Daniel I. Rhon’s research while affiliated with Uniformed Services University of the Health Sciences and other places

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Publications (183)


Risk-stratified Care Improves Pain-related Knowledge and Reduces Psychological Distress for Low Back Pain: A Secondary Analysis of a Randomized Trial
  • Article

January 2025

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11 Reads

Clinical Orthopaedics and Related Research

Tina A Greenlee

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Steven Z George

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Bryan Pickens

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Daniel I Rhon

Background A number of efforts have been made to tailor behavioral healthcare treatments to the variable needs of patients with low back pain (LBP). The most common approach involves the STarT Back Screening Tool (SBST) to triage the need for psychologically informed care, which explores concerns about pain and addresses unhelpful beliefs, attitudes, and behaviors. Such beliefs that pain always signifies injury or tissue damage and that exercise should be avoided have been implied as psychosocial mediators of chronic pain and can impede recovery. The ability of physical therapy interventions guided by baseline stratification for risk of persistent LBP or related functional limitations to improve unhelpful pain beliefs has not been well assessed. Because treatments are aimed at addressing these beliefs, understanding a bit more about the nature of beliefs about pain (for example, attitudes and knowledge) might help us understand how to better tailor this care or even our risk-stratification approaches for future treatment of patients with LBP. Questions/purposes (1) Did patients assigned to receive risk-stratified care score higher on an assessment of pain science knowledge? (2) Did patients assigned to receive risk-stratified care have fewer unhelpful attitudes related to pain? (3) Did patients assigned to receive risk-stratified care have less pain-associated psychological distress? (4) Regardless of intervention received, is baseline SBST risk category (low, medium, or high) associated with changes in attitudes and knowledge about pain? Methods This is a secondary analysis of short-term changes in pain beliefs following the 6-week treatment phase of a randomized controlled trial that examined the effectiveness of a risk-stratified physical therapy intervention on pain-related disability at 1 year. Between April 2017 and February 2020, a total of 290 patients in the Military Health System seeking primary care for LBP were enrolled in a trial comparing a behavioral-based intervention to usual care. The intervention involved psychologically informed physical therapy using cognitive behavioral principles and included tailored education, graded exercise, and graded exposure. Individuals assigned to usual care followed treatment plans set forth by their primary care provider. Thirty-one patients were removed from Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool analyses due to missing assessments at 6 weeks (n = 15 intervention; n = 16 usual care). This resulted in 89% (259 of 290) of participants included for secondary analysis, with no difference in baseline demographic characteristics between groups. The usual-care group comprised 50% of the total study group (129 of 259), with a mean age of 34 ± 9 years; 67% (87 of 129) were men. The risk-stratified care group comprised 50% (130 of 259) of the total study group, with a mean ± SD age of 35 ± 8 years; 64% (83 of 130) were men. Six additional individuals were removed from Survey of Pain Attitudes harm scale (SOPA-h) and revised Neurophysiology of Pain Questionnaire (rNPQ) analyses for missing baseline data (n = 1 intervention) and 6-week data (n = 2 intervention; n = 3 usual care). The rNPQ captured current pain science knowledge, the SOPA-h examined patient attitudes about pain (the extent of beliefs that pain leads to damage and that movement is harmful), and the OSPRO-YF assessed patients for yellow flag clinical markers of pain-related psychological distress across 11 constructs within domains of negative mood, fear avoidance, and positive affect/coping indicative of elevated vulnerability and decreased resilience. Outcomes were assessed at baseline and 6 weeks, and data were analyzed per protocol. We assessed between-group differences at 6 weeks using linear mixed-effects models of pain attitudes and knowledge and related distress, controlling for age, gender, and baseline pain. Regardless of treatment group, we also analyzed differences in rNPQ and SOPA-h scores at 6 weeks based on SBST risk category (low versus medium or high) using generalized linear (Gaussian) regression models. Results Risk-stratified treatment was associated with improvements in pain knowledge (rNPQ mean difference 6% [95% confidence interval (CI) 1% to 11%]; p = 0.01) and a reduction in indicators of pain-associated psychological distress (OSPRO-YF mean difference -1 [95% CI -2 to 0]; p = 0.01) at 6 weeks compared with usual care. There was no difference between groups for SOPA-h score at 6 weeks (mean difference -0.2 [95% CI -0.3 to 0.0]; p = 0.09). Patients with medium- or high-risk scores on the SBST, regardless of intervention, improved slightly more on SOPA-h (β = -0.31; p < 0.01) but not rNPQ (β = 0.02; p = 0.95) than those scoring low risk. Conclusion Patients receiving risk-stratified care showed small improvements in pain knowledge and reductions in pain-related psychological distress at 6 weeks, immediately after intervention, compared with usual care. Implementation of this risk-stratified care approach for LBP was able to change patients’ perceptions about pain and reduce some of their psychological distress beyond what was achieved by usual care in this setting. As these factors are believed to favorably mediate treatment outcomes, future studies should investigate whether these improvements persist over the long term, determine how they influence clinical outcomes, and explore alternatives for risk stratification and treatment to elicit greater improvements. Level of Evidence Level III, therapeutic study.


