Acute Musculoskeletal Research Articles

Is a Major New Guideline on the Treatment of Acute Musculoskeletal Pain Fundamentally Flawed?

The Back Letter: November 2020 - Volume 35 - Issue 11 - p 121-131 doi: 10.1097/01.BACK.0000721180.56125.e8

<p>Predictors of Opioid Prescription Among a Sample of Patients with Acute Musculoskeletal Pain at a Tertiary Care Hospital in Saudi Arabia</p>

BackgroundMusculoskeletal pain is one of the most complex and debilitating types of pain. Although different pharmacologic treatments are available, very few studies have explored the predictors for opioid analgesics prescription to manage this type of pain.ObjectiveThe aim of this study was to explore the predictors for opioid prescription in patients with acute musculoskeletal pain in Saudi Arabia.MethodsThis was a single-center, retrospective chart review of adult patients (≥18 yrs.) with an acute nociceptive musculoskeletal pain at a university-affiliated medical center in Riyadh, Saudi Arabia. Cancer patients and those with chronic neuropathic pain were excluded. Patients’ age, gender, number of comorbidities, duration of pain management, number of clinic visits for pain, and Numeric Pain Rating Scale (NPRS) scores at rest and with normal activities were collected. Multiple logistic regression was conducted to examine the relationship between the type of musculoskeletal pain and the prescription of opioid analgesics controlling for NPRS score on activity, age, gender, number of comorbidities, duration of pain treatment, and number of clinic visits for pain.ResultsThe mean age of the 227 patients, who met the inclusion criteria, was 39 years and 68% of them were male. Sixty-three percent of the patients were prescribed opioid analgesics, and 61% of them had shoulder pain, 29% had back pain, and 10% had lower extremity pain (eg, hip, thigh, lower leg, knee, ankle, and foot pain). Tramadol was the most commonly prescribed opioid analgesic (82%), followed by codeine (13%). Ninety-seven percent of patients who were prescribed non-opioid analgesics had shoulder pain. Patients with shoulder pain had lower odds of receiving opioid analgesics (OR=0.019, P<0.0001, 95% CI=0.004–0.081) in comparison to their counterparts who had lower extremity or back pains. Moreover, the higher the pain score on activity was, the higher odds of receiving opioid analgesics (OR=1.317, P<0.0001, 95% CI=1.029–1.685).ConclusionFuture studies should explore the impact of different opioid prescribing policies to improve the quality of patient care and reduce the unnecessary prescribing of opioids for patients with non-cancer musculoskeletal pain.

Cost of Medications, Preference and Willingness-to-Pay for Pain Relief among Adult Patients Diagnosed with Acute and Chronic Musculoskeletal Pain Conditions

Objective. To determine the current cost, medication preferences, willingness to pay for symptom relief and reducedadverse events of adult patients with acute and chronic musculoskeletal pain.&#x0D; Methods. This was a cross-sectional study among adult Filipinos consulted for musculoskeletal conditions at FamilyMedicine Clinic. Data were collected through a questionnaire and a systematic sampling of respondents.&#x0D; Results. The study had a total of 342 participants with degenerative osteoarthritis as the most common primarydiagnosis. Twenty percent (N=69/342) were acutely symptomatic while 273/342 (80%) have chronic musculoskeletalpain. Most would prefer medicines at a lower price point, effectively reduces pain, fast onset of action, longertherapeutic effects and less adverse effects. Willingness-to-pay was at an average price of Php 86.11 (SD±15.47)per pill for complete symptom relief.&#x0D; Conclusion. Adult Filipinos with musculoskeletal pain symptoms prefer pain medicines with good symptom control,less adverse event and were willing to pay for complete symptom relief at an average of eighty-six pesos per pill.

Predictors of Prolonged Opioid Use After Initial Prescription for Acute Musculoskeletal Injuries in Adults : A Systematic Review and Meta-analysis of Observational Studies.

