Prescription of exercises for the treatment of chronic pain along the continuum of nociplastic pain: A systematic review with meta-analysis

The effect of stretching intensity on pain sensitivity: A randomized crossover study on healthy adults

BACKGROUND

Stretching exercises have effects on local and widespread pain sensitivity. A dose-response relationship may exist between the analgesic effect and the intensity of stretching, such that a higher intensity of stretching may generate a larger reduction in analgesic response, but this remains to be studied. This study aimed to examine the dose-response relationship between stretching intensity and the analgesic effect.

METHODS

A randomized, repeated-measures crossover study was performed to examine the effect of stretching to the first point of pain onset and stretching to the point of a sensation of stretching (discomfort). The primary outcome was regional and distant pressure pain thresholds.

RESULTS

Thirty-one participants (n = 24 female) were available for analysis. We observed a 22.2% increase in regional pressure pain thresholds (93.2 kPa, p = 0.001) and a 15.0% increase in distant pressure pain thresholds (50.9 kPa, p = 0.012) following stretching to the point of stretch. We observed a 20.0% increase in regional pressure pain thresholds (90.3 kPa, p = 0.001) and a 15.1% increase in distant pressure pain thresholds (52.1 kPa, p = 0.004) following stretching to the point of pain.

CONCLUSIONS

The results showed that local and widespread pain sensitivity decreased following acute stretching, regardless of stretching intensity. No differences in pain sensitivity were found between stretching to the point of stretch or stretching to the first onset of pain. Thus, the results showed no evidence of a dose-response relationship between stretching intensity and the analgesic effect.

SIGNIFICANCE

The study showed a significant acute hypoalgesic effect of stretching exercises regardless of stretching intensity. This may have appropriate clinical implications for patients with musculoskeletal and nociplastic pain.

Acute and long-term effect of specific and non-specific exercises in patients with chronic neck pain: A protocol for a randomized controlled trial

Exercise therapy is the most common approach for people with chronic neck pain (CNP). Although well-established, it remains unknown which type of exercise is the best for treating this condition. Moreover, pain processing can play a role in the persistence of pain and in the response to interventions. Thus, the aim of this randomized controlled trial is to compare the acute and long-term effects of two exercise protocols (specific and non-specific) on pain and pain processing in individuals with CNP. One hundred and ten participants aged between 18 and 65 years who have had non-specific neck pain for more than 3 months will be recruited. They will be randomized and allocated into two groups (specific exercises and non-specific exercises) and both groups will perform an exercise programme twice a week for 8 weeks. Both programmes are divided into two progressive and individualized phases. The primary outcomes are change in pain intensity after 8 weeks of exercise and exercise-induced hypoalgesia, and secondary outcomes are pressure pain threshold, temporal summation of pain, conditioned pain modulation, the Neck Disability Index, the Baecke Physical Activity Questionnaire, and the Global Perception of Change Scale. Outcomes will be assessed at baseline, after 8 weeks of intervention, and at 6-month follow-up.

Relationships Between Socioecological Factors and Self-Efficacy to Participate in Physical Activity for Adults With Chronic Musculoskeletal Pain: An Integrative Review

OBJECTIVE

Self-efficacy for leisure-time or health-promoting physical activity (SEPA) is a psychosocial determinant of physical activity. The socioecological model can provide a robust perspective of SEPA. The objective of this study was to synthesize the evidence on multilevel correlates of SEPA among individuals with chronic musculoskeletal pain. The second aim examined the extent to which socioecological disparities are associated with SEPA among individuals with chronic musculoskeletal pain.

METHODS

An integrative review was conducted. Included studies needed to investigate the relationship between SEPA and socioecological factors at the interpersonal, institutional, community, and/or macrosystem level among adults with chronic musculoskeletal pain (≥3 months). Searches in PubMed, EMBASE, PsycINFO, and CINAHL were performed (December 30, 2020, and October 12, 2022), yielding 4047 records after duplicates were removed. Two independent reviewers completed screening, full-text reviews, and data extraction. After title and abstract screening and full-text reviews, 17 studies were included. The constant comparison method included: data reduction, data display, data comparison, and conclusion drawing/verification. Quality of evidence was assessed using the Joanna Briggs Institute appraisal tools.

RESULTS

Five themes emerged with respect to relationships between SEPA and socioecological factors: social relations, social comparisons, patient-provider relationship, organizational resources, and accessibility to physical activity. Relationships between interpersonal factors and SEPA were most prominently studied. One study examined and addressed potential disparities in SEPA at the macrosystem level.

CONCLUSION

A spectrum of relationships from supporting to straining SEPA were found at the interpersonal level. Relationships between institutional, community, and macrosystem factors and SEPA were comparably sparse. Gaps in the literature were identified regarding how health disparities present across the socioecological model with respect to SEPA.

IMPACT

Clinicians can use this review to evaluate how SEPA can be supported or threatened by factors across the socioecological model. This may be a preliminary step towards examining and addressing health disparities in SEPA.

The effect of six-week regular stretching exercises on regional and distant pain sensitivity: an experimental longitudinal study on healthy adults

BACKGROUND

Stretching exercises are widely used for pain relief and show positive effects on musculoskeletal, nociplastic and neuropathic pain; the magnitude of altered pain sensitivity responses following regular stretching is currently unknown. This study aimed to investigate the effect of six weeks of regular stretching exercise on regional and widespread pain sensitivity and range of motion and the effect of stretching cessation on regional and widespread pain sensitivity and range of motion.

METHODS

An experimental single-blind longitudinal repeated measures study. Twenty-six healthy adults were recruited. Regional and distant pressure pain thresholds and passive knee extension range of motion were measured at three points: before (baseline) and after six weeks (post-stretch) of daily bilateral hamstring stretching exercises and following four weeks of cessation (post-cessation) from stretching exercises.

RESULTS

Participants had a mean ± standard deviation (range) age of 23.8 ± 2.1 (21-30) years. There was a 36.7% increase in regional (p = 0.003), an 18.7% increase in distant pressure pain thresholds (p = 0.042) and a 3.6% increase in range of motion (p = 0.002) between baseline and post-stretch measures. No statistically significant differences were found for regional (p = 1.000) or distant pressure pain thresholds (p = 1.000), or range of motion (p = 1.000) between post-stretch and post-cessation. A 41.2% increase in distant pressure pain thresholds (p = 0.001), a 15.4% increase in regional pressure pain thresholds from baseline to post-cessation (p = 0.127) and a 3.6% increase in passive knee extension range of motion (p = 0.005) were found from baseline to post-cessation.

CONCLUSIONS

Six weeks of regular stretching exercises significantly decreased regional and widespread pain sensitivity. Moreover, the results showed that the hypoalgesic effect of stretching on regional and widespread pain sensitivity persisted following four weeks of cessation. The results further support the rationale of adding stretching exercises to rehabilitation efforts for patients experiencing nociceptive, nociplastic, and neuropathic pain. However, further research is needed to investigate how the long-term effects of stretching exercises compare with no treatment in clinical populations.

TRIAL REGISTRATION

The trial was registered June 1st, 2021 at ClinicalTrials.gov (Trial registration number NCT04919681).

Nociplastic Pain: A Critical Paradigm for Multidisciplinary Recognition and Management

Our understanding of chronic pain has evolved significantly, shifting from a focus on peripheral damage to recognizing the central mechanisms underlying pain perception. This perspective article explores the concept of nociplastic pain, a term introduced by the International Association for the Study of Pain (IASP) in 2017, which describes pain arising from altered pain modulation within the central nervous system, without clear evidence of tissue damage or inflammation. The historical progression from fibrositis to fibromyalgia, and now to nociplastic pain, underscores the complexity of chronic pain syndromes and the need for a multidisciplinary approach to management. Nociplastic pain is characterized by central sensitization, leading to heightened pain sensitivity and often accompanied by comorbidities such as fatigue, sleep disturbances, and cognitive difficulties. Advances in neuroimaging have revealed altered connectivity within key brain networks, such as the default mode and salience networks, in patients with nociplastic pain, providing insights into the neural underpinnings of this condition. The article also addresses controversies surrounding the role of small fiber neuropathy and autonomic dysfunction in nociplastic pain, highlighting the ongoing debates in the field. The practical importance of recognizing nociplastic pain across various medical disciplines-including primary care, orthopedics, neurology, psychiatry, and rheumatology-is emphasized, with recommendations for integrating this knowledge into clinical practice. Emerging therapies, such as neurofeedback, hyperbaric oxygen therapy, and neuromodulation, offer new avenues for treatment, particularly for patients who do not respond to conventional approaches. The article calls for continued research into the mechanisms of nociplastic pain, the development of reliable diagnostic tools, and the exploration of novel therapeutic strategies to improve patient outcomes. The recognition and management of nociplastic pain are crucial for advancing the care of patients with chronic pain, necessitating interdisciplinary collaboration and a patient-centered approach.

The effectiveness of aerobic exercise compared to other types of treatment on pain and disability in patients with orofacial pain: A systematic review

PURPOSE

To compile and synthesise the evidence regarding the effectiveness of aerobic exercise (AE) compared with other treatments to reduce pain and disability of individuals with orofacial pain (OFP).

