Publications by authors named "Kelli D Allen"

101 Publications

Pilot study of an internet-based pain coping skills training program for patients with systemic Lupus Erythematosus.

BMC Rheumatol 2021 Jun 17;5(1):20. Epub 2021 Jun 17.

Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Patients with Systemic Lupus Erythematosus (SLE) often experience pain and other symptoms that negatively impact quality of life. Interventions that enhance the use of behavioral and cognitive coping strategies may lead to improved outcomes among patients with SLE. Pain coping skills training (PCST) programs have been shown to improve outcomes among patients with other rheumatic conditions, but there have been no trials of PCST among patients with SLE. This study was a preliminary assessment of the feasibility and efficacy of painTRAINER, an automated, internet-based PCST program, among patients with SLE.

Methods: Participants (n = 60) with SLE from one health care system were randomly assigned with equal allocation to painTRAINER or a wait list control group. PainTRAINER involves 8 modules; participants were instructed to complete one module weekly, along with practice activities for each cognitive or behavioral coping skill. Outcome measures were assessed at baseline and 9-week follow-up, including the Pain Catastrophizing Scale, PROMIS Subscales (Pain Interference, Physical Function, Sleep Disturbance, Anxiety, Depression, Fatigue and Participation), and the LupusPRO questionnaire. Mean changes in outcomes from baseline to follow up and Cohen's d effect sizes were computed.

Results: Effect sizes for the painTRAINER group (relative to the wait list group) were small, with changes being greatest for the PROMIS Depression score (d = - 0.32). Among those randomized to the painTRAINER group, 50% accessed the program ("painTRAINER users"). Most of those who did not access the program stated that they did not receive instructions via email. Effect sizes for "painTRAINER users" (relative to wait list) were larger than for the whole painTRAINER group: Pain Catastrophizing d = - 0.60, PROMIS Pain Interference d = - 0.3., PROMIS Depression d = - 0.44, LupusPRO Health-Related Quality of Life d = 0.30.

Conclusions: PainTRAINER users reported meaningful improvements in multiple physical and psychological outcomes, supporting the potential of PCST programs to benefit individuals with SLE. However, strategies are needed to improve engagement with the program and tailor content to comprehensively address key SLE symptoms and challenges.

Trial Registration: NCT03933839 , May 1, 2019.
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http://dx.doi.org/10.1186/s41927-021-00191-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210367PMC
June 2021

Arthritis Care & Research: Celebrations and Opportunities.

Arthritis Care Res (Hoboken) 2021 Jul;73(7):919-920

University of North Carolina, Chapel Hill.

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http://dx.doi.org/10.1002/acr.24714DOI Listing
July 2021

Racial/Ethnic, Socioeconomic, and Geographic Disparities in the Epidemiology of Knee and Hip Osteoarthritis.

Rheum Dis Clin North Am 2021 Feb 29;47(1):1-20. Epub 2020 Oct 29.

School of Medicine, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3330 Thurston Building, CB 7280, Chapel Hill, NC 27599, USA; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 3300 Thurston Building CB 7280, Chapel Hill, NC 27599-7280, USA.

It is estimated that 32.5 million US adults have clinical osteoarthritis (OA), with the most common sites being knee and hip. OA is associated with substantial individual and societal costs. Race/ethnicity, socioeconomic status (SES), and geographic variations in the prevalence of knee and hip OA are well established around the world. In addition, clinical outcomes associated with hip and knee OA differ according to race/ethnicity, SES, and geography. This variation is likely multifactorial and may also reflect country-specific differences in health care systems. The interplay between different factors, such as geography, SES, and race/ethnicity, is difficult to study.
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http://dx.doi.org/10.1016/j.rdc.2020.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248516PMC
February 2021

Resilience and pain catastrophizing among patients with total knee arthroplasty: a cohort study to examine psychological constructs as predictors of post-operative outcomes.

Health Qual Life Outcomes 2021 May 1;19(1):136. Epub 2021 May 1.

Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA.

Background: Patients' psychological health may influence recovery and functional outcomes after total knee arthroplasty (TKA). Pain catastrophizing, known to be associated with poor function following TKA, encompasses rumination, magnification, and helplessness that patients feel toward their pain. Resilience, however, is an individual's ability to adapt to adversity and may be an important psychological construct that supersedes the relationship between pain catastrophizing and recovery. In this study we sought to identify whether pre-operative resilience is predictive of 3-month postoperative outcomes after adjusting for pain catastrophizing and other covariates.

Methods: Patients undergoing TKA between January 2019 and November 2019 were included in this longitudinal cohort study. Demographics and questionnaires [Brief Resilience Scale (BRS), Pain Catastrophizing Scale (PCS), Knee injury and Osteoarthritis Outcome Score, Junior (KOOS, JR.) and Patient-Reported Outcomes Measurement Information System Physical and Mental Health (PROMIS PH and MH, respectively)] were collected preoperatively and 3 months postoperatively. Multivariable regression was used to test associations of preoperative BRS with postoperative outcomes, adjusting for PCS and other patient-level sociodemographic and clinical characteristics.

Results: The study cohort included 117 patients with a median age of 67.0 years (Q1-Q3: 59.0-72.0). Fifty-three percent of patients were women and 70.1% were white. Unadjusted analyses identified an association between resilience and post-operative outcomes and the relationship persisted for physical function after adjusting for PCS and other covariates; in multivariable linear regression analyses, higher baseline resilience was positively associated with better postoperative knee function (β = 0.24, p = 0.019) and better general physical health (β = 0.24, p = 0.013) but not general mental health (β = 0.04, p = 0.738).

Conclusions: Our prospective cohort study suggests that resilience predicts postoperative knee function and general physical health in patients undergoing TKA. Exploring interventions that address preoperative mental health and resilience more specifically may improve self-reported physical function outcomes of patients undergoing TKA.
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http://dx.doi.org/10.1186/s12955-021-01772-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088639PMC
May 2021

Accelerometer-Based Physical Activity Patterns and Associations With Outcomes Among Individuals With Osteoarthritis.