Differences in content of care and outcomes between a clinical practice guideline adherent program and usual care for patellofemoral pain: A retrospective pilot study

January 2025

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31 Reads

PM&R

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Sara Gorczynski

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[...]

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Marisa Pontillo

Background Patellofemoral pain (PFP) is a common knee condition in young and active individuals that is managed with highly variable treatment strategies. Objective To determine whether the length, number of visits, and content of physical therapy care for patients with PFP differ between a Clinical Practice Guidelines (CPG) adherent program and usual care. Additionally, the percentage of patients reporting clinically important improvements in patient‐reported outcomes in each group was evaluated as an exploratory aim. Design Retrospective analysis of clinical data. Setting Military outpatient physical therapy clinics. Patients Thirty‐two patients who received CPG‐adherent care and 46 patients who received usual care. Interventions Patients in the CPG‐adherent group were classified into overuse/overload, movement coordination deficits, muscle performance deficits, or mobility impairments subcategories based on CPG‐recommended examination procedures and received the CPG‐recommended interventions. Patients in the usual care group received interventions based on clinical expertise and organizational practice standards. Main Outcomes Measures Length of care, number of visits, and intervention content were used as primary outcomes. The Anterior Knee Pain Scale (AKPS), Defense and Veterans Pain Rating Scale (DVPRS), and Global Rating of Change (GROC) scores were used as secondary outcomes. These scores were extracted from routinely collected health data available in medical records; as a result, not all patients completed these outcomes during the follow‐up time points because they were optional. Results The number of physical therapy visits and percentage of patients receiving knee‐targeted exercises, soft tissue mobility interventions, neuromuscular reeducation, patient education, patellar taping, and foot orthoses were greater in the CPG‐adherent group compared to usual care ( p < .05). Additionally, most patients in the CPG‐adherent group reported clinically meaningful improvements in secondary outcomes: AKPS (1 month: 13/23; 3 months: 11/16), DVPRS (1 month: 11/20; 3 months: 8/14), and GROC (1 month: 14/22; 3 months: 11/16). In contrast, fewer than half of the patients in the usual care group reached clinically meaningful thresholds: AKPS (1 month: 1/17; 3 months: 3/8), DVPRS (1 month: 3/15; 3 months: 3/7), and GROC (1 month: 2/12; 3 months: 2/7). Conclusion The content of the CPG‐adherent care was significantly different versus usual care and associated with meaningful changes in outcomes. Several CPG‐recommended interventions appeared to be underused in usual care, underscoring the value of further CPG adoption.



Adapting to change: experiences and recommendations from the Pain Management Collaboratory on modifying statistical analysis plans

November 2024

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2 Reads

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1 Citation

Pain Medicine

Background Best practices for clinical trials stipulate that statistical analysis plans (SAPs) need to be finalized before initiation of any analysis. However, there is limited guidance about when changes to SAPs are acceptable and how these changes should be incorporated into the research plan with appropriate documentation. Methods We conducted a survey of 12 pragmatic clinical trials (PCTs) in the Pain Management Collaboratory that evaluated nonpharmacological interventions for pain to assess the following SAP information: (1) location of statistical analysis details, (2) types of statistical analyses planned, (3) sponsor requirements, (4) templates used for development, (5) publication plan, (6) changes since trial launch, (7) process of documenting changes, and (8) process of updating the trial registry. Results All 12 PCTs provided details of their SAPs for the primary outcomes in the institutional review board–approved trial protocol; 8 included plans for secondary outcomes, and 6 included plans for tertiary/exploratory outcomes. Most PCTs made SAP changes after trial initiation, many as a result of COVID-19–related issues. Eleven of the PCTs were actively recruiting participants. Changes were made to sample size, study design, study arms, and analytical methods, all before the data lock/unblinding. In all cases, justification for the changes was documented in the trial protocol or SAP, signed off by the trial biostatistician and principal investigator, and reviewed/approved by an institutional review board, data and safety monitoring board, or sponsor. Conclusions We recommend that SAP changes can be acceptable up to the time of data lock/unblinding. To maintain full transparency and necessary rigor, clear documentation of such changes should include details, rationale, date(s) such changes were implemented, and evidence of approval by relevant oversight bodies.