METHODS

Electronic searches were conducted on five databases (MEDLINE, Embase, CINAHL, Cochrane Library, and Scopus). Randomised controlled trials (RCT) or controlled trials including adults of both sexes with painful OFP diagnoses were targeted. The intervention of interest was AE (e.g., walking, cycling, running, among others), compared to any other conservative and non-conservative therapy. The primary outcome was pain intensity. The risk of bias (RoB) was determined using a compiled set of items and the Cochrane RoB-2 tools. The overall certainty of the evidence was evaluated with the GRADE approach.

RESULTS

Out of 4.669 records screened, four manuscripts were included. However, three of them used the same population but presented different outcomes. These studies included subjects with headache associated with temporomandibular disorders (TMD) and general TMD. Both studies used aerobic exercise (AE) as the intervention of interest. Manual therapy (MT) plus exercise (Ex) (strengthening exercise (Str ex) or general exercises) were used as a comparison group. The combined treatment, including a multimodal therapy (AE + MT + Str ex), was superior to MT + Ex (MD: -8.65 points [95% CI -13.73, -3.57]) on pain intensity (orofacial pain [OFP] and headache intensity) at the end of the treatment and also after 12-week follow-up (MD: -9.43 points [95% CI -14.97, -3.89]). Also, the combination of three treatment modalities (AE + MT + Ex) was better on quality of life than AE alone (MD: -14.60 points [95% CI -16.74, -12.46]) and MT + Ex (MD: -12.30 point [95% CI -14.50, -10.10]) at the end of the treatment.

CONCLUSIONS

Aerobic exercise plus MT and general exercises achieved the greatest positive effects on pain and other outcomes in the short/medium term in patients with OFP. However, the scientific evidence supporting the isolated effects of AE for OFP is limited, indicating the need for more studies. Further studies are also needed to elaborate guidelines when using AE for individuals with OFP.

The applied study to improve the treatment of knee sports injuries in ultimate frisbee players based on personalized exercise prescription: a randomized controlled trial

Objective

Ultimate frisbee can lead to severe sports injuries, especially joint injuries in the lower limbs, such as knee meniscus injuries. This study examines the impact of personalized exercise therapy on knee meniscus injuries in ultimate frisbee players in the Lingnan region of China.

Methods

Seventy-six patients with confirmed meniscal injuries participated in the study, divided into an intervention group (n = 38) and a control group (n = 38). The control group received standard treatment, including drug therapy and physical therapy. The intervention group received standard treatment plus a personalized exercise regimen based on FITT-VP (frequency, intensity, time, type, volume, and progression) principles, incorporating strength training, aerobic exercise, flexibility training, neuromuscular training, and aquatic exercise. This program was monitored and adjusted over a six-month period through both online and offline methods. The primary outcomes were joint range of motion (ROM), thigh circumference atrophy index (TCAI), Lysholm Rating Scale (LRS) scores, and visual analog scores (VAS). The secondary outcome was the International Knee Documentation Committee (IKDC) score. Data were collected before the intervention, and at 1 month and 6 months after the intervention. Statistical analysis was conducted using SPSS 24.0 and GraphPad 10.0, with a significance level set at α = 0.05.

Results

After 1 month, the intervention group showed significantly better results in ROM (116.67 ± 9.063), LRS score (86.316 ± 3.750), and IKDC score (80.473 ± 5.421) compared to the control group (111.784 ± 4.778, 82.579 ± 3.818, and 77.684 ± 4.430, respectively) (p < 0.05). The TCAI (3.219 ± 1.889) and VAS score (1.921 ± 0.673) in the intervention group were significantly lower than those in the control group (5.228 ± 2.131 and 2.710 ± 1.112, respectively) (p < 0.01). After 6 months, the differences in LRS and VAS scores between the groups were not significant. However, the intervention group continued to show significant improvements in ROM (134.934 ± 3.011), TCAI (1.107 ± 1.158), and IKDC score (93.315 ± 1.847) compared to the control group (125.395 ± 18.554, 4.574 ± 1.109, and 87.789 ± 4.437, respectively) (p < 0.05).

Conclusion

Personalized exercise prescriptions offer significant therapeutic and rehabilitative benefits for ultimate frisbee players with knee meniscus injuries. This approach helps to reduce symptoms, alleviate pain, and improve joint function, muscle strength, and athletic performance after sports-related injuries.

Widespread Pressure Pain Hyperalgesia Is Not Associated With Morphological Changes of the Wrist Extensor Tendon in Unilateral Lateral Epicondylalgia: A Case-Control Study

OBJECTIVE

The aims of the current study were to investigate the presence of widespread pressure hyperalgesia, the presence of structural changes in the wrist extensor tendon and muscle, and their association in people with lateral epicondylalgia (LE).

METHODS

Thirty-seven patients with LE (43% women; mean age = 45.5 [SD = 9.5] years) and 37 controls matched for age and sex and free of pain participated in this study. Pressure pain thresholds (PPTs) were assessed bilaterally over the symptomatic area (elbow), 2 segment-related areas (C5-C6 joint, second intermetacarpal space), and 1 remote area (tibialis anterior) in a blinded design. Ultrasound measurements (eg, cross-sectional area, thickness, and width) of the common wrist extensor tendon and extensor carpi radialis brevis muscle as well as the thickness of the supinator muscle were assessed.

RESULTS

Patients with LE exhibited lower PPTs bilaterally at all points and lower PPTs at the lateral epicondyle and second intermetacarpal space on the symptomatic side as compared to the nonsymptomatic side (η2 from 0.123-0.369; large effects). Patients exhibited higher cross-sectional area and width of the common wrist extensor tendon (η2 from 0.268-0.311; large effects) than controls bilaterally, whereas tendon thickness was also higher (η2 = 0.039; small effects) on the painful side than on the nonpainful side.

CONCLUSIONS

This study reported bilateral widespread pressure pain hyperalgesia and morphological changes in the tendon, but not the muscle, in LE. Pressure pain sensitivity and morphological changes were not associated in individuals with LE.

IMPACT

Management of LE should consider altered nociceptive pain processing and structural tendon changes as 2 different phenomena in patients with LE.

Discordance between pain specialists and patients on the perception of dependence on pain medication: A multi-centre cross-sectional study

AIM

Patients with chronic non-cancer pain are referred to pain centres to improve their pain treatment. The discontinuation of pain medications in case of poor efficacy can be difficult to accept for patients, particularly opioid analgesics. Previous research has described that from the patients' perspective, the psychological relief of a negative effect of chronic pain and withdrawal symptoms of prescription opioids represent drivers of persistent use and first stage of opioid use disorder, despite insufficient pain relief. There is no validated tool to investigate this psychological dependence. This study aimed to assess discordance between patients and pain specialists in their perception of dependence on pain medication and investigate associations with characteristics of patients, type of pain and iatrogenic pharmacodependence.

METHODS

Self-administered questionnaires (patients and physicians) were administered in six pain centres in France. A question on perceived dependence on pain medications was addressed to the patient and the physician in a matched pair. Discordance between them was evaluated by the Cohen kappa coefficient. Demographics, pain, anxiety and depression, pain medication withdrawal symptoms, diverted use, and craving represented variables studied in a multivariate model as potentially associated with patient-physician discordance.

RESULTS

According to the 212 pairs of completed questionnaires, a perceived dependence was reported by the majority of patients (65.6%) and physicians (68.4%). However, the concordance was fair (kappa=0.38; CI [95%]: 0.25-0.51). Almost all patients (89.3%) were treated with an opioid analgesic. A higher likelihood of discordance was observed when patients suffered from nociplastic pain (odds ratio [OR]: 2.72, 95% [CI]: 1.29-5.84).

CONCLUSION

Medical shared-decision for changing pain treatment could be improved by taking into account the perception of patient dependence on medications for pain relief and or psychoactive effects, particularly in nociplastic pain for which the treatment is challenging.

Prevalence of chronic pelvic pain and associated factors among indigenous women of reproductive age in Ecuador

BACKGROUND

Chronic pelvic pain is a common disease that affects approximately 4% of women of reproductive age in developed countries. This number is estimated to be higher in developing countries, with a significant negative personal and socioeconomic impact on women. The lack of data on this condition in several countries, particularly those in development and in socially and biologically vulnerable populations such as the indigenous, makes it difficult to guide public policies.

OBJECTIVES

To evaluate the prevalence of chronic pelvic pain (dysmenorrhea, dyspareunia, non-cyclical pain) and identify which variables are independently associated with the presence of the condition in indigenous women from Otavalo-Ecuador.

DESIGN

A cross-sectional study was carried out including a sample of 2429 women of reproductive age between 14 and 49 years old, obtained from April 2022 to March 2023. A directed questionnaire was used, collected by bilingual interviewers (Kichwa and Spanish) belonging to the community itself; the number of patients was selected by random sampling proportional to the number of women estimated by sample calculation. Data are presented as case prevalence, odds ratio, and 95% confidence interval, with p < 0.05.

RESULTS

The prevalence of primary dysmenorrhea, non-cyclic pelvic pain, and dyspareunia was, respectively, 26.6%, 8.9%, and 3.9%.all forms of chronic pain were independently associated with each other. Additionally, dysmenorrhoea was independently associated with hypertension, intestinal symptoms, miscegenation, long cycles, previous pregnancy, use of contraceptives and pear body shape. Pain in other sites, late menarche, exercise, and pear body shape were associated with non-cyclic pelvic pain. And, urinary symptoms, previous pregnancy loss, miscegenation, and pear body shape were associated with dyspareunia.

