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Purpose The purpose of this study is to describe the prevalence, intensity and distress of five symptoms in intensive care unit (ICU) patients and to investigate possible predictive factors associated with symptom intensity. Methods This is a prospective cohort study of ICU patients. A symptom questionnaire (i.e., Patient Symptom Survey) was used to describe the prevalence, intensity and distress of pain, thirst, anxiousness, tiredness, and shortness of breath over seven ICU days. Associations between symptom intensity and possible predictive factors were assessed using the general estimating equation (GEE) model. Results Out of 603 eligible patients, 353 (Sample 2) were included in the present study. On the first ICU day, 195 patients (Sample 1) reported thirst as the most prevalent symptom (66%), with the highest mean intensity score (6.13, 95% confidence interval (CI) [5.7-6.56]). Thirst was the most prevalent (64%) and most intense (mean score 6.05, 95%CI [5.81-6.3]) symptom during seven days in the ICU. Anxiousness was the most distressful (mean score 5.24, 95%CI [4.32-6.15]) symptom on the first day and during seven days (mean score 5.46, 95%CI [4.95-5.98]). During seven days, analgesic administration and sepsis diagnosis were associated with increased thirst intensity. Older age and being mechanically ventilated were associated with decreased pain intensity, and analgesic administration was associated with increased pain intensity. Family visits and female gender were associated with increased intensity of anxiousness and shortness of breath, respectively. Conclusions Self-reporting ICU patients experienced a high and consistent symptom burden across seven days. Certain variables were associated with the degree of symptom intensity, but further research is required to better understand these associations., Author(s): Christin Saltnes-Lillegård [sup.1] [sup.2], Tone Rustøen [sup.2] [sup.3], Sigrid Beitland [sup.4], Kathleen Puntillo [sup.5], Milada Hagen [sup.3] [sup.6], Anners Lerdal [sup.7] [sup.8], Kristin Hofsø [sup.1] [sup.3] [sup.9] Author Affiliations: [...]

BackgroundOne in five patients experience chronic pain 12 months following total knee arthroplasty (TKA). This longitudinal study used a person-centred approach to identify subgroups of patients with distinct chronic pain profiles following TKA and identified preoperative characteristics associated with these profiles.MethodsOn the day before surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression and illness perceptions. Average and worst pain were assessed prior to surgery, on postoperative day 4, at 6 week and at 3 and 12 months following surgery. Using growth mixture modelling, two subgroups with distinct average and worst pain profiles were identified.ResultsPatients in the "lower average" and "lower worst" pain classes had moderate preoperative pain scores that decreased over the remaining 9 months following TKA. Patients in the "higher average" and "higher worst" pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine; had higher preoperative fatigue severity and interference scores; and had worse perceptions of illness than patients in the lower pain classes.ConclusionsThese risk factors may be used to identify subgroups of patients at higher risk for more severe pain after TKA. Future studies should test whether modifying these risk factors can improve patients' outcomes after TKA.Significance statementThe present study provides a novel and original analysis of pain profiles following total knee arthroplasty that may contribute to our understanding of the transition from acute to chronic pain. Our results may be used to identify patients at higher risk for poorer outcomes based on preoperative risk factors.

