Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education

EFFECTIVENESS OF A PAIN INFORMED MOVEMENT PROGRAM IN POST COVID-19 CONDITION PATIENTS: A RANDOMIZED CONTROL TRIAL

OBJECTIVES

To evaluate the early impact of the Pain Informed Movement (PIM) program in patients with post COVID-19 condition experiencing new onset persistent pain.

DESIGN

A single-blind, 2 arm, parallel-group, randomized controlled trial.

SETTING

A public health sciences faculty.

PARTICIPANTS

Fifty-seven patients (n=57) with post COVID-19 condition were randomized into the PIM (n=27) and the control (usual care and educational booklet) groups (n=30).

INTERVENTION

Patients in the intervention group received an 8-week PIM program. Each week, participants attended 2 face-to-face sessions of 1 hour per week. The first session was group-based and focused on pain neuroscience education. The second session was individual and consisted of functional exercises and relaxation techniques. Additionally, patients were required to perform these exercises and techniques at home twice a week, recording their compliance and progress.

MAIN OUTCOME MEASURES

Measured outcomes include pain intensity and interference measured with the Brief Pain Inventory (BPI), catastrophizing assessed with the Pain Catastrophizing Scale (PCS), kinesiophobia measured with the Tampa Kinesiophobia Scale (TSK) and functionality assessed using World Health Organization Disability Assessment Schedule (WHODAS 2.0). Participants were assessed at baseline and post intervention.

RESULTS

The intervention group showed a significant reduction in all variables with respect to baseline values. In addition, the intervention group showed significant differences with respect to the control group in pain intensity (MD=2.84±0.62; p<.001; Cohen's d=1.21), pain interference (MD=3.10±0.70; p < .001; Cohen's d=1.18), catastrophizing (MD=12.52±2.48; p<.001; Cohen's d=1.34), kinesiophobia (MD=8.07±1.34; p<.001; Cohen's d=1.56) and functionality (MD=16.16±6.92; p=.039; Cohen's d=0.62).

CONCLUSIONS

In conclusion, the PIM program suggests to be an effective intervention for the reduction of new onset persistent pain and improvement of functionality in patients with post COVID-19 condition. This study underscores the importance of multidimensional and personalized approaches to persistent pain management, although more research is needed to confirm its applicability in clinical practice.

Body Mass Index Predicts Function in Individuals With Plantar Fasciopathy: A Longitudinal Observational Study

CONTEXT

Plantar fasciopathy (PF) is a common, self-limiting condition with notable economic impact and multifactorial origins. Clinical tests help clinicians to identify specific dysfunction and limitations influencing PF's clinical course. This study aims to investigate whether body mass index (BMI) influences the performance of clinical tests and clinical presentation of individuals with PF and to determine whether BMI and clinical tests predict the clinical course of PF over a 3-month follow-up period.

DESIGN

This study is a longitudinal observational study. Participants were grouped, according to the median BMI, into low and high BMI.

SETTING

Healthcare centers and physiotherapy clinics.

PARTICIPANTS

Fifty-two individuals with PF participated in this study.

MAIN OUTCOME MEASURES

Baseline: Ankle dorsiflexion range of motion and navicular drop, heel-rise, and step-down tests were administered. Pain intensity and function were measured at baseline and at 3-month follow-up.

RESULTS

Low BMI group showed better function (mean difference = 11.8; 95% CI, 1.9 to 21.6) and lower pain intensity (mean difference = -1.5; 95% CI, -2.6 to -0.3) than the high BMI group. In the multivariable regression model, higher BMI predicted lower function (beta coefficient = -1.20; 95% CI, -2.3 to -0.3).

CONCLUSIONS

In individuals with PF, BMI levels influenced PF clinical presentation. The high BMI group showed more severe pain and lower function. Higher BMI was found to be a poor prognostic factor for function in individuals with PF.

Perceived factors influencing the success of pain neuroscience education in chronic musculoskeletal pain: a meta-synthesis of qualitative studies

PURPOSE

We aimed to identify the factors influencing the success of Pain Neuroscience Education (PNE) in chronic musculoskeletal (MSK) pain from the perspective of those experiencing PNE first-hand.

MATERIALS AND METHODS

We conducted a meta-synthesis of qualitative studies. Articles were found on MEDLINE via Pubmed, EMBASE, Cochrane Library, CINHAL, and PsycINFO up to April 2023. Eligible qualitative studies focussed on adults (>16 years old) with a diagnosis of chronic primary or secondary MSK pain who performed PNE. Thematic synthesis by Thomas and Harden was followed. The Critical Appraisal Skills Programme (CASP) tool ensured the quality of the studies, while the Confidence in Evidence from the Reviews of Qualitative Research (CERQual) approach facilitated data confidence assessment.

RESULTS

Nine studies were included (188 participants). Three analytical themes were developed: (i) "Efficient Communication of Information", emphasising the importance of accurate content transmission; (ii) "Emotional Support and Well-being", recognising emotional aspects as integral to treatment; and (iii) "Empowerment Promotion", focusing on information retention and personal transformation. The studies showed good quality, with moderate confidence in the evidence.

CONCLUSIONS

The perceived factors influencing the success of PNE are intricately related to the domain of communication, the emotional dimension of personal experience, and the capacity to be empowered.

[Development and validation of a questionnaire to assess physiotherapists' postural-structural-biomechanical-oriented beliefs about pain]

BACKGROUND

Therapists frequently use the postural-structural-biomechanical (PSB) model in clinical practice to explain the symptom of pain using biomechanical deficits. Adequate knowledge about pain encompasses not only the neurophysiology of pain but also knowledge that existing PSB-oriented explanations of the development and enhancement of pain are outdated. There is no assessment to evaluate physiotherapists' PSB-oriented beliefs about pain.

AIM

The aim of the present study was to develop a questionnaire to assess physiotherapists' PSB-oriented beliefs about pain and to evaluate its reliability (internal consistency), validity, and agreement.

METHODS

The Essential Knowledge of Pain Questionnaire (EKPQ) was constructed on the basis of a literature search and discussions between experts. In a pilot study, 32 pupils of a physiotherapy school were then asked to complete the German version of the revised Neurophysiology of Pain Questionnaire (rNPQ-D) and the EKPQ using the SoSci Survey in order to assess their knowledge and beliefs about pain.

RESULTS

The internal consistency of the EKPQ was acceptable with a Cronbach's α = 0.784. There was a strong positive significant correlation between the questionnaires (r = 0.518; p = 0.002). The Bland-Altman analysis revealed a mean difference of 28.9% (± standard deviation of the difference 15.3%) with an upper limit of 95% agreement of 58.8% and a lower limit of 95% agreement of -1.0% between the questionnaires. Participants achieved a mean score of 60.7% in the rNPQ‑D and a mean score of 31.8% in the EKPQ.

CONCLUSION

The newly developed EKPQ questionnaire seems to be a reliable and valid assessment to determine physiotherapists' PSB-oriented beliefs about pain. The results also confirm that a high level of knowledge about the neurophysiology of pain does not exclude a PSB orientation. Whether the EKPQ can be used alongside the rNPQ as an additional assessment to evaluate beliefs about pain should be investigated in the future with suitable study designs, e.g. Delphi study.

Pain revolution in the public health system: Active coping strategies for chronic pain unit

BACKGROUND

Chronic pain represents a global health challenge demanding a transition from traditional biomedical to patient-centered biopsychosocial models. This masterclass explores active coping strategies for effective chronic pain management within healthcare systems. It describes the Unit of Active Coping Strategies for Chronic Pain (UAAD - Unidad de Afrontamiento Activo para el Dolor) in Primary Care in Valladolid, Spain, as a successful example of implementing a biopsychosocial care model for treating chronic pain.

OBJECTIVE

To provide tools that allow the application of active coping strategies in the treatment of patients with chronic pain and how to implement the UAAD units in other healthcare systems.

METHODS

This masterclass describes the UAAD's innovative approach, starting with its comprehensive and personalized methodology. This includes a referral system, a thorough assessment encompassing biological, psychological, and social factors, and a functional categorization system. These elements guide personalized treatment plans delivered through group and individual programs grounded in therapeutic exercise and pain science education. Four key pillars are highlighted: clinical care, teaching, resource management, research and dissemination.

CONCLUSION

Embracing this model empowers healthcare providers to address the growing burden of chronic pain. It also enables patients to take an active role in their recovery and self-management.