CONCLUSION

The prevalence of primary dysmenorrhea and non-cyclical chronic pelvic pain was notably high, in contrast with the frequency of reported dyspareunia. Briefly, our results suggest an association between dysmenorrhoea and conditions related to inflammatory and/or systemic metabolic disorders, including a potential causal relationship with other manifestations of pelvic pain, and between non-cyclical pelvic pain and signs/symptoms suggesting central sensitization. The report of dyspareunia may be influenced by local cultural values and beliefs.

Online Exercise Programs for Chronic Nonspecific Neck Pain: A Randomized Controlled Trial Reveals Comparable Effects of Global, Local, and Combined Approaches

OBJECTIVE

Specific neck exercises are recommended in the rehabilitation of chronic nonspecific neck pain (CNNP). They are unfortunately often accompanied by acute pain flare-ups. Global exercises might be a beneficial addition, as they activate endogenous analgesia without overloading painful structures. However, it is still unclear which type of exercise is most effective. This randomized controlled trial was done to evaluate the effect of an online blended program of global and specific neck exercises, compared to programs including only 1 of both types of exercise.

METHODS

Forty-eight patients with CNNP were randomized into 3 groups. Online questionnaires were collected at baseline, at midtreatment, immediately after treatment, and at the 3-month follow-up. Quantitative sensory testing and actigraphy were assessed at baseline and after treatment. Linear mixed-model analyses were performed to evaluate treatment effects within and between groups. Neck pain-related disability after treatment was considered the primary outcome.

RESULTS

No time × treatment interaction effects were found. All groups improved in neck pain-related disability, pain intensity, self-reported symptoms of central sensitization, local pain sensitivity, physical activity, and pain medication use. No effects were found on quality of life, sleep quality, depression, anxiety, stress, widespread pain sensitivity, health economics, or actigraphy measurements. A higher global perceived effect was reported after performing the blended program, compared to the other groups.

CONCLUSION

A blended exercise program was not superior to the stand-alone programs in reducing disability. Nevertheless, the global perceived effect of this type of exercise was higher. Future research necessitates larger sample sizes to adequately explore the optimal type of exercise for patients with CNNP.

IMPACT

Exercise therapy should be an important part of the rehabilitation of patients with CNNP, regardless of the type of exercise.

Functional neurological disorder, physical activity and exercise: What we know and what we can learn from comorbid disorders

Functional neurological disorder (FND) is a common neurologic disorder associated with many comorbid symptoms including fatigue, pain, headache, and orthostasis. These concurrent symptoms lead patients to accumulate multiple diagnoses comorbid with FND, including fibromyalgia, chronic fatigue syndrome, postural orthostatic tachycardia syndrome, persistent post-concussive symptoms, and chronic pain. The role of physical activity and exercise has not been evaluated in FND populations, though has been studied in certain comorbid conditions. In this traditional narrative literature review, we highlight some existing literature on physical activity in FND, then look to comorbid disorders to highlight the therapeutic potential of physical activity. We then consider abnormalities in the autonomic nervous system (ANS) as a potential pathophysiological explanation for symptoms in FND and comorbid disorders and postulate how physical activity and exercise may provide benefit via autonomic regulation.

Physical activity should be the primary intervention for individuals living with chronic pain A position paper from the European Pain Federation (EFIC) 'On the Move' Task Force

BACKGROUND

There is clear evidence demonstrating the benefits of physical activity (PA) on pain and overall health, however, PA is challenging for many individuals living with chronic pain. Even non-exercise specialists can (cost) effectively promote PA, but many health professionals report a number of barriers in providing guidance on PA, suggesting that it is not consistently promoted. This expert position paper summarizes the evidence and provides five recommendations for health professionals to assess, advise and support individuals living with any chronic pain condition with a long life expectancy in adopting and sustaining physically active lifestyles.

METHODS

This position paper was prepared by the 'On The Move' Task Force of the European Pain Federation EFIC. Final recommendations were endorsed by the European Pain Forum, Pain Alliance Europe and the Executive Board of EFIC.

RESULTS

We recommend that all health professionals (1) Take a history of the persons' PA levels, and put PA on the agenda, (2) Advise that PA is important and safe for individuals living with chronic pain, (3) Deliver a brief PA intervention and support individuals living with chronic pain in becoming physically active, (4) Discuss acceptable levels of PA-related soreness and pain and (5) Provide ongoing support in staying physically active.

SIGNIFICANCE

Physical activity is safe and offers several advantages, including general health benefits, low risk of side effects, low cost and not requiring access to healthcare. Adoption of these recommendations can improve the quality of care and life of individuals living with chronic pain and reduce their overall health risks.

Promoting pain coping skills in haemophilia: A remote intervention integrating exercise and pain education

BACKGROUND

Chronic joint pain is a significant and widespread symptom in people with haemophilia (PWH). Despite medical advancements, effective pain management remains challenging.

AIM

This study presents an innovative approach that integrates remote physical exercises, pain neuroscience education, and coping strategies to address chronic pain in PWH.

METHODS

The remote intervention consisted of sixteen 5-min videos encompassing physical exercises for chronic pain management and pain education strategies. These videos formed an 8-week remote intervention program. Clinical and physical assessments were conducted before and after the intervention.

RESULTS

A total of thirty-one PWHs, with a median age of 34 years (ranging from 16 to 59 years), completed the remote intervention. The study revealed significant improvements in pain intensity, disability, and physical performance among PWH with chronic pain. Enhanced functional capacity was evident in the Timed Up and Go and Single Leg Stance tests, accompanied by improved scores on the Functional Independence Score in Haemophilia (FISH). Although lacking a control group, our findings are consistent with other successful exercise and pain education programs.

CONCLUSIONS

This innovative intervention holds promise for managing chronic pain in PWH, underscoring patient empowerment, education, and collaboration. Notably, our study stands out by uniquely combining pain education and coping strategies, bolstering evidence for effective pain management.

A perspective on a precision approach to pain in cancer; moving beyond opioid therapy

PURPOSE

Cancer-related pain is primarily treated with opioids which while effective can add significant patient burden due to side effects, associated stigma, and timely access. The purpose of this perspective discussion is to argue for a precision approach to pain in cancer based on a biopsychosocial and spiritual model which we argue can offer a higher quality of life while limiting opioid use.

CONCLUSIONS

Pain in cancer represents a heterogenous process with multiple contributing and modulating factors. Specific characterization of pain as either nociceptive, neuropathic, nociplastic, or mixed can allow for targeted treatments. Additional assessment of biopsychosocial and spiritual issues can elucidate further points of targeted intervention which can lead to overall greater pain control.

Effects of Nature-Based Multisensory Stimulation on Pain Mechanisms in Women with Fibromyalgia Syndrome: A Randomized Double-Blind Placebo-Controlled Trial

BACKGROUND

The term "nature-based sensory stimuli" refers to the sensory information produced by biotic and abiotic agents from natural environments. The literature has reported the beneficial effects of these agents on various pain dimensions in non-clinical populations.

AIMS

To evaluate the potential analgesic effects of nature-based multisensory stimulation in women with fibromyalgia syndrome.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group trial with a 1:1 allocation ratio was conducted. Forty-two women with fibromyalgia syndrome interacted with either different plant species with flowers, stones, and soil organic matter or their synthetic imitations for 30 minutes. Outcome measurements were performed before and after the intervention, including clinical pain intensity using the Numeric Rating Scale, cold pain thresholds using the Cold Pressor Test, mechanical hyperalgesia and wind-up using a monofilament, and pressure pain thresholds using a pressure algometer.

RESULTS

Analyses revealed group × time interactions for clinical pain intensity (F = 7.915, p = .008), cold-water immersion time (F = 7.271, p = .010), mechanical hyperalgesia (F = 4.701, p = .036), and pressure pain threshold (p ≤ .017). Between-group differences were found in clinical pain intensity (p = .012), cold pain thresholds (p = .002), and pressure pain thresholds (p < .05). The experimental group exhibited reduced clinical pain intensity (p = .001) and increased pressure pain thresholds (p ≤ .034).

CONCLUSIONS

Women with fibromyalgia syndrome may benefit from multisensory stimulation using biotic and abiotic agents from natural environments for 30 minutes. Interacting with flowering plants and soil components appears to induce analgesic effects.

Exercise as Medicine for People with a Substance Use Disorder: An ACSM Call to Action Statement

ABSTRACT

Over 20 million Americans are living with a substance use disorder (SUD) and nearly 100,000 die annually from drug overdoses, with a majority involving an opioid. Many people with SUD have co-occurring chronic pain and/or a mental health disorder. Exercise is a frontline treatment for chronic pain and is an effective strategy for reducing depression and anxiety and improving overall mental health. Several studies have shown that exercise improves SUD-related outcomes including abstinence; however, there is limited large-scale randomized clinical trial evidence to inform integration of exercise into practice. In this Call to Action, we aim to raise awareness of the specific issues that should be addressed to advance exercise as medicine in people with SUD including the challenges of co-occurring chronic pain, mental illness, and cardiopulmonary health conditions. In addition, specialized training for exercise professionals and other support staff should be provided on these issues, as well as on the multiple dimensions of stigma that can impair engagement in treatment and overall recovery in people with SUD.

