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Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury

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Abstract

Orthopedic traumas are common, costly, and burdensome – particularly for patients who transition from acute to chronic pain. Psychosocial factors, such as pain catastrophizing and pain anxiety, increase risk for poor outcomes after injury. The Toolkit for Optimal Recovery (TOR) is a novel multi-component mind–body intervention informed by the fear-avoidance model to promote re-engagement in daily activities and prevent transition toward chronic pain and physical dysfunction. The current case series aims to 1) describe the intervention and 2) showcase the treatment course of three TOR completers from diverse geographic locations in the U.S. with distinct injury types and varying personal identities to illustrate how the intervention can be delivered flexibly. Results indicate pre-to-post program improvement in physical function, pain severity, pain catastrophizing, pain anxiety, and other relevant outcomes targeted by the intervention (i.e., depression, mindfulness, coping). Experiences of our three TOR completers suggest that integrating TOR with standard orthopedic care may promote physical recovery after injury.

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References

  • Abrams, M. P., Carleton, R. N., & Asmundson, G. J. (2007). An exploration of the psychometric properties of the PASS-20 with a nonclinical sample. The Journal of Pain, 8(11), 879–886.

    PubMed  Google Scholar 

  • Andersen, T. E., Karstoft, K. I., Brink, O., & Elklit, A. (2016). Pain-catastrophizing and fear avoidance beliefs as mediators between post-traumatic stress symptoms and pain following whiplash injury - A prospective cohort study. European Journal of Pain, 20(8), 1241–1252.

    CAS  PubMed  Google Scholar 

  • Antoni, M. H., Lechner, S. C., Kazi, A., Wimberly, S. R., Sifre, T., Urcuyo, K. R., & Carver, C. S. (2006). How stress management improves quality of life after treatment for breast cancer. Journal of Consulting and Clinical Psychology, 74(6), 1143.

    PubMed  PubMed Central  Google Scholar 

  • Asghari, A., & Nicholas, M. K. (2001). Pain self-efficacy beliefs and pain behavior. A prospective study. Pain, 94(1), 85–100.

    PubMed  Google Scholar 

  • Attkisson, C. C., & Zwick, R. (1982). The Client Satisfaction Questionnaire: Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning, 5(3), 233–237.

    CAS  PubMed  Google Scholar 

  • Baldwin, M. L. (2004). Reducing the costs of work-related musculoskeletal disorders: Targeting strategies to chronic disability cases. Journal of Electromyography and Kinesiology, 14(1), 33–41.

    PubMed  Google Scholar 

  • Brodke, D. J., Saltzman, C. L., & Brodke, D. S. (2016). PROMIS for orthopaedic outcomes measurement. Journal of the American Academy of Orthopaedic Surgeons, 24(11), 744–749.

    PubMed  Google Scholar 

  • Chien, C. W., Bagraith, K. S., Khan, A., Deen, M., & Strong, J. (2013). Comparative responsiveness of verbal and numerical rating scales to measure pain intensity in patients with chronic pain. The Journal of Pain, 14(12), 1653–1662.

    PubMed  Google Scholar 

  • Coyle, S., Kinsella, S., Lenehan, B., & Queally, J. M. (2018). Cost-utility analysis in orthopaedic trauma; what pays? A systematic review. Injury, 49(3), 575–584.

    CAS  PubMed  Google Scholar 

  • Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.

    PubMed  PubMed Central  Google Scholar 

  • Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W., & Karoly, P. (2012). Fear avoidance model of chronic pain: The next generation. The Clinical Journal of Pain, 28(6), 475–483.

    PubMed  Google Scholar 

  • Darnall, B. D., Sturgeon, J. A., Kao, M. C., Hah, J. M., & Mackey, S. C. (2014). From catastrophizing to recovery: A pilot study of a single-session treatment for pain catastrophizing. Journal of Pain Research, 7, 219.

