Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

An Exploratory Study on the Physical Activity Health Paradox-Musculoskeletal Pain and Cardiovascular Load during Work and Leisure in Construction and Healthcare Workers

Using a novel approach, this exploratory study investigated whether the physical activity (PA) paradox extends to cardiovascular load and musculoskeletal pain. At baseline, 1–2 days of 24 h heart rate was assessed in 72 workers from construction and healthcare. Workers then reported pain intensity in 9 body regions (scale 0–3) every 6 months for two years. The 2 year average of musculoskeletal pain (sum of 9 pain scores; scale 0–27) was regressed on time spent during work and leisure above three thresholds of percentage heart rate reserve (%HRR), i.e., ≥20 %HRR, ≥30 %HRR, and ≥40 %HRR, using a novel ilr structure in compositional data analysis. Analyses were stratified for several important variables. Workers spending more time in physical activity at work had higher pain, while workers with more time in physical activity during leisure had less pain (i.e., the PA paradox), but none of the associations were statistically significant. Higher aerobic capacity and lower body mass index lowered the pain score among those with higher physical activity at work. This exploratory study suggests that the PA paradox may apply to musculoskeletal pain and future studies with larger sample sizes and additional exposure analyses are needed to explain why this occurs.

The Patient-Centered Approach in Rheumatologic Painful Diseases: A Narrative Review

A patient-centric approach to pain control represents a paradigm shift in analgesia and one that is both easy to endorse but challenging to execute. As pain mechanisms become increasingly elucidated, the understanding of pain has changed to encompass its complexities. Multiple types and mechanisms of pain have been described, and pain must be seen through the subjective experience of the patient. Earlier descriptions of pain based on intensity are one-dimensional and do not fully encompass the experience of pain. Thus, treating rheumatology patients or any patient in pain requires an understanding of the primary or secondary nature of the pain, underlying conditions, and patient factors such as anxiety, depression, fearfulness, and catastrophizing, all of which can shape and change the nature of the pain. Further, it is important to manage patient expectations concerning chronic pain as complete pain relief may not be possible, but a Patient Acceptable Symptomatic State (PASS) may serve. Functional goals are often more meaningful to patients than pain scores. Pharmacologic therapy for pain must consider side effects as well as analgesia. Patient-centered pain control requires a focus on wellness and disease prevention, personalized care plans, education, support for self-care, and may involve coordination across disciplines to help the patient meet personally meaningful objectives. While patient-centric care has become a buzzword in modern medicine, it is extremely relevant and may be very beneficial to pain patients.

Relationship between Alcohol Intake and Chronic Pain with Depressive Symptoms: A Cross-Sectional Analysis of the Shika Study

Although alcohol intake is associated with chronic pain (CP) and analgesia, epidemiological studies have not yet examined the factors affecting the relationship between alcohol intake and CP in detail. Therefore, the present cross-sectional study investigated the relationship between alcohol intake and CP in community-dwelling middle-aged and elderly individuals with/without depressive symptoms. Participants comprised 2223 inhabitants of Shika town in Ishikawa prefecture, located on the Noto Peninsula facing the Sea of Japan, and included 1007 males and 1216 females. CP, depressive symptoms, and alcohol intake were assessed using a CP questionnaire, the Geriatric Depression Scale-15 and the brief-type self-administered diet history questionnaire, respectively. In males without depressive symptoms, mean alcohol intake was significantly higher at 5.70% energy (27.92 g/day) in the CP group than that of 3.75% energy (20.00 g/day) in the non-CP group. The prevalence of low back/knee pain was also significantly higher in males with than in those without depressive symptoms. The present results suggest that long-term alcohol intake is related to CP by reducing the pain threshold and enhancing nociceptive pain as a possible mechanism. However, even a low alcohol intake was associated with psychogenic pain in participants with depressive symptoms. Further studies to investigate the involvement of depressive symptoms and alcohol intake in CP and its prevention are needed.

Behavioral Medicine Physiotherapy in the Context of Return to Work for Chronic Pain: A Single-Case Experimental Design Study

Effective interventions are needed for return-to-work (RTW) for individuals with chronic pain on long-term sick leave. In this study, a behavioral medicine physiotherapy protocol was systematically replicated and added to workplace components. The intervention was evaluated for fidelity and effects on target activities and work ability. A single-case experimental design was used with five participants. Daily and weekly ratings of personalized target activities at work as well as work ability were carried out throughout the study period of 26-28 weeks. Effects of the behavioral medicine physiotherapy intervention were evaluated for each individual using visual analysis of displayed graphs and quantitative non-overlap methods. Goal achievement for target activities was reviewed. Three participants completed the intervention. The results indicated an effect from the behavioral medicine physiotherapy intervention on task-specific self-efficacy for target activities, but no consistent effect on experience of target activities or work ability. All three participants had increased function in target activities in line with pre-defined goals. Fidelity to the intervention manual was good. Behavioral medicine physiotherapy can be successfully adapted to work disability and was here replicated in an RTW context for individuals with chronic pain. The intervention protocol should be further evaluated in large-scale studies.

Opioid Consumption in Chronic Pain Patients: Role of Perceived Injustice and Other Psychological and Socioeconomic Factors

BACKGROUND

Chronic pain is a complex biopsychosocial phenomenon. Lifestyle, behavioral, socioeconomic, and psychosocial factors such as depression and perceived injustice are often associated with the development of chronic pain and vice versa. We sought to examine the interaction of these factors with opioid intake.

METHODS

At our institution, 164 patients with chronic pain undergoing an interdisciplinary assessment within a three-month period participated in the study and completed the Injustice Experience Questionnaire (IEQ). Data regarding opioid intake, pain levels, pain diagnosis, depression, anxiety, stress, quality of life, pain-related disability, habitual well-being, occupational status, and ongoing workers compensation litigation were extracted from the patients' charts.

RESULTS

Approximately one-fourth of the patients used opioids. The IEQ total was significantly higher in patients using Schedule III opioids. Depression, but not the anxiety and stress scores, were significantly higher in patients using opioids. There were no significant differences regarding pain-related disability, habitual well-being, and the coded psychosocial diagnoses. In the patient group without opioids, the percentage of employed persons was significantly higher but there were no significant differences regarding work leave, pension application, or professional education.

CONCLUSIONS

Opioid use appears to be more closely related to psychological factors and single social determinants of pain than to somatic factors.

Effect of Blood Flow Restriction on Functional, Physiological and Structural Variables of Muscle in Patients with Chronic Pathologies: A Systematic Review

The main objective of this systematic review of the current literature is to analyze the changes that blood flow restriction (BFR) causes in subjects with neuro-musculoskeletal and/or systemic pathologies focusing on the following variables: strength, physiological changes, structural changes and cardiocirculatory variables. The search was carried out in seven databases, including randomized clinical trials in which therapeutic exercise was combined with the blood flow restriction tool in populations with musculoskeletal pathologies. Outcome variables are strength, structural changes, physiological changes and cardiocirculatory variables. Twenty studies were included in the present study. Although there is a lot of heterogeneity between the interventions and evaluation instruments, we observed how the restriction of blood flow presents significant differences in the vast majority of the variables analyzed. In addition, we observed how BFR can become a supplement that provides benefits when performed with low intensity, similar to those obtained through high-intensity muscular efforts. The application of the BFR technique can provide benefits in the short and medium term to increase strength, muscle thickness and cardiovascular endurance, even improving the physiological level of the cardiovascular system. In addition, BFR combined with low-load exercises also achieves benefits comparable to high-intensity exercises without the application of BFR, benefiting patients who are unable to lift high loads.

Evaluating the effects of maternal positions in childbirth: An overview of Cochrane Systematic Reviews

INTRODUCTION

The purpose of this study is to conduct an overview of Cochrane systematic reviews (SRs) evaluating the effects of maternal positions in childbirth in order to compile existing evidence for relevant research questions that have been addressed by more than one review, to provide a succinct summary of the up-to-date evidence and to identify areas for future research.

METHODS

An electronic search was conducted in the Cochrane database. Two primary outcomes were the duration of labor and birth, and operative birth. The quality of included reviews was assessed using the AMSTAR criteria, and the quality of the evidence was rated using the GRADE criteria.

RESULTS

We included 3 Cochrane SRs. There was a significant mean difference (MD) found in the duration of the first stage by 1 hour and 22 minutes (MD= -1.21; 95% CI: -2.35 - -0.07, I2=94%) and reduction in caesarean section rates (RR=0.71; 95% CI: 0.54-0.94, I2=0%) in the upright birth position group compared with the horizontal. Also, there was a statistically significant difference in the duration (minutes) of the second stage of labor (MD= -6.16; 95% CI: -9.74 - -2.59, I2=91%) and a reduction in assisted vaginal birth rates (RR=0.75, 95% CI: 0.66-0.86, I2=29%) in the upright group compared with the horizontal without epidural analgesia. The quality of evidence within the reviews was very low to moderate.

