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

Voluntary exercise prevents and eradicates anxiety-like behavior by influencing parvalbumin-positive neurons, perineuronal nets, and microglia activation in corticolimbic regions of neuropathic pain rats

Anxiety-like behavior often emerges in the later stages of neuropathic pain, exacerbating the pain condition and potentially involving parvalbumin-positive (PV+) neurons. This study aimed to investigate the effects of voluntary exercise on neuropathic pain-induced anxiety and its relationship with PV+ neurons, perineuronal nets (PNNs, labeled with Wisteria floribunda agglutinin [WFA]), and microglia in the corticolimbic regions. Male Wistar rats with partial sciatic nerve ligation (PSL) were given access to running wheels either from 3 days (early voluntary exercise [EEx]) or from 4 weeks (late voluntary exercise [LEx]) postoperatively. Nociceptive behaviors were assessed using the von Frey and acetone tests, while anxiety-like behaviors were assessed using the open field and elevated plus maze tests. Brain sections were histologically analyzed using immunohistochemistry and immunofluorescence 8 weeks post-surgery. Both early and late exercise partially restored the paw withdrawal thresholds and the arousal response. PSL-EEx rats did not exhibit anxiety-like behaviors. PSL-LEx rats transiently showed anxiety-like behaviors, but these were eradicated by exercise. PSL altered PV+ neurons and PNNs in specific corticolimbic subregions. Notably, voluntary exercise restored the densities of PV+-strong WFA+ neurons in the basolateral amygdala, PV+-WFA-, and PV+-WFA+ neurons in the anterior cingulate cortex, and PV+-WFA+ neurons in the hippocampal cornu ammonis 1. These changes correlated with reduced anxiety-like behaviors. Exercise modulated PSL-induced microglial activation and interacted differently with these neurons. These findings suggest that voluntary exercise prevents and eliminates chronic pain-induced anxiety through neuronal mechanisms other than analgesic effects, potentially involving PV+ neurons, PNNs, and microglia in the corticolimbic subregions.

"You have just got to be careful"-A Qualitative Study Disentangling Health Beliefs and Behaviors Regarding Falls Among Community-Dwelling Older Adults in Singapore

OBJECTIVES

Understanding older adults' health beliefs regarding falls is important for the design of participant-centric programs. Although there is evidence on older adults' perceptions toward falls and falls prevention, there is insufficient understanding of older adults' adaptive responses to cope with falls. In addition, these perceptions are understudied within the context of Asia for the development of programs in Asia.

METHODS

In-depth interviews were conducted with 30 community-dwelling older adults (aged 60 and older) in Singapore. The Health Belief Model, adapted to falls and falls prevention, helped guide interviews.

RESULTS

Our findings uncovered a discordance between perceived susceptibility to falls and actual physical ability, influencing the actions toward falls prevention. Adaptive responses to falls were encapsulated as the concept "being careful" in this context. This manifested in two groups: those who monitor their physical health due to perceived high risk and those who only manage external hazards due to perceived low risk. In addition, we examined cues to actions: caregiver and clinician support, managing chronic pain, and prioritizing social roles; and discussed their implications for future program development. The findings also highlighted the importance of engaging family and caregivers in falls prevention efforts, a strategy that resonates deeply across Asian sociocultural contexts.

DISCUSSION

Falls prevention practices should integrate tailored education and behavioral strategies based on older adults' perceived susceptibility to falls. In Asian contexts and other cultures with a strong focus on family, caregiver-supported interventions in addition to personalized interventions should also be optimized to encourage participation and sustain adherence.

Effectiveness of Isostretching on Pain and Disability in Individuals Diagnosed With Low Back Pain: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

To systematically review the evidence on the effectiveness of Isostretching on pain, physical function and quality of life in individuals with Low Back Pain (LBP).

DATA SOURCES

We searched the following databases until November 11, 2024: PubMed, Embase, Cochrane CENTRAL, CINAHL, PEDro, Virtual Health Library Regional Portal, Scopus, Web of Science, SportDiscus and Rehabilitation and Sports Medicine. PRISMA-S was used to strengthen the reporting quality of our search strategy.

METHODS

This review followed the PRISMA checklist. Randomized clinical trials that investigated the effects of Isostretching against any control intervention in individuals with non-specific LBP were eligible. Literature screening and data extraction were performed independently by the authors. The PEDro scale, the GRADE approach and the TIDier checklist were used to assess the risk of bias, quality of the evidence and reporting quality of the intervention, respectively. Results were analysed and synthesised narratively.

RESULTS

Five articles were included (pooled n = 155). Only adults (76% female) between 19 and 60 years were included. The PEDro score ranged from 2-8 points (mean of 5.6). Very-low quality evidence suggests that isostretching may reduce pain and improve functional capacity in the short term when compared with no intervention. Also, very-low quality evidence suggests that isostretching is not superior to any active intervention to reduce pain and improve functional capacity and quality of life. The mean number of reported TIDier items was 6.4.

CONCLUSION

This review supports Isostretching to reduce pain and improve physical function and quality of life in patients with non-specific LBP.

Combined chiropractic care and Tai Chi for chronic neck pain: A protocol for a pilot randomized trial

Background

Neck pain presents a personal and socioeconomic burden globally. Despite increasing prevalence, research on chronic neck pain (CNP) is limited and management relies on generalized approaches. There is growing interest in non-pharmacological interventions, however their efficacy remains uncertain due to the multifactorial etiology of CNP. Two interventions, multimodal chiropractic care (MCC) and Tai Chi, have shown promise individually in managing CNP, and when combined may offer synergistic benefits. This pilot study aims to assess the feasibility of combining these interventions for CNP.Methods/design: Forty-eight adults, aged 18-65y, with CNP defined as occurring ≥5 days a week for ≥3 consecutive months, severity of ≥3 on the numeric rating scale, and a score of ≥5 on the Neck Disability Index will be recruited. Participants will be randomized 1:1:1 to one of the three treatment groups (MCC plus Tai Chi and Enhanced Usual Care (EUC), MCC plus EUC, or EUC alone). The MCC was validated using a modified Delphi approach. Primary outcomes relate to feasibility (recruitment, retention, and adherence) and secondary outcomes include clinical measures of neck pain severity and disability, health-related quality-of-life, psychosocial well-being, and physical function. Outcomes will be assessed at baseline, 16-weeks (post-intervention), and 24-weeks. Qualitative interviews will be conducted.

Discussion

Results of this study will provide preliminary evidence regarding the feasibility and clinical evaluation of pragmatically delivered MCC, alone or in combination with Tai Chi, for individuals with CNP. These data will be used to inform the design of a fully powered, factorial trial evaluating two promising non-pharmacological therapies for CNP.

Trial registration

This study is registered in ClinicalTrials.gov (NCT05726331).

[Chronic pain syndrome in musculoskeletal diseases-how different are fibromyalgia and long Covid?-Part 1]

Chronic pain is a common problem in rheumatology. Nociceptive pain is distinguished from neuropathic and nociplastic pain. Mechanistically, the former is explained by persistent inflammation, for example. Included in the second category is nerve damage of various causes. In contrast, nociplastic pain is not caused by tissue damage or a lesion in the somatosensory nerve system. It is caused by an altered sensation of pain through the modulation of stimulus processing. The concept of central sensitization, together with further neurobiological and psychosocial mechanisms, best explains such pain conditions. Fibromyalgia (FM) plays a big part in rheumatology - on the one hand, as a differential diagnosis, and on the other, because the management of inflammatory rheumatic conditions is made more difficult by the simultaneous occurrence of FM. In the context of the coronavirus pandemic, persistent pain syndromes with similarities to FM have been described after COVID-19 infection. There is an increasing scientific controversy whether the so-called long Covid syndrome is an actual entity or "only" a variant of FM. This discussion and the current state of knowledge on the problem are the subject of this review.

Effectiveness of pharmacological therapies for fibromyalgia syndrome in adults: an overview of Cochrane Reviews

OBJECTIVES

To summarize and evaluate Cochrane reviews of pharmacological therapies for adults with fibromyalgia syndrome (FMS) pain.

METHODS

Systematic search of Cochrane Database of Systematic Reviews to May 2024. Generic quality assessment used AMSTAR-2 criteria, validity checks of potentially critical factors in evaluation of analgesic efficacy and assessment of susceptibility of results to publication bias. Pain outcomes were participant-reported pain relief of ≥30% or ≥50%, or PGIC much or very much improved.

RESULTS

Twenty-one reviews (87 trials, 17 631 patients) were included. All rated moderate (15) or high-quality (6) using AMSTAR-2 and at least seven of eight critical pain criteria were met by 13 of 21 reviews. Diagnosis of FMS used recognized criteria. Seven reviews found no trials (carbamazepine, clonazepam, lamotrigine, phenytoin, oxycodone, topiramate or valproate), seven had limited and inadequate data (antipsychotics, cannabinoids, combination therapy, gabapentin, lacosamide, monoamine oxidase inhibitors, NSAIDs) and two were subject to publication bias (amitriptyline, SSRI). Mirtazapine had moderate evidence of no effect. Duloxetine, milnacipran and pregabalin had moderate/good evidence of substantial pain relief for 4-12 weeks in around 1 in 10 adults with moderate or severe FMS pain, without evidence of efficacy beyond six months. Serious adverse events were no more common than with placebo. There was no evidence about who might benefit or experience adverse events. There was no substantial efficacy evidence for other medicines.

