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.

Osteoarthritis physical activity care pathway (OA-PCP): results of a feasibility trial.

BACKGROUND: To obtain information on feasibility and acceptability, as well as preliminary data on efficacy, of an Osteoarthritis Physical activity Care Pathway (OA-PCP). METHODS: This was a single group pilot study involving 60 participants with symptomatic, physician diagnosed knee or hip OA, recruited from primary care clinics. Participants self-reported completing less than 150 min per week of moderate-to-vigorous physical activity (MVPA) at baseline. The 3-month OA-PCP intervention involved 3 physical activity (PA) coaching calls (focused on goal setting), three check-in emails and linkage with community-based or online resources to support PA. Efficacy outcomes were collected at baseline and 4-month follow-up. The primary efficacy outcome was minutes of MVPA, assessed via accelerometer. Secondary outcomes included minutes of light intensity activity, sedentary minutes, step counts, and Western Ontario and McMaster Universities (WOMAC) pain and function subscales. Participants were also asked to rate the helpfulness of the OA-PCP intervention on a scale of 0-10. Differences in efficacy outcomes between baseline and 4-month follow-up were assessed using paired t-tests. RESULTS: Among participants beginning the study, 88% completed follow-up assessments and ≥ 90% completed each of the intervention calls. Average daily minutes of MVPA was 8.0 at baseline (standard deviation (SD) = 9.9) and 8.9 at follow-up (SD = 12.1, p = 0.515). There were no statistically significant changes in light intensity activity, sedentary time or step counts. The mean WOMAC pain score improved from 8.1 (SD = 3.6) at baseline to 6.2 (SD = 3.8) at follow-up (p < 0.001); the mean WOMAC function score improved from 26.2 (SD = 13.2) to 20.2 (SD = 12.5; p < 0.001). The mean rating of helpfulness was 7.6 (SD = 2.5). CONCLUSIONS: Results supported the feasibility and acceptability of the study, and participants reported clinically relevant improvements in pain and function. PA metrics did not improve substantially. Based on these results and participant feedback, modifications including enhanced self-monitoring are being made to increase the impact of the OA-PCP intervention on PA behavior. TRIAL REGISTRATION: NCT03780400, December 19, 2018.

Interventions to Improve Long-Term Adherence to Physical Rehabilitation: A Systematic Review.

OBJECTIVE: To evaluate the impact of physical rehabilitation interventions, supplemented with one or more adherence-enhancing components, on outcomes among adults with hip or knee osteoarthritis or chronic lower back pain. DESIGN: Primary literature search from inception of each database to July 27, 2021, guided by relevant search terms and keywords to search titles and abstracts. All articles meeting eligibility criteria were included for data abstraction. DATA SOURCES: MEDLINE, CINAHL Complete, and Embase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomized and nonrandomized trials evaluating adherence-focused intervention components conducted in addition to an index usual care or usual care-like physical rehabilitation program among adults with hip or knee osteoarthritis or chronic low back pain. Eligible studies included a comparator group of the same index physical rehabilitation intervention without the adjunctive adherence components. Included studies measured outcomes at least 3 months after the rehabilitation course. RESULTS: Of the 10 studies meeting inclusion criteria, 6 interventions were delivered concurrent to an index rehabilitation program and 4 were delivered sequentially. Of the 3 studies that reported a positive effect on long-term adherence, only 1 was a low risk of bias study. There is very limited evidence of a beneficial treatment effect of adjunct adherence interventions on long-term physical function, self-efficacy, or adverse events. CONCLUSION: We found inadequate evidence evaluating adherence-enhancing interventions for the specific promotion of long-term adherence to home rehabilitation programs. Future studies should consider testing interventions specifically built to target behavioral maintenance of home rehabilitation programs.

Social Power and the Movement System: Why and How Physical Therapists Might Influence the Upstream Currents of Health.

