Using Different Expectation Mechanisms to Optimize Treatment of Patients With Medical Conditions: A Systematic Review

Objective Patients' expectations have been shown to predict the course and treatment success of a variety of medical conditions. Therefore, expectation-focused psychological interventions (EFPIs) have been developed to use these expectation effects clinically. Importantly, EFPI differ with regard to the particular expectation mechanism being addressed, i.e., expectation optimization or expectation violation. The aims of this systematic review were to give an overview of the application of these expectation interventions and to evaluate their effectiveness. Methods Several databases were searched to identify clinical trials or experimental studies that conducted EFPI among participants with various medical conditions. Risk of bias was evaluated using the Cochrane Risk of Bias tool. Results Eleven studies (N = 944) investigating different medical conditions (coronary heart disease, cancer, chronic pain) were included. Qualitative synthesis revealed positive effects of EFPI on clinical outcome variables in all studies. Expectation optimization approaches yielded particularly promising results. Because of the large heterogeneity of outcome measures, quantitative synthesis was not possible. Conclusion This review highlights the potential of EFPI for optimizing treatment of patients with medical conditions. However, it seems that different expectation mechanisms might have different application possibilities. Therefore, we provide suggestions for further developing EFPI to tailor treatment and develop personalized psychological interventions. We argue that for this purpose, it is important to consider both disease-specific aspects and patients' personality traits. In addition, we discuss future challenges such as implementing EFPI into routine medical care.

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Temporal dynamics of pain: an application of regime-switching models to ecological momentary assessments in patients with rheumatic diseases

Advances in pain measurement using ecological momentary assessments offer novel opportunities for understanding the temporal dynamics of pain. This study examined whether regime-switching models, which capture processes characterized by recurrent shifts between different states, provide clinically relevant information for characterizing individuals based on their temporal pain patterns. Patients with rheumatic diseases (N = 116) provided 7 to 8 momentary pain ratings per day for 2 weekly periods, separated by 3 months. Regime-switching models extracted measures of Average pain (mean level over time), Amplitude (magnitude of shifts in pain levels), Persistence (average duration of pain states), and Dominance (relative duration of higher vs lower pain states) for each patient and assessment period. After controlling for Average pain, the Persistence of pain states uniquely predicted emotional functioning measures, whereas the Dominance of higher pain uniquely predicted physical functioning and pain interference. Longitudinal analyses of changes over the 3 months largely replicated cross-sectional results. Furthermore, patients' retrospective judgments of their pain were uniquely predicted by Amplitude and Dominance of higher pain states, and global impressions of change over the 3 months were predicted by changes on Dominance, controlling for Average pain levels. The results suggest that regime-switching models can usefully capture temporal dynamics of pain and can contribute to an improved measurement of patients' pain intensity.

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Chronic pain impairs cognitive flexibility and engages novel learning strategies in rats

Cognitive flexibility, the ability to adapt behavior to changing outcomes, is critical to survival. The prefrontal cortex is a key site of cognitive control, and chronic pain is known to lead to significant morphological changes to this brain region. Nevertheless, the effects of chronic pain on cognitive flexibility and learning remain uncertain. We used an instrumental paradigm to assess adaptive learning in an experimental model of chronic pain induced by tight ligation of the spinal nerves L5/6 (spinal nerve ligation model). Naive, sham-operated, and spinal nerve ligation (SNL) rats were trained to perform fixed-ratio, variable-ratio, and contingency-shift behaviors for food reward. Although all groups learned an initial lever-reward contingency, learning was slower in SNL animals in a subsequent choice task that reversed reinforcement contingencies. Temporal analysis of lever-press responses across sessions indicated no apparent deficits in memory consolidation or retrieval. However, analysis of learning within sessions revealed that the lever presses of SNL animals occurred in bursts, followed by delays. Unexpectedly, the degree of bursting correlated positively with learning. Under a variable-ratio probabilistic task, SNL rats chose a less profitable behavioral strategy compared with naive and sham-operated animals. After extinction of behavior for learned preferences, SNL animals reverted to their initially preferred (ie, less profitable) behavioral choice. Our data suggest that in the face of uncertainty, chronic pain drives a preference for familiar associations, consistent with reduced cognitive flexibility. The observed burst-like responding may represent a novel learning strategy in animals with chronic pain.

