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

Working nights and lower leisure-time physical activity associate with chronic pain in Southern African long-distance truck drivers: A cross-sectional study

Background

In South Africa, the trucking industry employs over 70,000 people and the prevalence of chronic pain in this occupational group was reported at 10%. We investigated factors associated with chronic pain in truck drivers including mental health, physical activity, and sleep, as no study has done so.

Methods

Southern African male, long-distance truck drivers were recruited at truck stops in Gauteng and Free State Provinces, South Africa (n = 614). Chronic pain was defined as pain present for at least the last three months. Depressive symptoms were assessed with the Patient Health Questionnaire-9, post-traumatic stress disorder with the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), exposure to traumatic events with the Life Events Checklist-5 (LEC-5) and daytime sleepiness with the Epworth Sleepiness Scale. Sleep quality was measured on a four-point Likert scale. Leisure-time physical activity was measured using the Godin-Shephard leisure-time physical activity questionnaire. Associations between these factors, demographic factors and chronic pain were investigated.

Results

Multivariate analysis showed that working ≥ 2 nights/week (OR = 2.68, 95% CI = 1.55–4.68) was associated with chronic pain and physical activity was protective (OR = 0.97, 95% CI 0.95–0.98). In an exploratory analysis, greater depressive symptoms (p = 0.004), daytime sleepiness (p = 0.01) and worse sleep quality (p = 0.001) was associated with working ≥ 2 nights/week. Lower leisure-time physical activity was associated with worse sleep quality (p = 0.006), but not daytime sleepiness or depressive symptoms (p>0.05).

Conclusions

There is a clear relationship between working nights and activity levels, and chronic pain, sleep quality, and depression in truck drivers.

Association between frailty and chronic pain among older adults: a systematic review and meta-analysis

PURPOSE

Frailty and chronic pain are prevalent among older adults. However, no study has systematically reviewed the association between frailty and chronic pain in older adults. Therefore, we aimed to estimate the prevalence of frailty and prefrailty among older adults with chronic pain and review the longitudinal association between frailty status and chronic pain.

METHODS

Embase, Medline, Pubmed, and Cochrane library were searched from inception to March 2020. The methodological quality of the studies was assessed using the Newcastle Ottawa Scale. Random effect models and Mantel-Haenszel weighting were adopted to synthesize the estimates.

RESULTS

Among the initial 846 articles retrieved, 24 were included in the review (12 cross-sectional, and 12 longitudinal). The pooled prevalence in persons with chronic pain was 18% (95% CI 14-23%; I2 = 98.7%) for frailty and 43% (95% CI 36-51%; I2 = 98.2%) for prefrailty. The pooled prevalence of chronic pain was 50% (95% CI 45-55%; I2 = 88.3%) for individuals with frailty and 37% (95% CI 31-42%; I2 = 97.1%) for individuals with prefrailty. Persons with chronic pain were 1.85 (95% CI 1.49-2.28; I2 = 93.2%) times more likely to develop frailty after an average follow-up of 5.8 years compared to those without.

CONCLUSION

Frailty and prefrailty are common in persons with chronic pain. Chronic pain among non-frail older persons significantly predicts the incidence of frailty after an average follow-up of 5.8 years. Future studies should explore the efficacy of different pain management strategies in reducing physical frailty and clarify the association of other types of frailty (cognitive, social and psychological) with chronic pain.

Physical Fitness Levels among Colon Cancer Survivors with a Stoma: A Preliminary Study

Background and Objectives: Stoma surgery is linked to reduced physical activity in colon cancer survivors and leads to decreased physical fitness, activity of daily living dysfunction, and poorer quality of life. However, few studies have investigated the physical fitness levels of colon cancer survivors living with stomas. This study aimed to compare the physical fitness levels of colon cancer survivors with stomas and healthy adults, assessing them in a variety of dimensions (e.g., strength and flexibility) and in terms of physical fitness age (PFA), an integrated index of overall fitness. Materials and Methods: The study population consisted of 17 colon cancer survivors with (stoma group) and 20 healthy adults without (control group) a stoma. Physical fitness was assessed using a battery of five tests: repeated back-and-forth steps, 30-s chair stand, chair sit-and-reach, grip strength, and single-leg balance with eyes closed. Respective performance values were converted into PFA, which was compared between the stoma and control groups. Fitness indicators were compared between groups by analysis of covariance, and PFA and chronological age (CA) by paired t-tests. Results: The mean ages (±standard deviation) of the stoma and control groups were 74.1 ± 7.9 and 73.5 ± 7.1 years, respectively. Colon cancer survivors with stomas had poorer lower limb muscular strength, endurance, and flexibility than controls. In the stoma group, the marginal mean (±standard error) PFA was calculated to be 82.5 ± 3.7 years, significantly higher than the CA and PFA of the control group (69.6 ± 3.9 years). Conclusions: Colon cancer survivors with stomas have lower physical fitness levels than healthy adults, with apparent deficits in lower limb flexibility, muscular strength, and endurance. Our findings demonstrated the need for exercise interventions in this population, focusing on these dimensions of fitness. However, our results should be corroborated by means of a larger-scale comparison in future studies.

Higher Disease and Pain Severity and Fatigue and Lower Balance Skills Are Associated with Higher Prevalence of Falling among Individuals with the Inflammatory Disease of Neuromyelitis Optica Spectrum Disorder (NMOSD)

Background: Neuromyelitis optica spectrum disorder (NMOSD) is a chronic inflammatory and autoimmune disorder that is associated with impaired vision, sensory loss, pain, fatigue, and spasms in the upper and lower limbs. Typically, persons with this disorder are also at higher risks of falls. Given this, the aims of the study were to compare the prevalence rates of falling for NMOSD cases and healthy controls (HCs), and to predict falling in the former group based on sociodemographic, psychological, and illness-related factors. Method: A total of 95 adults with NMOSD (Mean age = 34.89 years; 70.5% females) and 100 matched HCs took part in the study. All participants completed a series of questionnaires covering sociodemographic information and falling rates. The NMOSD individuals also reported on disease duration, pain, fatigue, and fear of falling, while their balance performance was objectively assessed. Results: Compared to healthy controls, the NMOSD cases had a 2.5-fold higher risk of falling. In this latter group, higher scores for pain, fatigue, fear of falling, and higher EDSS scores were distinguished between fallers and non-fallers, and objective balance skills had no predictive value. Conclusions: Compared to healthy controls, NMOSD sufferers had a 2.5-fold higher risk of experiencing falls. In this group, disease impairments (EDSS, fatigue, pain) predicted falling. Specific interventions such as regular resistance training might reduce the risk of falling.

Association Between Physical Activity Levels and Chemotherapy-Induced Peripheral Neuropathy Severity in Cancer Survivors

OBJECTIVES

To evaluate for differences in demographic and clinical characteristics, as well as subjective and objective measures of chemotherapy-induced peripheral neuropathy (CIPN), among different exercise groups.

SAMPLE & SETTING

Cancer survivors (N = 290) were recruited from throughout the San Francisco Bay Area.

METHODS & VARIABLES

Based on the recommended 150 minutes or more of exercise per week, survivors were classified into the no exercise (NoEx), less exercise (LessEx), or recommended exercise (RecEx) group. Survivors completed self-report questionnaires and underwent sensory and balance testing.

RESULTS

Compared to the RecEx group, survivors in the NoEx group had less education, were less likely to be married/partnered, had a lower household income, had a higher level of comorbidity, and had poorer functional status. No differences were found among the groups in CIPN duration; pain intensity scores; or changes in light touch, cold, and pain sensations.

IMPLICATIONS FOR NURSING

Clinicians can recommend walking as a therapeutic option for survivors with CIPN and refer them to physical therapy.

[On the move-Prevention of chronic pain with physical activity and movement]

BACKGROUND

Sufficient physical activity and exercise shows a variety of health-promoting positive effects. In the context of pain therapy, promotion of physical activity could be an important contribution to primary, secondary and tertiary prevention of chronic pain.

OBJECTIVES

The aim is to investigate the relationship between physical activity and chronic pain, the preventive effect of physical activity on pain and the factors to successfully promote physical activity in people with chronic pain.

METHODS

For this narrative review databases of the Cochrane Library, MEDLINE (via PubMed) and the Physiotherapy Evidence Database (PEDro) were searched for reviews and studies with the keywords chronic pain, physical activity, movement, exercise and prevention.

RESULTS

A total of 10 reviews, 10 clinical studies and 4 surveys were included and summarized.

CONCLUSION

Although the evidence base on this topic is still insufficient, positive effects of physical activity on the prevention of chronic pain could be demonstrated. Interventions for people with chronic pain that sustainably increase physical activity should take into account individual resources, address barriers such as maladaptive beliefs, and create positive movement experiences.