Social determinants of health are an emerging focus within physical therapist practice, research, education, and advocacy as a necessary condition for movement system health disparities. Fundamental cause theory suggests that the sociopolitical environment sets the context for individuals' socioeconomic positioning, which determines the availability of resources that are necessary for groups and individuals to maintain health. These resources include knowledge, money, power, prestige, and social connections. Yet, it is the hierarchical organization of society that dictates both the availability of socioeconomic resources and the ability of patients and clients to use those resources to promote and maintain movement system health. The presence of social hierarchies indicates the need for physical therapists to consider social power as a key determinant of movement system health. Consideration of social power in clinical initiatives and advocacy agendas would provide a framework for physical therapists to begin the dynamic, and often, adversarial process of breaking down social hierarchies and redistributing social power, rather than simply redistributing socioeconomic resources, in pursuit of societal transformation and community-building. This Perspective discusses social power as the fundamental driver of movement system health inequalities and explores the effects of social power on exposure, susceptibility, experience, and recovery related to movement system pathology-including the influence of social power on the ability of people to acquire socioeconomic resources and convert them to health-relevant resources. This perspective concludes with recommendations for physical therapists to identify and dismantle inequalities in social power through structural competency.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review.

INTRODUCTION: Quality improvement (QI) is a useful methodology for improving healthcare, often through iterative changes. There is no prior review on the application of QI in physical therapy (PT). PURPOSE AND RELEVANCE: To characterize and evaluate the quality of the QI literature in PT. METHODS: We searched four electronic databases from inception through September 1, 2022. Included publications focused on QI and included the practice of PT. Quality was assessed using the 16-point QI Minimum Quality Criteria Set (QI-MQCS) appraisal tool. RESULTS: Seventy studies were included in the review, 60 of which were published since 2014 with most ( n = 47) from the United States. Acute care ( n = 41) was the most prevalent practice setting. Twenty-two studies (31%) did not use QI models or approaches and only nine studies referenced Revised Standards for QI Reporting Excellence guidelines. The median QI-MQCS score was 12 (range 7-15). CONCLUSIONS/IMPLICATIONS: Quality improvement publications in the PT literature are increasing, yet there is a paucity of QI studies pertaining to most practice settings and a lack of rigor in project design and reporting. Many studies were of low-to-moderate quality and did not meet minimum reporting standards. We recommend use of models, frameworks, and reporting guidelines to improve methodologic rigor and reporting.

Social Risk Factors Are Associated With Disability Prevalence - Results From 17 States in the 2017 Behavioral Risk Factor Surveillance System.

PURPOSE: Determine the association between incremental increases in the number of social risk factors and the prevalence of any disability and disability type. DESIGN: The cross-sectional analysis was conducted using 2017 Behavioral Risk Factor Surveillance System data from states whose surveys included items about social risk factors. SETTING: Respondents from 17 US states. SUBJECTS: Respondents included 136 432 adults. MEASURES: Dichotomized social risk factors included food, housing, and financial insecurity, unsafe neighborhood, and healthcare access hardship. ANALYSIS: Weighted χ2 and logistic regression analyses adjusted for demographic characteristics, measures of socioeconomic position, and comorbid health conditions were used to examine differences in the prevalence of disability by social risk factor and via a social risk index created by summing the social risk factors. RESULTS: Compared to those reporting 0 social risk factors, respondents reporting ≥4 had more than thrice the odds of reporting a cognition ((adjusted odds ratio [AOR]=3.37; 95%CI [2.75-4.13]), independent living (AOR=3.24 [2.52-4.15]), self-care (AOR=3.33 [2.55-4.34]), or any disability (AOR=3.90 [3.24-4.70]); more than twice the odds of reporting a vision (AOR=2.61 [1.93-3.52]) or mobility (AOR=2.72 [2.16-3.41]) disability; and more than 1.5 times the odds of reporting a hearing disability (AOR=1.59 [1.22-2.07]). CONCLUSIONS: Incremental increases in the number of social risk factors were independently associated with higher odds of disability. Intervention efforts should address the social context of US adults with disabilities to improve health outcomes.

From expert to coach: health coaching to support behavior change within physical therapist practice.

BACKGROUND: Negative health behaviors are a significant risk factor for non-communicable diseases (NCDs) and are responsible for 40-50% of the burden of disease in the US population. Physical therapists (PTs) have the capacity to effect behavior change in their patients to reduce their risk of disease and promote health. Competence in health behavior change is recommended for physical therapists. One way to achieve this competence is by learning and adopting a health coaching approach. OBJECTIVES: To provide a theoretical and practical approach to applying a health coaching approach in physical therapist clinical practice. METHODS: 1) Describe a health coaching approach to facilitating behavior change; 2) present behavior change theories, communication strategies, and models underpinning health coaching; and 3) provide suggestions for ways PTs can integrate health coaching in clinical practice. RESULTS: Health coaching is a dynamic and collaborative approach to health behavior change that harnesses the patient's or client's values and strengths to realize their goals for health. CONCLUSION: Adopting a health coaching approach may enhance adherence to physical therapists' recommendations as well as improve health outcomes.

