Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding ...contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery.
We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms?
Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors.
Greater pain intensity in the uninjured leg (regression coefficient RC 0.09 95% CI 0.02 to 0.16; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 95% CI 0.08 to 0.27; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 95% CI -0.38 to -0.12; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms.
A patient's report of concerns regarding pain in the uninjured limb (such as, "I'm overcompensating for the pain in my other leg") can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors.
Level II, prognostic study.
Many symptoms are not associated with a specific, measurable pathophysiology. Such nonspecific illnesses may carry relative social stigma that biases humans in favor of specific diseases. Such a bias ...could lead musculoskeletal surgeons to diagnose a specific disease in the absence of a specific, measurable pathology, resulting in potential overdiagnosis and overtreatment.
(1) What factors are associated with surgeon implicit preference for specific disease over nonspecific illness? (2) What factors are associated with surgeon explicit preference for specific disease over nonspecific illness? (3) Is there a relationship between surgeon implicit and explicit preferences for specific disease over nonspecific illness?
One hundred three members of the Science of Variation Group participated in a survey-based experiment that included an Implicit Associations Test (IAT) to assess implicit preferences for specific, measurable musculoskeletal pathophysiology (specific disease) compared with symptoms that are not associated with a specific, measurable pathophysiology (nonspecific illness), and a set of four simple, face valid numerical ratings of explicit preferences. The Science of Variation Group is an international collaborative of mostly United States and European (85% 88 of 103 in this study), mostly academic (83% 85 of 103), and mostly fracture and upper extremity surgeons (83% 86 of 103), among whom approximately 200 surgeons complete at least one survey per year. The human themes addressed in this study are likely relatively consistent across these variations. Although concerns have been raised about the validity and utility of the IAT, we believe this was the right tool, given that the timed delays in association that form the basis of the measurement likely represent bias and social stigma regarding nonspecific illness. Both measures were scaled from -150, which represents a preference for nonspecific illness, to 150, which represents a preference for specific disease. The magnitude of associations can be assessed relative to the standard deviation or interquartile range. We used multivariable linear regression to identify surgeon factors associated with surgeon implicit and explicit preference for specific disease or nonspecific illness. We measured the relationship between surgeon implicit and explicit preferences for specific disease or nonspecific illness using Spearman correlation.
Overall, there was a notable implicit bias in favor of specific diseases over nonspecific illness (median IQR 70 54 to 88; considered notable because the mean value is above zero neutral by more than twice the magnitude of the IQR), with a modestly greater association in the hand and wrist subspecialty. We found no clinically important explicit preference between specific disease and nonspecific illness (median 8 -15 to 37; p = 0.02). There was no correlation between explicit preference and implicit bias regarding specific disease and nonspecific illness (Spearman correlation coefficient -0.13; p = 0.20).
Given that our study found an implicit bias among musculoskeletal specialists toward specific diseases over nonspecific illness, future research might address the degree to which this bias may account, in part, for patterns of use of low-yield diagnostic testing and the use of diagnostic labels that imply specific pathophysiology when none is detectable.
Patients and clinicians might limit overtesting, overdiagnosis, and overtreatment by anticipating an implicit preference for a specific disease and intentionally anchoring on nonspecific illness until a specific pathophysiology accounting for symptoms is identified, and also by using nonspecific illness descriptions until objective, verifiable pathophysiology is identified.
There are two general frameworks that conceptualize pain that is more intense or persistent than expected based on measurable pathologic findings: the psychological (unhelpful thoughts and emotions) ...and the physiological (purported nervous system dysfunction, such as central sensitization). Some clinicians believe people will be more receptive to a physiological conceptualization. Prior quantitative research demonstrated that carefully crafted psychological explanations are rated similarly to crafted physiological explanations, with relatively mixed reactions. This qualitative study was undertaken in parallel with that quantitative study to help develop effective communication and treatment strategies by identifying specific thoughts and feelings (themes) regarding the physiological and psychological conceptualizations of disproportionate pain that make people more or less comfortable considering comprehensive, biopsychosocial treatment approaches.
What themes arise in patient thoughts and feelings regarding physiological and psychological conceptualizations of pain that is more intense or persistent than expected?