Physical therapist characteristics and therapeutic relationship process construct factors that improve patient health outcomes in physical therapy: a systematic review

BACKGROUND

It appears that the therapeutic relationship in physiotherapy practice facilitates the success of patient health outcomes, although the process by which it is carried out has been poorly studied.

OBJECTIVE

To explore the influence of the therapeutic relationship on any patient health outcomes in physical therapy settings.

METHODS

PubMed, Web of Science, Scopus, CINAHL, LILACS and Dialnet databases were systematically searched following PRISMA guidelines. The searches were completed in August 2024. Qualitative and quantitative studies measuring the therapeutic relationship and assessing its influence on health outcomes of patients treated with physical therapy were included.

RESULTS

The search yielded a total of 769 results. 13 studies ultimately retained for analysis. A total of 1555 individuals were studied who had suffered injuries such as low back pain; osteoarthritis; underwent cardiac surgery; hip fracture and elite athletes recovering from injuries. The results obtained were classified into three main themes: characteristics and skills of physical therapists (interpersonal, organizational, leadership and communication skills), therapeutic relationship factors (shared decision making, trusting relationships, motivating the patient and individualization of care) and patient health outcomes influenced by therapeutic relationship (functional outcomes, disability, pain intensity, outcome expectations, perceived global effect, adherence, self-efficacy, sports performance and lung function).

CONCLUSIONS

Through physical therapist's soft skills, therapeutic relationship factors are built under the paradigm of person-centered care and shared decision making, having a positive influence on certain patient health outcomes. Therefore, evidence support that therapeutic relationship contributes to improved patient health outcomes.

The effect of peri-operative pain neuroscience education on pain and recovery in adult patients receiving laparoscopic inguinal hernia repair

To optimize the efficacy of analgesia for patients receiving laparoscopic inguinal hernia repair, peri-operative pain neuroscience education (PNE) as a pain-specific cognitive therapy was incorporated into multi-modal analgesia. A randomized controlled trial was conducted to compare conventional analgesia (group CA) and the addition of pain neuroscience education into it (group PNE) in patients receiving laparoscopic inguinal hernia repair. Characteristics of peri-operative pain was evaluated with Douleur Neuropathique 4 questionnaire (DN-4), central sensitization inventory (CSI), pain catastrophizing scale (PCS) post-operatively and pressure pain threshold. Post-operative quality of recovery was measured with EuroQol five dimensions questionnaire (EQ-5D-5L). The incidence of chronic post-operative pain was also recorded. A total of 184 patients consented to participate in this study and finished follow-up. Compared with those receiving conventional analgesia (group CA, N = 91), patients in group PNE (N = 93) reported reduced incidence of moderate-to-severe pain and less dosages of opioid during hospitalization (p < 0.05). Catastrophing, sensitization related to pain were reduced in group PNE (p < 0.05). Quality of recovery was improved till 1 month after surgery (p < 0.05). The addition of pain neuroscience education improved analgesic effect and quality of recovery for patients undergoing laparoscopic inguinal hernia repair. It also helped reduce sensitization and catastrophic of acute surgical pain. This psychologically-oriented analgesic approach merits future research and application for these patients.

"I Have Faith in God That I Will Get Better"-The Multidimensional Perceptions and Expectations of Patients With Chronic Shoulder Pain: A Qualitative Analysis of Common Sense

OBJECTIVE

This descriptive qualitative study aimed to gain insights into the expectations of individuals with chronic shoulder pain and to investigate how different levels of disability may influence their beliefs and expectations regarding improvement.

METHODS

This qualitative study utilized the Common Sense Model as its theoretical framework. Conducted within a public physical therapy clinic, individuals with chronic shoulder pain who were awaiting the initiation of the treatment were included. Participants, female and male (aged 30-69 years), were purposefully sampled. Thirty participants, categorized into 2 groups based on the Shoulder Pain and Disability Index (SPADI) scores, underwent semi-structured interviews. Group 1, lower SPADI scores (0-60), had 10 participants, and Group 2, higher SPADI scores (61-100), had 20 participants. Thematic analysis and inductive coding were employed to analyze the interviews.

RESULTS

Common themes emerged in both groups: the use of medical terms for understanding the diagnosis and the multidimensional impact of pain. The last 2 themes differed between groups. Notable differences included Group 1's focus on resources for pain relief and positive expectations with physical therapy, while Group 2 emphasized rest, religion as a resource for pain relief, and God's role in improvement.

CONCLUSION

These findings highlight the complexity of beliefs and expectations among patients with chronic shoulder pain. Individuals with greater disability often incorporated religious beliefs into their coping strategies, but they held lower recovery expectations and reported negative treatment experiences. These insights have implications for tailoring patient-centered care approaches.

IMPACT

This study underscores the need for health care providers to consider the multidimensionality of recovery expectations, which can significantly influence patient outcomes. Clinicians can reflect on this knowledge to optimize treatment strategies and improve patient prognosis.

A Multimodal Patient-Centered Teleprehabilitation Approach for Patients Undergoing Surgery for Breast Cancer: A Clinical Perspective

Breast cancer is the most common malignancy among women worldwide, and advances in early detection and treatment have significantly increased survival rates. However, people living beyond breast cancer often suffer from late sequelae, negatively impacting their quality of life. Prehabilitation, focusing on the period prior to surgery, is a unique opportunity to enhance oncology care by preparing patients for the upcoming oncological treatment and rehabilitation. This article provides a clinical perspective on a patient-centered teleprehabilitation program tailored to individuals undergoing primary breast cancer surgery. The proposed multimodal program includes three key components: patient education, stress management, and physical activity promotion. Additionally, motivational interviewing is used to tailor counseling to individual needs. The proposed approach aims to bridge the gap between diagnosis and oncological treatment and provides a holistic preparation for surgery and postoperative rehabilitation in breast cancer patients. The aim of this preparation pertains to improving mental and physical resilience. By integrating current evidence and patient-centered practices, this article highlights the potential for teleprehabilitation to transform clinical care for breast cancer patients, addressing both logistical challenges and holistic well-being.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is chronic pain caused by central sensitization? A review and critical point of view

Chronic pain causes disability and loss of health worldwide. Yet, a mechanistic explanation for it is still missing. Frequently, neural phenomena, and among them, Central Sensitization (CS), is presented as causing chronic pain. This narrative review explores the evidence substantiating the relationship between CS and chronic pain: four expert researchers were divided in two independent teams that reviewed the available evidence. Three criteria were established for a study to demonstrate a causal relationship: (1) confirm presence of CS, (2) study chronic pain, and (3) test sufficiency or necessity of CS over chronic pain symptoms. No study met those criteria, failing to demonstrate that CS can cause chronic pain. Also, no evidence reporting the occurrence of CS in humans was found. Worryingly, pain assessments are often confounded with CS measures in the literature, omitting that the latter is a neurophysiological and not a perceptual phenomenon. Future research should avoid this misconception to directly interrogate what is the causal contribution of CS to chronic pain to better comprehend this problematic condition.

What is the Status Quo of Patient-Centred Physiotherapy Management of People with Headache within a Biopsychosocial Model? - A Narrative Review

PURPOSE OF REVIEW

Patient-centred care (PCC) is deemed essential in the rehabilitation of musculoskeletal pain. Integrating such care within a biopsychosocial framework, enables to address all facets of the individual pain experience, and to manage the individual instead of the condition. This narrative review describes the status quo of PCC physiotherapy management of people with headache within a biopsychosocial model. PubMed, EMBASE, Web of Science, Scopus were searched (update 07.05.2024). The search-query comprised terminology relating to "headache", "patient-centred", "biopsychosocial", "physiotherapy". Additional eligibility criteria were reviews, trials, cohort, case report, case-control studies in English, Dutch, French.

RECENT FINDINGS

Gaps are exposed in patient-centred physiotherapy management of migraine, tension-type headache, and cervicogenic headache. While a biopsychosocial approach is advised to manage migraine and tension-type headache, its use in clinical practice is not reflected by the literature. A biopsychosocial approach is not advised in cervicogenic headache. Psychosocial-lifestyle interventions are mainly delivered by health-care providers other than physiotherapists. Additionally, psychologically-informed practice is barely introduced in physiotherapy headache management. Though, managing the social context within a biopsychosocial framework is advised, the implementation by physiotherapists is unclear. Comparable conclusions apply to PCC. PCC is recommended for the physiotherapy management of primary and secondary headache. Such recommendation remains however theoretical, not reaching clinical implementation. Yet, a shift from the traditional disease-centred model of care towards PCC is ongoing and should be continued in physiotherapy management. With this implementation, clinical and economical studies are needed to evaluate its effectiveness.