Widespread Pain With Nociplastic Features is an Independent Predictor of Low Physical Activity in People with Multiple Sclerosis

Exploring the relationship between underlying pain mechanisms and physical activity could inform interventions to optimize physical activity in persons with multiple sclerosis (PwMS). This cross-sectional nationwide survey examined whether pain phenotype is a significant predictor of self-reported physical activity in PwMS. The study included 938 persons with a self-reported diagnosis of MS (93% reported neurologist-diagnosed MS) who completed surveys of demographic, clinical information, pain intensity, indicators of underlying pain mechanisms (Fibromyalgia Survey Criteria and painDETECT), and physical activity (Godin Leisure-Time Exercise Questionnaire). Responses were used to categorize pain phenotypes as widespread pain with nociplastic features (WPNF), neuropathic, nociceptive, or mixed (neuropathic/WPNF). Following current physical activity guidelines, self-reported physical activity was categorized as active or insufficiently active/sedentary. Applying multivariable logistic regression, participants with no chronic pain had 2.30 higher odds of being physically active when compared to participants with chronic mixed pain. Similarly, participants with neuropathic and nociceptive pain had, respectively, 1.90 and 1.66 higher odds of being physically active compared to individuals with mixed pain. Higher scores on the fibromyalgia survey criteria (operationalized in this study as an indicator of WPNF) were a significant independent predictor of insufficient physical activity (OR = .93, P < .01). Findings indicate that experience and phenotype of chronic pain, in particular WPNF, are associated with physical inactivity in PwMS. This suggests that assessing pain phenotype may be important to identify individuals at risk of inadequate physical activity and may guide the tailoring of behavioral therapeutic approaches to help PwMS achieve the recommended level of physical activity. PERSPECTIVE: This study examines the association between pain mechanism and physical activity in multiple sclerosis. These findings highlight the possibility that a basic screening for pain mechanism could offer clinically useful information without requiring extensive neurobiological phenotyping and may inform the development of behavioral interventions to enhance physical activity in multiple sclerosis.

Tonic cuff pressure pain sensitivity in chronic pain patients and its relation to self-reported physical activity

OBJECTIVES

Physical inactivity is a global health concern and a significant problem among chronic pain patients. They often experience pain flare-ups when they try to increase their physical activity level. Most research on the relationship between pain sensitivity and physical activity has been on healthy participants. Data on chronic pain patients are lacking. Using cuff pressure algometry, this study investigated tonic cuff pressure pain sensitivity and its associations to self-reported physical activity and other patient-reported outcomes in chronic pain patients.

METHODS

Chronic pain patients (n=78) were compared to healthy controls (n=98). Multivariate data analysis was used to investigate the associations between tonic cuff pressure pain sensitivity, physical activity, and other patient-reported outcome measures.

RESULTS

The three most important variables for group discrimination were perceived health status (EQVAS: p(corr)=-0.85, i.e., lower in patients), depression (HADS-D: p(corr)=0.81, i.e., higher in patients), and the tonic cuff pressure pain sensitivity variable maximum pain intensity (VAS-peak-arm: p(corr)=0.75, i.e., higher in patients). In patients, the most important predictors for high VAS-peak-arm were female sex (p(corr)=-0.75), higher number of painful regions (p(corr)=0.72), higher pain intensity (p(corr)=0.55), followed by lower level of self-reported physical activity (p(corr)=-0.39). VAS-peak-arm in patients correlated negatively with self-reported physical activity (rho=-0.28, p=0.018).

CONCLUSIONS

Physical activity may be the most important patient-changeable variable correlating to pain sensitivity. This study highlights the importance of more research to further understand how increased physical activity may decrease pain sensitivity in chronic pain patients.

Pain and the Non-Pharmacological Management of Pain in People with Parkinson's Disease

Pain is a distressing and universal experience, yet everyone's pain experience is influenced by a complex array of biological, psychological, and social factors. For people with Parkinson's disease (PwP), these biopsychosocial factors include neurodegeneration and the psychological and social factors that accompany living with a chronic, neurodegenerative condition in addition to the factors experienced by those in the general population (e.g., living with co-morbidities such as osteoarthritis). The way these factors influence each individual is likely to determine which pain management strategies are optimal for them. This review first describes pain and the biopsychosocial model of pain. It explores how pain is classified in Parkinson's disease (PD) and describes the three main types of pain: nociceptive, neuropathic, and nociplastic pain. This background provides context for a discussion of non-pharmacological pain management strategies that may aid in the management of pain in PwP; exercise, psychological strategies, acupuncture and massage. While there is little PD-specific research to inform the non-pharmacological management of pain, findings from current PD research are combined with that from chronic pain research to present recommendations for clinical practice. Recommendations include assessment that incorporates potential biopsychosocial contributors to pain that will then guide a holistic, multi-modal approach to management. As exercise provides overall benefits for PwP, those with chronic pain should be carefully monitored with exercise prescribed and adjusted accordingly. Research is needed to develop and evaluate multi-modal approaches to pain management that are delivered in a biopsychosocial framework.

Physiotherapists clinical reasoning to prescribe exercise for patients with chronic pain: A qualitative study research protocol

BACKGROUND

Physiotherapists' play a key role in the management of chronic pain, and as part of the National Institute for Health and Care Excellence (NICE) guidelines, prescribe exercise to support patients with chronic pain. However, there is very limited evidence supporting physiotherapists on what type of exercise or dose of exercise should be prescribed. Physiotherapists' therefore have more onus on their ability to clinically reason how to prescribe exercise. At present, there is no research investigating how physiotherapists' working with patients that have chronic pain, clinically reason when prescribing exercise. This study proposes to investigate how physiotherapists experienced in pain management prescribe exercise, to understand what the key influences are on their reasoning, and how these impact on clinical practice.

METHODS

This will be a qualitative study, utilising semi-structured individual interviews. Participants will be Health and Care Professions Council registered physiotherapists, working predominantly with patients that have chronic pain. Recruitment will focus on physiotherapists working within the United Kingdom (UK). Up to twenty participants will be recruited. The study, including the interview guide, will be supported by a steering group consisting of academics and physiotherapists experienced in chronic pain. The data will be analysed using framework analysis.

RESULTS

The study will be reported using the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines. The findings of the study will be disseminated through publication in a peer reviewed journal.

CONCLUSION

This study will provide novel insight into how physiotherapists experienced working with and managing chronic pain patients, prescribe exercise, and will gain new insight into clinical practice to help inform future research and education.

Summarizing the effects of different exercise types in chronic neck pain - a systematic review and meta-analysis of systematic reviews

BACKGROUND

To date, no consensus exists as to whether one exercise type is more effective than another in chronic neck pain. This systematic review and meta-analysis of systematic reviews aimed to summarize the literature on the effect of various exercise types used in chronic neck pain and to assess the certainty of the evidence.

METHODS

We searched the databases Ovid MEDLINE, Embase, Cochrane Library, SportDiscus, and Web of Science (Core Collection) for systematic reviews and meta-analyses on adults between 18 and 70 years with chronic neck pain lasting ≥ 12 weeks which investigated the effects of exercises on pain and disability. The included reviews were grouped into motor control exercise (MCE), Pilates exercises, resistance training, traditional Chinese exercise (TCE), and yoga. Study quality was assessed with AMSTAR-2 and the level of certainty for the effects of the exercise through GRADE. A narrative analysis of the results was performed and in addition, meta-analyses when feasible.

RESULTS

Our database search resulted in 1,794 systematic reviews. We included 25 systematic reviews and meta-analyses including 17,321 participants (overlap not accounted for). The quality of the included reviews ranged from critically low to low (n = 13) to moderate to high (n = 12). We found low to high certainty of evidence that MCE, Pilates exercises, resistance training, TCE, and yoga have short-term positive effects on pain and that all exercise types except resistance training, show positive effects on disability compared to non-exercise controls. We found low to moderate certainty of evidence for conflicting results on pain and disability when the exercise types were compared to other exercise interventions in the short-term as well as in intermediate/long-term apart for yoga, as no long-term results were available.

CONCLUSION

Overall, our findings show low to high certainty of evidence for positive effects on pain and disability of the various exercise types used in chronic neck pain compared to non-exercise interventions, at least in the short-term. Based on our results, no optimal exercise intervention for patients with chronic neck pain can be recommended, since no large differences between the exercise types were shown here. Because the quality of the included systematic reviews varied greatly, future systematic reviews need to increase their methodological quality.

TRIAL REGISTRATION

Prospero CRD42022336014.

Precision management of post-COVID pain: An evidence and clinical-based approach

Background Pain after a SARS-CoV-2 acute infection (post-COVID pain) is becoming a new healthcare emergency but remains underestimated and most likely undertreated due to a lack of recognition of the phenomenon and knowledge of the underlying pain mechanisms. Evidence supporting any particular treatment approach for the management of post-COVID pain is lacking. Large variability in the patient response to any standard pain treatments is clinically observed, which has led to calls for a personalized, tailored approach to treating patients with chronic post-COVID pain (i.e. 'precision pain medicine'). Applying the global concerted action towards precision medicine to post-COVID pain could help guide clinical decision-making and aid in more effective treatments. Methods The current position paper discusses factors to be considered by clinicians for managing post-COVID pain ranging from identification of the pain phenotype to genetic consideration. Results The ability of clinicians to phenotype post-COVID pain into nociceptive, neuropathic, nociplastic or mixed type is suggested as the first step to better planification of a treatment programme. Further, the consideration of other factors, such as gender, comorbidities, treatments received at the acute phase of infection for onset-associated COVID-19 symptoms, factors during hospitalization or the presence of emotional disturbances should be implemented into a treatment programme. Conclusions Accordingly, considering these factors, management of post-COVID pain should include multimodal pharmacological and non-pharmacological modalities targeting emotional/cognitive aspects (i.e. psychological and/or coping strategies), central sensitization-associated mechanisms (i.e. pain neuroscience education), exercise programmes as well as lifestyle interventions (e.g. nutritional support and sleep management). SIGNIFICANCE: This position paper presents an evidence-based clinical reasoning approach for precision management of post-COVID pain.