We sought to understand the experience of considering pain as a biopsychosocial experience (phenomenology approach) by studying the thoughts and feelings that arise as people seeking care for arm and back pain engage with physiological and psychological conceptualizations of pain that is more intense or persistent than one would expect based on the pathology. We recruited 29 patients presenting for upper extremity or back pain specialty care at one of two urban offices, intentionally recruiting people of various ages, genders, backgrounds, socioeconomic status, as well as type and duration of pain (purposive sampling). The 29 patients included 18 women and 11 men (16 married, 15 non-White, 20 with arm pain) with a median (interquartile range) age of 62 years (42 to 67). The interviews were conducted by a trained woman orthopaedic surgeon interviewer using a semistructured interview guide soliciting participants' thoughts and feelings about a physiological explanation (nerves in the central nervous system stuck in the on position can make pain more intense) and a psychological explanation (unhelpful thoughts and feelings of distress can make pain more intense) for pain more intense or persistent than expected. The interviews were transcribed and themes were identified as the data were collected. Based on current experimental evidence, including what is known about the physiological effects of thoughts, feelings, and context (placebo/nocebo effects), we assumed an underlying physiological basis for pain that is variably experienced and expressed (mixed postpositive/interpretive approach). Themes were identified in the interview transcripts systematically by two coders and then discussed with the entire research team to arrive at consensus. We stopped enrolling patients when the authors agreed that additional themes did not arise in five consecutive interviews.
The following themes and interpretations were derived from the analysis: Neither the physiological nor the psychological explanation for disproportionate pain (1) avoided the stigma associated with mental health, (2) was consistently understood, (3) provided a consistent sense of control, (4) consistently provided hope, and (5) represented the stress and emotion of disproportionate or persistent pain. The physiological explanation also generated mixed reactions regarding whether or not it: (1) was a useful point of conversation, (2) was reassuring or frightening, and (3) supported physiological or psychological treatments. The psychological explanation made some people feel worse.
People have mixed reactions to both physiological and psychological explanations of disproportionate pain. As such, without direction on content, communication might be most effective by focusing on relational aspects, such as emotional connection and trust.
Although there is room to improve the content of strategies for explaining more pain than expected to patients, our findings extend the discoveries of others in highlighting the need for tailored relational communication strategies that prioritize feeling heard, validated, and accompanied.
Tendinopathy, enthesopathy, labral degeneration, and pathologic conditions of the articular disc (knee meniscus and ulnocarpal) are sometimes described in terms of inflammation or damage, while the ...histopathologic findings are often consistent with mucoid degeneration. A systematic review of the histopathology of these structures at diverse locations might reconceptualize these diseases as expected aspects of human aging. The potential benefits of this evolution might include healthier patient and clinician mindsets as well as a reduced likelihood of overdiagnosis and overtreatment resulting from greater awareness of base rates of pathology.
In this systematic review of studies of surgical specimens, we asked: Are there are any differences in the histopathologic findings of structural soft tissue conditions (mucoid degeneration, inflammation, and vascularity) by anatomic site (foot, elbow, or knee) or structure (tendon body, muscle or tendon origin or insertion enthesis, labrum, or articular disc)?
Studies between 1980 and 2021 investigating the histopathologic findings of specimens from surgery for trigger digit, de Quervain tendinopathy, plantar fasciitis, lateral and medial elbow enthesopathy, rotator cuff tendinopathy, posterior tibial tendinopathy, patellar tendinopathy, Achilles tendinopathy, or disease of the hip labrum, ulnocarpal articular disc, or knee meniscus were searched for in the PubMed, EMBASE, and CINAHL databases. Inclusion criteria were the prespecified anatomic location or structure being analyzed histologically and any findings described with respect to inflammation, vascularity, or mucoid degeneration. Studies were excluded if they were nonhuman studies or review articles. Search terms included "anatomy," "pathology," and "histopathology." These terms were coupled with anatomic structures or disorders and included "trigger finger," "de Quervain," "fasciitis, plantar," "tennis elbow," "rotator cuff tendinopathy," "elbow tendinopathy," "patellar tendonitis," "posterior tibial tendon," and "triangular fibrocartilage." This resulted in 3196 studies. After applying the inclusion criteria, 559 articles were then assessed for eligibility according to our exclusion criteria, with 52 eventually included. We recorded whether the study identified the following histopathologic findings: inflammatory cells or molecular markers, greater than expected vascularity (categorized as quantitative count, with or without controls; molecular markers; or qualitative judgments), and features of mucoid degeneration (disorganized collagen, increased extracellular matrix, or chondroid metaplasia). In the absence of methods for systematically evaluating the pathophysiology of structural (collagenous) soft tissue structures and rating histopathologic study quality, all studies that interpreted histopathology results were included. The original authors' judgment regarding the presence or absence of inflammation, greater than expected vascularity, and elements of mucoid degeneration was recorded along with the type of data used to reach that conclusion.
