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Papers by Heidi Prather

Bone & Joint Open

AimsThe primary aim of this prospective, multicentre study is to describe the rates of returning ... more AimsThe primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery.MethodsThis is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undert...

Acupuncture in Medicine

Background: To assess whether structure-based medical acupuncture (SMA) can improve Patient-Repor... more Background: To assess whether structure-based medical acupuncture (SMA) can improve Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients presenting with musculoskeletal pain. Methods: An audit was conducted of all patients presenting with musculoskeletal pain treated by a single provider with SMA in 2017. Inclusion criteria included a pre-treatment and at least one post-treatment PROMIS score. Patient demographics and previous treatments tried were recorded. Documented events other than acupuncture that were thought to interfere with PROMIS scores were recorded, and no further scores were used after these events. A maximum of nine visits after the initial visit were used. The PROMIS domains assessed included anxiety, depression, pain interference and physical function. Results: Seventy-two patients who had been treated with SMA met the inclusion criteria. Sixty-five of the patients (90%) had chronic pain. For their presenting complaint, 59 (82%) had p...

American Journal of Lifestyle Medicine

Interprofessional care improves outcomes for medically complex patients and may be a valuable add... more Interprofessional care improves outcomes for medically complex patients and may be a valuable addition to standard lifestyle medicine practice, but implementation barriers exist. The purpose of this study was to explore the key features, perceived impact, and implementation considerations related to holding interprofessional team meetings as part of an intensive lifestyle medicine program. In this mixed-methods study, focus groups were conducted with 15 lifestyle medicine clinicians from various healthcare disciplines who had participated in interprofessional team meetings. Quantitative descriptive statistics of the meeting minutes were also calculated. Clinician-perceived benefits from participating in interprofessional team meetings included increased acquisition of knowledge, access to other clinicians, collaborative decision-making, patient satisfaction, and achievement of patient-centered goals. Participants described the importance of preparing an agenda for the interprofessio...

The Spine Journal, 2021

BACKGROUND CONTEXT High quality evidence is difficult to generate, leaving substantial knowledge ... more BACKGROUND CONTEXT High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) is a means of determining appropriate recommendations when high quality evidence is lacking. PURPOSE Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine. STUDY DESIGN/SETTING Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations. OUTCOME MEASURES Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters. METHODS Inclusion criteria for scenarios included patients aged 18-80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed. RESULTS Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, P < 0.01). A multivariable ordinal regression adjusting for symptom type, diagnosis and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance. CONCLUSIONS Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."

American Journal of Physical Medicine & Rehabilitation, 2021

Objective: To better address sociodemographic-related health disparities, this study examined whi... more Objective: To better address sociodemographic-related health disparities, this study examined which sociodemographic variables most strongly correlate with self-reported health in patients with chronic musculoskeletal pain. Design: This single-center, cross-sectional study examined adult patients followed by a physiatrist for chronic (≥4 years) musculoskeletal pain. Sociodemographic variables considered were race, sex, and disparate social disadvantage (measured as residential address in the worst versus best Area Deprivation Index national quartile). The primary comparison was the adjusted effect size of each variable on physical and behavioral health (measured by Patient-Reported Outcomes Measurement Information System (PROMIS)). Results: In 1,193 patients (age 56.3±13.0 years), disparate social disadvantage was associated with worse health in all domains assessed

Orthopaedic Journal of Sports Medicine, 2020

Background: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetab... more Background: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes. Purpose: To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation. Study Design: Cohort study; Level of evidence, 3. Methods: An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted ...

PM&R, 2020

BackgroundDifferences in patient–physician interactions based on physician gender have been demon... more BackgroundDifferences in patient–physician interactions based on physician gender have been demonstrated. However, the association between patients' self‐perceived health and their decision to see a female versus male physician is still unclear.ObjectiveTo determine if self‐reported physical or behavioral health is different in musculoskeletal patients who present to female vs male physicians. We hypothesized that patients who present to female physicians report worse physical and behavioral health.DesignCross‐sectional study.SettingTertiary academic medical center.PatientsConsecutive 21 980 adult patients who presented to a musculoskeletal medicine specialist for initial evaluation of a musculoskeletal condition between April 1, 2016 and November 1, 2017.Main Outcome MeasuresPhysical Function, Pain Interference, Anxiety, and Depression Computer Adaptive Test domains of the Patient‐Reported Outcomes Measurement Information System (PROMIS). The primary study outcome was the mean ...

