Krista J. Howard

The Development and Psychometric Validation of the Central Sensitization Inventory

Central sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term “central sensitivity syndrome (CSS)” has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs and quantifies the degree of these symptoms. The utility of the CSI, to differentiate among different types of chronic pain patients who presumably have different levels of CS impairment, was then evaluated. Study 1 demonstrated strong psychometric properties (test–retest reliability = 0.817; Cronbach’s alpha = 0.879) of the CSI in a cohort of normative subjects. A factor analysis (including both normative and chronic pain subjects) yielded 4 major factors (all related to somatic and emotional symptoms), accounting for 53.4% of the variance in the dataset. In Study 2, the CSI was administered to 4 groups: fibromyalgia (FM); chronic widespread pain without FM; work‐related regional chronic low back pain (CLBP); and normative control group. Analyses revealed that the patients with FM reported the highest CSI scores and the normative population the lowest (P < 0.05). Analyses also demonstrated that the prevalence of previously diagnosed CSSs and related disorders was highest in the FM group and lowest in the normative group (P < 0.001). Taken together, these 2 studies demonstrate the psychometric strength, clinical utility, and the initial construct validity of the CSI in evaluating CS‐related clinical symptoms in chronic pain populations. ▪

Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population.

BACKGROUND Factors other than surgical technique and implants impact patient outcomes following a total knee arthroplasty. The purpose of this study was to analyze the effects of psychopathology on the rate of improvement following total knee arthroplasty in an indigent population. METHODS One hundred and fifty-four consecutive indigent patients undergoing a primary total knee arthroplasty for arthritis were enrolled and available for follow-up. Patients were classified as having psychopathology on the basis of the presence of somatization, depression, and/or a panic or anxiety disorder as assessed with the Patient Health Questionnaire. Outcome measures were completed preoperatively and one year postoperatively. Univariate analyses, controlled for sex and age, were used to compare the rates of improvement in patients who exhibited psychopathology with the rates in those without psychopathology. RESULTS Fifty-four patients (35%) were diagnosed with at least one Axis-I psychological disorder. The psychopathology group showed significantly lower Short Form-36 mental component summary scores both at baseline and one year postoperatively (p < 0.001 for both). The psychopathology group also reported significantly higher levels of perceived disability at baseline on the Pain Disability Questionnaire (p < 0.001) and worse scores on the Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.004); however, the improvement on both of these scales did not differ significantly between the two groups (p > 0.05). The Knee Society Score differed significantly between the two groups at both baseline and the one-year follow-up evaluation (p = 0.003 and p = 0.001, respectively), but there was no significant difference in the total rate of improvement between the two comparison groups (p > 0.05). CONCLUSIONS Not only is there a high prevalence of psychopathology in the indigent population, but psychopathology may result in lower patient-perceived outcome scores at one year after a total knee arthroplasty. Even though outcome scores may be worse for patients with psychopathology, our study showed that these patients still benefit, with the same degree of improvement in function.

Effects of presenteeism in chronic occupational musculoskeletal disorders: stay at work is validated.

Objective: The present study takes a new approach to understanding how presenteeism relates to chronic pain or disability patient outcomes. Methods: The sample consisted of 2191 consecutive chronic disabling musculoskeletal disorder patients, classified as either presentees (N = 704), or absentees (N = 1487), who were admitted to a functional restoration program. The measures included medical evaluations, demographic data, psychiatric diagnoses at admission, an 1 year follow-up socioeconomic outcome assessment and validated questionnaires evaluating pain, depression, and function. Results: The findings revealed that patients classified as presentees were significantly more likely to complete the prescribed functional restoration treatment program, to return to work (full-duty or full-time), to retain work 1-year posttreatment, and not to have a decrease in job demand from preinjury to posttreatment. Conclusions: Both employees and employers will benefit if the ill or injured employee stays at work postinjury in lieu of short- or long-term disability.