BackgroundOne in five patients report chronic pain following total knee arthroplasty (TKA) and are considered non-improvers. Psychological interventions such as cognitive behavioral therapy (CBT), combined with exercise therapy and education may contribute to reduced pain an improved function both for patients with OA or after TKA surgery, but the evidence for the effectiveness of such interventions is scarce. This randomized controlled trial with three arms will compare the clinical effectiveness of patient education and exercise therapy combined with internet-delivered CBT (iCBT), evaluated either as a non-surgical treatment choice or in combination with TKA, in comparison to usual treatment with TKA in patients with knee OA who are considered candidates for TKA surgery.MethodsThe study, conducted in three orthopaedic centers in Norway will include 282 patients between ages 18 and 80, eligible for TKA. Patients will be randomized to receive the exercise therapy + iCBT, either alone or in combination with TKA, or to a control group who will undergo conventional TKA and usual care physiotherapy following surgery. The exercise therapy will include 24 one hour sessions over 12 weeks led by a physiotherapist. The iCBT program will be delivered in ten modules. The physiotherapists will receive theoretical and practical training to advise and mentor the patients during the iCBT program. The primary outcome will be change from baseline to 12 months on the pain sub-scale from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include the remaining 4 sub-scales from the KOOS (symptoms, function in daily living, function in sports and recreation, and knee-related quality of life), EQ-5D-5L, the Pain Catastrophizing Scale, the 30-s sit-to-stand test, 40-m walking test and ActiGraph activity measures. A cost-utility analysis will be performed using QALYs derived from the EQ-5D-5L and registry data.DiscussionThis is the first randomized controlled trial to investigate the effectiveness of exercise therapy and iCBT with or without TKA, to optimize outcomes for TKA patients. Findings from this trial will contribute to evidence-based personalized treatment recommendations for a large proportion of OA patients who currently lack an effective treatment option.Trial registrationClinicaltrials.gov : NCT03771430 . Registered: Dec 11, 2018.

BackgroundThe concept of hope has been measured using the Herth Hope Index (HHI) in different samples, but varying factor structures comprising different items from the HHI have been reported. Therefore, further testing with regard to the dimensionality of the instrument is recommended. Rasch modeling can be used to evaluate validity evidence of an instrument's underlying structure, to identify items with poor fit to the rest of the scale, and to identify items that perform inconsistently across groups. The aim of this study was to assess the HHI's psychometric properties in a sample of cancer patients using a Rasch model. Adult oncology outpatients (n = 167) with pain from bone metastasis were included, and medical records were reviewed for disease and treatment information. Patients completed the 12-item HHI, which measures various dimensions of hope using a 4-point Likert scale that ranges from 1 (strongly disagree) to 4 (strongly agree). The internal scale validity, person response validity, unidimensionality, and uniform differential item functioning were evaluated by applying a Rasch rating scale model.ResultsFive (42%) of the twelve items (#3, #4, #5, #6 and #7) did not meet the criterion set for item goodness-of-fit. After removing these 5 items, the resulting 7-item scale demonstrated acceptable item fit to the model, acceptable unidimensionality (52.6% of the variance explained), acceptable person goodness-of-fit, adequate separation, and no differential item function.ConclusionA 7-item version of the HHI had better psychometric properties than the original 12-item version among patients with cancer-related pain.Trial registrationThe protocol ID is 158,707/V10 and it was registered on ClinicalTrials.gov as NCT00760305 . Registered September 25, 2008.

BackgroundFew studies have examined changes in the pain experience of patients with COPD and predictors of pain in these patients.ObjectivesThe objectives of the study were to examine whether distinct groups of COPD patients could be identified based on changes in the occurrence and severity of pain over 12 months and to evaluate whether these groups differed on demographic, clinical, and pain characteristics, and health-related quality of life (HRQoL).Patients and methodsA longitudinal study of 267 COPD patients with very severe COPD was conducted. Their mean age was 63 years, and 53% were females. The patients completed questionnaires including demographic and clinical variables, the Brief Pain Inventory, and the St Georges Respiratory Questionnaire at enrollment, and 3, 6, 9, and 12 months follow-up. In addition, spirometry and the 6 Minute Walk Test were performed. Latent class analysis was used to identify subgroups of patients with distinct pain profiles based on pain occurrence and worst pain severity.ResultsMost of the patients (77%) reported pain occurrence over 12 months. Of these, 48% were in the "high probability of pain" group, while 29% were in the "moderate probability of pain" group. For the worst pain severity, 37% were in the "moderate pain" and 39% were in the "mild pain" groups. Females and those with higher body mass index, higher number of comorbidities, and less education were in the pain groups. Patients in the higher pain groups reported higher pain interference scores, higher number of pain locations, and more respiratory symptoms. Few differences in HRQoL were found between the groups except for the symptom subscale.ConclusionPatients with COPD warrant comprehensive pain management. Clinicians may use this information to identify those who are at higher risk for persistent pain.