French translation and transcultural adaptation of the shoulder pain and disability index (SPADI)

BACKGROUND

A French version of the Shoulder Pain and Disability Index (SPADI) is currently unavailable for clinical and research use in French-speaking countries.

OBJECTIVES

To translate and transculturally adapt the Shoulder Pain And Disability Index (SPADI) from English to French language.

DESIGN

Translation and transcultural adaptation of a Patient-Reported Outcome Measure.

METHODS

Following international guidelines for translating and adapting PROMs, we carried out a seven-step process involving 15 contributors. The forward translation was performed by five independent native French speakers, while five independent native English speakers conducted the blinded back-translation. A bilingual expert committee synthesized the translations, and three healthcare professionals participated in the pre-test phase. Ten patients were involved in pre-testing to evaluate the pre-final version.

RESULTS

A final French version of the SPADI was achieved after making seven adjustments across the 18 items, instructions, and examples on the Likert scale. Changes were implemented only if at least 20% of the pre-test participants suggested modifications to enhance readability or coherence. Face validity was assessed by the expert committee.

CONCLUSION

The French version of the SPADI is now available, enabling condition-specific self-assessment and quantitative follow-up of shoulder pain and function in both clinical practice and research. Although psychometric properties of this version are yet to be assessed, future studies are expected to confirm the preservation of the original tool's validity and reliability.

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Therapeutic expectancy in physiotherapy

In health sciences, including physical therapy, communication techniques are a critical part of the success in the therapeutic process. Managing the patient's beliefs, perceptions, and the narrative of their problems, becomes an essential part of the therapeutic process. This is the key to achieving real changes regarding how the patient copes with pain, illness, dysfunction, as well as the ability to develop adequate resources for facing them. We call this "Therapeutic expectancy" a new concept that originates from the well-known Therapeutic alliance and incorporates practices from the field of Motivational interviewing and Strategic dialogue. The Therapeutic expectancy starts from the first interaction with the patient and continues throughout the different stages of the therapeutic process. This article describes the structure of the relationship with the patient and some verbal communication techniques to generate an effective physical therapist-patient interaction, building Therapeutic expectancy, through a "centered on the patient's narrative" strategy. Expectancy constitutes a desirable goal in any patient and in any pathological condition as it pursues a change in an individual's perception of their state of health, thereby enhancing the desire for healing and empowerment.

Alshehri Y. Cross-cultural adaptation and psychometric properties of the Arabic version of the Central Sensitization Inventory in people with chronic musculoskeletal pain

Background

The Central Sensitization Inventory (CSI) is a patient-reported screening instrument that can be used to identify and assess central sensitization (CS)/Central Sensitization Syndrome (CSS)-related symptoms.

Objective

The aim was to translate the CSI into Arabic (CSI-Ar) and to subsequently validate its psychometric properties.

Design

Cross-sectional.

Methods

The CSI was translated and cross-culturally adapted into Arabic, and validated following international standardized guidelines. This study included patients with chronic musculoskeletal pain (n = 264) and healthy control participants (n = 56). Patients completed the CSI-Ar, Pain Catastrophizing Scale (PCS), Depression, Anxiety, and Stress scale (DASS-21), Tampa Scale of Kinesiophobia (TSK), and 5-level EuroQol-5D (EQ-5D). Patients completed the CSI-Ar twice to assess test-retest reliability. To evaluate discriminative validity, healthy controls participants completed the CSI-Ar. Statistical analyses were conducted to test the internal consistency, reliability, and structural, construct and discriminant validity of CSI-Ar.

Results

The CSI-Ar showed acceptable internal consistency (Cronbach's alpha = 0.919) and excellent test-retest reliability (intraclass correlation coefficient = 0.874). The CSI-Ar scale had significant correlations (P < 0.001) with all PCS subscales and total score (Spearman's rho = 0.459-0.563, P < 0.001), all DASS-21 subscales and total score (Spearman's rho = 0.599-0.685, P < 0.001), the TSK (Spearman's rho = 0.395, P < 0.001), and the EQ-5D (Spearman's rho = -0.396, P < 0.001). The Mann-Whitney U-test showed a statistically significant difference between the patient group and the healthy control group (P < 0.001), with the healthy controls displaying a lower average CSI-Ar score (12.27 ± 11.50) when compared to the patient group (27.97 ± 16.08). Factor analysis indicated that the CSI-Ar is a unidimensional tool.

Conclusion

The CSI-Ar is a reliable and valid screening tool that can be used to assess CS/CSS-related symptoms in Arabic-speaking people with chronic musculoskeletal pain.

Commentary: The Effect of Corticosteroid Injection in the Treatment of Greater Trochanter Pain Syndrome

Greater Trochanteric Pain Syndrome is a broad term employed to characterize lateral hip pain originating from the structures attached to the greater trochanter of the femur. The documented decrease in work participation, elevated levels of pain and dysfunction impeding physical activity, and diminished quality of life align with those observed in individuals with severe hip osteoarthritis. Effectively managing Greater Trochanteric Pain Syndrome can present considerable challenges. Generally, patients with Greater Trochanteric Pain Syndrome tend to respond favourably to conservative management. However, regarding the conservative approach of using corticosteroid injections there is still some debate regarding the specific estimation of effect. A recent systematic review by Wang et al. (2022) was undertaken to explore the effect of corticosteroid injection in the treatment of Greater Trochanteric Pain Syndrome. This commentary seeks to critically assess the methodologies employed in the review conducted by Wang et al. (2022) and provide a broader understanding of the findings in the context of the four pillars of advanced practice; clinical practice, leadership, education and research.

'Leaving my comfort zone'. A qualitative study of physiotherapists' experiences blending an eHealth psychosocial intervention with face-to-face physiotherapy

BACKGROUND

Many physiotherapists do not feel adequately equipped to address psychosocial risk factors in people with complex pain states. Hence, a biopsychosocial blended intervention (Back2Action) was developed to assist physiotherapists to manage people with persistent spinal pain and coexisting psychosocial risk factors associated with the development or maintenance of persistent pain.

OBJECTIVE

This study aimed to gain insight into the experiences of physiotherapists with this blended psychosocial intervention.

DESIGN

and methods: This was an interpretative qualitative study with a reflexive thematic analysis of semi-structured interviews with physiotherapists (N = 15) who delivered Back2Action. The interview started with the grand-tour question: "What was your experience in using Back2Action?" Physiotherapist were encouraged to provide examples, and follow-up questions were posed to ensure a deeper understanding could be reached.

RESULTS

Four themes were constructed: Physiotherapists became increasingly aware of (1) their own implicit expectations, biases and skills, and underlying treatment paradigms, and (2) the implicit expectations from their patients towards them. This led to (3) creating a deeper and stronger therapeutic alliance with the patient, but also (4) an understanding that implementation of a true biopsychosocial intervention - even if offered in a blended form - requires more practice, confidence and resources.

CONCLUSIONS

Back2Action is considered a valuable treatment to deliver a biopsychosocial intervention in primary care. Considering the high level of knowledge, skills and competency of the participating physiotherapists, the perceived barriers may be more difficult to overcome for more junior physiotherapists.

General exercises are not superior to specific exercises for pain and functional disability in individuals with chronic nonspecific neck pain. A systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness of general exercises with specific exercises for pain and functional disability of individuals with chronic nonspecific neck pain.

METHOD

This systematic review of clinical trials searched MEDLINE, CINAHL, Embase, CENTRAL, and PEDro databases with no date or language restriction. Methodological quality of evidence were assessed using the PEDro scale and GRADE, respectively. Pain and functional disability were the primary outcomes.

RESULTS

This review included 14 articles from 12 studies, from which nine were included in meta-analyses. Data were from 926 individuals with chronic nonspecific neck pain, comparing specific exercises with mind-body and aerobic exercises (general exercises). Pain intensity was not different between aerobic and specific exercises, with a mean difference (MD) of 0.95 points (95% CI -1.62 to 3.51) in the medium-term and 0.32 points (95% CI -1.05 to 1.68) in the long-term. Mind-body exercises were not better than specific exercises for pain intensity in medium- (MD 0.54 points; 95% CI 0.00 to 1.08) or long-term (MD 0.06 points; 95% CI -0.59 to 0.46). Also, mind-body exercises did not improve functional disability compared with specific exercises in medium- or long-term (MD 0.01 points; 95% CI -0.25 to 0.27). The quality of evidence among studies ranged from very low to low across all comparisons.