    PubMed  PubMed Central  Google Scholar 

  • Diouf, F., Lemley, B., Barth, C., Goldbarg, J., Helgenberger, S., Grimm, B., & Bonnevie, E. (2022). Mental Health Stigma Reduction in the Midwestern United States Evidence from a Digital Campaign Using a Collective Impact Model. Journal of Community Health, 47(6), 924–931.

    PubMed  PubMed Central  Google Scholar 

  • Doornberg, J. N., Ring, D., Fabian, L. M., Malhotra, L., Zurakowski, D., & Jupiter, J. B. (2005). Pain dominates measurements of elbow function and health status. JBJS, 87(8), 1725–1731.

    Google Scholar 

  • Farrar, J. T., Young, J. P., Jr., LaMoreaux, L., Werth, J. L., & Poole, R. M. (2001). Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain, 94(2), 149–158.

    PubMed  Google Scholar 

  • Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J. P. (2007). Mindfulness and emotion regulation: The development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). Journal of Psychopathology and Behavioral Assessment, 29(3), 177–190.

    Google Scholar 

  • Feldman, G., Westine, M., Edelman, A., Higgs, M., Renna, M., & Greeson, J. (2022). Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). Handbook of Assessment in Mindfulness Research (pp. 1–24). Springer International Publishing.

    Google Scholar 

  • Ferreira-Valente, M. A., Pais-Ribeiro, J. L., & Jensen, M. P. (2011). Validity of four pain intensity rating scales. Pain, 152(10), 2399–2404.

    PubMed  Google Scholar 

  • Fischerauer, S. F., Talaei-Khoei, M., Bexkens, R., Ring, D. C., Oh, L. S., & Vranceanu, A. M. (2018). What is the relationship of fear avoidance to physical function and pain intensity in injured athletes? Clinical Orthopaedics and Related Research, 476(4), 754–763.

    PubMed  PubMed Central  Google Scholar 

  • Greenberg, J., Braun, T. D., Schneider, M. L., Finkelstein-Fox, L., Conboy, L. A., Schifano, E. D., & Lazar, S. W. (2018). Is less more A randomized comparison of home practice time in a mind-body program. Behaviour Research and Therapy, 111, 52–56.

    PubMed  PubMed Central  Google Scholar 

  • Hayes, S. C., & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17(2), 289–303.

    CAS  PubMed  PubMed Central  Google Scholar 

  • Helmerhorst, G. T., Vranceanu, A. M., Vrahas, M., Smith, M., & Ring, D. (2014). Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. JBJS, 96(6), 495–499.

    Google Scholar 

  • Hirata, J., Tomiyama, M., Koike, Y., Yoshimura, M., & Inoue, K. (2021). Relationship between pain intensity, pain catastrophizing, and self-efficacy in patients with frozen shoulder: A cross-sectional study. Journal of Orthopaedic Surgery and Research, 16(1), 542.

    PubMed  PubMed Central  Google Scholar 

  • Hjermstad, M. J., Fayers, P. M., Haugen, D. F., Caraceni, A., Hanks, G. W., Loge, J. H., Fainsinger, R., Aass, N., Kaasa, S., & European Palliative Care Research Collaborative (EPCRC). (2011). Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: A systematic literature review. Journal of Pain and Symptom Management, 41(6), 1073–1093.

    Google Scholar 

  • Jaeschke, R., Singer, J., & Guyatt, G. H. (1989). Measurement of health status: Ascertaining the minimal clinically important difference. Controlled Clinical Trials, 10(4), 407–415.

    CAS  PubMed  Google Scholar 

  • Jarman, M. P., Weaver, M. J., Haider, A. H., Salim, A., & Harris, M. B. (2020). The national burden of orthopedic injury: Cross-sectional estimates for trauma system planning and optimization. Journal of Surgical Research, 249, 197–204.

