Identifying Patient Characteristics Associated With Opioid Use to Inform Surgical Pain Management.

Objective: Balancing surgical pain management and opioid stewardship is complex. Identifying patient-level variables associated with low or no use can inform tailored prescribing. Methods: A prospective, observational study investigating surgical procedures, prescription data, and patient-reported outcomes at an academic health system in Pennsylvania. Surgical patients were consented following surgery, and prospective data were captured using automated text messaging (May 1, 2021-February 29, 2022). The primary outcome was opioid use. Results: Three thousand six hundred three (30.2%) patients consented. Variation in patient reported used included 28.1% of men reported zero use versus 24.3% of women, 20.5% of Black patients reported zero use versus 27.2% of white patients. Opioid-naïve patients reported more zero use as compared with chronic use (29.7% vs 9.8%). Patients reporting higher use had more telephone calls and office visits within 30 days but no change in emergency department utilization or admissions. Higher discharge pain score was associated with higher use. In the adjusted analysis, opioid use relative to the guideline, higher use was associated with age, male sex, obesity, discharge pain score, and history of mental health disorder. In the adjusted model, younger age and being opioid-naïve to be associated with low to zero use across procedures. Conclusions: Younger age, being opioid-naïve, and lower discharge pain score are associated with low or no postoperative opioid use. These characteristics can be used by clinicians to help tailor opioid prescribing to specific patients to reduce the risk of prolonged exposure and unused `ts in the community.

Patient and clinician perspectives of a remote monitoring program for COVID-19 and lessons for future programs.

COVID Watch is a remote patient monitoring program implemented during the pandemic to support home dwelling patients with COVID-19. The program conferred a large survival advantage. We conducted semi-structured interviews of 85 patients and clinicians using COVID Watch to understand how to design such programs even better. Patients and clinicians found COVID Watch to be comforting and beneficial, but both groups desired more clarity about the purpose and timing of enrollment and alternatives to text-messages to adapt to patients' preferences as these may have limited engagement and enrollment among marginalized patient populations. Because inclusiveness and equity are important elements of programmatic success, future programs will need flexible and multi-channel human-to-human communication pathways for complex clinical interactions or for patients who do not desire tech-first approaches.

The Implementation of a Return-to-Play Protocol with Standardized Physical Therapy Referrals in a Collegiate Football Program: PT's Role in Return-to-Play, A Clinical Commentary.

Sport-related concussions (SRCs) are multi-faceted injuries requiring coordinated care for return-to-play (RTP). Although the number of concussions in collegiate football is increasing annually, there is poor standardization among RTP protocols. Recent evidence suggests there is an increased risk of lower extremity injury, neuropsychiatric consequences, and re-injury after SRC, and risk factors for a prolonged recovery from SRC have also been identified. Evidence demonstrates a faster RTP and improved outcomes with early physical therapy intervention; however, this is not yet common practice in the treatment of acute SRC. There is little guidance available on the development and implementation of a multidisciplinary RTP rehabilitation protocol for SRC that incorporates standardized physical therapy. By describing an evidence-based RTP protocol with standardized physical therapy management, and measures taken to implement this protocol, this clinical commentary aims to identify steps in treating SRC that can be used to improve recovery. The purpose of this commentary is to: a) survey the current state of standardization of RTP protocols in collegiate football; b) highlight the development and implementation of a RTP protocol with standardized physical therapy referral and management in an NCAA Division II collegiate football program; and c) describe results of a full-season pilot study, including time to evaluation, time to RTP, rate of re-injury or lower extremity injury, and the clinical significance of protocol implementation. Level of Evidence: Level V.

Patient and clinician perspectives of a remote monitoring program for COVID-19 and lessons for future programs.

COVID Watch is a remote patient monitoring program implemented during the pandemic to support home dwelling patients with COVID-19. The program conferred a large survival advantage. We conducted semi-structured interviews of 85 patients and clinicians using COVID Watch to understand how to design such programs even better. Patients and clinicians found COVID Watch to be comforting and beneficial, but both groups desired more clarity about the purpose and timing of enrollment and alternatives to text-messages to adapt to patients’ preferences as these may have limited engagement and enrollment among marginalized patient populations. Because inclusiveness and equity are important elements of programmatic success, future programs will need flexible and multi-channel human-to-human communication pathways for complex clinical interactions or patients who do not desire tech-first approaches.

The Utility of Neuromotor Retraining to Augment Manual Therapy and Vestibular Rehabilitation in a Patient with Post-Concussion Syndrome: A Case Report.