Regarding differences in the histopathology of surgical specimens of structural soft tissue conditions by anatomic site, there were no differences in inflammation or mucoid degeneration, and the knee meniscus was less often described as having greater than normal vascularity. There were no differences by anatomic structure. Overall, 20% (10 of 51) of the studies that investigated for inflammation reported it (nine inflammatory cells and one inflammatory marker). Eighty-three percent (43 of 52) interpreted increased vascularity: 40% (17 of 43) using quantitative methods (14 with controls and three without) and 60% (26 of 43) using imprecise criteria. Additionally, 100% (all 52 studies) identified at least one element of mucoid degeneration: 69% (36 of 52) reported an increased extracellular matrix, 71% (37 of 52) reported disorganized collagen, and 33% (17 of 52) reported chondroid metaplasia.
Our systematic review of the histopathology of diseases of soft tissue structures (enthesopathy, tendinopathy, and labral and articular disc) identified consistent mucoid degeneration, minimal inflammation, and imprecise assessment of relative vascularity; these findings were consistent across anatomic sites and structures, supporting a reconceptualization of these diseases as related to aging (senescence or degeneration) rather than injury or activity.
This reconceptualization supports accommodative mindsets known to be associated with greater comfort and capability. In addition, awareness of the notable base rates of structural soft tissue changes as people age might reduce overdiagnosis and overtreatment of incidental, benign, or inconsequential signal changes and pathophysiology.
Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic ...opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care.
Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities?
This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses.
After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 95% confidence interval 0.023 to 0.050; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 95% CI 0.03 to 0.09; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 95% CI -0.037 to -0.014; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 95% CI -2.2 to -0.42; p = 0.004 and -0.53 95% CI -0.95 to -0.12; p = 0.01).
Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience.
Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.
We sought to evaluate the potential reinforcement of misconceptions in websites discussing carpal tunnel syndrome (CTS).
After removing all cookies to limit personalization, we entered “carpal tunnel ...syndrome” into five search engines and collected the first 50 results displayed for each search. For each of the 105 unique websites, we recorded publication date, author background, and number of views. The prevalence of potential reinforcement and/or reorientation of misconceptions for each website was then scored using a rubric based on our interpretation of the best current evidence regarding CTS. The informational quality of websites was graded with the DISCERN instrument, a validated tool for assessing online health information.
Every website contained at least one potentially misleading statement in our opinion. The most common misconceptions reference “excessive motion” and “inflammation.” Greater potential reinforcement of misinformation about CTS was associated with fewer page views and lower informational quality scores.
Keeping in mind that this analysis is based on our interpretation of current best evidence, potential misinformation on websites addressing CTS is common and has the potential to increase symptom intensity and magnitude of incapability via reinforcement of unhelpful thoughts regarding symptoms.
The prevalence of patient-directed health information that can increase discomfort and incapability by reinforcing common unhelpful thoughts supports the need for innovations in how we develop, oversee, and evolve healthy online material.
•Potential misinformation on websites addressing CTS is common.•Misinformation on websites has the potential to increase symptom intensity.•Greater reinforcement of misinformation was associated with fewer page views.
Social desirability bias (a tendency to underreport undesirable attitudes and behaviors) may account, in part, for the notable ceiling effects and limited variability of patient-reported experience ...measures (PREMs) such as satisfaction, communication effectiveness, and perceived empathy. Given that there is always room for improvement for both clinicians and the care environment, ceiling effects can hinder improvement efforts. This study tested whether weighting of satisfaction scales according to the extent of social desirability can create a more normal distribution of scores and less ceiling effect. In a cross-sectional study 118 English-speaking adults seeking musculoskeletal specialty care completed 2 measures of satisfaction with care (one iterative scale and one 11-point ordinal scale), a measure of social desirability, and basic demographics. Normality of satisfaction scores was assessed using Shapiro-Wilk tests. After weighting for social desirability, scores on the iterative satisfaction scale had a more normal distribution while scores on the 11-point ordinal satisfaction scale did not. The ceiling effects in satisfaction decreased from 47% (n = 56) to 2.5% (n = 3) for the iterative scale, and from 81% (n = 95) to 2.5% (n = 3) for the ordinal scale. There were no differences in mean satisfaction when the social desirability was measured prior to completion of the satisfaction surveys compared to after. The observation that adjustment for levels of social desirability bias can reduce ceiling effects suggests that accounting for personal factors could help us develop PREMs with greater variability in scores, which may prove useful for quality improvement efforts.