Utility of the PICOTS framework to assess clinical trial disruptions: monitoring the impact of COVID-19 in the Pain Management Collaboratory

November 2024

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8 Reads

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1 Citation

Pain Medicine

Objective Despite careful design of clinical trials, unforeseen disruptions can arise. The PICOTS (Patient population, Intervention, Comparator, Outcomes, Timepoints, Setting) framework was used to assess disruptions in pain management research imposed by coronavirus disease 2019 (COVID-19) within the Pain Management Collaboratory. Methods Rapid qualitative methods were employed to identify trial disruptions due to COVID-19 in 11 pragmatic clinical trials of nonpharmacological approaches for pain management. The PICOTS framework was applied by investigators of 4 Collaboratory trials selected to cover 4 types of trial designs (individually randomized, stepped-wedge, cluster, sequential multiple assignment randomized trial—SMART). Interviews with the lead investigators of these trials were completed, and findings were presented/discussed on video calls over a 6-month period (March-August 2021) from which themes/lessons learned were identified and consensus reached. Results Investigators indicated that patient populations remained generally stable. A major COVID-19 trial disruption was moving from in-person to virtual care affecting delivery of interventions/comparators and outcome assessments. The resultant mixed-mode of care delivery created issues with intervention fidelity posing analytic challenges. COVID-19 also induced ongoing/intermittent delays and other barriers to accessing primary and specialty care at some facilities, creating research capacity issues affecting delivery of experimental interventions requiring sustained, reliable participation of clinical partners. Study designs most affected by COVID-19 were stepped-wedge (intervention/comparator changing over time), cluster (increased site variability inflating intracluster correlation), and SMART (second-stage randomizations disrupted); stratified individually-randomized trials were less vulnerable because of individual-level randomization. Conclusions PICOTS provides a framework for assessing the impact of trial disruptions in a structured manner. Given the COVID-19 experience, it is important for researchers to consider the potential impact of future trial disruptions during study planning.


Erratum in: Pragmatism in manual therapy trials for knee osteoarthritis: a systematic review
  • Article
  • Full-text available

October 2024

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9 Reads

Archives of Physiotherapy

Download

Prevention of Post-Traumatic Osteoarthritis in the Military: Relevance of OPTIKNEE and Osteoarthritis Action Alliance recommendations

October 2024

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25 Reads

BMJ Military Health

Musculoskeletal injury (MSKI) is the most common reason for short-term occupational limitation and subsequent medically related early departure from the military. MSKI-related medical discharge/separation occurs when service personnel are unable to perform their roles due to pain or functional limitations associated with long-term conditions, including osteoarthritis (OA). There is a clear link between traumatic knee injuries, such as anterior cruciate ligament or meniscal, and the development of post-traumatic OA (PTOA). Notably, PTOA is the leading cause of disability following combat injury. Primary injury prevention strategies exist within the military, with interventions focused on conditioning, physical health and leadership. However, not every injury can be prevented, and there is a need to develop secondary prevention to mitigate or reduce the risk of PTOA following an MSKI. Two international collaborative groups, OPTIKNEE and OA Action Alliance, recently produced rigorous evidence-based consensus statements for the secondary prevention of OA following a traumatic knee injury, including consensus definitions and clinical and research recommendations. These recommendations focus on patient-centred lifespan interventions to optimise joint health and prevent lost decades of care. This article aims to describe their relevance and applicability to the military population and outline some of the challenges associated with service life that need to be considered for successful integration into military care pathways and research studies.


Figure 1. Consensus process.
Delphi participant descriptive statistics.
Continued
Data elements combined with other elements (already with consensus) after round two.
No consensus after round two.

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Methodology used to develop the minimum common data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement

September 2024

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28 Reads

Background The objective was to summarize the methodology used to reach consensus for recommended minimum data elements that should be collected and reported when conducting injury surveillance research in military settings. This paper summarizes the methodology used to develop the international Minimum Data Elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement. Methods A Delphi methodology was employed to reach consensus for minimum reporting elements. Preliminary steps included conducting a literature review and surveying a convenience sample of military stakeholders to 1) identify barriers and facilitators of military musculoskeletal injury (MSKI) prevention programs, 2) identify relevant knowledge/information gaps and 3) establish future research priorities. The team then led a sequential three-round Delphi consensus survey, including relevant stakeholders from militaries around the world, and then conducted asynchronous mixed knowledge user meeting to explore level of agreement among subject matter experts. Knowledge users, including former and current military service members, civil servant practitioners, and global-wide subject matter experts having experience with policy, execution, or clinical investigation of MSKI mitigation programs, MSKI diagnoses, and MSKI risk factors in military settings. For each round, participants scored each question on a Likert scale of 1-5. Scores ranged from No Importance (1) to Strong Importance (5). Results Literature review and surveys helped informed the scope of potential variables to vote on. Three rounds were necessary to reach minimum consensus. Ninety-five, 65 and 42 respondents participated in the first, second and third rounds of the Delphi consensus, respectively. Ultimately, consensus recommendations emerged consisting of one data principle and 33 minimum data elements. Conclusions Achieving consensus across relevant stakeholders representing military organizations globally can be challenging. This paper details the methodology employed to reach consensus for a core minimum data elements checklist for conducting MSKI research in military settings and improve data harmonization and scalability efforts. These methods can be used as a resource to assist in future consensus endeavors of similar nature.