CONCLUSIONS

There is currently a limited body of evidence to clearly assess the benefits and risks of assuming upright positions during childbirth. The overview highlights the need for high-quality research studies, involving better definition and comprehensive assessment of the effects of squatting during childbirth.

Musculoskeletal pain and sedentary behaviour in occupational and non-occupational settings: a systematic review with meta-analysis

BACKGROUND

Sedentary behaviour (SB; time spent sitting) is associated with musculoskeletal pain (MSP) conditions; however, no prior systematic review has examined these associations according to SB domains. We synthesised evidence on occupational and non-occupational SB and MSP conditions.

METHODS

Guided by a PRISMA protocol, eight databases (MEDLINE, CINAHL, PsycINFO, Web of Science, Scopus, Cochrane Library, SPORTDiscus, and AMED) and three grey literature sources (Google Scholar, WorldChat, and Trove) were searched (January 1, 2000, to March 17, 2021) for original quantitative studies of adults ≥ 18 years. Clinical-condition studies were excluded. Studies' risk of bias was assessed using the QualSyst checklist. For meta-analyses, random effect inverse-variance pooled effect size was estimated; otherwise, best-evidence synthesis was used for narrative review.

RESULTS

Of 178 potentially-eligible studies, 79 were included [24 general population; 55 occupational (incuding15 experimental/intervention)]; 56 studies were of high quality, with scores > 0.75. Data for 26 were meta-synthesised. For cross-sectional studies of non-occupational SB, meta-analysis showed full-day SB to be associated with low back pain [LBP - OR = 1.19(1.03 - 1.38)]. Narrative synthesis found full-day SB associations with knee pain, arthritis, and general MSP, but the evidence was insufficient on associations with neck/shoulder pain, hip pain, and upper extremities pain. Evidence of prospective associations of full-day SB with MSP conditions was insufficient. Also, there was insufficient evidence on both cross-sectional and prospective associations between leisure-time SB and MSP conditions. For occupational SB, cross-sectional studies meta-analysed indicated associations of self-reported workplace sitting with LBP [OR = 1.47(1.12 - 1.92)] and neck/shoulder pain [OR = 1.73(1.46 - 2.03)], but not with extremities pain [OR = 1.17(0.65 - 2.11)]. Best-evidence synthesis identified inconsistent findings on cross-sectional association and a probable negative prospective association of device-measured workplace sitting with LBP-intensity in tradespeople. There was cross-sectional evidence on the association of computer time with neck/shoulder pain, but insufficient evidence for LBP and general MSP. Experimental/intervention evidence indicated reduced LBP, neck/shoulder pain, and general MSP with reducing workplace sitting.

CONCLUSIONS

We found cross-sectional associations of occupational and non-occupational SB with MSP conditions, with occupational SB associations being occupation dependent, however, reverse causality bias cannot be ruled out. While prospective evidence was inconclusive, reducing workplace sitting was associated with reduced MSP conditions. Future studies should emphasise prospective analyses and examining potential interactions with chronic diseases.

PROTOCOL REGISTRATION

PROSPERO ID # CRD42020166412 (Amended to limit the scope).

Yoga-Based Cardiac Rehabilitation: Current Perspectives from Randomized Controlled Trials in Coronary Artery Disease

Coronary artery disease carries a high morbidity and mortality worldwide, and exercise-based cardiac rehabilitation programmes play a large role in secondary prevention. Exercise-based rehabilitation programmes are expensive, and in certain subgroups uptake is poor. Yoga has been suggested to show improvements in cardiovascular health which would support its use in cardiac rehabilitation programmes. We carried out a review of current randomized controlled trials to determine if yoga-based cardiac rehabilitation leads to reduced cardiac risk factors, and improved physiological and psychological outcomes in patients with coronary artery disease compared to standard care. Six randomized controlled studies were identified after a medical database search, and meta-analysis was carried out for the different outcomes. Overall, the addition of yoga to standard care resulted in improved subjective feeling of cardiac health and quality of life. There was also a trend towards improvement in left ventricular systolic function. Improvement in cardiac risk factors, MACE and psychological health in this cohort has still to be proven, but was not inferior to standard or enhanced care, and the benefits became more pronounced at longer follow-up. Future studies with longer follow-up and larger patient numbers would aid in accurately assessing the long-term benefit of yoga-based rehabilitation.

MusicCohort: Pilot feasibility of a protocol to assess students' physical and mental health in a Canadian post-secondary school of music

Objective

Music-related physical and mental health conditions are common among post-secondary music students, with many studies reporting a prevalence greater than 70%. However, there is currently no consensus on appropriate, validated assessments for this population. The aim of this pilot study was to test the feasibility of an assessment protocol developed for a German longitudinal study with Canadian post-secondary music students, and to compare the health of music students to non-music students. Using a cross-sectional design, first-semester music and non-music control students were recruited at two campuses at the same university. Both groups completed questionnaires and physical testing, including range of motion, core strength, and pressure pain threshold. Nineteen music students and 50 non-music student controls participated in this study.

Results

The German protocol is feasible in a Canadian post-secondary setting. Canadian music students demonstrated similar health outcomes to those in the parent study. All participants demonstrated poorer mental and physical quality of life than the Canadian norms, though this was not statistically significant. The results of this study should be confirmed in a larger study. Future studies with larger sample sizes can provide further insight into the health of Canadian music students, providing a basis for prevention and intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05829-9.

Conolidine: A Novel Plant Extract for Chronic Pain

Pain, the most common symptom reported among patients in the primary care setting, is complex to manage. Opioids are among the most potent analgesics agents for managing pain. Since the mid-1990s, the number of opioid prescriptions for the management of chronic non-cancer pain (CNCP) has increased by more than 400%, and this increased availability has significantly contributed to opioid diversion, overdose, tolerance, dependence, and addiction. Despite the questionable effectiveness of opioids in managing CNCP and their high rates of side effects, the absence of available alternative medications and their clinical limitations and slower onset of action has led to an overreliance on opioids. Conolidine is an indole alkaloid derived from the bark of the tropical flowering shrub Tabernaemontana divaricate used in traditional Chinese, Ayurvedic, and Thai medicine. Conolidine could represent the beginning of a new era of chronic pain management. It is now being investigated for its effects on the atypical chemokine receptor (ACK3). In a rat model, it was found that a competitor molecule binding to ACKR3 resulted in inhibition of ACKR3's inhibitory activity, causing an overall increase in opiate receptor activity. Although the identification of conolidine as a potential novel analgesic agent provides an additional avenue to address the opioid crisis and manage CNCP, further studies are necessary to understand its mechanism of action and utility and efficacy in managing CNCP.

Monitoring Pharmacological Treatment in Patients With Chronic Noncancer Pain

Chronic pain has been not recognized as a chronic illness, and its far-reaching impacts are often ignored. Chronic noncancer pain (CNCP) is a chronic disease and health care professionals need recommendations on how to monitor treatments, patients and long-term side effects of the different medications used to control CNCP. CNCP patients make up a vulnerable population due to the various associated pathologies and the challenging socio-economic conditions experienced by many of these patients. CNCP is more common among older adults, females, cancer survivors, indigenous peoples, veterans, and populations affected by social inequities and discrimination. These social determinants can lead to a complex interplay between chronic pain, mental illness, and substance use disorders. Given these realities, long-term pharmacological and side effect surveillance is more complex. Follow-up of patients with CNCP is a challenge for physicians, and thus it is important to provide recommendations on how to monitor treatments and long-term side effects of the different medications used to control CNCP.

Effect of Anti-Inflammatory Diets on Pain in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

Various nutritional therapies have been proposed in rheumatoid arthritis, particularly diets rich in ω-3 fatty acids, which may lead to eicosanoid reduction. Our aim was to investigate the effect of potentially anti-inflammatory diets (Mediterranean, vegetarian, vegan, ketogenic) on pain. The primary outcome was pain on a 10 cm visual analogue scale. Secondary outcomes were C-reactive protein levels, erythrocyte sedimentation rate, health assessment questionnaire, disease activity score 28, tender/swollen joint counts, weight, and body mass index. We searched MEDLINE (OVID), Embase (Elsevier), and CINAHL for studies published from database inception to 12 November 2021. Two authors independently assessed studies for inclusion, extracted study data, and assessed the risk of bias. We performed a meta-analysis with all eligible randomized controlled trials using RevMan 5. We used mean differences or standardized mean differences and the inverse variance method of pooling using a random-effects model. The search retrieved 564 unique publications, of which we included 12 in the systematic review and 7 in the meta-analysis. All studies had a high risk of bias and the evidence was very low. The main conclusion is that anti-inflammatory diets resulted in significantly lower pain than ordinary diets (-9.22 mm; 95% CI -14.15 to -4.29; p = 0.0002; 7 RCTs, 326 participants).

