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. Author manuscript; available in PMC: 2024 Jun 1.
Published in final edited form as: PM R. 2022 Jul 19;15(6):761–771. doi: 10.1002/pmrj.12847

Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain

Abby L Cheng 1, Katherine V Carbonell 2, Heidi Prather 3, Barry A Hong 4, Dana L Downs 4, John P Metzler 1, Devyani M Hunt 1
PMCID: PMC9659670  NIHMSID: NIHMS1808028  PMID: 35567523

Abstract

Introduction:

Factors that motivate musculoskeletal patients to pursue an intensive, lifestyle medicine based approach to care are poorly understood.

Objective:

To determine whether, compared to patients seeking musculoskeletal care through traditional pathways, patients who choose an intensive lifestyle medicine program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and/or more biopsychosocial comorbidities.

Design:

Cross-sectional analysis of existing medical records from 2018–2021.

Setting:

Orthopedic department of one academic medical center.

Patients:

Fifty consecutive patients who enrolled in an intensive lifestyle medicine program to address a musculoskeletal condition. Comparison groups were: 1.) 100 patients who presented for standard non-operative musculoskeletal care, and 2.) 100 patients who presented for operative evaluation by an orthopedic surgeon and qualified for joint arthroplasty.

Intervention:

Not applicable.

Main Outcome Measures:

Primary outcomes were age-adjusted, between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS) physical and psychological health measures. Secondary outcomes were between-group differences in sociodemographic and medical history characteristics.

Results:

Patients who enrolled in the intensive lifestyle medicine program were more racially diverse (non-white race: lifestyle cohort 34% versus comparison cohorts 16–18%, p≤.029) and had a higher prevalence of obesity and diabetes than both comparison groups (mean body mass index: lifestyle cohort 37.6 kg/m2 versus comparison cohorts 29.3–32.0, p<.001; diabetes prevalence: lifestyle cohort 32% versus comparison cohorts 12–16%, p≤.024). Compared to standard non-operative patients, there were no clear between-group differences in PROMIS physical or psychological health scores. Compared to standard operative evaluation patients, patients in the lifestyle program reported worse anxiety but less pain interference (PROMIS Anxiety: B=3.8 points [0.1–7.4], p=.041; Pain Interference: B=−3.6 [−6.0- −1.2], p=.004).

Conclusions:

Compared to musculoskeletal patients who sought care through traditional pathways, patients who chose an intensive lifestyle medicine pathway had a higher prevalence of metabolic comorbidities, but there was substantial overlap in patients’ physical, psychological, and sociodemographic characteristics.

Keywords: Interdisciplinary health team, Multidisciplinary/interdisciplinary rehabilitation, Musculoskeletal conditions, Metabolic diseases, Obesity, Pain, Joint replacement, Psychotherapy

INTRODUCTION

Standard care for most musculoskeletal conditions includes physical therapy, medications, injections, and surgery, and these traditional treatment options are often prescribed to patients in a stepwise fashion.1 ,2 Unfortunately, despite well-established evidence for each of these treatments, many patients with musculoskeletal pain do not sufficiently respond to this care pathway.3 ,4 The inadequacies of this structure-based approach may be related to the presence of: 1.) biopsychosocial variables which interact and can contribute to the experience of pain,5 and 2.) lifestyle related chronic diseases (e.g., hypertension, diabetes, obesity) that hinder a patient’s progress in successfully managing a painful musculoskeletal condition.6 ,7

In contrast to traditional musculoskeletal care, in an intensive lifestyle medicine based care model, patients are active participants in every component of their treatment, and clinicians from multiple disciplines meet regularly to coordinate the patient’s care and holistically address patients’ biopsychosocial impairments simultaneously.8 ,9 In a Cochran review of patients with chronic low back pain, compared with patients who received traditional musculoskeletal care, patients who participated in an intensive rehabilitation program achieved greater pain relief and twice the likelihood of returning to work within six to twelve months.8 Additionally, musculoskeletal patients who have participated in an intensive program that focuses on lifestyle and psychosocial interventions have reported relatively low overall healthcare resource usage despite high satisfaction regarding access to care.10 ,11 Because of their effectiveness, intensive care models are becoming widely available for management of metabolic conditions such as cardiovascular disease and diabetes.12 ,13 Yet, even though psychosocial risk factors such as a sedentary lifestyle, poor diet, tobacco use, and anxiety are known to exacerbate pain and physical dysfunction,14–19 intensive lifestyle medicine based care programs are not currently a standard care pathway for musculoskeletal conditions.20

Even if intensive lifestyle medicine based care programs become widely available for patients with musculoskeletal conditions, the factors that motivate patients to choose this care model over a more traditional care pathway are poorly understood. Lifestyle-based care requires active participation by the patient to implement daily lifestyle changes, whereas traditional care pathways are often characterized by passive treatments such as medications and procedures. To efficiently identify patients who might be interested in this pathway (and therefore benefit from referral for consultation to such a program), it is important to identify and understand unique characteristics of patients who are attracted to lifestyle medicine based intensive care for musculoskeletal pain.