Cost-effectiveness of Risk Stratified Care vs Usual Care for Low Back Pain in the Military Health System

September 2024

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5 Reads

Spine

Study Design Cost-effectiveness of two trial interventions for low back pain Objective To investigate the incremental cost-effectiveness between risk-stratified and usual care for low back pain. Summary of Background Data A recent trial compared risk-stratified care to usual care for patients with low back pain (LBP) in the US Military Health System. While the outcomes were no different between groups, risk-stratified care is purported to use fewer resources and therefore could be a more cost-effective intervention. Risk-stratified care matches treatment based on low, medium, or high risk for poor prognosis. Methods The cost-effectiveness of usual care versus risk-stratified care for low back pain was assessed, using the healthcare perspective. Patients were recruited from primary care. The main outcome was indicating incremental cost-effectiveness between two alternative treatments. Acceptability curves of bootstrapped incremental cost effectiveness ratios (ICER) were used to identify the proportion of ICERs under the specific willingness-to-pay (WTP) level (50,000to50,000 to 100,000). Health system costs (total and back-related) and health-related quality-of-life (HRQoL) based on quality-adjusted-life-years (QALYs) were obtained. Results 271 participants (33.6% female), mean age 34.3 +/-8.7 were randomized 1:1 and followed for 1 year. Mean back-related medical costs were not significantly different (mean difference 5;95CI5; 95CI -398, 407;P=0.982),norweretotalmedicalcosts(meandifference407; P =0.982), nor were total medical costs (mean difference 827, 95CI -1748, 3403; P =0.529). The mean difference in QALYs was not significantly different between groups (0.009; 95CI -0.014, 0.032; P =0.459). The incremental net monetary benefit (NMB) at the willingness to pay (WTP) threshold of 100,000was100,000 was 792 for back-related costs, with the lower bound confidence interval negative at all WTP levels. Conclusion Risk-stratified care was not cost-effective for medium- and low-risk individuals compared to usual care. Further research is needed to assess whether there is value for high-risk individuals or for other risk-stratification approaches.


Citations (52)


... The Shapiro-Wilk's test was employed to assess the normality of the data distribution, while paired t-tests were used to determine the significance of changes observed between consecutive visits in terms of both objective and subjective measurements. This meticulous approach ensured a comprehensive evaluation of the study's objectives, adhering to the principles outlined in the Declaration of Helsinki regarding ethical standards in human experimentation (27,28). ...

Reference:

Effect of Pain Neuroscience Education and Physical Exercise for Patients with Lumbar Radiculopathy: A Randomized Clinical Trail
Developing Manual Therapy Frameworks for Dedicated Pain Mechanisms
  • Citing Article
  • July 2023

... A recent study of over 17 000 US individuals seeking care in a Military Health System over a 4-year period for patellofemoral pain reported that only 25% had a supervised exercise or physiotherapy session, despite being recommended in every national and international OA treatment guideline. [14][15][16] Exercise-based treatments not only facilitate improvements in joint health and associated morbidity but also provide significant benefits to cardiovascular health, as poorly managed OA is linked to increased mortality. 16 It is unknown if adequate treatment of MSKIs can reduce the risk or delay the onset of subsequent PTOA, but it is likely, given common risk factors between the two, including muscular weakness, joint mal-alignment and overloading. ...

Pre-Arthroplasty Treatments for Knee Osteoarthritis: A Four-Year Analysis within a US Health System
  • Citing Article
  • April 2024

Osteoarthritis and Cartilage

... Accordingly, radiographic imaging is not recommended for routine diagnosis of OA [14,16,18], and instead, a clinical diagnosis is advocated based on age and symptom presentation [6]. Despite this, many primary healthcare providers globally still rely on X-rays to diagnose OA [8,19,20] and people with musculoskeletal conditions, including OA, expect imaging as part of their clinical care [21][22][23]. Qualitative studies suggest that, when people with OA are shown X-rays, they believe they need to protect their joint from further damage [21,24], and therefore, may be less willing to engage in first-line nonsurgical care like exercise. However, no empirical evidence from randomised controlled trials (RCTs) exists to determine if use of Xrays to diagnose and explain OA influences people's beliefs about OA management. ...