    PubMed  Google Scholar 

  • Jayakumar, P., Overbeek, C. L., Lamb, S., Williams, M., Funes, C., Gwilym, S., & Vranceanu, A. M. (2018). What factors are associated with disability after upper extremity injuries? A systematic review. Clinical Orthopaedics and Related Research, 476(11), 2190.

    PubMed  PubMed Central  Google Scholar 

  • Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8(2), 73.

    Google Scholar 

  • Kamper, S. J., Grootjans, S. J., Michaleff, Z. A., Maher, C. G., McAuley, J. H., & Sterling, M. (2015). Measuring pain intensity in patients with neck pain: Does it matter how you do it? Pain Practice, 15(2), 159–167.

    PubMed  Google Scholar 

  • Karayannis, N. V., Sturgeon, J. A., Kemani, M. K., Mackey, S. C., Greco, C. M., Wicksell, R. K., & McCracken, L. M. (2023). Pain acceptance and psychological inflexibility predict pain interference outcomes for persons with chronic pain receiving pain psychology. Scandinavian Journal of Pain. https://doi.org/10.1515/sjpain-2022-0107

    Article  PubMed  PubMed Central  Google Scholar 

  • Linehan, M. (2014). DBT Skills training manual. Guilford Publications.

  • Macfarlane, G. J. (2016). The epidemiology of chronic pain. Pain, 157(10), 2158–2159.

    PubMed  Google Scholar 

  • McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary development and validity. Pain Research and Management, 7(1), 45–50.

    PubMed  Google Scholar 

  • Minetama, M., Kawakami, M., Teraguchi, M., Kagotani, R., Mera, Y., Sumiya, T., & Nakagawa, Y. (2021). Supervised physical therapy versus unsupervised exercise for patients with lumbar spinal stenosis: 1-year follow-up of a randomized controlled trial. Clinical Rehabilitation, 35(7), 964–975.

    PubMed  Google Scholar 

  • Morris, S., Lenihan, B., Duddy, L., & O’Sullivan, M. (2000). Outcome after musculoskeletal trauma treated in a regional hospital. Journal of Trauma and Acute Care Surgery, 49(3), 461–469.

    CAS  Google Scholar 

  • Nissen, T., & Wynn, R. (2014). The clinical case report: A review of its merits and limitations. BMC Research Notes. https://doi.org/10.1186/1756-0500-7-264

    Article  PubMed  PubMed Central  Google Scholar 

  • Osman, A., Barrios, F. X., Gutierrez, P. M., Kopper, B. A., Merrifield, T., & Grittmann, L. (2000). The Pain Catastrophizing Scale: Further psychometric evaluation with adult samples. Journal of Behavioral Medicine, 23(4), 351–365.

    CAS  PubMed  Google Scholar 

  • Parsons, C. E., Crane, C., Parsons, L. J., Fjorback, L. O., & Kuyken, W. (2017). Home practice in Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction: A systematic review and meta-analysis of participants’ mindfulness practice and its association with outcomes. Behaviour Research and Therapy, 95, 29–41.

    PubMed  PubMed Central  Google Scholar 

  • Proctor, T. J., Mayer, T. G., Gatchel, R. J., & McGeary, D. D. (2004). Unremitting health-care utilization outcomes of tertiary rehabilitation of patients with chronic musculoskeletal disorders. JBJS, 86(1), 62–69.

    Google Scholar 

  • Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401.

    Google Scholar 

  • Rai, S. K., Yazdany, J., Fortin, P. R., & Aviña-Zubieta, J. A. (2015). Approaches for estimating minimal clinically important differences in systemic lupus erythematosus. Arthritis Research & Therapy, 17(1), 143.

    Google Scholar 

  • Reichman, M., Grunberg, V. A., Doorley, J. D., Bakhshaie, J., Lester, E. G., Mace, R. A., & Vranceanu, A. M., (2021). In P. C. Kendall (Ed.), Flexibility within Fidelity: Breathing Life into a Psychological Treatment Manual (pp. 95–117). Oxford University Press, Oxford

  • Ring, D., Kadzielski, J., Malhotra, L., Lee, S. G. P., & Jupiter, J. B. (2005). Psychological factors associated with idiopathic arm pain. JBJS, 87(2), 374–380.