Opioids are frequently prescribed for acute musculoskeletal injuries and may result in long-term use and consequent harms. To explore factors associated with persistent opioid use after its prescription for acute musculoskeletal injury. Searches of multiple electronic databases, without language restrictions, from inception to 6 January 2020, and reference lists of selected articles. Observational studies of adults with opioid prescriptions for outpatient acute musculoskeletal injuries, in an adjusted model, that explored risk factors for prolonged use. 6 reviewers, working in pairs, independently extracted data, rated the quality of studies, and evaluated the certainty of evidence. 14 cohorts with 13263393 participants were included. The overall prevalence of prolonged opioid use after musculoskeletal injury for high-risk populations (that is, patients receiving workers' compensation benefits, Veterans Affairs claimants, or patients with high rates of concurrent substance use disorder) was 27% (95% CI, 18% to 37%). The prevalence among low-risk populations was 6% (CI, 4% to 8%; P for interaction < 0.001). Moderate-certainty evidence showed increased odds of persistent opioid use with older age (absolute risk increase [ARI] for every 10-year increase, 1.1% [CI, 0.7% to 1.5%]) and physical comorbidity (ARI, 0.9% [CI, 0.1% to 1.7%]). Low-certainty evidence suggested increased risk for persistent opioid use with past or current substance use disorder (ARI, 10.5% [CI, 4.2% to 19.8%]), prescriptions lasting more than 7 days (median ARI, 4.5%), and higher morphine milligram equivalents per day. Sparse, heterogeneous data with suboptimal adjustment for potential confounders. Avoiding prescribing opioids for acute musculoskeletal injuries to patients with past or current substance use disorder, and restricting duration to 7 days or less and using lower doses when they are prescribed, are potentially important targets to reduce rates of persistent opioid use. National Safety Council. (PROSPERO: CRD42018104968).

Isolated Infraspinatus Weakness Due To Suprascapular Neuropathy In A National Level Volleyball Player

HISTORY: 15-year-old female national-level volleyball player with no PMH who presented for nagging right shoulder pain and subjective right arm weakness for 1.5 years. The patient did not endorse a specific inciting injury. The pain was located at the anterolateral aspect of the deltoid with radiation down the arm without numbness or tingling, made worse with volleyball activity and made better with rest. Due to her continued pain and right shoulder weakness, she was held from participating in volleyball matches. MRI arthrogram was negative for pathology, so she was referred for EMG. PHYSICAL EXAMINATION: General Appearance: Young Caucasian female in no acute distress Musculoskeletal: 4 out of 5 strength at right shoulder external rotation. 5 strength in bilateral upper extremities otherwise. No atrophy of the bilateral shoulder muscles. Normal bilateral scapulothoracic movement. Full range of motion at the bilateral upper extremities. Bilateral shoulders non-tender to palpation over the anterior, lateral, or posterior aspects. Neck non-tender to palpation. No pain noted with cervical neck flexion, extension, or rotation. DIFFERENTIAL DIAGNOSIS: 1) Labral Tear 2) Rotator Cuff Tendinopathy 3) Suprascapular nerve palsy at the spinoglenoid notch TEST AND RESULTS: Bilateral upper extremity EMG: On nerve conduction studies, no response obtained from the right infraspinatus, response normal at the supraspinatus when stimulating at Erb’s point. On needle EMG, 4+ fibrillations and no recruitment seen at the right infraspinatus; normal supraspinatus. Electrodiagnostic evidence suggestive of a right suprascapular nerve neuropathy selectively affecting the infraspinatus. Findings compatible with suprascapular nerve palsy proximal to or at the spinoglenoid notch. FINAL WORKING DIAGNOSIS: Suprascapular neuropathy selectively affecting the infraspinatus due to repetitive overhead activity. TREATMENT AND OUTCOMES: The patient was prescribed a 4-week course of physical therapy for range of motion exercises and shoulder rotator cuff muscle strengthening. She was advised to initiate a return-to-play graduated exercise program after completion of PT based on strength and tolerance to pain. The patient's pain significantly improved with PT and rest. She was able to return to competitive play within 8 weeks.

Reliability, Discriminative, and Prognostic Validity of the Multidimensional Symptom Index in Musculoskeletal Trauma.