Journal of Sport Rehabilitation, 2019

Context: Although elite adolescent female soccer athletes have unique injury risk factors and man... more Context: Although elite adolescent female soccer athletes have unique injury risk factors and management challenges, limited epidemiological data exist for this population. Objective: To describe lower-body injury patterns and to determine whether a screening hip physical examination is predictive of future injuries in elite adolescent female soccer athletes. Design: Prospective cohort study. Setting: One US premier soccer club. Participants: One hundred seventy-seven female soccer athletes aged 10–18 years (mean [SD] 14.6 [1.8] y) completed a demographic questionnaire and screening hip physical examination that included range of motion and provocative tests. Interventions: At least 5 years after baseline screening, athletes completed an electronic follow-up injury survey. Injury was defined as pain that interfered with sporting activity. Main Outcome Measures: In addition to descriptive analyses of athletes’ injury profiles, associations between players’ baseline demographics and s...

PM&R, 2019

The purpose of this narrative review was to present and review the evidence of the relationship o... more The purpose of this narrative review was to present and review the evidence of the relationship of musculoskeletal impairments found in people with non-specific chronic pelvic pain (CPP). The musculoskeletal impairments assessed in this review include pelvic floor muscle: performance, resting state, strength, activation, posture and movement patterns. A search was performed systematically using PubMed, Cochrane, CINAHL, Embase, and Web of Science databases from 1998 to 2018 to identify studies reporting the relationship of non-specific CPP and musculoskeletal impairments of the hip, pelvis and trunk. The search resulted in 2106 articles that were screened by 2 authors. Remaining articles were screened by an additional 2 authors for inclusion in this review. Thirty-one articles remained after initial screening. Full text publications were reviewed and an additional 25 articles were excluded. Six additional articles were located through review of the reference lists of included articles. The final review included 12 publications. Seven of these studies were cross-sectional cohorts or a case-control comparing patients with CPP to asymptomatic controls. One cohort study included patients with CPP alone. The remaining studies were treatment studies. The level of evidence for the studies included in this review was low at levels 4 and 5. We were unable to make clear conclusions regarding the relationships of musculoskeletal impairments and CPP because validity and use of terms and assessments were inconsistent. Further research is needed with standardized definitions and measurements to better understand the musculoskeletal system as it relates to nonspecific CPP.

PM & R : the journal of injury, function, and rehabilitation, Jan 16, 2017

Relationships between low back pain (LBP) and the hip in patient cohorts have been described prim... more Relationships between low back pain (LBP) and the hip in patient cohorts have been described primarily in patients with moderate to severe hip osteoarthritis (OA). Less is known about the links of LBP with hip radiographic findings of hip deformity and minimal OA. The objectives were as follows: to describe the incidence of radiographic hip deformity or hip OA; to describe and compare spine- and hip-related pain and function in the subset of patients who were found to have radiographic hip deformity or hip OA; and to compare patients with evidence of radiographic hip deformity or hip OA to patients without hip radiographic findings. Prospective cohort study with cross-sectional design. Tertiary university. A total of 63 patients (40 women, 23 men) with a mean age of 48.5 ± 14 years with LBP and a minimum of one positive provocative hip test. Hip radiographs were assessed by an independent examiner for hip OA and deformity. Comparisons of hip and lumbar spine pain and function were c...