Identifying and Managing Nociplastic Pain in Individuals With Rheumatic Diseases: A Narrative Review

Chronic pain is a burdensome and prevalent symptom in individuals with rheumatic disease. The International Association for the Study of Pain classifies pain into 3 descriptive categories: nociceptive, neuropathic, and nociplastic. These categories are intended to provide information about the mechanisms underlying the pain, which can then serve as targets for drug or non-drug treatments. This review describes the 3 types of pain as they relate to patients seen by rheumatology health care providers. The focus is on identifying individuals with nociplastic pain, which can either occur in isolation as in fibromyalgia, or as a comorbidity in individuals with primary autoimmune conditions, such as rheumatoid arthritis and systemic lupus erythematosus. Practical information about how rheumatology health care providers can approach and manage chronic pain is also provided.

Multimodal non-invasive non-pharmacological therapies for chronic pain: mechanisms and progress

BACKGROUND

Chronic pain conditions impose significant burdens worldwide. Pharmacological treatments like opioids have limitations. Non-invasive non-pharmacological therapies (NINPT) encompass diverse interventions including physical, psychological, complementary and alternative approaches, and other innovative techniques that provide analgesic options for chronic pain without medications.

MAIN BODY

This review elucidates the mechanisms of major NINPT modalities and synthesizes evidence for their clinical potential across chronic pain populations. NINPT leverages peripheral, spinal, and supraspinal mechanisms to restore normal pain processing and limit central sensitization. However, heterogeneity in treatment protocols and individual responses warrants optimization through precision medicine approaches.

CONCLUSION

Future adoption of NINPT requires addressing limitations in standardization and accessibility as well as synergistic combination with emerging therapies. Overall, this review highlights the promise of NINPT as a valuable complementary option ready for integration into contemporary pain medicine paradigms to improve patient care and outcomes.

The Role of Back Muscle Dysfunctions in Chronic Low Back Pain: State-of-the-Art and Clinical Implications

Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.

Effects of a Novel Web-Based Sensorimotor Exercise Program for Patients With Subacute Whiplash-Associated Disorders: Protocol for a Randomized Clinical Trial

INTRODUCTION

Whiplash-associated disorder (WAD) often becomes a persistent problem and is one of the leading causes of disability in the world. It is a costly condition for individuals, for insurance companies, and for society. Guidelines for the management of WAD have not been updated since 2014, and the use of computer-based sensorimotor exercise programs in treatment for this patient group has not been well documented. The purpose of this randomized clinical trial is to explore the degree of association between self-reported and clinical outcome measures in WAD.

METHODS

Individuals (n = 180) with subacute WAD grades I and II will be randomized into 3 groups using block randomization. The 2 primary intervention groups (A and B) will receive physical therapy involving manual therapy and either a remote, novel, computer-based cervical kinesthetic exercise (CKE) program starting at visit 2 (Group A) or neck exercises provided by the corresponding physical therapist (Group B). These groups will be compared to a "treatment as usual" Group C. Movement control, proprioception, and cervical range of motion will be measured. Neck disability and pain intensity, general health, self-perceived handicap, and physical, emotional, and functional difficulties due to dizziness will be measured using questionnaires. The short-term effects will be measured 10 to 12 weeks after the baseline measurements, and the long-term effects will be measured 6 to 12 months after the baseline measurements.

IMPACT

The successful completion of this trial will help guide clinicians in the selection of outcome measures for patients with subacute WAD in the assessment of the short- and long-term effectiveness of treatment combining manual therapy with computer-based CKE compared with manual therapy and non-computer-based exercises. This trial will also demonstrate the potential of using a computer-based intervention to increase the exercise dose for this patient group and how this influences outcomes such as levels of pain and disability in the short and long term.

Top Ten Tips Palliative Care Clinicians Should Know About Behavioral Pain Management for Persistent Pain

Seriously ill patients often experience persistent pain. As a part of a comprehensive repertoire of pain interventions, palliative care clinicians can help by using behavioral pain management. Behavioral pain management refers to evidence-based psychosocial interventions to reduce pain intensity and enhance functional outcomes and quality of life. Conceptualized using the biopsychosocial model, techniques involve promoting helpful behaviors (e.g., activity pacing, stretching, and relaxation exercises) and modifying underlying patterns of thinking, feeling, and communicating that can exacerbate pain. The authors have expertise in pain management, clinical health psychology, geropsychology, behavioral science, and palliative medicine. The article reviews the current evidence for behavioral interventions for persistent pain and provides 10 recommendations for behavioral pain management.

What Do We Know about Nociplastic Pain?

Nociplastic pain is a recently distinguished type of pain, distinct from neuropathic and nociceptive pain, and is well described in the literature. It is often mistaken for central sensitization. Pathophysiology has not been clearly established with regard to alteration of the concentration of spinal fluid elements, the structure of the white and gray matter of the brain, and psychological aspects. Many different diagnostic tools, i.e., the painDETECT and Douleur Neuropathique 4 questionnaires, have been developed to diagnose neuropathic pain, but they can also be applied for nociplastic pain; however, more standardized instruments are still needed in order to assess its occurrence and clinical presentation. Numerous studies have shown that nociplastic pain is present in many different diseases such as fibromyalgia, complex regional pain syndrome type 1, and irritable bowel syndrome. Current pharmacological and nonpharmacological treatments for nociceptive and neuropathic pain are not entirely suitable for treating nociplastic pain. There is an ongoing effort to establish the most efficient way to manage it. The significance of this field has led to several clinical trials being carried out in a short time. The aim of this narrative review was to discuss the currently available evidence on pathophysiology, associated diseases, treatment possibilities, and clinical trials. It is important that physicians widely discuss and acknowledge this relatively new concept in order to provide optimized pain control for patients.

Can Baseline Characteristics Predict Successful Outcomes after Individual, Physiotherapist-Led Rehabilitation in Patients with Chronic Musculoskeletal Pain?

Background

No strong and consistent variables to predict outcome after pain rehabilitation have been reported in patients with chronic musculoskeletal pain. The aim of the present study was to clarify if baseline variables could predict successful outcome after a unique, individualized, physiotherapist-led rehabilitation of nine sessions.

Methods

In 274 individuals with severe chronic musculoskeletal pain, the risk ratio (RR) and 95% confidence intervals (CIs) were estimated for potentially predictive baseline variables on successful outcomes of pain management, overall health, and pain rating.

Results

Statistically significant results show that patients rating moderate or severe baseline pain were in both cases 14% less likely to improve pain management compared to patients rating mild baseline pain (RR = 0.86; 95% CI 0.77-0.97, RR = 0.86; 95% CI 0.74-1.00). Patients with the shortest pain duration were 1.61 times more likely to improve overall health (RR = 1.61; 95% CI 1.13-2.29) compared to patients reporting the longest pain duration (>5 years). Patients reporting anxiety/depression or severe pain were in both cases 1.48 times more likely to improve overall health compared to better baseline presentations (RR = 1.48; 95% CI 1.16-1.88, RR = 1.48; 95% CI 1.03-2.15). Patients with regional/generalized pain were 36% less likely to rate pain reduction (RR = 0.64; 95% CI 0.41-1.00) compared to patients rating localized baseline pain. Of 17 potentially predictive baseline variables, four reached statistical significance for at least one of the three outcomes; although none of them for all three outcomes.

Conclusions

Of 17 potentially predictive baseline variables, mild pain ratings, short pain duration, and localized baseline pain were statistically significantly associated with improvements after individual, physiotherapist-led rehabilitation for patients with chronic musculoskeletal pain. This suggests that this type of rehabilitation probably should be offered early in the pain process. Reporting anxiety/depression or severe pain at the baseline did not hinder the improvements of overall health.

Effect of exercise prescription teaching on exercise quality and mental health status of college students

BACKGROUND

The teaching mode of fitness exercise prescriptions for college students in physical education conforms to the scientific principles and rules of fitness, which can adapt to the characteristics of students' individual physiological functions and stimulate their interest in learning.

AIM

To analyze the effect of prescribed exercise teaching on the sports quality and mental health of college students.

METHODS

The participants of the study were 240 students in our class of 2021, of which 142 were men and 98 were women. The 240 students were randomly divided into an experimental group using the exercise prescription teaching model and a control group using the conventional teaching model. The experimental and control groups were divided into four classes of 30 students each. The teaching activities of the two teaching mode groups were strictly controlled, and the same tests were used before and after the experiment to test the subjects' exercise quality (in-cluding standing long jump, 50 m race, 800 m race, sit-ups, sit-and-reach), physical form (including height, weight, Ketorolai index), cardiopulmonary function (including heart rate, blood pressure, spirometry, 12-min running distance, maximum oxygen intake) and mental health (SCL-90, including somatization, obsessive-compulsive, interpersonal, depression, anxiety, hostility, phobia, paranoia, psychotic symptoms) to understand the effects of the exercise prescription teaching mode on students' physical and mental health status.

