same level of math performance in children; however, time of day may impact this relationship. These findings may have important implications for instructional time in elementary classrooms.

Combining Wearable Technology and Telehealth Counseling for Rehabilitation After Lumbar Spine Surgery: Feasibility and Acceptability of a Physical Activity Intervention.

OBJECTIVE: The purpose of this study was to examine the feasibility and acceptability of a wearable device and telehealth counseling physical activity intervention early after lumbar spine surgery. METHODS: Sixteen patients were randomized to an 8-session physical activity intervention or to usual postoperative care after surgery. The intervention included a wearable device (ie, Fitbit) and telehealth counseling by a licensed physical therapist. The feasibility of study procedures was assessed through recruitment, randomization, retention, and participation rates. Acceptability was assessed through a satisfaction survey and median within-participant change in objective physical activity (steps per day and time spent in moderate-to-vigorous physical activity [MVPA]) and patient-reported outcomes. RESULTS: Of 64 participants who were eligible, recruitment and randomization rates were 41 and 62%, respectively. Retention for objective physical activity and patient-reported outcomes was 94 and 100%, respectively, at 6-month follow-up. Seven (88%) participants in the intervention group completed all telehealth sessions, and 6 (75%) met step goals over the 8 sessions. All participants in the intervention group found the wearable device and telehealth counseling to be helpful and reported it much or somewhat more important than other postoperative services. Median within-participant change for steps per day improved from baseline (preoperative) to 6 months after surgery for both the intervention (1070) and usual care (679) groups, while MVPA only improved for the intervention group (2.2. minutes per day). Improvements in back and leg pain and disability were noted for both groups. No adverse events were reported in the study. CONCLUSION: Combining wearable technology and telehealth counseling is a feasible approach to promote the physical activity during the early postoperative period after spine surgery. Future randomized controlled trials are needed to investigate the efficacy of leveraging wearables and telehealth during postoperative rehabilitation. IMPACT: This study has implications for the clinical dissemination of physical activity strategies in the rehabilitation setting.

Return to Sports After Anterior Cruciate Ligament Reconstruction: Validity and Reliability of the SPORTS Score at 6 and 12 Months.

Background: The Subjective Patient Outcome for Return to Sports (SPORTS) score is a single-item scale that measures athletes' ability to return to their preinjury sport based on effort and performance. Purpose/Hypothesis: The purpose of this study was to examine the psychometric properties of the SPORTS score and a modified score within the first year after anterior cruciate ligament reconstruction (ACLR). The modified version replaced "same sport" with "any sport" in the answer choices. It was hypothesized that both versions of the SPORTS score would have acceptable floor and ceiling effects and internal responsiveness, moderate convergent validity, and excellent test-retest reliability. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients were recruited preoperatively from 2 academic medical centers. The authors collected responses to the 1-item SPORTS scores at 6 and 12 months after ACLR and the Tegner activity scale, Lysholm knee score, Knee injury and Osteoarthritis Outcome Score (KOOS)-sport/recreation subscale, and Marx activity rating scale preoperatively and 6 and 12 months after ACLR. Ceiling and floor effects and responsiveness were assessed using descriptive statistics and cross-tabulations, respectively, at both follow-up time points. Spearman correlations and intraclass correlation coefficients were used to examine convergent validity and test-retest reliability, respectively. Results: Follow-up rates at 6 and 12 months were 100% and 99%, respectively. Test-retest follow-up was 77%. Floor effects for the SPORTS scores were not observed, while ceiling effects at 12 months ranged from 38% to 40%. Cross-tabulation of the SPORTS scores showed that 64% to 66% of patients reported a change in their score from 6 to 12 months, with significant differences noted between the proportions that improved versus worsened for return to any sport. Convergent validity was observed at 6 and 12 months via moderate correlations with the Tegner, Lysholm, KOOS-sport/recreation, and Marx scores (r = 0.31 to 0.47). Fair to good test-retest reliability (intraclass correlation coefficient, 0.58 and 0.60) was found at 12 months after ACLR. Conclusion: The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.

Design of the Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure Trial (SPINE CARE) study: Methods and lessons from a multi-site pragmatic cluster randomized controlled trial.

BACKGROUND: Low back and neck pain (together, spine pain) are among the leading causes of medical visits, lost productivity, and disability. For most people, episodes of spine pain are self-limited; nevertheless, healthcare spending for this condition is extremely high. Focusing care on individuals at high-risk of progressing from acute to chronic pain may improve efficiency. Alternatively, postural therapies, which are frequently used by patients, may prevent the overuse of high-cost interventions while delivering equivalent outcomes. METHODS: The SPINE CARE (Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure) trial is a cluster-randomized multi-center pragmatic clinical trial designed to evaluate the clinical effectiveness and healthcare utilization of two interventions for primary care patients with acute and subacute spine pain. The study was conducted at 33 primary care clinics in geographically distinct regions of the United States. Individuals ≥18 years presenting to primary care with neck and/or back pain of ≤3 months' duration were randomized at the clinic-level to 1) usual care, 2) a risk-stratified, multidisciplinary approach called the Identify, Coordinate, and Enhance (ICE) care model, or 3) Individualized Postural Therapy (IPT), a standardized postural therapy method of care. The trial's two primary outcomes are change in function at 3 months and spine-related spending at one year. 2971 individuals were enrolled between June 2017 and March 2020. Follow-up was completed on March 31, 2021. DISCUSSION: The SPINE CARE trial will determine the impact on clinical outcomes and healthcare costs of two interventions for patients with spine pain presenting to primary care. TRIAL REGISTRATION NUMBER: NCT03083886.

Acute Effects of Intermittent Physical Activity on Perceptions of Exercise-Related Fatigue in Children.