Musculoskeletal Physical Examination, 2006

Http Www Libreriasaulamedica Com, 2008

Tienda online donde Comprar Gender Specific Medicine: The Psychiatrist and Women's Health, An... more Tienda online donde Comprar Gender Specific Medicine: The Psychiatrist and Women's Health, An Issue of Physical Medicine and Rehabilitation Clinics al precio 69,81 € de Sheila A. Dugan | Heidi Prather, tienda de Libros de Medicina, Libros de Ginecologia y Obstetricia - Ginecologia general

American Journal of Physical Medicine & Rehabilitation, 1997

Previous studies demonstrate associations of low 25-hydroxyvitamin D (25(OH)D) concentrations wit... more Previous studies demonstrate associations of low 25-hydroxyvitamin D (25(OH)D) concentrations with low bone mineral density (BMD) and fractures, motivating widespread use of vitamin D supplements for bone health. However, previous studies have been limited to predominantly White populations despite differences in the distribution and metabolism of 25(OH)D by race/ethnicity. We determined associations of serum 25(OH)D, 24,25dihydroxyvitamin D (24,25(OH 2)D 3), and parathyroid hormone (PTH) with BMD among 1773 adult participants in the Multi-Ethnic Study of Atherosclerosis (MESA) in a staggered cross-sectional study design. Vitamin D metabolites were measured using liquid chromatography-mass spectroscopy and PTH using a 2-site immunoassay from serum collected in 2000-2002. Volumetric trabecular lumbar BMD was measured from computed tomography scans performed in 2002-2005 expressed as g/cm 3. We used linear regression and graphical methods to compare associations of vitamin D metabolite and PTH concentrations with BMD as the outcomes measure among White (n = 714), Black (n = 353), Chinese (n = 249), and Hispanic (n = 457) participants. Serum 25(OH)D and 24,25(OH 2)D 3 concentrations were highest among Whites and lowest among Blacks. BMD was greatest among Black participants. Higher serum 25(OH)D was only associated with higher BMD among Whites and Chinese participants (P-for-interaction = 0.054). Comparing the lowest category of 25(OH)D (b 20 ng/ml) to the highest (≥30 ng/ml), the adjusted mean difference in BMD was-8.1 g/cm 3 (95% CI −14.8, −1.4) for Whites; − 10.2 g/cm 3 (− 20.4, 0.0) for Chinese vs. 8.8 g/cm 3 (− 2.8, 20.5) for Black and − 1.1 g/cm 3 (− 8.3, 6.2) for Hispanic. Similar results were observed for serum 24,25(OH 2)D 3. Serum PTH was not associated with BMD. In a multi-ethnic population, associations of 25(OH)D with BMD were strongest among White and Chinese participants and null among Black and Hispanic participants. Further studies are needed to determine optimal biomarkers for bone health for multiple ethnic groups.

The Spine Journal, 2021

BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly r... more BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN A Modified Delphi process was used. METHODS The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static vs. dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS Multidisciplinary appropriate treatment criteria were generated based on the RAND methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

PM&R, 2021

Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proporti... more Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum one year follow-up. Retrospective cohort study. Single tertiary care academic medical center. Thirteen to 40-year-olds who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n=713 patients, 830 hips). Not applicable. The primary outcome was the rate of progression to surgery at minimum one year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. In a cohort with mean age 25.4 (SD 8.1) years, 72.7% female, and mean follow-up 2.6 (range 1.0-4.8) years, 429/830 hips (51.7% [95% CI 48.2%-55.1%]) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year [95% CI 0.93-0.98]), pain duration longer than six months (OR 1.87-2.03, p≤.027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System (PROMIS) point [0.92-0.99]), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47 [2.05-5.89]), acetabular dysplasia (OR 2.75 [1.73-4.35]), and/or labral tear (OR 10.71 [6.98-16.47]). Radiographic dysplasia (lateral center edge angle<200 ) increased the likelihood of surgery in all subgroups (OR 2.05-8.47, p≤.008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α>630 ) (OR 1.03/degree [1.00-1.06]). Almost half of patients with pre-arthritic hip pain did not progress to surgery at minimum one year follow-up. A trial of conservative management is likely worthwhile in most patients. This article is protected by copyright. All rights reserved.

