The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature

The immediate effect of a single session of pain neuroscience education on pain and the autonomic nervous system in subjects with persistent pain, a pilot study

BACKGROUND

The autonomic nervous system is a system that operates at the subconscious level and has been associated with neurobehavioral aspects of pain. Overall, persistent pain has a stimulating effect on the sympathetic nervous system. A promising emerging nonpharmacological treatment to manage persistent pain is neuroscience-based pain education. The overarching goal of neuroscience-based pain education is to change cognitions about pain and the pain experience through education. The aim was to determine the immediate and short-term impact of a neuroscience-based pain education video on the autonomic nervous system and pain in a subgroup of individuals with persistent pain.

METHODS

A convenience sample of 26 subjects were recruited for this study. Each subject indicated their pain level at the time of testing using a Visual Analogue Scale. Automated pupillometry was utilized to measure pupil diameter. After two minutes of accommodation to the goggles, the pupil was measured continuously for 60 s. Following this a 5-minute video presentation "Understanding Pain" was watched, followed by a continuous pupil measurement for 60 s. Three minutes after this measure, the final pupil diameter measurement was taken for 60 s. After completing the final pupil measure, the subject was asked to fill out a second Visual Analogue Scale and a Global Rate of Change.

OUTCOMES

Each subject completed a Global Rating of Change Scale and the mean score was 1.14 (SD = 1.61 and a SEM = 0.), supporting the hypothesis of an overall self-perceived benefit from the intervention. There was a statistically significant difference in pain following the video, P < 0.01. A significant correlation was observed between the self-perceived decrease in pain level and the Global Rating of Change score, p = 0.02. There was no statistically significant difference in the mean pupil diameter following the video with p = 0.76 for the right eye and p = 0.250 for the left eye.

DISCUSSION

This pilot study demonstrated that a 5-minute neuroscience-based pain education video reduced perceived pain in a small sample of subjects with persistent pain. Watching the neuroscience-based pain education video did not seem to result in an immediate generalized autonomic nervous system response. However, it resulted in a different reaction on each eye. This unequal response might be the result of the hemispheric lateralization of the ANS. This study supports the fact that the pain experience is determined by the balance between conscious cognitive processes and subconscious processes based on previous psychological experiences.

Effects of neuromuscular training on knee proprioception in individuals with anterior cruciate ligament injury: a systematic review and GRADE evidence synthesis

OBJECTIVE

To systematically review and summarise the evidence for the effects of neuromuscular training compared with any other therapy (conventional training/sham) on knee proprioception following anterior cruciate ligament (ACL) injury.

DESIGN

Systematic Review.

DATA SOURCES

PubMed, CINAHL, SPORTDiscus, AMED, Scopus and Physical Education Index were searched from inception to February 2020.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials investigating the effects of neuromuscular training on knee-specific proprioception tests following a unilateral ACL injury were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened and extracted data and assessed risk of bias of the eligible studies using the Cochrane risk of bias 2 tool. Overall certainty in evidence was determined using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool.

RESULTS

Of 2706 articles retrieved, only 9 RCTs, comprising 327 individuals with an ACL reconstruction (ACLR), met the inclusion criteria. Neuromuscular training interventions varied across studies: whole body vibration therapy, Nintendo-Wii-Fit training, balance training, sport-specific exercises, backward walking, etc. Outcome measures included joint position sense (JPS; n=7), thresholds to detect passive motion (TTDPM; n=3) or quadriceps force control (QFC; n=1). Overall, between-group mean differences indicated inconsistent findings with an increase or decrease of errors associated with JPS by ≤2°, TTDPM by ≤1.5° and QFC by ≤6 Nm in the ACLR knee following neuromuscular training. Owing to serious concerns with three or more GRADE domains (risk of bias, inconsistency, indirectness or imprecision associated with the findings) for each outcome of interest across studies, the certainty of evidence was very low.

CONCLUSIONS

The heterogeneity of interventions, methodological limitations, inconsistency of effects (on JPS/TTDPM/QFC) preclude recommendation of one optimal neuromuscular training intervention for improving proprioception following ACL injury in clinical practice. There is a need for methodologically robust RCTs with homogenous populations with ACL injury (managed conservatively or with reconstruction), novel/well-designed neuromuscular training and valid proprioception assessments, which also seem to be lacking.

PROSPERO REGISTRATION NUMBER

CRD42018107349.

The Effect of Literacy-Adapted Psychosocial Treatments on Biomedical and Biopsychosocial Pain Conceptualization

This is a secondary data analysis of a subgroup of participants who received the Learning About My Pain (LAMP) intervention (clinicaltrials.gov identifier NCT01967342). We examined the effects of LAMP on pre-to-post changes in biomedical and biopsychosocial pain conceptualization and whether those changes in pain conceptualization were associated with physical and psychological functioning. Participants were randomized into three conditions: Cognitive Behavioral Therapy (CBT), Pain Psychoeducation (EDU), or Usual Medical Care (UC). Results based on 225 participants who completed the Pain Concepts Questionnaire (PCQ) showed a pre-to-post reduction in biomedical pain conceptualization (BM), an increase in biopsychosocial pain conceptualization (BPS), and an increase in BPS/BM ratio for CBT and EDU but not UC. There were no differences between CBT and EDU in post-treatment PCQ scores. Compared to those with lower BM pain beliefs scores at post-treatment, participants endorsing higher BM pain beliefs scores reported greater pain intensity and greater pain interference. Furthermore, higher BM pain beliefs scores at post-treatment and lower BPS/BM ratio were associated with higher levels of pain catastrophizing. Overall, results of this study suggest the need for targeting specific pain beliefs that influence pain-related outcomes. PERSPECTIVE: This article presents the potential benefits of providing literacy-adapted psychosocial treatments to expand pain conceptualization beyond a biomedical-only understanding and toward a biopsychosocial conceptualization of the experience of pain. Furthermore, the association of changes in pain conceptualization and pain-related functioning argues for its potential clinical relevance.

"A journey to learn about pain": the development and validation of a comic book about pain neuroscience education for children

BACKGROUND

Pain education resources for children using appropriate language and illustrations remain scarce.

OBJECTIVES

We aimed to summarize the development process and testing for face and content validity of a structured comic book about pain education for children.

METHODS

A first draft of a comic book was developed (Portuguese and English) based on pain education concepts. Experts in pediatric pain from different countries analyzed content, objectives, language, illustrations, layout, motivation, and cultural adjustment. A third draft developed in Portuguese considering experts' suggestions was presented to children and parents in Brazil. The total adequacy score was calculated from the sum of the scores obtained in each domain, divided by the maximum total score. Descriptive analysis is presented.

RESULTS

The expert panel was composed of 11 (64.7%) physical therapists, and 6 (35.3%) psychologists. The total adequacy score (0-100%) was 87.74%. The third draft version of the comic book was presented to 28 children and the final version was presented to 16 children with a mean age of 9.6 years. Children were totally satisfied (n=4; 26.7%) or satisfied (n=9; 56.2%) with the story of the comic book. The readability of the comic book was considered suitable for grades 4 to 6 educational level.

CONCLUSION

The comic book "A Journey to Learn about Pain" was validated for face and content validity by the expert panel and the Brazilian target population. This comic book is available in Portuguese and English and can be a potentially useful resource for children.

Exploring physiotherapy practice within hospital-based interprofessional chronic pain clinics in Ontario

Background: Chronic pain affects one in five persons and is a leading contributor to years lived with disability and high health care costs. In 2016, the government of Ontario increased public funding for pediatric and adult hospital-based interprofessional chronic pain clinics (HICPCs) in Ontario, Canada, expanding the role of physiotherapy in chronic pain management in the province. This role has yet to be described in the literature.

Aim: The aim of this study was to explore physiotherapy practice within HICPCs in Ontario.

Methods: We conducted an interpretive description qualitative study based on semistructured interviews with physiotherapists employed in pediatric and adult HICPCs in Ontario. Interviews were audio recorded, transcribed verbatim, and reviewed for accuracy. We analyzed interview data using thematic analysis.

Results: Ten physiotherapists who practiced in pediatric and adult HICPCs (n = 4 pediatric; n = 6 adult) in Ontario were interviewed between February and April 2020. We constructed five themes related to physiotherapy practice in this setting. Themes included (1) contributing a functional lens to care; (2) empowering through pain education; (3) facilitating participation in physical activity and exercise; (4) supporting engagement in self-management strategies; and (5) implementing a collaborative approach to whole-person care.

Conclusions: Our results illuminate how physiotherapy practice within HICPCs in Ontario focuses on providing a collaborative and whole-person approach to care, with an emphasis on supporting patients to increase their functional capacity by promoting engagement in active chronic pain management strategies.