Strengthening Population Health Perspectives in Physical Therapist Practice Using Epigenetics.

Health starts where we live, learn, work, and play. Population health represents a unifying paradigm for understanding systematic variations in health and related factors, informing integrated action, and reducing health disparities. The pathways connecting social, environmental, and structural factors and various health outcomes have been illuminated by the emergence of epigenetic and epigenomic research, further bolstering the value of population health perspectives in supporting clinical practice, community-based programs, and societal policies. The purpose of this perspective is to consider the placement of epigenetic and epigenomic insights within a population health framework to strengthen the physical therapy profession's understanding of variations in health, inform integrated action, and further justify our role in reducing health-related disparities.

Physical Activity Promotion: Moving From Talking the Talk to Walking the Walk.

SYNOPSIS: Despite its demonstrated efficacy, physical activity (PA) promotion is not routinely practiced by clinicians. We provide recommendations to improve PA promotion in routine clinical practice by (1) improving clinicians' capacity through enhancing knowledge, skills, and confidence and (2) improving organizations' capacity through building PA promotion pathways. Promoting PA in routine clinical practice is urgently needed to maximize clinicians' impact on the health of society. J Orthop Sports Phys Ther 2022;52(5):236-242. doi:10.2519/jospt.2022.10859.

Identifying Factors That Influence Physical Activity Promotion in Outpatient Physical Therapist Practice Using the Theoretical Domains Framework.

BACKGROUND AND PURPOSE: Physical activity (PA) promotion is not routine practice for physical therapists. Understanding the PA promotion beliefs of physical therapists may offer targets for behavior change interventions to improve PA promotion. The purpose of this study was to explore outpatient US physical therapists' beliefs about PA promotion and determine which Theoretical Domains Framework (TDF) domains can inform implementation efforts. METHODS: We used a descriptive qualitative research design. A TDF-based interview guide was developed to identify beliefs about PA promotion. Twenty-six outpatient US physical therapists (13 regular PA promoters and 13 irregular PA promoters) completed semistructured interviews. Directed content analysis identified specific beliefs by grouping similar belief statements. Specific beliefs were mapped to TDF domains. RESULTS AND DISCUSSION: Five TDF domains were identified as likely relevant to changing physical therapists' PA promotion behaviors. Key beliefs within those domains included conflicting comments about PA guidelines being evidence based, a lack of confidence to promote PA due to perceived deficits in communication skills, and time constraints as key barriers. Beliefs about improving PA promotion included incorporating screening for baseline PA and continuing education targeting confidence and communication. CONCLUSIONS: We identified key beliefs that influence outpatient US physical therapists' PA promotion. These beliefs identify targets for behavior change interventions to improve PA promotion rates among outpatient US physical therapists including incorporating baseline screening for PA and the development of continuing education training programs.

The Collective Influence of Social Determinants of Health on Individuals Who Underwent Lumbar Spine Revision Surgeries: A Retrospective Cohort Study.

OBJECTIVE: To analyze the collective effect of social determinants of health (SDH) on lumbar spine revision surgery outcomes using a retrospective cohort study design. METHODS: Data from the Quality Outcomes Database were used, including 7889 adults who received lumbar spine revision surgery and completed 3 and 12 months' follow-up. The SDH of interest included race/ethnicity, educational attainment, employment status, insurance payer, and sex. A stepwise regression model using each number of SDH conditions present (0 of 5, 1 of 5, 2 of 5, ≥3 of 5) was used to assess the collective influence of SDH. The odds of demonstrating a minimum clinically important difference was evaluated in back and leg, disability, quality of life, and patient satisfaction at 3-months and 12-months follow-up. RESULTS: An additive effect for SDH was found across all outcome variables at 3 and 12 months. Individuals with ≥3 SDH were at the lowest odds of meeting the minimum clinically important difference of each outcome. At 12 months, individuals with ≥3 SDH had a 67%, 65%, 71%, 65%, and 46% decrease in the odds of a clinically meaningful outcome in back and leg pain, disability, quality of life, and patient satisfaction. CONCLUSIONS: Health care teams should evaluate SDH in individuals who may be considered for lumbar spine revision surgery. Viewing social factors in aggregate may be useful as a screening tool for lumbar spine revision surgeries to identify at risk patients who may require pre-emptive care strategies and postoperative resources to mitigate these risks.