BACKGROUND AND PURPOSE: Less than half of patients discharged from the emergency department post-concussion receive patient education or follow-up care, and 10-20% of individuals will develop symptoms that last longer than six months. Current research on interventions for post-concussion syndrome (PCS) shows inconsistent results, and recommendations for effective physical therapy treatment for patients with chronic PCS are lacking. The purpose of this case report is to highlight a successful, multi-system approach to physical therapy examination and treatment of a patient with chronic PCS. CASE DESCRIPTION: This case describes a 21-year-old male who sustained a concussion 356 days prior to evaluation. He received no follow-up treatment and reported periods of worsening symptoms since the injury. Impairments in cervical range of motion and accessory mobility, vestibular and vestibulo-ocular function, and postural stability were identified. Both cognitive and emotional symptoms were also present. The patient attended eight, sixty-minute sessions over a five-week period in an outpatient setting. Comprehensive physical therapy interventions included manual therapy, vestibular rehabilitation, and neuromotor retraining aimed at restoring proper sensory integration and midline postural orientation. OUTCOMES: Outcomes included cervical spine goniometric measurements and accessory mobility assessments. Objective measures of postural stability included the Modified Clinical Test of Sensory Interaction in Balance (m-CTSIB) and the Fukuda Step Test. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was used to subjectively assess symptom severity. At discharge, goniometric measurements returned to within normal limits except left cervical rotation active range of motion (ROM), and both the m-CTSIB and Fukuda Step Test were within normal ranges. The RPQ score reduced from 20 to 2 demonstrating symptom resolution in all items but "headache." DISCUSSION: PCS can affect multiple systems, necessitating a comprehensive approach to examination and intervention. Manual therapy was used to restore cervical spine ROM, vestibular rehabilitation was utilized to improve gaze stability and visual motion sensitivity, and neuromotor retraining was implemented to improve postural stability and sensory integration. Physical therapists have the ability to treat multiple systems impacted with PCS, with the potential to reduce the longevity and severity of impairments for patients. LEVEL OF EVIDENCE: Level V.

Mistaking randomness for free will.

Belief in free will is widespread. The present research considered one reason why people may believe that actions are freely chosen rather than determined: they attribute randomness in behavior to free will. Experiment 1 found that participants who were prompted to perform a random sequence of actions experienced their behavior as more freely chosen than those who were prompted to perform a deterministic sequence. Likewise, Experiment 2 found that, all else equal, the behavior of animated agents was perceived to be more freely chosen if it consisted of a random sequence of actions than if it consisted of a deterministic sequence; this was true even when the degree of randomness in agents' behavior was largely a product of their environments. Together, these findings suggest that randomness in behavior--one's own or another's--can be mistaken for free will.

Time warp: authorship shapes the perceived timing of actions and events.

It has been proposed that inferring personal authorship for an event gives rise to intentional binding, a perceptual illusion in which one's action and inferred effect seem closer in time than they otherwise would (Haggard, Clark, & Kalogeras, 2002). Using a novel, naturalistic paradigm, we conducted two experiments to test this hypothesis and examine the relationship between binding and self-reported authorship. In both experiments, an important authorship indicator - consistency between one's action and a subsequent event - was manipulated, and its effects on binding and self-reported authorship were measured. Results showed that action-event consistency enhanced both binding and self-reported authorship, supporting the hypothesis that binding arises from an inference of authorship. At the same time, evidence for a dissociation emerged, with consistency having a more robust effect on self-reports than on binding. Taken together, these results suggest that binding and self-reports reveal different aspects of the sense of authorship.

Stepping up the pressure: arousal can be associated with a reduction in male aggression.

The attentional myopia model of behavioral control [Mann and Ward, 2007] was tested in an experiment investigating the relationship between physiological arousal and aggression. Drawing on previous work linking arousal and narrowed attentional focus, the model predicts that arousal will lead to behavior that is relatively disinhibited in situations in which promoting pressures to aggress are highly salient. In situations in which inhibitory pressures are more salient, the model predicts behavior that is relatively restrained. In the experiment, 81 male undergraduates delivered noise-blasts against a provoking confederate while experiencing either high or low levels of physiological arousal and, at the same time, being exposed to cues that served either to promote or inhibit aggression. In addition to supporting the predictions of the model, this experiment provided some of the first evidence for enhanced control of aggression under conditions of heightened physiological arousal. Implications for interventions designed to reduce aggression are discussed.

The role of social groups in the persistence of learned fear.

Classical fear conditioning investigates how animals learn to associate environmental stimuli with an aversive event. We examined how the mechanisms of fear conditioning apply when humans learn to associate social ingroup and outgroup members with a fearful event, with the goal of advancing our understanding of basic learning theory and social group interaction. Primates more readily associate stimuli from certain fear-relevant natural categories, such as snakes, with a negative outcome relative to stimuli from fear-irrelevant categories, such as birds. We assessed whether this bias in fear conditioning extends to social groups defined by race. Our results indicate that individuals from a racial group other than one's own are more readily associated with an aversive stimulus than individuals of one's own race, among both white and black Americans. This prepared fear response might be reduced by close, positive interracial contact.