The effects of quality of evidence communication on perception of public health information about COVID-19: Two randomised controlled trials

BACKGROUND

The quality of evidence about the effectiveness of non-pharmaceutical health interventions is often low, but little is known about the effects of communicating indications of evidence quality to the public.

METHODS

In two blinded, randomised, controlled, online experiments, US participants (total n = 2140) were shown one of several versions of an infographic illustrating the effectiveness of eye protection in reducing COVID-19 transmission. Their trust in the information, understanding, feelings of effectiveness of eye protection, and the likelihood of them adopting it were measured.

FINDINGS

Compared to those given no quality cues, participants who were told the quality of the evidence on eye protection was 'low', rated the evidence less trustworthy (p = .001, d = 0.25), and rated it as subjectively less effective (p = .018, d = 0.19). The same effects emerged compared to those who were told the quality of the evidence was 'high', and in one of the two studies, those shown 'low' quality of evidence said they were less likely to use eye protection (p = .005, d = 0.18). Participants who were told the quality of the evidence was 'high' showed no statistically significant differences on these measures compared to those given no information about evidence quality.

CONCLUSIONS

Without quality of evidence cues, participants responded to the evidence about the public health intervention as if it was high quality and this affected their subjective perceptions of its efficacy and trust in the provided information. This raises the ethical dilemma of weighing the importance of transparently stating when the evidence base is actually low quality against evidence that providing such information can decrease trust, perception of intervention efficacy, and likelihood of adopting it.

Association of photobiomodulation therapy and therapeutic exercises in relation to pain intensity and neck disability in individuals with chronic neck pain: a systematic review of randomized trials

Exercise is often pointed out as an effective form of treatment in the clinical management of chronic neck pain (CNP). However, due to its complex range of causal factors and great diversity of signs and symptoms, other resources such as photobiomodulation therapy (PBMT) have been routinely used for the treatment of CNP. The aim of this study was to systematically review the literature on the use of the association of PBMT and therapeutic exercises in relation to pain intensity and neck disability in individuals with CNP. PubMed, Medline (via Ovid), Embase (via Ovid), Cinahl (via Ebsco), and Central (via Cochrane library) databases were searched using the following terms: "laser," "low-level laser," "photobiomodulation," "light emitting diodes," "phototherapy," "exercise," "chronic neck pain." After verification and implementation of eligibility criteria, seven manuscripts were considered eligible for data analysis. These manuscripts had methodological quality between 5 and 8 points on the PEDro scale. Most studies used low infrared laser therapy to perform PBMT, with a wide range of parameters and energy density between 2 and 7 J/cm² and a total treatment time between 2 and 6 weeks. Four studies showed significant benefits in terms of pain intensity at short-term follow-up and one at intermediate-term follow-up. However, only one showed a minimal clinically important change. No studies have shown significant improvement in disability. This review demonstrates that the association of PBMT with therapeutic exercises in general promotes significant benefits only for the intensity of pain. However, it does not seem to promote a minimally effective clinical difference in individuals with CNP.

Effect of Spinal Alignment Changes on Lower Back Pain in Patients Treated with Total Hip Arthroplasty for Hip Osteoarthritis

Background and objectives: The influence of changes in spinal alignment after total hip arthroplasty (THA) on improvement in lower back pain (LBP) remains controversial. To evaluate how changes in spinal malalignment correlate with improvement in preoperative LBP in patients who underwent THA for hip osteoarthritis. Materials and Methods: From November 2015 to January 2017, 104 consecutive patients who underwent unilateral THA were prospectively registered. Whole spine X-rays and patient-reported outcomes (PROs) were obtained preoperatively and 12 months postoperatively. The PROs used were the Numerical Rating Scale (NRS) for back pain, EuroQol 5 Dimension, and Short Form-12. Results: Seventy-four (71%) patients with complete data were eligible for the analysis. The sagittal parameters changed slightly but significantly. Coronal alignment significantly improved. Twenty-six (37%) patients had LBP preoperatively. These patients had smaller lumbar lordosis (LL), larger PT, and larger PI minus LL than the patients without LBP. Fourteen (54%) of the 26 patients with preoperative LBP showed pain improvement, but there were no significant differences in the radiographic parameters. Conclusions: Although preoperative LBP was likely to be resolved after THA, there were no significant correlations between alignment changes and LBP improvement. The cause of LBP in patients with hip osteoarthritis (OA) patients might be multifactorial.

Changes in the International Classification of Functioning, Disability, and Health Components "Activity/Participation" as Predicted Through Patient-Reported Outcomes Along With Comprehensive Back Pain Rehabilitation

OBJECTIVES

The World Health Organization (WHO) recommended the International Classification of Functioning, Disability and Health (ICF) but its use in clinical practice is sparse. This study investigated the limitations and restrictions in the most relevant brief ICF core set categories for chronic low back pain (cLBP) as automatically predicted from routinely measured outcomes using a novel, validated mapping algorithm.

MATERIALS AND METHODS

Of 2718 cLBP patients recruited, data from 1541 (64% females) were available from before and at the end of 6 months comprehensive outpatient rehabilitation. Assessments included the Roland Morris Disability Questionnaire (RMDQ) and Pain Disability Index (PDI) questionnaires, the percentage of patients with predicted limitations and restrictions in important activity and participation ICF categories, bodily functional measurements, pain intensity, and anxiety/depression (EQ-5D).

RESULTS

At baseline, both the RMDQ and the PDI measures were within the third of the lowest disability scores whilst 80% of the patients had limitations with "maintaining a body position" and 30% with "walking" ICF categories. Intervention-associated gains in the maximum isometric lumbar extension and flexion strength and the lumbar range of motion were significant overall, but improvements in patients' ICF limitations/restrictions varied. Anxiety/depression, lumbar range of motion, and extension strength all had a significant impact on the majority of the ICF categories, whereas flexion strength had none.

DISCUSSION

The rate of patients with predicted limitations/restrictions in activity/participation ICF core categories for cLBP partly mirrored disability levels and the impact of the body function scores on these limitations/restrictions in ICF categories was varied. Thus, assessing problems in the ICF activity/participation core categories is of relevance to clinical practice for both treatment goal setting and intervention planning. This may be achieved by computer-generated mapping without additional time burden.

Professional Status of Persistent Spinal Pain Syndrome Patients after Spinal Surgery (PSPS-T2): What Really Matters? A Prospective Study Introducing the Concept of "Adapted Professional Activity" Inferred from Clinical, Psychological and Social Influence

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2) represents a main cause of work disruption. Beyond its societal consequences, occupational inactivity is responsible for a major decrease in physical/mental health in individuals but remains poorly analyzed. We designed a study to prospectively examine Professional Status (PS) evolution and its association with key bio-psychological markers. Data from 151 consecutively included working-age PSPS-T2 patients were analyzed to determine the proportion of professional inactivity and the relationships between PS and Social Gradient of Health (SGH), Numeric Pain Rating Scale (NPRS), EuroQol 5-Dimensional 5-Level (EQ-5D-5L), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Fear-Avoidance Belief Questionnaire work subscale (FABQ-W). Despite optimized medical management, 73.5% of PSPS-T2 patients remained inactive after 1 year of follow-up/p = 0.18. Inactive patients presented a low SGH/p = 0.002, higher NPRS/p = 0.048, lower EQ-5D-5L/p < 0.001, higher ODI/p = 0.018, higher HADS-D/p = 0.019 and higher FABQ-W/p < 0.001. No significant mediation effect of FABQ-W on SGH consequences regarding PS was observed in our structural model/p = 0.057. The link between unemployment and bio-psycho-social pain dimensions appears bidirectional and justifies intense collaboration with social workers. Optimizing therapeutical sequencing towards personalized professional plans implies restoring "Adapted Physical Function" as an initial goal, and tailoring an "Adapted Professional Activity", matching with patient expectations and capabilities, as a final objective.

Physiotherapist-led rehabilitation for patients with chronic musculoskeletal pain: interventions and promising long-term outcomes

BACKGROUND

There is no consensus on best content, set-up, category of involved healthcare professionals or duration of rehabilitation-programs for patients with chronic musculoskeletal pain, and outcomes show varying results. Individual care regimes for sub-groups of patients have been proposed.

AIM

To describe the type of interventions used in a physiotherapist-led, rehabilitation-program for patients with chronic musculoskeletal pain, refractory to preceding treatments. A second aim was to report clinical outcomes at 1-year follow-up after the intervention period.

METHODS

All patients referred to physiotherapist within a specialist pain-unit due to being refractory to preceding treatments, and deemed fit to undergo physiotherapy-based, individualized rehabilitation during 2014-2018 were consecutively included and followed-up 1 year after ending the program. The inclusion was based on structured 'clinical reasoning' using the referral, examination and on patient-relevant outcome measures. The individual interventions, recorded according to a manual used when reading the patients' medical records, were described. Primary outcomes were clinical results of perceived pain, disability and overall health at start, discharge and 1 year after discharge.