CONCLUSION

General exercises are not superior to specific exercises for pain and functional disability in individuals with chronic nonspecific neck pain.

Central sensitization-related symptoms and their relationship to disability in prevalent chronic musculoskeletal pain: A cross-sectional study

BACKGROUND

Central sensitization (CS) has an important role in chronic musculoskeletal (MSK) pain, which is one of the leading causes of disability worldwide.

OBJECTIVES

To investigate the relationship between CS-related symptoms and disability in chronic MSK pain.

DESIGN

Multi-center cross-sectional survey.

METHODS

Demographic and clinical variables including location, duration, and severity of pain were recorded. In the examination of disability, Istanbul Low Back Pain Disability Index for low back pain, Neck Pain and Disability Scale for neck pain, Quick Disability of the Arm, Shoulder, and Hand for shoulder/upper extremity pain, and Knee Injury and Osteoarthritis Outcome Score for knee pain were used. CS-related symptoms were investigated via the central sensitization inventory (CSI). Based on CSI scores, patient data were compared using the T test and an ANOVA. The association between CSI and selected variables was investigated using Pearson correlation and multivariate regression analysis.

RESULTS

The mean CSI score of five hundred participants was 40.46 (SD: 15.87). Patients with CSI≥40 were found to have higher levels of pain and disability and a poorer quality of life (p < 0.05). In ANOVA, significant differences between groups were observed in CS severity levels for VAS, symptom duration, and all clinical scores (p < 0.01). In the multivariate regression analysis, CSI and VAS scores were found to be related to disability in all pain groups, while pain duration was effective only in the change of knee disability.

CONCLUSION

CS-related symptoms, which are related to increased pain and disability, should be closely monitored in patients with chronic MSK pain.

Coping strategies for combating chronic pain among professional ballet dancers in Cali, Colombia. Qualitative study

INTRODUCTION

Pain is part of the daily life of ballet dancers. To achieve perfection in the dance, techniques based on repetitive movements that overload different parts of the body are used, which generate pain. The purpose of this study is identify coping strategies used by professional ballet dancers to manage chronic pain.

METHODS

A qualitative study was conducted using a phenomenological design with a population of 17 professional dancers from a ballet company in Cali, Colombia. The Chronic Pain Coping Questionnaire (CAD) and a open interview with guiding questions were applied as research instruments.

RESULTS

The dancers of the Colombian Ballet Company engage in a physically demanding practice that necessitates continuous movement. The majority of these dancers are under 30 years of age and have been with the company for less than 5 years. Unfortunately, their frequent injuries include sprains, back pain, and disc herniation, often attributed to a lack of strengthening and the imposition of high physical loads. In coping with the pain, the dancers commonly resort to seeking information about their injuries and engaging in self-affirmation of their exceptional abilities.

CONCLUSIONS

Dancers get used to pain to continue in professional dance companies. Coping with pain involves developing strategies for self-affirmation and motivation to continue in their profession.

[Current knowledge of German physiotherapy trainees and students on pain and the influence of a teaching intervention]

BACKGROUND

In order to properly inform patients about their pain and initiate targeted therapies, it is important for physiotherapists to learn about the latest scientific evidence on pain during their training.

AIM

This study aimed to assess the pain knowledge of German physiotherapy trainees and students. In addition, the influence of a teaching intervention (Pain Neuroscience Education, PNE) on their pain knowledge was investigated.

METHODS

An online test was performed, which contained the German versions of the revised Neurophysiology of Pain Questionnaire (rNPQ-D) and the Essential Knowledge of Pain Questionnaire (EKPQ). This test was completed by physiotherapy trainees and students (N = 279) in their final semester of vocational education or graduation under virtual supervision. After the test, a sub-cohort of physiotherapy trainees (n = 31) received a four-hour online teaching intervention (PNE), whereupon two retests took place.

RESULTS

The mean rNPQ-D score (63.8%) was significantly higher than the mean EKPQ score (28.4%) (p < 0.001). There was a significant positive correlation between the scores of rNPQ-D and EKPQ (r = 0.365, p < 0.001). Undergraduate students from university (n = 142) achieved significantly higher scores in both questionnaires (p < 0.001) compared to trainees from vocational schools (n = 137). In the sub-cohort, the online teaching intervention significantly improved the scores of both questionnaires immediately (p < 0.001) and six weeks after intervention (p < 0.001).

CONCLUSION

The knowledge of German physiotherapy students about pain seems to be insufficient for an evidence-based treatment of pain patients. A PNE-based online learning program with the latest scientific evidence can significantly improve physiotherapy students' knowledge about pain.

Chronic Pain Management Approaches among Spanish Physiotherapists: Influences, Practices, Barriers, and Challenges

This study evaluated Spanish physiotherapists' orientations toward biopsychosocial and biomedical approaches in chronic pain management through a cross-sectional survey of 447 registered professionals. Validated questionnaires assessed knowledge, attitudes, and beliefs. Multivariate analysis of covariance (MANCOVA) identified influential factors and ordinal regression determined the frequency of biopsychosocial application. Content analysis of open-ended responses explored barriers to biopsychosocial implementation. Over 50% of physiotherapists favored the biopsychosocial model, influenced by interdisciplinary work settings, advanced pain knowledge, and specific training. Comprehensive pain knowledge significantly impacted both biomedical and biopsychosocial orientations inversely. The biomedical approach was more prevalent among those with lower education levels and less pain knowledge, particularly at the beginning or over 20 years into their careers. Despite the theoretical preference for biopsychosocial among Spanish physiotherapists, practical application was infrequent, with only 9.8% always using it and 40.7% frequently. Self-reported confidence and skills were crucial determinants of biopsychosocial implementation frequency. Significant barriers included inadequate psychological skills (63.6%), coordination challenges (47.6%), time constraints (43.6%), patient misconceptions (34.2%), and systemic issues. These findings align with international research, highlighting the need to bridge the gap between theoretical knowledge and clinical practice. Addressing these challenges through targeted training and systemic reforms is crucial for improving chronic pain management globally.

Italian versions of the Neurophysiology of Pain Questionnaire (NPQ): psychometric properties and an investigation on the understanding of pain neurophysiology in physical therapists

OBJECTIVES

The Neurophysiology of Pain Questionnaire (NPQ) is widely used to assess pain knowledge among clinicians and patients with pain, but an Italian version is not available. This study aimed to translate and cross-culturally adapt the NPQ into Italian, to test its psychometric properties, to assess the knowledge of Italian physical therapists (PTs) on pain, and to evaluate which characteristics are associated with pain knowledge.

METHODS

The NPQ was translated into Italian, integrated with some additional questions (IT-NPQ-New), and sent by email via the Italian Association of Physiotherapy newsletter. Rasch analysis (RA) was used to test the psychometric properties of the Italian versions. Multivariable regression analyses were used to check for associations between participants' characteristics and their NPQ scores.

RESULTS

A sample of 753 PTs completed the survey. RA of the NPQ-19 and IT-NPQ-New revealed that 10 (IT-NPQ-10) and 18 (IT-NPQ-18) items fit the model. Both questionnaires showed good psychometric properties. The overall median score among Italian PTs was 6.0 [5.0-7.0] and 11.0 [9.0-13.0] points for the IT-NPQ-10 and the IT-NPQ-18, respectively. These scores were statistically different among groups according to gender, age, years of professional activity, post-graduate specialization and days attended of targeted pain courses, with the latter being the most influential variable.

CONCLUSIONS

Italian PTs now dispose of two tools to assess their basic knowledge related to pain science. Our study also showed that pain knowledge among Italian PTs needs improvement, especially considering recent biopsychosocial approaches to pain.

Pain Neuroscience Education Following Arthroscopic Rotator Cuff Repair for Patients With Rotator Cuff Tears: A Double-Blind Randomized Controlled Clinical Trial

OBJECTIVE

This trial examines the efficacy of the pain neuroscience education on clinical outcomes in patients with arthroscopic rotator cuff repair.