Physical Therapists' Knowledge, Skills, Beliefs, and Organizations Impact Physical Activity Promotion: A Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study was to characterize factors that influence physical therapists' physical activity (PA) promotion practices and map these factors to the Theoretical Domains Framework (TDF) to inform future implementation efforts. METHODS: Six databases (MEDLINE, EMBASE, Scopus, CINAHL, PsychInfo, and Web of Science) were searched from inception to March 11, 2021. Studies were included if they reported physical therapists' PA promotion practices and factors influencing these practices. Study quality was assessed with a modified Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme checklist. Studies were excluded if they did not separate physical therapist PA promotion practices and influencing factors from other health professionals. RESULTS: The search yielded 12,835 references and 27 included studies. Twenty studies were included in a meta-analysis of proportions, whereas 15 studies were included in a meta-analysis of correlations. Very-low to moderate-quality evidence suggests that factors at the individual and organizational levels have very small to moderate associations with PA promotion practices. CONCLUSION: Efforts to improve PA promotion by physical therapists should consider incorporating combinations of individual and organizational factors. Limitations to the body of evidence highlight the need for future research. IMPACT: With PA projected to decrease in the general population by an additional 20% by 2050, PA promotion is urgently needed to maximize physical therapists' impact on the health of society. This study identifies factors that may prove useful for guiding the development of strategies to encourage greater engagement in PA promotion by physical therapists.

Social risk factors predicting outcomes of cervical myelopathy surgery.

OBJECTIVE: Combinations of certain social risk factors of race, sex, education, socioeconomic status (SES), insurance, education, employment, and one's housing situation have been associated with poorer pain and disability outcomes after lumbar spine surgery. To date, an exploration of such factors in patients with cervical spine surgery has not been conducted. The objective of the current work was to 1) define the social risk phenotypes of individuals who have undergone cervical spine surgery for myelopathy and 2) analyze their predictive capacity toward disability, pain, quality of life, and patient satisfaction-based outcomes. METHODS: The Cervical Myelopathy Quality Outcomes Database was queried for the period from January 2016 to December 2018. Race/ethnicity, educational attainment, SES, insurance payer, and employment status were modeled into unique social phenotypes using latent class analyses. Proportions of social groups were analyzed for demonstrating a minimal clinically important difference (MCID) of 30% from baseline for disability, neck and arm pain, quality of life, and patient satisfaction at the 3-month and 1-year follow-ups. RESULTS: A total of 730 individuals who had undergone cervical myelopathy surgery were included in the final cohort. Latent class analysis identified 2 subgroups: 1) high risk (non-White race and ethnicity, lower educational attainment, not working, poor insurance, and predominantly lower SES), n = 268, 36.7% (class 1); and 2) low risk (White, employed with good insurance, and higher education and SES), n = 462, 63.3% (class 2). For both 3-month and 1-year outcomes, the high-risk group (class 1) had decreased odds (all p < 0.05) of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Being in the low-risk group (class 2) resulted in an increased odds of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Neither group had increased or decreased odds of being satisfied with surgery. CONCLUSIONS: Although 2 groups underwent similar surgical approaches, the social phenotype involving non-White race/ethnicity, poor insurance, lower SES, and poor employment did not meet MCIDs for a variety of outcome measures. This finding should prompt surgeons to proactively incorporate socially conscience care pathways within healthcare systems, as well as to optimize community-based resources to improve outcomes and personalize care for populations at social risk.

Connecting at the Webside: Rapid Telehealth Implementation for Musculoskeletal Clinicians.