RESULTS

In total, 274 patients (mean age 42 years, 71% women) were included, suffering from chronic, severe, musculoskeletal pain (VAS median 7/10, duration median 2.8 years) and moderate disability. The most frequent interventions were education, sensorimotor training, physical activity-advice and interventions for structures/functions (for example manual techniques, stretching) for a median of nine sessions during five months. Despite refractory to preceding treatments, 45% of the patients rated clinically important improvements on pain, 61% on disability and 50% on overall health at discharge and the figures were similar at 1-year follow-up.

CONCLUSIONS

A physiotherapist-led, one-to-one, rehabilitation-program of median nine sessions during five months, combining individualized education, sensorimotor training, physical activity-advice and interventions for structures/functions rendered clinically relevant improvements on pain, disability and overall health in half of the patients at 1-year follow-up. Since the cohort consisted of patients refractory to preceding treatments, we believe that these results warrant further studies to identify the subgroups of patients with chronic musculoskeletal pain that will improve from new, distinctive, resource-effective rehabilitation-programs involving individualized rehabilitation.

The hierarchy of different treatments for myogenous temporomandibular disorders: a systematic review and network meta-analysis of randomized clinical trials

The best treatment modality for the management of painful temporomandibular disorders of muscular origin (M-TMD) with predictable outcomes based on solid evidence is still not well defined. Thus, the aim of this network meta-analysis (NMA) was to identify the best treatment for adult patients with M-TMD. An electronic search was undertaken from the inception of each database to August 2018, to identify randomized clinical trials (RCTs), which are comparing two or more of the following treatment modalities in patients with M-TMD: counseling therapy; occlusal appliances; manual therapy; laser therapy; dry needling; intramuscular injection of local anesthesia (LA) or botulinum toxin-A (BTX-A); muscle relaxants; hypnosis/relaxation therapy; oxidative ozone therapy; and placebo or no treatment. Primary outcome variables were the reduction of pain and mechanical sensitivity. The secondary outcome was the maximal mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Standardized mean difference was used to analyze via frequentist network meta-analysis (NMA), using STATA software. 52 RCTs were included in this NMA. At the most follow up moments, manual therapy, counseling therapy, occlusal splints therapy, and needling using BTX-A or LA as well as dry needling significantly decreased post-treatment pain intensity in M-TMDs, when compared to placebo.  At short term (≤5 months), the four highest-ranked treatments for post-treatment pain reduction were manual therapy (83.5%, low quality evidence), ozone therapy (75.7%, very low quality evidence),counseling  therapy (71.2%, moderate quality), and occlusal appliances  (71.7%,moderate quality evidence). When intermediate term (≥6 months)was considered, BTX-A (85.8%, very low quality evidence) , counseling therapy(80%, low quality evidence), occlusal appliances  (62.8%, low quality evidence) and hypnosis (50.6%, very low quality evidence) were the four highest-ranked treatments.  This NMA reveals that manual therapy can be considered the most effective treatment for M-TMD, followed by counseling treatment, intramuscular injection of LA, and occlusal appliances  . However, considering the limitations of the studies included, and the scarce of strong evidence, the present findings should be interpreted cautiously.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

Chronic Pain and Associated Factors Related to Depression among Older Patients in Hanoi, Vietnam

The interaction of chronic pain and depression among older people has been studied for many years. This study aimed to investigate the frequency of chronic pain and depression among older patients and correlated factors. A cross-sectional study was conducted in 921 older patients at the National Geriatric Hospital from November 2019 to March 2020. We used the Charlson Comorbidity Index (CCI) to assess the comorbid condition, a numerical rating scale (NRS) to examine pain severity, and Geriatric Depression Scale-15 items (GDS-15) to measure depression among participants. A chi-square test and Tobit regression were used to analyze the relationships. A total of 921 older patients participated in the study. The proportion of depression accounted for 55.8%. The mean Charlson score and number of diseases were 1.2 and 4.7, respectively. A positive correlation was found between comorbidity and chronic pain and depression. Moreover, socio-demographic variables such as occupation, education, and income were associated with pain and depressive symptoms. This study highlights the issue of mental health in older people with chronic pain. The results indicate the necessity of frequent depression screening, pain management, and social activity programs for older people to enhance their health.

Comment on Siracusa et al. Fibromyalgia: Pathogenesis, Mechanisms, Diagnosis and Treatment Options Update. Int. J. Mol. Sci. 2021, 22, 3891

We have read the study by Siracusa et al. [...].

Exercise interventions can improve muscle strength, endurance, and electrical activity of lumbar extensors in individuals with non-specific low back pain: a systematic review with meta-analysis

Exercise interventions have been recommended for people with non-specific low back pain. The literature is scarce regarding the effects of exercise on muscle strength, endurance, and electrical activity of lumbar extensor muscles. Electronic searches were carried out from May 2020 until August 2020 in the following databases: PUBMED, CENTRAL, EMBASE, PEDro, SPORTDiscus, Scielo, and LILACS. Only randomized controlled trials with passive and active control groups were included. The methodological quality of the included studies was performed using the Physiotherapy Evidence Database Scale. Eight studies, involving 508 participants, were included in metanalytical procedures. Exercise interventions demonstrated superior effects on muscle activity (Electromyography) when compared with active controls (p < 0.0001). Exercise interventions demonstrated superior effects on muscle endurance (Sorensen Test) when compared with passive (p = 0.0340) and active controls (p = 0.0276). Exercise interventions demonstrated superior effects on muscle strength (Machine) when compared with passive controls (p = 0.0092). Exercise interventions can improve muscle strength, endurance, and electrical activity in people with non-specific low back pain.

The effects of race/ethnicity and physician recommendation for physical activity on physical activity levels and arthritis symptoms among adults with arthritis

BACKGROUND

Among U.S. adults with physician-diagnosed arthritis, we examined the association of 1) participant race/ethnicity with meeting physical activity guidelines and arthritis symptoms, and 2) the association of receipt of a physician exercise recommendation with physical activity levels and arthritis symptoms, and whether race/ethnicity moderates these associations.

METHODS

Retrospective, cross-sectional study of National Health Interview Survey pooled data from 2002, 2006, 2009, and 2014 from 27,887 U.S. adults aged ≥18 years with arthritis. Outcomes were meeting aerobic (yes/no) and strengthening guidelines (yes/no), arthritis-associated activity limitations (yes/no) and arthritis-related pain (0-10; higher score = more pain). Predictors were race/ethnicity (White, African American, Latino, and Asian) and receipt of physician recommendation for exercise (yes/no). Covariates included demographic and health characteristics.

RESULTS

Adjusting for covariates, African Americans were more likely (AOR = 1.27; 95% CI 1.12, 1.43) and Asians were less likely (AOR = 0.75; 95% CI 0.61, 0.92) than Whites to meet muscle strengthening activity guidelines. Compared to Whites, African Americans (B = 0.48; 95% CI 0.24, 0.72) and Latinos (B = 0.44; 95% CI 0.15, 0.72) reported more severe, while Asians reported less severe (B = -0.68; 95% CI -1.22, - 0.14) joint pain. Controlling for covariates, physician exercise recommendation was associated with meeting aerobic (AOR = 1.20; 95% CI 1.11, 1.30) and strengthening (AOR = 1.21; 95% CI 1.11, 1.33) guidelines, regardless of race/ethnicity except for a weak negative association with meeting strengthening guidelines (AOR = 0.85; CI 0.74-0.99) among Latinos.

CONCLUSIONS

Disparities in pain exist for African Americans and Latinos with arthritis. Physician exercise recommendation is critical among patients with arthritis to relieve symptom burden.

Move to health-a holistic approach to the management of chronic low back pain: an intervention and implementation protocol developed for a pragmatic clinical trial

BACKGROUND

The prevalence of chronic pain conditions is growing. Low back pain was the primary cause of disability worldwide out of 156 conditions assessed between 1990 and 2016, according to the Global Burden of Disease Study. Conventional medical approaches have failed to identify effective and long-lasting approaches for the management of chronic pain, and often fail to consider the multiple domains that influence overall health and can contribute to the pain experience. Leading international organizations that focus on pain research have stated the importance of considering these other domains within holistic and multidisciplinary frameworks for treating pain. While the research behind the theoretical link between these domains and chronic pain outcomes has expanded greatly over the last decade, there have been few practical and feasible methods to implement this type of care in normal clinical practice.

METHODS

The purpose of this manuscript is to describe an implementation protocol that is being used to deliver a complex holistic health intervention at multiple sites within a large government health system, as part of a larger multisite trial for patients with chronic low back pain. The Move to Health program developed by the US Army Medical Command was tailored for specific application to patients with low back pain and begins by providing an empirical link between eight different health domains (that include physical, emotional, social, and psychological constructs) and chronic low back pain. Through a six-step process, a health coach leverages motivational interviewing and information from a personal health inventory to guide the patient through a series of conversations about behavioral lifestyle choices. The patient chooses which domains they want to prioritize, and the health coach helps implement the plan with the use of SMART (Specific, Measurable, Attainable, Realistic, Time-bound) goals and a series of resources for every domain, triaged from self-management to specialist referral.