A physical activity program versus usual care in the management of quality of life for pre-frail older adults with chronic pain: randomized controlled trial

BACKGROUND

Exercise has shown being effective for managing chronic pain and preventing frailty status in older adults but the effect of an exercise program in the quality of life of pre-frail older adults with chronic pain remains unclear. Our objective was to evaluate the effectiveness of multicomponent structured physical exercise program for pre-frail adults aged 65 years or more with chronic pain to improve their perceived health related quality of life, compared with usual care.

METHODS

Open label randomized controlled trial. Participants were community-dwelling pre-frail older adults aged 65 years or older with chronic pain and non-dependent for basic activities of daily living attending a Primary Healthcare Centre. Forty-four participants were randomly allocated to a control group (n = 20) that received usual care or an intervention group (n = 24) that received an 8-week physical activity and education program. Frailty status (SHARE Frailty Index), quality of life (EuroQol-5D-5L), pain intensity (Visual Analogue Scale), physical performance (Short Physical Performance Battery) and depression (Yessavage) were assessed at baseline, after the intervention and after 3 months follow-up. The effect of the intervention was analysed by mean differences between the intervention and control groups.

RESULTS

The follow-up period (3 months) was completed by 32 patients (73%), 17 in the control group and 15 in the intervention group. Most participants were women (78.1%) with a mean age (standard deviation) of 77.2 (5.9) years and a mean pain intensity of 48.1 (24.4) mm. No relevant differences were found between groups at baseline. After the intervention, mean differences in the EuroQol Index Value between control and intervention groups were significant (- 0.19 95% CI(- 0.33- -0.04)) and remained after 3 months follow-up (- 0.21 95% CI(- 0.37- -0.05)). Participants in the exercise group showed better results in pain intensity and frailty after the intervention, and an improvement in physical performance after the intervention and after 3 months.

CONCLUSIONS

An eight-week physical activity and education program for pre-frail older adults with chronic pain, compared with usual care, could be effective to improve quality of life after the intervention and after three-months follow-up.

STUDY REGISTRATION DETAILS

This study was retrospectively registered in ClinicalTrials.gov with the identifier NCT04045535 .

Consensus of potential modifiable prognostic factors for persistent pain after a first episode of nonspecific idiopathic, non-traumatic neck pain: results of nominal group and Delphi technique approach

BACKGROUND

Identify and establish consensus regarding potential prognostic factors for the development of chronic pain after a first episode of idiopathic, non-traumatic neck pain.

DESIGN

This study used two consensus group methods: a modified Nominal Group (m-NGT) and a Delphi Technique.

METHODS

The goal of the m-NGT was to obtain and categorize a list of potential modifiable prognostic factors. These factors were presented to a multidisciplinary panel in a two-round Delphi survey, which was conducted between November 2018 and January 2020. The participants were asked whether factors identified are of prognostic value, whether these factors are modifiable, and how to measure these factors in clinical practice. Consensus was a priori defined as 70% agreement among participants.

RESULTS

Eighty-four factors were identified and grouped into seven categories during the expert meeting using the modified NGT. A workgroup reduced the list to 47 factors and grouped them into 12 categories. Of these factors, 26 were found to be potentially prognostic for chronification of neck pain (> 70% agreement). Twenty-one out of these 26 factors were found to be potentially modifiable by physiotherapists based on a two-round Delphi survey.

CONCLUSION

Based on an expert meeting (m-NGT) and a two-round Delphi survey, our study documents consensus (> 70%) on 26 prognostic factors. Twenty-one out of these 26 factors were found to be modifiable, and most factors were psychological in nature.

Facing obesity in pain rehabilitation clinics: Profiles of physical activity in patients with chronic pain and obesity-A study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Background

The obesity epidemic has influenced pain rehabilitation clinics. To date, little is known about baseline level of physical activity (PA) in patients referred to pain rehabilitation clinics. We aimed to investigate the PA levels of patients referred to pain rehabilitation clinics and to evaluate the effect of excess weight on PA level.

Methods and findings

Data were obtained from the Swedish Quality Registry for Pain Rehabilitation between 2016 and 2017. These data included PA time (everyday PA and physical exercise per week), Body Mass Index (BMI), sociodemographic factors, chronic pain and psychological aspects (e.g., pain intensity, depressive and anxiety symptoms and insomnia problems). Insufficient PA was defined as less than 150 minutes per week. We performed logistic regressions as well as orthogonal partial least square regression to estimate the effects of excess weight on PA. Over one-fourth of the patients were classified as obese (BMI ≥30 kg/m², 871/3110, 25.3%) and nearly one-third of these patients were classified as severely obese (BMI ≥35 kg/m², 242/871, 27.8%). Time estimations for physical exercise varied among the BMI groups, but patients in the higher BMI category were more likely to spend less time on everyday PA. Compared to normal weight, mild obesity [odds ratio (OR) 0.65, 95% confidence interval (CI) 0.53–0.81] and severe obesity (OR 0.56, 95% CI 0.42–0.74) were associated with less PA. Mild obese patients had an elevated risk of 65% and severe obese patients had an elevated risk of 96% for insufficient PA. Increased pain intensity was positively related to insufficient PA (OR 1.17, 95% CI 1.06–1.29) among the obese patients.

Conclusion

Having low PA is very common for patients referred to pain rehabilitation clinics, especially for those with comorbid obesity. As a first step to increase PA, obese patients need to be encouraged to increase the intensity and amount of less painful daily PA.

Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain

This review describes methodology used in the assessment of the manifestations of exercise-induced hypoalgesia in humans and previous findings in individuals with and without pain. Possible mechanisms and future directions are discussed.

Exercise and physical activity is recommended treatment for a wide range of chronic pain conditions. In addition to several well-documented effects on physical and mental health, 8 to 12 weeks of exercise therapy can induce clinically relevant reductions in pain. However, exercise can also induce hypoalgesia after as little as 1 session, which is commonly referred to as exercise-induced hypoalgesia (EIH). In this review, we give a brief introduction to the methodology used in the assessment of EIH in humans followed by an overview of the findings from previous experimental studies investigating the pain response after acute and regular exercise in pain-free individuals and in individuals with different chronic pain conditions. Finally, we discuss potential mechanisms underlying the change in pain after exercise in pain-free individuals and in individuals with different chronic pain conditions, and how this may have implications for clinical exercise prescription as well as for future studies on EIH.

Exercise-induced pain threshold modulation in healthy subjects: a systematic review and meta-analysis

Background

The use of exercise is a potential treatment option to modulate pain (exercise-induced hypoalgesia). The pain threshold (PT) response is a measure of pain sensitivity that may be a useful marker to assess the effect of physical exercise on pain modulation.

Aim

The aim of this systematic review and meta-analysis is to evaluate the PT response to exercise in healthy subjects.

Methods

We searched in MEDLINE, EMBASE, Web of Science, Lilacs, and Scopus using a search strategy with the following search terms: "exercise" OR "physical activity" AND "Pain Threshold" from inception to December 2nd, 2019. As criteria for inclusion of appropriate studies: randomized controlled trials or quasi-experimental studies that enrolled healthy subjects; performed an exercise intervention; assessed PT. Hedge's effect sizes of PT response and their 95% confidence intervals were calculated, and random-effects meta-analyses were performed.

Results

For the final analysis, thirty-six studies were included (n=1326). From this we found a significant and homogenous increase in PT in healthy subjects (ES=0.19, 95% CI= 0.11 to 0.27, I2=7.5%). According to subgroup analysis the effect was higher in studies: with women (ES=0.36); performing strength exercise (ES=0.34), and with moderate intensity (ES=0.27), and no differences by age were found. Confirmed by the meta-regression analysis.

Conclusion

This meta-analysis provides evidence of small to moderate effects of exercise on PT in healthy subjects, being even higher for moderate strength exercise and in women. These results support the idea of modulation of the endogenous pain system due to exercise and highlight the need of clinical translation to chronic pain population.