The purpose of this study was to determine whether, compared to patients seeking musculoskeletal care through traditional pathways, musculoskeletal patients who choose to pursue an intensive lifestyle medicine based care program have unique physical, behavioral, and/or other clinical characteristics. We hypothesized that, compared to patients who seek musculoskeletal care through a traditional care pathway, patients who choose an intensive lifestyle medicine based care program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and more biopsychosocial comorbidities.

METHODS

In this single-center study, a cross-sectional analysis was performed using data from existing medical records. All patients were evaluated at a tertiary referral academic medical center in the United States between 11/19/18 and 1/12/21. This study conforms to the standards set forth in the Declaration of Helsinki, and university institutional review board approval was obtained via a waiver of written consent.

Eligible patients for the study included adults (18 years or older) who presented for initial evaluation to a musculoskeletal physician within the orthopedic surgery department and who completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical and behavioral health questionnaires prior to the physician evaluation. Three distinct subgroups of patients were included in the study (Table 1).

Table 1:

Summary of eligibility criteria for patients who presented to one of three different care settings for musculoskeletal care: an intensive lifestyle medicine program, standard non-operative care, or standard operative evaluation.

Patient group Inclusion criteria Exclusion criteria
All patient groups

  • Presented for initial evaluation to a physician with subspecialty expertise in musculoskeletal medicine

  • Age < 18 years

  • Did not complete PROMIS measures
Intensive lifestyle medicine program

  • Presented for consultation for the intensive lifestyle medicine program

  • Enrolled in the intensive lifestyle medicine program
  • Did not enroll in intensive lifestyle medicine program because:
    • Not interested in enrolling
    • Not interested in making lifestyle changes
    • Not appropriate for the program because did not demonstrate need for 2+ program services and/or had active, severe psychiatric illness
Standard non-operative care

  • Presented to a physiatrist with subspecialty expertise in sports and/or pain medicine

  • Endorsed musculoskeletal pain ≥ 6 months duration

  • Presented to a walk-in acute injury clinic, for consultation to the intensive lifestyle medicine program, or specifically for a procedure
Standard operative evaluation

  • Presented to an orthopedic surgeon with subspecialty expertise in hip and/or knee reconstructive surgery

  • Surgeon documented the patient’s musculoskeletal condition would warrant hip or knee arthroplasty

  • Referred to the intensive lifestyle medicine program for perioperative optimization
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Abbreviations: PROMIS (Patient-Reported Outcomes Measurement Information System).

Primary patient group: Intensive lifestyle medicine program

The primary patient group of interest was patients who enrolled in an intensive lifestyle medicine program to simultaneously address their musculoskeletal condition(s) and metabolic and/or psychological comorbidities. The full program has previously been described.11 In brief, patients are referred to the program by a non-operative musculoskeletal specialist, orthopedic surgeon, primary care provider, other medical provider, or via self-referral. All patients who enter the program have previously undergone standard musculoskeletal evaluation and treatment, as appropriate. The program is directed by a board-certified physiatrist with subspecialty board certification in sports medicine and additional training in lifestyle medicine. All patients included in this patient group were managed by one of three physiatrists or a nurse practitioner with over ten years of experience in musculoskeletal care. At the initial program consultation, patients complete a comprehensive screening process including a physical activity history, anthropometric measurements, and metabolic labs, and providers use a shared decision making approach with patients to define functional goals which can be achieved within 90–120 days. Possible program goals include: reduction of perioperative risk in preparation for an elective orthopedic surgery (most commonly hip, knee, or spine surgery); improvement of pain and functional status to avoid an extensive, elective orthopedic surgery; and/or improvement of pain and functional status to meet a specific quality-of-life goal (e.g., dancing at an upcoming wedding, taking care of grandchildren, etc). To achieve their goals, as appropriate, patients engage with two or more of the following clinicians: a clinical psychologist, dietitian, smoking cessation counselor, physical therapist, acupuncturist, and/or massage therapist. When possible, patients are scheduled with multiple clinicians on the same day in order to consolidate their clinical visits. The program clinicians meet monthly for an interprofessional team meeting to discuss patients’ progress and address any barriers to care.