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Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial

Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial

Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation

Reasons for Distress Among Burn Survivors at 6, 12, and 24 Months Postdischarge: A Burn Injury Model System Investigation

Effectiveness of Botulinum Toxin A for Persistent Upper Limb Pain After Breast Cancer Treatment: A Double-Blinded Randomized Controlled Trial

Lower Quadriceps Rate of Force Development Is Associated With Worsening Physical Function in Adults With or at Risk for Knee Osteoarthritis: 36-Month Follow-Up Data From the Osteoarthritis Initiative

Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis

Clinical Benefits of Joint Mobilization on Ankle Sprains: A Systematic Review and Meta-Analysis

Interpreting the Results in Terms of Clinical Significance: Comment on “Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial”

Comprehensive non-surgical treatment versus self-directed care to improve walking ability in lumbar spinal stenosis: A randomized trial

Imaging of acute abdominal pain in the third trimester of pregnancy

What you need to knowUltrasound is generally first line and magnetic resonance imaging (MRI) second line for investigating acute abdominal pain in the third trimester of pregnancy.We suggest early...

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Lumbar Vertebral Endplate Defects on Magnetic Resonance Images: Classification, Distribution Patterns, and Associations with Modic Changes and Disc Degeneration

Study Design. A cross-sectional magnetic resonance (MR) imaging study. Objective. To classify and characterize endplate defects using routine lumbar MR images and to determine associations of endplate defects with Modic changes (MCs) and disc degeneration. Summary of Background Data. Previously, a cadaveric study revealed that endplate lesions were common and associated with back pain history. New in vivo approaches appropriate for clinical studies are needed to further this potentially important line of research on the clinical significance of endplate lesions, including their relation with MCs, disc degeneration, and back pain. Methods. Using a MRI archive, 1564 endplates of 133 subjects (59 men and 74 women, mean age 58.9 ± 11.9 years) with the presence of MCs were retrospectively collected from April of 2014 to June of 2015. On the basis of morphological characteristics, a protocol was proposed to identify three distinct types of endplate defects, including focal, corner, and erosive defects. The location, size, and distribution patterns of various endplate lesions were characterized. MCs and disc degeneration were measured to examine their associations with endplate defects. Results. Endplate defects were observed in 27.8% of endplates studied. Greater age was associated with the presence of endplate defects. Focal defects were the most common (13.5%), followed by erosive defects (11.1%) and corner defects (3.2%). Defect types also differed in size and distribution patterns. Endplate defects and MCs had similar distribution patterns in the lumbar spine. The presence of endplate defects were associated with the presence of MCs (odds ratio = 4.29, P < 0.001), and associated with less disc signal intensity and disc height, and greater disc bulging (P < 0.05). Conclusion. The three endplate defects identified on routine MR images appear to represent different pathologies and may play a key role in the pathogenesis of MCs. This classification system may facilitate clinical studies on endplate defects. Level of Evidence: 4

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Minimum Detectable Measurement Difference for Health-Related Quality of Life Measures Varies With Age and Disability in Adult Spinal Deformity: Implications for Calculating Minimal Clinically Important Difference