Do Maladaptive Imaging Beliefs Predict Self-Reported Pain Interference and Physical Function in Patients With Musculoskeletal Disorders?
  • Citing Article
  • July 2024

Journal of Orthopaedic and Sports Physical Therapy

... The adverse events described after manipulation frequently include transient and/or moderate disorders, or otherwise only requiring conservative therapy [17]. However, the reporting of adverse events is poor, so the analysis of major and permanent ones could be useful for identifying opportunities for improvement [18] In Italy, the osteopath is an acknowledged health professional within the class of prevention, licensed after a three-year university degree and enrolled to a specific Board, dedicated to the maintenance and improvement of psycho-physical well-being [19,20]. Osteopath intervention is based on manual techniques correcting imbalances and restoring physiological movement conditions, thus acting on health without the use of drugs, natural remedies, medical or electromedical instruments [8]. ...

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review
  • Citing Article
  • March 2024

Journal of Integrative and Complementary Medicine

... Rehabilitation, which includes manual techniques and instrumental physical therapies, is considered a cornerstone of KOA management, and in the literature, several rehabilitative interventions have been described as effective for reducing pain and improving function in individuals with knee OA [16][17][18][19][20][21]. Exercise therapy is beneficial to patients with KOA for relieving pain, alleviating stiffness, improving function, and improving quality of life, representing a useful therapeutic option, especially for early knee osteoarthritis [17]. ...

Pragmatism in manual therapy trials for knee osteoarthritis: a systematic review

Archives of Physiotherapy

... However, there is a dearth of research exploring the relationship between obesity and psychological distress in patients with musculoskeletal pain. Several recent studies have examined psychological distress and mental illness in orthopaedic patient populations and implemented psychological assessment tools such as the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) [28][29][30][31][32][33][34][35][36], but none have investigated the relationship between elevated BMI, obesity, and pain-associated psychological distress in patients with hip pain. ...

General and Pain‐Associated Psychological Distress Phenotypes Among Patients With Low Back Pain in the Military Health System

... Specifically, the intervention group exhibited notable enhancements in shoulder range of motion and strength, as evidenced by the significant differences in the Paired t-test results (Regno et al., 2021;Skazalski et al., 2024). Moreover, the Wilcoxon Signed-Rank Test highlighted a significant reduction in baseline pain levels among participants in the intervention group, underscoring the potential benefits of manual therapy techniques (Ruzich et al., 2024;Wengert et al., 2019). These findings suggest that a comprehensive manual therapy program, encompassing soft tissue and joint mobilization techniques alongside tailored exercise therapy, holds promise in effectively addressing shoulder injuries among women volleyball players (Granley & Vidlock., 2024). ...

How Reproducible Are Manual Therapy Interventions in Trials for Low Back Pain? A Scoping Review
  • Citing Article
  • January 2024

Journal of Orthopaedic and Sports Physical Therapy

... In addition, ACL injuries are more common in military populations than in the general population. 26 Therefore, most of the lifespan-based consensus recommendations promoted by OPTIKNEE and OAAA are likely to be translatable to a military population, with a finite amount of tailoring to adjust to the nuance of Service life. ...

Timing of Outcomes and Expectations After Knee Surgery in the US Military: A Systematic Review
  • Citing Article
  • December 2023

Sports Health A Multidisciplinary Approach

... Recent systematic reviews have found that research reporting and quality of TF remains low across trials investigating exercise therapy and manual therapy for chronic pain, neck pain, and low back pain (11)(12)(13). Possible reasons for this deficit include increased time, additional cost, real-world feasibility, and "provider fatigue" from prescriptive and possibly clinician-limiting research designs (14). ...

Reproducibility of Exercise Interventions in Randomized Controlled Trials for the Treatment of Rotator Cuff-Related Shoulder Pain: A Systematic Review
  • Citing Article
  • September 2023

Archives of Physical Medicine and Rehabilitation

... A recent study concluded that physiotherapists use a biopsychosocial framework to determine prognosis (Smith et al., 2023). In contrast, our findings suggest that physiotherapists may instead predominantly rely upon a biomedical framework to determine prognosis. ...

What factors do physical therapists consider when determining patient prognosis: A mixed methods study
  • Citing Article
  • September 2023

Musculoskeletal Care