DESIGN

A total of 36 participants undergoing arthroscopic rotator cuff repair were assigned to either the experimental group ( n = 18) or control group ( n = 18) in this randomized study. A 6-wk-long conventional physiotherapy program was administered for both groups. In addition, a pain neuroscience education protocol was administered for the experimental group for a whole period of 6 wks (1 session/week, 15-60 mins per session). The primary outcomes were to compare pretreatment and posttreatment scores of the experimental versus control groups on the pain and disability. Our secondary outcomes included the comparisons of scores on the catastrophizing, anxiety, depression, kinesiophobia, and quality of life. The participants were assessed both at baseline and posttreatment.

RESULTS

The improvement in pain catastrophizing, anxiety, depression, and kinesiophobia was greater in the experimental group ( P < 0.05). The improvement was similar in both groups in terms of the rest of outcome measures.

CONCLUSIONS

This study showed that the pain neuroscience education improved only psychological aspects of the chronic pain in arthroscopic rotator cuff repair. Therefore, adding pain neuroscience education to the conventional program might be useful to improve pain catastrophizing, anxiety, depression, and kinesiophobia in patients with arthroscopic rotator cuff repair.

Therapeutic Patient Education as Part of the Physiotherapy Management of Adults with Headache: A Scoping Review

PURPOSE OF REVIEW

Physiotherapy interventions for headache mostly include exercise and manual therapy. Yet, the complex nature of headache, sometimes characterized by symptoms of facilitated central pain mechanisms, demands an individualized approach in which therapeutic patient education could be supportive. This scoping review aimed to summarize the position of therapeutic patient education within the physiotherapy management of adults with headache. PubMed, EMBASE, Web of Science, and Scopus were searched. The search-query comprised terminology relating to "headache", "education", and "physiotherapy". Eligibility criteria were: adults with headache, interventions including education within the domain of physiotherapy, reviews, clinical trials, cohort, case report, case-control studies.

RECENT FINDINGS

Eleven publications were included from the 281 retrieved publications. These publications were clinical trials (n = 4), reviews (n = 4), case-reports (n = 2), and a guideline (n = 1). Type of headaches studied were migraine (n = 3), post-traumatic headache (n = 2), tension-type headache (n = 2), cervicogenic headache (n = 1), primary headaches (n = 1), chronic daily headache (n = 1), and mixed migraine-cervicogenic headache (n = 1). Education seems an umbrella-term for postural education, lifestyle advice, and pain education. Three themes emerged across the publications: handling headache triggers (migraine, post-traumatic headache), promoting active lifestyle (post-traumatic headache, chronic daily headache, migraine), evaluating posture (post-traumatic headache, chronic daily headache, tension-type headache, cervicogenic headache). All publications recommended education in the management of headache. Only one (of the 11 included) publication described the educational program and determined its efficacy. Based on this scoping review, therapeutic patient education seems supported within physiotherapy management of headache. However, it is unclear how such education is tailored to the specific needs of the individual, the headache subtype, or when it should be added to physiotherapy management of headache.

Quality of life and level of physical activity of individuals with temporomandibular disorders with and without otological symptoms: Secondary analysis of a cross-sectional study

BACKGROUND AND PURPOSE

Otological symptoms (OS) are highly prevalent in individuals with temporomandibular disorders (TMD). Individuals with TMD and OS have more neck disability and decreased deep neck muscles endurance when compared to individuals without OS. However, no studies have evaluated whether OS is associated with lower Quality of Life (QoL) and worse levels of physical activity. This study aimed to evaluate the QoL and level of physical activity of individuals with TMD with and without OS.

METHODS

In this cross-sectional study, 62 individuals with TMD were allocated into 2 groups: TMD with OS (n = 36) or TMD without OS (n = 26). Self-reported complaints of dizziness, vertigo, tinnitus, earache, ear fullness, or hypoacusis were considered as OS. QoL was assessed with the WHOQOL-Bref and physical activity with the IPAQ-SF. Independent t-test and chi-squared test were used for analysis between-groups. Effect sizes were reported using Cohen's d. A Pearson correlation was used to compare the number of OS and QoL scores. A significance level of p < 0.05% and 95% confidence intervals were considered statistically significant.

RESULTS

The total generic scores for QoL were not different between-groups (p = 0.076), but individuals with TMD with OS had lower satisfaction (p = 0.015; d: 0.63) and physical domain (p = 0.015; d: 0.64) scores with a moderate effect size. In TMD with OS, 69.4% of individuals were irregularly active and 50% for the TMD without OS, with no statistical significance (p > 0.05). The number of OSs was inversely and weakly associated with the QoL total score.

CONCLUSION

Individuals with TMD and OS are associated with worsened QoL (physical domain and satisfaction) when compared to individuals with TMD without OS. The higher the number of OS, the worse the QoL score. Individuals with TMD with and without OS had similar levels of physical activity, but a high prevalence of irregularly active and sedentary individuals within TMD diagnosed population was found.

Cross-sectional experimental assessment of pain modulation as part of multidimensional profiling of people with cervicogenic headache: protocol for a feasibility study

BACKGROUND

An endogenous pain modulation profile, reflecting antinociceptive and pronociceptive mechanisms, may help to direct management by targeting the involved pain mechanism. For individuals with cervicogenic headache (CeH), the characteristics of such profiles were never investigated. However, the individual nature of experiencing pain demands profiling within a multidimensional framework including psychosocial lifestyle characteristics. The objective of the current protocol is to assess the pain modulation profile, which includes psychosocial lifestyle characteristics among people with CeH.

METHODS AND ANALYSIS

A protocol is described to map pain modulation profiles in people with CeH. A cross-sectional non-randomised experimental design will be used to assess feasibility of mapping these profiles. The pain modulation profile is composed based on results on the Depression, Anxiety, Stress Scale, Pittsburgh Sleep Quality Index, Headache Impact Test and on responses to temporal summation of pain (pinprick), conditioned pain modulation and widespread hyperalgesia (mechanical pressure pain threshold and cuff algometry). Primary analyses will report results relating to outcomes on feasibility. Secondary analyses will involve an analysis of proportions (%) of the different psychosocial lifestyle profiles and pain profiles.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethics Committee Research UZ/KU Leuven (Registration number B3222024001434) on 30 May 2024. Results will be published in peer-reviewed journals, at scientific conferences and, through press releases. Protocol V.3. protocol date: 3 June 2024.

Evidence for the role of multidisciplinary team care in people with pelvic pain and endometriosis: A systematic review

BACKGROUND

Endometriosis is a chronic, inflammatory condition characterised by the presence of endometrial-like tissue outside the uterine cavity. Given the multi-system nature of the disease and the potential for significant negative impact on quality of life, there has been a long-standing recognition of the need for multidisciplinary care for people with endometriosis. However, there is paucity to the data supporting this approach, and much of the evidence is anecdotal.

AIM

This systematic review aims to describe recent evidence-based models and patient-centred perspectives of multidisciplinary care for endometriosis, to improve understanding of the role of an integrated, multidisciplinary team in effectively addressing patients' care needs.

MATERIALS AND METHODS

PubMed, Medline, Embase and Web of Science were searched for relevant articles published between 1 January 2010 to 7 July 2022.

RESULTS

Nineteen studies met the inclusion and exclusion criteria and pinpointed a multidisciplinary team consisting of gynaecologists, pain specialists, nurses, physiotherapists, psychologists, sex therapists, nutritionists, complementary medicine practitioners, and social workers to be most commonly utilised in holistically managing people with pelvic pain and endometriosis. Furthermore, patient perspectives on care highlighted the need for reliable information, respect and validation of experiences or preferences, discussion of long-term treatment plans and social and emotional supports.

CONCLUSION

The trend for multidisciplinary team care for people with endometriosis is growing. Further consumer-driven clinical studies and outcome evaluations need to be conducted to determine the effect of multidisciplinary care on improvements to quality of life for people living with endometriosis and or pelvic pain.

Effects of pain education on disability, pain, quality of life, and self-efficacy in chronic low back pain: A randomized controlled trial

BACKGROUND

Low back pain stands as a prevalent contributor to pain-related disability on a global scale. In addressing chronic low back pain (CLBP), there is a growing emphasis on incorporating psychological strategies into the management process. Among these, pain education interventions strive to reshape pain beliefs and mitigate the perceived threat of pain. This randomized controlled trial sought to assess the effects of pain education on various aspects, including pain levels, disability, quality of life, self-efficacy, and prognostic characteristics in individuals grappling with CLBP.