Interference and Impact of Dysmenorrhea on the Life of Spanish Nursing Students

Dysmenorrhea is a cause of absenteeism in universities which, in the context of nursing studies, may affect mandatory attendance. Moreover, presenteeism is associated with medication errors, patient falls, and a reduced quality of patient care. This study sought to identify the degree of interference of dysmenorrhea on daily life and its impact on academic performance among Spanish nursing students, and to explore the reasons for presenteeism. A cross-sectional descriptive study was conducted on 261 nursing students. Data were collected using a self-administered questionnaire. The chi square tests, chi-square linear trend, Student's t-test, one-way analysis of variance of polynomial contrasts, and post hoc tests for the bi-variate analysis were used to compare the participants' responses regarding their type of dysmenorrhea and pain intensity. In addition, a multivariate regression was performed to predict absenteeism. The answers to the open questions were analyzed using thematic content analysis techniques. We observed 62.8% of absenteeism and 92.7% of presenteeism due to dysmenorrhea. Absenteeism was observed to be 3.079 (confidence interval (CI): 95%1.724-5.499; p < 0.001) times more likely among women with severe menstrual pain, 2.513 (CI 95%1.314-4.807; p = 0.005) times more in those suffering from menstrual nausea and 1.936 (CI 95%1.098-3.411; p = 0.022) times more frequent in those suffering from diarrhea. The reasons for presenteeism were grouped into five categories: the pain was bearable, it is not a reason to be absent, others don't consider it a reason to be absent, responsibility and guilt, and academic consequences. Dysmenorrhea can have a significant impact on academic performance. The concern among students about the academic repercussions and even feelings of guilt and incomprehension from others leads to high rates of presenteeism with potentially negative consequences for patient care.

Does chronic pain hinder physical activity among older adults with type 2 diabetes?

Background: Physical activity (PA) is a key component in management of type 2 diabetes (T2D). Pain might be a barrier to PA especially among older adults with T2D, but surprisingly few studies have investigated the association between chronic pain and PA. Our aim was to evaluate the prevalence of chronic pain among older adults with T2D and to examine the association between chronic pain and PA while taking important life-contextual factors into account. Methods: Data of this register-based, cross-sectional study were collected in a survey among adults with T2D (n=2866). In the current study, only respondents aged 65-75 years were included (response rate 63%, n=1386). Data were analysed by means of descriptive statistics and multivariate logistic regression analysis. Results: In total, 64% reported chronic pain. In specific groups, e.g. women and those who were obese, the prevalence was even higher. Among respondents experiencing chronic pain, frequent pain among women and severe pain among both genders were independently associated with decreased likelihood of being physically active. Moreover, the likelihood of being physically active decreased with higher age and BMI, whereas it increased with higher autonomous motivation and feelings of energy. Among physically active respondents suffering from chronic pain, neither intensity nor frequency of pain explained engagement in exercise (as compared with incidental PA). Instead, men were more likely to exercise regularly as were those with good perceived health and higher autonomous motivation. Conclusions: The prevalence of chronic pain is high among older adults with T2D. This study shows that among those suffering from chronic pain, severe pain is independently and inversely associated with being physically active, as is frequent pain, but only among women. Moreover, the findings show the importance of autonomous motivation and health variables for both incidental PA and exercise among older adults with T2D experiencing chronic pain.

Health and wellness coaching positively impacts individuals with chronic pain and pain-related interference

Objectives

Health and wellness coaching (HWC) interventions have been reported to improve health outcomes for individuals with chronic diseases such as diabetes, cardiovascular disease, or cancer. However, HWC also holds potential as an effective intervention within a biopsychosocial chronic pain management framework. The aim of the present study was to evaluate the effects of HWC on individuals with chronic pain.

Methods

Participants were referred by their primary care provider or insurance company to a comprehensive telephonic 12-month pain management HWC program. Relationships between pain outcomes and physical and psychological factors were retrospectively analyzed. Mixed linear-effects modeling explored whether physical and psychological variables were associated with pain outcomes over time.

Results

Four hundred nineteen participants (female, 58.9%; mean age, 54.8) enrolled in the program and 181 completed the intervention. After 12 months in the program, statistically and clinically significant reductions were observed for pain intensity (Hedges’ g = 1.00) and pain-related interference (Hedges’ g = 1.13). Linear mixed-effects modeling indicated that improvements in physical functioning and psychological factors were associated with improvements in pain intensity.

Discussion

Our results provide a novel analysis on the effects of HWC on chronic pain and pain-related interference. HWC appears to be a promising intervention to improve pain-related outcomes in a population with chronic pain. Further investigation of HWC as an intervention for chronic pain is warranted.

The Impact of a Primary Care, Pharmacist-Driven Intervention in Patients with Chronic Non-Cancer Pain-A Pilot Study

Background: Chronic pain is a prevalent condition, experienced by 15.3% to 55% of Canadians, that is difficult to manage. With their broad accessibility and expertise on drugs, primary care pharmacists can help patients optimize their pain management. Methods: The objective of this study is to examine the effectiveness of a primary care, pharmacist-driven chronic pain intervention on pain and quality of life in patients with chronic non-cancer pain. A three-month naturalistic prospective study was conducted in primary care settings (five community pharmacies and one Family Health Team) across Ontario, Canada with a total of six pharmacists and 19 study participants. The primary care, pharmacist-driven chronic pain intervention consisted of patient assessments, medication reviews, care plan recommendations, and patient education. In order to evaluate the effectiveness of the intervention, pain intensity, pain interference, and quality of life were evaluated at baseline and at follow up (week 2 and month 3). Results: Trends towards improvement in pain and quality of life were found, however, these improvements were not statistically significant at follow up (month 3). Conclusions: This study provides the foundational research required to better understand the impact of Ontario pharmacists' extended role in pain management in non-cancer patients within multiple primary care settings (e.g., Family Health Team, etc.) and has illustrated the importance of modifying and customizing care plans in patients with chronic pain. A larger sample size with tailored outcome measures may be necessary to better highlight significant improvements in pain and quality of life in patients with chronic non-cancer pain using a primary care, pharmacist-driven intervention.

Altered relationship between anandamide and glutamate in circulation after 30 min of arm cycling: A comparison of chronic pain subject with healthy controls

The insufficient knowledge of biochemical mechanisms behind the emergence and maintenance of chronic musculoskeletal pain conditions constrains the development of diagnostic and therapeutic tools for clinical use. However, physical activity and exercise may improve pain severity and physical function during chronic pain conditions. Nevertheless, the biochemical consequences of physical activity and exercise in chronic pain need to be elucidated to increase the precision of this therapeutic tool in chronic pain treatment. The endocannabinoid system has been suggested to play an important role in exercise-induced reward and pain inhibition. Moreover, glutamatergic signalling has been suggested as an important factor for sensation and transmission of pain. In addition, a link has been established between the endocannabinoid system and glutamatergic pathways. This study examines the effect of dynamic load arm cycling (30 min) on levels of lipid mediators related to the endocannabinoid system and glutamate in plasma of chronic pain subjects and pain-free controls. Pain assessments and plasma levels of arachidonoylethanolamide (anandamide), 2-aracidonoylglycerol, oleoylethanolamide, palmitoylethanolamide, stearoylethanolamide and glutamate from 21 subjects with chronic neck pain (chronic pain group) and 11 healthy controls were analysed pre and post intervention of dynamic load arm cycling. Pain intensity was significantly different between groups pre and post exercise. Post exercise, anandamide levels were significantly decreased in health controls but not in the chronic pain group. A strong positive correlation existed between anandamide and glutamate in the control group post exercise but not in the chronic pain group. Moreover, the glutamate/anandamide ratio increased significantly in the control group and differed significantly with the chronic pain group post exercise. The altered relationship between anandamide and glutamate after the intervention in the chronic pain group might reflect alterations in the endocannabinoid-glutamate mechanistic links in the chronic pain group compared to the pain-free control group.

Longitudinal associations of changes in physical activity and TV viewing with chronic musculoskeletal pain in Brazilian schoolteachers

This study analyzed the longitudinal association of changes in leisure-time physical activity (LTPA) practice and television viewing (TV viewing) with chronic musculoskeletal pain (CMP). The data about LTPA, TV viewing, and CMP were obtained in 2012 and after 24 months through individual interviews with schoolteachers from elementary and secondary education public schools in a large city in the southern region of Brazil. The statistical analysis was performed using generalized estimating equation regression models adjusted for sex, age, body mass index and depression. A total of 527 schoolteachers were studied, among which 66.6% were women, and the median age was 42 years (interquartile range: 34 to 49). A total of 170 (32.3%) participants reported CMP at baseline and 130 (24.7%) at follow-up. Both LTPA and TV viewing were independently and significantly associated with CMP regardless of all adjustment variables. Concretely, increasing LTPA by 60 minutes/week was associated with a 6.2% lower likelihood of CMP, and increasing TV viewing by 30 minutes/day was associated with a 5.1% higher likelihood of having CMP among the participants. In summary, this study showed that LTPA and TV viewing have independent and opposite relationships with the longitudinal risk of CMP, which suggests that the potential benefits obtained from practicing more LTPA are insufficient to compensate for the potential detrimental effect of viewing TV for longer with respect to the CMP.

Exercise for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials

Background

Exercise is recommended as a treatment for premenstrual syndrome (PMS) in clinical guidelines, but this is currently based on poor-quality trial evidence.