Sports Health: A Multidisciplinary Approach, 2019

An elite high school American football athlete sustained a traumatic, isolated, axillary nerve in... more An elite high school American football athlete sustained a traumatic, isolated, axillary nerve injury. Axillary nerve injuries are uncommon, but serious injuries in American football. With the advent of nerve transfers and grafts, these injuries, if diagnosed in a timely manner, are treatable. This case report discusses the multidisciplinary approach necessary for the diagnosis and treatment of an elite high school American football player who presented with marked deltoid atrophy. The athlete’s injury was diagnosed via electrodiagnostic testing and he underwent a medial triceps nerve to axillary nerve transfer. After appropriate postsurgical therapy, the athlete was able to return to American football the subsequent season and continue performing at an elite level. This case report reviews the evaluation and modern treatment for axillary nerve injuries in the athlete, including nerve transfers, nerve grafts, and return to play.

Clinical Orthopaedics & Related Research, 2021

Abstract Background Social deprivation negatively affects a myriad of physical and behavioral hea... more Abstract Background Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions. Questions/purposes (1) Which measure of social deprivation, defined as “limited access to society’s resources due to poverty, discrimination, or other disadvantage,” is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture? Methods Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful. Results Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains. Conclusion To capture the most variability due to social deprivation in orthopaedic patients’ self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider…

PM&R, 2021

INTRODUCTION Lifestyle factors are associated with musculoskeletal pain and metabolic chronic dis... more INTRODUCTION Lifestyle factors are associated with musculoskeletal pain and metabolic chronic diseases. To date, intensive lifestyle medicine programs have predominantly targeted metabolic rather than musculoskeletal conditions. OBJECTIVE To assess the feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions. DESIGN Prospective observational feasibility study. SETTING Tertiary academic medical center. PATIENTS Adults diagnosed with musculoskeletal condition(s) and lifestyle-related chronic disease(s) who previously completed standard-of-care musculoskeletal treatments, enrolled from 2018-2020. INTERVENTIONS Patients enrolled in an intensive interprofessional lifestyle medicine program led by a physiatrist, with options to interface with an acupuncturist, dietician, massage therapist, psychologist, physical therapist, and smoking cessation specialist. The physiatrist engaged in shared decision making with patients to establish program goals related to function, overall health, and required lifestyle changes. Bi-monthly interprofessional team conferences facilitated communication between treatment team and patients. MAIN OUTCOME MEASURES Feasibility was measured by patient participation and goal attainment. Secondary outcomes included changes from program enrollment to discharge in patient anthropometric, metabolic lab, sleep apnea risk, and Patient-Reported Outcomes Measurement Information System (PROMIS) function, pain, and behavioral health measures. RESULTS Twenty-six patients enrolled in the program (18 (69%) female, mean age 59 (SD 14.5) years, baseline HbA1c 6.0% (0.8%), hs-CRP 7.7 (12.1) mg/dL, 25-hydroxy Vitamin D 32.0 (14.2) ng/mL). Of 21 (81%) patients who completed the program, 13/21 (62%) met their goal. On average, program completers presented for 26.2 (10.6) total visits over 191 (88) days. By discharge, program completers achieved clinically meaningful improvement in PROMIS Anxiety (mean difference -3.5 points 95% CI (-6.5-.5), p=.035), whereas non-completers did not (p>.05). CONCLUSIONS An intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions is feasible. With training in lifestyle intervention, physiatrists are well-suited to lead interprofessional teams aimed at assisting patients in making lifestyle changes to achieve personalized function- and health-related goals. This article is protected by copyright. All rights reserved.

The Journal of orthopaedic and sports physical therapy, 2017

Study Design Prospective cohort study, cross-sectional design. Background The hip-spine syndrome ... more Study Design Prospective cohort study, cross-sectional design. Background The hip-spine syndrome is described in patients with known arthritis of the hip. This study describes the hip examination findings of people presenting with low back pain (LBP). Objectives To (1) report examination findings of the hip in patients with LBP and (2) compare pain and function in patients with positive hip examination findings to those in patients without positive hip examination findings. Methods An examination and validated questionnaires of spine and hip pain and function were completed. Pain and function scores were compared between patients with and without positive hip findings. Results Consecutive patients (68 women, 33 men) with a mean age of 47.6 years (range, 18.4-79.8 years) participated. On physical examination, 81 (80%) had reduced hip flexion; 76 (75%) had reduced hip internal rotation; and 25 (25%) had 1, 32 (32%) had 2, and 23 (23%) had 3 positive provocative hip tests. Patients wit...