METHODS

The clinical trial, retrospectively registered with the Clinical Trials Registry of India (CTRI/2021/08/035963), employed a two-arm parallel randomized design. Ninety-two participants with CLBP were randomly assigned to either the standard physiotherapy care with a pain education program or the control group. Both groups underwent a 6-week intervention. Assessment of pain intensity (using NPRS), disability (using RMDQ), self-efficacy (using the general self-efficacy scale), and well-being (using WHO 5I) occurred both before and after the 6-week study intervention.

FINDINGS

Post-intervention score comparisons between the groups revealed that the pain education intervention led to a significant reduction in disability compared to the usual standard care at 6 weeks (mean difference 8.2, p < 0.001, effect size Cohen d = 0.75), a decrease in pain intensity (mean difference 3.5, p < 0.001, effect size Cohen d = 0.82), and an improvement in the well-being index (mean difference 13.7, p < 0.001, effect size Cohen d = 0.58).

CONCLUSION

The findings suggest that integrating a pain education program enhances the therapeutic benefits of standard physiotherapy care for individuals dealing with chronic LBP. In conclusion, the clinical benefits of pain education become apparent when delivered in conjunction with standard care physiotherapy during the management of chronic low back pain.

Effects of Pain Neuroscience Education and Physiotherapy on Chronic Low Back Pain, Fear of Movement and Functional Status: A Randomised Pilot Study

Background: Chronic non-specific low back pain is a non-harmous condition often found in the general population. It is one of the most significant disabilities and needs different treatment modalities. This study investigates the effects of pain neuroscience education and physiotherapy on pain intensity, fear of movement and functional status in a Lithuanian cohort with non-specific low back pain. Methods: The study was performed at the primary health care unit in Kaunas, Lithuania. The key inclusion criterion was persistent non-specific low back pain longer than three months and which affects daily life functions. Thirty participants (mean 33.47, SD 4.38 years age, 70% women) were randomised into two training groups with and without pain neuroscience education (for a total of 60 min of teaching). Physiotherapy was performed twice per week during 45 min/session for a period of 10 weeks with exercises which strengthen, stabilize, and stretch the spinal cord muscles. Outcomes included pain intensity, kinesiophobia and disability and these were measured by self-scored questionnaires (numeric rating scale, Tampa scale for kinesiophobia-11, Oswestry disability index and the Roland-Morris questionnaire, respectively). Results: The results indicate that both groups improved in the measured outcomes, with the only difference between them being a better improvement in kinesiophobia in the group receiving physiotherapy and pain neuroscience education. Conclusions: The results of this study confirm that a relatively short intervention of pain neuroscience education enhances the effects of physiotherapy and should be implemented in clinical practice.

Mobile health technologies for workers' health and wellbeing: A systematic search of mHealth applications in Brazil

BACKGROUND

Inadequate working conditions and sedentary work can exert a negative impact on workers' health and wellbeing, leading to musculoskeletal disorders and disability. Mobile health (mHealth) applications (apps) have high potential for the self-management of workers' health.

OBJECTIVE

To identify mHealth apps aimed at promoting workers' health and wellbeing available in Brazilian online stores and assess these apps in terms of engagement, functionality, aesthetics and information quality.

METHODS

A systematic search for apps was conducted in the Brazilian online App Store and Play Store in December 2022. Only smartphone apps in Brazilian Portuguese directed at workers' health were assessed. The appraisal of the quality of the applications was performed using the Mobile App Rating Scale (MARS).

RESULTS

Among the 3449 mHealth apps found, ten were eligible for inclusion. The mean overall score was 3.15 ± 0.91 on a scale of 1-5. The lowest score was found for the "credibility" item. Exercises and breaks were the most frequent strategies. Most apps provided low-quality information from questionable sources and therefore received a mean score of 2.1 ± 1.5 on the MARS information subscale.

CONCLUSION

Ten relevant mHealth apps were eligible for inclusion. The mHealth apps for the promotion of workers' health and wellbeing currently available in Brazil exhibited moderate quality and limited functionality.

Development of an interdisciplinary training program about chronic pain management with a cognitive behavioural approach for healthcare professionals: part of a hybrid effectiveness-implementation study

BACKGROUND

Many applied postgraduate pain training programs are monodisciplinary, whereas interdisciplinary training programs potentially improve interdisciplinary collaboration, which is favourable for managing patients with chronic pain. However, limited research exists on the development and impact of interdisciplinary training programs, particularly in the context of chronic pain.

METHODS

This study aimed to describe the development and implementation of an interdisciplinary training program regarding the management of patients with chronic pain, which is part of a type 1 hybrid effectiveness-implementation study. The targeted groups included medical doctors, nurses, psychologists, physiotherapists, occupational therapists, dentists and pharmacists. An interdisciplinary expert panel was organised to provide its perception of the importance of formulated competencies for integrating biopsychosocial pain management with a cognitive behavioural approach into clinical practice. They were also asked to provide their perception of the extent to which healthcare professionals already possess the competencies in their clinical practice. Additionally, the expert panel was asked to formulate the barriers and needs relating to training content and the implementation of biopsychosocial chronic pain management with a cognitive behavioural approach in clinical practice, which was complemented with a literature search. This was used to develop and adapt the training program to the barriers and needs of stakeholders.

RESULTS

The interdisciplinary expert panel considered the competencies as very important. Additionally, they perceived a relatively low level of healthcare professionals' possession of the competencies in their clinical practice. A wide variety of barriers and needs for stakeholders were formulated and organized within the Theoretical Domain Framework linked to the COM-B domains; 'capability', 'opportunity', and 'motivation'. The developed interdisciplinary training program, including two workshops of seven hours each and two e-learning modules, aimed to improve HCP's competencies for integrating biopsychosocial chronic pain management with a cognitive behavioural approach into clinical practice.

CONCLUSION

We designed an interdisciplinary training program, based on formulated barriers regarding the management of patients with chronic pain that can be used as a foundation for developing and enhancing the quality of future training programs.

Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis

Multiple sclerosis is a chronic inflammatory disease that affects the central nervous system and can cause various types of pain including ongoing extremity pain, Lhermitte's phenomenon, trigeminal neuralgia, and mixed pain. Neuropathic pain is a major concern for individuals with multiple sclerosis as it is directly linked to myelin damage in the central nervous system and the management of neuropathic pain in multiple sclerosis is challenging as the options available have limited efficacy and can cause unpleasant side effects. The literature search was conducted across two databases, PubMed, and Google Scholar. Eligible studies included clinical trials, observational studies, meta-analyses, systematic reviews, and narrative reviews. The objective of this article is to provide an overview of literature on pharmacological and non-pharmacological strategies employed in the management of neuropathic pain in multiple sclerosis. Pharmacological options include cannabinoids, muscle relaxants (tizanidine, baclofen, dantrolene), anticonvulsants (benzodiazepines, gabapentin, phenytoin, carbamazepine, lamotrigine), antidepressants (duloxetine, venlafaxine, tricyclic antidepressants), opioids (naltrexone), and botulinum toxin variants, which have evidence from various clinical trials. Non-pharmacological approaches for trigeminal neuralgia may include neurosurgical methods. Non-invasive methods, physical therapy, and psychotherapy (cognitive behavioral therapy, acceptance and commitment therapy and mindfulness-based stress reduction) may be recommended for patients with neuropathic pain in multiple sclerosis. The choice of treatment depends on the severity and type of pain as well as other factors, such as patient preferences and comorbidities. There is a pressing need for healthcare professionals and researchers to prioritize the development of better strategies for managing multiple sclerosis-induced neuropathic pain.

Psychological/behavioral interventions for emerging adults with chronic pain

Background

Emerging adults, of whom significant numbers report chronic pain, are characterized as having unique needs and challenges. Psychological/behavioral treatments found to be beneficial for reducing pain outcomes in children and adults are understudied in emerging adults. Following a systematic review of the literature, our objective is to report on quantitative studies of psychological/behavioral interventions for chronic pain in emerging adults.

Method

We conducted a search of six databases (Cochrane Central Register of Controlled Trials, Google Scholar, ProQuest, PsycINFO, PubMed, and Web of Science) and reference sections in dissertations and systematic reviews to 4/29/2023. Keywords and phrases were search term combinations of "chronic/persistent pain", "emerging/young adults," and "intervention/treatment" using Boolean logic.