BackgroundA subgroup of patients continue to report pain with walking 12 months after total knee arthroplasty (TKA). The association between walking pain and self-rated health (SRH) after TKA is not known. This prospective longitudinal study aimed to investigate the association between a comprehensive list of preoperative factors, postoperative pain with walking, and SRH 12 months after TKA.MethodsPatients (N = 156) scheduled for TKA completed questionnaires that evaluated demographic and clinical characteristics, symptoms, psychological factors, and SRH. SRH was re-assessed 12 months after TKA. Clinical variables were retrieved from medical records. Pain with walking was assessed before surgery, at 6 weeks, 3, and 12 months after TKA. Subgroups with distinct trajectories of pain with walking over time were identified using growth mixture modeling. Multiple linear regression was used to investigate the relationships between pain with walking and other factors on SRH.ResultsHigher body mass index, a higher number of painful sites at 12 months, recurrent pain with walking group membership, ketamine use, higher depression scores, and poorer preoperative self-rated health were associated with poorer SRH 12 months after TKA. The final model was statistically significant (p = 0.005) and explained 56.1% of the variance in SRH 12 months after surgery. SRH improved significantly over time. Higher C-reactive protein levels, higher number of painful sites before surgery, higher fatigue severity, and more illness concern was associated with poorer preoperative SRH.ConclusionsIn patients whose walking ability decreases over time, clinicians need to assess for unreleaved pain and decreases in SRH. Additional research is needed on interventions to improve walking ability and SRH.

ObjectiveTotal knee arthroplasty is a painful procedure. No studies have evaluated modifiable predictors of acute postoperative pain trajectories during hospitalization.MethodsConsecutive patients (N = 188) were enrolled in a longitudinal cohort study and completed a demographic questionnaire, as well as the Brief Pain Inventory, Hospital Depression and Anxiety Scale, Lee Fatigue Scale, Fatigue Severity Scale, and Brief Illness Perception Questionnaire on the day before surgery. Clinical data were extracted from medical records.Setting and patientsEach patient completed a pain diary that assessed pain at rest and with activity, and hours per day in pain every evening from day of surgery until postoperative day 3. Using hierarchical linear modeling, we investigated which demographic, clinical, symptom, and psychological characteristics predicted initial levels as well as the trajectories of acute pain at rest and with activity, and hours per day in pain.ResultsHigher levels of all three acute pain characteristics on the day of surgery resulted in worse trajectories. Higher pain scores with rest and with activity on the day of surgery were associated with more days with femoral block, higher average dose of opioids, and higher emotional response to osteoarthritis. Higher number of comorbidities, higher average dose of opioids, and lower perceived control predicted more hours per day in pain on the day of surgery.ConclusionsThis study identified several potentially modifiable predictors of worsening pain trajectories following total knee arthroplasty. Optimal pain management warrants identification of these high-risk patients and treatment of modifiable risk factors.

Background and purpose - Functional limitations after total knee arthroplasty (TKA) are common. In this longitudinal study, we wanted to identify subgroups of patients with distinct trajectories of pain-related interference with walking during the first year after TKA and to determine which demographic, clinical, symptom-related, and psychological characteristics were associated with being part of this subgroup. Patients and methods - Patients scheduled for primary TKA for osteoarthritis (n = 202) completed questionnaires that evaluated perception of pain, fatigue, anxiety, depression, and illness on the day before surgery. Clinical characteristics were obtained from the medical records. Interference of pain with walking was assessed preoperatively, on postoperative day 4, and at 6 weeks, 3 months, and 12 months after TKA. Results - Using growth mixture modeling, 2 subgroups of patients were identified with distinct trajectories of pain-related interference with walking over time. Patients in the Continuous Improvement class (n = 157, 78%) had lower preoperative interference scores and reported a gradual decline in pain-related interference with walking over the first 12 months after TKA. Patients in the Recurrent Interference class (n = 45, 22%) reported a high degree of preoperative pain-related interference with walking, initial improvement during the first 3 months after TKA, and then a gradual increase-returning to preoperative levels at 12 months. Patients in the Recurrent Interference class had higher preoperative pain, fatigue, and depression scores, and poorer perception of illness than the Continuous Improvement class. Interpretation - 1 in 5 patients did not improve in pain-related interference with walking at 12 months after TKA. Future studies should test the efficacy of interventions designed to modify preoperative characteristics.