CONCLUSIONS

Duloxetine, milnacipran and pregabalin had good evidence that about 1 person in 10 with moderate or severe pain experienced pain intensity reduction by at least 50%.

Acceptability of multimodal and multidisciplinary group-based program for chronic low back pain: a qualitative study

BACKGROUND

The Programa d'Atenció Integral pels Pacients amb Dolor Crònic (PAINDOC) is a multimodal and multidisciplinary group-based program that integrates pain neuroscience education, mindfulness meditation, pain psychotherapy, Empowered Relief, and therapeutic exercise. It serves as a therapeutic option for individuals with chronic low back pain, providing them with comprehensive adaptive strategies for pain management.

OBJECTIVE

This qualitative study explores participants' retrospective acceptability of the PAINDOC Program.

METHODS

To ensure demographic variability and information power, a purposive sampling approach was applied. Twelve participants were interviewed through three focus groups, supplemented with four individual semi-structured interviews. Data was analyzed using reflexive thematic analysis and evaluated based on the Therapeutic Framework of Acceptability.

RESULTS

Participants provide positive feedback regarding active pain coping strategies and improved self-management. While certain aspects of the Program were more emphasized, participants integrated tools from all components. Strategies included pain reconceptualization, positive self-talk, or problem-solving. The Program's ethicality was closely linked to individual values and may also be influenced by time constraints of certain program elements, the immediate effects of specific approaches, participant perceptions, and individual preferences.

CONCLUSIONS

The findings provide valuable insights into the acceptability of the PAINDOC Program, guiding future improvements and the development of similar interventions.

Mixed adverse ergonomic factors exposure in relation to work-related musculoskeletal disorders: a multicenter cross-sectional study of Chinese medical personnel

Exposure to adverse ergonomic factors is associated with elevated risk of work-related musculoskeletal disorders (WMSDs) in medical personnel. We aimed to reveal how different adverse ergonomic factors act individually and in combination to influence the risk of WMSDs in medical personnel. From June 2018 to December 2020, we applied multistage cluster random sampling to select a total of 6,099 medical personnel from 54 hospitals in 12 cities in China. All participants were aged over 18 years and had at least one year of hospital working experience. The weighted quantile sum (WQS) model was employed to evaluate the effect of mixed exposures of multiple adverse ergonomic factors on the risk of WMSDs. Compared to a single factor, multiple adverse ergonomic factors significantly increased the risk of WMSDs across body parts, with an OR ranging from 2.83 (95% CI: 2.33, 3.43) to 6.92 (95% CI: 4.91, 9.74). "Working in awkward positions" had the greatest impact on the risk of WMSDs in the neck, shoulder, upper back, and lower back, while "standing for prolonged periods of time" mostly affected the risk of WMSDs in the foot, leg, and knee. Compared with single factor exposure, mixed exposure resulted in a higher risk of WMSDs.

Exercise for low back pain in adolescents and children

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of exercise compared to placebo/sham/attention control or no treatment for low back pain in adolescents and children.

Recent Cannabis Use and Accelerometer-Measured Physical Activity and Sedentary Behavior Among Young-to-Midlife Adults: An Analysis of the National Health and Nutrition Examination Survey from 2011 to 2014

Introduction: Cannabis use has been associated with reduced physical activity and increased sedentary behavior in adolescents. In adults, however, there is no conclusive evidence of such an association, and existing studies have primarily relied on self-reported activity measures. As cannabis use increases globally, a deeper understanding of its relationship with activity levels may inform clinical counseling and guidelines. This study investigated the association between recent cannabis use and accelerometer-measured activity. Methods: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2014. We included adults in the United States who responded to a cannabis questionnaire and had at least 4 days of activity data from an ActiGraph GT3X+ accelerometer, which comprised participants from 18 to 59 years. The primary exposure was any self-reported cannabis use in the past 30 days. The primary outcome was daily sedentary time and secondary outcomes were daily light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA). Analyses were performed with multivariable quasi-Poisson regression models. Results: Of 4666 included adults, 658 (14.1%) reported recent cannabis use. After covariate adjustment, recent cannabis use was not associated with daily sedentary time (adjusted incidence rate ratio [aIRR] 0.99, 95% confidence interval [CI]: 0.98-1.01) or daily MVPA time (aIRR 1.01, 95% CI: 0.98-1.04). Daily LPA time was 4% greater with recent cannabis use (aIRR 1.04, 95% CI: 1.01-1.06). Conclusion: Recent cannabis use in young to midlife adults was not associated with accelerometer-measured sedentary or MVPA time, but it was associated with a marginal increase in LPA time of unclear clinical significance. Our findings provide evidence against existing concerns that cannabis use independently promotes sedentary behavior and decreases physical activity. Future prospective studies are needed to determine if these findings generalize to specific populations using cannabis including chronic pain patients.

Relationships between pain cognitions and physical function in a sample of racially diverse, sedentary individuals with chronic pain

BACKGROUND

Pain from musculoskeletal pain conditions is often persistent, bothersome, and negatively impacts physical function. Individuals with musculoskeletal pain report difficulty with walking and regular activities. For some, this may be related to overly negative pain cognitions, such as pain catastrophizing and kinesiophobia. In a geographically and racially diverse sample, we examined relationships between pain catastrophizing, kinesiophobia, and multimodal physical function (i.e., self-report, performance-based, objective).

METHODS

Participants were sedentary adults with ≥3 months of chronic musculoskeletal pain. Participants completed self-report measures of pain catastrophizing (Pain Catastrophizing Scale), kinesiophobia (Tampa Scale of Kinesiophobia), and physical function (World Health Organization Disability Assessment Scale 2.0). Performance-based physical function was assessed in-clinic with the Six-Minute Walk Test (6MWT). Physical function was objectively measured with ≥4 days of ActiGraph wear outside the clinic. We conducted descriptive, correlation, and linear regression statistics in SPSS.

RESULTS

Higher levels of pain catastrophizing (β = 0.42) and kinesiophobia (β = 0.25) were significantly associated with worse self-reported physical function. Neither pain catastrophizing nor kinesiophobia were related to performance-based or objectively measured physical function. The direction and significance of relationships between pain catastrophizing, kinesiophobia, and physical function measures were consistent in unadjusted and adjusted regression models.

CONCLUSIONS

Pain catastrophizing and kinesiophobia are associated with an individual's perceived physical functioning. Behavioral interventions designed to enhance physical function may benefit from including cognitive restructuring to challenge catastrophic thoughts about pain, as well as thoughts about injuring oneself or worsening pain with movement. More work is needed to understand why neither pain catastrophizing nor kinesiophobia were significantly associated with performance-based or objective assessment of physical function. It is possible that other pain-related cognitions, for example self-efficacy for pain control, or variables (e.g., in vivo pain catastrophizing, mood, stress, sleep) assessed closer in time to performance-based or objective measures of physical function are more relevant.

Chronic postsurgical pain after cardiac surgery: A narrative review

Chronic postsurgical pain (CPSP) is a prevalent and debilitating sequela of cardiac surgery, exerting a profound impact on patients' quality of life, functional recovery, and healthcare systems. Its pathophysiology includes complex mechanisms, including peripheral and central sensitization, neuroplastic alterations, and inflammatory pathways, influenced by demographic, psychological, and perioperative factors. Inadequate management of acute pain is a critical contributor to its development. This review examines the etiology of CPSP, presents key risk factors, and critically evaluates pharmacological and nonpharmacological interventions. Particular attention is devoted to the role of regional anesthesia techniques and emerging preventive and therapeutic strategies, highlighting the necessity of multidisciplinary, evidence-informed approaches to address this persistent clinical challenge.

Navigating diagnostic uncertainty in children's chronic lower limb pain: A qualitative study of management strategies using vignette-based focus groups

BACKGROUND

Chronic lower limb pain is common in children and adolescents and is frequently managed by podiatrists. Due to the complexities of understanding the cause of chronic pain, clinicians may experience uncertainty around the diagnosis, which in turn may impact their communication and management approaches. Limited research explores how podiatrists manage chronic lower limb pain in children, especially in the presence of diagnostic uncertainty. This study aimed to explore the management strategies including language that podiatrists report using to address the pain experience of children with chronic lower limb pain and to investigate if and how the reported management strategies used by podiatrists to address the pain experience of children with chronic lower limb pain vary based upon the level of diagnostic uncertainty.

METHODS

Eight focus groups were conducted with a total of 48 podiatrists. Participants were presented with three vignettes, each describing a child with chronic lower limb pain. They were then asked to discuss their certainty in the child's diagnosis presented and their approaches to explain and manage the child's pain. Audio data were recorded, transcribed and analysed using thematic analysis. Three key themes were generated: Language strategies, non-verbal communication strategies and treatment strategies.

RESULTS

Podiatrists were overall certain in the diagnosis presented in vignettes 1 (calcaneal apophysitis) and 2 (juvenile idiopathic arthritis); however, they expressed significant uncertainty in vignette 3, which was written to elicit uncertainty presenting a case with generalised lower limb pain. Many groups fixated on the Beighton score of 5/9 and interpreted this to mean hypermobility, which is inconsistent with the current clinical guidance. Podiatrists used similar language strategies across all 3 vignettes and supported their language strategies with non-verbal communication strategies. Podiatrists also discussed activity modification, passive and self-care strategies and building a team as the treatment strategies they would use.