Results

Our review resulted in identifying 37 articles, of which 2 duplicates were removed, and 31 were further excluded by a screening process based on various inclusionary and exclusionary criteria. The search yielded four studies on psychological/behavioral interventions (yoga, acceptance and commitment therapy and relaxation), all of which positively affected the pain experience and/or pain-related outcomes. These studies presented issues in design such as not being blinded or randomized, having a small sample size, and potential confounds that were not reported or examined.

Discussion

The low number of studies reveals a large gap in the literature and is a call-to-action to further expand our understanding of effective and safer psychological/behavioral therapies for chronic pain in emerging adults. Successful pain management during this developmental phase may help young adults achieve positive trajectories for personal, occupational, relational, and health aspects of their lives.

Facilitators and barriers to the implementation of pain neuroscience education in the current Lebanese physical therapist health care approach: a qualitative study

PURPOSE

The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability.

METHOD

A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis.

RESULTS

Two topics were generated and constructed by the researchers: (1) "barriers to the implementation of pain neuroscience education, with subthemes including (a) "current health care approach," (b) "basic curriculum and continuing education," (c) "patients' barriers"; (2) "facilitators to the implementation of pain neuroscience education," with subthemes containing (a) "interest in the BPS model, (b) "therapeutic alliance," and (c) "motivation for future training on BPS approach."

CONCLUSION

The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach.IMPLICATIONS FOR REHABILITATIONThe exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management.The most important barriers were the dominant characteristic of the Lebanese physical therapist's health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective.

Pain medication misuse in the South African spinal cord injury context

Background

Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce.

Aim

To determine PMM and the associated factors in PWSCI.

Setting

Homes of community-dwelling manual wheelchair users with SCI in South Africa.

Methods

Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance.

Results

Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively).

Conclusion

Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose.

Contribution

This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.

Therapeutic management of the painful nerve: a narrative review of common rehabilitation interventions

There are many ways that rehabilitation therapists, including occupational and physical therapists, treat nerve-related pain. Commonly used interventions include neurodynamic treatment, pain neuroscience education, desensitization, exercise, physical agent modalities, mirror box therapy, and Kinesio taping. Despite common practice and anecdotal support, it can be challenging to determine the appropriate intervention for each patient. In this article, each of these treatment approaches is discussed, including indicated pain phenotypes and diagnoses, timing, efficacy, mechanism, contraindications, and limitations.

Health literacy and pain neuroscience education in an interdisciplinary pain management programme: a qualitative study of patient perspectives

Introduction

Pain neuroscience education is part of interdisciplinary pain management programs (IPMPs). To date, the role of health literacy on patients' understanding of pain neuroscience education has not sufficiently been examined.

Objectives

Drawing on interviews with patients with diverse levels of health literacy, this article explores patient perspectives on pain neuroscience education.

Methods

Purposively sampled patients from an IPMP were interviewed twice (waiting list and after 4 weeks). A directed qualitative content analysis was performed with the Integrated Conceptual Model of Health Literacy as an analytic framework.

Results

Thirteen patients with chronic musculoskeletal pain were interviewed: 4 men and 9 women aged from 21 to 77 years with diverse educational and mostly low health literacy. One participant dropped out after baseline. Some participants gained access to health information actively; others relied on the expertise of their healthcare providers. Most participants did not seem to receive the information in the pain neuroscience education as intended, experienced difficulties with understanding the message, negatively appraised the information, and were not able to apply this in their daily lives. Health literacy levels likely played a role in this.

Conclusions

Pain neuroscience education tailored to patients' health literacy levels, information needs, and learning strategies is needed.

Classification of pain intensity with the pain beliefs and perceptions inventory (PBPI) and the pain catastrophizing scales (PCS)

PURPOSE

The pain beliefs and perceptions inventory (PBPI) and the pain catastrophizing scales (PCS) characterize beliefs or distress dimensions of the pain experience. It is relatively unknown, however, to what degree the PBPI and the PCS are well suited to classifying pain intensity.

METHODS

This study applied a receiver operating characteristic (ROC) approach to these instruments against the criterion of a visual analogue scale (VAS) of pain intensity with fibromyalgia and chronic back pain patients (n = 419).

RESULTS

The largest areas under the curve (AUC) were moderate and limited to the constancy subscale (71%) and total score (70%) of the PBPI and to the helplessness subscale (75%) and total score (72%) of the PCS. The best cut-off scores for the PBPI and PCS were better off at detecting true negatives than true positives, with larger specificity than sensitivity values.

CONCLUSION

Whereas, the PBPI and PCS are certainly useful instruments to evaluate diverse pain experiences, they may be inappropriate to classify intensity. The PCS performs marginally better than the PBPI for classifying pain intensity.

The effect of patient-led goal setting approach combined with pain neuroscience education or manual therapy in patients with chronic low back pain: protocol for a parallel-group randomized controlled trial

BACKGROUND

Low back pain (LBP) is a multifactorial disorder associated with a high range of physical and psychological burden on the society. Patient-led goal-setting approach has shown potential effects for improving chronic LBP. However, there are few studies investigating its benefits when combined with a supplementary intervention. This paper, therefore, presents a protocol for a randomized control trial (RCT) to study the effect of a patient-led goal-setting approach combined with pain neuroscience education (PNE) or manual therapy (MT) among patients with chronic LBP.

METHODS

A total of 105 patients suffering from chronic LBP will be recruited via flyers displayed in hospitals and universities, and those meeting the study's criteria will randomly be allocated into a patient-led goal-setting approach with the PNE group, and/or with the MT program group, and/or a control group. The primary outcomes will be the pain intensity and disability. Secondary outcomes include quality of life, depression, anxiety and stress, fear avoidance beliefs, kinesophobia, pain self-efficacy, catastrophic pain, neurophysiology of pain, and central sensitivity. All the outcomes will be recorded at 2 months after receiving the treatment as post-test sessions and after 4 and 12 months as follow-up sessions. The Ethics Committee in Research at Sport Sciences Research Institute of Iran approved the protocol of this trial (IR.SSRC.REC.1400.084). Written, informed consent to participate will be obtained from all participants. All methods will be conducted in accordance with the ethical standards of the Declaration of Helsinki and in accordance with relevant guidelines and regulations. We will disseminate the findings through peer-reviewed publications and conference presentations and send them to the participants.

DISCUSSION

This trial will demonstrate which supplementary intervention can better improve the impact of a patient-led goal-setting approach to treat LBP. If successful, the results will potentially have implications for athletic trainers, physiotherapists, and health care practitioners.

TRIAL REGISTRATION

IRCT Iranian Registry of Clinical Trials IRCT20210927052616N1. Registered on November 03, 2021.

Physiotherapy management of nociplastic pain: A Delphi study of Italian specialists

BACKGROUND AND PURPOSE

Nociplastic pain due to central sensitization (CS) is common in people suffering from chronic pain, but no clinical practice guideline is available in rehabilitative settings for patients' management. The aim of this study is to achieve expert consensus on physiotherapy competencies in the management of people with nociplastic pain and suspected CS mechanisms.

METHODS

A web-based Delphi process was employed. Experts in the rehabilitation field were recruited following pre-defined eligibility criteria. Following completion of three Delphi rounds, the final list of competencies was generated.

RESULTS

In all, 23 participants were recruited. They all completed Round 1 (23/23, 100%), twenty Round 2 and Round 3 (20/23, 87%). Following Round 1, seven areas were identified by the panel as crucial for CS physiotherapy management; 19 competencies out of 40 reached the consensus between experts, and nine additional competencies were added to Round 2 following literary review. Round 2 identified the agreement for all the 29 competencies. During Round 3, all the experts confirmed the final list generated through the consensus process.

DISCUSSION

An agreement between experts was found for the final list of competencies that a physiotherapist should implement every time it approaches people with suspected CS mechanisms. Further research is needed to support the clinical utility of our findings and their applicability in daily practice.

Pain neuroscience education in persistent painful tendinopathies: A scoping review from the Tendon PNE Network

OBJECTIVE

to conduct and report a scoping review of the available evidence of the effects and content of pain neuroscience education for patients with persistent painful tendinopathies.

METHODS

PubMed, Embase, Web of Science, CINAHL, SPORTDiscus, and grey literature databases were searched from database inception to May 2022. Randomised and non-randomised controlled trials, non-controlled clinical trials, cohort studies, case series, case studies including people with persistent painful tendinopathy aged ≥18 years, a pain education intervention, and in English were included. Studies were excluded if they were cross-sectional studies, reviews, editorials, abstracts, or full-text not available or if included heterogeneous study cohorts, patients with tendon rupture, or patients with systemic diseases.