The Multidimensional Symptom Index (MSI) is a 10-item parallel score frequency×interference patient-reported outcome for use in clinical pain research. This manuscript describes results related to measurement stability, discriminative accuracy when screening for major depressive disorder (MDD), and prognostic validity when predicting recovery trajectories after acute musculoskeletal (MSK) trauma. Data were drawn from a longitudinal cohort study of adults with acute MSK trauma, supplemented by a secondary sample of adults with chronic pain. In a sample of n=23 stable participants over a 1-month period, reliability metrics indicated good stability for all 5 subscales (ICC3,1: 0.70 to 0.91). In a mixed acute/chronic sample (n=148), the Number of Symptoms and Nonsomatic Symptoms subscales showed clinically useful discriminative accuracy for MDD screening (area under the curve=0.86 and 0.88, respectively). In n=129 with acute MSK trauma, the Mean Interference and Nonsomatic Symptoms subscales showed significant prognostic validity for classifying participants into "recovery expected" or "recovery not expected" groups with 72.5% and 92.2% accuracy, respectively. The MSI holds promise as a tool for evaluating change, screening for MDD, and identifying those at high or low risk of poor recovery. The results favor sensitivity over specificity. The labile nature of the acute pain symptoms and a truncated distribution of Nonsomatic Symptoms scores in that group both require some caution in interpretation. The MSI appears to be a potentially useful tool for rapid pain phenotyping, evaluation, and quick screening purposes in clinical practice.

Current Practices in Acute Musculoskeletal Injury Care: A National Survey of Athletic Trainers

Current Practices in Acute Musculoskeletal Injury Care: A National Survey of Athletic Trainers

Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection.

Septic arthritis (SA) is responsible for 20% of pediatric musculoskeletal infections (MSKI) and can have significant consequences. Early detection of SA is critical, and procalcitonin (PCT) has emerged as a promising biomarker. This study assessed the test performance of PCT and traditional biomarkers for suspected SA. We conducted a prospective study at two pediatric emergency departments (ED). Data collected measured serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and PCT. Box and whisker plots were generated to compare the of the biomarkers by positive MSKI or a non-MSKI diagnosis. The diagnostic performance of biomarkers was examined using the area under the receiver operating characteristic curve (AUC), and optimal cut -points were identified using the Liu method. Procalcitonin performed reasonably well for detection of MSKI (AUC, 0.72; confidence interval [95% CI], 0.59-0.84). However, CRP and ESR performed better (AUC, 0.88 and 0.78, respectively). White blood cell count was not predictive of MSKI. Patients with a PCT value >0.1 ng/mL, ESR values >19.5 mm/h, and a temperature higher than 99.0°F were more than twice as likely to have acute MSKI. A high CRP level was most predictive of acute MSKI, and patients with levels >2.38 mg/dL were 3.5 times more likely to have acute MSKI. Procalcitonin is a potential biomarker for the clinical differential of MSKI in the pediatric ED. Additional research is warranted to establish the optimal diagnostic level for PCT, to increase sample size, and to examine any impact on cost.

Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

A Mediational Analysis of Stress, Inflammation, Sleep, and Pain in Acute Musculoskeletal Trauma.

Differences in pain severity among acutely injured people may be related to the perceived stress of the event and pre-existing vulnerabilities. In this study, we test the hypotheses that pretrauma life stress influences posttrauma pain severity, and 2 potential mediating pathways, 1 biological (C-reactive protein, CRP) and 1 contextual (sleep quality). Data collected from participants within 3 weeks of a noncatastrophic musculoskeletal trauma were used in this observational cross-sectional mediation analysis. The primary outcome was pain severity as measured using the Brief Pain Inventory. Predictors were posttrauma CRP assayed from plasma, sleep interference measured by the Brief Pain Inventory, and a study-specific "General Life Stressors" scale. First, the sample was split into low and high life-stress groups, and mean differences in the pain and the predictor variables were explored by t test. Next, a mediation model was tested through a regression-based path analysis. The base model explored the predictive association between pretrauma life stress and posttrauma pain. Sleep quality and CRP concentration were then entered as possible mediators of the association. The sample of 112 participants was 54.6% female, and 52.7% reported high pretrauma life stress. Mean differences in pain severity, sleep interference, and CRP was significant between the high-stress and low-stress groups. In path analysis, life stress explained 8.0% of the variance in acute pain severity, 6.3% of the variance in sleep interference, and 8.0% of the variance in CRP concentration, all P-value <0.05. In mediation analysis, the association between life stress and pain severity was fully mediated by sleep interference. CRP did not mediate the association. Pretrauma life stress predicted pain severity, sleep interference, and plasma CRP. In mediation analysis, pretrauma stress was associated with pain severity only through its association with sleep interference, while CRP did not mediate the association. Implications of these results are discussed.