RESULTS

There were differences in the exercise scores of standing long jump, 50 m, 800 m/1000 m running, sit-ups, and sit-and-reach in the experimental group after the experiment compared with those before the experiment, and the above indices of the experimental group were different from those of the control group after the experiment (P < 0.05). There were differences in body weight and Ketorolai index in the experimental group after the experiment compared to those before the experiment, and the indices of the experimental group were also different from those of the control group after the experiment (P < 0.05). After the experiment, there were differences in spirometry, 12-min running distance, and maximum oxygen intake in the experimental group compared to those before the experiment, and the indices of the experimental group were also different from those of the control group after the experiment (P < 0.05). After the experiment, the indicators of somatization, interpersonal sensitivity, depression, anxiety, and hostility in the experimental group were different from those in the pre-experimental group, and the indexes of the experimental group were also different from those of the control group after the experiment (P < 0.05).

CONCLUSION

Exercise prescription teaching can mobilize college students' consciousness, enthusiasm, and initiative; expand personalities; enhance physical fitness and improve their mental health more than the conventional fitness exercise prescription teaching method.

Consistent pattern between physical activity measures and chronic pain levels: the Tromsø Study 2015 to 2016

ABSTRACT

Epidemiological literature on the relationship between physical activity and chronic pain is scarce and inconsistent. Hence, our aim was to assess the relationship applying comprehensive methodology, including self-reported and accelerometer measures of physical activity and different severity levels of chronic pain. We used data from the Tromsø Study (2015-2016). All residents in the municipality, aged 40 years and older were invited to participate (n = 32,591, 51% women). A total of 21,083 (53%) women reported on questionnaires. Additionally, 6778 participants (54% women) were invited to wear accelerometers (6125 with complete measurements). Our exposure measures were self-reported leisure time physical activity, exercise frequency, duration, and intensity and 2 accelerometer measures (steps per day and minutes of moderate to vigorous physical activity per day). Outcome measurements were chronic pain and moderate-to-severe chronic pain. We used Poisson regression to estimate chronic pain prevalence and prevalence ratios for each physical activity measure, with adjustments for sex, age, education level, smoking history, and occupational physical activity. Our main analyses showed an inverse dose-response relationship between all physical activity measures and both severity measures of chronic pain, except that the dose-response relationship with exercise duration was only found for moderate-to-severe pain. All findings were stronger for the moderate-to-severe pain outcomes than for chronic pain. Robustness analyses gave similar results as the main analyses. We conclude that an inverse dose-response association between physical activity and chronic pain is consistent across measures. To summarize, higher levels of physical activity is associated with less chronic pain and moderate-to-severe chronic pain.

Myofascial Pain Syndrome: A Nociceptive Condition Comorbid with Neuropathic or Nociplastic Pain

Myofascial pain syndrome is featured by the presence of myofascial trigger points (TrPs). Whether TrPs are primary or secondary phenomena or if they relate to central or peripheral nervous system disorders is controversial. Referred pain, a cardinal sign of TrPs, is a central phenomenon driven by peripheral input. In 2021, the International Association for the Study of Pain (IASP) proposed a clinical criteria and grading system for classifying patients with pain on nociceptive, neuropathic, or nociplastic phenotypes. Myofascial TrP pain has been traditionally categorized as a nociceptive phenotype; however, increasing evidence supports that this condition could be present in patients with predominantly nociplastic pain, particularly when it is associated with an underlying medical condition. The clinical response of some therapeutic approaches for managing TrPs remains unclear. Accordingly, the ability to classify myofascial TrP pain into one of these phenotypes would likely be critical for producing more successful clinical treatment outcomes by a precision medicine approach. This consensus paper presents evidence supporting the possibility of subgrouping individuals with myofascial TrP pain into nociceptive, nociplastic, or mixed-type phenotype. It is concluded that myofascial pain caused by TrPs is primarily a nociceptive pain condition, is unlikely to be classified as neuropathic or nociplastic, but can be present in patients with predominantly neuropathic or nociplastic pain. In the latter cases, management of the predominant central pain problem should be a major treatment goal, but the peripheral drive from TrPs should not be ignored, since TrP treatment has been shown to reduce sensitization-associated symptomatology in nociplastic pain conditions, e.g., fibromyalgia.

Understanding the Psychophysiological and Sensitization Mechanisms Behind Fibromyalgia Syndrome: A Network Analysis Approach

OBJECTIVE

Current evidence suggests that fibromyalgia syndrome (FMS) involves complex underlying mechanisms. This study aimed to quantify the multivariate relationships between clinical, psychophysical, and psychological outcomes in women with FMS by using network analysis to understand the psychobiological mechanisms driving FMS and generating new research questions for improving treatment strategies.

METHODS

Demographic (age, height, weight), clinical (pain history, pain intensity at rest and during daily living activities), psychophysical (widespread pressure pain thresholds [PPT]), sensory-related (PainDETECT, S-LANSS, Central Sensitization Inventory [CSI]) and psychological (depressive and anxiety levels) variables were collected in 126 women with FMS. Network analysis was conducted to quantify the adjusted correlations between the modeled variables and to assess their centrality indices (i.e., the connectivity with other symptoms in the network and the importance in the system modelled as network).

RESULTS

The network showed several local associations between psychophysical and clinical sensory-related variables. Multiple positive correlations between PPTs were observed, being the strongest weight between PPTs on the knee and tibialis anterior muscle (ρ: 0.33). PainDETECT was associated with LANSS (ρ: 0.45) and CSI (ρ: 0.24), whereas CSI was associated with HADS-A (ρ: 0.28). The most central variables were PPTs over the tibialis anterior (the highest Strength centrality) and CSI (the highest Closeness and Betweenness centrality).

CONCLUSION

Our findings support a model where clinical sensory-related, psychological, and psycho-physical variables are connected, albeit in separate clusters, reflecting a nociplastic condition with a relevant role of sensitization. Clinical implications of the findings, such as developing treatments targeting these mechanisms, are discussed.

Transcranial direct current electrical stimulation in combination with aerobic exercise: A pilot study in post-COVID-19 systemic autoimmune rheumatic patients

BACKGROUND

Systemic autoimmune rheumatic diseases (SARDs) are a group of diseases with multiorgan involvement and a high prevalence of chronic pain and fatigue. Patients with SARDs and post-coronavirus disease 2019 (COVID-19) syndrome experience aggravation of symptoms. In this context, it is essential to establish strategies to reduce chronic pain and fatigue and improve quality of life.

AIM

To assess the efficacy of transcranial direct current stimulation (tDCS) for the treatment of fatigue and pain-associated post-COVID-19 syndrome in patients with SARDs.

METHODS

This study included nine patients with different types of SARDs. All patients had reverse transcription-polymerase chain reaction (RT-PCR) test confirmed COVID-19 as well as significant, persistent fatigue and pain that began to worsen after infection. Anodal tDCS was administered in five daily sessions (2mA, 20 min). Concomitantly, patients were involved in aerobic exercise program. All participants were evaluated using specific questionnaires and strength assessment by handgrip and physical function by timed-up-and-go test and sit-to-stand test at baseline (within one week before tDCS protocol), and one week after tDCS protocol. During all procedures, the patients’ treatments remained unchanged.

RESULTS

The sample comprised eight women and one man with a mean age of 48.7 ± 9.6 years. After the tDCS protocol, pain and fatigue significantly improved on the visual analog scale (P < 0.05). The physical function also improved 9.5 ± 2.7 vs 6.8 ± 0.8 (P = 0.001) for timed-up-go-test and 10.3 ± 3.7 vs 15.1 ± 4.0 (P = 0.037) for sit-to-stand test. None of the patients experienced any adverse events.

CONCLUSION

The present study showed that tDCS in combination with aerobic exercise was effective in improving physical function, and reducing fatigue/pain in SARDs patients with post-COVID-19 syndrome.

The Psychosocial Characteristics and Somatosensory Function of Children and Adolescents Who Meet the Criteria for Chronic Nociplastic Pain

Purpose

Nociplastic pain distinguishes individuals with pain and hypersensitivity in body regions with apparently normal tissues, without any signs of neuropathy, but with contribution of central and/or peripheral sensitization. There is a lack of literature describing nociplastic pain in the pediatric population. The objective of this study was to investigate the differences between pediatric patients with nociplastic pain compared with patients with non-nociplastic pain.

Patients and Methods

This study included 414 pediatric patients followed at an interdisciplinary centre for complex pain. All patients underwent an exhaustive pain assessment consisting of face-to-face interviews, validated self-report questionnaires and quantitative sensory testing. Recently established criteria for chronic nociplastic pain, and quantitative sensory testing was used to describe and stratify our cohort.

Results

One hundred and sixty-five patients (40%) were stratified as having possible nociplastic pain and two hundred and forty-nine (60%) patients, as non-nociplastic pain. Patients with nociplastic pain displayed pain hypersensitivity in the region of pain, more symptoms of panic and social phobia, and worse sleep quality than patients with non-nociplastic pain. The proportion of patients achieving a meaningful clinical outcome after completion of their treatment (medications, physiotherapy, psychology, nursing, social worker, and/or interventional procedures) was lower in patients with nociplastic pain (62%) than those without nociplastic pain (86%).

Conclusion

Our results suggest that patients who meet the criteria for nociplastic pain can be identified in a population of children and adolescents being treated in a center for complex pain. Combining screening with validated questionnaires and quantitative sensory testing facilitates the phenotyping and graded severity of patients with nociplastic pain in daily clinical practice.

Effectiveness of aquatic therapy on sleep in persons with fibromyalgia. A meta-analysis

CONTEXT

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal condition characterized by persistent, widespread pain, myofascial tenderness, negative affect, fatigue, memory problems and sleep disturbances.

