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To examine the prognostic value of the Fear Avoidance Model (FAM) variables when predicting pain intensity and disability 10-weeks postoperative following lumbar disc surgery. We recruited patients scheduled for first-time, single level lumbar disc surgery. The following aspects of the FAM were assessed at preoperative baseline and after 10 postoperative weeks: numeric pain rating scale (0-10) for leg and back pain intensity separately, Pain Catastrophizing Scale (PCS), Fear Avoidance Beliefs Questionnaire (FABQ), Beck Depression Inventory (BDI), Oswestry Disability Questionnaire (ODI), and the International Physical Activity Questionnaire (IPAQ). Multivariate regression models were used to examine the best combination of baseline FAM variables to predict the 10-week leg pain, back pain, and disability. All multivariate models were adjusted for age and sex. 60 patients (30 females, mean [SD] age = 40.4 [9.5]) were enrolled. All FAM measures correlated with disability at baseline. Adding FAM variables to each of the stepwise multiple linear regression model explained a significant amount of the variance in disability (Adj. R2 = .38, p < .001), leg pain intensity (Adj. R2 = .25, p = .001), and back pain intensity Adj. R2 = .32, p < .001 at 10-weeks). After adjusting for age and gender, BDI and FABQ-work subscale were the only significant predictors added to each of the prediction models for the 10-week clinical outcome (leg pain, back pain, and ODI). BDI and FABQ-work subscale variables are associated with baseline pain intensity and disability and predict short-term pain and disability following lumbar disc surgery. Measuring these variables in patients being considered for lumbar disc surgery may improve patient outcome.

IntroductionAlthough evidence-based guidelines recommend non-pharmacologic treatments as first-line care for chronic low back pain (LBP), uptake has been limited, particularly in rural, low-income and ethnically diverse communities. The BeatPain study will evaluate the implementation and compare the effectiveness of two strategies to provide non-pharmacologic treatment for chronic LBP. The study will use telehealth to overcome access barriers for persons receiving care in federally qualified health centres (FQHCs) in the state of Utah.Methods and analysisBeatPain Utah is a pragmatic randomised clinical trial with a hybrid type I design investigating different strategies to provide non-pharmacologic care for adults with chronic LBP seen in Utah FQHCs. The intervention strategies include a brief pain consult (BPC) and telehealth physical therapy (PT) component provided using either an adaptive or sequenced delivery strategy across two 12-week treatment phases. Interventions are provided via telehealth by centrally located physical therapists. The sequenced delivery strategy provides the BPC, followed by telehealth PT in the first 12 weeks for all patients. The adaptive strategy uses a stepped care approach and provides the BPC in the first 12 weeks and telehealth PT to patients who are non-responders to the BPC component. We will recruit 500 English-speaking or Spanish-speaking participants who will be individually randomised with 1:1 allocation. The primary outcome is the Pain, Enjoyment and General Activity measure of pain impact with secondary outcomes including the additional pain assessment domains specified by the National Institutes (NIH) of Health Helping to End Addiction Long Initiative and implementation measures. Analyses of primary and secondary measures of effectiveness will be performed under longitudinal mixed effect models across assessments at baseline, and at 12, 26 and 52 weeks follow-ups.Ethics and disseminationEthics approval for the study was obtained from the University of Utah Institutional Review Board. On completion, study data will be made available in compliance with NIH data sharing policies.Trial registration numberNCT04923334.

Purpose This qualitative study explored the health needs of patients after undergoing bariatric surgery. The study specifically aimed to describe the unique physical, emotional, and social challenges patients face following surgery in order to inform the development of future obesity treatment programs. Methods A 90-min focus group was conducted using a semi-structured interview guide. Bariatric surgery patients were enrolled using purposive sampling. The mean number of months since surgery was 20.2 (SD 10.8). The mean age of participants was 53.3 (SD 9.8) years. The focus group was both audio and video recorded, transcribed, and analyzed using topic and analytical coding. Results Three main themes emerged revealing postoperative needs for (1) assistance with physical changes and reduced barriers to exercise, (2) reinforcement for healthy eating behaviors, and (3) emotional support from peers, family, and community. Conclusions Findings suggest that rehabilitation following bariatric surgery is complex in nature and patients may benefit from both pre- and post-surgery programs that address their unique needs. Weight maintenance and sustaining healthy behavior change post-surgery requires ongoing personal and professional assistance. Interventions should emphasize healthy eating practices, include practical exercise suggestions, and offer social and emotional support.