CONCLUSIONS

This study highlights the variety of clinical management strategies used by approaches and highlights how their approach may change depending on their certainty in the diagnosis.

Digitally supported physical activity counselling for people with chronic back pain: a randomised controlled parallel feasibility study

BACKGROUND

Guiding individuals with chronic back pain (CBP) to initiate and adhere to physical activity (PA) remains challenging. The study rationale is based on the need for innovative strategies, like digital tools, to better promote PA. The aim of this study was to evaluate the feasibility and acceptability of using the digital consultation app ExPa (Exercise against Pain) to support PA consultations for CBP and its potential for a future effectiveness trial. The ExPa app shows the effect of PA on pain and provides individually tailored support to increase PA.

METHODS

In a 2-arm randomised controlled feasibility study, we recruited 9 physicians and 37 CBP patients in Hesse (Germany). Using computer assisted cluster randomisation, 14 patients received ExPa counselling from their physician, while 17 patients received standard treatment. Main outcomes focused on study procedures and software use, with secondary outcome including pre- and post-intervention measurements of PA (International Physical Activity Questionnaire (IPAQ), pain and mood (Short Form-12 (SF-12), Von Korff pain intensity and disability score and Hospital Anxiety and Depression Scale (HADS)). Additionally, project-tailored questionnaires and qualitative interviews assessed study procedures and software performance.

RESULTS

Study procedures were generally feasible. However, they took more time and dropouts as well as missing data presented challenges. This provided valuable insights for planning an effectiveness trial. Quantitative and qualitative data indicated that ExPa could have benefits for increasing PA and reducing pain.

CONCLUSIONS

Results from the feasibility study indicate that improved procedures are necessary for a larger RCT. ExPa shows potential for positively impacting pain and PA.

Trajectories of mHealth-Tracked Mental Health and Their Predictors in Female Chronic Pelvic Pain Disorders

Background

Female chronic pelvic pain disorders (CPPDs) affect 1 in 7 women worldwide and are characterized by psychosocial comorbidities, including a reduced quality of life and 2-10-fold increased risk of depression and anxiety. Despite its prevalence and morbidity, CPPDs are often inadequately managed with few patients experiencing relief from any medical intervention. Characterizing mental health symptom trajectories and lifestyle predictors of mental health is a starting point for enhancing patient self-efficacy in managing symptoms. Here, we investigate the association between mental health, pain, and physical activity (PA) in females with CPPD and demonstrate a method for handling multi-modal mobile health (mHealth) data.

Methods

The study sample included 4270 person-level days and 799 person-level weeks of data from CPPD participants (N=76). Participants recorded PROMIS global mental health (GMH) and physical functioning and pain weekly for 14 weeks using a research mHealth app, and moderate-to-vigorous PA (MVPA) was passively collected via activity trackers.

Data Analysis

We used penalized functional regression (PFR) to regress weekly GMH-T (GMH-T) on MVPA and weekly pain outcomes while adjusting for baseline measures, time in study, and the random intercept of the individual. We converted 7-day MVPA data into a single smooth using spline basis functions to model the potential non-linear relationship.

Results

MVPA was a significant, curvilinear predictor of GMH-T (F=18.989, p<0.001), independent of pain measures and prior psychiatric diagnosis. Physical functioning was positively associated with GMH-T, while pain was negatively associated with GMH-T (B=2.24, B=-1.16, respectively; p<0.05).

Conclusion

These findings suggest that engaging in MVPA is beneficial to the mental health of females with CPPD. Additionally, this study demonstrates the potential of ambulatory mHealth-based data combined with functional models for delineating inter-individual and temporal variability.

Impact of education in patients undergoing physiotherapy for lower back pain: a level I systematic review and meta-analysis

INTRODUCTION

Lower back pain (LBP) is one of the most common musculoskeletal disorders in modern society, with a lifetime incidence of up to 90%. According to most national and international guidelines, educational interventions play a central role in the multimodal treatment of LBP. This systematic review and meta-analysis investigated the impact of educational interventions on pain and disability in patients with LBP undergoing physiotherapy compared to patients without educational interventions undergoing physiotherapy.

METHODS

In October 2024, a comprehensive computer-aided search was performed to assess the online databases PubMed, Web of Science, Google Scholar, and Embase. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria with an established PICOTD algorithm. Two authors independently performed the data extraction and risk of bias evaluation. The primary outcome measures extracted were a pain score (VAS or NRS) and the Roland Morris Disability Questionnaire (RMQ).

RESULTS

Data from 8152 patients were retrieved. The mean length of follow-up was 6.2 ± 3.9 months, the mean length of symptom duration was 66.7 ± 51.6 months, and the mean age of the patients was 46.7 ± 9.2 years. Compared to physiotherapy alone, additional education did not reduce pain (P = 0.4) or disability according to the RMQ (P = 0.9).

CONCLUSION

The addition of education did not impact pain and disability in patients undergoing physiotherapy for chronic non-specific LPB.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis of RCTs.

Examining recovery trajectories of physical function, activity performance, cognitive and psychological functions, and health related quality of life in COVID-19 patients treated in ICU: a Swedish prospective cohort study

PURPOSE

To investigate the recovery trajectories of physical function, activity performance, cognitive and psychological functions, and health related quality of life, as well as potential interaction effects, in individuals with COVID-19 treated in an intensive care unit (ICU).

METHODS

This prospective cohort study included patients with confirmed COVID-19 infection, treated in an ICU. Clinical assessments and self-ratings of functioning, disability and health were performed > 1 month and > 12 months after discharge from hospital.

RESULTS

Among the 65 included individuals (mean age 56.6, SD 11) significant improvements in physical and psychological function were observed over time, although not reaching population norms. Cognition remained unchanged (MoCA median 27, IQR 4). At the 12-month follow-up, physical limitations in activity (RAND-36) were found to be associated with dyspnea (mMRC-Dyspnea), mental and physical fatigue (MFI-20), and walking endurance (6-minute walk test) (r2 0.509 p < 0.001). Role limitations due to physical health (RAND-36) was found to be associated with physical and mental fatigue (MFI-20) and pain (r2 0.530 p < 0.001).

CONCLUSION

Despite improvements in functioning and health in this group of predominantly younger age recovery did not reach population norms. These results highlight persistent impairments and activity limitations that may necessitate long-term healthcare interventions.

Can Wearable Device Promote Physical Activity and Reduce Pain in People with Chronic Musculoskeletal Conditions?

Objective: The purpose of this systematic review is to identify and appraise the evidence on the effectiveness of using wearable devices to promote physical activity and reduce pain in people with chronic musculoskeletal pain. Methods: Systematic searches of electronic databases PubMed, CINAHL, and Medline (Ovid) were undertaken for randomised control trials and observational studies of wearable-based interventions in patients with chronic musculoskeletal conditions. Result: Thirteen studies were included in this review. The methodological quality of the included articles was found to vary between moderate and high quality. Studies included patients with osteoarthritis hip/knee (number; n = 5), low back pain (n = 3), rheumatoid arthritis (n = 1), juvenile idiopathic arthritis (n = 1), inflammatory arthritis (n = 1), spondylarthritis (n = 1), and ankylosing spondylitis (n = 1). The intervention group of some of the studies included additional components associated with the use of wearable devices such as step or diet diary, motivational interviewing or counselling, goal setting, and multidimensional and tailored exercise programme interventions delivered in person, remotely, or in a hybrid format. Intervention duration ranged from 1 week to 28 weeks. There were no serious adverse events related to the use of wearables. Overall, evidence from this systematic review shows that wearable technology intervention was effective in increasing physical activity significantly, especially where extra components (counselling, coaching, prescribed physical activity, goal setting, physiotherapist) were used among clinical and non-clinical populations. However, no significant effect was found in pain reduction with the use of wearable devices. Conclusions: It is concluded that the use of wearable technology should be encouraged in patients with chronic musculoskeletal conditions. Additional research is needed, such as increasing the duration of the intervention, which may have an impact on pain.

Aerobic Exercise Prescription for Pain Reduction in Fibromyalgia: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Fibromyalgia is a condition characterised by disabling levels of pain of varying intensity. Aerobic exercise may play a role in reducing pain in these patients. The aim of this review is to assess the dose of aerobic exercise needed, based on the frequency, intensity, type, time, volume and progression (FITT-VP) model, to obtain clinically relevant reductions in pain.

DATABASES AND DATA TREATMENT

A systematic review and meta-analysis of randomised clinical trials was conducted in the Web of Science (WoS), PEDro, PubMed and Scopus databases, the search having been conducted between July and October of 2023. Risk of bias was assessed with the Cochrane Risk of Bias assessment tool 2.

RESULTS

Seventeen studies were included. The risk of bias varied, with six studies showing low risk; five, some concerns; and six, high risk. Aerobic exercise interventions were analysed using the FITT-VP model. Frequency ranged from 1 to 10 times per week, intensity varied from light to vigorous, and the types of exercise included music-based exercise, interval training, pool-based exercise, stationary cycling, swimming and walking. The intervention durations ranged from 3 to 24 weeks, with session lengths ranging from 10 to 45 min. Most of the studies presented significant differences, favouring aerobic exercise (MD -0.49; CI [-0.90, -0.08; p = 0.02]), with moderate to low heterogeneity in subgroup analyses.