Bone & Joint Open

AimsThe primary aim of this prospective, multicentre study is to describe the rates of returning ... more AimsThe primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery.MethodsThis is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undert...

Acupuncture in Medicine

Background: To assess whether structure-based medical acupuncture (SMA) can improve Patient-Repor... more Background: To assess whether structure-based medical acupuncture (SMA) can improve Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients presenting with musculoskeletal pain. Methods: An audit was conducted of all patients presenting with musculoskeletal pain treated by a single provider with SMA in 2017. Inclusion criteria included a pre-treatment and at least one post-treatment PROMIS score. Patient demographics and previous treatments tried were recorded. Documented events other than acupuncture that were thought to interfere with PROMIS scores were recorded, and no further scores were used after these events. A maximum of nine visits after the initial visit were used. The PROMIS domains assessed included anxiety, depression, pain interference and physical function. Results: Seventy-two patients who had been treated with SMA met the inclusion criteria. Sixty-five of the patients (90%) had chronic pain. For their presenting complaint, 59 (82%) had p...

American Journal of Lifestyle Medicine

Interprofessional care improves outcomes for medically complex patients and may be a valuable add... more Interprofessional care improves outcomes for medically complex patients and may be a valuable addition to standard lifestyle medicine practice, but implementation barriers exist. The purpose of this study was to explore the key features, perceived impact, and implementation considerations related to holding interprofessional team meetings as part of an intensive lifestyle medicine program. In this mixed-methods study, focus groups were conducted with 15 lifestyle medicine clinicians from various healthcare disciplines who had participated in interprofessional team meetings. Quantitative descriptive statistics of the meeting minutes were also calculated. Clinician-perceived benefits from participating in interprofessional team meetings included increased acquisition of knowledge, access to other clinicians, collaborative decision-making, patient satisfaction, and achievement of patient-centered goals. Participants described the importance of preparing an agenda for the interprofessio...

The Spine Journal, 2021

BACKGROUND CONTEXT High quality evidence is difficult to generate, leaving substantial knowledge ... more BACKGROUND CONTEXT High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) is a means of determining appropriate recommendations when high quality evidence is lacking. PURPOSE Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine. STUDY DESIGN/SETTING Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations. OUTCOME MEASURES Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters. METHODS Inclusion criteria for scenarios included patients aged 18-80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed. RESULTS Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, P < 0.01). A multivariable ordinal regression adjusting for symptom type, diagnosis and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance. CONCLUSIONS Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."

American Journal of Physical Medicine & Rehabilitation, 2021

Objective: To better address sociodemographic-related health disparities, this study examined whi... more Objective: To better address sociodemographic-related health disparities, this study examined which sociodemographic variables most strongly correlate with self-reported health in patients with chronic musculoskeletal pain. Design: This single-center, cross-sectional study examined adult patients followed by a physiatrist for chronic (≥4 years) musculoskeletal pain. Sociodemographic variables considered were race, sex, and disparate social disadvantage (measured as residential address in the worst versus best Area Deprivation Index national quartile). The primary comparison was the adjusted effect size of each variable on physical and behavioral health (measured by Patient-Reported Outcomes Measurement Information System (PROMIS)). Results: In 1,193 patients (age 56.3±13.0 years), disparate social disadvantage was associated with worse health in all domains assessed

Orthopaedic Journal of Sports Medicine, 2020

Background: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetab... more Background: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes. Purpose: To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation. Study Design: Cohort study; Level of evidence, 3. Methods: An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted ...

PM&R, 2020

BackgroundDifferences in patient–physician interactions based on physician gender have been demon... more BackgroundDifferences in patient–physician interactions based on physician gender have been demonstrated. However, the association between patients' self‐perceived health and their decision to see a female versus male physician is still unclear.ObjectiveTo determine if self‐reported physical or behavioral health is different in musculoskeletal patients who present to female vs male physicians. We hypothesized that patients who present to female physicians report worse physical and behavioral health.DesignCross‐sectional study.SettingTertiary academic medical center.PatientsConsecutive 21 980 adult patients who presented to a musculoskeletal medicine specialist for initial evaluation of a musculoskeletal condition between April 1, 2016 and November 1, 2017.Main Outcome MeasuresPhysical Function, Pain Interference, Anxiety, and Depression Computer Adaptive Test domains of the Patient‐Reported Outcomes Measurement Information System (PROMIS). The primary study outcome was the mean ...