OBJECTIVE

To summarize the evidence of the effects of aquatic therapy on sleep quality in patients with FMS.

METHODS

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2020 (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO), whit the registration number CRD42021249982. Cochrane library, Medline (PubMed), Science Direct Web of Science (WOS), Scopus, and PEDro were searched from inception until September 2021. The search included only randomized clinical trials.

RESULTS

Of the 7711 studies identified in the initial search, a total of 7 trials (361 participants) satisfied the eligibility criteria. Finally, a meta-analysis was conducted with 6 studies (311 participants). The overall pooled effect favored aquatic therapy interventions in improving sleep quality in patients with FMS (pooled MD, -2.05; 95% CI, -4.35 to 0.25).

CONCLUSIONS

The results of this systematic review and meta-analysis provide evidence that aquatic therapy improved sleep quality in patients with FMS. This study highlights the importance of aquatic therapy for sleep. Nonetheless, although an aquatic therapy intervention may represent a good option to improve sleep, given the low number of studies the evidence should be taken with caution.

Multidimensional evaluation of the pain profile as prognostic factor in individuals with hip or knee osteoarthritis receiving total joint replacement: protocol of a 2-year longitudinal prognostic cohort study

INTRODUCTION

Knee and hip osteoarthritis are two highly prevalent musculoskeletal pain conditions. Unsuccessful rates after hip/knee replacement range from 10% to 20%. Subjects with sensitisation manifestations are vulnerable to worse clinical outcomes. Most studies have analysed outcomes up to 1 year after surgery. The aim of this 2-year longitudinal study will be to evaluate sensory-related, psychological and psychophysical pain sensitisation manifestations and a potential epigenetic biomarker as prognostic clinical outcomes for the development of chronic postoperative pain after knee or hip replacement.

METHODS AND ANALYSIS

A prospective longitudinal study with a 2-year follow-up period will be conducted. The prognostic variables will include pain, function, related-disability, anxiety, depression, quality of life, sensitisation-associated symptoms, kinesiophobia, neuropathic pain and catastrophising, and expectative of the intervention will be assessed before surgery. We will also evaluate the presence of the Val158Met polymorphism as a possible epigenetic marker. Clinical outcomes including pain, related-disability and self-perceived satisfaction, sensitisation-associated symptoms and neuropathic pain will be assessed 3, 6, 12, 18 and 24 months after surgery. These variables will be used to construct three prediction models: (1) pain and function, (2) sensitisation-associated symptomatology and (3) neuropathic pain features classifying those patients in responders and non-responders. Data from knee or hip osteoarthritis will be analysed separately. Statistical analyses will be conducted with logistic regressions.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Committee of both institutions involved (Hospital Universitario Fundación Alcorcón (HUFA) 19-141 and Universidad Rey Juan Carlos (URJC) 0312201917319). Participants will sign the written informed consent before their inclusion. Study results will be disseminated through peer-reviewed publications and presentations at scientific meetings.

Contemporary management of pain in cirrhosis: Toward precision therapy for pain

Chronic pain is highly prevalent in patients with cirrhosis and is associated with poor health-related quality of life and poor functional status. However, there is limited guidance on appropriate pain management in this population, and pharmacologic treatment can be harmful, leading to adverse outcomes, such as gastrointestinal bleeding, renal injury, falls, and hepatic encephalopathy. Chronic pain can be categorized mechanistically into three pain types: nociceptive, neuropathic, and nociplastic, each responsive to different therapies. By discussing the identification, etiology, and treatment of these three mechanistic pain descriptors with a focus on specific challenges in patients with cirrhosis, we provide a framework for better tailoring treatments, including nonpharmacologic therapies, to patients' needs.

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion

It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.

Is Pilates more effective and cost-effective than aerobic exercise in the treatment of patients with fibromyalgia syndrome? A randomized controlled trial with economic evaluation

BACKGROUND

The aim of this study was to assess the effectiveness and cost-effectiveness of Pilates versus aerobic exercises in the treatment of patients with fibromyalgia syndrome from a societal perspective.

METHODS

This two-arm randomized controlled trial with blinded assessor and economic evaluation included 98 patients diagnosed with fibromyalgia syndrome using the American College of Rheumatology 2010 criteria, aged between 20 and 75 years, and pain intensity ≥3 points in the Pain Numerical Rating Scale. Patients were randomly allocated into the aerobic or Pilates group. Treatment was performed twice a week for 8 weeks. The primary outcome was the impact of fibromyalgia measured 8 weeks after randomization. Cost-effectiveness and cost-utility analyses were conducted for the impact of fibromyalgia and quality-adjusted life-years (QALYs), respectively, with a 12-month time horizon.

RESULTS

There was no difference between the groups for the impact of fibromyalgia (MD: 6.5 points; 95% CI: -1.8 to 14.9). The incremental cost-effectiveness ratio showed that 1-point increase in the impact of fibromyalgia was on average associated with a societal cost of £56 for the Pilates group compared to the aerobic group. The cost-utility analysis showed that the Pilates group had a 0.71 probability of being cost-effective at a willingness-to-pay of £30,000 per QALY gained.

CONCLUSION

There was no significant difference between groups for the impact of fibromyalgia. Pilates was not cost-effective compared to aerobic exercises for the impact of fibromyalgia. However, Pilates seemed to be the preferred option of treatment considering QALYs, although it depends on the willingness-to-pay threshold.

SIGNIFICANCE

Pilates showed to be a safe and effective alternative for the treatment of patients with fibromyalgia syndrome. Pilates presented similar results for the impact of fibromyalgia and superior results for pain relief compared to aerobic exercises, a highly recommended intervention for the treatment of fibromyalgia syndrome. Pilates was not cost-effective compared to aerobic exercises for the impact of fibromyalgia. However, Pilates seemed to be a cost-effective intervention for QALYs, depending on the decision-maker's willingness-to-pay threshold.

Data-Driven Path Analytic Modeling to Understand Underlying Mechanisms in COVID-19 Survivors Suffering from Long-Term Post-COVID Pain: A Spanish Cohort Study

Pain can be present in up to 50% of people with post-COVID-19 condition. Understanding the complexity of post-COVID pain can help with better phenotyping of this post-COVID symptom. The aim of this study is to describe the complex associations between sensory-related, psychological, and cognitive variables in previously hospitalized COVID-19 survivors with post-COVID pain, recruited from three hospitals in Madrid (Spain) by using data-driven path analytic modeling. Demographic (i.e., age, height, and weight), sensory-related (intensity or duration of pain, central sensitization-associated symptoms, and neuropathic pain features), psychological (anxiety and depressive levels, and sleep quality), and cognitive (catastrophizing and kinesiophobia) variables were collected in a sample of 149 subjects with post-COVID pain. A Bayesian network was used for structural learning, and the structural model was fitted using structural equation modeling (SEM). The SEM model fit was excellent: RMSEA < 0.001, CFI = 1.000, SRMR = 0.063, and NNFI = 1.008. The only significant predictor of post-COVID pain was the level of depressive symptoms (β=0.241, p = 0.001). Higher levels of anxiety were associated with greater central sensitization-associated symptoms by a magnitude of β=0.406 (p = 0.008). Males reported less severe neuropathic pain symptoms (−1.50 SD S-LANSS score, p < 0.001) than females. A higher level of depressive symptoms was associated with worse sleep quality (β=0.406, p < 0.001), and greater levels of catastrophizing (β=0.345, p < 0.001). This study presents a model for post-COVID pain where psychological factors were related to central sensitization-associated symptoms and sleep quality. Further, maladaptive cognitions, such as catastrophizing, were also associated with depression. Finally, females reported more neuropathic pain features than males. Our data-driven model could be leveraged in clinical trials investigating treatment approaches in COVID-19 survivors with post-COVID pain and can represent a first step for the development of a theoretical/conceptual framework for post-COVID pain.

Phenotyping Post-COVID Pain as a Nociceptive, Neuropathic, or Nociplastic Pain Condition

Pain after an acute Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) condition (post-COVID pain) is becoming a new healthcare emergency. Precision medicine refers to an evidence-based method of grouping patients based on their diagnostic/symptom presentation and then tailoring specific treatments accordingly. Evidence suggests that post-COVID pain can be categorized as nociceptive (i.e., pain attributable to the activation of the peripheral receptive terminals of primary afferent neurons in response to noxious chemical, mechanical, or thermal stimuli), neuropathic (i.e., pain associated with a lesion or disease of the somatosensory nervous system and limited to a "neuroanatomically plausible" distribution of the system), nociplastic (i.e., pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain), or mixed type (when two pain phenotypes co-exist). Each of these pain phenotypes may require a different treatment approach to maximize treatment effectiveness. Accordingly, the ability to classify post-COVID pain patients into one of these phenotypes would likely be critical for producing successful treatment outcomes. The 2021 International Association for the Study of Pain (IASP) clinical criteria and grading system provide a framework for classifying pain within a precision pain medicine approach. Here we present data supporting the possibility of grouping patients with post-COVID pain into pain phenotypes, using the 2021 IASP classification criteria, with a specific focus on nociplastic pain, which is probably the primary mechanism involved in post-COVID pain. Nociplastic pain, which is usually associated with comorbid symptomology (e.g., poor sleep quality, fatigue, cognitive-emotional disturbances, etc.) and is considered to be more difficult to treat than other pain types, may require a more nuanced multimodal treatment approach to achieve better treatment outcomes.