CONCLUSIONS

The study findings underscore the efficacy of aerobic exercise in alleviating pain among fibromyalgia patients, advocating for tailored exercise dosing to optimise adherence and outcomes.

SIGNIFICANCE STATEMENT

Individuals with fibromyalgia should engage in aerobic exercises two to three times weekly, for twenty-five to forty minutes in each session, aiming for more than a hundred minutes per week. They should start at low intensity, gradually increasing to higher intensities over six to twelve weeks, for optimal pain management. Exercise types should be selected in collaboration with the patient and based on personal preferences and accessibility, such as walking, and swimming, to ensure long-term adherence to the regimen.

Peripheral nerve stimulation for lower-limb postoperative recovery: A systematic review and meta-analysis of randomized controlled trials

Patients undergoing lower-limb orthopedic surgery may experience multiple postoperative complications. Although peripheral nerve stimulation (PNS) is a promising non-pharmacological approach that has been used in lower-limb postoperative recovery, the clinical efficacy of PNS remains inconclusive. This study systematically searched three databases (PubMed, Embase, and Cochrane Library) for randomized controlled trials (RCTs) that examined the treatment effects of PNSs in patients who underwent lower-limb orthopedic surgery up to September 29, 2023. Two investigators independently identified studies, extracted data, and conducted meta-analyses with Review Manager 5.4. The outcomes were pain relief (measured by reductions in pain intensity and analgesic consumption) and functional improvements (range of motion [ROM] and length of hospitalization [LOH]). A total of 633 patients including 321 in the experimental groups and 312 in the control groups from eight RCTs were included. PNS showed no significant effect on pain intensity, while analgesic consumption was marginally significantly reduced in the experimental group. Furthermore, no significant differences were observed regarding functional improvements in ROM or LOH after the intervention. Although PNS had no significant effect on pain relief or functional improvements, the intervention exhibited a marginally significant reduction in analgesic consumption. Future trials should be conducted with larger sample sizes, longer follow-up periods, and more varied stimulation parameters.

[How does an intervention work?-German Version. : Development of an effect model for a complex intervention to prevent recurring or persistent pain using the example of PAIN 2.0]

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like.

Lipid nanoparticle delivery of siRNA to dorsal root ganglion neurons to treat pain

Sensory neurons within the dorsal root ganglion (DRG) are the primary trigger of pain, relaying activity about noxious stimuli from the periphery to the central nervous system; however, targeting DRG neurons for pain management has remained a clinical challenge. Here, we demonstrate the use of lipid nanoparticles (LNPs) for effective intrathecal delivery of small interfering RNA (siRNA) to DRG neurons, achieving potent silencing of the transient receptor potential vanilloid 1 (TRPV1) ion channel that is predominantly expressed in nociceptor sensory neurons. This leads to a reversible interruption of heat-, capsaicin-, and inflammation-induced nociceptive conduction, as observed by behavioral outputs. Our work provides a proof-of-concept for intrathecal siRNA therapy as a novel and selective analgesic modality.

How does an intervention work?-English Version : Development of an effect model for a complex intervention to prevent recurring or persistent pain using the example of PAIN 2.0

In addition to the usual evaluation approach (usually a clinical randomized trial in the sense of the question: does an intervention work), complex interventions require further systematic investigations to prove their effectiveness. The role of the context in which the intervention is delivered is essential here, as is consideration of the question of why an intervention works (or does not work). Detailed recommendations exist for the planning and implementation of effectiveness studies on complex interventions, to which interdisciplinary multimodal pain therapy undoubtedly belongs. In an effectiveness model, concrete, verifiable assumptions are formulated as to how an intervention produces changes that are reflected in the endpoint. This article provides a brief introduction to methodological approaches to effectiveness research on complex interventions and uses the PAIN 2.0 project (01NVF20023) to describe in concrete terms what an effectiveness model for interdisciplinary multimodal pain therapy for the prevention of chronic pain in an outpatient setting might look like.

Utilization of telemedicine in conjunction with wearable devices for patients with chronic musculoskeletal pain: a randomized controlled clinical trial

The present randomized controlled trial aimed to investigate the effects of home-based telemedicine with wearable devices and usual care on pain-related outcomes in patients with chronic musculoskeletal pain, compared to usual care alone. The patients with chronic musculoskeletal pain were randomly allocated to the usual care group or the telemedicine group, which participated in telemedicine with wearable devices, the objective data from which were recorded, in conjunction with usual care for six months. The primary outcome measure was the Numeric Rating Scale (NRS) for pain. The secondary outcome measures were the Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), Pain Disability Assessment Scale (PDAS), and EuroQol-five dimensions-three level (EQ-5D-3L). Seventy-one participants were analyzed. At 1 and 3 months, there were no significant differences in the NRS scores between the groups; however, the telemedicine group had a significantly superior effect on all of the outcome measures at 6 months compared to the usual care group. The number of steps and distance were significantly increased at 6 months compared to baseline in the telemedicine group. Home-based telemedicine with wearable devices and usual care has a modest effect on pain-related outcomes compared to usual care in patients with chronic musculoskeletal pain.This study was registered (UMIN000052994 - 04/12/2023).

9. Chronic knee pain

INTRODUCTION

Chronic knee pain is defined as pain that persists or recurs over 3 months. The most common is degenerative osteoarthritis (OA). This review represents a comprehensive description of the pathology, diagnosis, and treatment of OA of the knee.

METHODS

The literature on the diagnosis and treatment of chronic knee pain was retrieved and summarized. A modified Delphi approach was used to formulate recommendations on interventional treatments.

RESULTS

Patients with knee OA commonly present with insidious, chronic knee pain that gradually worsens. Pain caused by knee OA is predominantly nociceptive pain, with occasional nociplastic and infrequent neuropathic characteristics occurring in a diseased knee. A standard musculoskeletal and neurological examination is required for the diagnosis of knee OA. Although typical clinical OA findings are sufficient for diagnosis, medical imaging may be performed to improve specificity. The differential diagnosis should exclude other causes of knee pain including bone and joint disorders such as rheumatoid arthritis, spondylo- and other arthropathies, and infections. When conservative treatment fails, intra-articular injections of corticosteroids and radiofrequency (conventional and cooled) of the genicular nerves have been shown to be effective. Hyaluronic acid infiltrations are conditionally recommended. Platelet-rich plasma infiltrations, chemical ablation of genicular nerves, and neurostimulation have, at the moment, not enough evidence and can be considered in a study setting. The decision to perform joint-preserving and joint-replacement options should be made multidisciplinary.

CONCLUSIONS

When conservative measures fail to provide satisfactory pain relief, a multidisciplinary approach is recommended including psychological therapy, integrative treatments, and procedural options such as intra-articular injections, radiofrequency ablation, and surgery.

UK medical cannabis registry: A clinical outcome analysis of medical cannabis therapy in chronic pain patients with and without co-morbid sleep impairment

INTRODUCTION

Chronic pain (CP) affects 35.0%-51.3% of the UK population, with 67%-88% reporting sleep disturbances. Cannabis-based medicinal products (CBMPs) have shown therapeutic potential in managing CP. Evidence suggests poor sleep worsens pain perception; therefore, this study aimed to assess patient-reported outcome measures (PROMs) following CBMP treatment in CP patients with and without co-morbid sleep impairment.

METHODS

A prospective cohort study of CP patients from the UK Medical Cannabis Registry was conducted. Participants were separated by baseline single-item sleep quality scale (SQS) score into sleep impaired (SQS ≤3) and unimpaired (SQS ≥4) cohorts. The primary outcome assessed changes in PROMs from baseline to 1-, 3-, 6-, and 12-months. Participants completed the following: SQS, General Anxiety Disorder-7, EQ-5D-5L, Brief Pain Inventory (BPI), and Short-Form McGill Pain Questionnaire-2. Significance was defined as p < 0.050.

RESULTS

1139 participants met the inclusion criteria (sleep impaired: n = 517, 45.4%; sleep unimpaired: n = 622, 54.61%). The sleep impaired cohort showed improvements in all PROMs at each follow-up (p < 0.010). The sleep unimpaired cohort showed similar results (p < 0.050), except in SQS and ED-5Q-5L: self-care and anxiety/depression scores (p > 0.050). However, the sleep impaired cohort observed greater improvements in BPI pain severity (p < 0.050) and SQS (p < 0.001) than the sleep unimpaired cohort at all follow-ups. 2817 adverse events were self-reported between both cohorts (p = 0.197).

DISCUSSION

These findings align with literature that shows associated improvements in pain outcomes following CBMP administration. Sleep impaired individuals were more likely to experience greater pain severity improvements. However, this was not confirmed on multivariate logistic regression analysis and instead may be confounded by baseline pain severity.

CONCLUSION

Whilst these results show promise for the effects of CBMPs on CP, they must be examined within the limitations of the study design. These findings provide further evidence to support the design of subsequent randomized controlled trials to verify causality between CBMPs and pain outcomes.

Effectiveness of a Telerehabilitation-Based Exercise Program in Patients with Chronic Neck Pain-A Randomized Clinical Trial

BACKGROUND

Non-specific chronic neck pain is a prevalent musculoskeletal disorder with a significant impact on individuals' quality of life. The lack of consensus on effective therapeutic management complicates the establishment of standardized treatment protocols. Home exercise programs have yielded positive results. This study aimed to assess the effectiveness of a telerehabilitation program distributed through videoconferencing for patients with non-specific chronic neck pain compared to a home-based exercise program.