SYNOPSIS: Telehealth is rapidly being implemented during the COVID-19 pandemic. Despite evidence for the effectiveness of telehealth for musculoskeletal examination and treatment, there is a lack of clear guidance related to implementation. We provide recommendations on practical concerns related to delivering telehealth, including choice of platform; legal, ethical, and administrative considerations; building a "webside manner"; and implications for musculoskeletal examination and treatment. J Orthop Sports Phys Ther 2021;51(1):8-11. doi:10.2519/jospt.2021.9902.

Physical Activity Promotion Attitudes and Practices Among Outpatient Physical Therapists: Results of a National Survey.

BACKGROUND AND PURPOSE: Physical activity (PA) promotion delivered by physical therapists is effective. However, little is known about how much PA promotion is integrated into outpatient US physical therapist practice. The purpose of this study was to determine the current PA promotion practices and factors that influence those practices among outpatient US physical therapists. METHODS: A sample of outpatient US physical therapists from the Academy of Orthopaedic Physical Therapy and American Physical Therapy Association (APTA) Geriatrics completed an adaptive online survey that included questions related to PA promotion practices and factors that influence those practices. We dichotomized levels of PA promotion as regular and irregular. Multivariable logistic regression was used to determine what factors predicted regular PA promotion. RESULTS AND DISCUSSION: A total of 522 individuals participated and 393 surveys were included in the analyses (75.3%). Most participants (58.5%) irregularly promoted PA and few reported always screening for patients' PA levels (12.7%). The strongest predictor of regularly promoting PA was screening for baseline PA (odds ratio = 5.07, 95% confidence interval = 2.23, 11.57). Physical therapists' own PA levels compared favorably to the US adult population and other health professionals and predicted PA promotion. Other factors related to capability, opportunity, and environment were predictors of PA promotion. Perceived lack of financial support from insurance companies, lack of support from clinical employers, and a perception of competing priorities were barriers to PA promotion. Despite being a public health priority, the majority of physical therapists surveyed infrequently screen for baseline PA and irregularly promote PA. Perceived financial barriers, lack of organizational support, and prioritizing other patient problems hinder PA promotion in the outpatient setting. CONCLUSION: Despite guidance from national and international governing bodies, US outpatient physical therapists do not regularly promote PA to patients and perceive financial constraints and competing priorities as key barriers. Professional and patient stakeholders should be involved in designing pathways to improve PA promotion practices among outpatient US physical therapists.

Construct Validity and Item Response Theory Analysis of the PROMIS-29 v2.0 in Recipients of Lumbar Spine Surgery.

STUDY DESIGN: Observational cohort design involving measurement property assessment. OBJECTIVES: The aim of this study was to assess construct validity through hypothesis testing and to examine reliability and discrimination of the PROMIS-29 v2.0 using item response theory (IRT) analyses. SUMMARY OF BACKGROUND DATA: Patient-Reported Outcomes Measurement Information System (PROMIS) 29.0 version 2.0 includes 28 questions for the seven domains of Physical function, Anxiety, Depression, Fatigue, Sleep disturbance, Social role, and Pain interference, and one item related to pain intensity. To date, the tool has not been tested for construct validity for selected concepts, nor has it been evaluated using IRT in a population of spine surgery recipients. METHODS: Using the Quality Outcomes Dataset lumbar registry, we evaluated the construct validity of the PROMIS-29 v2.0 against pain intensity measures for back and leg, the Oswestry Disability Index, the EQ5D 3L-visual analog scale (quality of life) and proxy measures of activities, mobility and self-care. IRT was used to test PROMIS-29 v2.0 assumptions and fit. RESULTS: The sample included 652 surgery recipients (mean age = 60.1, SD = 14.0) who had a high level of baseline disability. Hypothesis testing confirmed direction and magnitude of correlation between the PROMIS and legacy measures in 10 of the 12 hypotheses. IRT identified three misfit items, but otherwise adequate scale reliability and unidimensionality. CONCLUSION: The PROMIS-29 v2.0 measures several different constructs pertinent to a patient's health and recovery during spine surgery. We feel that the PROMIS-29 v2.0 tool is a useful and effective outcome measure for populations who receive spine surgery.Level of Evidence: 4.

What Are DPT Program Practices and Attitudes Related to Population Health, Prevention, Health Promotion, and Wellness? Results of a National Survey.