Patients were included in this analysis group if they presented for a consultation for the program, were assessed by the clinician to be appropriate for the program, and initiated participation in the intensive program. Inclusion in this analysis group was not affected by whether patients successfully completed the program, self-discharged prematurely, or were still enrolled in the program at the time of data collection. Patients were excluded if, after initial consultation for the program, the patient was not interested in enrolling, not interested in making lifestyle changes to achieve their goals, and/or the evaluating clinician determined the patient was not appropriate for an intensive lifestyle medicine based program because the patient did not demonstrate need for two or more services offered through the program. Patients were also not eligible for the program, and were therefore excluded from analysis, if they had active, severe psychiatric illness (e.g., severe depression, bipolar disorder, schizophrenia, active suicidal behaviors/thoughts, alcoholism, and/or substance abuse). Given these eligibility criteria, this group represents patients who could benefit from and who chose an intensive lifestyle medicine based care pathway for their musculoskeletal condition(s) and medical comorbidities.

Comparison patient groups: Standard non-operative care and standard operative evaluation

Patients who enrolled in the intensive lifestyle medicine program were compared to two groups of patients who presented for more standard musculoskeletal care. In reverse chronological order, one hundred patients were consecutively added to each of these groups from the medical record, starting from 10/29/20.

The first comparison group consisted of patients with chronic musculoskeletal pain who presented to a physiatrist for standard non-operative musculoskeletal management. All patients presented for initial evaluation to one of eleven board-certified physiatrists with subspecialty expertise in sports and/or pain medicine, and patients had to endorse at least six months of musculoskeletal pain. Based on institutional protocols, patients are scheduled for this type of evaluation if they are referred for and are interested in standard, problem-based, non-surgical management for one or more musculoskeletal conditions. The most common conditions for which patients present to this setting include lumbopelvic and/or neck/shoulder pain. Patients who presented for evaluation to the department’s walk-in acute injury clinic, the intensive lifestyle medicine clinic, or specifically for a procedure (i.e., injection or acupuncture) were excluded.

The second comparison group consisted of patients who presented to a board-certified orthopedic surgeon with subspecialty expertise in hip and/or knee reconstructive surgery. This group was chosen because perioperative risk reduction for joint replacement surgery is a common goal for patients enrolling in the intensive lifestyle medicine program, so this group essentially captures a potential referral base for the intensive lifestyle medicine program. To be included in this group, the treating surgeon had to have documented that, from a musculoskeletal/pain standpoint, the patient would benefit from hip or knee arthroplasty, regardless of whether medical and/or psychological comorbidities would increase their perioperative risk of complications (e.g., morbid obesity, uncontrolled diabetes and/or hypertension, ongoing tobacco use, uncontrolled anxiety and/or depression). Based on institutional protocols, patients are scheduled for this type of evaluation if they are referred for and are interested in considering surgical management for their hip and/or knee condition. Common indications for advising against elective orthopedic surgery at the study institution include a body mass index (BMI) > 40 kg/m2, HgbA1c > 7.5%, and/or tobacco use within six weeks of surgery. Patients who were ultimately referred from the surgeon to the intensive lifestyle medicine program for perioperative optimization were also excluded from analysis.

Outcome measures

The primary outcomes were the age-adjusted between-group differences in PROMIS physical and behavioral health measures. PROMIS is a set of questionnaires which uses Computer Adaptive Testing (CAT) technology to obtain precise symptom scores with minimal survey burden.21 Patients in this study completed the Adult PROMIS CAT Physical Function v2.0, Pain Interference v1.1, Anxiety v1.0, and Depression v1.0 measures on preloaded tablet computers (iPad mini, Apple, Cupertino, CA) as standard care prior to clinician evaluation. All included PROMIS measures are normalized to the general United States population with a mean score of 50 and standard deviation of 10. A higher score represents more of the domain expressed, so for instance, a PROMIS Physical Function score of 60 is favorable, whereas a PROMIS Pain Interference score of 60 is unfavorable. Clinically meaningful PROMIS score differences between patients in the intensive lifestyle medicine group and the two comparison groups were a priori chosen as the upper thresholds for published, within-group minimal clinically important differences (MCIDs) of patients with conservatively managed chronic musculoskeletal pain. The rationale for these MCID threshold choices is that patients presenting to the intensive lifestyle medicine program are enrolling in a conservative care option, but they are often hoping to achieve enough symptom improvement such that they do not feel elective surgery is warranted. Furthermore, any effect size smaller than the standard error of measurement at the study institution for each PROMIS CAT domain was considered to not be clinically meaningful, even if it met published MCID thresholds. As a result, clinically meaningful PROMIS score differences were defined for this study as 3.9 points for Physical Function, 3.5 points for Pain Interference, 3.4 points for Anxiety, and 3.2 points for Depression.22–24

Secondary comparisons between the intensive lifestyle medicine patients and those in the two comparison groups included sociodemographic, musculoskeletal, medical, and psychiatric history variables. All variables were extracted from the medical record. Sociodemographic variables included age, sex, race, ethnicity, and national Area Deprivation Index (ADI) percentile. The ADI is a marker for community level social disadvantage and is determined by patients’ nine-digit residential zip codes.25 ,26 Higher percentiles indicate worse social disadvantage. Patients’ musculoskeletal history included pain duration; prescription pain medication use (and which medication class); and number of previous orthopedic surgeries. Medical history variables included patients’ BMI; established diagnoses of hypertension, hyperlipidemia, diabetes, sleep apnea, and/or lung disease (e.g., chronic obstructive pulmonary disease, emphysema); and tobacco use (current and/or previous). Psychiatric history variables included an established diagnosis of anxiety and/or depression; prescription mood medication use (and which medication class), regardless whether used for mood or sleep; and prescription sleep medication use.