Assessment Tools of Patient Competences: The Spanish Version of the R-NPQ and Three Practical Cases in Women with Breast Cancer and Persistent Pain

Persistent pain following treatment for breast cancer (PPBCT) is a prevalent and complex clinical issue. Education together with physiotherapy have been shown to lessen pain and disability in chronic pain. Although the evaluation of the patient’s competences is a major part of the educational program, the published educational programs rarely describe the tools used to assess competences, especially regarding those related to decision-making and problem-solving. The aim of this study was to provide two competences assessment tools: the cross-cultural adaptation and validation of the Spanish version of the Revised Neurophysiology of Pain Questionnaire (R-NPQ) and practical cases of women with PPBCT. The Spanish cross-cultural adaptation was conducted following recognized criteria. Measurement properties testing included an analysis of construct validity (known-groups approach), reliability (internal consistency and test-retest reliability), responsiveness, interpretability, and feasibility. To promote a tool that would allow evaluation of the educational program competences, a group of experts developed three cases extracted from real contexts by means of an iterative process. A total of 80 women with PPBCT (mean age 56 years) and 81 physiotherapy students (mean age 20 years) participated in the measurement properties analysis. The three developed cases were presented to the same 80 women with PPBCT before and after the educational program. As we expected, students showed a significantly higher score (p < 0.001) than did women with PPBCT in the R-NPQ questionnaire, with a large effect size (d = 2.49), demonstrating good construct validity. The Cronbach alpha was 0.90 (95% CI, 0.87–0.92) and the intraclass correlation coefficient was 0.82 (95% CI, 0.73–0.88). A large effect size (5.2) was found, as we expected, between baseline and post-treatment scores, suggesting adequate responsiveness. In addition, identifying and analyzing, decision making, communicating needs, knowing how to manage, and problem-solving skills were evaluated through the three practical cases. Most women (88.75%) reached the highest level in the assessment rubric of the proposed practical cases. The Spanish R-NPQ is a comprehensible, valid, reliable, and responsive tool for Spanish women with PPBCT. The practical cases are a useful competence assessment tool and were well accepted by women with PPBCT. Further studies are needed to investigate more competence assessment tools and to investigate whether the achievement of different levels of competences has an effect on health behaviors.

Effect of a Psychologically Informed Intervention to Treat Adolescents With Patellofemoral Pain: A Randomized Controlled Trial

OBJECTIVE

To determine whether the addition of a brief psychologically informed video to traditional physical therapy influenced function (primary aim), pain, and psychological beliefs (secondary aims) among adolescents with patellofemoral pain (PFP).

DESIGN

Double-blind randomized controlled trial.

SETTING

Outpatient physical therapy clinics of a single pediatric hospital.

PARTICIPANTS

Sixty-six adolescents with PFP (14.8±1.7 years old, 65% female).

INTERVENTION

Adolescents were randomly assigned to view a brief psychologically informed video (n=34) or control video (n=32). The psychologically informed video targeted pain-related fear and pain catastrophizing, and the control video related basic anatomy and factors involved in PFP.

MAIN OUTCOME MEASURES

The primary outcome was change in function (Anterior Knee Pain Scale). Secondary outcomes were change in psychological beliefs (fear-avoidance beliefs, kinesiophobia, pain catastrophizing) and pain. Outcomes were assessed at baseline, immediately post intervention, at 2 weeks, at 6 weeks, and at 3 months.

RESULTS

Using a 2-way mixed analysis of variance, change in function in the intervention group was greater than the control group, with a moderate treatment effect noted (P=.001, partial η²=0.1). Post hoc testing revealed that there was a significant interaction between the intervention and time from baseline to 2 weeks, but no interaction was noted between 2 weeks and 3 months. The psychologically informed video significantly reduced maladaptive psychological beliefs (P=.01, η²=0.32). No significant between-group differences in pain were noted.

CONCLUSIONS

Incorporating a brief one-time psychologically informed video into standard physical therapy care significantly reduced pain-related fear, reduced pain catastrophizing, and improved function among adolescents with PFP. The immediate effect noted on function did not continue throughout the course of care.

Development of the Conceptualization of Pain Questionnaire: A Measure to Study How Children Conceptualize Pain

(1) Background: Research has shown that thoughts about pain are important for the management of chronic pain in children. In order to monitor changes in thoughts about pain over time and evaluate the efficacy of treatments, we need valid and reliable measures. The aims of this study were to develop a questionnaire to assess a child’s concept of pain and to evaluate its psychometric properties; (2) Methods: This is a cross-sectional, two-phase, mixed-method study. A total of 324 individuals aged 8 to 17 years old responded to the newly created questionnaire. The Conceptualization of Pain Questionnaire (COPAQ) was calibrated using the Rasch model. The chi-square test was used for the fit statistics. Underfit and overfit of the model were determined and a descriptive analysis of infit and outfit was conducted to identify who responded erratically. Internal consistency was measured using the Person Separation Index (PSI); (3) Results: Fit to the Rasch model was good. Suitable targeting indicated which items were simple to answer; Person Fit identified 9.56% children who responded erratically; PSI = 0.814; (4) Conclusions: The findings suggest that COPAQ is a measure of a child’s concept of pain that is easy to administer and respond to. It has a good fit and a good internal consistency.

Effectiveness of perioperative pain science education on pain, psychological factors and physical functioning: A systematic review

OBJECTIVE

To synthesize the evidence on the effectiveness of pain science education on pain, psychological factors and physical functioning in adults who underwent surgery.

DATA SOURCES

A systematic literature search of English articles using PubMed/Medline, Embase, Web of Science Core Collection, and Cochrane Library.

REVIEW METHODS

The search strategy was constructed as follows: (((pain) AND (education)) OR (pain education)) AND (surgery). Only controlled quantitative studies in adults reporting outcome(s) on pain, psychological factors and/or physical functioning were included. Risk of bias was assessed using the Cochrane risk of bias tools. P-values and corresponding effect sizes for interaction-effect (time × group) portrayed the difference in change over time between groups were of interest. The last search was conducted on February 28, 2021.

RESULTS

Nine papers (n = 1078) were deemed eligible for this review. Two randomized controlled trials showed significant interaction effects. Breast cancer patients who had received one preoperative pain science education session showed a significant increase in postoperative pain compared to controls (P-value = 0.0394). Furthermore, psychological factors (pain catastrophizing and kinesiophobia) decreased in participants who had received pain science education before total knee arthroplasty, while this was not the case in the control group (P-value < 0.001, ƞ2p:0.11).

CONCLUSIONS

Overall, pain science education did not result in any significant postoperative effects on pain, psychological factors and/or physical functioning compared to controls. There is currently no strong evidence for the implementation of pain science education in the perioperative period.Registration number: PROSPERO: ID 161267, registration number CRD42020161267.

Knowledge and attitudes toward musculoskeletal pain neuroscience of manual therapy postgraduate students in the Netherlands

BACKGROUND

Health care practitioners' knowledge and attitudes influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. It is unclear to what extent physiotherapists undertaking a postgraduate master in manual therapy (MT students) possess the knowledge and attitudes toward pain neuroscience to be able to apply the biopsychosocial model in patients with MSK pain.

OBJECTIVES

The aim of this study was to assess the knowledge and attitudes toward pain neuroscience in MT students.

DESIGN

A cross-sectional study.

METHOD

Self-reported knowledge and attitudes were measured among students (n = 662) at baseline and in all years of the MT postgraduate programs in the Netherlands. The Knowledge and Attitudes of Pain questionnaire (KNAP) was used as a primary measure. Difference in KNAP-scores between baseline (0), year 1, year 2 and year 3 was tested using a one-way ANOVA (hypothesis: 0 < 1<2 < 3). A two factor ANOVA was used to determine the interaction effect of focused pain education and year in the curriculum with KNAP.

RESULTS

There was an overall significant difference of KNAP scores with a medium effect size (F(3, 218.18) = 13.56, p < .001, ω² = 0.059). Differences between years ranged from small to medium. Interaction effect of knowledge and attitudes and focused pain education was significant with a small effect size (F(6) = 2.597, p = .017, ω² = 0.012). Sensitivity analyses were consistent with the main results.

CONCLUSIONS

Positive differences in knowledge and attitudes toward pain neuroscience in MT students occur between the progressing years of the curriculum. Differences may be related to the provision of focused pain education.