J Clin Rheumatol 2021 Apr 24. Epub 2021 Apr 24.

From the Medical College of Georgia at Augusta University, Augusta, GA Department of Medicine and Thurston Arthritis Research Center Division of Physical Therapy and Thurston Arthritis Research Center, Injury Prevention Research Center, Department of Epidemiology Department of Nutrition Gillings School of Global Public Health and Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC.

Background: This study examined patterns of physical activity and associations with pain, function, fatigue, and sleep disturbance among individuals with knee or hip osteoarthritis.

Methods: Participants (n = 54) were enrolled in a telephone-based physical activity coaching intervention trial; all data were collected at baseline. Self-reported measures of pain and function (WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index] subscales), fatigue (10-point numeric rating scale), and PROMIS (Patient-Reported Outcomes Information System) Sleep Disturbance were collected via telephone. Accelerometers were mailed to participants and were worn for at least 3 days. Proportion of time participants spent in sedentary behavior during the morning (from wake until 12:00 PM), afternoon (12:00 PM until 5:59 PM) and evening (6:00 PM until sleep) each day was averaged across all days of wear. Pearson correlations assessed associations between activity and self-reported measures.

Results: Participants spent a large proportion of time in sedentary behavior: 65.6% of mornings, 70.0% of afternoons, and 76.6% of evenings. Associations between proportion of time spent in sedentary behavior and reported outcomes were generally strongest in the afternoon, strongest for WOMAC function, and lowest for PROMIS Sleep Disturbance. In the evening hours, sedentary time was most strongly associated with fatigue.

Conclusions: Overall, findings stress the importance of reducing sedentary behavior among adults with osteoarthritis and suggest behavioral interventions may be strengthened by considering patients' within-day variation in symptoms and activity.
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http://dx.doi.org/10.1097/RHU.0000000000001750DOI Listing
April 2021

Discrimination Experiences and Depressive Symptoms among African Americans with Osteoarthritis Enrolled in a Pain Coping Skills Training Randomized Controlled Trial.

J Health Care Poor Underserved 2021 ;32(1):145-155

African Americans are more likely than members of other racial groups to report perceived discrimination in health care settings, and discrimination is linked to depression. Using data from a randomized controlled trial of pain coping skills training (PCST) for African Americans with osteoarthritis (N=164), we evaluated the interaction between discrimination experiences and experimental condition (PCST or control group) in linear regression models predicting depressive symptoms. There was a significant interaction between personal discrimination and experimental condition on depressive symptoms (interaction term coefficient: b=-3.2, 95% CI [- 6.4, - .02], p=.05). Discrimination was associated with depressive symptoms among those in the control group but not among those who received PCST. Participation in a PCST intervention may have reduced the association between discrimination experiences and depressive symptoms among participants in this sample. Future research should explore whether interventions aimed at teaching coping skills may be effective in ameliorating the harmful mental health effects of perceived discrimination.
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http://dx.doi.org/10.1353/hpu.2021.0014DOI Listing
January 2021

Accelerating Implementation of Virtual Care in an Integrated Health Care System: Future Research and Operations Priorities.

J Gen Intern Med 2021 Jan 26. Epub 2021 Jan 26.

Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.

Background: Virtual care is critical to Veterans Health Administration (VHA) efforts to expand veterans' access to care. Health care policies such as the Veterans Access, Choice, and Accountability (CHOICE) Act and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act impact how the VHA provides care. Research on ways to refine virtual care delivery models to meet the needs of veterans, clinicians, and VHA stakeholders is needed.

Objective: Given the importance of virtual approaches for increasing access to high-quality VHA care, in December 2019, we convened a Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to consider challenges to virtual care research and practice across the VHA, discuss novel approaches to using and evaluating virtual care, assess perspectives on virtual care, and develop priorities to enhance virtual care in the VHA.

Methods: We used a participatory approach to develop potential priorities for virtual care research and activities at the VHA. We refined these priorities through force-ranked prioritization and group discussion, and developed solutions for selected priorities.

Results: Think Tank attendees (n = 18) consisted of VHA stakeholders, including operations partners (e.g., Office of Rural Health, Office of Nursing Services, Health Services Research and Development), clinicians (e.g., physicians, nurses, psychologists, physician assistants), and health services researchers. We identified an initial list of fifteen potential priorities and narrowed these down to four. The four priorities were (1) scaling evidence-based practices, (2) centralizing virtual care, (3) creating high-value care within the VHA with virtual care, and (4) identifying appropriate patients for virtual care.

Conclusion: Our Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within the VHA. We brought together research and operations stakeholders and identified possibilities, partnerships, and potential solutions for virtual care.
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http://dx.doi.org/10.1007/s11606-020-06517-3DOI Listing
January 2021

Application of Heterogeneity of Treatment Effect Methods: Exploratory Analyses of a Trial of Exercise-Based Interventions for Knee OA.

Arthritis Care Res (Hoboken) 2021 Jan 18. Epub 2021 Jan 18.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, HSRD (152), 508 Fulton Street, Durham, NC, 27705, United States.

Objective: To evaluate heterogeneity of treatment effects (HTE) in a trial of exercise-based interventions for knee osteoarthritis (OA).

Methods: Participants (n=350) were randomized to standard physical therapy (PT; n=140), Internet-Based Exercise Training (IBET; n=142), or wait list control (WL; n=68). We applied QUalitative INteraction Trees (QUINT), a sequential partitioning method, and Generalized Unbiased Interaction Detection and Estimation (GUIDE), a regression tree approach, to identify subgroups with greater improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score over 4-months. Predictors included 24 demographic, clinical and psychosocial characteristics. We conducted internal validation to estimate optimism (bias) in the range of mean outcome differences among arms.