Statistical analysis

Continuous variables are reported as mean (SD), and categorical variables are reported as n (%). Based on the categories of available data in the medical record and the data distribution, pain duration was condensed to a binary cutoff of three years or less versus greater than three years. For the primary outcomes, four linear regression models were created, one for each PROMIS domain. The independent variables in each model were patient group and age (continuous, in years). PROMIS scores were adjusted for age because age is known to affect patients’ self-reported health.27 For the secondary comparison measures, between-group differences between the intensive lifestyle medicine patient group and the two comparison groups were determined using independent t-tests, chi-square tests, and Fisher exact tests, as appropriate. Matching was not performed between the intensive lifestyle medicine group and the two comparison groups because one objective of the study was to compare demographic characteristics between the groups. The sample size of each comparison group was chosen to double the available sample size for the intensive lifestyle medicine patient group. Missing data are listed in the results tables and were excluded from analyses. Because of the exploratory and descriptive nature of this study, p<.05 was pre-specified to represent statistical significance for all analyses. All data was collected and managed using Research Electronic Database Capture (REDCap) hosted by the study institution.28 ,29 Statistical analyses were performed using SAS Base v9.4 (SAS Institute, Cary, NC).

RESULTS

A total of 250 patients were included in the analysis (mean age 58.3 (SD 14.6) years, range 18–86 years) (Figure 1). In the entire sample, 149 (60%) were female, and 101 (40%) were male. Of the 50 patients who enrolled in the intensive lifestyle medicine program, 13 (26%) had a primary goal of perioperative risk reduction, 11 (22%) had a primary goal of avoiding elective orthopedic joint or spine surgery, and 26 (52%) had a primary goal to reduce pain and improve health, not specifically related to surgical intervention.

Figure 1:

Figure 1:

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Inclusion flowsheet of patients who presented for evaluation to one of three musculoskeletal care settings between 2018 and 2021: (A) an intensive lifestyle medicine program, (B) standard non-operative care, and (C) standard operative evaluation. †Of the 33 patients who were assessed to be “not appropriate” by the clinician for the intensive lifestyle medicine program, 3 (9%) patients were referred for consultation to the program but expressed they were not interested in making lifestyle changes, and 30 (91%) were assessed to require only one of the program services.

Compared to patients who sought care through a standard non-operative or operative pathway (i.e., traditional physiatric care or joint arthroplasty), patients who chose to enroll in the intensive lifestyle medicine program were more racially diverse (non-white race: lifestyle cohort 34% versus comparison cohorts 16–18%, OR 2.3–2.7, p≤.029) and had a higher prevalence of obesity and diabetes (mean BMI: lifestyle cohort 37.6 kg/m2 versus comparison cohorts 29.3–32.0, mean difference 5.6–8.2 kg/m2, p<.001; diabetes prevalence: lifestyle cohort 32% versus comparison cohorts 12–16%, OR 2.5–3.5, p≤.024) (Table 2) (Figure 2).

Table 2:

Sociodemographic characteristics of patients who presented for musculoskeletal care to one of three care settings between 2018 and 2021.

Intensive lifestyle
(n=50)		 Standard non-operative care
(n=100)		 Standard operative evaluation
(n=100)		 Missing†
Mean (SD) or n (%) Mean (SD) or n (%) MD [95% CI] or OR [95% CI] p Mean (SD) or n (%) MD [95% CI] or OR [95% CI] p n
Age (years) 58.8 (12.1) 53.8 (16.9) 5.1 [−0.3 to 9.8] .06 62.5 (11.8) −3.6 [−7.7 to 0.4] .08 0/0/0
Sex .15 .10 0/0/0
 Female 35 70% 58 (58%) 1.7 [0.8 to 3.48] 56 (56%) 1.8 [0.9 to 3.8]
 Male 15 30% 42 (42%) 0.6 [0.3 to 1.2] 44 (44%) 0.5 [0.3 to 1.1]
Race .029 .012 0/0/0
 White 33 (66%) 82 (82%) 0.4 [0.2 to 0.9] 84 (84%) 0.4 [0.2 to 0.8]
 Non-white 17 (34%) 18 (18%) 2.3 [1.1 to 5.1] 16 (16%) 2.7 [1.2 to 6.0]
  Black 14 (28%) 15 (15%) 14 (14%)
  Asian 1 (2%) 3 (3%) 1 (1%)
  Other 2 (4%) 0 (0%) 1 (1%)
Ethnicity >.99 .61 0/1/0
 Hispanic 1 (2%) 2 (2%) 1.0 [0.1 to 11.2] 1 (1%) 2.0 [0.1 to 33.0]
 Not Hispanic 49 (98%) 97 (98%) 1.0 [0.1 to 11.4] 99 (99%) 0.5 [0.0 to 8.1]
ADI percentile 41.6 (23.6) 47.4 (25.5) −5.8 [−14.3 to 2.7] .18 50.4 (26.7) −8.8 [−17.7 to 0.0] .0496 0/1/2
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All bivariate analyses are compared to the “Intensive lifestyle” group.

