Patient-Centered Framework for Rehabilitation Research in Outpatient Settings

Conducting high-quality clinical research is dependent on merging scientific rigor with the clinical environment. This is often a complex endeavor that may include numerous barriers and competing interests. Overcoming these challenges and successfully integrating clinical research programs into clinical practice settings serving rehabilitation outpatients is beneficial from both a logistical perspective (eg, supports efficient and successful research procedures) and the establishment of a truly patient-centered research approach. Leveraging our experience with navigating this research-clinical care relationship, this article (1) proposes the Patient-Centered Framework for Rehabilitation Research, a model for integrating patient-centered research in an outpatient clinical setting that incorporates a collaborative, team-based model encompassing patient-centered values, as well as strategies for recruitment and retention, with a focus on populations living with disabilities or chronic diseases; (2) describes application of this framework in a comprehensive specialty multiple sclerosis center with both general strategies and specific examples to guide adaptation and implementation in other settings; and (3) discusses the effect of the framework as a model in 1 center, as well as the need for additional investigation and adaptation for other populations. The 5 interconnected principles incorporated in the Framework and which prioritize patient-centeredness include identifying shared values, partnering with the clinical setting, engaging with the population, building relationships with individuals, and designing accessible procedures. The Patient-Centered Framework for Rehabilitation Research is a model presented as an adaptable roadmap to guide researchers in hopes of not only improving individual patients’ experiences but also the quality and relevance of rehabilitation research as a whole. Future investigation is needed to test the Framework in other settings.     

Comparison between conventional CT and grayscale inversion CT images in the assessment of the post-operative spinal orthopaedic implants

AimTo compare the accuracy of the inverted greyscale CT versus the conventional CT in the assessment of post-operative spinal orthopaedic implants and osseous fusion.Methods50 patients who had CT as part of their routine spinal implant follow up were evaluated for the presence of fusion, fracture and loosening with conventional CT and with greyscale inverted CT images. 3 independent observers assessed the images 2 months apart. Diagnostic performance (sensitivity and specificity) of the conventional and greyscale inversion images relative to the reference standard were calculated. Agreement with the reference standard was assessed using Cohen's kappa for conventional and greyscale inversion images.ResultsCorrect classifications increased when using the greyscale inverted CT images for each reader compared to conventional CT images (40–46, 39 to 42 and 41 to 44 (out of 50)). Inverted images demonstrated better agreement with the reference standard than conventional grayscale images for assessment of fusion (kappa of 0.588 for inverted CT versus 0.484 for conventional CT) and loosening (kappa 0.386 for inverted versus 0.293 for conventional). Sensitivity was increased for assessment of fusion and loosening. McNemar's test performed for assessment of sensitivity differences showed statistical significance (p = 0.038 for fusion and p = 0.0313 for loosening).ConclusionGreyscale inversion CT is a useful adjunct which has advantages (improved sensitivity and better agreement) over conventional CT imaging in cases of fusion and loosening of metallic implants following spinal instrumentation. We recommend the use of both the greyscale inversion CT images and conventional CT imaging when assessing post-operative spinal orthopaedic implants.     

Pain Trajectories and Predictors: A 7-Year Longitudinal Study of Women With Vulvodynia

IntroductionA significant proportion of women report a reduction of symptoms over time—even without treatment—yet the natural progression of vulvodynia and which factors may explain decrease vs persistence of pain remain unclear.AimTo identify subgroups of pain trajectories in women with vulvodynia and to predict these different trajectories by treatments undertaken, pain characteristics, and psychosocial factors.MethodsData on pain intensity, treatments undertaken, pain characteristics, and psychosocial factors were collected 3 times over a 7-year period from 173 women who screened positive for vulvodynia. Latent class growth analysis was conducted to identify homogeneous subgroups with distinct pain trajectories. A multivariate binomial logistic regression was used to examine whether treatments, pain characteristics, and psychosocial factors predicted these trajectories.Main Outcome MeasureThe main outcome was pain intensity (0–10), measured at 3 time points with the numerical rating scale.Results2 pain trajectories were identified: 1 where pain persisted (28.9%), and 1 where pain decreased over time (71.1%). Whether a treatment had been undertaken was not predictive of the course of pain over time. Women who were older at first pain onset, had pain at another location than the entrance of the vagina, and reported more anxiety were more likely to have a persistent pain trajectory relative to the decreased pain trajectory.Clinical ImplicationsFindings suggest that the evolution of pain differs among women with vulvodynia depending on pain characteristics and anxiety.Strengths & LimitationsStrengths of the study include the 7-year longitudinal design to examine the natural history of provoked vestibulodynia and the inclusion of biopsychosocial factors as predictors of pain trajectories. However, women with major medical and psychiatric illnesses or deep dyspareunia were not included, and, thus, these factors could not be examined as predictors.ConclusionAssessing baseline characteristics associated with different pain trajectories during medical visits could have positive implications for the management of vulvodynia.Pâquet M, Vaillancourt-Morel M-P, Jodouin J-F, et al. Pain Trajectories and Predictors: A 7-Year Longitudinal Study of Women With Vulvodynia. J Sex Med 2019;16:1606–1614.     