OBJECTIVE: Noncommunicable diseases have increased in prevalence and are now responsible for the majority of the burden of disease. Aligning entry-level (professional) physical therapist education with these changing societal needs may position physical therapists to best address them. However, no comprehensive understanding of the practices and attitudes related to population health, prevention, health promotion, and wellness (PHPW) content among accredited US professional doctor of physical therapy (DPT) programs has been established. This study aims to identify practices and attitudes related to PHPW content among accredited US DPT programs. METHODS: A mixed-methods cross-sectional design using an electronic survey was utilized. Program directors of each accredited DPT program were identified using an official Commission on Accreditation in Physical Therapy Education list and invited to ascertain the perceived importance of PHPW, describe the delivery of PHPW content, and identify factors that influence inclusion of PHPW content in US DPT programs. RESULTS: Individuals from 49% of 208 invited programs responded. Nearly all programs reported teaching prevention (96.1%), health promotion (95.1%), and wellness content (98.0%), while fewer reported teaching population health (78.4%). However, only 15% of PHPW topics were covered in depth. Facilitators and barriers to the delivery of PHPW content were reciprocal and included faculty with PHPW expertise, logistical flexibility and support, and the perceived importance of PHPW content. CONCLUSIONS: The majority of US DPT programs are teaching PHPW content. Lack of trained faculty and lack of professional competencies hinder further integration of PHPW content into curricula. IMPACT: The findings of this study highlight avenues for additional research to determine professional PHPW competencies and additional educational needs for faculty members.

Health and wellness coaching positively impacts individuals with chronic pain and pain-related interference.

OBJECTIVES: Health and wellness coaching (HWC) interventions have been reported to improve health outcomes for individuals with chronic diseases such as diabetes, cardiovascular disease, or cancer. However, HWC also holds potential as an effective intervention within a biopsychosocial chronic pain management framework. The aim of the present study was to evaluate the effects of HWC on individuals with chronic pain. METHODS: Participants were referred by their primary care provider or insurance company to a comprehensive telephonic 12-month pain management HWC program. Relationships between pain outcomes and physical and psychological factors were retrospectively analyzed. Mixed linear-effects modeling explored whether physical and psychological variables were associated with pain outcomes over time. RESULTS: Four hundred nineteen participants (female, 58.9%; mean age, 54.8) enrolled in the program and 181 completed the intervention. After 12 months in the program, statistically and clinically significant reductions were observed for pain intensity (Hedges' g = 1.00) and pain-related interference (Hedges' g = 1.13). Linear mixed-effects modeling indicated that improvements in physical functioning and psychological factors were associated with improvements in pain intensity. DISCUSSION: Our results provide a novel analysis on the effects of HWC on chronic pain and pain-related interference. HWC appears to be a promising intervention to improve pain-related outcomes in a population with chronic pain. Further investigation of HWC as an intervention for chronic pain is warranted.

Quantifying the collective influence of social determinants of health using conditional and cluster modeling.

OBJECTIVES: Our objective was to analyze the collective effect of social determinants of health (SDoH) on lumbar spine surgery outcomes utilizing two different statistical methods of combining variables. METHODS: This observational study analyzed data from the Quality Outcomes Database, a nationwide United States spine registry. Race/ethnicity, educational attainment, employment status, insurance payer, and gender were predictors of interest. We built two models to assess the collective influence of SDoH on outcomes following lumbar spine surgery-a stepwise model using each number of SDoH conditions present (0 of 5, 1 of 5, 2 of 5, etc) and a clustered subgroup model. Logistic regression analyses adjusted for age, multimorbidity, surgical indication, type of lumbar spine surgery, and surgical approach were performed to identify the odds of failing to demonstrate clinically meaningful improvements in disability, back pain, leg pain, quality of life, and patient satisfaction at 3- and 12-months following lumbar spine surgery. RESULTS: Stepwise modeling outperformed individual SDoH when 4 of 5 SDoH were present. Cluster modeling revealed 4 distinct subgroups. Disparities between the younger, minority, lower socioeconomic status and the younger, white, higher socioeconomic status subgroups were substantially wider compared to individual SDoH. DISCUSSION: Collective and cluster modeling of SDoH better predicted failure to demonstrate clinically meaningful improvements than individual SDoH in this cohort. Viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDoH on outcomes.