Boldface indicates p<.05.

For binary variables (e.g., sex), the odds ratio of a category (e.g., female) is the inverse of the odds ratio for the other category (e.g., male).

†

Missing data are reported as: Intensive lifestyle / Standard non-operative care / Standard operative evaluation.

Abbreviations: MD (mean difference), ADI (national Area Deprivation Index).

Figure 2:

Figure 2:

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Summary of sociodemographic, musculoskeletal, and medical differences between patients who presented for musculoskeletal care to one of three care settings between 2018 and 2021.

Furthermore, compared to patients who presented for standard non-operative treatment, after adjusting for age, patients in the intensive lifestyle medicine program reported average depression symptoms which barely met the clinical threshold to be meaningfully worse (PROMIS Depression: B = 3.2 points [95% CI −0.4 to 6.8], p=.08) (Table 3). However, this difference did not meet statistical significance, and the un-adjusted between group difference was neither statistically nor clinically different (PROMIS Depression: mean difference=2.8 points, p=.11). There were no other between-group differences in patients’ self-reported physical or psychological health between patients in the intensive lifestyle medicine program and those seeking standard non-operative treatment. On average, though, the intensive lifestyle medicine program patients had pain that was more chronic (34 (69%) versus 39 (40%) with pain > 3 years, OR 3.4 [1.7 to 7.1], p<.001) and had a higher prevalence of hyperlipidemia (20 (40%) versus 19 (19%), OR 2.8 [1.3 to 6.1], p=.006) and sleep apnea (17 (34%) vs 12 (12%), OR 3.8 [1.6 to 8.8], p=.001) (Table 4).

Table 3:

Comparison of between-group mean differences and age-adjusted beta coefficients for self-reported physical and behavioral health in patients who presented for musculoskeletal care to one of three care settings between 2018 and 2021.

Intensive lifestyle
(n=50)		 Standard non-operative care
(n=100)		 Standard operative evaluation
(n=100)
PROMIS Domain Mean Mean MD p B [95% CI] p Mean MD p B [95% CI] p
Physical Function 37.8 40.7 −2.9 .011 −2.6 [−5.2 to .07] .06 35.7 2.1 .06 1.9 [−0.8 to 4.5] .17
Pain Interference 62.0 61.8 0.2 .82 0.1 [−2.4 to 2.5] .96 65.7 −3.7 .002 −3.6 [−6.0 to −1.2] .004
Anxiety 55.4 54.1 1.3 .44 1.4 [−2.2 to 5.1] .45 51.5 3.9 .023 3.8 [0.1 to 7.4] .041
Depression 50.2 47.5 2.8 .11 3.2 [−0.4 to 6.8] .08 50.1 0.1 .94 −0.1 [−3.7 to 3.4] .94
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Between-group differences represent comparison of the “Standard non-operative care” and “Standard operative evaluation” patients to the “Intensive lifestyle” patients.

Boldface indicates p<.05.

Abbreviations: PROMIS (Patient-Reported Outcomes Measurement Information System), MD (mean difference), B (beta coefficient).

Table 4:

Personal and family history of patients who presented for musculoskeletal care to one of three care settings between 2018 and 2021.