Journal of Sport Rehabilitation, 2019

Context: Although elite adolescent female soccer athletes have unique injury risk factors and man... more Context: Although elite adolescent female soccer athletes have unique injury risk factors and management challenges, limited epidemiological data exist for this population. Objective: To describe lower-body injury patterns and to determine whether a screening hip physical examination is predictive of future injuries in elite adolescent female soccer athletes. Design: Prospective cohort study. Setting: One US premier soccer club. Participants: One hundred seventy-seven female soccer athletes aged 10–18 years (mean [SD] 14.6 [1.8] y) completed a demographic questionnaire and screening hip physical examination that included range of motion and provocative tests. Interventions: At least 5 years after baseline screening, athletes completed an electronic follow-up injury survey. Injury was defined as pain that interfered with sporting activity. Main Outcome Measures: In addition to descriptive analyses of athletes’ injury profiles, associations between players’ baseline demographics and s...

PM&R, 2019

The purpose of this narrative review was to present and review the evidence of the relationship o... more The purpose of this narrative review was to present and review the evidence of the relationship of musculoskeletal impairments found in people with non-specific chronic pelvic pain (CPP). The musculoskeletal impairments assessed in this review include pelvic floor muscle: performance, resting state, strength, activation, posture and movement patterns. A search was performed systematically using PubMed, Cochrane, CINAHL, Embase, and Web of Science databases from 1998 to 2018 to identify studies reporting the relationship of non-specific CPP and musculoskeletal impairments of the hip, pelvis and trunk. The search resulted in 2106 articles that were screened by 2 authors. Remaining articles were screened by an additional 2 authors for inclusion in this review. Thirty-one articles remained after initial screening. Full text publications were reviewed and an additional 25 articles were excluded. Six additional articles were located through review of the reference lists of included articles. The final review included 12 publications. Seven of these studies were cross-sectional cohorts or a case-control comparing patients with CPP to asymptomatic controls. One cohort study included patients with CPP alone. The remaining studies were treatment studies. The level of evidence for the studies included in this review was low at levels 4 and 5. We were unable to make clear conclusions regarding the relationships of musculoskeletal impairments and CPP because validity and use of terms and assessments were inconsistent. Further research is needed with standardized definitions and measurements to better understand the musculoskeletal system as it relates to nonspecific CPP.

PM & R : the journal of injury, function, and rehabilitation, Jan 16, 2017

Relationships between low back pain (LBP) and the hip in patient cohorts have been described prim... more Relationships between low back pain (LBP) and the hip in patient cohorts have been described primarily in patients with moderate to severe hip osteoarthritis (OA). Less is known about the links of LBP with hip radiographic findings of hip deformity and minimal OA. The objectives were as follows: to describe the incidence of radiographic hip deformity or hip OA; to describe and compare spine- and hip-related pain and function in the subset of patients who were found to have radiographic hip deformity or hip OA; and to compare patients with evidence of radiographic hip deformity or hip OA to patients without hip radiographic findings. Prospective cohort study with cross-sectional design. Tertiary university. A total of 63 patients (40 women, 23 men) with a mean age of 48.5 ± 14 years with LBP and a minimum of one positive provocative hip test. Hip radiographs were assessed by an independent examiner for hip OA and deformity. Comparisons of hip and lumbar spine pain and function were c...