Network Analysis for Better Understanding the Complex Psycho-Biological Mechanisms behind Fibromyalgia Syndrome

The aim of this study was to assess potential associations between sensory, cognitive, health-related, and physical variables in women with fibromyalgia syndrome (FMS) using a network analysis for better understanding the complexity of psycho-biological mechanisms. Demographic, clinical, pressure pain threshold (PPT), health-related, physical, and psychological/cognitive variables were collected in 126 women with FMS. A network analysis was conducted to quantify the adjusted correlations between the modeled variables and to assess the centrality indices (i.e., the degree of connection with other symptoms in the network and the importance in the system modeled as a network. This model showed several local associations between the variables. Multiple positive correlations between PPTs were observed, being the strongest weight between PPTs over the knee and tibialis anterior (ρ: 0.28). Catastrophism was associated with higher hypervigilance (ρ: 0.23) and lower health-related EuroQol-5D (ρ: −0.24). The most central variables were PPT over the tibialis anterior (the highest strength centrality), hand grip (the highest harmonic centrality) and Time Up and Go (the highest betweenness centrality). This study, applying network analysis to understand the complex mechanisms of women with FMS, supports a model where sensory-related, psychological/cognitive, health-related, and physical variables are connected. Implications of the current findings, e.g., developing treatments targeting these mechanisms, are discussed.

Lifestyle and chronic pain: double jeopardy?

Given the often disappointing results of pharmacotherapy, many patients with chronic pain seek to modify their lifestyle. Some lifestyle factors, such as the consumption of alcohol, tobacco, cannabis, or psychostimulants, are deleterious in this context, whereas others, such as physical activity and a balanced diet, are considered beneficial, but these require substantial effort on the part of patients. In all cases, it is important to analyse lifestyle factors in patients with chronic pain, without stigmatisation, as the co-existence of pain and inappropriate behaviour can be seen as double jeopardy in patients with pain.

Understanding Sensitization, Cognitive and Neuropathic Associated Mechanisms behind Post-COVID Pain: A Network Analysis

This study aimed to describe a network including demographic, sensory-related, psychological/cognitive and other variables in individuals with post-COVID pain after hospitalization. Demographic (i.e., age, height, weight, months with symptoms), sensory-related (Central Sensitization Inventory -CSI-, Self-Report Leeds Assessment of Neuropathic Symptoms -S-LANSS-, PainDETECT), psychological/cognitive (Hospital Anxiety and Depression Scale -HADS-A/HADS-D-, Pain Catastrophizing Scale -PCS-, Tampa Scale for Kinesiophobia -TSK-11-) and other (sleep quality and health-related quality of life -EQ/5D/5L) variables were collected in 146 COVID-19 survivors with post-COVID pain. A network analysis was conducted to quantify the adjusted correlations between the modelled variables, and to assess their centrality indices (i.e., the connectivity with other symptoms in the network and the importance in the system modelled as network). The network revealed associations between sensory-related and psychological/cognitive variables. PainDETECT was associated with S-LANSS (ρ: 0.388) and CSI (ρ: 0.207). Further, CSI was associated with HADS-A (ρ: 0.269), TSK-11 (ρ: 0.165) and female gender (ρ: 0.413). As expected, HADS-A was associated with HADS-D (ρ: 0.598) and TSK-11 with PCS (ρ: 0.405). The only negative association was between sleep quality and EQ-5D-5L (ρ: -0.162). Gender was the node showing the highest strength, closeness, and betweenness centralities. In addition, CSI was the node with the second highest closeness and betweenness centralities, whereas HADS-D was the node with the second highest strength centrality. This is the first study applying a network analysis for phenotyping post-COVID pain. Our findings support a model where sensitization-associated symptoms, neuropathic phenotype, and psychological aspects are connected, reflecting post-COVID pain as a nociplastic pain condition. In addition, post-COVID pain is gender dependent since female sex plays a relevant role. Clinical implications of current findings, e.g., developing treatments targeting these mechanisms, are discussed.

Blended-Learning Pain Neuroscience Education and Exercise in High School Students With Chronic Neck Pain: A Randomized Controlled Trial

OBJECTIVE

Pain neuroscience education (PNE) and exercise have emerged as potential interventions in adolescents with chronic pain; however, very few studies have explored their effectiveness. Blended-learning approaches combining face-to-face and online educational sessions have also emerged as facilitating methods of health education. This study aimed to compare the effectiveness of exercises and PNE versus exercise alone in adolescents with chronic neck pain (NP).

METHODS

A randomized controlled trial with 6-month follow-up was conducted in 2 high schools. Over 8 weeks, a total of 127 adolescents with chronic NP were randomly allocated to either (1) perform functional and region-specific exercises, including generalized neuromuscular control, endurance, and strength exercises, as well as exercises targeting the deep neck flexor and extensor muscles and scapular stabilizer muscles; or (2) perform the same exercise-based intervention plus PNE. Pain intensity (primary outcome), disability, sleep, catastrophizing, fear of movement, self-efficacy, and knowledge of pain neuroscience were assessed at baseline, postintervention, and 6-month follow-up. Neck and scapular muscle endurance and pressure pain thresholds were assessed at baseline and postintervention. Patient's Global Impression of Change was assessed postintervention and at 6-month follow-up.

RESULTS

There was a significant decrease in pain intensity from baseline to postintervention and from baseline to follow-up in both groups, but there were no between-group differences or interactions between time and groups. These results were similar for the secondary outcomes, except for knowledge of pain neuroscience, for which a significant group and time interaction was found.

CONCLUSION

Exercise and exercise plus PNE were similarly effective in treating adolescents with chronic NP, and the results were maintained for up to 6 months. Further studies are needed to explore the effect of these interventions for longer follow-ups.

Use of behavioural activation to manage pain: a systematic scoping review

BACKGROUND

Behavioural activation (BA) is an effective treatment for depression; however, it is unclear if it can be used to manage pain.

OBJECTIVES

To conduct a scoping review of primary research that reported using BA to support people living with chronic pain to understand how BA had been used in relation to pain. In addition, we wanted to understand whether there were any reported changes in that pain, and how and who delivered BA.

ELIGIBILITY CRITERIA

Primary research published in English.

SOURCES OF EVIDENCE

We searched seven databases MEDLINE, Ovid Embase, Ovid Emcare, PsycINFO, CINAHL, Scopus and Web of Science, for primary research. No initial date limit was used with the date the searches were conducted used as the end date limit (1 July 2021).

CHARTING METHODS

A customised data extraction table was developed, piloted and used.

RESULTS

551 papers were screened for inclusion, with 15 papers included in our review. Studies were conducted in North America and in Canada. These included three case studies, nine uncontrolled trials and three randomised controlled trials. Only two studies reported pain as the primary outcome. BA was applied across a range of pain related conditions. The dose of BA ranged from 3 to 16 sessions. Duration of treatment was 3 weeks to 12 months. Most studies reported reductions in pain following exposure to BA.

CONCLUSION

BA has the potential to reduce pain. Caution needs to be exercised in the interpretation of these findings as a high risk of bias was observed in most studies. High-quality research is required to test if BA is an effective intervention for chronic pain.

Benefits of Exergame Training for Female Patients With Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the effects of exergame training on female patients with fibromyalgia syndrome (FMS). Outcome measurements mainly include overall functioning, pain perception, quality of life, exercise capacity, health perception, kinesiophobia, and fatigue severity.

DATA SOURCES

Five electronic databases (PubMed, Web of Science, PsycInfo, Scopus, and Cochrane Library) were searched from inception until June 24, 2021. In addition to searches, review the reference lists of relevant papers by hand was also conducted. Cochrane Collaboration's tool for assessing risk of bias was used to evaluate the risk of bias in the included studies.

STUDY SELECTION

Articles were collected with the following study inclusion criteria: (1) randomized controlled trial (RCT) design; (2) participants were female patients with FMS aged older than 18 years; (3) participants in experimental groups received exergame training using any modality; and (4) outcome measures included overall functioning, quality of life, exercise capacity, health perception, kinesiophobia, and fatigue severity.

DATA EXTRACTION

The data were independently extracted by 2 researchers. The extracted data related to the document characteristics (first author, publication year, and country) participant characteristics (number and age of participants in the experimental and control groups), and interventions (intervention content, frequency, and duration, and measurement tools).

DATA SYNTHESIS

Nine RCTs including 466 female patients with FMS were included in the analysis. Exergame training had significant positive effects on overall functioning (standardized mean difference [SMD], -0.52; 95% confidence interval [CI], -0.77 to 0.27; P<.0001), pain perception (SMD, -0.49; 95% CI, -0.97 to -0.02; P=.04), quality of life (SMD, 0.77; 95% CI, 0.44-1.10; P<.00001), exercise capacity (SMD, 0.58; 95% CI, 0.32-0.84; P<.0001), health perception (SMD, 0.69; 95% CI, 0.38-1.01; P<.0001), and fatigue severity (SMD, -0.97; 95% CI, -1.55 to -0.38; P=.001). However, exergame training did not have significant effects on kinesiophobia (SMD, -1.13; 95% CI, -2.88 to 0.62; P=.21).

CONCLUSIONS

Exergame training has beneficial effects on the overall functioning, pain perception, quality of life, exercise capacity, health perception and fatigue severity of female patients with FMS. Exergame training is a potential non-drug therapy for the treatment of patients with FMS.