Results: Both QUINT and GUIDE indicated that for participants with lower body mass index (BMI), IBET was better than PT (improvements of WOMAC ranged from 6.3 to 9.1 points lower) and for those with higher BMI and longer duration of knee OA, PT was better than IBET (WOMAC improvement was 6.3 points). In GUIDE analyses comparing PT or IBET to WL, participants not employed had improvements in WOMAC ranging from 1.8 to 6.8 points lower with PT or IBT vs. WL. From internal validation, there were large corrections to the mean outcome differences among arms; however, after correction some differences remained in the clinically meaningful range.

Conclusion: Results suggest there may be subgroups who experience greater improvement in symptoms from PT or IBET, and this could guide referrals and future trials. However, uncertainty persists for specific treatment effect size estimates and how they apply beyond this study sample.
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http://dx.doi.org/10.1002/acr.24564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286274PMC
January 2021

Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial.

Ann Intern Med 2021 03 29;174(3):298-307. Epub 2020 Dec 29.

Durham VA Health Care System and Duke University Medical Center, Durham, North Carolina (C.J.C.).

Background: Evidence-based models are needed to deliver exercise-related services for knee osteoarthritis efficiently and according to patient needs

Objective: To examine a stepped exercise program for patients with knee osteoarthritis (STEP-KOA).

Design: Randomized controlled trial. (ClinicalTrials.gov: NCT02653768).

Setting: 2 U.S. Department of Veterans Affairs sites.

Participants: 345 patients (mean age, 60 years; 15% female; 67% people of color) with symptomatic knee osteoarthritis.

Intervention: Participants were randomly assigned in a 2:1 ratio to STEP-KOA or an arthritis education (AE) control group, respectively. The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks.

Measurements: Primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Scores for the STEP-KOA and AE groups at 9 months were compared by using linear mixed models.

Results: In the STEP-KOA group, 65% of participants (150 of 230) progressed to step 2 and 35% (81 of 230) to step 3. The estimated baseline WOMAC score for the full sample was 47.5 (95% CI, 45.7 to 49.2). At 9-month follow-up, the estimated mean WOMAC score was 6.8 points (CI, -10.5 to -3.2 points) lower in the STEP-KOA than the AE group, indicating greater improvement.

Limitation: Participants were mostly male veterans, and follow-up was limited.

Conclusion: Veterans in STEP-KOA reported modest improvements in knee osteoarthritis symptoms compared with the control group. The STEP-KOA strategy may be efficient for delivering exercise therapies for knee osteoarthritis.

Primary Funding Source: Department of Veterans Affairs, Health Services Research and Development Service.
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http://dx.doi.org/10.7326/M20-4447DOI Listing
March 2021

Learning to Apply Mindfulness to Pain (LAMP): Design for a Pragmatic Clinical Trial of Two Mindfulness-Based Interventions for Chronic Pain.

Pain Med 2020 12;21(Suppl 2):S29-S36

VA HSR&D Center for Care Delivery and Outcomes Research, VA Medical Center, Minneapolis, USA.

Background: Mindfulness-based interventions (MBIs) are evidence-based nonpharmacological treatments for treating chronic pain. However, the predominant MBI, mindfulness-based stress reduction, has features that pose significant implementation barriers.

Objectives: This study will test two approaches to delivering MBIs for improving Veterans' chronic pain and mental health comorbidities. These two approaches address key implementation barriers.

Methods: We will conduct a four-site, three-arm pragmatic randomized controlled trial, Learning to Apply Mindfulness to Pain (LAMP), to test the effectiveness of two MBIs at improving pain and mental health comorbidities. Mobile+Group LAMP consists of prerecorded modules presented by a mindfulness instructor that are viewed in an online group setting and interspersed with discussions led by a facilitator. Mobile LAMP consists of the same prerecorded modules but does not include a group component. We will test whether either of these MBIs will be more effective than usual care at improving chronic pain and whether the Mobile+Group LAMP will be more effective than Mobile LAMP at improving chronic pain. Comparisons for the primary hypotheses will be conducted with continuous outcomes (Brief Pain Inventory interference score) repeated at 10 weeks, 6 months, and 12 months. The secondary hypotheses are that Mobile+Group LAMP and Mobile LAMP will be more effective than usual care at improving secondary outcomes (e.g., post-traumatic stress disorder, depression). We will also confirm the comparisons for the primary and secondary hypotheses in gender-specific strata.

Implications: This trial is expected to result in two approaches for delivering MBIs that will optimize engagement, adherence, and sustainability and be able to reach large numbers of Veterans.
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http://dx.doi.org/10.1093/pm/pnaa337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734658PMC
December 2020

Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial.

Pain Med 2020 12;21(Suppl 2):S62-S72

Durham Center of Innovation to Accelerate Discovery and Practice, Durham VA Health Care System, Geriatric Research, Education and Clinical Center at Durham VAHCS Health Services Research & Development, Durham, North Carolina.

Background: Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown.

Design: The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures.

Summary: AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.
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http://dx.doi.org/10.1093/pm/pnaa348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734660PMC
December 2020

Self-Report Measures of Physical Activity.

Arthritis Care Res (Hoboken) 2020 10;72 Suppl 10:717-730

School of Nursing, The University of Hong Kong, Hong Kong.

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http://dx.doi.org/10.1002/acr.24211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586463PMC
October 2020

Implementation of a stepped wedge cluster randomized trial to evaluate a hospital mobility program.

Trials 2020 Oct 16;21(1):863. Epub 2020 Oct 16.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.

Background: Stepped wedge cluster randomized trials (SW-CRT) are increasingly used to evaluate new clinical programs, yet there is limited guidance on practical aspects of applying this design. We report our early experiences conducting a SW-CRT to examine an inpatient mobility program (STRIDE) in the Veterans Health Administration (VHA). We provide recommendations for future research using this design to evaluate clinical programs.