Study Design. Retrospective cohort. Objective. To investigate the minimum detectable measurement difference (MDMD) in the Scoliosis Research Society-22r (SRS-22r) outcomes instrument in adult spinal deformity (ASD) and to evaluate the effect of baseline data on measurable difference. Summary of Background Data. The minimum clinically important difference (MCID) is the smallest, clinically relevant change observed and has been proposed for the SRS-22r instrument in ASD as 0.4. The MCID must be greater than the MDMD to be useful. The MDMD for the SRS-22r has not been calculated, nor have the effect of patient baseline values on MDMD. Methods. A prospective observation cohort was queried for patients treated both operatively and nonoperatively for ASD. Patients with baseline and 1-year, 2-year follow-up SRS-22r data were included in the analysis. The MDMD was calculated using classical test theory and item-response theory methods. Effect size and standardized response means were calculated. The effect of baseline data values was evaluated for MDMD. Results. A total 839 Patients were eligible for cohort inclusion with 428 (51%) eligible for analysis with complete data. MDMD for Pain (0.6) and Self-Image (0.5) were greater than 0.4. MDMD varied with age (highest for the youngest patients) and with disability (highest for SF-36 Physical Component Summary <28.6). MDMD was less than 0.4 for Activity (0.3), Mental Health (0.3), and Total Score (0.2). Gender and mental health did not affect MDMD for the SRS-22r instrument. Conclusion. An MCID of 0.4 for the SRS-22r total score and domain scores may not be an appropriate value as the calculated MDMD is greater than 0.4 for both the Pain and Self-Image subscores. The MDMD for the SRS-22r instrument varied with age and baseline disability, making the assessment of clinically significant change more difficult using this tool. The MCID must be considered in the setting of the MDMD for instruments used to assess outcomes in ASD. Level of Evidence: 3

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Cervical Sagittal Range of Motion as a Predictor of Symptom Severity in Cervical Spondylotic Myelopathy

Study Design. A retrospective review of radiographic data and functional outcomes. Objective. The aim of this study was to evaluate whether myelopathy symptom severity upon presentation corresponds to sagittal plane alignment or nonmyelopathy symptoms, such as pain, in patients with cervical spondylotic myelopathy (CSM). Summary of Background Data. Cervical sagittal balance is an important parameter in the outcome of surgical reconstruction. However, the effect of sagittal alignment on symptom severity in patients who have not undergone spine surgery is not well defined. Methods. A consecutive series of CSM patients was identified at an academic institution. Preoperative radiographs were analyzed for sagittal vertical axis (C2SVA), C7 slope (C7S), C2-C7 angle in neutral (C27N), flexion (C27F), and extension (C27E), and range of motion (C27ROM). Neutral alignment was categorized as lordotic, kyphotic, or sigmoid/straight. Outcomes collected were SF-12, neck disability index, arm pain, neck pain, and modified JOA (mJOA). Pearson coefficients determined correlations between radiographic and outcome parameters. Multivariate regression evaluated predictive factors of mJOA. Results. Radiographic parameters did not correlate with pain. Increasing age, smaller C27ROM, and smaller flexion angles correlated to lower (more severe) baseline mJOA scores. ROM (and not static alignment) was the only significant predictor of mJOA in the multivariate regression. Despite significant radiographic differences between lordotic, kyphotic, and sigmoid/straight alignment groups, myelopathy severity did not differ between these groups. Conclusion. Static, neutral alignment, including SVA and lordosis, did not correlate with myelopathy or pain symptoms. Greater C27ROM and increased maximal flexion corresponded to milder myelopathy symptoms, suggesting that patients with myelopathy may compensate for cervical stenosis with hyperflexion, similar to that which is observed in the lumbar spine. In a CSM patient population, dynamic motion and compensatory deformities may play a more significant role in myelopathy symptom severity than what can be discerned from standard, neutral position radiographs. Level of Evidence: 3

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Comparing Health-Related Quality of Life Outcomes in Patients Undergoing Either Primary or Revision Anterior Cervical Discectomy and Fusion