Pre-Outpatient Group Education and Assessment in Chronic Pain: A Systematic Review

BACKGROUND

Pre-outpatient interventions in chronic pain have the potential to improve patient self-management earlier in primary or secondary care, which may minimize pain chronicity and negative health outcomes. The literature for this is sparse, and there are no existing systematic reviews on this topic.

METHODS

The purpose of this systematic review is to examine the evidence for pre-outpatient group interventions in chronic pain.

RESULTS

We identified four studies that looked at this: two randomized control trials, one prospective observational study, and one descriptive study. We identified high-quality evidence that a pre-outpatient group intervention reduces waiting times, moderate-quality evidence that it results in reduced costs per patient, very low-quality evidence that it reduces health care utilization, and very low-quality evidence that it improves service throughput. There were moderate-to-low levels of participant engagement with the initiative, which varied across the included studies. For patient outcome measures, we found no evidence that a pre-outpatient group intervention improves pain intensity, very low-quality evidence that it improves pain-related interference, low-quality evidence that it increases use of pain management strategies and produces high satisfaction levels, low-quality evidence that it improves pain self-efficacy, and no evidence that it improves psychological distress.

CONCLUSIONS

Group interventions before individual appointments have the potential to provide important improvements in service delivery, including improvements in waiting times and cost per patient. Benefits for patient outcome measures are less clear. Clinical heterogeneity and high levels of bias existed in the included studies. Further research is required so that meaningful conclusions can be made about these interventions.

Effectiveness of Pain Neurophysiology Education on Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Objectives

To estimate the effectiveness and safety of Pain Neurophysiology Education (PNE) on pain, disability, and psychological distress at post-intervention and long-term (closest to twelve months after initiating the intervention) in musculoskeletal pain (MSKP).

Methods

Randomized Controlled Trials (RCT) were identified in six engines, reference lists, ClinicalTrials.gov, and by contacting key researches. Risk of bias was assessed using Cochrane Collaboration Risk of Bias Tool 2.0. Meta-analyses, using Restricted Maximum Likelihood Method, were conducted to estimate standardized mean differences (SMD) and overall quality of evidence was evaluated according to GRADE.

Results

In total, 18 RCTs (n = 1,585) were included. There was small to moderate effects of PNE on pain at post-intervention and long-term: SMD = -0.32 (95% confidence interval [CI]: −.58; −.05) and SMD = −0.40 (95% CI: −.78; −.03), respectively. On disability, PNE had a small effect at post-intervention: SMD = -0.17 (95% CI: −.34; −.01) but was insignificant at long-term: SMD = −0.27 (95% CI: −.59; .06). Likewise, there was a small to moderate effect on psychological distress at post-intervention: SMD = −0.36 (95% CI: −.67; −.06) but was insignificant at long-term: SMD = −0.37 (95% CI: −.75; .01). Quality of evidence was low across all outcomes. Additional analyses showed significant effects of PNE, corresponding to moderate effects, on pain and psychological distress at both time points in chronic MSKP.

Conclusions

Overall quality of evidence was low, supporting PNE being safe and having small to moderate effects on pain at both time points, and on disability as well as psychological distress at post-intervention.

Effect of perioperative pain neuroscience education in patients with post-mastectomy persistent pain: a retrospective, propensity score-matched study

PURPOSE

Central sensitization (CS)-related symptoms and pain catastrophizing contribute to persistent post-mastectomy pain (PPMP). Pain neuroscience education (PNE) is effective in reducing CS-related symptoms and pain catastrophizing in patients with chronic pain. However, to date, no intervention study of PNE has been conducted to patients with PPMP. This study was aimed to examine whether PNE is more effective than biomedical education (BME) for PPMP.

METHODS

In this retrospective case-control study, 118 patients were included. We intervened different patients at different times as follows: (1) a BME group (n = 58) of patients who received BME combined with physiotherapy and (2) a PNE group (n = 60) of patients who received PNE combined with physiotherapy. One year after surgery, we assessed pain intensity and interference (brief pain inventory [BPI]), CS-related symptoms (central sensitization inventory [CSI]), and pain catastrophizing (pain catastrophizing scale [PCS]). Propensity score matching was used to reduce or minimize selection bias and confounding biases and to make the number of cases in both groups match 1:1.

RESULTS

Propensity score matching generated the BME group (n = 51) and the PNE group (n = 51). The BPI score, CSI score, and PCS score were statistically significantly lower in the PNE group than in the BME group (all, p < 0.05). The effect sizes for the BPI intensity (r = 0.31) were moderate.

CONCLUSIONS

PNE resulted in a better outcome of pain management with less functional disability and CS-related symptoms compared to BME after breast surgery.

Early post-immobilization pain at rest, movement evoked pain, and their ratio as potential predictors of pain and disability at six- and 12-months after distal radius fracture

Background

Removal of immobilization is a critical phase of distal radius fracture (DRF) rehabilitation, typically occurring by 2 months post injury. This study examined the extent to which pain at rest (PAR), movement evoked pain (MEP), or the ratio between those (MEPR) assessed at 2-months after DRF predicts the occurrence of chronic pain or disability at 6- and 12-months after the injury.

Methods

This secondary analysis of a prospective cohort study was done at the Hand and Upper Limb Centre (HULC), London, Ontario, Canada. A total of 229 patients with DRF (159 (69.4%) women) were included. Scores for the pain and function subscales of the Patient-Rated Wrist Evaluation (PRWE) were extracted for 2, 6 and 12 months after DRF. Logistic as well as nonlinear quartile regression examined whether PAR and MEP predicted the severity of chronic pain and disability at 6- and 12-months after DRF. Receiver Operating Characteristics Curve were plotted, where area under the curve (AUC) examined the accuracy of the PAR and MEP scores in classifying those who experienced chronic pain and disability.

Results

Scores of ≥3 (AUC of 0.77) for PAR or ≥ 6 (AUC of 0.78) for MEP at 2 months after DRF predicted moderate to severe wrist pain at 6-months, whereas scores of ≥7 (AUC of 0.79) for MEP at 2-months predicted ongoing wrist disability at 6-months after the injury. The MEPR of 2 ≤ or ≥ 8 at 2-months was associated with adverse pain at 6-months and functional outcomes at 6- and 12-months (R-square = 0.7 and 0.04 respectively), but prediction accuracy was very poor (AUC ≤ 0.50).

Conclusion

Chronic wrist-related pain at 6-months can be predicted by either elevated PAR ≥ 3/10) or MEP (≥ 6/10) reported at 2-months after the injury, while disability experienced at 6-months after DRF is best predicted by MEP (≥7/10) reported at 2-months. The ratio of these two pain indicators increases assessment complexity and reduces classification accuracy.

Workplace physiotherapy for musculoskeletal pain-relief in office workers: A pilot study

BACKGROUND

Musculoskeletal pain is highly prevalent among office workers and causes high costs to the public health system. Strategies including education and exercise are recommended, with major benefits when conducted by physical therapists in the occupational environment. However, the required investment is uncommon among companies. This study aimed to evaluate the efficacy of a multimodal physiotherapy intervention to relieve musculoskeletal pain in office workers.

MATERIALS AND METHODS

The study employed a single group study with a pre-post study design and was conducted at Universidad San Jorge in 2018. Outcome variables were: workplace ergonomics (INSHT Guide), existence and severity of musculoskeletal disorders (Nordic Musculoskeletal Questionnaire), musculoskeletal pain intensity (Numeric Rating Scale), and Clinical Global Impression Scale. Office workers in a university setting (n = 24, 19 females) were assessed at baseline, after 4 weeks of in-person sessions and following 3 weeks of autonomous performance. The physiotherapy program included education, ergonomic supervision, self-treatment, strengthening, and stretching exercises. A repeated-measures ANOVA or Friedman test (with post hoc comparisons) and Chi-squared test were used to compare the study variables.

RESULTS

At baseline, cervical spine (54%), shoulder (42%), and lumbar regions (37.5%) were the most symptomatic regions according to the Nordic Musculoskeletal Questionnaire. Even if the proportion of symptomatic areas did not decrease significantly after the intervention, a great reduction of musculoskeletal pain intensity was observed after the program in the cervical (P < 0.001), lower back (P = 0.005), shoulder (P = 0.006) regions, and in the overall pain level (P < 0.001).

CONCLUSIONS

These results support that a multimodal physiotherapy program can relieve work-related musculoskeletal pain in office workers and serve as a basis for future controlled trials.

International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD)

BACKGROUND

Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.

AIM

To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.

METHODS

A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.

OUTCOMES

The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.

RESULTS

The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.

CLINICAL IMPLICATIONS

The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.

STRENGTHS AND LIMITATIONS

Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.

CONCLUSION

We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.