DISCUSSION

Complex interventions described in clinical trials are often challenging to implement because they lack sufficient details. Implementation protocols can improve the ability to properly deliver trial interventions into regular clinical practice with increased fidelity.

TRIAL REGISTRATION

Implementation of this intervention protocol was developed for a clinical trial that was registered a priori (clinicaltrials.gov #NCT04172038).

The Effect of Compression Socks on Maximal Exercise Performance and Recovery in Insufficiently Active Adults

In athletic populations, compression socks (CS) may improve exercise performance recovery. However, their potential to improve performance and/or recovery following exercise in non-athletic populations is unknown. Our study evaluated the effects of CS on exercise performance and recovery from a graded maximal treadmill test. Insufficiently active adults (n = 10, 60% female, average physical activity ~60 minutes/week) performed two graded maximal exercise tests; one while wearing below-knee CS, and the other trial with regular socks (CON). Order of trials was randomized. For both trials, heart rate, lactate, and rating of perceived exertion were measured at each stage and at one, five, and ten-minutes post-exercise. Additionally, recovery variables (soreness, tightness, annoyingness, tenderness, pulling) were measured at 24 and 48 hours post-exercise using a visual analog scale. Paired-samples t-tests were used to compare exercise and recovery variables between CS and CON trials. Heart rate, lactate, and rating of perceived exertion were not different between trials for any stage during the exercise test or immediate recovery. Most 24-and 48-hour recovery variables were significantly improved after the CS trial, with values 34.6 - 42.3% lower at 24 hours and 40.3 - 61.4% lower at 48 hours compared to CON. Compression socks provided a significant and meaningful improvement in recovery variables 24-48 hours following maximal exercise. Therefore, CS may remove a common barrier to exercise adherence and facilitate more effective training recovery for insufficiently active adults.

Associates of Insomnia in People with Chronic Spinal Pain: A Systematic Review and Meta-Analysis

Insomnia is a major problem in the chronic spinal pain (CSP) population and has a negative impact on health and well-being. While insomnia is commonly reported, underlying mechanisms explaining the relation between sleep and pain are still not fully understood. Additionally, no reviews regarding the prevention of insomnia and/or associated factors in people with CSP are currently available. To gain a better understanding of the occurrence of insomnia and associated factors in this population, we conducted a systematic review of the literature exploring associates for insomnia in people with CSP in PubMed, Web of Science and Embase. Three independent reviewers extracted the data and performed the quality assessment. A meta-analysis was conducted for every potential associate presented in at least two studies. A total of 13 studies were found eligible, which together identified 25 different potential associates of insomnia in 24,817 people with CSP. Twelve studies had a cross-sectional design. Moderate-quality evidence showed a significantly higher rate for insomnia when one of the following factors was present: high pain intensity, anxiety and depression. Low-quality evidence showed increased odds for insomnia when one of the following factors was present: female sex, performing no professional activities and physical/musculoskeletal comorbidities. Higher healthcare use was also significantly related to the presence of insomnia. One study showed a strong association between high levels of pain catastrophizing and insomnia in people with chronic neck pain. Last, reduced odds for insomnia were found in physically active people with chronic low back pain compared to inactive people with chronic low back pain. This review provides an overview of the available literature regarding potential associates of insomnia in people with CSP. Several significant associates of insomnia were identified. These findings can be helpful to gain a better understanding of the characteristics and potential origin of insomnia in people witch CSP, to identify people with CSP who are (less) likely to have insomnia and to determine directions of future research in this area.

Expert consensus on the important chronic non-specific neck pain motor control and segmental exercise and dosage variables: An international e-Delphi study

BACKGROUND

Chronic non-specific neck pain is highly prevalent, resulting in significant disability. Despite exercise being a mainstay treatment, guidance on optimal exercise and dosage variables is lacking. Combining submaximal effort deep cervical muscles exercise (motor control) and superficial cervical muscles exercise (segmental) reduces chronic non-specific neck pain, but evaluation of optimal exercise and dosage variables is prevented by clinical heterogeneity.

OBJECTIVE

To gain consensus on important motor control and segmental exercise and dosage variables for chronic non-specific neck pain.

METHODS

An international 3-round e-Delphi study, was conducted with experts in neck pain management (academic and clinical). In round 1, exercise and dosage variables were obtained from expert opinion and clinical trial data, then analysed thematically (two independent researchers) to develop themes and statements. In rounds 2 and 3, participants rated their agreement with statements (1-5 Likert scale). Statement consensus was evaluated using progressively increased a priori criteria using descriptive statistics.

RESULTS

Thirty-seven experts participated (10 countries). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 generated 79 statements outlining the interacting components of exercise prescription. Following rounds 2 and 3, consensus was achieved for 46 important components of exercise and dosage prescription across 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables). Excellent agreement and qualitative data supports exercise prescription complexity and the need for individualised, acceptable, and feasible exercise. Only 37% of important exercise components were generated from clinical trial data. Agreement was highest (88%-96%) for 3 dosage variables: intensity of effort, frequency, and repetitions.

CONCLUSION

Multiple exercise and dosage variables are important, resulting in complex and individualised exercise prescription not found in clinical trials. Future research should use these important variables to prescribe an evidence-informed approach to exercise.

Relationship between pain, fatigue, and physical activity levels during a technology-based physical activity intervention

Objective: The majority of individuals with spinal cord injury (SCI) experience chronic pain. Chronic pain can be difficult to manage because of variability in the underlying pain mechanisms. More insight regarding the relationship between pain and physical activity (PA) is necessary to understand pain responses during PA. The objective of this study is to explore possible relationships between PA levels and secondary conditions including pain and fatigue.Design: Prospective cohort analysis of a pilot study.Setting: Community.Participants: Twenty individuals with SCI took part in the study, and sixteen completed the study.Interventions: Mobile-health (mHealth) based PA intervention for two-months during the three-month study.Outcome measures: Chronic Pain Grade Scale (CPGS) questionnaire, The Wheelchair User's Shoulder Pain Index (WUSPI), Fatigue Severity Scale (FSS), and PA levels measured by the mHealth system.Results: A positive linear relationship was found between light-intensity PA and task-specific pain. However, the relationship between moderate-intensity PA and pain interference was best represented by a curvilinear relationship (polynomial regression of second order). Light-intensity PA showed positive, linear correlation with fatigue at baseline. Moderate-intensity PA was not associated with fatigue during any phase of the study.Conclusion: Our results indicated that PA was associated with chronic pain, and the relationship differed based on intensity and amount of PA performed. Further research is necessary to refine PA recommendations for individuals with SCI who experience chronic pain.Trial registration: ClinicalTrials.gov identifier: NCT03773692.

Risk Indicators for Early Childhood Caries in South Africa: Protocol for a Systematic Review

Background

Early childhood caries (ECC) is a common disorder characterized by the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces of primary teeth in children 71 months old or younger. South Africa has a diverse population in terms of culture, education, income, and occupation. This diversity is due to the consequences of historical racial discrimination, poverty, unemployment, lack of accessibility to health services, and quality of education. These factors make South Africa unique, and the disease and risk profiles for this country differ from those of other countries at similar stages of development. For these reasons, it is important to identify the unique maternal and infant risk factors for ECC in the South African context.

Objective

The purpose of this study is to determine the risk factors associated with the incidence and prevalence of ECC in South Africa in children under the age of 6 years.

Methods

All cross-sectional and cohort studies documenting risk factors associated with the prevalence and incidence of dental disease and severity (decayed, missing, and filled scores) will be included. We will search 7 databases for eligible studies, and those included will be based on prespecified inclusion criteria. Only studies conducted with South African children who are aged 6 years and younger in which dental caries risk factors are documented will be included. There is no restriction on the time or language of publication. Included articles will be scrutinized for quality by using a risk of bias tool developed by the Joanna Briggs Institute. The results will be presented narratively, and if possible, a meta-analysis will be performed.

Results

The literature search was conducted in November 2020.

Conclusions

The results of this study will provide a framework to inform medical and dental personnel to highlight mothers and infants at risk of developing ECC.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020216455; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=216455

International Registered Report Identifier (IRRID)

DERR1-10.2196/26701

The quality of intervention reporting in trials of therapeutic exercise for hip osteoarthritis: a secondary analysis of a systematic review

BACKGROUND

Therapeutic exercise is recommended as a core treatment for hip osteoarthritis (HOA). Whilst it is widely accepted that exercise can improve pain and disability, optimal type and dose of exercise are yet to be agreed upon. This may, in part, be attributed to the wide variation and inadequate reporting of interventions within the literature. This study evaluates the quality of intervention reporting among trials of therapeutic exercise in HOA.