METHODS

A randomized controlled trial was conducted involving 36 participants who were divided into two groups: the experimental group (n = 18) received manual therapy combined with telerehabilitation, while the home-based group (n = 18) received the same manual therapy treatment along with recommendations for home exercises. Key outcome measures, including neck-related disability, kynesiophobia, anxiety and depression, pain intensity, pressure pain threshold, quality of life, and adherence to self-treatment, were evaluated at baseline and post-treatment.

RESULTS

No statistically significant differences were observed between groups. However, both groups demonstrated improvements in all study variables except for the mental component of quality of life immediately post-treatment.

CONCLUSIONS

After eight weeks of manual therapy and exercise, both the telerehabilitation and home-based exercise programs resulted in significant improvements in disability, pain, and kynesiophobia, indicating that telerehabilitation is as effective as home-based exercise.

Effectiveness of a brief multicomponent intervention to improve physical activity level and functional capacity in fibromyalgia and chronic fatigue syndrome (Synchronize+)

Introduction

Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are complex central sensitization syndromes that represent an important public health problem. Low cardiorespiratory fitness and muscle function with habitual intolerance to efforts are common characteristics of FM and CFS. This study aimed to examine the effect of a brief multicomponent intervention based on physical activity (PA), nutrition, and chronobiology on movement behaviors (PA, sedentary and sleep time), muscle strength, and cardiorespiratory capacity.

Methods

randomized controlled trial was conducted in primary healthcare in Catalonia. A total of 143 individuals with FM or FM and CFS concomitantly (age 50.8, SD 8.1; 94.4% women) were randomly allocated to the intervention (IG, n = 69) or control (CG, n = 74) groups. The IG participated in a brief multicomponent (PA, nutrition, and chronobiology) group-based intervention (4 sessions, 3 h/session) while the CG received usual primary care practice. Primary outcome measure was PA measured by the REGICOR-Short Physical Activity Questionnaire. Secondary outcomes were sedentary (International Physical Activity Questionnaire) and sleep time (Pittsburgh Sleep Quality Index), upper- and lower-body muscle strength (handgrip and sit-to-stand test, respectively), and aerobic capacity (6-min walk test). Data were collected at baseline and 3 months post-intervention.

Results

The IG showed positive differences at 3-month follow-up, with highly appreciably PA levels, less sedentary time, and significantly improved sleep time. Significant between-group differences were also observed at 3 months, with better health values in the IG: PA and sleep time (370.3 ± 307.0 vs. 195.9 ± 289.1 min/week and 6.1 ± 1.6 vs. 5.5 ± 1.8 h/night, respectively) and less sedentary time (266.2 ± 153.3 vs. 209.4 ± 199.9 min/day). The IG also showed higher upper limb strength and significant lower-body strength both between and within groups, as well as significantly improved cardiorespiratory capacity.

Conclusion

The Synchronize + multicomponent program implemented at primary healthcare has shown short-term effectiveness in improving 24-h movement behaviors and health outcomes in individuals with FM, with or without CFS. This intervention may be a first step in educating and motivating people with FM and CFS to adopt an active lifestyle, leading to improved health. Long-term follow-up will determine whether the changes are maintained over time and their impact on quality of life and healthcare costs.

Sustainability of a Non-pharmacological, Self-Managed Intervention for Chronic Musculoskeletal Pain: 3-group Randomized Controlled Pilot Trial

Background

Chronic musculoskeletal pain (CMP) affects around 1.7 billion people globally, causing significant physical, psychological, and economic burdens. Current treatments often involve medications with risks, creating an urgent need for accessible alternatives. Interventionist-administered Auricular Point Acupressure (APA) has shown effectiveness in reducing pain. To explore whether this low-risk, non-invasive, non-pharmacologic, and non-opioid pain relief method can be expanded digitally, this study developed a self-managed APA program using mobile health technology and coaching videos, allowing individuals to self-administer APA and evaluate its impact and sustainability.

Methods

A 3-group pilot randomized controlled trial was conducted among 37 participants with CMP. The participants were randomly assigned to in-person APA (n=14) with face-to-face APA instruction, self-guided APA (n=12) with remote APA coaching, or control (n=11). All received conventional healthcare, with the APA groups also receiving adjuvant APA intervention for a 4-weeks supplemented with mobile app coaching videos, followed by monthly monitoring for three months. Data on pain intensity, physical disability, physical function, anxiety, depression, fatigue, sleep disturbance, fear avoidance of work, and satisfaction were collected at baseline, immediately following the 4-week APA intervention, and during the 2-month and 3-month follow-ups post-intervention.

Results

Both the in-person and self-guided APA groups experienced a 47% reduction in pain intensity. Over 50% of participants achieved at least a 30% reduction in pain, and more than 17% had a 30% reduction in physical disability. Improvements included an 18% boost in physical function, decreased fatigue, improved sleep disturbance, and less depression (with increases noted in the control group), a 50% reduction in fear-avoidance of work, and only 3.8% reported not being satisfied with the APA at the 3-month follow-up. No adverse effects related to APA were reported.

Conclusion

APA improved physical and mental health in participants with CMP, enhanced readiness to return to work, and demonstrated sustainability for at least three months. Coaching videos delivered via a mobile app proved to be a feasible approach for teaching APA, increasing the accessibility of the intervention. This study highlights the impact of APA and recommends further research into its mechanisms and long-term benefits to support integration into standard practice.

Posture and Pain: Beliefs and Attitudes of Patients With Chronic Low Back Pain

BACKGROUND AND OBJECTIVES

Posture is often associated with pain by patients, professionals, and health information channels. However, the extent to which patients perceive the relationship between posture and chronic pain is not well understood. This study aimed to investigate and understand the beliefs and attitudes related to posture among patients with chronic low back pain.

METHODS

This is a qualitative descriptive study that investigated individuals with chronic low back pain, who were on the waiting list for physiotherapy. Data were collected through individual and semi-structured interviews. Thematic content analysis was used to analyse the data.

RESULTS

Fifteen adults (11 women and 4 men) were interviewed. Three themes were identified and mapped within the dimensions proposed by the Common Sense Model: (1) Identity, (2) Cause and (3) Control. Participants' statements about posture predominantly followed the biomedical model, with participants holding a mental representation of a 'correct' posture necessary for maintaining a healthy spine. They associated perceived incorrect postures or positions with the cause or worsening of pain. To control symptoms, participants believed that constant care and monitoring of posture in various situations were necessary.

CONCLUSION

Misconceptions about ideal posture and its relationship to chronic pain can lead individuals with low back pain to engage in constant monitoring and avoid certain movements and positions in daily activities. These beliefs may negatively impact prognosis, contribute to the maintenance of symptoms, and affect adherence to treatments.

Changes in analgesic prescriptions in Dutch general practice

BACKGROUND

Increases in opioid prescriptions have been described; however, recent trends and prescribing patterns of analgesics in Dutch general practice are largely unknown.

OBJECTIVE

To investigate recent changes in the number of analgesic prescriptions, and the indications for prescribing strong opioids. Furthermore, we aim to identify risk factors for chronic opioid use in Dutch general practice.

DESIGN AND SETTING

A retrospective cohort study from 1 July 2013 to 31 June 2022, using a primary care practice based research network.

SUBJECTS

Patients with ≥1 prescription for analgesics during the study period were included.

MAIN OUTCOME MEASURE

Changes in the number of prescriptions for paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in Dutch general practice during the 9-year study period. Moreover, we analyzed indications for prescribing strong opioids by the general practitioner (GP).

RESULTS

A total of 18,433 analgesic users were identified. Over time, prescriptions for paracetamol, NSAIDs and weak opioids decreased, while the number of strong opioid prescriptions increased. General practitioners prescribed more strong opioids for non-malignant pain, whereas prescriptions for malignant pain remained stable over time. Risk factors for chronic opioid use (≥90 days) included older age, lower educational level, smoking status and having a history of a musculoskeletal or psychological disorder, a malignancy or sexual, physical or psychological abuse.

CONCLUSIONS

Considering the increase in strong opioid prescriptions for benign conditions, GPs need to be vigilant for patients who are at risk for chronic use. Regular monitoring and awareness for psychosocial factors in treatment of chronic pain may be key in preventing harms associated with persistent opioid use.