Effectiveness of Dry Needling Therapy on Pain, Hip Muscle Strength, and Physical Function in Patients With Hip Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To investigate the short-term effects of dry needling (DN) on physical function, pain, and hip muscle strength in patients with hip osteoarthritis (OA).

DESIGN

A double-blind, placebo-control, randomized controlled trial.

SETTING

Private practice physiotherapy clinic.

PARTICIPANTS

Patients with unilateral hip OA (N=45) were randomly allocated to a DN group, sham DN group, or control group.

INTERVENTIONS

Patients in the DN and sham groups received 3 treatment sessions. Three active myofascial trigger points (MTrPs) were treated in each session with DN or a sham needle procedure. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae, and gluteus minimus muscles.

MAIN OUTCOME MEASURES

Physical function was assessed with the Western Ontario and McMaster Universities (WOMAC) physical function subscale, the timed Up and Go test, and the 40-meter self-paced walk test. Intensity of hip pain related to physical function was evaluated using the visual analog scale and WOMAC pain subscale. The maximal isometric force of hip muscles was recorded with a handheld dynamometer.

RESULTS

Significant group by time interactions were shown for physical function, pain, and hip muscle force variables. Post hoc tests revealed a significant reduction in hip pain and significant improvements in physical function and hip muscle strength in the DN group compared with the sham and control groups. The DN group showed within- and between-groups large effect sizes (d>0.8).

CONCLUSIONS

DN therapy in active MTrPs of the hip muscles reduced pain and improved hip muscle strength and physical function in patients with hip OA. DN in active MTrPs of the hip muscles should be considered for the management of hip OA.

Effect of pain neuroscience education and transcutaneous electrical nerve stimulation on trigeminal postherpetic neuralgia. A case report

Introduction: Postherpetic neuralgia (PHN) is a complex neuropathic painful condition in which pain is a direct consequence of the response to peripheral nerve damage experienced during herpes zoster attack. PHN is the most common chronic complication of herpes zoster and it causes considerable suffering, affecting the physical functioning and psychological well-being of patients. Objective: To describe the effect of a conservative treatment using pain neuroscience education (PNE) and transcutaneous electrical nerve stimulation (TENS) in a patient with trigeminal PHN. Case Description: A 67-year-old woman sought care for pain, dysfunction, and sensory loss in the left jaw. The assessment included: 1) pain, using the numerical pain rating scale (NPRS), pressure pain threshold (PPT), Douleur Neuropathique 4 (DN4), McGill Pain Questionnaire (MPQ), Graded Chronic Pain Scale (GCPS), and classic body charts of the cranial region; 2) somatosensory function, by means of mechanical detection threshold (MDT) and pressure pain threshold (PPT); 3) jaw function, using the Jaw Functional Limitation Scale-20 (JFLS-20); and 4) psychosocial features, by means of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorders Questionnaire-7 (GAD-7). Treatment consisted of 12 sessions of PNE and TENS. Outcomes: After treatment, a clinically significant improvement in NPRS, DN4, MDT, GCPS, and PHQ-9 was observed. Conclusion: In this case report, a treatment based on the combination of PNE and TENS seemed to have contributed to improving pain, sensory abnormalities, and jaw function. Psychosocial factors also showed a trend to improve after the treatment.

Postoperative Psychosocial Factors in Health Functioning and Health-Related Quality of Life After Knee Arthroplasty: A 6-Month Follow up Prospective Observational Study

OBJECTIVE

Knee arthroplasty (KA) is an effective and cost-effective treatment for end-stage knee osteoarthritis. Despite high surgical success rates, as many as 25% of patients report compromised postoperative functioning, persistent pain, and reduced quality of life. The purpose of this study was to assess the predictive value of psychological factors in health functioning and quality of life, during a 6-month period after KA.

DESIGN

A prospective observational study.

SETTING

Surgery at two hospitals and follow-up was carried out through the domiciliary rehabilitation service.

SUBJECTS

In total, 89 patients (age 70.27 ± 7.99 years) met the inclusion criteria.

METHOD

A test battery composed of Health functioning associated with osteoarthritis (WOMAC), Health-related quality of life (EQ-5D-5L), Anxiety and Depression (HADS), Pain attitudes (SOPA-B), Pain catastrophizing (PCS), and Fear of Movement (TSK-11) was assessed at 1 week, and 1, 3, and 6 months after surgery. A mixed effects linear model was used to estimate the effect of time and covariates. An exploratory factor analysis was used to identify the number of dimensions underlying the group of psychological measurements.

RESULTS

In WOMAC model, anxiety level (F = 120.8), PCS (F = 103.9), depression level (F = 93.6) and pain score (F = 72.8) were the most influential variables. Regarding EQ-5D-5L model, anxiety level (F = 98.5), PCS (F = 79.8), depression level (F = 78.3) and pain score (F = 45) were the most influential variables. Pain score and the psychosocial variables of PCS, TSK, HADS-A, HADS-D, SOPA-B Emotion, SOPA-B Harm and SOPA-B Disability loaded in one single dimension.

CONCLUSIONS

Postoperative acute pain and psychosocial factors of pain catastrophizing, anxiety, depression, and pain attitudes might influence health functioning and quality of life during KA rehabilitation. Such factors could be gathered into one single dimension defined as pain-related psychologic distress.

Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients but a Primary Focus of Clinician Education

Society is mired in a serious health care crisis regarding pain and opioid abuse. Pain neuroscience education (PNE) has gained support in the last 20 years as an intervention to help people manage chronic pain. In this Viewpoint, we argue that exercise and movement must be the primary intervention for chronic pain conditions, and that PNE or other adjunctive therapies should only be used if they can foster increased exercise and movement participation. Pain education should be the primary focus of a chronic pain management strategy for students and clinicians. It would help to advance knowledge and skills, and ultimately enhance care and outcomes for patients with chronic pain. J Orthop Sports Phys Ther 2021;51(2):57-59. doi:10.2519/jospt.2021.9804.

Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians

INTRODUCTION

Research on musculoskeletal disorders indicates that pain sensitivity can be an important consideration for musculoskeletal clinicians in the holistic view of a patient presentation. However, diversity in research findings in this field can make this a difficult concept for clinicians to navigate. Limited integration of the concept of pain sensitivity into clinical practice for musculoskeletal clinicians has been noted.

PURPOSE

The purpose of this masterclass is to provide a framework for the consideration of pain sensitivity as a contributing factor in the presentation of people with musculoskeletal pain. It provides pragmatic synthesis of the literature related to pain sensitivity through a lens of how this information can inform clinical practice for musculoskeletal clinicians. Guidance is provided in a 'how to' format for integration of this knowledge into the clinical encounter to facilitate personalised care.

IMPLICATIONS

The relationship of pain sensitivity with pain and disability is not clear or linear. The real importance of pain sensitivity in a clinical presentation may be: (1) the potential for pain sensitivity to modify the effect of common treatments utilised by musculoskeletal clinicians, or (2) the effect of pain sensitivity on the prognosis/course of a disorder. Screening tools and subjective features have been highlighted to indicate when physical assessment of pain sensitivity should be prioritised in the physical examination. A pragmatic blueprint for specific assessment related to pain sensitivity has been outlined. A framework for integrating assessment findings into clinical reasoning to formulate management plans for the pain sensitive patient is provided.

Effectiveness of a structured group intervention based on pain neuroscience education for patients with fibromyalgia in primary care: A multicentre randomized open-label controlled trial

Background

There has been increased interest in pain neuroscience education (PNE) as a therapeutic approach for the management of fibromyalgia (FM).

Methods

A multicentre randomized, open‐label, controlled trial was conducted to assess the effectiveness of a structured group intervention based on PNE in patients with FM. A total of 139 patients were included in the study and randomized to the intervention group (7 group sessions of education in neurobiology of pain) or to the control group (treatment as usual only). The primary outcome was the improvement of functional status and pain measured with the Fibromyalgia Impact Questionnaire (FIQ), and secondary outcomes were the reduction in the impact of pain and other symptoms (catastrophizing, anxiety and depression) and number of patients reaching no worse than moderate functional impairment (FIQ score <39). Differences between groups were calculated by linear mixed‐effects (intention‐to‐treat approach) and mediational models through path analyses.

Results

At 1 year, improvements in FIQ scores were higher in the intervention group with moderate or high effect size, and decreases of ≥20% in 69.1% of patients (20.9% in the control group) and of ≥50% in 39.7% (4.5% in the control group). Also, 52.9% of patients had a FIQ <39 points (13.4% in the control group).

Conclusions

In this sample of patients with FM, the improvement in quality of life and control of symptoms obtained by adding a PNE intervention showed promising results, equalling or surpassing previously reported outcomes.