Methods: Based on data from study records and reflections from the investigator team, we describe and assess the design and initial stages of a SW-CRT, from site recruitment to program launch in 8 VHA hospitals.

Results: Site recruitment consisted of thirty 1-h conference calls with representatives from 22 individual VAs who expressed interest in implementing STRIDE. Of these, 8 hospitals were enrolled and randomly assigned in two stratified blocks (4 hospitals per block) to a STRIDE launch date. Block 1 randomization occurred in July 2017 with first STRIDE launch in December 2017; block 2 randomization occurred in April 2018 with first STRIDE launch in January 2019. The primary study outcome of discharge destination will be assessed using routinely collected data in the electronic health record (EHR). Within randomized blocks, two hospitals per sequence launched STRIDE approximately every 3 months with primary outcome assessment paused during the 3-month time period of program launch. All sites received 6-8 implementation support calls, according to a pre-specified schedule, from the time of recruitment to program launch, and all 8 sites successfully launched within their assigned 3-month window. Seven of the eight sites initially started with a limited roll out (for example on one ward) or modified version of STRIDE (for example, using existing staff to conduct walks until new positions were filled).

Conclusions: Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate rollout of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a "ramp-up" period. Successful execution of SW-CRT designs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out.

Trial Registration: ClinicalsTrials.gov NCT03300336 . Prospectively registered on 3 October 2017.
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http://dx.doi.org/10.1186/s13063-020-04764-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574435PMC
October 2020

Acceptability of telephone-based pain coping skills training among African Americans with osteoarthritis enrolled in a randomized controlled trial: a mixed methods analysis.

BMC Musculoskelet Disord 2020 Aug 14;21(1):545. Epub 2020 Aug 14.

Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.

Background: Osteoarthritis (OA) disproportionately impacts African Americans compared to Caucasians, including greater pain severity. The Pain Coping Skills Training for African Americans with Osteoarthritis (STAART) study examined a culturally enhanced Pain Coping Skills Training (CST) program among African Americans with OA. This mixed methods study evaluated the acceptability of the Pain CST program among STAART participants.

Methods: STAART was a randomized controlled trial evaluating the effectiveness of an 11-session, telephone-based pain CST program, compared to a usual care control group. Participants were from the University of North Carolina and Durham Veterans Affairs Healthcare Systems. The present analyses included 93 participants in the CST group who completed a questionnaire about experiences with the program. Descriptive statistics of the questionnaire responses were calculated using SAS software. Thematic analysis was applied to open-response data using Dedoose software.

Results: Participants' mean rating of overall helpfulness of the pain CST program for managing arthritis symptoms was 8.0 (SD = 2.2) on a scale of 0-10. A majority of participants reported the program made a positive difference in their experience with arthritis (83.1%). Mean ratings of helpfulness of the specific skills ranged from 7.7 to 8.8 (all scales 0-10). Qualitative analysis of the open-response data identified four prominent themes: Improved Pain Coping, Mood and Emotional Benefits, Improved Physical Functioning, and experiences related to Intervention Delivery.

Conclusions: The high ratings of helpfulness demonstrate acceptability of this culturally enhanced pain CST program by African Americans with OA. Increasing access to cognitive-behavioral therapy-based programs may be a promising strategy to address racial disparities in OA-related pain and associated outcomes.

Trial Registration: NCT02560922 , registered September 25, 2015.
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http://dx.doi.org/10.1186/s12891-020-03578-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427940PMC
August 2020

Core and adjunctive interventions for osteoarthritis: efficacy and models for implementation.

Nat Rev Rheumatol 2020 08 13;16(8):434-447. Epub 2020 Jul 13.

Institute of Bone and Joint Research, The University of Sydney, Kolling Institute, St Leonards, NSW, Australia.

Osteoarthritis (OA) is a complex musculoskeletal disease and a leading cause of pain and disability worldwide. Hip and knee OA alone are major contributors to global disability, having notable effects on individual well-being, increasing the reliance of individuals on health-care services and contributing to a rise in the socioeconomic burden. Consistent, coordinated and tailored approaches are important for providing appropriate care to all people with OA, but despite the scale of the challenge many individuals are still not offered the safe, best-evidence treatments recommended for OA care. This Review discusses the core priority treatments for OA, including exercise and physical activity, weight-loss, education and support for self-management. Additional physical or psychological evidence-based adjunctive therapies and combined therapies that can be used to tailor individual programmes are also discussed. These options include cognitive behavioural therapy, heat therapy, walking aids and splints, manual therapies and transcutaneous electrical nerve stimulation. International examples of OA treatment options, models of care and resources available are also given. Many challenges still need to be addressed to advance the uptake of these conditions, including further discussion around the risks and costs involved with all treatments.
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http://dx.doi.org/10.1038/s41584-020-0447-8DOI Listing
August 2020

Implementation of a group physical therapy program for Veterans with knee osteoarthritis.

BMC Musculoskelet Disord 2020 Feb 3;21(1):67. Epub 2020 Feb 3.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.

Background: A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program.

Methods: This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0-96)) and a 30-s chair rise test.

Results: During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0).

Conclusions: Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.
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http://dx.doi.org/10.1186/s12891-020-3079-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998361PMC
February 2020

Early-phase study of a telephone-based intervention to reduce weight regain among bariatric surgery patients.

Health Psychol 2020 May 30;39(5):391-402. Epub 2020 Jan 30.

William S. Middleton Memorial Veterans Hospital.

Objective: This study describes early-phase development of a behavioral intervention to reduce weight regain following bariatric surgery. We utilized the Obesity-Related Behavioral Intervention Trials model to guide intervention development and evaluation. We sought to establish recruitment, retention, and fidelity monitoring procedures; evaluate feasibility of utilizing weight from the electronic medical record (EMR) as an outcome; observe improvement in behavioral risk factors; and evaluate treatment acceptability.