Patients With Chronic Disabling Occupational Musculoskeletal Disorder Failing to Complete Functional Restoration: Analysis of Treatment-Resistant Personality Characteristics

OBJECTIVE To identify the risk factors for noncompletion of a functional restoration program for patients with chronic disabling occupational musculoskeletal disorders. DESIGN Prospective cohort study. SETTING Consecutive patients undergoing functional restoration treatment in a regional rehabilitation referral center. PARTICIPANTS A sample of 3052 consecutive patients, classified as either completers (n=2367) or noncompleters (n=685), who entered a functional restoration program. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The measures used included medical evaluations, demographic data, Diagnostic and Statistical Manual of Mental Disorders psychiatric diagnoses, the Minnesota Multiphasic Personality Inventory, and validated questionnaires evaluating pain, depression, and occupational factors. RESULTS The findings revealed that patients who did not complete the program had a longer duration of total disability between injury and admission to treatment (completers=20mo vs noncompleters=13mo; P<.001). Furthermore, patients who were opioid-dependent were 1.5 times more likely to drop out of rehabilitation, and patients diagnosed with a socially problematic Cluster B Personality Disorder were 1.6 times more likely to drop out. CONCLUSIONS Although some risk factors associated with program noncompletion may be addressed in treatment, socially maladaptive personality disorders, long-neglected disability, and chronic opioid dependence are the major barriers to successful treatment completion. The patients identified with personality disorders may display resistance to treatment and may be difficult for the treatment staff to deal with. Early recognition of these treatment-resistant personality characteristics in the functional restoration process may assist the treatment team in developing more effective strategies to help this dysfunctional group.

Fibromyalgia syndrome in chronic disabling occupational musculoskeletal disorders: prevalence, risk factors, and posttreatment outcomes.

Objective: To identify the prevalence, risk factors, and treatment outcomes of patients with chronic disabling occupational musculoskeletal disorders (CDOMD) who met criteria for fibromyalgia. Methods: This was a prospective prognostic study of a consecutive cohort of CDOMD patients (n = 449) admitted for treatment. Patients were assessed for chronic widespread pain and fibromyalgia. The measures included demographic, injury-related and occupational information, psychosocial measures, and 1-year work status follow-up. Results: The CDOMD patients with fibromyalgia reported higher-level psychosocial distress. Women with fibromyalgia were 9.6 times less likely to return to work 1-year posttreatment and, of those who did, were 4.3 times less likely to retain work. Conclusions: Of this cohort, 23.2% patients met criteria for fibromyalgia. Patients with fibromyalgia were found to show greater psychosocial distress and significantly poorer rates of work return and work retention 1-year postrehabilitation.

Psychosocial Profiles of Indigent Patients with Severe Osteoarthritis Requiring Arthroplasty

This study documents the prevalence of Axis I diagnoses (ie, depression, anxiety, and others) and their effects on preoperative pain, disability, function, and quality of life assessments in an indigent population undergoing total joint arthroplasty. Consecutive indigent patients scheduled for total joint arthroplasty were categorized by psychosocial testing as either psychologically distressed (PD) or nonpsychologically distressed. Of the subjects, 38% were found to be psychologically distressed. The PD group had significantly lower measures on 7 of the 8 components of the Short Form-36, the Harris hip score, and Knee Society score (P < .05). The PD group also scored significantly worse on both the Western Ontario MacMaster (P < .001) and the Pain Disability Questionnaire (P < .001). There is a high prevalence of psychopathology in the indigent population undergoing total joint arthroplasty, exhibiting poorer scores on pain, disability, function, and quality of life measures before surgery.

