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BackgroundGiven the relationship between psychological distress and activity tolerance (capability), a stressful life event might diminish accommodation, increase symptoms, and induce a person to seek specialty care. As a first step to investigate this possibility, this study addressed whether difficult life events are associated with greater activity intolerance and pain intensity.MethodsA cohort of 127 patients seeking specialty care for lower extremity symptoms completed questionnaires that inquired about difficult life events within the last 12 months as derived from the Holmes Rahe Life Stress Inventory, and recorded pain intensity on an 11-point ordinal scale, activity tolerance [Patient Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test (CAT)], symptoms of anxiety (GAD-2; 2 item version of the Generalized Anxiety Disorder questionnaire), symptoms of depression (PROMIS Depression CAT), self-efficacy when in pain (Pain Self-Efficacy Questionnaire, 2 question version), and demographics. The treating clinician indicated if the disease was established (e.g. arthritis) or relatively new (e.g. sprain/strain). Bivariate and multivariable analyses sought factors associated with activity intolerance and pain intensity.ResultsGreater activity intolerance was associated with difficult life events in bivariate analyses (t = 2.13, MD = 3.18, 95% C.I. = 0.22–6.13, p = 0.04) and in multivariable analyses that excluded symptoms of depression. Greater pain intensity was not associated with difficult life events, but was associated with surgeon rating of established disease (β = 1.20, 95% C.I. = 0.33–2.08, p < 0.01), greater symptoms of anxiety (MD = 3.35, s = 1.72; ρ = 0.30, p < 0.01), and less education (β =  − 1.06, 95% C.I. =  − 1.94– − 0.18, p = 0.02) (no college degree).ConclusionWhen a musculoskeletal specialist identifies less activity tolerance (less capability) than anticipated for a given injury or pathology, they can anticipate a potential difficult life event, and expect alleviation of symptoms and improved capability as the stress is ameliorated with time and support. Specialists can be prepared to direct people to community or professional support if requested.

Patient-reported experience measures have notable ceiling effects which can hinder efforts to learn and improve. This study tested whether an iterative (Guttman-style) satisfaction questionnaire combined with instructions intended to give people agency to critique us primes responses on an ordinal scale and reduces ceiling effects. Among the 161 subjects randomly assigned to complete an iterative satisfaction questionnaire before or after an ordinal scale, there was no difference in mean satisfaction (no priming). The Guttman scale was more normally distributed and had slightly less ceiling effect when compared to the ordinal scale. Iterative satisfaction scales partially mitigate ceiling effects. The absence of priming suggests that attempts to encourage agency and reflection have limited ability to reduce ceiling effects, and alternative approaches should be tested.

Objectives: Rotator cuff disease is one of the most common reasons for people to seek upper extremity specialty care. Rotator cuff tendinopathy is typically a part of the normal aging process and is often well adapted. Healthcare utilization for the condition varies widely and can range from formal physical therapy to surgery. Evidence of the effectiveness of some interventions for rotator cuff tendinopathy is lacking and for others, such as steroid injection or subacromial decompression, suggests no benefit. There is an opportunity to streamline care for this common condition and, in doing so, conserve finite healthcare resources. The purpose of this study was to characterize the current healthcare utilization for rotator cuff tendinopathy using a large claims database in an effort to identify opportunities to streamline care and develop value-based treatment algorithms. Methods: Using de-identified records in a large claims data base that includes over 350 private-sector payers, we identified patients with a new visit claim between April and June 2016 in one state with an ICD-10 diagnosis code for rotator cuff tendinopathy. The most common atraumatic diagnoses and the frequency of interventions, such as surgery, physical or occupational therapy, advanced imaging, and injections were tracked. We recorded all return visits (including post-operative visits), tests, treatments, and costs for 3 months prior and 6 months after diagnosis. We then calculated the potential cost savings using an alternative treatment strategy for rotator cuff tendinopathy based on value-based care principals. Results: The percentage of enrollees undergoing specific interventions was MRI 19%; physical therapy visit 29%; injections 52%; return visits 44%; and surgery 17%. Alternative treatment strategies, such as a reliance on home exercises rather than formal physical therapy, avoidance of injections and limiting MRIs to patients considering surgery accounted for a potential mean payment that was 8% of the actual mean payments of claims paid out in the database. Conclusions: Conclusion: Our analysis identified notable variation in care of people with rotator cuff tendinopathy. Alternative treatment strategies identified an opportunity for improving value given growing evidence that limiting some of the more commonly used interventions is unlikely to diminish health and might even improve it by increasing self-efficacy.