Intensive lifestyle
(n=50)		 Standard non-operative care
(n=100)		 Standard operative evaluation
(n=100)		 Missing†
Patient History Mean (SD) or n (%) Mean (SD) or n (%) MD [95% CI] or OR [95% CI] p Mean (SD) or n (%) MD [95% CI] or OR [95% CI] p n
Musculoskeletal
Pain duration <.001 .84 1/2/4
 ≤ 3 years 15 (31%) 59 (60%) 0.3 [0.1 to 0.6] 31 (32%) 0.9 [0.4 to 1.9]
 > 3 years 34 (69%) 39 (40%) 3.4 [1.7 to 7.1] 65 (68%) 1.1 [0.5 to 2.3]
Pain med used 37 (74%) 68 (69%) 1.3 [0.6 to 2.8] .50 82 (82%) 0.6 [0.3 to 1.4] .25 0/1/0
 NSAID 24 (48%) 42 (42%) 1.3 [0.6 to 2.5] .49 62 (62%) 0.6 [0.3 to 1.1] .10 0/0/0
 Opioid 13 (26%) 27 (27%) 1.0 [0.4 to 2.1] .90 34 (34%) 0.7 [0.3 to 1.5] .32 0/0/0
 Neuropathic 20 (40%) 36 (36%) 1.2 [0.6 to 2.4] .63 28 (28%) 1.7 [0.8 to 3.5] .14 0/0/0
 Other 12 (24%) 25 (25%) 1.0 [0.4 to 2.1] .89 28 (28%) 0.8 [0.4 to 1.8] .60 0/0/0
 MEDD (mg) 4.4 (11.7) 4.4 (9.8) 0.0 [−3.6 to 3.7] .98 6.2 (12.8) −1.8 [−6.2 to 2.5] .40 2/1/0
# Orthopedic surgeries .83 .65 0/0/0
 0 19 (38%) 42 (42%) 0.9 [0.4 to 1.7] 33 (33%) 1.2 [0.6 to 2.5]
 1 11 (22%) 23 (23%) 0.9 [0.4 to 2.1] 19 (19%) 1.2 [0.5 to 2.8]
 2+ 20 (40%) 35 35%) 1.2 [0.6 to 2.5] 48 (48%) 0.7 [0.4 to 1.4]
Medical
BMI (kg/m2) 37.6 (9.1) 29.3 (6.9) 8.2 [5.3 to 11.2] <.001 32.0 (7.9) 5.6 [2.7 to 8.4] <.001 0/15/1
Hypertension 22 (44%) 31 (31%) 1.8 [0.9 to 3.5] .12 61 (61%) 0.5 [0.3 to 1.0] .048 0/0/0
Hyperlipidemia 20 (40%) 19 (19%) 2.8 [1.3 to 6.1] .006 36 (36%) 1.2 [0.6 to 2.4] .63 0/0/0
Diabetes 16 (32%) 12 (12%) 3.5 [1.5 to 8.1] .003 16 (16%) 2.5 [1.1 to 5.5] .024 0/0/0
Sleep apnea 17 (34%) 12 (12%) 3.8 [1.6 to 8.8] .001 21 (21%) 1.9 [0.9 to 4.1] .08 0/0/0
Lung disease 7 (14%) 16 (16%) 0.9 [0.3 to 2.2] .75 15 (15%) 0.9 [0.4 to 2.4] .87 0/0/0
Tobacco use
  Current 2 (4%) 11 (11%) 0.3 [0.1 to 1.6] .15 6 (6%) 0.7 [0.1 to 3.3] .60 0/1/1
  Prior 14 (28%) 21 (25%) 1.9 [0.5 to 2.6] .67 36 (39%) 0.6 [0.3 to 1.3] .20 0/15/7
Psychiatric
Anxiety diagnosis 14 (28%) 20 (20%) 1.6 [0.7 to 3.4] .27 25 (25%) 1.2 [0.5 to 2.5] .72 0/0/1
Depression diagnosis 16 (32%) 18 (18%) 2.1 [1.0 to 4.6] .06 29 (29%) 1.2 [0.6 to 2.4] .71 0/1/0
Mood med used 16 (32%) 30 (30%) 1.1 [0.5 to 2.3] .80 38 (38%) 0.8 [0.4 to 1.6] .47 0/0/0
 SSRI 6 (12%) 20 (20%) 0.6 [0.2 to 1.5] .22 19 (19%) 0.6 [0.2 to 1.6] .28 0/0/0
 SNRI 5 (10%) 3 (3%) 3.6 [0.8 to 15.7] .12 5 (5%) 2.1 [0.6 to 7.7] .25 0/0/0
 Benzodiazepine 8 (16%) 13 (13%) 1.3 [0.5 to 3.3] .62 15 (15%) 1.1 [0.4 to 2.8] .87 0/0/0
 Other 3 (6%) 14 (14%) 0.4 [0.1 to 1.4] .15 13 (13%) 0.4 [0.1 to 1.6] .19 0/0/0
Sleep med used 8 (16%) 16 (16%) 1.0 [0.4 to 2.5] >.99 23 (23%) 0.6 [0.3 to 1.6] .32 0/0/0
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Boldface indicates p<.05.

For categorical variables (e.g., pain duration), the odds ratio of a category (e.g., duration ≤ 3 years) is the inverse of the odds ratio for the other category (e.g., duration > 3 years).

†

Missing data are reported as: Intensive lifestyle / Standard non-operative care / Standard operative evaluation.

Abbreviations: MD (mean difference), NSAID (non-steroidal anti-inflammatory), MEDD (morphine equivalent daily dose), BMI (body mass index), SSRI (selective serotonin reuptake inhibitor), SNRI (serotonin-norepinephrine reuptake inhibitor).