Aim

To systematically review the evidence for the effectiveness of exercise as a treatment for PMS.

Design & setting

This systematic review searched eight major databases, including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL), and two trial registries from inception until April 2019.

Method

Randomised controlled trials (RCTs) comparing exercise interventions of a minimum of 8-weeks duration with non-exercise comparator groups in women with PMS were included. Mean change scores for any continuous PMS outcome measure were extracted from eligible trials and standardised mean differences (SMDs) were calculated where possible. Random-effects meta-analysis of the effect of exercise on global PMS symptoms was the primary outcome. Secondary analyses examined the effects of exercise on predetermined clusters of psychological, physical, and behavioural symptoms.

Results

A total of 436 non-duplicate returns were screened, with 15 RCTs eligible for inclusion (n = 717). Seven trials contributed data to the primary outcome meta-analysis (n = 265); participants randomised to an exercise intervention reported reduced global PMS symptom scores (SMD = -1.08; 95% confidence interval [CI] = -1.88 to -0.29) versus comparator, but with substantial heterogeneity (I² = 87%). Secondary results for psychological (SMD = -1.67; 95% CI = -2.38 to -0.96), physical (SMD = -1.62; 95% CI = -2.41 to -0.83) and behavioural (SMD = -1.94; 95% CI = -2.45 to -1.44) symptom groupings displayed similar findings. Most trials (87%) were considered at high risk of bias.

Conclusion

Based on current evidence, exercise may be an effective treatment for PMS, but some uncertainty remains.

Periodized resistance training for persistent non-specific low back pain: a mixed methods feasibility study

Background

We investigated the feasibility of a 16-week supervised heavy resistance training program with weekly undulating periodization for individuals with persistent non-specific low-back pain (LBP).

Methods

Twenty-five adults with persistent non-specific LBP participated in this mixed methods feasibility study. Participants trained a whole-body program consisting of squat, bench press, deadlift and pendlay row two times per week for 16 weeks. We assessed pain intensity, pain-related disability, pain self-efficacy and one-repetition maximum strength at baseline, 8 weeks and 16 weeks. Three focus group interviews were conducted at the end of the program. Linear mixed models were used to assess changes in outcomes, and the qualitative data was assessed using systematic text condensation.

Results

We observed clinically meaningful reductions in pain intensity after 8 and 16 weeks of training. The mean difference on the numeric pain rating scale (0–10) in the last 2 weeks from baseline to 8 weeks was 2.6 (95% CI: 1.8–3.6) and from baseline to 16 weeks 3.4 (95% CI: 2.5–4.4). In addition, there were improvements in pain-related disability (3.9, 95% CI: 2.3–5.5), pain self-efficacy (7.7, 95% CI: 5.4–10.1) and muscle strength. In the focus group interviews, participants talked about challenges regarding technique, the importance of supervision and the advantages of periodizing the training. Perceived benefits were improved pain, daily functioning, energy level and sleep, and changes in views on physical activity.

Conclusion

Periodized resistance training with weekly undulating periodization is a feasible training method for this group of individuals with persistent non-specific LBP. A randomized clinical trial should assess the efficacy of such an intervention.

Trial registration

clinicaltrials.gov/ Identifier – NCT04284982, Registered on February 24th 2020.

Fear of analgesic side effects predicts preference for acupuncture: a cross-sectional study of cancer patients with pain in the USA

PURPOSE

Approximately one in two cancer patients globally are under-treated for pain. Opioids and other analgesics represent the mainstay of cancer pain management; however, barriers to their use are well-documented. We evaluated whether acupuncture would be a preferable treatment option among cancer patients with attitudinal barriers to pharmacological pain management.

METHODS

We conducted a cross-sectional survey of cancer patients at a tertiary urban cancer center and eleven suburban/rural hospitals in the Northeastern United States. We assessed attitudinal barriers to pharmacological pain management with the Barriers Questionnaire (BQ-13). The BQ-13 consists of two subscales: pain management beliefs and analgesic side effects. We also asked patients whether they prefer acupuncture, analgesics, or have no preference between these two modalities for pain management. Covariates included sociodemographics, clinical characteristics, and attitudes/beliefs about acupuncture. We used logistic regression to examine the association between attitudinal barriers and acupuncture preference.

RESULTS

Among 628 patients, 197 (31.4%) preferred acupuncture for pain management, 146 (23.3%) preferred analgesics, and 285 (45.4%) had no preference. The highest reported attitudinal barriers were fear of addiction and fear of analgesic-associated constipation and nausea. Adjusting for covariates, we found that attitudinal barriers related to fear of analgesic side effects were significantly associated with acupuncture preference (adjusted odds ratio [AOR] 1.45, 95% confidence interval [CI] 1.17-1.81), but barriers related to pain management beliefs were not (AOR 1.17, 95% CI 0.91-1.51). Attitudes/beliefs about acupuncture (i.e., greater expected benefits, fewer perceived barriers, and more positive social norms) and female gender also predicted acupuncture preference, whereas race and educational status did not.

CONCLUSION

Acupuncture may be a preferable treatment option among cancer patients at risk of inadequately controlled pain due to fear of analgesic side effects. Evidence-based integration of acupuncture and analgesics, guided by patient treatment preferences, represents an essential aspect of patient-centered care and has potential to address unmet cancer pain management needs.

Assessing the impact of the five senses on quality of life in mucopolysaccharidoses

BACKGROUND

The mucopolysaccharidoses (MPSs) are lysosomal storage disorders associated with progressive multi-organ and skeletal abnormalities. Clinical manifestations can affect each of the five senses: hearing, vision, smell, taste, and touch. On 24-26 May 2018, 46 specialists with expertise in managing symptoms of MPS and experts specialized in evaluating and managing impairments in each one of the five senses gathered in Lisbon, Portugal at the "MPS & the five senses" meeting to discuss how loss of one or multiple senses can affect activities of daily living (ADL) and quality of life (QoL) in MPS patients and best practices in evaluating and managing the loss of senses in these individuals. The meeting confirmed that MPS can affect the senses considerably, but how these impairments affect ADL and overall QoL from a patient's perspective remains unclear. A better insight may be achieved by prospectively collecting patient-reported outcome (PRO) data internationally in a standardized way, using a standard battery of tools. To identify relevant PRO tools, a systematic literature review and a selection of existing published questionnaires, focused on adults with no intellectual delay, were performed after the meeting. The search strategy identified 33 PRO tools for hearing, 30 for speech, 125 for vision, 49 for touch (including pain and upper limb function), and 15 for smell/taste. A further selection was made based on several criteria, including applicability/relevance for MPS, applicability in different countries (languages)/cultures, availability in English, ease of use, validation, and normative data, resulting in a final set of 11 tools. In addition to these sense-specific PRO tools, a general QoL tool, the EuroQol (EQ)-5D-5 L, was selected to assess overall QoL and reveal coping behaviors.

SHORT CONCLUSION

MPS can affect each of the five senses, but current knowledge on the impact of sense impairments on QoL/ADL in MPS patients remains limited. Collection of data in a standardized fashion using sense-specific patient-reported outcome tools and a general QoL tool may fill the current knowledge gap.

Central sensitization predicts greater fatigue independently of musculoskeletal pain

Objectives

To test whether central sensitization was associated with greater fatigue, independently of musculoskeletal pain.

Methods

2477 prospective cohort study participants completed a baseline questionnaire comprising the Chalder Fatigue Scale (CFQ), pain, demographics, physical activity, anxiety, depression and medication use. In a clinical assessment of 290 (11.7%) participants, central sensitization was measured by the wind-up ratio test at the hand (WUR-H) and foot (WUR-F). Bioelectric impedance determined proportion body fat. All participants were followed up 12 months later, at which time they completed the CFQ. Linear regression, with inverse probability sampling weights, tested the relationship between WUR at baseline and CFQ at 12 months, adjusted for baseline CFQ, demographics, lifestyle factors, mental health and baseline pain.

Results

At baseline, the median interquartile range WUR-H and WUR-F were similar (2.3 (1.5, 4.0) and 2.4 (1.6, 3.9) respectively) and did not differ by sex (difference WUR-H: −0.29, 95% confidence interval −1.28–0.71; WUR-F: −0.57 (−1.50–0.36) or age(WUR-H: −0.53, −1.49–0.43; WUR-F:−0.08, −0.98–0.82). WUR-H scores (β = 0.11, 95% confidence interval: 0.07–0.16) and WUR-F scores (0.13, 0.08–0.17) were positively associated with CFQ scores at follow-up, independently of baseline CFQ and other covariates. These associations were not explained by baseline pain.