Evaluating an Educational Video Plus Telecare to Improve Pain Recovery in Older Adults With Acute Musculoskeletal Pain

Evaluating an Educational Video Plus Telecare to Improve Pain Recovery in Older Adults With Acute Musculoskeletal Pain

Evaluation of the Safety and Efficacy of JointAid Oil in Patients with acute and chronic Musculoskeletal pain: An open label, Non-Comparative, Multicenter clinical trial

Evaluation of the Safety and Efficacy of JointAid Oil in Patients with acute and chronic Musculoskeletal pain: An open label, Non-Comparative, Multicenter clinical trial

Parent Factors are Associated With Pain and Activity Limitations in Youth With Acute Musculoskeletal Pain: A Cohort Study.

Biopsychosocial models emphasize the influence of parent/family factors on pediatric chronic pain. Little is known about how parent factors differ across the acute to chronic pain continuum, or contribute to youths' pain experience in the acute pain period. The purpose of the study was to describe parent factors in youth with acute musculoskeletal pain (n=84) compared with youth with chronic pain (n=60) and youth without pain (n=61). Further, within the acute pain sample, we tested parent factors as predictors of child pain characteristics, as well as the moderating role of child sex on associations. Participants were 205 youth (age, 10 to 17) and one biological parent per child. Children reported on their own pain and activity limitations. Parents reported on their own chronic pain, somatization, and protective pain responses. Parents of youth with acute pain had higher prevalence of chronic pain and greater somatization than parents of youth without pain. Parents of youth with acute and chronic pain did not differ. Linear regressions within the acute pain sample revealed presence of parent chronic pain and protective behavior were associated with child pain. Moreover, parent somatization was associated with child activity limitations. Within the acute pain sample, associations between parent protectiveness and child pain were moderated by child sex, with relationships stronger for female children. Findings highlight the importance of parent factors on pain experiences of youth with acute musculoskeletal pain. Future longitudinal research can elucidate temporal associations that underlie how parent factors may impact transition from acute to chronic pain.

Leucocyte Profile of Adult Nigerians as Indicator of Severity Level of Acute Musculoskeletal Trauma

Leucocytosis, marked increase in the number of white blood cells (WBC) is a known physiological response to trauma. In recent times, several studies have asserted the absence of this response in Africans. In view of this, current study investigated the existence of, and prognostic implications of post-traumatic leucocytosis amongst adult Nigerians with acute musculoskeletal (MSK) trauma. Two hundred and twenty three (223) adult male and females (MSK traumatized) and fifty apparently healthy volunteers (adults) were ethically recruited from the National Orthopaedic Hospital, Enugu, regional centre for trauma, orthopaedic, burns and plastic surgery in south-east Nigeria. Using the Leishman’s stained blood smear technique, leucocyte profiles [Neutrophil, Lymphocytes, Basophils, Eosinophils and Monocyte counts] were obtained for each participant. In all case, Age, Gender and duration of hospitalization were also obtained. Following careful analysis, study found, using one way analysis of variance (ANOVA), a statistically significant increase (p &lt; .05) in acutely traumatized subjects; with adults of ages 20 to 49 years constituting the majority (70%). A statistically significant lymphopenia was also observed in test population, with Pearson Product Moment Correlation proving positive for higher levels of WBC counts. A negative correlation was also seen for Neutrophils and lymphocyte counts, implicating the Neutrophil-Lymphocyte Stress Factor (NLSF). We recommend the exploration of the NLSF for prognosis of Leucocytosis in Africans.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018. We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy. Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

A Randomized Control Trial Comparing the Safety and Analgesic Efficacy of Diclofenac Administered Through Intramuscular versus Oral Route in Patients with Acute Musculoskeletal Injuries