METHODS

Randomised controlled trials (RCTs) were sourced in a systematic review, completed in August 2020. Two raters independently used the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT) to evaluate intervention reporting. Correlations between quality assessment scores and CERT and TIDieR scores evaluated the relationship between internal validity and external applicability. The year of publication was compared to the quality of reporting scores.

RESULTS

Fourteen RCTs were included in the analysis. On average, studies were awarded 9.43 ± 1.95 out of 12 points for the TIDieR checklist (range 4-12) and 13.57 ± 4.01 out of 19 points for the CERT (range 5-19). Pearson's correlation coefficient suggested that the quality of reporting had improved over time and that there was a fair, positive relationship between internal validity and external applicability.

DISCUSSION

Whilst the quality of intervention reporting is improving, many RCTs of therapeutic exercise in HOA lack the detail necessary to allow accurate evaluation and replication. Researchers are encouraged to utilise the standardised reporting guidelines to increase the translation of effective interventions into clinical practice.

Effects of behavioural exercise therapy on the effectiveness of multidisciplinary rehabilitation for chronic non-specific low back pain: a randomised controlled trial

BACKGROUND

The long-term effects of behavioural medical rehabilitation (BMR), as a type of multidisciplinary rehabilitation, in the treatment of chronic non-specific low back pain (CLBP) have been shown. However, the specific effects of behavioural exercise therapy (BET) compared to standard exercise therapy (SET) within BMR are not well understood. The aim of the study was to assess the effectiveness of BMR + BET compared to BMR + SET in individuals with CLBP in a two-armed, pre-registered, multicentre, parallel, randomised controlled trial (RCT).

METHODS

A total of 351 adults with CLBP in two rehabilitation centres were online randomised based on an 'urn randomisation' algorithm to either BMR + SET (n = 175) or BMR + BET (n = 176). Participants in both study groups were non-blinded and received BMR, consisting of an multidisciplinary admission, a psychosocial assessment, multidisciplinary case management, psychological treatment, health education and social counselling. The intervention group (BMR + BET) received a manualised, biopsychosocial BET within BMR. The aim of BET was to develop self-management strategies in coping with CLBP. The control group (BMR + SET) received biomedical SET within BMR with the aim to improve mainly physical fitness. Therapists in both study groups were not blinded. The BMR lasted on average 27 days, and both exercise programmes had a mean duration of 26 h. The primary outcome was functional ability at 12 months. Secondary outcomes were e.g. pain, avoidance-endurance, pain management and physical activity. The analysis was by intention-to-treat, blinded to the study group, and used a linear mixed model.

RESULTS

There were no between-group differences observed in function at the end of the BMR (mean difference, 0.08; 95% CI - 2.82 to 2.99; p = 0.955), at 6 months (mean difference, - 1.80; 95% CI; - 5.57 to 1.97; p = 0.349) and at 12 months (mean difference, - 1.33; 95% CI - 5.57 to 2.92; p = 0.540). Both study groups improved in the primary outcome and most secondary outcomes at 12 months with small to medium effect sizes.

CONCLUSION

BMR + BET was not more effective in improving function and other secondary outcomes in individuals with CLBP compared to BMR + SET.

TRIAL REGISTRATION

Current controlled trials NCT01666639 , 16/08/2012.

Adherence and characteristics of participants enrolled in a standardised programme of patient education and exercises for low back pain, GLA:D® Back - a prospective observational study

BACKGROUND

Low back pain is often long-lasting, and implementation of low-cost interventions to improve care and minimise its burden is needed. GLA:D® Back is an evidence-based programme consisting of patient education and supervised exercises for people with low back pain, which was implemented nationwide in primary care clinics in Denmark. To assess how the intervention was received and factors influencing adherence to the program, we aimed to evaluate participants' adherence to the intervention and identified characteristics related to the completion of GLA:D® Back. Specifically, we investigated: 1) level of attendance of participants enrolled in the programme, and 2) participant-related factors associated with low attendance.

METHODS

Primary care clinicians delivered GLA:D® Back, a standardised 10-week programme of 2 educational and 16 supervised exercise sessions, to patients with low back pain. Attendance was defined as low, medium or high based on self-reported number of attended sessions. Additional participant-reported data included demographic characteristics, pain, prognostic risk profiles, self-efficacy, illness-beliefs, function and clinician-reported physical performance tests. Results for high, medium, low, and unknown attendance were reported descriptively. Odds ratios for low attendance compared to medium/high attendance were calculated by including all baseline factors in a mixed-model logistic regression model.

RESULTS

Of 1730 participants, 52% had high, 23% medium, and 25% low levels of attendance. Level of attendance was not strongly associated with participants' individual factors, but in combination, prediction of low attendance was fair (AUC 0.77; 95% CI 0.74-0.79). The strongest indicator of low attendance was not completing the baseline questionnaire.

CONCLUSIONS

Most participants of a 10-week low back pain programme attended almost all session. Non-response to the baseline questionnaire was strongly associated with low attendance, whereas individual patient characteristics were weakly related to attendance. Not completing baseline questionnaires might be an early indicator of poor adherence in programs for people with persistent low back pain.

TRIAL REGISTRATION

The Health Research Ethics for Southern Denmark decided there was no need for ethical approval (S-20172000-93). The Danish data collection has obtained authorisation from the Danish Data Protection Agency as part of the University of Southern Denmark's institutional authorisation (DPA no. 2015-57-0008 SDU no. 17/30591). The trial was registred at ClinicalTrials.gov NCT03570463 .

The characteristics and its contributing factors of refractory rheumatoid arthritis, view of the rheumatologists of China: results of a nationwide cross-sectional survey

OBJECTIVE

To explore the characteristics of refractory RA and its contributory factors based on the understanding of the rheumatologists of China.

METHODS

A national cross-sectional survey was performed in 32 provinces across China, and 1381 rheumatologists were recruited. Information about the sociodemographic background, refractory RA characteristics, and contributory factors was collected using a pre-made questionnaire including fourteen single-choice and four multiple-choice questions, respectively. Each of the single-choice and multiple-choice question had several items.

RESULTS

In response to the single-choice questions regarding the definition of refractory RA, 52.28% responded that "the 28 joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR) > 5.1 with presence of signs suggestive of inflammatory disease" is characteristic of refractory RA, whereas 50.18% opined that "If target was not achieved with 2 conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) combined with 1 biological or 1 targeted synthetic DMARD (b/tsDMARD), over a total of 3~6 months" should be considered refractory RA. In addition, 39.32% rheumatologists were in favor of inability to taper glucocorticoids (GCs) ≤ 10mg prednisone or equivalent daily. Additional features considered characteristics of refractory RA were extra-articular manifestations (84.94%), interfering comorbidities (76.32%), and radiographic progression (71.83%). Among the contributory factors, 92.03% considered infection, and interstitial lung disease was chosen by 90.95%, vasculitis by 82.26%, osteoporosis by 70.67%, and fibromyalgia syndrome by 70.38%.

CONCLUSIONS

Our survey has demonstrated a variety of concepts of refractory RA among the rheumatologists of China. Disease activity assessment, treatment options, interfering comorbidities, and radiological progression all were associated with the characteristics of refractory RA. Key Points • This study demonstrated the definition, characteristics, and contributing factors of refractory RA from the rheumatologists' views in China. • The clarification of the insights and concepts on refractory RA will help to make comprehensive guidelines to treat this disease, further improving prognosis and reducing the societal burdens of RA.

Compared to Individuals with Mild to Moderate Obstructive Sleep Apnea (OSA), Individuals with Severe OSA Had Higher BMI and Respiratory-Disturbance Scores

Objective: Individuals with obstructive sleep apnea (OSA) are at increased risk to suffer from further somatic and sleep-related complaints. To assess OSA, demographic, anthropometric, and subjective/objective sleep parameters are taken into consideration, but often separately. Here, we entered demographic, anthropometric, subjective, and objective sleep- and breathing-related dimensions in one model. Methods: We reviewed the demographic, anthropometric, subjective and objective sleep- and breathing-related data, and polysomnographic records of 251 individuals with diagnosed OSA. OSA was considered as a continuous and as categorical variable (mild, moderate, and severe OSA). A series of correlational computations, X²-tests, F-tests, and a multiple regression model were performed to investigate which demographic, anthropometric, and subjective and objective sleep dimensions were associated with and predicted dimensions of OSA. Results: Higher apnea/hypopnea index (AHI) scores were associated with higher BMI, higher daytime sleepiness, a higher respiratory disturbance index, and higher snoring. Compared to individuals with mild to moderate OSA, individuals with severe OSA had a higher BMI, a higher respiratory disturbance index (RDI) and a higher snoring index, while subjective sleep quality and daytime sleepiness did not differ. Results from the multiple regression analysis showed that an objectively shorter sleep duration, more N2 sleep, and a higher RDI predicted AHI scores. Conclusion: The pattern of results suggests that blending demographic, anthropometric, and subjective/objective sleep- and breathing-related data enabled more effective discrimination of individuals at higher risk for OSA. The results are of practical and clinical importance: demographic, anthropometric, and breathing-related issues derived from self-rating scales provide a quick and reliable identification of individuals at risk of OSA; objective assessments provide further certainty and reliability.