Significance

A structured group intervention based on pain neuroscience education for 1 year in patients with fibromyalgia was associated with significant amelioration of the impact of the disease on scores of the Fibromyalgia Impact Questionnaire, the Health Assessment Questionnaire, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale and the Polysymptomatic Distress Scale as compared with only treatment as usual. These findings are clinically relevant considering the challenges posed by fibromyalgia to clinicians and patients alike.

Electronic Delivery of Pain Education for Chronic Overlapping Pain Conditions: A Prospective Cohort Study

OBJECTIVE

To examine the impact of educational materials for chronic overlapping pain conditions (COPCs), the feasibility of delivering materials online, and to explore its impact on self-reported self-management applications at 3-month follow-up.

DESIGN

Prospective cohort study.

SETTING

Online.

SUBJECTS

Individuals from a university-wide active research repository with ≥1 coded diagnostic COPC by ICD-9/10 in the medical record.

METHODS

We determined the number of COPCs per participant as indicated by diagnostic codes in the medical record. Consenting participants completed self-report questionnaires and read educational materials. We assessed content awareness and knowledge pre- and post-exposure to education. Comprehension was assessed via embedded questions in reading materials in real time. Participants then completed assessments regarding concept retention, self-management engagement, and pain-related symptoms at 3-months.

RESULTS

N = 216 individuals enrolled, with 181 (84%) completing both timepoints. Results indicated that participants understood materials. Knowledge and understanding of COPCs increased significantly after education and was retained at 3-months. Patient characteristics suggested the number of diagnosed COPCs was inversely related to age. Symptoms or self-management application did not change significantly over the 3-month period.

CONCLUSIONS

The educational materials facilitated teaching of key pain concepts in self-management programs, which translated easily into an electronic format. Education alone may not elicit self-management engagement or symptom reduction in this population; however, conclusions are limited by the study's uncontrolled design. Education is likely an important and meaningful first step in comprehensive COPC self-management.

The prevalence and management of central post-stroke pain at a hospital in Zimbabwe

Background

Central post-stroke pain (CPSP) is a poorly diagnosed chronic pain. It is under-treated and usually mismanaged.

Objective

To establish the prevalence of CPSP and its management in stroke clinics at a tertiary hospital.

Methods

This was a cross-sectional design with stroke patients and health professionals from the stroke clinic at the tertiary hospital in Zimbabwe.

Results

Out of 166 stroke survivors, 8% had CPSP. Younger age (<60 years) was significantly associated with CPSP (P<0.003). Pain characteristics of CPSP were hyperaesthesia (10, 71%), electric shocks (9, 64%), temperature allodynia (9, 64%) and allodynia (12, 86%). Ten health professionals participated in the study: one (10%) reported using Douleur Neuropathique 4 (to diagnose neuropathic pain) and two (20%) reported using sensory tests. Four patients (44%) were on paracetamol (acetaminophen) and on weak opiates such as codeine. None of the patients were on anticonvulsants or antidepressants. Two medical doctors (50%) used weak opiates as second-line management. Five patients (36%) reported receiving a combination of massage, stretching, general exercise and moist heat or cryotherapy.

Conclusion

The prevalence of CPSP in the study group is within international range. There is a need for appropriate management and use of tests and outcome measures for diagnosis of CPSP.

The global state of research in pain management of osteoarthritis (2000-2019): A 20-year visualized analysis

There has been a highly active area in the pain management of osteoarthritis (OA) over the past 2 decades. The study aims to unmask the global status and trends in this field.Publications on pain management of OA from 2000 to 2019 were retrieved from the Web of Science (WOS) database. The data were analyzed using bibliometric statistical methodology. The software VOS viewer was used for bibliographic coupling, co-authorship, co-citation, co-occurrence analysis and to investigate the publication trends in pain management of OA.A total of 8207 researches in amount were included. The relative research interests and number of publications indicated a rising trend. The USA made the greatest contribution to this field, with the most publications, total citations and the highest H-index, while Sweden had the highest average citation per publication. The most contributive organization was Boston University. The journal OA and Cartilage published the most relative articles. Researches could be grouped into 5 clusters based on co-occurrence network map: Health and Epidemiology; Sport Medicine; Clinical Study; Mechanism Research and Medical Technology and Science. Medical Technology and Science was predicted as the next research topic in this field.The number of publications about pain management of OA would be increasing based on current global trends. The USA made the largest contribution to this field. The development of Medical Technology and Science may be the next popular topics in the pain management of OA research.

Biomedical Beliefs Explain the Clinical Decisions Made by Exercise-Based Practitioners for People With Chronic Low Back Pain

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

This study surveyed the attitudes and beliefs of physiotherapists and accredited exercise physiologists (AEP) toward chronic low back pain (CLBP), in Australia. The objective of this study was to investigate the effect of biomedical and biopsychosocial attitudes and beliefs toward CLBP on clinical decision making in exercise-based practitioners.

SUMMARY OF BACKGROUND DATA

The attitudes and beliefs of AEPs toward CLBP have not been studied. Literature regarding physiotherapists suggests a biomedical approach leading to more conservative treatment and on occasion, treatment going against practice guidelines.

METHODS

Seventy five AEPs and 75 physiotherapists were surveyed using the pain attitudes and beliefs scale for physiotherapists, which consists of both a biomedical and biopsychosocial subscale. Clinical decision making was assessed using two patient vignettes.

RESULTS

AEPs held higher biomedical beliefs compared with physiotherapists. No between-group differences were observed on the biopsychosocial subscale. Indeed, biomedical attitudes and beliefs did explain clinical decision making with higher scores reflecting a more conservative approach. However, biomedical beliefs influenced decision making regardless of profession.

CONCLUSION

Biomedical attitudes and beliefs regarding CLBP influence clinical decision making in exercise-based practitioners, regardless of profession. AEPs reported higher biomedical scores, suggesting more frequent choice of conservative care. Thus, patients may receive inconsistent care and advice from practitioners within the same field. Based on clinical practice guidelines and the positive associations on clinical decision making of the biopsychosocial model, it is necessary to understand how best to provide exercise-based practitioners with education on how to apply a biopsychosocial approach to CLBP.Level of Evidence: 3.

Effect of pain neuroscience education and exercise on presenteeism and pain intensity in health care workers: A randomized controlled trial

OBJECTIVES

Decreased workforce productivity has a significant economic impact on healthcare systems. Presenteeism, the practice of working at reduced potential, is more harmful than absenteeism. Present workers most often experience musculoskeletal pain that is not mitigated by general exercise or stretching. We aimed to assess whether a regimen of pain neuroscience education (PNE) and exercise tailored to individual healthcare workers could reduce presenteeism and improve productivity.

METHODS

An independent investigator randomized 104 medical professionals into two groups (intervention and control). The control group received general feedback after answering a questionnaire, while the intervention group received a 6-month plan of exercises and PNE created by a physical therapist with 10 years of experience. Our primary outcome was the scores of the Japanese version of the World Health Organization Health and Work Performance Questionnaire (WHO-HPQ) to investigate presenteeism; and our secondary outcomes were pain intensity, widespread pain index (WPI), and EuroQol 5-dimension (EQ5D-5L).

RESULTS

In the intervention group, post intervention, we observed significant improvement in presenteeism, pain intensity, WPI, physical and psychological stress, and EQ5D-5L (P < .05). In the control group, we noted significant improvement only in the physical and psychological stress post intervention (P < .05). The results showed significant between-group differences in presenteeism post-intervention (P < .05).

CONCLUSION

We demonstrated that a combination of PNE and exercise decreases presenteeism of healthcare workers. Our findings will help healthcare facilities carry out better employee management and ensure optimal productivity.

Association Between Kinesiophobia and Life Space Among Community-Dwelling Older People with Chronic Musculoskeletal Pain

OBJECTIVE

Kinesiophobia (i.e., fear of movement caused by pain) is increasingly acknowledged as a determinant of disuse among patients with chronic musculoskeletal pain. Kinesiophobia may affect life space-a crucial indicator of an active lifestyle among older people. This study aimed to investigate the previously unexamined association between kinesiophobia and life space among community-dwelling older people with chronic musculoskeletal pain.

DESIGN

Cross-sectional study.

SETTING

Community.

SUBJECTS

We analyzed data from 194 community-dwelling older people (age ≥65 years, mean age = 75.7 years, 71.6% women) with chronic musculoskeletal pain.

METHODS

Kinesiophobia, life space, and pain severity were assessed using the Tampa Scale for Kinesiophobia, Life Space Assessment, and Brief Pain Inventory. Linear regression models were applied to analyze the associations between kinesiophobia and life space, and pain severity and life space.