Finally, compared to patients who presented to an orthopedic surgeon and were advised to consider a hip or knee arthroplasty as the next step in orthopedic management, patients who enrolled in the intensive lifestyle medicine program were more likely to live in a neighborhood which, on average, was less socially disadvantaged (ADI percentile mean difference −8.8 [−17.7 to 0.0], p=.0496) (Table 2). After adjusting for age, patients in the intensive lifestyle medicine program also reported meaningfully worse average anxiety symptoms but less average pain interference than traditional joint arthroplasty patients (PROMIS Anxiety: B = 3.8 points [0.1 to 7.4], p=.041; PROMIS Pain Interference: B = −3.6 points [−6.0 to −1.2], p=.004) (Table 3). Regarding their medical histories, on average, the intensive lifestyle medicine program patients had a lower prevalence of hypertension than the traditional joint arthroplasty patients (22 (44%) vs 61 (61%), OR 0.5 [0.3 to 1.0], p=.048) (Table 4).

DISCUSSION

Currently, intensive lifestyle medicine programs are most often designed to assist patients in addressing metabolic lifestyle-related diseases such as cardiovascular disease and diabetes. These programs are also a feasible, albeit currently uncommon, care pathway for patients seeking treatment for a musculoskeletal condition.11 In this study, we sought to identify unique characteristics of musculoskeletal patients who chose an intensive lifestyle medicine program to address their chronic musculoskeletal pain, as opposed to continuing with a more traditional care pathway. Overall, patients who chose the intensive lifestyle medicine program were more racially diverse and had a higher prevalence of obesity and diabetes. Compared to patients who chose standard non-operative treatment, on average they had a longer pain duration and had more metabolic comorbidities. In contrast to our hypothesis, patients’ self-reported, age-adjusted physical and psychological health did not meaningfully differ between patients who chose the intensive lifestyle medicine program and those involved in a standard non-operative approach to care. Compared to patients who chose a standard surgical evaluation, patients who chose the intensive lifestyle medicine program reported worse anxiety but had less social disadvantage, less pain interference, and a lower prevalence of hypertension.

The sociodemographic characteristics of patients who chose the lifestyle medicine program are consistent with previous literature. That is, minority racial/ethnic groups have been found to have a higher odds of perceiving benefit in non-traditional medicine (e.g., mindfulness, movement-based therapy, and dietary changes) when compared to non-Hispanic white patients.30 This may in part be related to lifestyle medicine’s emphasis on person-centered physical, mental, and social aspects of health, which is a common paradigm in many non-Caucasian cultures.31 Additionally, discrimination encountered in traditional medical settings has been hypothesized to be a driver of Black patients’ interest in alternative options.32 Nevertheless, because many healthcare services that are designed to educate and support patients in making a lifestyle change are not routinely covered by third party payers (e.g., nutrition counseling, smoking cessation counseling, etc), it is not surprising that patients who chose the intensive lifestyle medicine program resided in less socially disadvantaged neighborhoods than patients who presented for traditional joint arthroplasty evaluation, as indicated by their Area Deprivation Indices. With improved patient access and third-party financial coverage of lifestyle medicine healthcare services via private and government-sponsored insurance programs, we hypothesize this disparity in social disadvantage would diminish.

Regarding the between-group physical and psychological health differences that we identified, our results suggest that: 1.) patients who chose the intensive lifestyle medicine program may represent a “severe” subset of patients who present for standard non-operative musculoskeletal care (i.e., longer average pain duration, already tried some standard non-operative treatment without success), and 2.) when compared to patients presenting for operative evaluation, patients who chose the intensive lifestyle medicine program may be more limited by medical and psychological health comorbidities, rather than by pain intensity in isolation. That is, the intensive lifestyle medicine program patients had a higher prevalence of medical comorbidities than patients presenting for operative evaluation, especially when considering comorbidities which are known to increase perioperative risk and reduce operative candidacy due to reliable, reproducible associated metrics that can be used for preoperative medical clearance (e.g., BMI and HgbA1c).33–35 Essentially, it appears that patients who chose to enroll in an intensive lifestyle medicine program were more likely to have exhausted all other treatment options available to them at the time,36 and this may have prompted patients to explore a different treatment approach if they had the means to do so. One patient who participated in the intensive lifestyle medicine program described to clinicians that patients join the program because they feel “at the end of their rope.”