Objectives: There is a paucity of evidence quantifying the utility and value of pre-referral imaging tests among patients with atraumatic shoulder pain. The primary aim of this study was to assess the prevalence and relative influence of radiographs and MRIs obtained prior to referral to an orthopedic specialist among patients with atraumatic shoulder pain. We hypothesized that there are no patient factors independently associated with undergoing a pre-referral MRI or radiograph. Similarly, there are no factors associated with change of care based on imaging findings, nor do patient factors influence post-referral imaging. Methods: A total of 665 consecutive new adult patients age 35 and older presenting to a single specialty care clinic were included in the study cohort. PROMIS Global Health, PROMIS Mental Health, Patient Health Questionnaire (symptoms of depression), and Generalized Anxiety Disorder questionnaire were completed at the first specialty care visit. Pre-referral shoulder imaging studies were obtained in 462 of 665 (69%) patients; 49% (n = 324) had radiographs and 21% (n = 138) had MRI. We used logistic regression to identify factors independently associated with prereferral imaging and post-referral imaging. We also recorded whether or not pre-referral imaging changed treatment. Results: Pre-referral MRI was associated with worse overall health (P=0.012), greater symptoms of depression (P=0.049), and longer duration of symptoms (P=0.0072). Pre-referral radiographs were associated with worse PROMIS Global Physical Health (P<0.001), worse PROMIS Global Mental Health (p=0.012), greater symptoms of anxiety (p=0.055), greater symptoms of depression (p=0.026), and longer duration of symptoms (p<0.005). There was no relationship between diagnosis and pre-referral MRI or radiographs (p=0.34, p= 0.17). There were no factors associated with post-referral MRI. Post-referral radiograph was associated with worse PROMIS Global Mental Health (p=0.013) and duration of symptoms (p=0.014). Eight of the pre-referral radiographs (2.5%) helped distinguish arthritis from adhesive capsulitis, and six (4%) of the pre-referral MRIs were useful for planning surgery. Ultimately, no images were necessary prior to referral, all could have waited for an order from the specialist. Conclusions: The finding that patient factors, including symptoms of depression or anxiety and poorer overall health correlated with pre-referral imaging suggests that non-specialists may feel pressed to order imaging when patients are more incapable, worried and despairing, perhaps to demonstrate compassion, and possibly in an attempt to prioritize specialty care. Specialists were less influenced by patient factors in ordering imaging tests, perhaps due to a more selective and discerning use of tests largely for planning surgery on discrete pathology. Given that pre-referral imaging does little to influence specialist management, a preferred approach may be immediate specialist referral or electronic consultation without imaging when typical supportive treatments such as a simple set of rotator cuff strengthening exercises are unsatisfying to the patient.

BackgroundWritten communication can convey one’s emotions, personality, and sentiments. Radiology reports employ medical jargon and serve to document a patients’ condition. Patients might misinterpret this medical jargon in a way that increases their anxiety and makes them feel unwell. We were interested whether linguistic tones in MRI reports vary between radiologists and correlate with the severity of pathology.Questions/Purposes(1) Is there variation in linguistic tones among different radiologists reporting MRI results for rotator cuff tendinopathy? (2) Is the retraction of the supraspinatus tendon in millimeters associated with linguistic tones?MethodsTwo hundred twenty consecutive MRI reports of patients with full-thickness rotator cuff defects were collected. Supraspinatus retraction was measured on the MRI using viewer tools. Using Kruskal–Wallis H tests, we measured variation between 11 radiologists for the following tones: positive emotion, negative emotion, analytical thinking, cause, insight, tentativeness, certainty, and informal speech. We also measured the correlation of tones and the degree of tendon retraction. Multilevel mixed-effects linear regression models were constructed, seeking factors associated with the tone, accounting for retraction, the presence of prior imaging, and for the effects of each radiologist (nesting).ResultsThere were statistically significant differences for all of the tones by radiologist. In bivariate analysis, greater retraction of the supraspinatus muscle in millimeters was associated with more negative emotion and certainty, and with less tentativeness. In multilevel mixed-effects linear regression, more negative tones were associated with greater retraction and absence of prior imaging. Greater tentativeness was associated with the absence of prior imaging, but not with retraction.ConclusionsRadiology reports have emotional content that is relatively negative, varies by radiologist and is affected by pathology. Strategies for more hopeful, positive, optimistic descriptions of pathology have the potential to help patients feel better without introducing inaccuracies even if unlikely.Level of EvidenceLevel III, Diagnostic.