RESULTS

In our sample, the prevalence rates for chronic musculoskeletal pain were 10.82% (N = 21) for neck, 55.15% (N = 107) for lower back, 25.26% (N = 49) for shoulder, and 50.00% (N = 97) for knee. The results suggest that higher kinesiophobia is associated with smaller life space (adjusted beta = -0.91, 95% CI = -1.43 to -0.45, P < 0.001), even after adjustment for age, gender, years of education, pain severity, and presence of comorbidity. On the contrary, no significant association between pain severity and life space was observed (adjusted beta = -0.61, 95% CI = -2.92 to 1.72, P = 0.624).

CONCLUSIONS

Our findings suggest that kinesiophobia plays an important role in the determination of life space among older people with chronic musculoskeletal pain.

'He explains it in a way that I have confidence he knows what he is doing': A qualitative study of patients' experiences and perspectives of rotator-cuff-related shoulder pain education

BACKGROUND

Patient education is recommended in clinical practice guidelines for rotator-cuff-related shoulder pain (RCRSP), yet there are no guidelines for clinicians. A gap in the current literature relates to patients' perspectives.

AIMS

The aim of this study was to explore the experiences and perspectives of people with RCRSP about education for their condition.

MATERIALS AND METHODS

An inductive qualitative design was adopted. Eight participants with RCRSP participated in individual telephone interviews that were audio-recorded, transcribed and de-identified. Four researchers completed inductive thematic analysis. Institutional ethics approval was obtained.

RESULTS

Results are detailed as a thematic analysis from the interview responses. Three primary themes were identified: (1) a therapeutic alliance leads to trust of education; (2) education of RCRSP should be individualized and practical; and (3) delivery of educational interventions should be varied and multi-modal.

DISCUSSION

The results demonstrated that trust in the health professional providing the education facilitates adherence and increases belief that the condition is being effectively treated. Participants believed imaging were necessary for an individual diagnosis despite clinical practice guidelines not recommending imaging for the first 6-12 weeks of initial presentation. There was a general caution about generic online information which may adversely impact the value of exclusively online educational intervention in the future. Participants preferred clear and practical education about RCRSP, including activity modification, timeframes for recovery and potential detriments to their recovery. There was consensus that education is best delivered early in the rehabilitation process, however there were mixed preferences for delivery method between written, video and face-to-face which perhaps reflects different learning styles and indicates that a 'one size fits all' approach is not effective in adult education in this condition.

CONCLUSION

People with RCRSP believe education about their condition is important and is best delivered by a trusted source early in their rehabilitation. There is a belief that scans are necessary to provide an individualized diagnosis and assists in their understanding of the condition. There is an opportunity for online education; however, this may best be utilised as an adjunct method to face-to-face care.

Physical Therapist Management of Anterior Knee Pain

PURPOSE OF REVIEW

Anterior knee pain is a common musculoskeletal complaint among people of all ages and activity levels. Non-operative approaches with an emphasis on physical therapy management are the recommended initial course of care. The purpose of this review is to describe the current evidence for physical therapist management of anterior knee pain with consideration of biomechanical and psychosocial factors.

RECENT FINDINGS

The latest research suggests anterior knee pain is a combination of biomechanical, neuromuscular, behavioral, and psychological factors. Education strategies to improve the patient's understanding of the condition and manage pain are supported by research. Strong evidence continues to support the primary role of exercise therapy and load progression to achieve long-term improvements in pain and function. Preliminary studies suggest blood flow restriction therapy and movement retraining may be useful adjunct techniques but require further well-designed studies. Anterior knee pain includes multiple conditions with patellofemoral pain being the most common. An insidious onset is typical and often attributed to changes in activity and underlying neuromuscular impairments. A thorough clinical history and physical examination aim to identify the patient's pain beliefs and behaviors, movement faults, and muscle performance that will guide treatment recommendations. Successful physical therapist management involves a combination of individualized patient education, pain management, and load control and progression, with an emphasis on exercise therapy.

Pain Neuroscience Education in cancer survivors with persistent pain: A pilot study

PURPOSE

To describe the Pilot Study: Pain Neuroscience Education in Cancer Survivors and describe the innovative educational component of Pain Neuroscience Education (PNE).

DESIGN

Quasi experimental design.

METHOD

The PNE program, encompassing a one-on-one education session and an information leaflet was given to 30 cancer survivors. At baseline and two weeks after the PNE, participants were asked to fill out following outcome measures; pain intensity, pain catastrophizing, and HRQoL.

FINDINGS

Following PNE, a significant decrease on pain intensity (p = 0.001), on the SF-36 subscale pain (p = 0.003) and for the following PCS subscales: Helplessness (p < 0.001), Rumination (p = 0.002) and Total score (p < 0.001) was found compared to baseline.

CONCLUSIONS

Although the current results need to be verified in a larger randomized, controlled trial, preliminary evidence shows a decrease in pain intensity and pain catastrophizing following PNE in cancer survivors with persistent pain.

App-Based Pain Management and Opioid Education Program for Patients in Clinic Waiting Rooms

BACKGROUND

Best approaches to delivering patient education related to pain management and opioid safety are understudied.

AIMS

This study assessed the feasibility, acceptability, and preliminary patient-reported impact of an app-based patient pain education program.

DESIGN

Pilot study with data collection occurring on 43 weekdays between August 2019-February 2020.

SETTING

Waiting rooms at the pain clinic and a primary care medical home within two military treatment facilities.

PARTICIPANTS

Military health system beneficiaries seeking general care at the primary care medical home or pain-specific care at the pain clinic.

METHODS

The Joint Pain Education and Project curriculum includes patient-focused videos describing the biopsychosocial aspects of pain and pain management, medication take-back and safe disposal, and multidimensional pain assessments. The app-based videos were available on tablets in the waiting rooms for patients to view and complete surveys on after.

RESULTS

Overall, 152 patients viewed the videos and completed surveys. Most viewers were interested in receiving other tablet-based health education while in the waiting room (62%). Most viewers found videos to be moderately or very helpful (73%) and were satisfied or very satisfied with the information provided (85%). Participants at the primary care medical home were more likely to find videos helpful compared to participants at the pain clinic (OR = 2.11; 95% CI: 1.07, 4.20; p = .03).

CONCLUSION

Implementing app-based pain management education is feasible across clinic settings and is well received by patients. Clinics should consider providing pain education across care setting, rather than just pain specialty clinics, to help foster discussions between clinicians and patients regarding pain management and opioid safety.

Clinical Reasoning for the Examination and Physical Therapy Treatment of Temporomandibular Disorders (TMD): A Narrative Literature Review

The current narrative literature review aims to discuss clinical reasoning based on nociceptive pain mechanisms for determining the most appropriate assessment and therapeutic strategy and to identify/map the most updated scientific evidence in relation to physical therapy interventions for patients with temporomandibular disorders (TMDs). We will also propose an algorithm for clinical examination and treatment decisions and a pain model integrating current knowledge of pain neuroscience. The clinical examination of patients with TMDs should be based on nociceptive mechanisms and include the potential identification of the dominant, central, or peripheral sensitization driver. Additionally, the musculoskeletal drivers of these sensitization processes should be assessed with the aim of reproducing symptoms. Therapeutic strategies applied for managing TMDs can be grouped into tissue-based impairment treatments (bottom-up interventions) and strategies targeting the central nervous system (top-down interventions). Bottom-up strategies include joint-, soft tissue-, and nerve-targeting interventions, as well as needling therapies, whereas top-down strategies include exercises, grade motor imagery, and also pain neuroscience education. Evidence shows that the effectiveness of these interventions depends on the clinical reasoning applied, since not all strategies are equally effective for the different TMD subgroups. In fact, the presence or absence of a central sensitization driver could lead to different treatment outcomes. It seems that multimodal approaches are more effective and should be applied in patients with TMDs. The current paper also proposes a clinical decision algorithm integrating clinical diagnosis with nociceptive mechanisms for the application of the most appropriate treatment approach.

Effect of Additional Pain Neuroscience Education in Interdisciplinary Multimodal Pain Therapy on Current Pain. A Non-Randomized, Controlled Intervention Study

Purpose

Interdisciplinary multimodal pain therapy (IMPT) programs for chronic back pain are effective and recommended. The patient-centered and biopsychosocial nature of IMPT is grounded in contemporary understanding that chronic pain states reflect heightened sensitization of the nervous system rather than an issue in the tissue. Teaching patients about pain is part of IMPT programs, though a clinical guideline is lacking. This study aims to answer the following question: Does the addition of an evidence-based pain neuroscience education (PNE) lecture for patients, into an IMPT program, produce superior results than the IMPT program itself?