Integrating Chiropractic Care and Tai Chi Training for the Treatment of Chronic Nonspecific Neck Pain in Nurses: A Single-Arm Mixed-Methods Pilot Trial

Objectives: Chronic nonspecific neck pain (CNNP) is prevalent among health care workers, with particularly high rates among nurses. Nurses experiencing CNNP often report decreased job satisfaction, increased absenteeism, and reduced productivity. In recent years, nonpharmacologic approaches have gained attention as effective treatments for the management of CNNP, with exercise and manual therapies representing two of the most common. Early evidence shows that multimodal treatments may be more effective than unimodal strategies. The purpose of this current study was to assess the feasibility and observe the clinical outcomes of combined multimodal chiropractic care (MCC) and Tai Chi (TC) for CNNP in nurses. Methods: A single-arm mixed-methods pilot trial was conducted including 16 weeks of MCC and TC in nurses with self-reported CNNP. Feasibility outcomes were recruitment, retention, and adherence to the interventions. Clinical outcomes of interest included neck pain and related disabilities. Secondary outcomes of interest were functional, affective, and work-related performance. Qualitative interviews were also conducted. Results: Of the 59 screened, 36 met the eligibility criteria, and 21 were enrolled. The retention rate was 71.4%, and adherence rates were 85.3% for MCC and 62.5% for TC classes. Multiple pain and disability-related outcomes exhibited modest improvement from baseline to 16-week follow-up. Qualitative analysis identified six emergent themes: (1) neck pain being an inherent part of nursing, (2) nurses push through their pain, (3) MCC relieves pain and is instructive for preventing pain, (4) TC provides overall relaxation, (5) both interventions increased body awareness and improved posture, and (6) scheduling difficulties were a key obstacle for participating. Conclusions: Observed reductions in neck pain and disability suggest the potential utility of combined MCC and TC interventions for managing CNNP. Along with qualitative feedback regarding facilitators and barriers to participation, the findings support and inform a future randomized trial evaluating the combined benefits of MCC and TC for CNNP in nurses. Clinical Trial Registration #NCT06523036.

Factors associated with participation in a walking intervention for veterans who smoke and have chronic pain

This analysis was part of the Pain and Smoking Study (PASS), a randomized trial of a cognitive behavioral intervention (CBI) for Veterans with chronic pain who smoke. The objective of this study was to examine factors associated with participation in the walking component of the intervention. Demographics and clinical characteristics were obtained at baseline. Completion of two or more CBI counseling sessions was required to be included in analyses. Average daily step counts obtained via pedometer in the prior week were recorded in up to three telephone counseling sessions. Participants were then categorized as "sedentary" (≤ 4999 daily steps) or "not sedentary" (≥ 5000 daily steps). Multivariable logistic regression was used to model variance in activity categorization. Overall, 91.0% of participants were men, 70.5% were white, mean age was 58.4 years, mean BMI was 28.6, median pack years was 20.5, and 43.8% were depressed. Veterans reported moderate pain intensity (4.9/10) and pain interference (5.4/10). Pain locations included: lower extremity (67.4%), back (53.4%) and upper extremity (28.1%). Median daily steps were 2491 [IQR: 1720-3550] (sedentary) (n = 65), 7307 [IQR: 5952-8533] (not sedentary) (n = 24), and 3196 [IQR: 2237-5067] (overall) (n = 89). Veterans with older age (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04, 1.17) and presence of LE pain (OR: 5.98, 95% CI: 1.82, 19.65) had increased odds of being "sedentary." Integrated smoking cessation and chronic pain self-management interventions that include a walking component may need to consider the impact of age and pain location on participation.Trial registration: The trial is registered at www.ClinicalTrials.gov (NCT02971137). First posted on November 22, 2016.

How initial perceptions of the effectiveness of mind and body complementary and integrative health therapies influence long-term adherence in a pragmatic trial

OBJECTIVE

Beliefs and perceptions about pain intervention effectiveness when initiating a therapy may influence long-term engagement. This study examines how early perceived effectiveness of complementary and integrative health therapies impacts long-term engagement in a pragmatic trial context.

PARTICIPANTS

Veterans with chronic musculoskeletal pain participating in a pragmatic trial of provider-delivered complementary and integrative health therapies (acupuncture, chiropractic care, or massage therapy) used alone compared to combining those therapies with self-care therapies (yoga, Tai Chi/Qigong, or meditation). This analysis focuses on 1713 participants using self-care therapies at baseline.

SETTING

18 Veterans Healthcare Administration Medical Facilities.

DESIGN

Prospective cohort study.

METHODS

Predictors of total self-care complementary and integrative health therapy sessions over a 6-month assessment period were assessed using linear regression to determine how strongly perceptions of initial therapy effectiveness was associated with total utilization. Perception of initial therapy effectiveness was assessed at study entry across four domains (pain, mental health, fatigue, and general well-being).

RESULTS

In total, 56% (1032/1713) of Veterans reported a positive perceived effectiveness of their recent complementary and integrative health therapy use at study initiation. Older individuals and those using meditation were more likely to report early positive perceptions. Mean number of therapy sessions over the 6-month study was 11 (range 1 to 168). Early positive perceptions had a small effect on overall use, increasing mean sessions by 2.5 (1.3 to 3.6). Other factors such as recent physical therapy use and distance to primary care explained more variation in total utilization.

CONCLUSIONS

Pragmatic pain trials should examine factors associated with engagement across assigned treatment protocols, especially if any of the treatment protocols being tested are sensitive to long-term engagement.

Temporomandibular disorder pain is associated with increased sick leave and reduced health related quality of life

BACKGROUND

Temporomandibular disorders (TMD) are the most common reason for chronic pain in the orofacial area and significantly impact the lives of those affected. The role of lifestyle factors in TMD, however, remains less explored. This cohort study aims to estimate TMD prevalence by addressing potential selection biases and to evaluate the association between TMD and lifestyle factors with a specific focus on sick leave and health related quality of life.

METHODS

By linking data on TMD in the general population in Västerbotten, northern Sweden (n = 180,000) to health survey data (n = 120,000), information on sociodemographic factors and quality of life was available for 52,961 individuals (50.6% women) with a mean age of 53 years. We applied inverse probability weighting to adjust for selection bias and Poisson regression to explore associations with TMD.

RESULTS

TMD prevalence was 9.2% during the study period, being higher in women (12.9%) than men (5.4%). Weighting for varying visiting frequencies did not affect TMD prevalence (average difference 0.4% points). Individuals with TMD, especially women, reported more sick leave and use of pain medication, with a significant association between TMD and increased sick leave (prevalence ratio 1.89, 95% CI: 1.78-2.01) among both women and men. In addition, TMD was associated with a lower health related quality of life (p < 0.001).

CONCLUSION

The association of TMD with sick leave highlights the condition's profound impact on the lives of affected individuals. These findings underscore the influence of TMD on work life and the burden of TMD on the societal level.

SIGNIFICANCE STATEMENT

The findings provide insight into how TMD affect individuals, by incorporating lifestyle factors, social determinants and the impact of sick leave at a population level. By incorporating these areas into the study of TMD, we can deepen our understanding of how TMD affects individuals' lives. This approach may also create opportunities to develop more comprehensive strategies to address TMD, focusing on broader implications beyond the clinical symptoms.

Prevalence and treatment of chronic musculoskeletal pain focused on service gaps: a comparative analysis by age group and body part

Background

Occupational health, grounded in occupational medicine, aims to enhance the well-being and labor productivity of the working population. Within this realm, there has been growing concern over the increasing instances of labor loss due to diminished physical capacity and the rise in musculoskeletal disorders. Chronic pain is also associated with musculoskeletal disorders. Another pressing issue related to chronic musculoskeletal pain was needed assistance services are underutilized, is referred to as a "service gap". Understanding trends based on age and affected regions of the body is indispensable for developing strategies to address chronic musculoskeletal pain in workers. This study aimed to elucidate age-specific trends in the prevalence and number of pain sites in chronic musculoskeletal pain as well as the patterns of treatment during chronic musculoskeletal pain, categorized by age and affected site.

Methods

This study was conducted in December 2022 in contract to Cross Marketing Inc. The survey began on December 12, 2022 and ended on December 15, 2022. An online survey was administered to 1,946 participants (973 women and 973 men), and responses were collected, ensuring a roughly equal distribution of samples among men and women across six age groups ranging from their 20 to 70 s. The survey inquired about the presence of chronic pain in each of the eight body parts and the adoption of five different treatments when experiencing pain. Statistical analysis was performed using the chi-square test, with the measurement data categorized by age group and body part.

Results

The results indicated a significantly higher prevalence of chronic pain at three or more sites among individuals in their 30 s: the prevalence of pain at each of the eight body sites varied with age. Approximately half of the participants did not engage in specific treatments during episodes of chronic pain. The presence or absence of treatment showed no significant differences according to affected site or age group. This study revealed age- and body part-related relationships with chronic musculoskeletal pain in middle-aged patients and highlighted healthcare service gaps in its management in Japan.

What are the functional and clinical characteristics shared by fibromyalgia and low back pain? A scoping review

BACKGROUND

Fibromyalgia and chronic primary low back pain are two chronic pain conditions with a significant biopsychosocial burden. Recently, the International Association for the Study of Pain has grouped them under the term chronic primary pain. To further explore similarities and differences between these two conditions, the objective of this scoping review is to explore the pain-related, physiological and psychological outcomes in individuals with fibromyalgia and low back pain.

METHODS

The following databases were used to find relevant studies, using the PRISMA guidelines: Medline, Psycinfo, and CINAHL. Studies were included if they encompassed both participants with fibromyalgia or low back pain, with the objective to compare pain-related, physiological and/or psychological outcomes.

RESULTS

Nineteen studies were selected for extraction. Among the 2801 participants, 968 had fibromyalgia (mean age 48.56 ± 7.97 years, with 94% being female) and 896 had low back pain (mean age 47.48 ± 8.15 years, with 80% being female). Pain sensitivity, physical dysfunction, illness perception, psychological distress, alexithymia, depression, and anxiety were generally more severe in participants with fibromyalgia. Most studies found similar levels of pain intensity, kinesiophobia, quality of pain, quality of life, impact of pain, suicidal risk, anger, and social support comparing individuals with fibromyalgia and individuals with low back pain.

