Background Musculoskeletal specialists who attempt to discuss the connection between mental health (thoughts and emotions) and physical health (symptom intensity and activity tolerance) with patients, may fear that they risk offending those patients. In a search for language that creates comfort with difficult conversations, some specialists favor a biomedical framework, such as central sensitization, which posits abnormal central neuron activity. Without addressing the relative accuracy of mind- or brain-based conceptualizations, we addressed crafted and practiced communication strategies as conversation starters that allow specialists to operate within a biopsychosocial framework without harming the relationship with the patient. Questions/purposes We measured (1) patient resonance with various explanations of the mind-body connection, including examples of both mind- and brain-based communication strategies, and (2) factors associated with resonance and emotional reactions to the explanations. Methods In this cross-sectional study, all adult new and returning patients who were literate in English and who attended several musculoskeletal specialty offices were invited to complete questionnaires addressing reactions to one of seven explanations of the mind-body connection assigned using a random number generator. Acknowledging that the relative accuracy of mind-based and nerve- or brain-based strategies are speculative, we developed the following conversation starters: two explanations that were cognitively framed (“the mind is a great story teller”; one positively framed and one negatively framed), two emotionally framed explanations (“stressed or down”; one positively framed and one negatively framed), one mentioning thoughts and emotions in more neutral terms (“mind and body work together … thoughts and emotions affect the way your body experiences pain”), and two biomedical neurophysiology-based explanations (“nerves get stuck in an over-excited state” and “overstimulated nerves”), all crafted with the assistance of a communication scholar. It was unusual for people to decline (although the exact number of those who did was not tracked) and 304 of 308 patients who started the questionnaires completed them and were analyzed. In this sample, 51% (155 of 304) were men, and the mean ± SD age was 49 ± 17 years. Reactions were measured as resonance (a 1 to 5 Likert scale regarding the degree to which the stated concept aligns with their understanding of health and by inference is a comfortable topic of discussion) and self-assessment manikins using circled figurines to measure feelings of happiness (frowning to smiling figures), stimulation/excitement (a relaxed sleepy figure to an energized wide-eyed figure), and security/control (small to large figures). These are commonly used to quantify the appeal and emotive content of a given message. Patients also completed surveys of demographics and mental health. Multilevel multivariable linear regression models were constructed to assess factors associated with resonance, happiness, excitement, and control. Results Controlling for potential confounding variables such as demographics and mental health measures, a relatively neutral biopsychosocial explanation (“mind and body work together”) had the greatest mean resonance (4.2 ± 0.8 versus 3.8 ± 0.9 for the other explanations; p < 0.01) and the largest regression coefficient for resonance (0.78 [95% confidence interval 0.41 to 1.15]). The next-most-resonant explanations were biomedical (“excitable nerves”, “over-excited state”). Biopsychosocial explanations that mention stress, distress, or cognitive bias (“mind is a great storyteller”) had lower resonance. People with greater unhealthy cognitive bias regarding pain (more catastrophic thinking) were less comfortable with all the explanations (lower resonance, regression coefficient -0.03 [95% CI -0.06 to -0.01]). Emotional reactions were relatively comparable with the exception that people felt less control and security with specific explanations such as “excitable nerves” and “mind is a great storyteller.” Conclusion Crafted communication strategies allow musculoskeletal specialists to address health within the biopsychosocial paradigm without harming their relationship with the patient. Clinical Relevance Musculoskeletal specialists may be the first clinicians to notice mental health opportunities. It may be helpful for them to develop and practice effective communication strategies that make mental health a comfortable topic of discussion.

Background In general, journals can be divided in three categories: subscription-model, open-access, and hybrid (that is, open-access by choice). One measure of an article's impact is the number of citations it receives after publication. Open-access publishing may make articles more widely available because there is no financial barrier to a reader seeing the full-text version. As a result, we wondered whether articles published in fully open-access journals would be more likely to be cited than articles in other kinds of journals. Questions/purposes We assessed the yearly number and proportion of poorly cited articles published in orthopaedic journals and compared the proportion of poorly cited articles that were published in subscription-model journals with the proportion of poorly cited articles that were published in open-access and hybrid journals. Methods We identified all original articles (n = 135,029) published in orthopaedic peer-reviewed journals (n = 204) that were active from 2002 to 2012 and indexed in the Scopus ® citation database. For each journal, we recorded the type of access (subscription-model, open-access, or hybrid journal), their most-recent CiteScore, the number of well-and poorly cited articles per year (more than five versus five or fewer citations after publication) calculated from the date of publication until December 31, 2017 (data collection April 2018), and then calculated if the journals themselves were poorly cited per year (defined as journals that published 75% or more articles ranked as poorly cited per year). We compared the proportion of poorly cited articles in subscription-model journals with the proportion of poorly cited articles in open-access journals. Additionally, we compared these with hybrid journals. Results In total, 48,133 (36%) articles were classified as poorly cited. The total number and proportion of poorly cited articles increased over the years, from 2121 of 7860 (27%) in 2002 to 6927 of 16,282 (43%) in 2012. The proportion of poorly cited articles in subscription-model journals increased from 226 of 395 (57%) in 2002 to 411 of 578 (71%) in 2012. The proportion of poorly cited articles in open-access journals decreased from 264 of 434 (61%)One of the authors certifies that he (DR), or a member of his immediate family, has received or may receive payments or benefits, during the study period, in an amount of USD 10,000 to USD 100,000 from Skeletal Dynamics (Miami FL, USA); in an amount of less than USD 10,000 from Wright Medical for elbow implants (Memphis TN, USA); and receives a stipend as the deputy editor for Clinical Orthopaedics and Related Research®; has received honoraria for talks from various universities and hospitals; and has received personal fees for expert witness testimony, outside the submitted work. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before c...