Tenderness of the Skin after Chemical Stimulation of Underlying Temporal and Thoracolumbar Fasciae Reveals Somatosensory Crosstalk between Superficial and Deep Tissues

Musculoskeletal pain is often associated with pain referred to adjacent areas or skin. So far, no study has analyzed the somatosensory changes of the skin after the stimulation of different underlying fasciae. The current study aimed to investigate heterotopic somatosensory crosstalk between deep tissue (muscle or fascia) and superficial tissue (skin) using two established models of deep tissue pain (namely focal high frequency electrical stimulation (HFS) (100 pulses of constant current electrical stimulation at 10× detection threshold) or the injection of hypertonic saline in stimulus locations as verified using ultrasound). In a methodological pilot experiment in the TLF, different injection volumes of hypertonic saline (50–800 µL) revealed that small injection volumes were most suitable, as they elicited sufficient pain but avoided the complication of the numbing pinprick sensitivity encountered after the injection of a very large volume (800 µL), particularly following muscle injections. The testing of fascia at different body sites revealed that 100 µL of hypertonic saline in the temporal fascia and TLF elicited significant pinprick hyperalgesia in the overlying skin (–26.2% and –23.5% adjusted threshold reduction, p < 0.001 and p < 0.05, respectively), but not the trapezius fascia or iliotibial band. Notably, both estimates of hyperalgesia were significantly correlated (r = 0.61, p < 0.005). Comprehensive somatosensory testing (DFNS standard) revealed that no test parameter was changed significantly following electrical HFS. The experiments demonstrated that fascia stimulation at a sufficient stimulus intensity elicited significant across-tissue facilitation to pinprick stimulation (referred hyperalgesia), a hallmark sign of nociceptive central sensitization.

Persistent Somatic Symptom Burden and Sleep Disturbance in Patients with COVID-19 During Hospitalization and After Discharge: A Prospective Cohort Study

BACKGROUND The present study was designed to reveal the trajectory of self-reported somatic symptom burden and sleep quality over time in patients with COVID-19 and to identify prognostic factors for greater somatic symptom burden and sleep disturbance. MATERIAL AND METHODS Seventy-four patients with COVID-19 were prospectively followed for longitudinal assessment of somatic symptom burden and sleep quality. We used the 8-item Somatic Symptom Scale (SSS-8) and the modified Medical Research Council (mMRC) scale for somatic symptom burden and the Pittsburgh Sleep Quality Index for sleep quality investigation. Univariate and multivariate analyses were performed to identify independent factors associated with somatic symptom burden and sleep quality. RESULTS Although the degree of physical discomfort and sleep quality issues tended to decline during self-quarantine, patients still experienced these problems to a certain degree. Univariate and multivariate analyses showed that SSS-8 scores at admission (relative risk [RR] 1.234, 95% CI 1.075-1.417, P=0.003) and mMRC scores at discharge (RR 2.420, 95% CI 1.251-4.682, P=0.009) were 2 independent prognostic indicators of somatic symptom burden. In addition, muscle pain as a chief complaint (RR 4.682, 95% CI 1.247-17.580, P<0.022) and history of use of hypnotic drugs (RR 0.148, 95% CI 0.029-0.749, P<0.019) were 2 independent indicators of patient sleep quality during hospitalization. CONCLUSIONS To the best of our knowledge, the present study was the first dynamic assessment of the somatic symptom burden and sleep quality in patients with COVID-19 during hospitalization and quarantine after discharge. Patients with high somatic symptom burden at admission, especially muscle pain as the chief complaint, are prone to having a higher physical burden and more sleep disturbance at discharge.

Association between Participation Activities, Pain Severity, and Psychological Distress in Old Age: A Population-Based Study of Swedish Older Adults

Although chronic pain is common in old age, previous studies on participation activities in old age seldom consider pain aspects and its related consequences. This study analyses associations between participation activities, pain severity, and psychological distress in an aging population of Swedish older adults (N = 6611). We examined older adults' participation in five common leisure activities using the Multidimensional Pain Inventory (MPI), sociodemographic factors, pain severity, weight status, comorbidities, and pain-related psychological distress (anxiety, depression, insomnia severity, and pain catastrophising). We found that gender, body mass index (BMI) levels, and psychological distress factors significantly affected older adults' participation in leisure activities. Pain severity and multimorbidity were not significantly associated with older adults' participation in leisure activities nor with gender stratification in generalised linear regression models. The potentially modifiable factors, such as high levels of BMI and psychological distress, affected activity participation in men and women differently. Health professionals and social workers should consider gender and target potentially modifiable factors such as weight status and psychological distress to increase older adults' participation in leisure activities.

Integrated Meditation and Exercise Therapy: A Randomized Controlled Pilot of a Combined Nonpharmacological Intervention Focused on Reducing Disability and Pain in Patients with Chronic Low Back Pain

OBJECTIVE

This pilot trial examined the effects of a combined intervention of mindfulness meditation followed by aerobic walking exercise compared with a control condition in chronic low back pain patients. We hypothesized that meditation before exercise would reduce disability, pain, and anxiety by increasing mindfulness prior to physical activity compared with an audiobook control group.

PARTICIPANTS

Thirty-eight adults completed either meditation and exercise treatment (MedExT) (n=18) or an audiobook control condition (n=20).

SETTING

Duquesne University Exercise Physiology Laboratory.

DESIGN

A pilot, assessor-blinded, randomized controlled trial.

METHODS

Over a 4-week period, participants in the MedExT group performed 12-17 minutes of guided meditation followed by 30 minutes of moderate-intensity walking exercise 5 days per week. Measures of disability, pain, mindfulness, and anxiety were taken at baseline and postintervention. Pain perception measurements were taken daily.

RESULTS

Compared with the control group, we observed larger improvements in disability in the MedExT intervention, although the changes were modest and not statistically significant (mean between-group difference, -1.24; 95% confidence interval [CI], -3.1 to 0.6). For secondary outcome measures, MedExT increased mindfulness (within-group) from pre-intervention to postintervention (P=0.0141). Additionally, mean ratings of low back pain intensity and unpleasantness significantly improved with time for the MedExT group compared with that of the control group, respectively (intensity P=0.0008; unpleasantness P=0.0022).

CONCLUSION

. Overall, 4 weeks of MedExT produced suggestive between-group trends for disability, significant between-group differences for measures of pain, and significant within-group increases in mindfulness.

[Chondroitin sulfate role in the complex rehabilitation of elderly people with chronic pain syndrome]

The article presents the data of the latest domestic and foreign original studies, the results of a number of meta-analyses, conclusions of randomized clinical trials (RCTs), and other scientific studies that prove the effectiveness and necessity of mandatory inclusion in the treatment of chronic pain syndrome of the stage of non-invasive non-pharmacological therapy. One of the promising areas of pharmacotherapy for degenerative-dystrophic joint lesions is the use of chondroprotectors (CP), in particular chondroitin sulfate (CS). According to new Clinical Recommendations of Ministry Health (MH) of the Russian Federation (RF) «Chronic pain in patients of elderly and senile age» (2020), according to which the purpose of CS is recommended for patients older than 60 years with joint pain and contraindications to non-steroidal anti-inflammatory drugs (NSAIDs) or senile asthenia for the purpose of pain relief and the prevention of exacerbations of pain. A high level of reliability and persuasiveness of the recommendations was noted (1A) of CS use. Most of the CS is available in the form of forms for oral use, the bioavailability of which, according to clinical studies, is 13-38% due to the destruction of the CS molecules in the gastrointestinal tract. Intramuscular (i/m) administration of the drug can increase the bioavailability of CS, which can not only increase the effectiveness of therapy, but also lead to a more rapid development of the symptomatic effect. In Russia available parenteral forms of CS (Chondroguard) pharmaceutical quality, efficacy has been proven in randomized clinical trial (RCT) MH RF. To relieve pain in the joints, it is recommended to use parenteral forms of CS (Chondroguard) at a dose of 100-200 mg per day, every other day, the total duration of the course of treatment is 25-30 injections.

Acute Effects of a Brief Physical Exercise Intervention on Somatosensory Perception, Lumbar Strength, and Flexibility in Patients with Nonspecific Chronic Low-Back Pain

BACKGROUND

Evidence-based clinical guidelines consider physical exercise one of the best nonpharmacological interventions for low-back pain (LBP), but it is necessary to clarify the exercise-induced hypoalgesia effect of different modalities of exercise in chronic pain populations.

PURPOSE

This study focused on exploring acute changes in tactile and pressure-pain perception and lumbar strength and flexibility in patients with nonspecific chronic LBP (NSCLBP) after performing one of three 20-minute physical exercise modalities.