DISCUSSION

This scoping review highlights that although both conditions show similar pain intensity and impact on quality of life, fibromyalgia is associated with greater overall severity than low back pain, especially in sensitivity to pain and depression/anxiety.

Relationship of Pain, Depression, Fatigue, and Sleep Problems with Functional Capacity, Balance, and Fear of Falling in Women with Fibromyalgia: Cross-Sectional Study

(1) Background: Fibromyalgia (FM) is a syndrome marked by chronic widespread pain, fatigue, sleep issues, and other symptoms. Interventions like physical exercise can potentially enhance physical function in individuals with FM. This study aimed to assess physical function, perceived physical fitness, balance confidence, and fear of falling in women with FM based on their levels of pain, depression, fatigue, and sleep problems. (2) Methods: Participants underwent a series of tests and questionnaires to evaluate physical and perceptual aspects. These included the Time Up and Go, Four Step Square Test, 6-Minute Walking Test, Maximum Handgrip Strength, Back Scratch, International Fitness Scale, Activities-Specific Balance Confidence Scale, and Fall Efficacy Scale-International. Participants were categorised by the severity of their pain, depression, fatigue, and sleep problems (mild, moderate, severe). A Kruskal-Wallis test assessed intergroup differences, while Spearman's rho evaluated correlations between the study variables and symptom levels. (3) Results: Perceived physical condition varied significantly with symptom severity. Symptoms and sleep problems were notably linked to fear of falling, though no significant differences emerged in the physical tests. (4) Conclusions: In women with fibromyalgia, symptom severity was primarily related to perceptual and subjective aspects of physical condition and fall safety.

Effects of moderate physical activity on diabetic adhesive capsulitis: a randomized clinical trial

Background

Moderate physical activity (MPA) has proven advantages for glycemic control, cardiovascular health, and functional independence. However, physical activity is not part of routine conventional physical therapy (CPT) in managing diabetic adhesive capsulitis patients.

Objective

To determine the effects of moderate MPA on diabetic adhesive capsulitis (AC).

Methodology

A randomized control trial was conducted at the Combined Military Hospital (CMH), Muzaffarabad, Pakistan from March 2022 to October 2022. A total of n = 44 patients with diabetic AC, aged 40 to 65 years, HbA1c > 6.5% were enrolled. Group A received MPA and CPT, while Group B only received CPT for six weeks. The upper extremity function, pain, and range of motion were assessed at baseline, third week, and sixth week through the disability of arm, shoulder, and hand (DASH) questionnaire, numeric pain rating scale (NPRSS), and goniometer respectively.

Results

The NPRS score and ROMs showed significant improvement (p < 0.05) in group A compared to group B with a large effect size. When comparing the mean difference of the DASH score (73 + 7.21 vs. 57.9 + 12.64, p < 0.001, Cohen's d = 1.46) was significantly improved with large effect size in group A as compared to group B.

Conclusion

MPA along with CPT has positive effects on patient pain, range of motion, and disability in patients with diabetic adhesive capsulitis.

Association between metabolic score for insulin resistance and cardiovascular disease mortality in patients with rheumatoid arthritis: evidence from the NHANES 1999-2018

Aim

To explore the association between Metabolic Score for Insulin Resistance (METS-IR) and the risk of cardiovascular disease (CVD) death in patients with rheumatoid arthritis (RA).

Methods

This retrospective cohort study extracted data on 1,218 RA patients from the National Health and Nutrition Examination Survey. The weighted univariate and multivariate Cox regression model was established to explore the association between METS-IR and CVD mortality. Subgroup analysis was performed in terms of age, gender, body mass index, diabetes, and CVD. Hazard ratios (HRs) and 95% confidence levels (CIs) were presented.

Results

Increased METS-IR was associated with a significantly higher risk of CVD mortality (HR=4.59, 95%CI: 1.98-10.67), and METS-IR>2.48 was associated with higher odds of CVD mortality compared with METS-IR ≤ 2.25 (HR=3.57, 95%CI: 2.04-6.24). METS-IR was positively associated with the risk of CVD mortality (HR=3.83, 95%CI: 1.62-9.08), and METS-IR>2.48 was associated with a significantly higher risk of CVD mortality in contrast to METS-IR ≤ 2.25 (HR=3.38, 95%CI: 1.87-6.09).

Conclusion

Increased METS-IR was associated with a significantly higher risk of CVD mortality in RA patients. Clinicians could consider incorporating the METS-IR score into routine assessment of the prognosis of RA patients.

The impact of an exercise and sport intervention on cognitive function and pain among forcibly displaced individuals at risk for PTSD: a secondary analysis of the SALEEM randomized controlled trial

BACKGROUND

In response to the global scope of forced displacement, international organizations highlight the need of scalable solutions to support individuals' health and integration into host societies. Exposure to high mental and physical stress perceived before, during, and after displacement can impair functional capabilities, essential for adapting to a new environment. This secondary analysis examined the impact of an exercise and sport intervention on cognitive function and pain severity among individuals living in a refugee camp in Greece.

METHODS

We implemented a randomized controlled trial involving n = 142 (52.8% women) forcibly displaced individuals from Southwest Asia and Sub-Saharan Africa. Participants were randomly assigned to a waitlist or a 10-week co-designed exercise and sport intervention with a 1:1 allocation rate between groups and sexes. Assessments at baseline and follow-up included the Flanker task, the Oddball paradigm, pain severity via visual analog scales, and the Åstrand-Rhyming indirect test of maximal oxygen uptake. We analyzed the intervention effects using structural equation modeling.

RESULTS

Our findings did not indicate a direct intervention effect on cognitive function or pain (p ≥ .332). However, the intervention group significantly improved cardiorespiratory fitness, ß = .17, p = .010, which was associated with faster reaction times in cognitive tasks, ß =  - .22, p = .004. Moreover, there was some evidence that adherence might be linked to reduced pain severity, ß =  - .14, p = .065.

CONCLUSIONS

Exercise and sport did not directly impact cognitive function and pain severity among a sociodemographically diverse sample living in a refugee camp, suggesting the need for complementary measures. Nevertheless, our results indicate that improvements in cardiorespiratory fitness benefit aspects of attention.

TRIAL REGISTRATION

The study was approved by the local ethics committee of the University of Thessaly (no. 39) and registered prospectively on February 8, 2021 at the ISRCTN registry (no. 16291983).

Enhancing mental well-being of undergraduates: establishing cut-off values and analyzing substitutive effects of physical activity on depression regulation

Objective

This study aimed to analyze the effects of physical activity (PA), sleep quality, and sedentary behavior on subthreshold depression (StD) among undergraduates.

Methods

This study included 834 undergraduates and assessed the impact of PA time, sleep quality, and sedentary behavior on depression. The receiver operating characteristic (ROC) analysis was performed to determine cut-off values for StD risk, while the isochronous substitution analysis was performed to evaluate the effects of different activities on depression regulation.

Results

Gender, age, and academic grade had no significant influence on depression levels among undergraduates (p > 0.05). However, students engaging in sedentary behavior for more than 12.1 h per day or with a Pittsburgh Sleep Quality Index score above 3.5 were at an increased risk of subclinical depression. Additionally, the isochronous substitution of light-intensity physical activity for other activities (sleep, sedentary behavior, moderate and vigorous intensity physical activity) showed statistically significant effects (p < 0.05) in both 5-min and 10-min substitution models, demonstrating a positive effect on alleviating depression.

Conclusion

The findings indicate that specific lifestyle factors, particularly high levels of sedentary behavior and poor sleep quality, are crucial determinants of subclinical depression among undergraduates, independent of demographic variables such as gender, age, and academic grade. Notably, light-intensity PA plays a key role in StD regulation, as substituting it with more intense physical activities or improving sleep quality substantially reduces depression scores. Furthermore, the benefits such substitution became more pronounced with the increase in duration of the activity.

Acceptability of the combined online interactive mindfulness and exercise programme (MOVE-Online) for adults with chronic pain - A qualitative study

PURPOSE

The aim of this qualitative study was to utilise the recent Theoretical Framework of Acceptability (TFA) to explore participants' acceptability of the mindfulness and exercise interventions in the MOVE-Online pain management programme (PMP) and the programmes' online delivery method.

METHODS

Online focus groups were carried out following the completion of the PMP. The data were analysed using template analysis in terms of the seven TFA constructs of acceptability [(i) Perceived Effectiveness, (ii) Affective Attitude, (iii) Self-Efficacy, (iv) Ethicality, (v) Burden, (vi) Opportunity Costs and (vii) Intervention Coherence].

RESULTS

Twenty-one participants took part in the focus groups. Five of the seven TFA constructs of acceptability were identified in the analysis. The participants perceived the intervention to have been effective at achieving the goals of the PMP (TFA construct: (i) Perceived Effectiveness), to have supported their emotional management ((ii) Affective Attitude), promoted long term self-directed engagement ((iii) Self-Efficacy), fostered a valued group environment ((iv) Ethicality) and the online delivery of the programme reduced the physical burden associated with participation at an in-person PMP ((v) Burden).

CONCLUSION

The results of the study supports the utility of the TFA as a tool to explore the multi-dimensional construct of acceptability for the participants in the MOVE-Online programme.