Conclusion

Fatigue was predicted by central sensitization, independently of the presence of pain. For those seeking to treat fatigue, the benefit of interventions that reduce central sensitization should be investigated.

Low back pain should be considered a health and research priority in Brazil: Lost productivity and healthcare costs between 2012 to 2016

BACKGROUND

Low Back Pain (LBP) is associated with an increase in disability-adjusted life years, and increased risk of disability retirement and greater absenteeism in Brazil. Hence, evidence on healthcare and lost productivity costs due to LBP is of utmost importance to inform decision-makers.

METHODS

Cost-of-illness study with top-down approach, and societal perspective. We extracted data from National databases, considering the period 2012-2016. Outpatient expenses included clinical, surgical, diagnosis, orthosis/prosthetics, and complementary actions. Inpatient care expenses included hospital and professional services, intensive care unit, and companion stay. For productivity losses, duration of work absence and associated information (work-related and non-work-related; value of the sickness absence benefit; age; gender; and economic activity) were analyzed. Lost productivity costs were calculated multiplying the absence from work (days) by the daily-benefit.

RESULTS

The societal costs amounted to US$ 2.2 billion, and productivity losses represented 79% of the costs. Total healthcare expenses were estimated to US$ 460 million. We found more than 880,000 diagnostic images. Individuals with LBP were in total 59 million days absent from work between 2012-2016. The mean lost days absent from work per person, for each year investigated was, respectively, 88; 84; 83; 87; and 100. Men were more days absent from work than women. In addition, rural workers presented greater absence from work compared to other professional activities.

CONCLUSION

Healthcare expenses and lost productivity costs due to LBP were substantial, hence, there is a need for improvement of health services and policies to deal with this increasing burden of illness. We found an extensive use of diagnostic imaging, which is rather discouraged by clinical guidelines. We assume that men were experiencing high levels of back pain disability compared with women, as they presented greater absenteeism and higher lost productivity costs.

Relationship Between Spiritual Health and Pain Self-Efficacy in patients with Chronic Pain: A Cross-Sectional Study in West of Iran

In recent years, the prevalence of chronic diseases has had a growing trend, which has resulted in many health problems. Level of belief in God is effective on people's attitudes to life concepts, social deviations and psychological disorders, and improves them. Therefore, the present research was conducted with the aim of determining the relationship between spiritual health (SH) and pain self-efficacy (PSE) in Ilam City in 2018. This study was a descriptive cross-sectional study in the group of patients with chronic pain (CP). In this study, the study population was patients with CP in Ilam City and the study sample was 150 patients with CP referring to public and private health centers in Ilam, which had all the criteria for participation in the study. The findings showed mean (SD) of the total score of SH variables was 65.16 (9.88), and PSE was 34.48 (4.08). According to Pearson statistical analysis, there is a significant relationship between SH and PSE (r = 0.442, P = 0.000). Also, the standard beta and non-standard beta coefficients for SH variables in PSE show that the non-standard beta coefficient in SH is equal to 0.183. The results of this study showed that SH is a predictor of pain acceptance, so that patients who were more religious were more likely to tolerate CP. For this reason, it is suggested that religious interventions be performed to reduce pain in patients with CP, in order to provide the necessary context for pain reduction in this group of patients.

Longitudinal pain and pain interference in long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

The objective of this study was to characterize the prevalence and risk of pain, pain interference, and recurrent pain in adult survivors of childhood cancer in comparison with siblings.

METHODS

This study analyzed longitudinal data from survivors (n = 10,012; 48.7% female; median age, 31 years [range, 17-57 years]; median time since diagnosis, 23 years) and siblings (n = 3173) from the Childhood Cancer Survivor Study. Survivors were diagnosed between 1970 and 1986 at 1 of 26 participating sites. Associations between risk factors (demographics, cancer-related factors, and psychological symptoms) and pain, pain interference, and recurrent pain (5 years apart) were assessed with multinomial logistic regression. Path analyses examined cross-sectional associations between risk factors and pain outcomes.

RESULTS

Twenty-nine percent of survivors reported moderate to severe pain, 20% reported moderate to extreme pain interference, and 9% reported moderate to severe recurrent pain. Female sex, a sarcoma/bone tumor diagnosis, and severe/life-threatening chronic medical conditions were associated with recurrent pain. Depression and anxiety were associated with increased risk for all pain outcomes. Poor vitality mediated the effects of anxiety on high pain and pain interference (root mean square error of approximation, 0.002).

CONCLUSIONS

A large proportion of adult survivors report moderate to severe pain and pain interference more than 20 years after their diagnosis. Increased screening and early intervention for pain interference and recurrent pain are warranted.

Physical therapies for postural abnormalities in people with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is the most common life-threatening, inherited disease in white populations which causes several dysfunctions, including postural abnormalities. Physical therapy may help in some consequences of these postural abnormalities, such as pain, trunk deformity and quality of life.

OBJECTIVES

To determine the effects of a range of physical therapies for managing postural abnormalities in people with cystic fibrosis, specifically on quality of life, pain and trunk deformity.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches, hand-searched journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies. Date of the last search: 19 March 2020.

SELECTION CRITERIA

Randomised controlled trials examining any modality of physical therapy considered relevant for treating postural disorders compared with each other, no physical therapy, sham treatment or usual care in people with CF (of any age or disease severity).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted the data. We contacted trial authors to obtain missing or additional information. We assessed the quality of the evidence using the GRADE criteria.

MAIN RESULTS

Two trials, involving a total of 50 participants with CF and postural abnormalities, were included in this review. One was in people with stable disease (lasting three months) and one in hospital inpatients experiencing an exacerbation (20 days). Both trials compared manual therapy comprising mobilizations to the rib cage and thoracic spine, treatment of specific muscle dysfunction or tight muscle groups; and postural awareness and education versus medical usual care. The age of participants ranged from 17 years to 58 years. Both trials were conducted in the UK. The following outcomes were measured: change in quality of life, change in pain, change in trunk deformity and change in pulmonary function. Manual therapy may make little or no difference to the change in trunk deformity compared to usual care (low-quality evidence). No results could be analysed for quality of life (very low-quality evidence) and pain outcomes (very low-quality evidence) because of the high heterogeneity between trials. It is uncertain whether the intervention improves lung function: forced vital capacity (very low-quality evidence); forced expiratory volume in one second (very low-quality evidence); or Tiffeneau's index (ratio of forced expiratory volume at one second (FEV₁) and forced vital capacity (FVC)). Only one trial (15 participants) measured functional capacity, and the change in walked distance seemed to favour intervention over usual care, but with the possibility of no effect due to wide confidence intervals. The same trial also reported that six participants in the intervention group had positive comments about the intervention and no adverse events were mentioned.

AUTHORS' CONCLUSIONS

Due to methodological limitations in the included trials, and in addition to the very low to low quality of the current evidence, there is limited evidence about the benefits of physical therapies on postural abnormalities in people with CF. Therefore, further well-conducted trials with robust methodologies are required considering a prior inclusion criterion to identify the participants who have postural abnormalities.

Relationship between healthcare seeking and pain expansion in patients with nonspecific chronic low back pain

Objectives

Low back pain (LBP) is the most prevalent musculoskeletal problem, which implies a high rate of chronicity. The chronicity of symptoms can lead to pain expansion. The main objective of this study was to assess whether there were differences between patients with nonspecific chronic LBP (CLBP) who sought healthcare compared to those who did not in terms of pain expansion.

Methods

Ninety individuals participated in the study and were divided into three groups: 30 patients who sought care; 30 patients who did not seek care; and 30 asymptomatic individuals. The primary variable analyzed was pain expansion. Secondary physical and psychological variables were assessed later, and a regression analysis was performed.

Results

Patients who sought help showed significant differences in pain expansion and pain intensity compared with the group who did not seek help, with a medium effect size (0.50–0.79). The regression model for the care-seeking group showed that dynamic balance with the left leg and depression were predictors of percentage pain surface area (34.6%). The combination of dynamic balance, range of movement in flexoextension and depression were predictors of widespread pain (48.5%).

Conclusion

Patients who soughtcare presented greater pain expansion than patients whodidnot. A combination of functional and psychological variables can significantly predict pain expansion in patients with nonspecific CLBP who seek help.

Serious Gaming During Multidisciplinary Rehabilitation for Patients With Chronic Pain or Fatigue Symptoms: Mixed Methods Design of a Realist Process Evaluation

BACKGROUND

Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens.

OBJECTIVE

To realize this potential, insight is needed into how, why, for whom, and when it works in actual treatment circumstances.

METHODS

Following a realist approach, process evaluations were performed before, during, and after a two-armed, natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. During two sessions before and one session after the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers, and experts. Patients participated in a survey (n=114) and in semistructured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing-with regression models-routinely collected clinical outcome data. An updated program theory was formulated after mixing the qualitative and quantitative results.