Musculoskeletal Physical Examination, 2006

Http Www Libreriasaulamedica Com, 2008

Tienda online donde Comprar Gender Specific Medicine: The Psychiatrist and Women's Health, An... more Tienda online donde Comprar Gender Specific Medicine: The Psychiatrist and Women's Health, An Issue of Physical Medicine and Rehabilitation Clinics al precio 69,81 € de Sheila A. Dugan | Heidi Prather, tienda de Libros de Medicina, Libros de Ginecologia y Obstetricia - Ginecologia general

American Journal of Physical Medicine & Rehabilitation, 1997

Previous studies demonstrate associations of low 25-hydroxyvitamin D (25(OH)D) concentrations wit... more Previous studies demonstrate associations of low 25-hydroxyvitamin D (25(OH)D) concentrations with low bone mineral density (BMD) and fractures, motivating widespread use of vitamin D supplements for bone health. However, previous studies have been limited to predominantly White populations despite differences in the distribution and metabolism of 25(OH)D by race/ethnicity. We determined associations of serum 25(OH)D, 24,25dihydroxyvitamin D (24,25(OH 2)D 3), and parathyroid hormone (PTH) with BMD among 1773 adult participants in the Multi-Ethnic Study of Atherosclerosis (MESA) in a staggered cross-sectional study design. Vitamin D metabolites were measured using liquid chromatography-mass spectroscopy and PTH using a 2-site immunoassay from serum collected in 2000-2002. Volumetric trabecular lumbar BMD was measured from computed tomography scans performed in 2002-2005 expressed as g/cm 3. We used linear regression and graphical methods to compare associations of vitamin D metabolite and PTH concentrations with BMD as the outcomes measure among White (n = 714), Black (n = 353), Chinese (n = 249), and Hispanic (n = 457) participants. Serum 25(OH)D and 24,25(OH 2)D 3 concentrations were highest among Whites and lowest among Blacks. BMD was greatest among Black participants. Higher serum 25(OH)D was only associated with higher BMD among Whites and Chinese participants (P-for-interaction = 0.054). Comparing the lowest category of 25(OH)D (b 20 ng/ml) to the highest (≥30 ng/ml), the adjusted mean difference in BMD was-8.1 g/cm 3 (95% CI −14.8, −1.4) for Whites; − 10.2 g/cm 3 (− 20.4, 0.0) for Chinese vs. 8.8 g/cm 3 (− 2.8, 20.5) for Black and − 1.1 g/cm 3 (− 8.3, 6.2) for Hispanic. Similar results were observed for serum 24,25(OH 2)D 3. Serum PTH was not associated with BMD. In a multi-ethnic population, associations of 25(OH)D with BMD were strongest among White and Chinese participants and null among Black and Hispanic participants. Further studies are needed to determine optimal biomarkers for bone health for multiple ethnic groups.

The Spine Journal, 2021

BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly r... more BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN A Modified Delphi process was used. METHODS The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static vs. dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS Multidisciplinary appropriate treatment criteria were generated based on the RAND methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

PM&R, 2021

Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proporti... more Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum one year follow-up. Retrospective cohort study. Single tertiary care academic medical center. Thirteen to 40-year-olds who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n=713 patients, 830 hips). Not applicable. The primary outcome was the rate of progression to surgery at minimum one year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. In a cohort with mean age 25.4 (SD 8.1) years, 72.7% female, and mean follow-up 2.6 (range 1.0-4.8) years, 429/830 hips (51.7% [95% CI 48.2%-55.1%]) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year [95% CI 0.93-0.98]), pain duration longer than six months (OR 1.87-2.03, p≤.027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System (PROMIS) point [0.92-0.99]), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47 [2.05-5.89]), acetabular dysplasia (OR 2.75 [1.73-4.35]), and/or labral tear (OR 10.71 [6.98-16.47]). Radiographic dysplasia (lateral center edge angle<200 ) increased the likelihood of surgery in all subgroups (OR 2.05-8.47, p≤.008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α>630 ) (OR 1.03/degree [1.00-1.06]). Almost half of patients with pre-arthritic hip pain did not progress to surgery at minimum one year follow-up. A trial of conservative management is likely worthwhile in most patients. This article is protected by copyright. All rights reserved.