Study Design. A retrospective review of prospectively collected data. Objective. Compare health-related quality of life (HRQOL) outcome metrics in patients undergoing primary and revision anterior cervical discectomy and fusion (ACDF). Summary of Background Data. ACDF is associated with significant improvements in HRQOL outcome metrics. However, 2.9% of patients per year will develop symptomatic adjacent segment disease and there is a paucity of literature on HRQOL outcomes after revision ACDF. Methods. Patients were identified who underwent either a primary or revision ACDF, and who had both preoperative and a minimum of 1-year postoperative HRQOL outcome data. Pre- and postoperative Short Form 12 Physical Component Score (SF12 PCS), Short Form 12 Mental Component Score (SF12 MCS) Visual Analog Scale for neck pain (VAS-Neck), VAS-Arm, and Neck Disability Index (NDI) scores were compared. Results. A total of 360 patients (299 primary, 61 revision) were identified. Significant improvement in SF12 PCS, NDI, VAS-Neck, and VAS-Arm was seen in both groups; however, only a significant improvement in SF12 MCS was seen in the primary group. When comparing the results of a primary versus a revision surgery, the SF12 PCS score was the only outcome with a significantly different net improvement in the primary group (7.23 ± 9.72) compared to the revision group (2.9 ± 11.07; P = 0.006) despite similar baseline SF12 PCS scores. The improvement in each of the other reported HRQOL outcomes did not significantly vary between surgical groups. Conclusion. A revision ACDF for cervical radiculopathy or myelopathy leads to a significant improvement in the HRQOL outcome, and with the exception of the SF12 PCS, these results are similar to those of patients undergoing a primary ACDF. Level of Evidence: 2

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Adding Satellite Rods to Standard Two-rod Construct With the Use of Duet Screws: An Effective Technique to Improve Surgical Outcomes and Preventing Proximal Junctional Kyphosis in Posterior-Only Correction of Scheuermann Kyphosis

Study Design. A retrospective matched-cohort comparative study. Objective. The aim of this study was to compare the surgical results after the use of duet screw based satellite rods and bilateral satellite rods (S-RC) versus a standard two-rod construct (2-RC) across osteotomy sites in a matched cohort with Scheuermann kyphosis (SK). Summary of Background Data. Multiple Ponte osteotomies are frequently employed to correct SK via a posterior-only approach, with a 2-RC across the osteotomy sites. Whereas, correction rate and junction problems remain as the major concerns. Methods. This study reviewed a consecutive series of patients with SK who had undergone posterior-only correction with multilevel Ponte osteotomy between 2009 and 2014 and had been followed over 24 months. Twenty-two patients receiving placement with an S-RC with the use of duet screws were identified and closely matched with 22 patients with a 2-RC in terms of age, apex, and magnitude of kyphosis. Comparisons were made with regards to deformity magnitude, correction results, complications, and clinical outcomes between the two groups. Results. No significant difference was found between groups in preoperative patient's factors (age, gender, apex, magnitude of kyphosis, and SRS-22 scores) and surgical factors (blood loss, operation time, osteotomy levels, and fused levels). Compared with the 2-RC group, the S-RC group had higher correction rate (55.4% ± 7.5% vs. 46.2% ± 5.1%, P < 0.001), less correction loss (1.0 ± 0.8° vs. 2.4 ± 1.4°, P < 0.001) during the follow-up, and higher improvement of back pain as well (P < 0.05). None were detected with pseudarthrosis or implant failure in either group, but proximal junctional kyphosis was less frequently seen in S-RC group (1 of 22) than 2-RC group (7 of 22) (P < 0.05). Conclusion. As a safe method, use of S-RC is effective in providing increased kyphotic correction across multiple Ponte osteotomy levels, and improving patient-reported outcomes of management satisfaction and back pain. The biomechanical benefits of stress dispersion, coupled with increased stability and weight bearing ability, make it a powerful technique preventing correction loss and proximal junctional kyphosis. Level of Evidence: 3

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Home-based exercise enhances health-related quality of life in persons with spinal cord injury: A randomized controlled trial

Postoperative Rehabilitation Following Thumb Base Surgery: A Systematic Review of the Literature