BackgroundIn addition to their respiratory symptoms, patients with COPD experience multiple, co-occurring symptoms.ObjectivesThe aims of this study were to identify subgroups of COPD patients based on their distinct experiences with 14 symptoms and to determine how these subgroups differed in demographic and clinical characteristics and disease-specific quality of life.Patients and methodsPatients with moderate, severe, and very severe COPD (n=267) completed a number of self-report questionnaires. Latent class analysis was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of self-reported symptoms using the Memorial Symptom Assessment Scale.ResultsBased on the probability of occurrence of a number of physical and psychological symptoms, three subgroups of patients (ie, latent classes) were identified and named "high", "intermediate", and "low". Across the three latent classes, the pairwise comparisons for the classification of airflow limitation in COPD were not significantly different, which suggests that measurements of respiratory function are not associated with COPD patients' symptom burden and their specific needs for symptom management. While patients in both the "high" and "intermediate" classes had high occurrence rates for respiratory symptoms, patients in the "high" class had the highest occurrence rates for psychological symptoms. Compared with the "intermediate" class, patients in the "high" class were younger, more likely to be women, had significantly more acute exacerbations in the past year, and reported significantly worse disease-specific quality of life scores.ConclusionThese findings suggest that subgroups of COPD patients with distinct symptom experiences can be identified. Patients with a higher symptom burden warrant more detailed assessments and may have therapeutic needs that would not be identified using current classifications based only on respiratory function.

ObjectivesUnrelieved postoperative pain after total knee arthroplasty (TKA) is a significant problem. This longitudinal study investigated how preoperative pain intensity, as well as a comprehensive list of preoperative and perioperative factors, influenced the severity of acute average and worst pain after TKA.MethodsPrior to surgery, 203 patients completed a demographic questionnaire, Lee Fatigue Scale, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, and Brief Illness Perception Questionnaire. Brief Pain Inventory was completed prior to surgery as well as through postoperative days (POD) 0 to 4. Clinical data were extracted from medical records.ResultsSeveral factors were associated with higher levels of preoperative and postoperative pain. Lower preoperative average and worst pain intensity scores were associated with increases in average and worst postoperative pain from POD1 to POD4. A higher number of comorbidities, higher C-reactive protein values, and higher pain interference with function were associated with higher preoperative levels of average pain. Older age, higher fatigue levels, and higher scores on identity and emotional responses to osteoarthritis (OA) were associated with higher preoperative levels of worst pain. Lower perceived consequences of OA were associated with higher pain from POD1 to POD4. Males and patients with lower preoperative scores for average pain had higher worst pain following surgery.DiscussionPatients at higher risk for more severe postoperative pain can be identified through an assessment of pain and other risk factors identified in this study. Future research needs to test the efficacy of interventions that modify patients' perceptions of living with OA and pain intensity before surgery on short and long term postoperative outcomes.

Aim: To describe different patterns of communication aimed at preventing, identifying and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit. Design: We conducted a fieldwork study with triangulation of participant observation and individual interviews. Methods: Participant observation of nine patients and 50 clinicians: nurses, physiotherapists and physicians. Subsequent individual face‐to‐face interviews with nine of the clinicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview. Findings: Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co‐existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress. Conclusion: Recognition of symptoms in non‐speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom communication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress. Implications for Patient Care: Proactive and reactive symptom assessment of non‐speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alternative communication. Impact: This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units. Reporting Method: We used the consolidated criteria for reporting qualitative research. Patient Contribution: A user representative was involved in the design of the study. [ABSTRACT FROM AUTHOR]

PurposeThe purposes of this study were to compare the health-related quality of life (HRQOL) of long-term social assistance recipients (LTRs) with and without chronic pain and determine the effect of select demographic, social, pain, alcohol, and illicit drug use characteristics on the physical and mental components of their HRQOL.MethodsIn this cross-sectional study, which is part of a larger study that evaluated the health and functional abilities of LTRs in Norway, 405 LTRs of which 178 had chronic pain were recruited from 14 of 433 municipalities.ResultsLTRs with chronic pain were older (P