Method: The intervention comprised 4 weekly telephone calls addressing behavior change strategies for diet, physical activity, and nutrition supplement adherence and 5 biweekly calls addressing weight loss maintenance constructs. Veterans ( = 33) who received bariatric surgery 9-15 months prior consented to a 16-week, pre-post study. Self-reported outcomes were obtained by telephone at baseline and 16 weeks. Clinic weights were obtained from the EMR 6 months pre- and postconsent. Qualitative interviews were conducted at 16 weeks to evaluate treatment acceptability. We aimed to achieve a recruitment rate of ≥ 25% and retention rate of ≥ 80%, and have ≥ 50% of participants regain < 3% of their baseline weight.

Results: Results supported the feasibility of recruiting (48%) and retaining participants (93% provided survey data; 100% had EMR weight). Pre-post changes in weight (73% with < 3% weight regain) and physical activity (Cohen's ds 0.38 to 0.52) supported the potential for the intervention to yield clinically significant results. Intervention adherence (mean 7.8 calls of 9 received) and positive feedback from interviews supported treatment acceptability.

Conclusions: The intervention should be evaluated in an adequately powered randomized controlled trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/hea0000835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219473PMC
May 2020

Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention.

J Nurs Scholarsh 2020 01 9;52(1):23-33. Epub 2019 Sep 9.

Core Faculty, Margolis Center for Health Policy, Duke University, Durham, NC, USA.

Purpose: We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES).

Design: Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework.

Findings: Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention.

Conclusions: The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment.

Clinical Relevance: This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.
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http://dx.doi.org/10.1111/jnu.12511DOI Listing
January 2020

Racial Differences in Performance-Based Function and Potential Explanatory Factors Among Individuals With Knee Osteoarthritis.

Arthritis Care Res (Hoboken) 2020 09;72(9):1196-1204

University of North Carolina at Chapel Hill and Durham VA Medical Center, Durham, North Carolina.

Objective: In individuals with knee osteoarthritis (OA), self-reported physical function is poorer in African Americans than in whites, but whether this difference holds true for objective assessments is unclear. The purpose of this study was to examine racial differences in performance-based physical function as well as potential underlying factors contributing to these racial differences.

Methods: Participants with knee OA from a randomized controlled trial completed the 2-minute step test (2MST), timed-up-and-go (TUG), and 30-second chair stand (30s-CST) at baseline. Race differences in performance-based function were assessed by logistic regression. Separate models were adjusted for sets of demographic, socioeconomic, psychological health, and physical health variables.

Results: In individuals with knee OA (n = 322; 72% women, 22% African American, mean ± SD age 66 ± 11 years, mean ± SD body mass index 31 ± 8 kg/m ), African Americans (versus whites) had greater unadjusted odds of poorer function (30s-CST odds ratio [OR] 2.79 [95% confidence interval (95% CI) 1.65-4.72], 2MST OR 2.37 [95% CI 1.40-4.03], and TUG OR 3.71 [95% CI 2.16-6.36]). Relationships were maintained when adjusted for demographic and psychological health covariates, but they were either partially attenuated or nonsignificant when adjusted for physical health and socioeconomic covariates.

Conclusion: African American adults with knee OA had poorer unadjusted performance-based function than whites. Physical health and socioeconomic characteristics diminished these differences, emphasizing the fact that these factors may be important to consider in mitigating racial disparities in function.
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http://dx.doi.org/10.1002/acr.24018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935430PMC
September 2020

Implementing a Mandated Program Across a Regional Health Care System: A Rapid Qualitative Assessment to Evaluate Early Implementation Strategies.

Qual Manag Health Care 2019 Jul/Sep;28(3):147-154

Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina (Drs Sperber, Wang, Jackson, Van Houtven, Allen, and Hastings and Mss Bruening, Choate, and Mahanna); Department of Population Health Sciences (Drs Sperber, Wang, Jackson, Van Houtven, and Hastings), Division of General Internal Medicine (Dr Wang), and Division of Geriatrics, Department of Medicine and Center for the Study of Aging (Dr Hastings), Duke University School of Medicine, Durham, North Carolina; Department of Health Policy and Management, Gillings School of Global Public Health (Dr Powell), and Department of Medicine & Thurston Arthritis Research Center (Dr Allen), University of North Carolina, Chapel Hill, North Carolina; Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana (Dr Damush); and Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis (Dr Damush).

Background: Rapid qualitative assessment was used to describe early strategies to implement an evidence-based walking program for hospitalized older adults, assiSTed eaRly mobIlity for hospitalizeD older vEterans (STRIDE), mandated by a regional Department of Veterans Affairs health care system office (Veterans Integrated Service Network [VISN]).

Methods: Data were collected from 6 hospital sites via semistructured interviews with key informants, observations of telephone-based technical assistance, and review of VISN-requested program documents (eg, initial implementation plans). An overarching framework of actionable feedback for VISN leadership and specification of locally initiated implementation strategies, using the Expert Recommendations for Implementing Change (ERIC) compilation, was used. Actionable feedback was shared with VISN leadership 1 month after the initiative.

Results: ERIC implementation strategies identified were as follows: (1) promoting adaptability-4 sites had physical therapists/kinesiotherapists instead of assistants walk patients; (2) promoting network weaving-strengthening nursing and PT/KT partnership with regular communication opportunities or a point person was important for implementation; (3) distributing educational materials-2 sites distributed information about STRIDE via e-mail and in person; and (4) organizing clinician implementation team meetings-3 sites used interdisciplinary team meetings to communicate with the clinical staff about STRIDE.

Conclusion: This qualitative study sheds light on early experiences with implementing STRIDE; the results have been instructive for ongoing implementation and future dissemination of STRIDE, and the approach can be applied across contexts to inform implementation of other programs.
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http://dx.doi.org/10.1097/QMH.0000000000000221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558850PMC
April 2020

STepped exercise program for patients with knee OsteoArthritis (STEP-KOA): protocol for a randomized controlled trial.