Purpose
Obesity and its associated medical problems increase risk of kidney function decline while prior studies suggest that bariatric surgery may improve kidney outcomes. However, little is known ...about the comparative effectiveness of different types of bariatric surgery on kidney function. In this study, we compare the effects of laparoscopic one anastomosis gastric bypass (LOAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) on kidney function one year after surgery.
Materials and Methods
The patients’ demographic, medical, and surgical data were prospectively collected and retrospectively reviewed. Type 2 diabetes mellitus, hypertension, and dyslipidemia, body mass index (BMI), and kidney function tests were obtained before and one year after surgery. Kidney function was evaluated by estimated glomerular filtration rate (eGFR) and spot urine albumin to creatinine ratio (ACR). Changes in eGFR and ACR were compared between LRYGB vs. LOAGB after adjustment for confounders (age, sex, remission of associated medical problems, preoperative BMI, and percentage of excess BMI loss) using ANCOVA model.
Results
Both surgical techniques significantly decreased the post-surgery presence of diabetes, hypertension, and dyslipidemia (
p
< 0.001 for all paired comparisons). The eGFR level significantly increased and the ACR level significantly decreased in both groups (
p
< 0.001 for all paired comparisons before and after adjustment). However, eGFR and ACR mean differences between LRYGB and LOAGB were not significantly different after adjustment for confounding variables (
p
= 0.9 and 0.4, respectively).
Conclusion
Both LOAGB and LRYGB improved 1-year eGFR and ACR equally independently from weight loss and other confounders.
Background: There is evidence that unhelpful thoughts and distress regarding symptoms are associated with more frequent care utilization. Among people seeing a musculoskeletal specialist in person, ...we sought relationships between mental and social health factors and the number of 1) self-reported in-person healthcare contacts, 2) remote healthcare contacts, and 3) total healthcare contacts during the 6-week period prior to the visit.
Methods: We enrolled 148 adult patients in a cross-sectional study of people visiting a musculoskeletal specialist for a new or return visit. Patients indicated the number of self-reported remote and in-person healthcare contacts, and completed measures of social health, unhelpful thoughts regarding symptoms, general distress, and demographics.
Results: Accounting for potential confounding in multivariable analysis, more pre-visit self-reported in-person care episodes were independently associated with more unhelpful thoughts about symptoms higher score on Negative Pain Thoughts Questionnaire (NPTQ), regression coefficient: 0.05, P < 0.05 and household income between $15000 and $29999 or $30000 and $49999. No factors were associated with the total number of pre-visit remote and in-person care contacts.
Conclusion: The observation that patients with greater unhelpful thinking seek out more in-person care episodes for musculoskeletal symptoms supports the concept that comprehensive care strategies attentive to common unhelpful thoughts regarding symptoms could limit resource utilization.
Prior studies show that stressful life events are associated with greater magnitude of incapability and symptom intensity. We sought to understand the association of such events (i.e., both adverse ...childhood experiences and recent difficult life events DLEs) alongside feelings of worry or despair and unhelpful, on the magnitude of incapability and symptom intensity in musculoskeletal patients. One hundred and thirty-six patients presenting for musculoskeletal specialty care completed measures of incapability, pain intensity, adverse childhood experiences, DLEs in the last year, unhelpful thoughts, symptoms of anxiety and depression, and sociodemographic factors. Factors associated with the magnitude of incapability and pain intensity were sought in multivariable analysis. Accounting for potential confounders, greater incapability was associated with greater unhelpful thoughts (RC = −0.81; 95% CI = −1.2 to −0.42; P ≤ .001), but not with stressful life events (either during childhood or more recently). Greater pain intensity was associated with greater unhelpful thoughts(RC = 0.25; 95% CI = 0.16 to 0.35; P ≤ .001) and being divorced or widowed (RC = 1.8; 96% CI = 0.43 to 3.2; P = .011), but again, not with stressful life events. The strong association of unhelpful thoughts with magnitude of incapability and pain intensity can motivate musculoskeletal specialists to anticipate patients expressing negative pain thoughts and behaviors. Future studies might account for social and environmental context behind stressful life events and the influence of resiliency and pain-coping strategies on these interactions.
Level of Evidence:
Level III, prognostic study
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