RESULTS

Qualitative data showed that a subset of patients perceived improvement of their self-awareness in moments of daily social interactions. These results were explained by patients, who played the serious game LAKA, as a "confrontation with yourself," which reflected self-discrepancies. Important characteristics of serious gaming in the study's context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, and the limited flexibility in regard to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role-taking and the planning and facilitating (ie, local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed very small average differences between the study groups in self-reported depression, pain, and fatigue changes (-.07<beta<-.17, all 95% CI upper bounds <0), which were mediated by small group differences in mindfulness (beta=.26, 95% CI .02-.51). Mindfulness changes were positively associated with patient involvement in serious gaming (n=114, beta=.36, P=.001). Acceptance of serious gaming was lower in older patients. Average health outcome changes went up to a medium size in patients that reported lower active coping with stress and lower pain coping before serious gaming. Mindfulness changes and gaming acceptance perceptions covaried with group structure and immediate feedback sessions after serious gaming.

CONCLUSIONS

This study developed transferable insight into how and why serious gaming can facilitate additional learning about coping in order to reduce burdens of chronic pain or fatigue symptoms in certain patients and in actual treatment circumstances. Future studies are needed to continue the development of this fallible theory. Such research will further support decisions about using, designing, allocating, and tailoring serious gaming to optimize important patient health benefits.

TRIAL REGISTRATION

Netherlands Trial Register NTR6020; https://www.trialregister.nl/trial/5754.

Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people

BACKGROUND

Pain is an independent risk factor for falling. One in two older community-dwelling people with musculoskeletal pain fall each year. This study examined physical, psychological and medical factors as potential mediators to explain the relationship between knee pain and falls.

METHODS

Three hundred and thirty-three community-dwelling people aged 70+ years (52% women) participated in this cohort study with a 1-year follow-up for falls. Participants completed questionnaires (medical history, general health and concern about falls) and underwent physical performance tests. Participants were classified into 'pain' and 'no pain' groups based on self-reported knee pain. Poisson Regression models were computed to determine the Relative Risk (RR) of having multiple falls and potential mediators for increased fall risk.

RESULTS

One hundred and eighteen (36%) participants were categorised as having knee pain. This group took more medications and had more medical conditions (P < 0.01) compared to the no pain group. The pain group had poorer balance, physical function and strength and reported increased concern about falls. Sixty one participants (20%) reported ≥2 falls, with the pain group twice as likely to experience multiple falls over the 12 month follow up (RR = 2.0, 95% confidence interval (CI) = 1.27-3.13). Concern about falls, knee extension torque and postural sway with eyes closed were identified as significant and independent mediators of fall risk, and when combined explained 23% of the relationship between knee pain and falls.

CONCLUSION

This study has identified several medical, medication, psychological, sensorimotor, balance and mobility factors to be associated with knee pain, and found the presence of knee pain doubles the risk of multiple falls in older community living people. Alleviating knee pain, as well as addressing associated risk factors may assist in preventing falls in older people with knee pain.

Health Perception According to the Lifestyle of University Students

University students are characterized by having inadequate eating habits, along with an unhealthy lifestyle, which, among other factors, can affect the perception they have of their state of health. The aim of the study was to evaluate the health perception of a group of university students according to lifestyle. A cross-sectional observational study was carried out on 214 university students from different universities and branches of knowledge. Anthropometric data were collected. Three questionnaires were administered: PREDIMED (Mediterranean Diet (MD) adherence), SF-36 (perception of health state) and GPAQ (physical activity (PA)). The differences between variables were analyzed using Student-t or Mann-Whitney U, Kruskal-Wallis and Pearson Chi-Square tests. Statistical significance was reached at p < 0.05. Most students were found to be normal weighted. The subjects presented an moderate MD adherence, this being better in Health Sciences students. 75.7% practiced light PA. The health perception is worse for most of the subscales analyzed than that of the reference population (except physical-function, physical-role, and emotional-role). There is an association between PA and health perception: students with intense PA have less body pain and better physical function; the less active, the less vitality. The more physically active subjects the greater MD adherence. Lifestyle and eating habits of health sciences students are healthier than that of students from other branches of knowledge. The physically active subjects have a better perception of quality of life-related to health and greater MD adherence.

Voluntary exercise improves voiding function and bladder hyperalgesia in an animal model of stress-induced visceral hypersensitivity: A multidisciplinary approach to the study of urologic chronic pelvic pain syndrome research network study

OBJECTIVE

The underlying mechanism of interstitial cystitis/bladder pain syndrome (IC/BPS) is not well understood and evaluation of current therapeutic interventions has not identified any generally effective treatments. Physical activity has shown beneficial effects on individuals suffering from chronic pain. Anxiety-prone rats exposed to water avoidance stress (WAS) develop urinary frequency and lower bladder sensory thresholds with high face and construct validity for the study of IC/BPS. The aim of this study was to evaluate the role of chronic voluntary exercise on urinary frequency, voiding function, and hyperalgesia in animals exposed to WAS.

MATERIALS AND METHODS

Twenty-six female Wistar-Kyoto rats were exposed to WAS and thereafter randomized to either voluntary exercise for 3 weeks or sedentary groups. Voiding parameters were assessed at baseline, post-WAS, and weekly for 3 weeks. Before euthanasia, the animals underwent cystometrogram (CMG), external urinary sphincter electromyography, and assessment of visceromotor response (VMR) to isotonic bladder distension (IBD).

RESULTS

WAS exposure resulted in adverse changes in voiding parameters. Compared with sedentary animals, animals in the voluntary exercise group had improved voiding parameters during metabolic cage and CMG testing, as well as improved bladder sensory thresholds as determined by VMR during IBD.

CONCLUSION

Voluntary exercise in an animal model of chronic stress leads to improvement in voiding function and visceral bladder hyperalgesia.

Multidisciplinary Pain Management of Chronic Back Pain: Helpful Treatments from the Patients' Perspective

Multidisciplinary pain management programs (MPMP) for patients suffering from chronic back pain include a variety of treatment modalities. The patients’ perceived helpfulness of these treatment modalities remains unclear. The aims of this prospective observational cohort study were to assess (i) the patients’ perceived helpfulness of different treatment modalities, (ii) the influence of sociodemographic characteristics on the patient’s perspective and (iii) whether treatment outcomes are affected by helpfulness ratings. Treatment modalities of this three-week MPMP consisted of individual physiotherapy, group-based physiotherapy, relaxation therapy, aquatic therapy, back education, medical training therapy, biofeedback, psychological pain therapy and music therapy. The study comprised 395 patients. The main outcome was the patients’ perceived treatment helpfulness at the end of the program measured by a self-reported questionnaire ranging from 1 (not at all helpful) to 6 (extremely helpful). Secondary outcomes were treatment effects on pain, pain related disability, functional ability and level of depressive symptoms measured by self-reported questionnaires (NRS, PDI, FFbH-R, ADS-L). A total of 276 patients (22–64 years, 57% female) were available for overall analysis. Multivariate-analysis-of-variance- (MANOVA-) related results revealed that perceived treatment helpfulness (range 1–6) differed significantly between treatment modalities: individual physiotherapy (M = 5.00), group-based physiotherapy (M = 4.87), relaxation therapy (M = 4.6), aquatic therapy (M = 4.54), back education (M = 4.43), medical training therapy (M = 3.38), biofeedback (M = 3.31), psychological pain therapy (M = 3.15), music therapy (M = 3.02). Pain, pain related disability and levels of depressive symptoms significantly improved after the program (p < 0.001) whereas functional ability decreased (p < 0.01). Significant correlations were found between helpfulness ratings and sociodemographic data indicating that perceived treatment helpfulness was influenced by patient-related factors. Importantly, the degree of pain-related improvements was affected by the patients’ perceived treatment helpfulness. In conclusion, patients’ perceived treatment helpfulness differs significantly between treatment modalities and corresponds to treatment outcome.

Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL): A Responsive and Reliable Tool for Patients with Non-Operative Shoulder Pain

BACKGROUND

Medicare regulations require that physical therapists report functional limitations and severity modifiers utilizing a claims-based data collection tool. The Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL) captures key constructs about patient confidence and difficulty but has not been evaluated for responsiveness/ reliability during a routine clinical encounter with patients who have shoulder pathology. The purposes of this retrospective study are to 1) explore if mOPTIMAL changes after a single session with a physical therapist, and 2) determine if the tool is reliable among people with non-operative shoulder pain.