BMC Musculoskelet Disord 2019 May 28;20(1):254. Epub 2019 May 28.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System HSRD (152), 508 Fulton Street, Durham, NC, 27705, USA.

Background: Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions.

Methods / Design: Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA.

Discussion: STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA.

Trial Registration: Clinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016.
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http://dx.doi.org/10.1186/s12891-019-2627-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540433PMC
May 2019

Composite measures of physical activity and pain associate better with functional assessments than pain alone in knee osteoarthritis.

Clin Rheumatol 2019 Aug 30;38(8):2241-2247. Epub 2019 Mar 30.

Department of Medicine, Duke University Medical Center, Durham, NC, USA.

Introduction: Recent research showed that physical activity (PA)-adjusted pain measures were more strongly associated with radiographic osteoarthritis (OA) severity than an unadjusted pain measure. This exploratory study examined whether PA-adjusted pain measures were more closely associated with other key OA-related measures, compared to unadjusted pain scores.

Method: Participants were 122 Veterans (mean age = 61.2 years, 88.5% male) with knee OA. Baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were adjusted for accelerometer-derived daily: (1) step counts, (2) minutes of any activity, (3) minutes of moderate or greater intensity activity, (4) minutes of light intensity activity, and (5) energy expenditure. Partial correlations, adjusted for age, sex, and body mass index, estimated associations of unadjusted and PA-adjusted WOMAC pain scores with functional assessments (6-minute walk test, 8-foot walk test, chair stand test, satisfaction with physical function), fatigue (Brief Fatigue Inventory), and anxiety/depressive symptoms (single item).

Results: Significant (p < 0.05) associations were found in 29 of 36 of models. For the four function-related assessments, step count and energy expenditure-adjusted WOMAC pain scores had stronger associations (partial rs = 0.24-0.48) than WOMAC pain score (partial rs = 0.19-0.25). For fatigue and anxiety/depressive symptoms, WOMAC pain score had stronger, positive associations than most PA-adjusted pain scores. Of the PA-adjusted measures, the strongest associations overall were observed for step count and energy expenditure.

Conclusion: PA-adjusted pain scores may have particular value for OA studies involving functional assessments, whereas unadjusted WOMAC pain scores are more closely associated with psychological symptoms. This has implications for measurement in clinical OA studies.

Trial Registration: NCT01058304 KEY POINTS: • Among patents with osteoarthritis, physical activity-adjusted pain measures (particularly those adjusted for step count and energy expenditure) were more strongly associated with measures of physical function, compared to unadjusted pain scores, whereas unadjusted pain score was more strongly associated with a measure of psychological symptoms. • In clinical osteoarthritis research, the most appropriate or sensitive symptom measure (pain vs. physical activity-adjusted pain) may depend on the type of intervention or outcome being studied.
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http://dx.doi.org/10.1007/s10067-019-04530-4DOI Listing
August 2019

Pain coping skills training for African Americans with osteoarthritis: results of a randomized controlled trial.

Pain 2019 06;160(6):1297-1307

Department of Psychiatry and Behavioral Science, Duke University, Durham, NC, United States.

African Americans bear a disproportionate burden of osteoarthritis (OA), but they have been underrepresented in trials of behavioral interventions for pain. This trial examined a culturally tailored pain coping skills training (CST) program, compared to a wait list control group, among 248 African Americans with knee or hip OA. The pain CST program involved 11 telephone-based sessions over 3 months. Outcomes were assessed at baseline, 3 months (primary), and 9 months, and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (primary outcome), WOMAC total score and function subscale, PROMIS Pain Interference, Short-Form 12 Mental and Physical Composite Subscales, Coping Strategies Questionnaire-Total Coping Attempts, Pain Catastrophizing Scale, Patient Health Questionnaire-8, Arthritis Self-Efficacy Scale, and Patient Global Impression of Arthritis Symptom Change. Linear mixed models were fit for all outcomes. There were no significant between-group differences in WOMAC pain score at 3 months (-0.63 [95% confidence interval -1.45, 0.18]; P = 0.128) or 9 months (-0.84 [95% confidence interval -1.73, 0.06]; P = 0.068). Among secondary outcomes, at 3 months, there were significant differences, in favor of the CST group, for Coping Strategies Questionnaire Total Coping Attempts, Pain Catastrophizing Scale, Arthritis Self-Efficacy, and Patient Global Impression of Arthritis Symptom Change (P < 0.01). Coping Strategies Questionnaire Total Coping Attempts, Arthritis Self-Efficacy, and Patient Global Assessment Change were also significantly improved at 9 months in the CST group, compared with wait list (P < 0.01). The culturally tailored pain CST program did not significantly reduce pain severity but did improve key measures of pain coping and perceived ability to manage pain among African Americans with OA.
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http://dx.doi.org/10.1097/j.pain.0000000000001525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719680PMC
June 2019

Application of Traditional and Emerging Methods for the Joint Analysis of Repeated Measurements With Time-to-Event Outcomes in Rheumatology.

Arthritis Care Res (Hoboken) 2020 05 8;72(5):615-621. Epub 2020 Apr 8.

University of North Carolina, Chapel Hill.

Objective: The goal of this paper is to describe approaches for the joint analysis of repeatedly measured data with time-to-event end points, first separately and then in the framework of a single comprehensive model, emphasizing the efficiency of the latter approach. Data from the Johnston County Osteoarthritis (JoCo OA) Project will be used as an example to investigate the relationship between the change in repeatedly measured body mass index (BMI) and the time-to-event end point of incident worsening of radiographic knee OA that was defined as an increased Kellgren/Lawrence grade in at least 1 knee over time.

