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Objective: Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery., Methods: In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months., Results: Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1])., Conclusions: This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism., Impact: Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Unlabelled: The purpose of this study was to determine the efficacy of a cognitive-behavioral-based physical therapy (CBPT) program for improving outcomes in patients after lumbar spine surgery. A randomized controlled trial was conducted on 86 adults undergoing a laminectomy with or without arthrodesis for a lumbar degenerative condition. Patients were screened preoperatively for high fear of movement using the Tampa Scale for Kinesiophobia. Randomization to either CBPT or an education program occurred at 6 weeks after surgery. Assessments were completed pretreatment, posttreatment and at 3-month follow-up. The primary outcomes were pain and disability measured by the Brief Pain Inventory and Oswestry Disability Index. Secondary outcomes included general health (SF-12) and performance-based tests (5-Chair Stand, Timed Up and Go, 10-Meter Walk). Multivariable linear regression analyses found that CBPT participants had significantly greater decreases in pain and disability and increases in general health and physical performance compared with the education group at the 3-month follow-up. Results suggest a targeted CBPT program may result in significant and clinically meaningful improvement in postoperative outcomes. CBPT has the potential to be an evidence-based program that clinicians can recommend for patients at risk for poor recovery after spine surgery., Perspective: This study investigated a targeted cognitive-behavioral-based physical therapy program for patients after lumbar spine surgery. Findings lend support to the hypothesis that incorporating cognitive-behavioral strategies into postoperative physical therapy may address psychosocial risk factors and improve pain, disability, general health, and physical performance outcomes., (Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Fear of movement is a risk factor for poor postoperative outcomes in patients following spine surgery. The purposes of this case series were: (1) to describe the effects of a cognitive-behavioral-based physical therapy (CBPT) intervention in patients with high fear of movement following lumbar spine surgery and (2) to assess the feasibility of physical therapists delivering cognitive-behavioral techniques over the telephone., Case Description: Eight patients who underwent surgery for a lumbar degenerative condition completed the 6-session CBPT intervention. The intervention included empirically supported behavioral self-management, problem solving, and cognitive restructuring and relaxation strategies and was conducted in person and then weekly over the phone. Patient-reported outcomes of pain and disability were assessed at baseline (6 weeks after surgery), postintervention (3 months after surgery), and at follow-up (6 months after surgery). Performance-based outcomes were tested at baseline and postintervention. The outcome measures were the Brief Pain Inventory, Oswestry Disability Index, 5-Chair Stand Test, and 10-Meter Walk Test., Outcomes: Seven of the patients demonstrated a clinically significant reduction in pain, and all 8 of the patients had a clinically significant reduction in disability at 6-month follow-up. Improvement on the performance-based tests also was noted postintervention, with 5 patients demonstrating clinically meaningful change on the 10-Meter Walk Test., Discussion: The findings suggest that physical therapists can feasibly implement cognitive-behavioral skills over the telephone and may positively affect outcomes after spine surgery. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the CBPT intervention. Clinical implications include broadening the availability of well-accepted cognitive-behavioral strategies by expanding implementation to physical therapists and through a telephone delivery model.

Herniated disc (HD) is a common health problem that is resolved by surgery unless spontaneous resorption occurs. HD tissue contains abundant macrophage infiltration and high levels of matrix metalloproteinases (MMPs) MMP-3 and MMP-7. We developed a model system in which disc tissue or isolated chondrocytes from wild-type or MMP-null mice were cocultured with peritoneal macrophages and used this system to investigate the role of MMPs and chondrocyte/macrophage interactions in disc resorption. We observed a marked enhancement of MMP-3 protein and mRNA in chondrocytes after exposure to macrophages. Chondrocytic MMP-3, but not MMP-7, was required for disc resorption, as determined by assaying for a reduction in wet weight and proteoglycan content after 3 days of coculture. Surprisingly, chondrocyte MMP-3 was required for the generation of a macrophage chemoattractant and the subsequent infiltration of the disc tissue by proteolytically active macrophages. We conclude that macrophage induction of chondrocyte MMP-3 plays a major role in disc resorption by mechanisms that include the generation of a bioactive macrophage chemoattractant.

Herniated disc (HD), one of the major causes of low back pain, is often resolved spontaneously without surgical intervention. Resorption is associated with a marked increase in infiltrating macrophages, and the matrix metalloproteinases (MMP) MMP-3 and MMP-7 have been implicated in this phenomenon. We developed a murine organ culture model in which intact intervertebral discs were cocultured with peritoneal macrophages to investigate the role of MMPs in HD resorption. Using macrophages isolated from MMP-null mice, we report that macrophage-produced MMP-7 was required for proteoglycan degradation, loss of wet weight, and macrophage infiltration of cocultured discs. The inability of MMP-7-deficient macrophages to infiltrate discs could not be attributed to a defect in macrophage migration. MMP-7 was required for the release of the cytokine TNF-alpha from peritoneal macrophages. The generation of soluble TNF-alpha was essential for the induction of MMP-3 in disc cocultures, which in turn is required for the generation of a macrophage chemoattractant and subsequent macrophage infiltration. TNF-alpha release from macrophages was necessary but insufficient for disc resorption, which required macrophage infiltration. We conclude that there is extensive communication between macrophages and chondrocytes in HD resorption and that an essential component of this communication is the requirement for MMPs to release soluble bioactive factors.

A new method has been developed for the Department of Orthopaedics of Vanderbilt University Medical Center to access departmental clinical data. Previously this data was stored only in the medical center's mainframe DB2 database, it is now additionally stored in a departmental SQL database. Access to this data is available via any ODBC compliant front-end or a web client. With a small budget and no full time staff, we were able to give our department on-line access to many years worth of patient data that was previously inaccessible.

Uniaxial fatigue tests were conducted of devitalized cortical bone specimens machined from human femora. Specimens were tested at strain ranges from 0.005 to 0.010 under physiologic loading rates. The influence of compressive, zero, and tensile mean strains on fatigue life and on the stress/strain histories during fatigue were examined. Results showed that bone fatigue is a gradual damage process accompanied by a progressive increase in hysteresis and a loss of bone stiffness. The total number of cycles to fatigue failure was influenced only by the total strain range and was not affected by mean strain. Bone was shown to have extremely poor fatigue resistance. Fully reversed cyclic loading to one half of the yield strain caused fatigue fracture in 1000 cycles. Biological implications. The bone regions which experience the highest strain ranges in vivo generally have a compressive mean strain. The results of this study indicate that mechanical fatigue damage accumulates more rapidly in these "compressive" areas than in "tensile" areas of bone.

Excised specimens of cancellous bone from human femora were subjected to compressive or tensile testing, and the resulting force-displacement curves were recorded. The relationships between bone strength and apparent density were similar for specimens tested in these two loading modes. The modulus of elasticity was also comparable for the tensile and compressive specimens. Specimens loaded in compression absorbed considerable energy after the initial fracture because of progressive impaction of the trabeculae. In the specimens loaded in tension, the fractured bone fragments separated and therefore absorbed little additional energy after the initial failure. The energy absorption capacity was thus significantly lower for the tensile specimens. The results of this study show that the primary difference in mechanical properties of cancellous bone tested in tension and compression is the energy absorption capacity. This finding suggests that tensile and avulsion fractures of cancellous bone observed clinically are associated with minimal energy absorption and therefore may be precipitated by relatively minor trauma.