Patients and Methods

A non-randomized, controlled intervention study was performed with 179 back pain patients indicated for IMPT. Intervention group (N=102) received a four-week IMPT program, which contained 4 one-hour sessions PNE. Control group (N=77) received the same IMPT without the additional PNE. Primary outcome was current pain after intervention. Pain knowledge, physical function, depression, anxiety, stress, quality of life and fear-avoidance were analyzed as secondary outcomes. Outcomes were defined as change of the parameter measured before and immediately after the four-week IMPT. For each outcome, linear regression models were used to estimate the raw and adjusted (sex, age and BMI) effect of additional PNE.

Results

Despite improvement in all outcomes for both groups during the treatment phase, the implemented PNE did not result in additional pain reduction (regression coefficient for PNE effect on pain level 0.34; 95% CI −6.23–6.97). Between-group differences could only be shown for pain-related knowledge in favor for the intervention group (0.78; 95% CI 0.35–1.20).

Conclusion

The additional PNE lecture did not lead to pain reduction beyond the usual IMPT. However, the PNE did increase pain-related knowledge and, therefore, might be helpful in coping with pain after the IMPT program.

Perspectives of implementing the biopsychosocial model to treat chronic musculoskeletal pain in primary health care

Aim: To propose actions to organize healthcare of people with chronic musculoskeletal pain (CMP) into a biopsychosocial approach. Materials & methods: Narrative overview with the Brazilian Unified Health System as archetype to propose the implementation of a biopsychosocial approach to manage CMP. Results: Healthcare systems often use biomedical model for CMP management, which may explain the increase of demand and costs of CMP management. This is significant in Primary Health Care, where the healthcare professionals have difficulty with evaluating and treating psychosocial factors. Conclusion: The present perspective selected some actions that are part of the common procedures in Brazil's Primary Health Care and proposed a protocol of amplified care for CMP management in all levels: orientation, health promotion, prevention and rehabilitation.

A Meta-Analysis of Therapeutic Pain Neuroscience Education, Using Dosage and Treatment Format as Moderator Variables

OBJECTIVES

This meta-analysis aimed to assess the overall effect of therapeutic pain neuroscience education (TPNE) on chronic musculoskeletal pain and to further assess whether such an effect differs by TPNE dosage as well as other treatment format components. Dosage included the number of TPNE sessions provided as well as the amount of time per TPNE session. Structural components included TPNE provided alone as treatment or combined with other pain management modalities, as well as the inclusion of group-based treatment sessions.

METHODS

Electronic databases were utilized to search for randomized controlled trials that included TPNE. The overall effectiveness of TPNE was estimated on 4 pain outcome measures, including kinesiophobia, pain intensity, pain disability, and pain catastrophizing. The differential effectiveness of TPNE was examined using a mixed-methods moderator analysis on various study-level characteristics to identify potential moderators affecting the overall results.

RESULTS

Significant effects of TPNE were found on all the outcome measures. The only moderator that displayed a significant effect was group-based treatment on kinesiophobia (z = -2.23, P < 0.05, 95% confidence interval [CI] -2.70 to -0.20). Between-group analysis revealed that only interventions that included group sessions were found to be statistically significant (z = 2.20, P < 0.05) and displayed a large effect size (d = 0.80, 95% CI 0.09 to 1.50).

DISCUSSION

Therapeutic pain neuroscience education had a statistically significant impact on all the explored pain outcome measures. However, when investigating the treatment dosage and format moderator variables, they appeared to not have a statistically significant effect except for group-based interventions on kinesiophobia levels.

CONCLUSION

This meta-analysis examined the efficacy of TPNE for patients with chronic pain. It assessed various pain outcome measures following intervention. In addition, this research identified that various moderator variables do not have and do have an impact on the treatment modality of TPNE.

Baseline pain characteristics predict pain reduction after physical therapy in women with chronic pelvic pain. Secondary analysis of data from a randomized controlled trial

Background and aims Women with chronic pelvic pain represent a heterogeneous group, and it is suggested that the existence of sub-groups can explain varying results and inconclusiveness in clinical trials. Some predictors of treatment outcome are suggested, but the evidence is limited. The primary aim of this study was to explore if selected pre-treatment characteristics of the participants in a recently conducted randomized controlled trial were associated with treatment outcome. Methods In this study secondary analysis of data collected in a randomized trial were conducted. The participants were women with chronic pelvic pain randomized to two different physical therapy treatments. Analyses in this study were performed for the whole group as a cohort. The primary outcome measure was change in pain intensity from baseline to 12 months, measured with the numeric rating scale (0-10). The women were asked to rate their mean pelvic pain intensity during the last 7 days. Based on previous research and on available variables from the randomized controlled trial four potential predictive factors were derived from the baseline data and assessed one by one in a linear regression model, adjusted for age and treatment group. The variables with strongest association (p < 0.10) with the primary outcome were further included in a multivariable linear regression model with backward selection, adjusted for age and treatment group. Results Fifty women (mean age 38.1, SD = 12.2) were included in the analysis. For these women the mean change in pain intensity was -1.2 points (95% CI -1.8 to -0.7) from baseline to 12 months. The multivariable regression model showed that pelvic pain duration of 6 years or more was associated with less decrease in pain intensity with a regression coefficient of 1.3 (95% CI 0.3-2.4). Baseline pain intensity was associated with higher pain reduction after PT treatment with a regression coefficient per SD increase in baseline pain of -0.6 (95% CI -1.1 to -0.1). None of the women with main pain site other places than in the pelvis reported any pain reduction after physical therapy treatment, but due to the small numbers the predictor was not included in the regression analysis. Conclusions We identified that pelvic pain duration of 6 years or more was associated with less pain reduction, and that higher baseline pain intensity was associated with higher pain reduction after physical therapy treatment in this sample of women with chronic pelvic pain. For the variable main pain site other places than the pelvis the results are unsure due to small numbers. Implications Based on our finding of long pain duration as a negative predictor for pain reduction, we emphasize that early intervention is important. Many of the participants in our RCT reported pelvic surgeries or other treatments prior to referral for PT, and we suggest that referral to a non-invasive intervention such as PT should be considered at an earlier stage. In order to tailor interventions to the individual women's needs, thorough baseline assessments, preferably in a multidisciplinary setting, should be performed.

Introduction of a psychologically informed educational intervention for pre-licensure physical therapists in a classroom setting

BACKGROUND

There is an increasing need for physical therapists to address psychosocial aspects of musculoskeletal pain. Psychologically informed practice is one way to deliver this type of care through the integration of biopsychosocial interventions into patient management. An important component of psychologically informed practice is patient centered communication. However, there is little research on how to effectively implement patient centered communication into pre-licensure training for physical therapists.

METHODS

Thirty Doctor of Physical Therapy (DPT) students took part in an educational intervention that consisted of one 4-h didactic teaching session and three 1-h experiential learning sessions. Prior to the first session, students performed an examination of a standardized patient with chronic low back pain and were assessed on psychologically informed physical therapy (PIPT) adherent behaviors via a rating scale. Students also completed the Pain Attitudes and Beliefs Scale (PABS-PT). After the last experiential session, students evaluated another standardized patient and were reassessed on PIPT adherent behaviors. Students retook the PABS-PT and qualitative data was also collected.

RESULTS

After the educational intervention, students had positive changes in their pain attitudes and belief scores indicating a stronger orientation toward a psychosocial approach to patient care (p < 0.05). Additionally, after the intervention, students showed improvements in their adherence to using PIPT behaviors in their simulated patient interactions (p < 0.05). Qualitatively, students reported a high acceptability of the educational intervention with common themes indicating improved confidence with treating and communicating with complex patients.

CONCLUSION

Students had attitudes and beliefs shift towards a more psychosocial orientation and demonstrated improved PIPT behaviors in simulated patient interactions after a brief educational intervention. Future research should investigate best practices for implementation of psychologically informed physical therapy for licensed clinicians.

What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National Survey

Objective

The aim of this study was to investigate the knowledge of orthopedic manual therapists (OMTs) regarding context factors (CFs) capable of triggering nocebo effects during the treatment and how this knowledge is related to their socio-demographic features.

Design

A cross-sectional online survey.

Setting

National.

Main Outcome Measures

A 20 items questionnaire composed by open-ended and closed single-choice questions was administered to explore: (a) socio-demographic variables (10 questions); (b) the relation between different CFs and nocebo-related effects (2 questions); and (c) the knowledge of participants about nocebo-related effects and how they managed them in the clinical practice (8 questions).