Methods: First, we provide an overview of the methods for analyzing repeated measurements and time-to-event end points separately. Then, we describe traditional (Cox proportional hazards model [CoxPH]) and emerging (joint model [JM]) approaches, both of which allow combined analysis of repeated measures with a time-to-event end point in the framework of a single statistical model. Finally, we apply the models to JoCo OA data and interpret and compare the results from the different approaches.

Results: Applications of the JM (but not the CoxPH) showed that the risk of worsening radiographic OA is higher when BMI is higher or increasing, thus illustrating the advantages of the JM for analyzing such dynamic measures in a longitudinal study.

Conclusion: Joint models are preferable for simultaneous analyses of repeated measurement and time-to-event outcomes, particularly in the context of chronic disease, where dependency between the time-to-event end point and the longitudinal trajectory of repeated measurements is inherent.
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http://dx.doi.org/10.1002/acr.23881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761043PMC
May 2020

Early Mobility in the Hospital: Lessons Learned from the STRIDE Program.

Geriatrics (Basel) 2018 Dec 26;3(4). Epub 2018 Sep 26.

Center of Innovation for Health Services Research in Primary Care, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (K.D.A.); (C.H.V.H.); (V.W.).

Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available in U.S. hospitals. STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) is a supervised walking program for hospitalized older adults that fills this important gap in clinical care. This paper describes how STRIDE works and how it is being disseminated to other hospitals using the Replicating Effective Programs (REP) framework. Guided by REP, we define core components of the program and areas where the program can be tailored to better fit the needs and local conditions of its new context (hospital). We describe key adaptations made by four hospitals who have implemented the STRIDE program and discuss lessons learned for successful implementation of hospital mobility programs.
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http://dx.doi.org/10.3390/geriatrics3040061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371091PMC
December 2018

Core Outcome Measures for Chronic Musculoskeletal Pain Research: Recommendations from a Veterans Health Administration Work Group.

Pain Med 2019 08;20(8):1500-1508

Yale University and West Haven VAMC, West Haven, Connecticut, USA.

Objective: Chronic musculoskeletal pain (CMSP) disorders are among the most prevalent and disabling conditions worldwide. It would be advantageous to have common outcome measures when comparing results across different CMSP research studies.

Methods: The Veterans Health Administration appointed a work group to recommend core outcome measures for assessing pain intensity and interference as well as important secondary domains in clinical research. The work group used three streams of data to inform their recommendations: 1) literature synthesis augmented by three recently completed trials; 2) review and comparison of measures recommended by other expert groups; 3) two Delphi surveys of work group members.

Results: The single-item numerical rating scale and seven-item Brief Pain Inventory interference scale emerged as the recommended measures for assessing pain intensity and interference, respectively. The secondary domains ranked most important included physical functioning and depression, followed by sleep, anxiety, and patient-reported global impression of change (PGIC). For these domains, the work group recommended the Patient-Reported Outcome Information System four-item physical function and sleep scales, the Patient Health Questionnaire two-item depression scale, the Generalized Anxiety Disorder two-item anxiety scale, and the single-item PGIC. Finally, a single-item National Health Interview Survey item was favored for defining chronic pain.

Conclusions: Two scales comprising eight items are recommended as core outcome measures for pain intensity and interference in all studies of chronic musculoskeletal pain, and brief scales comprising 13 additional items can be added when possible to assess important secondary domains.
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http://dx.doi.org/10.1093/pm/pny279DOI Listing
August 2019

Contributions of symptomatic osteoarthritis and physical function to incident cardiovascular disease.

BMC Musculoskelet Disord 2018 Nov 10;19(1):393. Epub 2018 Nov 10.

Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599, USA.

Background: Osteoarthritis (OA) is associated with worsening physical function and a high prevalence of comorbid health conditions. In particular, cardiovascular disease (CVD) risk is higher in individuals with OA than the general population. Limitations in physical function may be one pathway to the development of CVD among individuals with OA. This study evaluated associations of symptomatic knee OA (sxKOA), baseline physical function and worsening of function over time with self-reported incident CVD in a community-based cohort.

Methods: Our sample consisted of individuals from the Johnston County Osteoarthritis Project who did not report having CVD at baseline. Variables used to evaluate physical function were the Health Assessment Questionnaire (HAQ), time to complete 5 chair stands, and the 8-ft walk. Worsening function for these variables was defined based on previous literature and cutoffs from our sample. Logistic regression analyses examined associations of sxKOA, baseline function and worsening of function over time with self-reported incident CVD, unadjusted and adjusted for relevant demographic and clinical characteristics.

Results: Among 1709 participants included in these analyses, the mean age was 59.5 ± 9.5 years, 63.6% were women, 15% had sxKOA, and the follow up time was 5.9 ± 1.2 years. About a third of participants reported worsening HAQ score, about two-fifths had worsened chair stand time, half had worsened walking speed during the 8-ft walk, and 16% self-reported incident CVD. In unadjusted analyses, sxKOA, baseline function, and worsening function were all associated with self-reported incident CVD. In multivariable models including all of these variables, sxKOA was not associated with incident CVD, but worsening function was significantly associated with increased CVD risk, for all three functional measures: HAQ odds ratio (OR) = 2.49 (95% confidence interval (CI) 1.90-3.25), chair stands OR = 1.58 (95% CI 1.20-2.08), 8-ft walk OR = 1.53 (95%CI 1.15-2.04). These associations for worsening function remained in models additionally adjusted for demographic and clinical characteristics related to CVD risk.

Conclusions: The association between symptomatic knee osteoarthritis and cardiovascular disease risk was explained by measures of physical function. This highlights the importance of physical activity and other strategies to prevent functional loss among individuals with symptomatic knee osteoarthritis.
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http://dx.doi.org/10.1186/s12891-018-2311-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6230250PMC
November 2018

Fall Risk and Utilization of Balance Training for Adults With Symptomatic Knee Osteoarthritis: Secondary Analysis From a Randomized Clinical Trial.