PURPOSE: To investigate the acute effects of intermittent activity performed at varying intensities on the perceptions of exercise-related fatigue in children. METHODS: A total of 30 children completed 4 experimental conditions in random order, which consisted of 8 hours of sitting interrupted with 20 two-minute low-, moderate-, or high-intensity activity breaks or 20 two-minute sedentary breaks. The perceptions of exercise-related fatigue were determined via the Subjective Exercise Experience Scale at the beginning (0 breaks), middle (after 10 breaks), and end (after 20 breaks) of each condition. RESULTS: The average heart rate was significantly higher with increasing exercise intensity (sedentary: 89.6 ± 1.2 beats/min, low: 114.6 ± 1.8 beats/min, moderate: 147.2 ± 1.8 beats/min, and high: 172.3 ± 1.8 beats/min, P < .0001). There was no significant main effect of condition (sedentary: -0.5 ± 0.6, low: -1.0 ± 0.7, moderate: -0.2 ± 0.5, and high: -0.6 ± 1.2; P = .86) and time (10-0 breaks: -0.7 ± 0.5 and 20-0 breaks: -0.5 ± 0.5; P = .45), nor time by condition interaction (P = .99) on change in exercise-related fatigue. CONCLUSIONS: Incorporating intermittent activity into physical activity programs may help to reduce barriers to regular exercise by minimizing perceptions of exercise-related fatigue in children.

The effects of interrupting prolonged sitting with intermittent activity on appetite sensations and subsequent food intake in preadolescent children.

BACKGROUND: Short-term and long-term exposure to prolonged sitting is associated with excess food intake and weight gain in children. Interrupting prolonged sitting with low-intensity activity has been shown to not alter hunger, satiety, or food consumption in children, however it is unclear whether interrupting sitting with high-intensity activity will alter appetite regulation in children. PURPOSE: The purpose of this study was to examine the acute effects of interrupting prolonged sitting with intermittent activity performed at varying intensities on hunger, satiety, prospective food consumption (PFC), and food intake in preadolescent children. METHODS: Thirty-nine children (ages 7-11 years, 54% female, 33% overweight/obese) completed four experimental conditions in random order: 8 hours of sitting interrupted with 20, 2-minute low-, moderate-, or high-intensity activity breaks or 20, 2-minute sedentary screen time breaks. Exercise intensity corresponded with 25%, 50% and 75% of heart rate reserve, respectively. Hunger, satiety, and PFC were assessed using the Visual Analog Scale, at five time points (pre- and post-breakfast, pre- and post-lunch, and pre-dinner) during each experimental condition. Dietary compensation was assessed as total caloric intake during a post-condition dinner standardized to provide 70% of estimated daily energy requirements. RESULTS: There was a significant effect of time on hunger, satiety, and PFC throughout each condition day (p< 0.001). There were no differences across conditions for hunger (sedentary: 4.9±0.3 cm, low: 5.0±0.3 cm, moderate: 5.1±0.3 cm, high: 5.1±0.3 cm, p>0.05), satiety (sedentary: 4.7±0.3 cm, low: 4.4±0.3 cm, moderate: 4.6±0.3 cm, high: 4.2±0.3 cm, p>0.05), and PFC (sedentary: 4.9±0.3 cm, low: 4.7±0.3 cm, moderate: 4.9±0.3 cm, high: 5.0±0.3 cm, p>0.05). There were no significant differences in post-activity food intake across conditions (sedentary: 1071.9±53.6 kcals; low: 1092.6±43.4kcals; moderate: 996.2±54.6kcals; high: 1138.7±62.8kcals, p>0.05). However, there was a significant effect of condition on energy balance (sedentary: +61.4±65.9 kcals, low: +74.9±57.6 kcals, moderate: -58.3±62.8 kcals, high: -391.2±77.9 kcals; p<0.001). There were no significant effects of weight status on hunger, satiety, PFC, post-activity food intake, and mean energy balance across conditions (all p's>0.05). CONCLUSIONS: Interrupting prolonged sitting with physical activity of any intensity does not alter appetite sensations and subsequent food consumption in children. These data suggest that interventions targeting prolonged sitting with high-intensity intermittent activity may be an effective strategy to increase physical activity energy expenditure without increasing food intake, allowing for a short-term energy deficit in both healthy weight and overweight/obese children. Future studies should examine the long-term effects of interrupting prolonged sitting with activity on food consumption and weight status in preadolescent children.

Affective Responses to Intermittent Physical Activity in Healthy Weight and Overweight/Obese Elementary School-Age Children.

BACKGROUND: The purpose of this study was to examine the acute effects of intermittent physical activity (2-min bouts of varying intensities) on psychological mood and enjoyment in elementary school-age children and to examine the effect of weight status on these psychological outcomes. METHODS: A total of 39 children (healthy weight, n = 26; overweight/obese, n = 13) completed 4 experimental conditions in random order, which consisted of 8 hours of sitting interrupted with 20 two-minute low--, moderate-, or high-intensity activity breaks or 20 two-minute screen-time breaks. Mood was assessed using the Feeling Scale immediately following each break. Enjoyment was assessed using the Physical Activity Enjoyment Scale immediately following 10 and 20 breaks. RESULTS: Mood was significantly higher during the sedentary versus active conditions (P < .01). Overweight/obese children reported lower mood scores compared with healthy weight children at the initiation of the low- (P < .05) and high-intensity conditions (P < .001) but experienced improvements in mood throughout the day in all 3 active conditions (P = .02). Enjoyment was significantly higher after completing the active versus sedentary conditions (P = .02). CONCLUSION: These findings suggest that both healthy weight and overweight/obese children felt better immediately after engaging in screen-time breaks but subsequently rated the activity breaks as more enjoyable compared with screen-time breaks.