Participants

1288 OMTs were recruited from the database of the Master in Rehabilitation of Musculoskeletal Disorders (MRDM) of the University of Genova from March to May 2019. Inclusion criteria were: (a) to possess a valid email account; (b) to understand and use as a native language the Italian; (c) to be graduated as OMTs; and (d) to be employed as physiotherapists specialized-OMTs during the survey.

Results

791 responses were received (61.4%); 473 of them were male (59.8%), with an average age of 31.0 ± 7.1 years. OMTs defined nocebo-related effects as the psychosocial context effects around therapy and patient with specific biological bases (72.2%). OMTs know that their clinical practice is pervaded by nocebo-related effects (42.5%), triggered by CFs. Participants communicated nocebo-related effects balancing the positive features of the therapy with the negative ones (50.9%), during the decision of the therapeutic plan (42.7%). They reported associative learning as the main mechanism involved in nocebo-related effects (28.8%). OMTs taught and trained patient’s strategies to manage nocebo-related effects (39.6%) through an evaluation and correction of patient’s anxieties, doubts and expectations (37.7%). OMTs most frequently considered themselves to have a “medium” education about nocebo-related effects (48.2%) and that their management should be taught during bachelor (78.6%).

Conclusion

OMTs believed that nocebo-related effects were present in their clinical practice and that they can be triggered by CFs.

Lipoedema and Pain: What is the role of the psyche? – Results of a pilot study with 150 patients with Lipoedema

Introduction The present exploratory study is the first so far to investigate the psychological stress in the period before the development of pain symptoms typical for lipoedema.

Methods 150 patients diagnosed with lipoedema syndrome were questioned in semi-structured interviews about psychological stress and were diagnosed with psychological disorders according to ICD-10 criteria. The development of the symptoms typical for lipoedema was recorded in a second interview. Both interviews were blended together in collaboration with the patients, this means Lipoedema-associated pain and psychological stress were related to time.

Result Exactly 80 % of the patients diagnosed with lipedema show a high level of psychological distress immediately before the onset of lipedema-associated symptoms! In this study, mental distress was defined as the presence of a manifest mental disorder (ICD 10 F diagnosis) such as Depression, eating disorder or post-traumatic stress disorder and/or serious psychological distress such as burnout syndrome or chronic stress.

Summary These results contradict a widespread statement that all psychological problems of patients with the diagnosis lipoedema syndrome are caused solely by lipoedema, that lipoedema even causes the patient’s mental disorder.

Moreover, depression and posttraumatic stress disorders are significantly related to the maximum pain intensity estimated by patients in everyday life. This demonstrates that it is imperative to rethink lipoedema therapy and to implement a psychosocial pillar in an overall therapy concept.

Talking to Children and Families about Chronic Pain: The Importance of Pain Education-An Introduction for Pediatricians and Other Health Care Providers

Chronic pain in children and adolescents is a common and debilitating health problem. This narrative review will give a brief overview on what pediatric chronic pain is and what treatment options there are for children and adolescents. The specific emphasis will be on pediatric chronic pain education and communication: this narrative review aims to show how important a good patient-health care provider relationship is-it builds the foundation for successful communication-and how this relationship can be established. In addition, we will present five steps that health care providers can perform to explain pediatric chronic pain to patients and their parents and what to keep in mind in their clinical routine. Our review is intended for pediatricians and other health care providers who treat pediatric patients with chronic pain but might feel uncertain on how to best communicate with them.

Low Self-Efficacy and High Kinesiophobia Are Associated With Worse Function in Patients With Femoroacetabular Impingement Syndrome

CONTEXT

Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS.

OBJECTIVE

(1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety.

DESIGN

Cross-sectional.

SETTING

University health center.

PARTICIPANTS

Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2).

MAIN OUTCOME MEASURES

Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function.

RESULTS

The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01).

CONCLUSION

Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.

Pain Catastrophizing Is Independently Associated with Quality of Life in Patients with Severe Hip Osteoarthritis

OBJECTIVE

Pain catastrophizing is an important pain-related variable, but its impact on patients with osteoarthritis is uncertain. The aim of the current study was to determine whether pain catastrophizing was independently associated with quality of life (QOL) in patients with osteoarthritis of the hip.

DESIGN

Cross-sectional study conducted between June 2017 and February 2018.

SETTING

Tertiary center.

SUBJECTS

Seventy consecutively enrolled patients with severe hip osteoarthritis who had experienced pain for six or more months that limited daily function, and who were scheduled for primary unilateral total hip arthroplasty.

METHODS

QOL was measured using the EuroQOL-5 Dimensions questionnaire, the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire, and a dissatisfaction visual analog scale. Covariates included pain intensity, pain catastrophizing, range of hip motion, and gait speed. The variables were subjected to multivariate analysis with each QOL scale.

RESULTS

The median age was 68 years, and the median Pain Catastrophizing Scale score was 26. In multiple regression analysis, pain catastrophizing, pain intensity in both hips, pain intensity on the affected side, hip flexion on the affected side, and gait speed were independently correlated with QOL.

CONCLUSIONS

Pain catastrophizing was independently associated with each QOL scale in preoperative patients with severe hip osteoarthritis. Pain catastrophizing had either the strongest or second strongest effect on QOL, followed by pain intensity.

Preoperative pain neuroscience education for shoulder surgery: A case series

Background

Central sensitisation, in addition to high levels of fear-avoidance and pain catastrophisation may exist in a subgroup of patients with shoulder pain. Pain neuroscience education (PNE) has been shown to positively influence sensitivity of the nervous system, as well as reduce fear and catastrophisation prior to lumbar and total knee surgery. To date, no study has examined the application of PNE prior to shoulder surgery.

Objectives

This study examined the response to preoperative PNE in patients preparing for shoulder surgery.

Method

An exploratory pre–post case series was conducted. Twelve patients scheduled for surgery completed various pre-education measurements including shoulder pain, fear-avoidance, pain catastrophisation, beliefs and expectations regarding surgery, active shoulder flexion and pressure pain thresholds for the involved and uninvolved shoulder and the dominant-sided knee. Patients underwent a standard 30-min, one-on-one PNE session with a physiotherapist prior to surgery.

Results

Following education, all measures improved with some failing to reach significance: self-reported pain (p = 0.125), pain catastrophisation (p = 0.250) and pain pressure threshold of the uninvolved shoulder (p = 0.68) and knee (p = 0.097). Fear-avoidance (p = 0.013), active shoulder flexion (p = 0.013) and pain pressure threshold for the involved shoulder (p = 0.004) significantly improved.

Conclusion

A small patient group improved beyond minimal detectable change and/or minimal clinical important difference after education. No significant shifts of the preoperative beliefs occurred after education.

Clinical implications

Preoperative PNE may be beneficial to a subgroup of patients scheduled for shoulder surgery.

Embedding pain neuroscience education in the physical therapy management of patients with chronic plantar fasciitis: a prospective case series

OBJECTIVES

The purpose of this case series was to describe the effects of a biopsychosocial approach that embeds pain neuroscience education (PNE) within physical therapy for improving foot and ankle function, pain, and psychosocial factors in patients with chronic plantar fasciitis.

METHODS

Seven female patients (mean [SD] age = 49.0 [11.4] years) receiving physical therapy for chronic plantar fasciitis were enrolled. Along with formal physical therapy, patients received six 15-minute PNE sessions. Knowledge of pain neuroscience was assessed before and after PNE with the Revised Neurophysiology of Pain Questionnaire. Patients completed questionnaires for foot and ankle function (Activities of Daily Living subscale of the Foot and Ankle Ability Measure), pain intensity (Numeric Rating Scale), pain catastrophizing (Pain Catastrophizing Scale), and fear of movement (Tampa Scale for Kinesiophobia) at baseline (before treatment) and 6 and 12 weeks. Local and remote pain sensitivity was assessed using a pressure algometer at baseline and 6 weeks.

RESULTS

Patients attended a mean (range) of 8.7 (7 to 12) physical therapy sessions over a mean (range) of 46.7 (42 to 56) days. After PNE, six (86%) patients demonstrated increased knowledge of pain neuroscience. At 12 weeks, six (86%) patients met or exceeded minimally clinically important difference (MCID) for foot and ankle function and pain. Five (71%) patients met or exceeded MCID for pain catastrophizing and fear of movement. Local pain sensitivity was reduced in six (86%) patients.

CONCLUSIONS

Physical therapy integrating PNE is potentially beneficial for patients with chronic plantar fasciitis. Future studies should examine the efficacy of PNE in randomized trials with larger representative samples.