METHODS

We included 106 individuals (58% female; mean age 45.8; range: 18-94 yrs.) with "non-operative" shoulder pathology who were seen in outpatient physical therapy from 2011 to 2012. Subjects completed a mOPTIMAL survey and a pain scale before and immediately after the initial physical therapy visit. The mOPTIMAL is a patient-centered instrument that assesses how much "Difficulty" and "Confidence" a client has in performing a battery of functional tasks. T-tests, Cronbach's Alpha, and Intra-class Correlations were used to assess responsiveness, internal consistency, and reliability, respectively.

RESULTS

After a single visit, participants reported improved Confidence with sleeping, dressing/ bathing, throwing, carrying, and lifting (adjusted for ceiling effects; p<0.002) but no change in pain. Cronbach's Alpha and Intra-class Correlations were excellent (0.821-0.923; 0.967, respectively).

CONCLUSIONS

mOPTIMAL is a reliable and responsive tool with excellent internal consistency. This observational study revealed that patient Confidence may change independent of Pain after a single physical therapy visit. Taken together, the mOPTIMAL appears to be an excellent tool to report severity modifiers in compliance with Medicare regulations.Level of Evidence: IV.

The Feasibility and Effectiveness of a New Practical Multidisciplinary Treatment for Low-Back Pain: A Randomized Controlled Trial

Low-back pain is a major health problem exacerbated by the fact that most treatments are not suitable for self-management in everyday life. Particularly, interdisciplinary programs consist of intensive therapy lasting several weeks. Additionally, therapy components are rarely coordinated regarding reinforcing effects, which would improve complaints in persons with higher pain. This study assesses the effectiveness of a self-management program, firstly for persons suffering from higher pain and secondly compared to regular routines. Study objectives were treated in a single-blind multicenter controlled trial. A total of n = 439 volunteers (age 18-65 years) were randomly assigned to a twelve-week multidisciplinary sensorimotor training (3-weeks-center- and 9-weeks-homebased) or control group. The primary outcome pain (Chronic-Pain-Grade) as well as mental health were assessed by questionnaires at baseline and follow-up (3/6/12/24 weeks, M2-M5). For statistical analysis, multiple linear regression models were used. N = 291 (age 39.7 ± 12.7 years, female = 61.1%, 77% CPG = 1) completed training (M1/M4/M5), showing a significantly stronger reduction of mental health complaints (anxiety, vital exhaustion) in people with higher than those with lower pain in multidisciplinary treatment. Compared to regular routines, the self-management-multidisciplinary treatment led to a clinically relevant reduction of pain-disability and significant mental health improvements. Low-cost exercise programs may provide enormous relief for therapeutic processes, rehabilitation aftercare, and thus, cost savings for the health system.

Association between lifestyle and musculoskeletal pain: cross-sectional study among 10,000 adults from the general working population

BACKGROUND

Work-related musculoskeletal pain is a major cause of work disability and sickness absence. While pain is a multifactorial phenomenon being influenced by work as well as lifestyle, less is known about the association between specific lifestyle factors and the type of musculoskeletal pain. The aim of the study was to investigate if a dose-response association existed between lifestyle factors and musculoskeletal pain intensity in the low back and neck-shoulder.

METHODS

Currently employed wage earners (N = 10,427) replied in 2010 to questions about work environment, lifestyle and health. Logistic regression analyses adjusted for various confounders tested the association of alcohol intake, physical activity, fruit and vegetable intake, and smoking (explanatory variables) with low back pain and neck-shoulder pain intensity (outcomes variables, scale 0-9, where ≥4 is high pain).

RESULTS

The minimally adjusted model found that physical activity and fruit and vegetable intake were associated with lower risk of musculoskeletal pain, while smoking was associated with higher risk of musculoskeletal pain. In the fully adjusted model, physical activity ≥5 h per week was associated with lower risk of low back pain and neck-shoulder pain with risk ratios (RR) of 0.95 (95% CI 0.90-1.00) and 0.90 (95% CI 0.82-0.99), respectively. No association was found between alcohol intake and pain.

CONCLUSION

Being physically active associated with lower risk of having musculoskeletal pain, while smoking habits and healthy eating were associated with higher pain when adjusting for age and gender. Considering the continuously increasing retirement age in many societies, initiatives to promote healthy habits should still be a political priority to help the workers to stay healthy and cope to their work.

Understanding Physiotherapists' Intention to Counsel Clients with Chronic Pain on Exercise: A Focus on Psychosocial Factors

Purpose: Twenty percent of Canadians experience chronic pain. Exercise is an effective management strategy, yet participation levels are low. Physiotherapists can be key to counselling clients to engage in long-term unsupervised exercise. Yet, investigations that identify psychosocial factors related to physiotherapists' intention to counsel are lacking. The purpose of this study was to examine whether physiotherapists' knowledge of chronic pain, beliefs about pain, and self-efficacy to counsel on exercise predicted their intention to counsel clients with chronic pain on exercise. Method: Practicing physiotherapists (N = 64) completed an online survey that assessed their knowledge of chronic pain, beliefs about pain, self-efficacy, and intention to counsel. A two-step hierarchical multiple regression predicted intention. Step 1 controlled for years of practice, and Step 2 included study variables significantly correlated with intention. Results: Beliefs about pain (r = -0.35, p < 0.01) and self-efficacy (r = 0.69, p < 0.01) were significantly correlated with intention. The overall regression model was significant, F _3,60 = 18.73; p < 0.001. Self-efficacy was the sole significant predictor, t ₆₀ = 5.71, p < 0.0001, sr ² = 28%. Conclusions: Self-efficacy may facilitate physiotherapists' intention to counsel on exercise for chronic pain. If shown to be a causal factor, interventions that target a change in physiotherapists' self-efficacy should be pursued.

Psychometric Evaluation of the Nursing Outcome Knowledge: Pain Management in People with Chronic Pain

Pain has a major impact on health and quality of life. Since the level of knowledge of painful conditions can influence how these are addressed and managed, assessing this knowledge in patients becomes crucial. As a result, it is necessary to have culturally adapted and validated instruments that specifically measure patients' knowledge of chronic pain management. The objective of this study was to carry out the Spanish cultural adaptation and the validation of the outcome Knowledge: Pain Management of the Nursing Outcomes Classification (NOC) in patients with chronic pain, defined as extent of understanding conveyed about causes, symptoms, and treatment of pain. A three-stage study was designed: 1) translation and cultural adaptation through an expert panel, 2) content validation, 3) clinical validation. This study provides nurses with a Spanish version of this scale adapted to their context, as well as a set of structured indicators to measure patients' knowledge about chronic pain. The results indicated that the culturally adapted Spanish version of the outcome Knowledge: Pain Management had a high level of content validity (CVI = 0.92), with 27 indicators being distributed between two factors. This version has been shown to be reliable in terms of inter-observer agreement (κ = 0.79) and internal consistency (α = 0.95). In conclusion, Knowledge: Pain Management has been shown to be reliable and valid to measure knowledge of chronic pain.

Neighborhood Walkability in Relation to Knee and Low Back Pain in Older People: A Multilevel Cross-Sectional Study from the JAGES

Few studies have focused on a relationship between the built environment and musculoskeletal pain. This study aimed to investigate an association between neighborhood walkability and knee and low back pain in older people. Data were derived from the Japan Gerontological Evaluation Study (JAGES) 2013, a population-based study of independently living people ≥65 years old. A cross-sectional multilevel analysis was performed, of 22,892 participants in 792 neighborhoods. Neighborhood walkability was assessed by residents' perceptions and population density. Dependent variables were knee and low back pain restricting daily activities within the past year. The prevalence of knee pain was 26.2% and of low back pain 29.3%. After adjusting for sociodemographic covariates, the prevalence ratio (PR) of knee and low back pain was significantly lower in neighborhoods with better access to parks and sidewalks, good access to fresh food stores, and higher population densities. After additionally adjusting for population density, easier walking in neighborhoods without slopes or stairs was significantly inversely correlated with knee pain (PR 0.91, 95% confidence interval 0.85-0.99). Neighborhoods with walkability enhanced by good access to parks and sidewalks and fresh food stores, easy walking without slopes or stairs, and high population densities, had lower prevalences of knee and low back pain among older people. Further studies should examine environmental determinants of pain.

Optimised transcranial direct current stimulation (tDCS) for fibromyalgia-targeting the endogenous pain control system: a randomised, double-blind, factorial clinical trial protocol

INTRODUCTION

Fibromyalgia (FM) is a common debilitating condition with limited therapeutic options. Medications have low efficacy and are often associated with adverse effects. Given that FM is associated with a defective endogenous pain control system and central sensitisation, combining interventions such as transcranial direct current stimulation (tDCS) and aerobic exercise (AE) to modulate pain-processing circuits may enhance pain control.