Despite the sociodemographic and health-related differences that we identified in patients who chose the intensive lifestyle medicine program, there were more between-group similarities than we expected. For instance, contrary to our hypothesis, average anxiety and depression symptoms were not convincingly worse in the intensive lifestyle medicine program patients than in patients who presented for standard non-operative care. Furthermore, although mean PROMIS Depression and Anxiety symptom scores were within half a standard deviation of the general US population for patients in all three treatment groups, all the treatment groups had a higher prevalence of depression (18–32% versus 8%) and at least as high, if not higher, prevalence of anxiety (20–28% versus 18%) when compared to the average US adult population.37 ,38 Chronic pain impairs psychological and social function, and in turn, fear of movement and pain catastrophizing are contributors to ongoing pain.39 As a result, musculoskeletal clinicians are increasingly advocating that addressing psychological health should become a more standard component of routine (operative and non-operative) musculoskeletal care.40 ,41

Overall, although the group-level sociodemographic and health-related profile of the lifestyle medicine program patients was somewhat unique, on an individual level, there was substantial overlap in the characteristics of patients in all three groups. Attribution theory, which is well-accepted in social psychology, states that a person’s behavioral choices are strongly influenced by whether the person believes those choices will cause the desired outcome, and people are empowered to commit effort to a behavior change when they expect their effort to result in success.42 ,43 Furthermore, the biopsychosocial model of pain acknowledges that somatic, cognitive, behavioral, and social factors all interact to influence an individual’s health.44 We now hypothesize that patients who recognize this biopsychosocial interplay, believe that lifestyle change will noticeably improve their musculoskeletal health, and, importantly, have the motivation and means to address the relevant biopsychosocial contributors to pain, are the patients who ultimately choose the lifestyle medicine pathway.45

Strengths and Limitations

The primary strength of this study is that it contributes novel information regarding identification of patients who may be interested in an intensive, lifestyle medicine program as a means for treating musculoskeletal conditions. However, correlation between baseline characteristics of patients who chose the intensive lifestyle medicine program and subsequent long-term success using this care approach cannot be established in this cross-sectional analysis. Specifically, this analysis was not designed to identify predictors of sustained engagement with the lifestyle medicine program, sustained lifestyle change, or measurable improvement in clinical outcomes. We are actively working to address those important follow-up research questions. Furthermore, the generalizability of the study findings are limited by the single-center design of the study, and the study results should be interpreted within the context of: 1.) the sociodemographic and medical characteristics of the included patients, and 2.) a high likelihood of the presence of multiple unknown factors which could have influenced referral patterns and the appropriateness of referrals to the program (e.g., familiarity by referring clinicians and the general community regarding the program’s existence, purpose, and approach). Our study results should be externally validated if and when similar care models become more widely available. The inclusion of many secondary outcomes also requires that the sociodemographic and medical between-group differences identified in this analysis be confirmed in subsequent investigations. Therefore, further study is warranted of the variables reported in this analysis and of other potentially relevant variables such as patients’ activation (i.e., involvement in their own health care) and readiness to change. As a larger sample size becomes available, cluster analysis would also be a helpful tool to understand how the variables interact to create phenotypes of patients with certain combinations of characteristics, rather than analyzing each variable one at a time.

CONCLUSIONS

On average, patients who chose an intensive lifestyle medicine program to treat their musculoskeletal condition(s) were more racially diverse and had a higher prevalence of obesity and diabetes than patients who chose a standard non-operative or operative musculoskeletal care pathway. Their physical and psychological functioning was not different than patients who sought care through a standard non-operative musculoskeletal care approach, and they reported worse symptoms of anxiety but less pain interference than patients who sought operative evaluation from an orthopedic surgeon. Although some unique characteristics were identified for patients who chose an intensive lifestyle medicine program, there was also substantial overlap in the biopsychosocial profiles of these patients when compared to patients who sought standard musculoskeletal care. We propose that, if presented the opportunity, many patients who seek care through standard musculoskeletal care pathways may also be interested in an intensive lifestyle medicine program approach, especially if they have chronic musculoskeletal pain and medical comorbidities. Further investigation is required to explore whether patient activation and readiness for change are quantifiably associated with a patient’s interest in this care model. Additional work is also needed to identify patient characteristics which are predictive of sustained engagement and clinical success through the intensive lifestyle medicine program approach.

Acknowledgments:

The authors thank Jerica Putman for her assistance with data collection.

DISCLOSURES:

This study was supported by grant K23AR074520 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (Cheng); grant support from the Doris Duke Charitable Foundation (Cheng); grant support from the Foundation for Barnes-Jewish Hospital (Hong); Clinical and Translational Science Award grant UL1TR000448; Siteman Comprehensive Cancer Center and NCI Cancer Center Support grant P30CA091842; and the Jacqueline N. Baker Living Well Center Fund (Hunt). None of the funding sources had any role in the study design; collection, analysis, or interpretation of the data; writing of the report; or decision to submit the report for publication. No other funding sources supported this study.

Dr Hong also reports grants from University of Kansas School of Medicine - Health Resources and Services Administration (HRSA) unrelated to the current work; and research consultant, Altschuler Center for Education and Research, MetroCare Dallas Texas / University of Texas Southwestern Medical Center.

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