    Google Scholar 

  • Rodriguez-Leal, F. A., Haase, R., Akgün, K., Eisele, J., Proschmann, U., Schultheiss, T., Kern, R., & Ziemssen, T. (2019). Nonwalking response to fampridine in patients with multiple sclerosis in a real-world setting. Therapeutic Advances in Chronic Disease, 10, 2040622319835136.

    PubMed  PubMed Central  Google Scholar 

  • Rogers, A. H., & Farris, S. G. (2022). A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain related disability and pain intensity. European Journal of Pain (london, England), 26(8), 1611–1635. https://doi.org/10.1002/ejp.1994

    PubMed  Google Scholar 

  • Rose, M., Bjorner, J. B., Becker, J., Fries, J. F., & Ware, J. E. (2008). Evaluation of a preliminary physical function item bank supported the expected advantages of the Patient-Reported Outcomes Measurement Information System (PROMIS). Journal of Clinical Epidemiology, 61(1), 17–33.

    CAS  PubMed  Google Scholar 

  • Royal Kenton, N., Broffman, L., Jones, K., Albrecht Mcmenamin, K., Weller, M., Brown, K., & Wright, B. (2019). Patient experiences in behavioral health integrated primary care settings: the role of stigma in shaping patient outcomes over time. Psychology Health Medicine, 24(10), 1182–1197.

    PubMed  Google Scholar 

  • Salaffi, F., Stancati, A., Silvestri, C. A., Ciapetti, A., & Grassi, W. (2004). Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. European Journal of Pain, 8(4), 283–291.

    PubMed  Google Scholar 

  • Sandvall, B., Okoroafor, U. C., Gerull, W., Guattery, J., & Calfee, R. P. (2019). Minimal clinically important difference for PROMIS physical function in patients with distal radius fractures. The Journal of Hand Surgery, 44(6), 454–459.

    PubMed  Google Scholar 

  • Shaffer, K. (2014). Center for Epidemiologic Studies Depression (CES-D) Scale. In A. C. Michalos (Ed.), Encyclopedia of Quality of Life and Well-Being Research. Dordrecht: Springer.

    Google Scholar 

  • Shim, R., & Rust, G. (2013). Primary care, behavioral health, and public health: Partners in reducing mental health stigma. American Journal of Public Health, 103(5), 774–776.

    PubMed  PubMed Central  Google Scholar 

  • Simmons, L. A., Wu, Q., Yang, N., Bush, H. M., & Crofford, L. J. (2015). Sources of health information among rural women in Western Kentucky. Public Health Nursing, 32(1), 3–14.

    PubMed  Google Scholar 

  • Soleymanha, M., Mobayen, M., Asadi, K., Adeli, A., & Haghparast-Ghadim-Limudahi, Z. (2014). Survey of 2582 cases of acute orthopedic trauma. Trauma Monthly. https://doi.org/10.5812/traumamon.16215

    Article  PubMed  PubMed Central  Google Scholar 

  • Sullivan, M. J., Bishop, S. R., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological Assessment, 7(4), 524.

    Google Scholar 

  • Tan, G., Teo, I., Anderson, K. O., & Jensen, M. P. (2011). Adaptive versus maladaptive coping and beliefs and their relation to chronic pain adjustment. The Clinical Journal of Pain, 27(9), 769–774.

    PubMed  Google Scholar 

  • Vincent, H. K., Horodyski, M., Vincent, K. R., Brisbane, S. T., & Sadasivan, K. K. (2015). Psychological distress after orthopedic trauma: Prevalence in patients and implications for rehabilitation. PM&R, 7(9), 978–989.

    Google Scholar 

  • Vlaeyen, J. W., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144–1147.