Sports Health: A Multidisciplinary Approach, 2019

An elite high school American football athlete sustained a traumatic, isolated, axillary nerve in... more An elite high school American football athlete sustained a traumatic, isolated, axillary nerve injury. Axillary nerve injuries are uncommon, but serious injuries in American football. With the advent of nerve transfers and grafts, these injuries, if diagnosed in a timely manner, are treatable. This case report discusses the multidisciplinary approach necessary for the diagnosis and treatment of an elite high school American football player who presented with marked deltoid atrophy. The athlete’s injury was diagnosed via electrodiagnostic testing and he underwent a medial triceps nerve to axillary nerve transfer. After appropriate postsurgical therapy, the athlete was able to return to American football the subsequent season and continue performing at an elite level. This case report reviews the evaluation and modern treatment for axillary nerve injuries in the athlete, including nerve transfers, nerve grafts, and return to play.

Clinical Orthopaedics & Related Research, 2021

Abstract Background Social deprivation negatively affects a myriad of physical and behavioral hea... more Abstract Background Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions. Questions/purposes (1) Which measure of social deprivation, defined as “limited access to society’s resources due to poverty, discrimination, or other disadvantage,” is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture? Methods Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful. Results Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains. Conclusion To capture the most variability due to social deprivation in orthopaedic patients’ self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider…

PM&R, 2021

INTRODUCTION Lifestyle factors are associated with musculoskeletal pain and metabolic chronic dis... more INTRODUCTION Lifestyle factors are associated with musculoskeletal pain and metabolic chronic diseases. To date, intensive lifestyle medicine programs have predominantly targeted metabolic rather than musculoskeletal conditions. OBJECTIVE To assess the feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions. DESIGN Prospective observational feasibility study. SETTING Tertiary academic medical center. PATIENTS Adults diagnosed with musculoskeletal condition(s) and lifestyle-related chronic disease(s) who previously completed standard-of-care musculoskeletal treatments, enrolled from 2018-2020. INTERVENTIONS Patients enrolled in an intensive interprofessional lifestyle medicine program led by a physiatrist, with options to interface with an acupuncturist, dietician, massage therapist, psychologist, physical therapist, and smoking cessation specialist. The physiatrist engaged in shared decision making with patients to establish program goals related to function, overall health, and required lifestyle changes. Bi-monthly interprofessional team conferences facilitated communication between treatment team and patients. MAIN OUTCOME MEASURES Feasibility was measured by patient participation and goal attainment. Secondary outcomes included changes from program enrollment to discharge in patient anthropometric, metabolic lab, sleep apnea risk, and Patient-Reported Outcomes Measurement Information System (PROMIS) function, pain, and behavioral health measures. RESULTS Twenty-six patients enrolled in the program (18 (69%) female, mean age 59 (SD 14.5) years, baseline HbA1c 6.0% (0.8%), hs-CRP 7.7 (12.1) mg/dL, 25-hydroxy Vitamin D 32.0 (14.2) ng/mL). Of 21 (81%) patients who completed the program, 13/21 (62%) met their goal. On average, program completers presented for 26.2 (10.6) total visits over 191 (88) days. By discharge, program completers achieved clinically meaningful improvement in PROMIS Anxiety (mean difference -3.5 points 95% CI (-6.5-.5), p=.035), whereas non-completers did not (p>.05). CONCLUSIONS An intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions is feasible. With training in lifestyle intervention, physiatrists are well-suited to lead interprofessional teams aimed at assisting patients in making lifestyle changes to achieve personalized function- and health-related goals. This article is protected by copyright. All rights reserved.

The Journal of orthopaedic and sports physical therapy, 2017

Study Design Prospective cohort study, cross-sectional design. Background The hip-spine syndrome ... more Study Design Prospective cohort study, cross-sectional design. Background The hip-spine syndrome is described in patients with known arthritis of the hip. This study describes the hip examination findings of people presenting with low back pain (LBP). Objectives To (1) report examination findings of the hip in patients with LBP and (2) compare pain and function in patients with positive hip examination findings to those in patients without positive hip examination findings. Methods An examination and validated questionnaires of spine and hip pain and function were completed. Pain and function scores were compared between patients with and without positive hip findings. Results Consecutive patients (68 women, 33 men) with a mean age of 47.6 years (range, 18.4-79.8 years) participated. On physical examination, 81 (80%) had reduced hip flexion; 76 (75%) had reduced hip internal rotation; and 25 (25%) had 1, 32 (32%) had 2, and 23 (23%) had 3 positive provocative hip tests. Patients wit...