BackgroundThe SARS-CoV-2 (COVID-19) pandemic has the potential to evoke lasting changes in the delivery of care, and the utilization of telehealth. We sought associations between surgeon personal factors and greater use of telehealth to treat fractures relative to in-person care.MethodsSeventy-five fracture surgeons participated in a survey-based experiment. All surgeons were asked about their preferences regarding remote compared to in-person communication. Participants rated the following items on slider scales: their degree of introversion, the importance of a hands-on/physical exam and surgeon preferences regarding telehealth. We identified factors associated with the use of, and comfort with, telehealth.ResultsThe use of telehealth during the pandemic was associated with comfort evaluating wounds via telehealth. A greater proportion of remote visits was associated with comfort evaluating wounds and confidence teaching exercises via telehealth. There was consensus that telehealth did not alter utilization rates of radiographs or offer of discretionary surgery. The use of absorbable sutures to limit in-person visits was associated with a preference for working from home and greater comfort with evaluating wounds remotely. The use of 2- and 6-week post-operative telehealth visits and plans to use telehealth after the pandemic (52%) were associated with greater comfort in evaluating wounds through telehealth and greater confidence with video instruction of exercises.ConclusionsThe finding that personal factors are associated with utilization of telehealth helps target strategies for increased use of telehealth and other technologies as the pandemic wanes. Given that telehealth adds convenience for people with ambulatory difficulties or in remote areas, such efforts are warranted.Level of EvidenceNot applicable.

Abstract The Toolkit for Optimal Recovery (TOR) is a mind–body program for patients with acute orthopedic injuries who are at risk for persistent pain/disability. In preparation for a multisite feasibility trial of TOR at three orthopedic trauma centers, we aim to qualitatively identify barriers and facilitators to study implementation and strategies to mitigate the implementation barriers and leverage facilitators.We conducted 18 live video focus groups among providers and three one-on-one interviews with department chiefs at Level 1 trauma centers in three geographically diverse sites (N = 79 participants). Using a content analysis approach, we detected the site-specific barriers and facilitators of implementation of TOR clinical trial. We organized the data according to 26 constructs of the Consolidated Framework for Implementation Research (CFIR), mapped to three Proctor implementation outcomes relevant to the desired study outcomes (acceptability, appropriateness, and feasibility). Across the three sites, we mapped six of the CFIR constructs to acceptability, eight to appropriateness, and three to feasibility. Prominent perceived barriers across all three sites were related to providers’ lack of knowledge/comfort addressing psychosocial factors, and organizational cultures of prioritizing workflow efficiency over patients’ psychosocial needs (acceptability), poor fit between TOR clinical trial and the fast-paced clinic structure as well as basic needs of some patients (appropriateness), and limited resources (feasibility). Suggestions to maximize the implementation of the TOR trial included provision of knowledge/tools to improve providers’ confidence, streamlining study recruitment procedures, creating a learning collaborative, tailoring the study protocol based on local needs assessments, exercising flexibility in conducting research, dedicating research staff, and identifying/promoting champions and using novel incentive structures with regular check-ins, while keeping study procedures as nonobtrusive and language as de-stigmatizing as possible. These data could serve as a blueprint for implementation of clinical research and innovations in orthopedic and other medical settings. Providers reported the main barriers and facilitators for implementation of our multisite feasibility trial of a mind-body program in acute orthopedic trauma, mapped to the 3 outcomes of acceptability, appropriateness, and feasibility.

Despite the pivotal role of psychosocial factors in pain and disability after orthopedic injury, there are no evidence-based preventive interventions targeting psychosocial factors in patients with acute orthopedic injuries. We developed the first mind-body intervention focused on optimizing recovery and improving pain and disability in patients with acute orthopedic injuries who exhibit high levels of catastrophic thinking about pain and/or pain anxiety (Toolkit for Optimal Recovery [TOR] after orthopedic injury). In a pilot single-site randomized controlled trial (RCT), the TOR met a priori set benchmarks for feasibility, acceptability, and satisfaction. The next step in developing TOR is to conduct a multisite feasibility RCT to set the stage for a scientifically rigorous hybrid efficacy-effectiveness trial. The objective of this study is to conduct a rigorous multisite feasibility RCT of TOR to determine whether the intervention and study methodology meet a priori set benchmarks necessary for the successful implementation of a future multisite hybrid efficacy-effectiveness trial. In this paper, we describe the study design, manualized treatments, and specific strategies used to conduct this multisite feasibility RCT investigation. This study will be conducted at 3 geographically diverse level 1 trauma centers, anonymized as sites A, B, and C. We will conduct a multisite feasibility RCT of TOR versus the minimally enhanced usual care (MEUC) control (60 patients per site; 30 per arm) targeting a priori set feasibility benchmarks. Adult patients with acute orthopedic injuries who endorse high pain catastrophizing or pain anxiety will be recruited approximately 1-2 months after injury or surgery (baseline). Participants randomized to the TOR will receive a 4-session mind-body treatment delivered via a secure live video by trained clinical psychologists. Participants randomized to the MEUC will receive an educational booklet. Primary outcomes include feasibility of recruitment, appropriateness, feasibility of data collection, acceptability of TOR (adherence to sessions), and treatment satisfaction across all sites. We will also collect data on secondary implementation outcomes, as well as pain severity, physical and emotional function, coping skills, and adverse events. Outcomes will be assessed at baseline, posttreatment, and at the 3-month follow-up. Enrollment for the RCT is estimated to begin in June 2021. The target date of completion of the feasibility RCT is April 2024. The institutional review board approval has been obtained (January 2020). This investigation examines the multisite feasibility of TOR administered via live videoconferencing in adult patients with acute orthopedic injuries. If feasible, the next step is a multisite, hybrid efficacy-effectiveness trial of TOR versus MEUC. Preventive psychosocial interventions can provide a new way to improve patient and provider satisfaction and decrease suffering and health care costs among patients with orthopedic injuries who are at risk for chronic pain and disability. PRR1-10.2196/28155.

Calcaneus has the most fracture prevalence among tarsal bones. About 3/4 of calcaneal fractures are intra-articular fractures with displacement. The majority of calcaneal fractures occur in 21 - 35 year old young men, and that are mostly active people, these fractures cause complete disability for 15 months. Moreover, inappropriate treatment leads to lots of social and economical damages. In this study we compared the incidence and the severity of peroneal tenosynovitis as a complication of non-operative and operative treatment of intra-articular calcaneal fractures. In this study, some other complications of this fracture were also analyzed and the prevalence of the complication was higher in non-operated patients. A total of 140 patients with intra-articular calcaneal fracture were analyzed prospectively. These patients were divided into 2 groups: operated group and non-operated group. In non-operated group (56 patients), 22 patients were complicated by peroneal tenosynovitis. In operated group (84 patients), 8 patients had the same complication. Statistical analysis revealed that the prevalence, and the severity of this complication in the mentioned groups had a meaningful difference. The results in operated group were much better than the non-operated one. Although some of the orthopedic surgeons are not interested to manage these fractures surgically and most of them treat these cases conservatively (casting, etc.), in most displaced intra-articular calcaneal fractures, surgical treatment is the method of choice. Moreover, in non-surgical treatment the prevalence of these complications among the patients is more and as a result, inevitable social, occupational and familial damages occur.