Background: Clinical trials comparing efficacy of NSAIDs administration through different routes have provided indefinite conclusions due to sev-eral limitations. The current study aimed to ascertain early post-medication pain reduction in participants presenting with acute musculoskeletal injuries (MSI) to the emergency department (ED) receiving intramuscular (IM) versus per oral (PO) diclofenac. Methods: This was a prospective, double blinded, randomized control trial. Adults (18-65 years of age) presenting to the ED within 24 hours of acute MSI, and who had a triage pain score on Numerical rating scale (NRS) of at least 5 were enrolled in this study. Participants were assigned (1:1) to either intramuscular (75mg) or oral (100mg) diclofenac group using a computer generated randomized concealed list in the blocks of six and eight. The primary objective was to evaluate and compare the proportions of IM vs. PO participants attaining a 50% reduction in pain score at 30 minutes from t0. Findings: Between January 15, and June 10, 2018, we enrolled 300 participants (150 in the IM diclofenac group, and 150 in the PO diclofenac group) in the study. The primary outcome was achieved in 99.3( 95% CI 96.3-100) in the intramuscular group and 86.7( 95% CI 80.2- 91.7) in per oral group. This corresponds to a number needed to teat (NNT) of 8 cases (95% CI, 6-14) receiving IM rather than the PO diclofenac, in order to achieve one additional case of 50% pain reduction within a half-hour of drug administration. There were no adverse events experienced in any treatment group. Interpretation: The overall efficacy and time taken for pain reduction by IM diclofenac injection has relatively little advantage over per oral admin-istration of diclofenac. Considering the additional resources and risks entailed in IM administration, per oral administration is prefera-ble when and if clinical circumstances allow a choice in NSAID administration route. Trial Registry: The trial was registered with ClinicalTrials.gov, number NCT03472339. Funding: Hamad Medical Corporation, Medical Research Center, Doha, Qatar (MRC#16413/16) Declaration of Conflict of interest: There is no conflict of interest among the authors. Ethics Approval Statement: The HGH institutional ethics board approved the study.

Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial

We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma. The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomlyassignedin a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive daysand need for additional analgesia. One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI]-1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI-0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and-0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin. Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

Does Acupressure Hit the Mark? A Three-Arm Randomized Placebo-Controlled Trial of Acupressure for Pain and Anxiety Relief in Athletes With Acute Musculoskeletal Sports Injuries.

Injuries are a common consequence of sports and recreational activity. The optimal management of symptoms is a crucial element of sports injury management. Acupressure has previously been shown to effectively decrease symptoms of musculoskeletal injury, thus may be considered a potentially useful intervention in the management of sport-related injuries. Therefore, this study was conducted to examine the effectiveness of acupressure in decreasing pain and anxiety in acutely injured athletes. A prospective 3-arm randomized placebo-controlled trial. A sports injury clinic, Dunedin, New Zealand. Seventy-nine athletes who sustained a sport-related musculoskeletal injury on the day. Three minutes of either acupressure, sham acupressure, or no acupressure. The primary outcomes of pain and anxiety intensity were measured before and immediately after the intervention on a 100-mm visual analog scale (VAS). Pain and anxiety relief, satisfaction with treatment, willingness to repeat a similar treatment, and belief in the effect of acupressure were secondary outcomes measured on Likert scales after the intervention. The acupressure group reported 11 mm less pain (95% CI: 5-17) on average than the sham acupressure group, and 9 mm less (95% CI: 3-16) than the control group as a result of the intervention (P < 0.05). There was no difference between groups in: anxiety levels, or in any of the secondary outcome measures. Three minutes of acupressure was effective in decreasing pain intensity in athletes who sustained an acute musculoskeletal sports injury when measured on the VAS, but did not change anxiety levels.

Predictors of the transition from acute to persistent musculoskeletal pain in children and adolescents: a prospective study

Strategies directed at the prevention of disabling pain have been suggested as a public health priority, making early identification of youth at risk for poor outcomes critical. At present, limited information is available to predict which youth presenting with acute pain are at risk for persistence. The aims of this prospective longitudinal study were to identify biopsychosocial factors in the acute period that predict the transition to persistent pain in youth with new-onset musculoskeletal (MSK) pain complaints. Participants were 88 children and adolescents (age 10-17 years) presenting to the emergency department (n = 47) or orthopedic clinic (n = 41) for evaluation of a new MSK pain complaint (&lt;1 month duration). Youth presented for 2 study visits (T1≤1 month post pain onset; T2= 4-month follow-up) during which they completed questionnaires (assessing pain characteristics, psychological factors, sleep quality) and participated in a laboratory task assessing conditioned pain modulation. Regression analyses tested T1 predictors of longitudinal pain outcomes (pain persistence, pain-related disability, quality of life [QOL]). Results revealed approximately 35% of youth had persistent pain at 4-month follow-up, with persistent pain predicted by poorer conditioned pain modulation and female sex. Higher depressive symptoms at T1 were associated with higher painrelated disability and poorer QOL at T2. Findings highlight the roles of depressive symptoms and pain modulation in longitudinally predicting pain persistence in treatment-seeking youth with acute MSK pain and suggest potential mechanisms in the transition from acute to chronic MSK pain in children and adolescents.

Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes.

Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG. Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined. 82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056). Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.