Background Considerable disparities in chronic pain management have been identified. Persons in rural, lower income, and minoritized communities are less likely to receive evidence-based, nonpharmacologic care. Telehealth delivery of nonpharmacologic, evidence-based interventions for persons with chronic pain is a promising strategy to lessen disparities, but implementation comes with many challenges. The BeatPain Utah study is a hybrid type 1 effectiveness-implementation pragmatic clinical trial investigating telehealth strategies to provide nonpharmacologic care from physical therapists to persons with chronic back pain receiving care in ommunity health centers (CHCs). CHCs provide primary care to all persons regardless of ability to pay. This paper outlines the use of implementation mapping to develop a multifaceted implementation plan for the BeatPain study. Methods During a planning year for the BeatPain trial, we developed a comprehensive logic model including the five-step implementation mapping process informed by additional frameworks and theories. The five iterative implementation mapping steps were addressed in the planning year: (1) conduct needs assessments for involved groups; (2) identify implementation outcomes, performance objectives, and determinants; (3) select implementation strategies; (4) produce implementation protocols and materials; and (5) evaluate implementation outcomes. Results CHC leadership/providers, patients, and physical therapists were identified as involved groups. Barriers and assets were identified across groups which informed identification of performance objectives necessary to implement two key processes: (1) electronic referral of patients with back pain in CHC clinics to the BeatPain team and (2) connecting patients with physical therapists providing telehealth. Determinants of the performance objectives for each group informed our choice of implementation strategies which focused on training, education, clinician support, and tailoring physical therapy interventions for telehealth delivery and cultural competency. We selected implementation outcomes for the BeatPain trial to evaluate the success of our implementation strategies. Conclusions Implementation mapping provided a comprehensive and systematic approach to develop an implementation plan during the planning phase for our ongoing hybrid effectiveness-implementation trial. We will be able to evaluate the implementation strategies used in the BeatPain Utah study to inform future efforts to implement telehealth delivery of evidence-based pain care in CHCs and other settings. Trial registration ClinicalTrials.gov Identifier: NCT04923334 . Registered June 11, 2021.

Background A Cardiac-centered Frailty Ontology can be an important foundation for using NLP to assess patient frailty. Frailty is an important consideration when making patient treatment decisions, particularly in older adults, those with a cardiac diagnosis, or when major surgery is a consideration. Clinicians often report patient’s frailty in progress notes and other documentation. Frailty is recorded in many different ways in patient records and many different validated frailty-measuring instruments are available, with little consistency across instruments. We specifically explored concepts relevant to decisions regarding cardiac interventions. We based our work on text found in a large corpus of clinical notes from the Department of Veterans Affairs (VA) national Electronic Health Record (EHR) database. Results The full ontology has 156 concepts, with 246 terms. It includes 86 concepts we expect to find in clinical documents, with 12 qualifier values. The remaining 58 concepts represent hierarchical groups (e.g., physical function findings ). Our top-level class is clinical finding , which has children clinical history finding , instrument finding , and physical examination finding , reflecting the OGMS definition of clinical finding. Instrument finding is any score found for the existing frailty instruments. Within our ontology, we used SNOMED-CT concepts where possible. Some of the 86 concepts we expect to find in clinical documents are associated with the properties like ability interpretation . The concept ability to walk can either be able, assisted or unable . Each concept-property level pairing gets a different frailty score. Each scored concept received three scores: a frailty score, a relevance to cardiac decisions score, and a likelihood of resolving after the recommended intervention score. The ontology includes the relationship between scores from ten frailty instruments and frailty as assessed using ontology concepts. It also included rules for mapping ontology elements to instrument items for three common frailty assessment instruments. Ontology elements are used in two clinical NLP systems. Conclusions We developed and validated a Cardiac-centered Frailty Ontology, which is a machine-interoperable description of frailty that reflects all the areas that clinicians consider when deciding which cardiac intervention will best serve the patient as well as frailty indications generally relevant to medical decisions. The ontology owl file is available on Bioportal at http://bioportal.bioontology.org/ontologies/CCFO .