Decompression status of the spinal cord after cervical laminoplasty in various body positions and neck postures observed using percutaneous ultrasonography: Relationship with neurological recovery

BackgroundPercutaneous ultrasonography (PUS) is used to evaluate the status of the spinal cord after cervical laminoplasty (CLP). This technique helps assess real-time movements of the spinal cord and provides immediate information regarding the decompression status. Additionally, it can also be utilized to evaluate the status of the spinal cord in various body positions and neck postures. This study aimed to examine changes in the decompression status of the spinal cord after CLP for cervical spondylotic myelopathy (CSM) in different body positions and neck postures using PUS and to assess whether these decompression statuses are related to clinical outcomes at each time point.MethodsThe study included 66 consecutive participants with CSM who underwent double-door CLP with suture anchors. PUS was performed postoperatively at 2 weeks, 3 months, 6 months, and 1 year in sitting [neck flexion (Flexion), neutral (Neutral), and extension (Extension)] and supine (Supine) positions. The decompression status was classified into grade I (noncontact), grade II (contact and apart), and grade III (contact). Clinical outcomes were evaluated using Japanese Orthopaedic Association (JOA) scores.ResultsThe decompression status improved until 3 months postoperatively in all body positions and neck postures and was stable onwards. It changed depending on body positions and neck postures and was worse in Flexion and better in Supine at all postoperative time points. Participants with grade I decompression status in Supine had a significantly better recovery rate of JOA scores after 3 months, 6 months, and 1 year postoperatively than those with grade II + III decompression status. However, this significant relationship was not observed in each sitting position.ConclusionsThe spinal cord after CLP is most decompressed in Supine. Sufficient and continuous restoration of the anterior subarachnoid space in supine position may indicate positive clinical outcomes after CLP.     

Bone Metabolism Discrepancy in Type 2 Diabetes Mellitus Patients With and Without Non-Alcoholic Fatty Liver Disease

To explore the distribution of several bone metabolic indicators in type 2 diabetes patients (T2DM) with and without non-alcoholic fatty liver disease (NAFLD) and to preliminarily evaluate the relationship of bone metabolism with NAFLD in patients with T2DM. The hospitalized patients with T2DM were divided into the group of T2DM complicated with NAFLD and the group of T2DM alone according to the results of ultrasonic diagnosis. The general information and laboratory test data such as bone metabolism indexes of these patients were collected and the differences of the indexes between the 2 groups were compared. Furthermore, the independent influencing factors of NAFLD in patients with T2DM were analyzed. A total of 186 patients were included in the study. Compared with patients with T2DM only, patients with T2DM combined with NAFLD were characterized with younger age (p < 0.001), higher BMI (p = 0.016), ALT (p = 0.001), TG (p = 0.005), HOMA-IR (p = 0.005), and lower HDL-C (p = 0.031). Significant discrepancy of age (OR 1.052, p = 0.001), ALT (OR 0.964, p = 0.047), HOMA-IR (OR 0.801, p = 0.005), and T-PINP (OR 1.022, p = 0.008) was found using multivariate logistic regression model. Significant discrepancy of T-PINP was found in T2DM patients with and without NAFLD. Further studies are needed to explore whether T-PINP could be used as a predictor of fatty liver disease, osteoporosis, and other related complications in patients with T2DM.     

The hip in arthrogryposis

Journal of Children's Orthopaedics - Hip dislocation is seen in approximately 30&nbsp;% of children with amyoplasia and approximately 50&nbsp;% of these will be bilateral. Closed...     

Preoperative scoring system for predicting early adjacent vertebral fractures after Balloon Kyphoplasty

BackgroundAdjacent vertebral fracture (AVF) is a major complication following Balloon Kyphoplasty (BKP). There is no scoring system for predicting AVF using only preoperative elements. The purposes of this study were to develop a scoring system for predicting early AVF after BKP based on preoperative factors and to investigate the appropriate surgical indication for BKP.MethodsOf 220 patients who underwent BKP at a single institution since 2011, 65 patients over the age of 60 who had undergone a standing whole spine X-ray preoperatively were enrolled. Factors affecting the occurrence of early AVF were examined. A scoring system was created consisting of the factors exhibiting significant differences, and the correlation between the total score and the incidence of early AVF was investigated.ResultsTwenty of the 65 patients (30.8%) had early AVF. In a univariate analysis, age, previous vertebral fracture, pelvic tilt, and Local kyphosis significantly influenced early AVF. In a multivariate logistic regression analysis, age had an odds ratio of 1.136 (95% CI 1.001–1.289), previous vertebral fractures 4.181 (1.01–17.309), and Local kyphosis 1.103 (1.021–1.191). The scoring system was set as follows: ①Age (<75 years: 0 points(P), 75years≦: 1P), ②The number of previous vertebral fractures (0: 0 P, 1: 1P, 2: 2P, 3 or more: 3P), and ③Local kyphosis (<10°: 0P, 10°≦: 1P). There was a correlation between the total score and the incidence of early AVF (r = 0.812, 1P = 0.05). The incidence of early AVF was 6.4% (2 cases/31 cases) for a score of ≦1P and 54.5% (18 cases/33 cases) for a score of ≧2P.ConclusionsThere was a correlation between the total score and the incidence of early AVF. A score of 1 point or less may represent the appropriate surgical indication for BKP.     

Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes – a case report

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.