J Geriatr Phys Ther 2019 Apr/Jun;42(2):E39-E44

Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill.

Background And Purpose: Knee osteoarthritis (KOA) is a common disease that hinders activity participation in older adults. Associated symptoms and physiological changes can increase risk of falling in individuals with KOA. Balance training can decrease fall risks in older adults. Limited evidence exists regarding utilization of balance training in physical therapy (PT) for this population. This secondary data analysis investigated the proportion of participants at high risk for falling in the PhysicAl THerapy vs. INternet-based Exercise Training for Patients with Osteoarthritis (PATH-IN) study and the frequency with which balance training was utilized as an intervention in PT.

Methods: PATH-IN study participants (N = 344) performed the Four-Stage Balance Test and the Timed Up and Go (TUG) test during baseline assessment. Participants were randomly allocated to PT, an Internet-based exercise program, or a control group. Participants were classified as being at high risk for falling if they did not progress to the single-leg stance (SLS) during the Four-Stage Balance Test, were unable to maintain SLS for 5 seconds, or took longer than 13.5 seconds to complete the TUG test. The proportion of participants at high risk for falling was calculated for all participants and separately for those allocated to PT. In addition, PT notes were coded for balance training and the frequency of balance training utilization was calculated.

Results And Discussion: Upon enrollment, 35.5% (N = 122) of all participants and 36.2% (N = 50) of those allocated to PT were at high risk for falling. Of participants allocated to PT with documentation available for coding (N = 118), 35.5% (N = 42) were at high risk for falling. Balance training was provided to 62.7% (N = 74) during at least one PT session. Of those classified as being at high risk for falling, 33.3% (N = 14) did not receive balance training.

Conclusions: The finding of high fall risks in more than one-third of all participants with KOA is consistent with previous reports of a higher risk of falling in this population. Many PT participants did receive some balance training; however, one-third of participants at high risk for falling did not. Balance training for individuals with KOA at high risk for falling may be underutilized.
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http://dx.doi.org/10.1519/JPT.0000000000000213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422722PMC
March 2020

A pilot study examining activity monitor use in older adults with heart failure during and after hospitalization.

Geriatr Nurs 2019 Mar - Apr;40(2):185-189. Epub 2018 Oct 31.

College of Health Solutions, Arizona State University, 500 N 3rd St, Phoenix, AZ 85004, United States. Electronic address:

Our study examined feasibility and acceptability of continuous objective activity monitoring during hospitalization and after discharge in older adults with heart failure. Recruitment rate was 49.2% of eligible patients with a 93.1% retention rate. Twenty-seven older patients admitted with heart failure (78 ± 9.8 years; 51.8% female) wore two inclinometric accelerometers to record posture in-hospital and an ankle accelerometer to record ambulatory activity in-hospital and 30-days after discharge. During hospitalization, participants had 96.2% recorded wear time for postural accelerometers, and 99% for the ankle accelerometer. During the post-discharge period, there was 92% recorded wear time of the ankle accelerometer. Themes identified by participants were ease of wear, compatibility with hospital technology, remembering device/device use, and need for feedback/curiosity. Our study demonstrates feasibility and acceptability of continuous objective monitoring during hospitalization and at home in this clinical population.
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http://dx.doi.org/10.1016/j.gerinurse.2018.10.001DOI Listing
August 2019

Pain coping skills training for African Americans with osteoarthritis study: baseline participant characteristics and comparison to prior studies.

BMC Musculoskelet Disord 2018 Sep 19;19(1):337. Epub 2018 Sep 19.

Department of Psychology, East Carolina University, Greenville, NC, USA.

Background: The Pain Coping Skills Training for African Americans with OsteoaRTthritis (STAART) trial is examining the effectiveness of a culturally enhanced pain coping skills training (CST) program for African Americans with osteoarthritis (OA). This disparities-focused trial aimed to reach a population with greater symptom severity and risk factors for poor pain-related outcomes than previous studies. This paper compares characteristics of STAART participants with prior studies of CST or cognitive behavioral therapy (CBT)-informed training in pain coping strategies for OA.

Methods: A literature search identified 10 prior trials of pain CST or CBT-informed pain coping training among individuals with OA. We descriptively compared characteristics of STAART participants with other studies, in 3 domains of the National Institutes of Minority Health and Health Disparities' Research Framework: Sociocultural Environment (e.g., age, education, marital status), Biological Vulnerability and Mechanisms (e.g, pain and function, body mass index), and Health Behaviors and Coping (e.g., pain catastrophizing). Means and standard deviations (SDs) or proportions were calculated for STAART participants and extracted from published manuscripts for comparator studies.

Results: The mean age of STAART participants, 59 years (SD = 10.3), was lower than 9 of 10 comparator studies; the proportion of individuals with some education beyond high school, 75%, was comparable to comparator studies (61-86%); and the proportion of individuals who are married or living with a partner, 42%, was lower than comparator studies (62-66%). Comparator studies had less than about 1/3 African American participants. Mean scores on the Western Ontario and McMaster Universities Osteoarthritis Index pain and function scales were higher (worse) for STAART participants than for other studies, and mean body mass index of STAART participants, 35.2 kg/m (SD = 8.2), was higher than all other studies (30-34 kg/m). STAART participants' mean score on the Pain Catastrophizing scale, 19.8 (SD = 12.3), was higher (worse) than other studies reporting this measure (7-17).

Conclusions: Compared with prior studies with predominantly white samples, STAART participants have worse pain and function and more risk factors for negative pain-related outcomes across several domains. Given STAART participants' high mean pain catastrophizing scores, this sample may particularly benefit from the CST intervention approach.

Trial Registration: NCT02560922.
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http://dx.doi.org/10.1186/s12891-018-2249-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145122PMC
September 2018