Therapeutic selective nerve root blocks (SNRBs) are a common intervention for patients with sciatica. Patients often are referred to physical therapy after SNRBs, although the effectiveness of this intervention sequence has not been investigated. This study was a preliminary investigation of the effectiveness of SNRBs, with or without subsequent physical therapy, in people with low back pain and sciatica. This investigation was a pilot randomized controlled clinical trial. The settings were spine specialty and physical therapy clinics. Forty-four participants (64% men; mean age=38.5 years, SD=11.6 years) with low back pain, with clinical and imaging findings consistent with lumbar disk herniation, and scheduled to receive SNRBs participated in the study. They were randomly assigned to receive either 4 weeks of physical therapy (SNRB+PT group) or no physical therapy (SNRB alone [SNRB group]) after the injections. All participants received at least 1 SNRB; 28 participants (64%) received multiple injections. Participants in the SNRB+PT group attended an average of 6.0 physical therapy sessions over an average of 23.9 days. Outcomes were assessed at baseline, 8 weeks, and 6 months with the Low Back Pain Disability Questionnaire, a numeric pain rating scale, and the Global Rating of Change. Significant reductions in pain and disability occurred over time in both groups, with no differences between groups at either follow-up for any outcome. Nine participants (5 in the SNRB group and 4 in the SNRB+PT group) underwent surgery during the follow-up period. The limitations of this study were a relatively short-term follow-up period and a small sample size. A physical therapy intervention after SNRBs did not result in additional reductions in pain and disability or perceived improvements in participants with low back pain and sciatica.

Background Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery. A period of non-surgical management is recommended for most patients, but there is little evidence to guide non-surgical decision-making. We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The results suggested this approach may be effective, particularly in a more specific sub-group of patients. The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation, and within the pre-defined sub-group. Methods/Design The study will recruit 120 patients with low back pain and signs of nerve root irritation. Patients will be randomized to receive an extension-oriented treatment approach, with or without the addition of mechanical traction. Randomization will be stratified based on the presence of the pre-defined sub-grouping criteria. All patients will receive 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments will occur after 6 weeks, 6 months, and 1 year. The primary outcome will be disability measured with a modified Oswestry questionnaire. Secondary outcomes will include self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups, and examine the interaction between treatment and sub-grouping status. Discussion This trial will provide a methodologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation, and will examine the validity of a pre-defined sub-grouping hypothesis. The results will provide evidence to inform non-surgical decision-making for these patients. Trial Registration This trial has been registered with http://ClinicalTrials.gov : NCT00942227

Background The optimal components of postoperative exercise programmes following single-level lumbar discectomy have not been identified. Facilitating lumbar multifidus (LM) function after discectomy may improve postoperative recovery. The aim of this study was to compare the clinical and muscle function outcomes of patients randomised to receive early multimodal rehabilitation following lumbar discectomy consisting of exercises targeting specific trunk muscles including the LM or general trunk exercises. Methods We included participants aged 18 to 60 years who were scheduled to undergo single-level lumbar discectomy. After two postoperative weeks, participants were randomly assigned to receive an 8-week multimodal exercise programme including either general or specific trunk exercises. The primary outcome was pain-related disability (Oswestry Index). Secondary outcomes included low back and leg pain intensity (0–10 numeric pain rating scale), global change, sciatica frequency, sciatica bothersomeness and LM function measured with real-time ultrasound imaging. Treatment effects 10 weeks and 6 months after surgery were estimated with linear mixed models. Results 61 participants were randomised to receive a general trunk (n=32) or specific (n=29) exercise programme. There were no between-group differences in clinical or muscle function outcomes. Participants in both groups experienced improvements in most outcome measures. Conclusions Following lumbar discectomy, multimodal rehabilitation programmes comprising specific or general trunk exercises have similar effects on clinical and muscle function outcomes. Local factors such as the individual patient characteristics identified by specific assessment findings, clinician expertise and patient preferences should direct therapy selection when considering the types of exercises tested in this trial for inclusion in rehabilitation programmes following lumbar disc surgery.

Abstract Physical therapists often treat pain and functional limitations associated with chronic musculoskeletal conditions common in aging adults. While patient report improvement after physical therapy, these results do not translate to sustained physical activity. This is a lost opportunity to support aging adults in adopting behaviors proven to improve quality of life and reduce comorbidity burden. We conducted semi-structured interviews with 30 physical therapists to understand how they support adoption of physical activity and identify what is needed to improve uptake. Physical therapists endorse physical activity as essential in the management of MSK conditions. Eliciting motivation, addressing psychosocial needs, and empowering patients to actively engage in solutions were identified as significant challenges in the effort to change physical activity. At the clinician level, physical therapists identified the need for improved skills in motivational interviewing and person-centered communication. Improved coordination with mental health providers and community resources were identified as environmental needs.

Purpose Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history. Methods We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome. Results Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability ( p  = 0.04) and LBP ( p  = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome. Conclusions Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation.