Mentors: Emily Fox PT, DPT, PhD, NCS, research assistant professor, UF Department of Physical Therapy, and Steven George, PT, PhD, FAPTA, professor, Department of Duke Orthopaedic Surgery
Graduation Date: Spring 2020
Future Plans: Dr. Butera has accepted a position as a Post-Doctoral Fellow in the lab of Dr. Jennifer Stevens-Lapsley at the University of Colorado- Denver.
Dissertation Title: Low Back Pain as a Nervous System Disease: Validation of Sensory, Psychological, and Motor Processing Subgroups
Dissertation Abstract: Low back pain (LBP) is a leading cause of disability, but the collective impact of nervous system factors on function and performance is unclear. The purpose of this study was to 1) empirically derive LBP subgroups using sensory, psychological, and motor variables and 2) validate these subgroups across walking performance, pain, and disability measures. Participants were adults with LBP (N=70). Nervous system variables were assessed via sensory (temporal summation; conditioned pain modulation), psychological (positive coping; negative coping), and motor (trunk extensor muscle activation during forward bending and walking) testing. A hierarchical cluster analysis using these variables determined LBP subgroups. Validation measures included walking (walking speed; TUG; TUG-Cog; obstacle negotiation) and clinical measures (Brief Pain Inventory-pain intensity and interference; low back pressure pain threshold; Oswestry Disability Index; movement-evoked pain during walking). Two subgroups were derived with 5/6 of the a priori selected nervous system variables statistically contributing to membership: 1) a “Maladaptive Subgroup” (n=21) characterized by low positive coping, high negative coping, low pain modulation, and atypical trunk extensor activation during forward bending and walking; 2) an “Adaptive Subgroup” (n=49) characterized by high positive coping, low negative coping, high pain modulation, and typical trunk extensor activation during forward bending and walking. Subgroups demonstrated similar demographics (age, sex, chronicity) and similar fastest-comfortable walking speeds, TUG-Cog completion, and pressure pain thresholds (p>0.05). The Maladaptive Subgroup demonstrated slower self-selected walking speeds (mean difference=0.12 meters/second; Cohen’s d=-0.68), slower TUG completion (mean difference=1.39 secs; Cohen’s d=0.86), slower obstacle approach (mean difference=0.23 meters/sec; Cohen’s d=-0.73), and slower obstacle crossing (mean difference=0.20 meters/sec; Cohen’s d=-0.67) speeds compared to the Adaptive Subgroup (p<0.05). The Maladaptive Subgroup demonstrated higher pain intensity (mean difference=1.34; Cohen’s d=0.69), higher pain interference (mean difference=2.320; Cohen’s d=1.05), greater disability (mean difference=14.58%; Cohen’s d=1.14), and higher movementevoked pain compared to the Adaptive Subgroup (p<0.05). Findings indicate nervous system-driven LBP subgrouping can effectively distinguish individuals with walking impairments and higher pain and disability. Future longitudinal studies are needed to determine the prognostic value of these Subgroups. Eventually concurrent assessment of multiple nervous system factors may guide future LBP interventions to optimize functional and clinical outcomes.
Butera KA, George SZ, Lentz T. Psychometric evaluation of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool: factor structure, reliability, and validity. Journal of Pain. 2019. [In press]
Zeppieri K, Butera KA, Iams D, Parvataneni H, George SZ. The Role of Social Support and Psychological Distress in Predicting Discharge: A Pilot Study for Hip and Knee Arthroplasty Patients. Journal of Arthroplasty. 2019;34(11):2555-2560.
Chatterjee SA, Fox EJ, Wu SS, Daly JJ, Rose DK, Christou EA, Hawkins KA, Otzel DM, Butera KA, Skinner JW, Clark DJ (2019). Interpreting prefrontal recruitment during walking after stroke: influence of individual differences in mobility and cognitive function. Frontiers in Human Neuroscience. 2019;13:194
Butera KA, Roff SR, Buford TW, Cruz-Almeida Y. The impact of multisite pain on functional outcomes in older adults: biospychosocial considerations. Journal of Pain Research. 2019;12:1115-1125.
Chatterjee SA, Daly JJ, Porges EC, Fox EJ, Rose DK, McGuirk TE, Otzel DM, Butera KA, and Clark DJ. Mobility function and recovery after stroke: preliminary insights from sympathetic nervous system activity. Journal of Neurologic Physical Therapy. 2018;42(4):224-232.
Hawkins KA, Fox EJ, Daly JJ, Rose DK, Christou EA, McGuirk TE, Otzel DM, Butera KA, Chatterjee SA, Clark DJ. Prefrontal over-activation during walking in people with mobility deficits: interpretation and functional implications. Human Movement Science. 2018;59:46-55.
Butera KA, George SZ, Borsa PA, Dover GC. Prolonged reduction in shoulder strength after transcutaneous electrical nerve stimulation treatment of exercise‐induced acute muscle pain. Pain Practice. 2018;18(8):954-968.
Fox EJ, Tester NJ, Butera KA, Howland DR, Spiess M, Castro-Chapman P, Behrman AL. Retraining walking adaptability following incomplete spinal cord injury. Spinal Cord Series and Cases. 2017;3(1): 17091.
Butera KA, Fox EJ, George SZ. Point of View: Towards a transformed understanding: from pain and movement to pain with movement. Physical Therapy. 2016;96(10):1503-1507.
Butera KA, Lentz TA, Beneciuk JM, George SZ. Preliminary evaluation of a modified STarT Back Screening Tool across different musculoskeletal pain conditions. Physical Therapy 2016;96(8):1251-1261.
George SZ, Butera KA. Low Back Pain. Chapter 19 in Mechanisms and management of pain for the physical therapist. International Association for the Study of Pain Press. Seattle, WA (USA). Editor: Sluka KA.
Select Honors and Awards
2020 Financial Aid/Travel Award to attend the 2020 IASP World Congress on Pain. Provided by the International Association for the Study of Pain Financial Aid Task Force.
2019-2021 NIH Loan Repayment Program Award; 2-year award, Provided by the National Institutes of Health, National Center for Complementary and Integrative Health.
2018-2019 Frederick Family Scholarship Award; University of Florida, Department of Physical Therapy, Gainesville, FL 2019
2019 Award for Best Graduate Student Poster at the Neuromuscular Plasticity Symposium
2018 Promotion of Doctoral Studies (PODS) II Scholarship; Foundation for Physical Therapy Neurology Section Endowment Fund
2018 P.E.O. Scholar Award; International Chapter of the P.E.O. Sisterhood
2018 NIH T-32 Neuromuscular Plasticity Pre-Doctoral Fellowship; Department of Physical Therapy, University of Florida.
2017 Promotion of Doctoral Studies (PODS) II Scholarship; Foundation for Physical Therapy Neurology Section Endowment Fund.
2016 Promotion of Doctoral Studies (PODS) I Scholarship; Foundation for Physical Therapy Neurology Section Endowment Fund.