The Comprehensive Muscular Activity Profile (CMAP): Its High Sensitivity, Specificity and Overall Classification Rate for Detecting Submaximal Effort on Functional Capacity Testing

Introduction A traditional problem faced by clinicians attempting to objectively measure musculoskeletal disorders such as low back pain, where there is often primarily soft tissue involvement, is that psychosocial factors (e.g., fear-avoidance, secondary gain) frequently influence the experience/reporting of pain. Nevertheless, there is still a great need for the quantification of physical function, with appropriate criteria in place, in order to help assess both physical impairment and therapeutic endpoint following treatment. One such potentially objective measure is surface electromyographic (sEMG) recordings during purposeful muscular activity and resting states. The present randomized controlled study assessed the potential validity of a new sEMG approach—the comprehensive muscular activity profile (CMAP)—by addressing the following question: can the CMAP accurately document whether a subject is exerting appropriate muscular effort during range-of-motion and lifting testing, or is submaximum effort being exerted? Methods Eighty healthy volunteers were randomly assigned to either: (1) an instruction group encouraging maximum effort on the tests; or (2) an instruction group encouraging “faking” and not putting in maximum effort on the tests. Therapists, who then administered the CMAP protocol (range-of-motion and lifting tests), were kept blind to subject group assignment. They were also asked to complete a rating scale evaluating whether subjects were exerting maximum effort after all the tests were completed. Results In differentiating between the two instruction groups, the CMAP demonstrated high levels of sensitivity [predicting maximum effort on all tests (ranging from 84.6 to 94.9%)]. In contrast, the sensitivity of the therapists’ ratings was much lower (ranging from only 72.5 to 80.0%). Most importantly, when the CMAP data and therapists’ ratings were combined, logistic regression analyses revealed high rates of sensitivity (94.4–97.2%), specificity (84.6–92.3%), and overall classification (90.7–93.3%). Conclusion The results of this study demonstrate the potential utility of the CMAP, combined with therapist ratings, as a valid method of objectively quantifying subject muscular performance and effort during lumbar range-of-motion and lifting tasks.

Comparison of chronic occupational upper extremity versus lumbar disorders for differential disability-related outcomes and predictor variables.

Objective: To systematically evaluate if an interdisciplinary functional restoration program (FRP), shown to be a viable treatment option for patients with chronic disabling occupational lumbar disorders, is as effective in treating chronic disabling occupational upper extremity disorders. Methods: Participants were 2484 consecutive patients with either arm or lumbar disorders admitted to an FRP. Analyses compared demographic, psychosocial, and work-related factors, and 1-year post-rehabilitation socioeconomic outcomes. Results: Socioeconomic outcomes showed that work-return and work-retention rates after successful completion of the FRP did not differ between the two groups, or among the upper extremity subgroups. Conclusions: FRP is equally effective for patients with chronic upper extremity or lumbar spine disorders, regardless of the injury type, site in the upper extremity, or the disparity in injury-specific and psychosocial factors identified before treatment.

White coat hypertension: improving the patient-health care practitioner relationship.

White coat hypertension is characterized by the variability of a patient’s blood pressure measurements between the physician’s office and the patient’s home environment. A patient with white coat hypertension has high blood pressure levels in the physician’s office and normal blood pressure levels in their typical environment. This condition is likely caused by the patient’s anxiety within the physician’s office and in the presence of the physician. Research has shown that improving the relationship between a patient and their health care provider can decrease the patient’s anxiety, with the implication of decreasing the patient’s likelihood of demonstrating white coat hypertension. This review provides an overview of the previous literature regarding white coat hypertension, its prevalence, and the consequences for those who develop persistent hypertension. Furthermore, this review discusses the implications of improving patient and health care provider interactions through effective communication, empathy, and trust, as well as the implications for future research studies in improving the patient and health care provider’s relationship.

Psychological factors that may influence outcome after joint replacement surgery

Current research on total joint arthroplasty has identified psychological distress as a predictor of poor treatment outcomes. Most recent studies on total knee or hip arthroplasty that include psychological variables have found that preoperative indicators of depression, anxiety, pain catastrophizing and low self-efficacy relate directly to higher levels of pain and lower levels of function postoperatively. The goal of this review was to emphasize the current research that has focused on the psychological factors associated with outcomes of knee and hip replacement. Routinely identifying, assessing and treating those with psychological distress before surgery may be warranted.