A Systematic Review of the Effectiveness of Rehabilitation Programmes or Strategies to Treat People With Persistent Knee Pain Following a Total Knee Replacement

BACKGROUND

Persistent high levels of knee pain after a total knee replacement have been estimated to affect 5%-10% of people and this is related to dissatisfaction with surgery, reduced function and reduced quality of life. This systematic review aims to evaluate the effectiveness of rehabilitation programs or strategies to reduce persistent pain and improve function and quality of life in people following a total knee replacement.

METHODS

The systematic review was conducted following PRISMA guidelines with a search of relevant online databases up to 17 July 2024. The search criteria included English language randomised controlled trials of rehabilitation programs or strategies in any setting to treat people with persistent knee pain more than 3 months after a total knee replacement. Rehabilitation could include exercise, education, cognitive strategies and self-management programs and excluded medication trials, procedural techniques and complementary therapies.

RESULTS

After removal of duplicates, there were 468 abstracts screened for eligibility with 23 remaining for full-text screening and finally, one study meeting the eligibility criteria. This study's interventions were pain neuroscience education alone and pain neuroscience education plus neuromuscular exercise. There were no statistically significant between-group differences for pain reduction or functional improvement.

CONCLUSION

The evidence examining the value of rehabilitation programs or strategies for pain reduction and functional improvement in people with persistent pain following total knee replacement is deficient. Given the high number of people affected annually, further research concerning both prevention and management of persistent pain after knee replacement is warranted.

Physical activity based on daily steps in patients with chronic musculoskeletal pain: evolution and associated factors

BACKGROUND

People with chronic musculoskeletal pain (CMSP) often have low physical activity. Various factors can influence the activity level. The aim of this study was to monitor physical activity, assessed by the number of steps per day, over time in people with CMSP and identify factors that could be associated with this activity feature.

METHODS

This prospective study involved people undergoing rehabilitation following an orthopedic trauma that had led to CMSP. At entry, participants completed self-reported questionnaires assessing pain, anxiety, depression, catastrophyzing, kinesiophobia, and behavioural activity patterns (avoidance, pacing and overdoing). They also underwent functional tests, assessing walking endurance and physical fitness. To determine daily step counts, participants wore an accelerometer for 1 week during rehabilitation and 3 months post-rehabilitation. The number of steps per day was compared among three time points: weekend of rehabilitation (an estimate of pre-rehabilitation activity; T1), weekdays of rehabilitation (T2), and post-rehabilitation (T3). Linear regression models were used to analyze the association between daily steps at T2 and at T3 and self-reported and performance-based parameters.

RESULTS

Data from 145 participants were analyzed. The mean number of steps was significantly higher during T2 than T1 and T3 (7323 [3047] vs. 4782 [2689], p < 0.001, Cohen's d = 0.769, and 4757 [2680], p < 0.001, Cohen's d = 0.693), whereas T1 and T3 results were similar (p = 0.92, Cohen's d = 0.008). Correlations of number of steps per day among time points were low (r ≤ 0.4). Multivariable regression models revealed an association between daily steps at T2 and pain interfering with walking, anxiety and overdoing behaviour. Daily steps at T3 were associated with overdoing behaviour and physical fitness.

CONCLUSIONS

Despite chronic pain, people in rehabilitation after an orthopedic trauma increased their physical activity if they were given incentives to do so. When these incentives disappeared, most people returned to their previous activity levels. A multimodal follow-up approach could include both therapeutic and environmental incentives to help maintain physical activity in this population.

The associations of chronic pain and 24-h movement behaviors with incident mental disorders: evidence from a large-scale cohort study

BACKGROUND

Chronic pain was associated with a higher risk of mental disorders (e.g., depression and anxiety). However, the role of 24-h movement behaviors in the association remains unclear.

METHODS

A total of 72,800 participants with accelerometer data and free of mental disorders from the UK Biobank were analyzed. The compositional mediation model and isotemporal substitution model were used to explore the associations between chronic pain, 24-h movement behaviors, and the incidence of overall mental disorders, depression, and anxiety.

RESULTS

With a median follow-up of 13.36 years, participants with chronic pain had a higher rate of incident overall mental disorders (hazard ratio (HR): 1.281, 95% confidence interval (CI): 1.219 to 1.344), anxiety (HR: 1.391, 95% CI: 1.280 to 1.536), and depression (HR: 1.703, 95% CI: 1.551 to 1.871). Increased sedentary behavior (SB) and reduced moderate-to-vigorous physical activity (MVPA) caused by chronic pain both increased the risk of mental disorders. Twenty-four-hour movement behaviors explained the relationship between chronic pain and overall mental disorders, depression, and anxiety by 10.77%, 5.70%, and 6.86%, respectively. Interaction effects were found between MVPA and chronic pain when predicting the incidence of depression and between MVPA, sleep (SLP), and chronic pain when predicting the incidence of mental disorders. People with chronic pain would recommend at least 0.5 h per day of MVPA and 7 h per day of SLP and restricting SB below 11.5 h per day.

CONCLUSIONS

Twenty-four-hour movement behaviors played a significant mediating role in the association between chronic pain and mental disorders. Individuals with chronic pain should engage in more MVPA, less sedentary behavior, and have 7-h sleep per day.

Exercises for the prevention of non-specific low back pain

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the effects of exercise alone or exercise plus education compared with inactive control or education alone to prevent non-specific LBP.

Knowledge and Attitude Toward Sciatica Pain and Treatment Methods Among the Population of Qassim in Saudi Arabia: A Cross-Sectional Study

Background: Sciatica, a pain radiating along the sciatic nerve, can cause significant suffering and functional limitations. Understanding individual populations' knowledge and attitudes about sciatica pain is crucial for designing targeted interventions and enhancing healthcare delivery, especially in Saudi Arabia. This study aimed to evaluate the knowledge and attitude toward sciatica pain and treatment methods among the population of Al-Qassim in Saudi Arabia. Methods and materials:This online cross-sectional study was conducted in the Al-Qassim region, Saudi Arabia, using a self-administered questionnaire. The data was analyzed using SPSS software, with numeric data presented as mean ± SD and categorical variables as frequencies and percentages. Correlation analyses included the Chi-squared test and one-way ANOVA. Results: The study received 398 responses, from mostly female (n=305, 76.6%) and Saudi adults aged under 30 (n=248, 62.3%). Most participants sought treatment for sciatica pain from a specialist doctor (n=28, 56.0%) or a general doctor (n=10, 20.0%). Physical therapy was the most common self-treatment method (n=11, 32.4%), followed by painkillers and muscle relaxants (n=10, 29.4%). Knowledge and attitude toward sciatica were generally low (mean score: 3.54 ± 2.61 out of 9), with only 70 (17.6%) showing good knowledge. Most respondents recognized practices like spinal imaging, surgery as a last resort, and exercise/sitting habits as impacting sciatica outcomes. Traditional therapies like massage, cupping, acupuncture, and cautery were considered beneficial. Educational level significantly impacted knowledge scores, with higher mean scores among postgraduate education holders and bachelor's degree holders (mean scores: 4.06 ± 2.48 and 3.98 ± 2.53, respectively). Age, gender, occupation, nationality, and region showed no significant differences in mean knowledge scores. Attitude scores were similar across sociodemographic spectra, with younger respondents having slightly more positive attitudes.  Conclusion: The study showed poor knowledge, influenced by education levels, and neutral attitudes about sciatica among residents of Al-Qassim. Therefore, educational programs and engagement of healthcare stakeholders are recommended to raise awareness and improve knowledge and attitudes.

Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions

BACKGROUND

Cerebral palsy (CP), the most common physical disability of childhood, is often accompanied by a range of comorbidities including pain. Pain is highly prevalent in children and young people with CP, yet has been poorly understood, inaccurately assessed, and inadequately managed in this vulnerable population. This narrative review presents recent research advances for understanding and managing pain in children and young people with CP, focusing on chronic pain, and highlights future research directions.

MAIN BODY

Pain prevalence rates in CP vary due to different methodologies of studies. Recent systematic reviews report up to 85% of children experience pain; higher in older children, females, and those with dyskinesia and greater motor impairment. Research examining the lived experience perspectives of children and their families demonstrate that even those with mild motor impairments have pain, children want to self-report pain where possible to feel heard and believed, and management approaches should be individualized. Notably, many children with cognitive and communication impairments can self-report their pain if adjustments are provided and they are given a chance. Past inadequacies of pain assessment in CP relate to a focus on pain intensity and frequency with little focus on pain interference and coping, a lack of tools appropriate for the CP population, and an assumption that many children with cognitive and/or communication limitations are unable to self-report. Recent systematic reviews have identified the most reliable and valid assessment tools for assessing chronic pain. Many were not developed for people with CP and, in their current form, are not appropriate for the spectrum of physical, communication, and cognitive limitations seen. Recently, consensus and co-design in partnership with people with lived experience and clinicians have identified tools appropriate for use in CP considering the biopsychosocial framework. Modifications to tools are underway to ensure feasibility and applicability for the spectrum of abilities seen.

CONCLUSION

Recent research advances have improved our understanding of the prevalence, characteristics and lived experience of chronic pain, and refined assessment methods in children and young people with CP. However, the very limited evidence for effective and novel management of chronic pain in this population is where research should now focus.