METHODS AND ANALYSIS

A prospective, randomised (1:1:1:1), placebo-controlled, double-blind, factorial clinical trial will test the hypothesis that optimised tDCS (16 anodal tDCS sessions combined with AE) can restore of the pain endogenous control system. Participants with FM (n=148) will undergo a conditioning exercise period and be randomly allocated to one of four groups: (1) active tDCS and AE, (2) sham tDCS and AE, (3) active tDCS and non-aerobic exercise (nAE) or (4) sham tDCS and nAE. Pain inhibitory activity will be assessed using conditioned pain modulation (CPM) and temporal slow pain summation (TSPS)-primary outcomes. Secondary outcomes will include the following assessments: Transcranial magnetic stimulation and electroencephalography as cortical markers of pain inhibitory control and thalamocortical circuits; secondary clinical outcomes on pain, FM, quality of life, sleep and depression. Finally, the relationship between the two main mechanistic targets in this study-CPM and TSPS-and changes in secondary clinical outcomes will be tested. The change in the primary efficacy endpoint, CPM and TSPS, from baseline to week 4 of stimulation will be tested with a mixed linear model and adjusted for important demographic variables.

ETHICS AND DISSEMINATION

This study obeys the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of Partners Healthcare under the protocol number 2017P002524. Informed consent will be obtained from participants. Study findings will be reported in conferences and peer-reviewed journal publications.

TRIAL REGISTRATION NUMBER

NCT03371225.

The dosing of aerobic exercise therapy on experimentally-induced pain in healthy female participants

Knowledge of efficacious dosing respective to exercise type and pain condition is extremely limited in the literature. This study aimed to determine the impact of dose of moderate intensity treadmill walking on experimentally-induced pain in healthy human participants. Forty females were divided into 4 groups: control (no exercise), low dose exercise (3×/wk), moderate dose exercise (5×/wk) or high dose exercise (10×/wk). Over a 7-day period, subjects performed treadmill walking during assigned exercise days. Both qualitative and quantitative measures of pain were measured at baseline, during the trial, and 24 hrs post-final intervention session via sensitivity thresholds to painful thermal and painful pressure stimulation. Significant effects of treatment were found post-intervention for constant pressure pain intensity (p = 0.0016) and pain unpleasantness ratings (p = 0.0014). Post-hoc tests revealed significant differences between control and moderate and control and high dose groups for constant pressure pain intensity (p = 0.0015), (p = 0.0094), respectively and constant pressure pain unpleasantness (p = 0.0040), (p = 0.0040), respectively. Moderate and high dose groups had the greatest reductions in ratings of pain, suggesting that our lowest dose of exercise was not sufficient to reduce pain and that the moderate dose of exercise may be a sufficient starting dose for exercise-based adjuvant pain therapy.

Early Therapeutic Mobility and Changes in Scores for Pain and Fatigue

This report is a secondary analysis of data from a larger study of a nurse-led early therapeutic mobility intervention among patients receiving mechanical ventilation. This analysis evaluated whether intervention frequency or intensity was associated with pain or fatigue. Frequency was defined as once-daily versus twice-daily interventions. Intensity was defined as low (in-bed activities) or moderate (out-of-bed activities). Thirty-nine patients self-reported pain and fatigue immediately before and after the intervention. Neither pain nor fatigue increased significantly (mean increase, <1 [scale of 0-10] for 95% of interventions). Four patients reported decrements in pain; 1 reported a decrease in fatigue. Less than 5% of enrolled patients indicated a score change of +4 to +6 for pain or fatigue, typically with the first intervention that included sitting at the edge of the bed. Future research could examine the distress associated with these symptoms in critically ill adults receiving early therapeutic mobility interventions.

Strong Labour Market Inequality of Opportunities at the Workplace for Supporting a Long and Healthy Work-Life: The SeniorWorkingLife Study

Most European countries are gradually increasing the state pension age, but this may run counter to the capabilities and wishes of older workers. The objective of this study is to identify opportunities in the workplace for supporting a prolonged working life in different groups in the labour market. A representative sample of 11,200 employed workers ≥ 50 years responded to 15 questions in random order about opportunities at their workplace for supporting a prolonged working life. Respondents were stratified based on the Danish version of the International Standard Classification of Occupations (ISCO). Using frequency and logistic regression procedures combined with model-assisted weights based on national registers, results showed that the most common opportunities at the workplace were possibilities for more vacation, reduction of working hours, flexible working hours, access to treatment, further education and physical exercise. However, ISCO groups 5–9 (mainly physical work and shorter education) had in general poorer access to these opportunities than ISCO groups 1–4 (mainly seated work and longer education). Women had poorer access than men, and workers with reduced work ability had poorer access than those with full work ability. Thus, in contrast with actual needs, opportunities at the workplace were lower in occupations characterized by physical work and shorter education, among women and among workers with reduced work ability. This inequality poses a threat to prolonging working life in vulnerable groups in the labour market.

Temporomandibular disorders: improving outcomes using a multidisciplinary approach

Patients with temporomandibular disorders (TMD) can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental. There are various health professions that have competence in the treatment of TMD, however, although in the most complex cases should be treated simultaneously, still too many patients receive unique treatments and only from one point of view. This review exposes the treatments available from a clinical-scientific perspective and also emphasizes the importance of working in specialized units with those professionals who have competencies on the different conditions that may occur.

Practical approach to a patient with chronic pain of uncertain etiology in primary care

Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.

Exercise as an Intervention to Mitigate Decreased Cognitive Function From Cancer and Cancer Treatment: An Integrative Review

BACKGROUND

Decreased cognitive function associated with non-central nervous system cancers and cancer treatment significantly affects cancer survivors' quality of life. Exercise may be an effective intervention to mitigate decreased cognitive function.

OBJECTIVE

The aim of this article is to conduct an integrative review to summarize and critique the available evidence related to the use of exercise as a potential intervention for decreased cognitive function from cancer and cancer treatment.

METHODS

We conducted an integrative review through January 2016 utilizing PubMed, CINAHL, and PsycINFO. Broad inclusion criteria included any quantitative study in which cognitive outcomes were reported in relationship to any type of exercise for adult cancer survivors. Effect sizes were calculated when possible based on available data.

RESULTS

Twenty-six studies were included for review. The majority of studies (including aerobic or resistance exercise as well as mindfulness-based exercise) were associated with some improved cognitive outcomes. However, studies varied significantly in levels of evidence, cognitive domains assessed, and types of cognitive measures. Less than half of the studies included objective measures of cognitive function.

CONCLUSIONS

The evidence shows promising trends for the use of exercise as a potential intervention for improving cognitive function following cancer and cancer treatment, but questions remain concerning exercise type, timing of initiation, intensity, frequency, and duration.

IMPLICATIONS FOR PRACTICE

Additional research is warranted to understand how various types of exercise influence cognitive function in the cancer survivor population and to better understand the mechanisms driving these effects. Trial designs that include both objective and subjective measures of cognitive function are needed.

Protocol for a feasibility randomised controlled trial of a musculoskeletal exercise intervention versus usual care for children with haemophilia

INTRODUCTION

Haemophilia is a rare, inherited disorder in which blood does not clot normally, resulting in bleeding into joints and muscles. Long-term consequence is disabling joint pain, stiffness, muscle weakness, atrophy and reduced mobility. The purpose of this proposed feasibility of a randomised controlled trial (RCT) is to test the feasibility of an age-appropriate physiotherapy intervention designed to improve muscle strength, posture and the way boys use their joints during walking and everyday activities.

METHODS AND ANALYSIS

A small-scale two-centre RCT of a 12-week muscle strengthening exercise intervention versus usual care for young children with haemophilia will be conducted. Primary outcomes will be safety and adherence to the exercise intervention. Secondary outcomes will include recruitment, retention and adverse event rates, clinical data, muscle strength, joint biomechanics and foot loading patterns during walking, 6 min timed walk, timed-up-and-down-stairs, EQ-5D-Y, participants' perceptions of the study, training requirements and relevant costs. Recruitment, follow-up, safety and adherence rates will be described as percentages. Participant diary and interview data will be analysed using a framework analysis. Demographic and disease variable distributions will be analysed for descriptive purposes and covariant analysis. Estimates of differences between treatment arms (adjusted for baseline) and 75% and 95% CIs will be calculated.

ETHICS AND DISSEMINATION

The study has ethical approval from the London-Fulham Research Ethics Committee (17/LO/2043) as well as Health Research Authority approval. As well as informing the design of the definitive trial, results of this study will be presented at local, national and international physiotherapy and haemophilia meetings as well as manuscripts submitted to peer-reviewed journals. We will also share the main findings of the study to all participants and the Haemophilia Society.