    PubMed  Google Scholar 

  • Vranceanu, A. M., Bakhshaie, J., Reichman, M., Doorley, J., Elwy, A. R., Jacobs, C., ... & Ring, D. (2021a). A live video program to prevent chronic pain and disability in at-risk adults with acute orthopedic injuries (Toolkit for Optimal Recovery): Protocol for a multisite feasibility study. JMIR Research Protocols, 10(4), e28155.

  • Vranceanu, A. M., Bakhshaie, J., Reichman, M., Doorley, J., Mace, R. A., Jacobs, C., & Elwy, A. R. (2021b). Understanding barriers and facilitators to implementation of psychosocial care within orthopedic trauma centers: a qualitative study with multidisciplinary stakeholders from geographically diverse settings. Implementation Science Communications, 2(1), 1–17.

    Google Scholar 

  • Vranceanu, A. M., Bachoura, A., Weening, A., Vrahas, M., Smith, R. M., & Ring, D. (2014). Psychological factors predict disability and pain intensity after skeletal trauma. JBJS, 96(3), e20.

    Google Scholar 

  • Vranceanu, A. M., Barsky, A., & Ring, D. (2009). Psychosocial aspects of disabling musculoskeletal pain. JBJS, 91(8), 2014–2018.

    Google Scholar 

  • Vranceanu, A. M., Jacobs, C., Lin, A., Greenberg, J., Funes, C. J., Harris, M. B., & Ring, D. (2019). Results of a feasibility randomized controlled trial (RCT) of the Toolkit for Optimal Recovery (TOR): a live video program to prevent chronic pain in at-risk adults with orthopedic injuries. Pilot and Feasibility Studies, 5(1), 1–11.

    Google Scholar 

  • Webster, B. S., Verma, S. K., & Gatchel, R. J. (2007). Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine, 32(19), 2127–2132.

    PubMed  Google Scholar 

  • Wheeler, C., Williams, A., & Morley, S. J. (2019). Meta-analysis of the psychometric properties of the Pain Catastrophizing Scale and associations with participant characteristics. Pain, 160(9), 1946–1953.

    PubMed  Google Scholar 

  • Williamson, A., & Hoggart, B. (2005). Pain: A review of three commonly used pain rating scales. Journal of Clinical Nursing, 14(7), 798–804.

    PubMed  Google Scholar 

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Funding

This study was supported by The National Center for Complementary and Integrative Health (1 R01 AT010462-01A1) and The National Research Service Award Institutional Research Training Grant (T32 AT000051).

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Authors and Affiliations

  1. Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research (CHOIR), Massachusetts General Hospital, One Bowdoin Square, Suite 100, Boston, MA, USA

    Brooke A. Duarte, Ryan A. Mace, James D. Doorley, Terence M. Penn, Jafar Bakhshaie & Ana-Maria Vranceanu

  2. Department of Psychology, Suffolk University, Boston, MA, USA

    Brooke A. Duarte

  3. Harvard Medical School, Boston, MA, USA

    Ryan A. Mace, James D. Doorley, Terence M. Penn, Jafar Bakhshaie & Ana-Maria Vranceanu

Authors
  1. Brooke A. Duarte
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  2. Ryan A. Mace
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  3. James D. Doorley
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  4. Terence M. Penn
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  5. Jafar Bakhshaie
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  6. Ana-Maria Vranceanu
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Contributions

AMV conceptualized the study. BD wrote the introduction, two cases, and the discussion. RM wrote one case study. JD wrote the intervention components. TP wrote part of the methods. JB and AMV provided input with interpretation and manuscript writing. All authors reviewed and agreed with the final manuscript prior to submission.

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Correspondence to Ana-Maria Vranceanu.

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Duarte, B.A., Mace, R.A., Doorley, J.D. et al. Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury. J Clin Psychol Med Settings 31, 91–107 (2024). https://doi.org/10.1007/s10880-023-09959-z

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