METHODS

A total of 81 patients with NSCLBP were pseudorandomly distributed into three groups of 20-minute physical exercise - 1) aerobic (n=21, mean age 42±9.72 years, nine men), 2) stretching (n=21, mean age 40±11.37 years, ten men), and 3) strengthening (n=20, mean age 35.80±11.56 years, ten men) - and 4) a control group (n=19, mean age 38.64±10.24 years, eight men), and completed self-reported questionnaires during the same period. Tactile and pressure-pain thresholds and isometric lumbar muscle endurance and flexibility were assessed before and after this brief exercise-based intervention.

RESULTS

All groups were comparable in terms of sociodemographic and clinical data, cardiovascular capacity, and self-reported data onphysical disability, mood, motivation, psychological response to stimulus properties of physical exercise, and physical activity enjoyment. Our analyses revealed higher tactile sensitivity (p<0.001) and pressure-pain thresholds (p<0.001) at the forefinger than other body locations. We also found lower pain sensitivity (p=0.010) and pressure pain-intensity ratings (p=0.001) and higher lumbar flexibility (p<0.001) after intervention. After calculation of absolute pre-post differences, higher tactile sensitivity was observed at the gluteus medius muscle than the erector spinal muscle only after aerobic intervention (p=0.046).

CONCLUSION

These results add some evidence about different modalities of exercise-induced hypoalgesia in NSCLBP. However, the fact that we also found improvements in the control group limits our conclusions.

Pain and Function in Chronic Musculoskeletal Pain-Treating the Whole Person

Chronic pain is often associated with functional limitations that have a huge impact on patients' lives. However, despite being relatively common, chronic musculoskeletal pain is still viewed by some as a symptom of another disease rather than its own condition, and is therefore poorly addressed. This is compounded by other challenges in the field, including education gaps for both healthcare professionals and patients, a lack of universal and comprehensive assessment tools, poor societal perceptions of chronic pain, and the current stigma around the use of opioids. Here, we review the current chronic musculoskeletal pain management landscape in the United States and offer professional insight into emerging methods that can be used to improve patient outcomes, in particular, the achievement of meaningful functional goals. This perspective incorporates our combined multidisciplinary (psychiatry, psychology, nursing, physical therapy, and general medicine) experience and insights. We believe that chronic pain is a multifactorial experience and treatment requires an integrated, multidisciplinary approach from a range of healthcare providers. For the best patient outcomes, this team should work together to assess and treat the patient as a whole, addressing their pain and also providing education, empowerment, and support to enable patients to set and achieve meaningful functional goals that will provide real improvement in their quality of life. We believe that the healthcare community should elevate the conversation around chronic musculoskeletal pain management beyond that of just pain, to encompass the meaningful benefits that improvement in functional outcomes brings to patients.

Differences in personality, perceived stress and physical activity in women with burning mouth syndrome compared to controls

OBJECTIVES

Burning mouth syndrome (BMS) is a long-lasting pain condition which is commonly associated with anxiety symptoms and experience of adverse, stressful life events have been reported by those diagnosed with the syndrome. Stress-related biomarkers have been related to personality traits in BMS and a personality with high stress susceptibility and perceived stress may be of importance. Although biopsychosocial approaches are suggested to manage long-lasting orofacial pain, to date little is known about physical activity in women with BMS. The aim of this study was to investigate if personality, perceived stress and physical activity distinguish women with BMS from controls.

METHODS

Fifty-six women with BMS and 56 controls matched on age and gender completed Swedish universities Scales of Personality (SSP), Perceived Stress Questionnaire (PSQ) and a general questionnaire with an item on weekly physical activity frequency. In addition, health-related quality of life was explored by additional questionnaires and reported in a companion article (Jedel et al. Scand J Pain. 2020. PubMed PMID: 32853174).

RESULTS

SSP subscales Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Verbal Trait Aggression differed between women with BMS and controls and the personality factor scores for Neuroticism and Aggressiveness were higher. Perceived stress measured by PSQ index was higher for women with BMS compared to controls. Women with BMS reported lower physical activity frequency compared to controls and those reporting physical activity <4 days/week scored higher on PSQ compared to those with weekly physical activity ≥4 days/week.

CONCLUSIONS

Personality distinguished women with BMS from controls in this study. Perceived stress was higher and weekly physical activity was lower in women with BMS compared to controls. Our findings suggest physical activity should be more comprehensively measured in future BMS studies and, by extension, physical activity may be a treatment option for women with BMS. Pain management aiming to restore function and mobility with stress reduction should be considered in clinical decision making for women with BMS who have a personality with stress susceptibility, especially if reporting high perceived stress and insufficient physical activity.

Auricular Point Acupressure Smartphone Application to Manage Chronic Musculoskeletal Pain: A Longitudinal, One-Group, Open Pilot Trial

BACKGROUND

Chronic musculoskeletal pain (CMP) is the most common self-reported chronic pain condition. Current treatment for CMP is limited.

METHODS

This was a two-phase study. In Phase 1, three auricular point acupressure (APA)-naïve participants were recruited to explore their experiences of APA and a smartphone app was developed based on their feedback. In Phase 2, a prospective longitudinal study was used to examine the effectiveness of the smartphone app to self-manage CMP.

RESULTS

Phase 1 resulted in the successful development of the APA smartphone app. In Phase 2, after four weeks of APA, participants reported reduced pain intensity (30%), pain interference (35%), and disability (40%), as well as improved physical function (47%). The mean score for the participants' perception of treatment efficacy was 4.94 (SD = 2.08, scale of 0-7) indicating that approximately 70% of participants rated global improvements with noticeable changes. The majority (88%, n = 22) of the participants were satisfied with the treatment: 32% [8] were very satisfied and 56% [n = 14] were somewhat satisfied. The average frequency of pressing APA seeds per day was 2.93 times (SD = 2.27, range 0-10) and 1.60 minutes per time (SD = 2.64, range 0-10); the participants were able to adhere to the suggested pressing time per day, although they only pressed the ear points about 53% of the suggested time.

CONCLUSION

It is feasible for individuals to learn APA from the smartphone app and successfully self-administer APA to manage their pain. Participants found the app useful and were satisfied with the information provided through the app.

Wrist-Worn Activity Trackers in Laboratory and Free-Living Settings for Patients With Chronic Pain: Criterion Validity Study

BACKGROUND

Physical activity is evidently a crucial part of the rehabilitation process for patients with chronic pain. Modern wrist-worn activity tracking devices seemingly have a great potential to provide objective feedback and assist in the adoption of healthy physical activity behavior by supplying data of energy expenditure expressed as metabolic equivalent of task units (MET). However, no studies of any wrist-worn activity tracking devices' have examined criterion validity in estimating energy expenditure, heart rate, or step count in patients with chronic pain.

OBJECTIVE

The aim was to determine the criterion validity of wrist-worn activity tracking devices for estimations of energy expenditure, heart rate, and step count in a controlled laboratory setting and free-living settings for patients with chronic pain.

METHODS

In this combined laboratory and field validation study, energy expenditure, heart rate, and step count were simultaneously estimated by a wrist-worn activity tracker (Fitbit Versa), indirect calorimetry (Jaeger Oxycon Pro), and a research-grade hip-worn accelerometer (ActiGraph GT3X) during treadmill walking at 3 speeds (3.0 km/h, 4.5 km/h, and 6.0 km/h) in the laboratory setting. Energy expenditure and step count were also estimated by the wrist-worn activity tracker in free-living settings for 72 hours. The criterion validity of each measure was determined using intraclass and Spearman correlation, Bland-Altman plots, and mean absolute percentage error. An analysis of variance was used to determine whether there were any significant systematic differences between estimations.

RESULTS

A total of 42 patients (age: 25-66 years; male: 10/42, 24%; female: 32/42, 76%), living with chronic pain (duration, in years: mean 9, SD 6.72) were included. At baseline, their mean pain intensity was 3.5 (SD 1.1) out of 6 (Multidimensional Pain Inventory, Swedish version). Results showed that the wrist-worn activity tracking device (Fitbit Versa) systematically overestimated energy expenditure when compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X). Poor agreement and poor correlation were shown between Fitbit Versa and both Jaeger Oxycon Pro and ActiGraph GT3X for estimated energy expenditure at all treadmill speeds. Estimations of heart rate demonstrated poor to fair agreement during laboratory-based treadmill walks. For step count, the wrist-worn devices showed fair agreement and fair correlation at most treadmill speeds. In free-living settings; however, the agreement for step count between the wrist-worn device and waist-worn accelerometer was good, and the correlation was excellent.

CONCLUSIONS

The wrist-worn device systematically overestimated energy expenditure and showed poor agreement and correlation compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X), which needs to be considered when used clinically. Step count measured with a wrist-worn device, however, seemed to be a valid estimation, suggesting that future guidelines could include such variables in this group with chronic pain.