RESULTS

five studies (n = 164) were included. Pain neuroscience education entailed face-to-face discussion sessions or educational materials including videos, brochures, paper drawings, and review questions. All studies used pain neuroscience education in conjunction with other interventions, obtaining significant benefits in outcomes related to pain, physical performance, or self-reported function, among others.

CONCLUSIONS

The application of pain neuroscience education in conjunction with other interventions seemed to improve several outcomes. However, considering the current knowledge about tendon pain and the scarcity of well-designed trials studying pain neuroscience education in tendinopathy, additional research is needed.

The Biology of Chronic Pain and Its Implications for Pain Neuroscience Education: State of the Art

Pain is an individualized experience for the person suffering from chronic pain. Significant strides have been made in the last few decades in understanding various biological changes that coincide with chronic pain. This state-of-the-art overview looks at the current evidence related to the biology of chronic pain and the implications these findings have on the delivery of pain neuroscience education (PNE). The paper summarizes the various (epi)genetic, neural, endocrine, and immune factors discovered and explored in the scientific literature concerning chronic pain. Each of these biological factors has various implications for the content and delivery of PNE. We discuss the future directions these biological factors have for the clinical implementation of PNE by linking the importance of behavior change, optimizing the learning environment, and using an individualized multimodal treatment approach with PNE. In addition, future directions for research of PNE based on these biological factors are provided with importance placed on individualized patient-centered care and how PNE can be used with traditional modes of care and growing trends with other care methods. PNE was originally and continues to be rooted in understanding chronic pain biology and how that understanding can improve patient care and outcomes.

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.

Consideration of Psychosocial Factors in Acute Low Back Pain by Physical Therapists

Clinical guidelines consistently recommend screening psychosocial (PS) factors in patients with low back pain (LBP), regardless of its mechanical nature, as recognized contributors to pain chronicity. However, the ability of physiotherapists (PTs) in identifying these factors remains controversial. This study aimed to assess the current identification of psychosocial risk factors by physical therapists (PTs) and which characteristics of PTs are associated with the identification of the main risk for chronicity (physical or psychosocial). A cross-sectional descriptive study surveying Spanish PTs in public and private health services was conducted, including questions on PT characteristics and three low back pain (LBP) patient vignettes with different biopsychosocial (BPS) clinical presentations. From 484 respondents, the majority of PTs agreed regarding the main risk for chronicity for each vignette (PS 95.7% for vignette A, PS and physical 83.5% for vignette B and PS 66% for vignette C). Female PTs were more likely to rate psychosocial compared with males (p < 0.05). PTs with higher levels of social and emotional intelligence (both, p < 0.05) were more likely to identify the main risk for chronicity. However, only gender and social information processing for vignette A (p = 0.024) and emotional clarity for vignette B (p = 0.006) were able to predict the identification of psychosocial and physical risk, respectively. The main risk for chronicity was correctly identified by a large majority of PTs through patient vignettes. Gender, social and emotional intelligence played a relevant role in the recognition of psychosocial risk and biopsychosocial factors.

Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain

INTRODUCTION

Factors that motivate musculoskeletal patients to pursue an intensive, lifestyle medicine-based approach to care are poorly understood.

OBJECTIVE

To determine whether, compared to patients seeking musculoskeletal care through traditional pathways, patients who choose an intensive lifestyle medicine program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and/or more biopsychosocial comorbidities.

DESIGN

Cross-sectional analysis of existing medical records from 2018 to 2021.

SETTING

Orthopedic department of one academic medical center.

PATIENTS

Fifty consecutive patients who enrolled in an intensive lifestyle medicine program to address a musculoskeletal condition. Comparison groups were the following: (1) 100 patients who presented for standard nonoperative musculoskeletal care, and (2) 100 patients who presented for operative evaluation by an orthopedic surgeon and qualified for joint arthroplasty.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Primary outcomes were age-adjusted, between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS) physical and psychological health measures. Secondary outcomes were between-group differences in sociodemographic and medical history characteristics.

RESULTS

Patients who enrolled in the intensive lifestyle medicine program were more racially diverse (non-White race: lifestyle cohort 34% vs. comparison cohorts 16%-18%, p ≤ .029) and had a higher prevalence of obesity and diabetes than both comparison groups (mean body mass index: lifestyle cohort 37.6 kg/m2 vs. comparison cohorts 29.3-32.0, p < .001; diabetes prevalence: lifestyle cohort 32% vs. comparison cohorts 12%-16%, p ≤ .024). Compared to standard nonoperative patients, there were no clear between-group differences in PROMIS physical or psychological health scores. Compared to standard operative evaluation patients, patients in the lifestyle program reported worse anxiety but less pain interference (PROMIS Anxiety: B = 3.8 points [95% confidence interval, 0.1 to 7.4], p = .041; Pain interference: B = -3.6 [-6.0 to -1.2], p = .004).

CONCLUSIONS

Compared to musculoskeletal patients who sought care through traditional pathways, patients who chose an intensive lifestyle medicine pathway had a higher prevalence of metabolic comorbidities, but there was substantial overlap in patients' physical, psychological, and sociodemographic characteristics.

Pain neuroscience education, blended exercises and booster sessions as an effective therapy for pain, functional and psychological factors in patients with knee osteoarthritis: a study protocol for a single-blind randomised controlled trial with 22 factorial design during 6-month follow-up

INTRODUCTION

This study aims to investigate whether a pain neuroscience education (PNE) combined with a blended exercises programme including aerobic, resistance, neuromuscular, breathing, stretching and balance exercises and diet education provides greater pain relief and improvement in functional and psychological factors than PNE and blended exercises alone and whether 'exercise booster sessions (EBS)' approach may improve outcomes and increase adherence in patients with knee osteoarthritis (KOA) (by telerehabilitation (TR)).

METHODS AND ANALYSIS

In this single-blind randomised controlled trial, 129 patients (both genders; age >40) diagnosed with KOA will be randomly assigned to one of the 22 treatment combinations as: (1) blended exercises alone (36 sessions over 12 weeks), (2) PNE alone (three sessions over 2 weeks), (3) combination of PNE with blended exercises (exercise three times a week for 12 weeks combined with three sessions of PNE) and (4) a control group. Outcome assessors will be blinded towards group allocation. The primary outcome variables are the visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis index in knee osteoarthritis (WOMAC) score. Secondary outcomes include Pain Self-Efficacy Questionnaire (PSEQ), Depression, Anxiety and Stress Scale (DASS), Tampa Scale for Kinesiophobia (TSK), Short Falls Efficacy Scale International (FES-I), Pain Catastrophising Scale (PCS), Short Form Health Survey (SF-12) and Exercise Adherence Rating Scale (EARS), 30 s sit-to-stand test (30CST), Timed Up and Go (TUG), lower limbs' muscle strength and lower limb joints' active range of motion (AROM) will be performed at baseline, 3 and 6 months' postinterventions. The primary and secondary outcomes will assess at baseline, 3 months and 6 months postinterventions.The findings will be useful in establishing an effective treatment strategy covering multiple aspects behind KOA. The study protocol is conducted in clinical settings, thereby enhancing the possibility of future implementation of the treatments in the healthcare systems and self-care management. Results in comparison between groups will help to clarify the most effective of mixed-method TR (blended exercise, PNE, EBS with diet education) on more improvement in pain, functional and psychological factors in patients with KOA. This study will combine some of the most critical interventions, to be able to introduce a 'gold standard therapy' in the treatment of KOA.

ETHICS AND DISSEMINATION

The trial has been approved by the ethics committee for research involving human subjects of the Sport Sciences Research Institute of Iran (IR.SSRC.REC.1401.021). The study findings will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

IRCTID: IRCT20220510054814N1.

Comprehensive assessment and classification of upper and lower limb pain in athletes: a scoping review

BACKGROUND

Upper and lower limb (peripheral) pain is prevalent in athletes. Contemporary research prioritises multidimensional pain assessment and classification. This study aims to review comprehensive athlete pain assessment practices against the reference standard (International Olympic Committee, IOC Athlete Pain framework), identifying trends and highlighting gaps.

METHODS AND ANALYSIS

Six databases were searched using a comprehensive search strategy. This review followed the Joanna Briggs Institute standardised methodology for scoping reviews and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Title and abstract, full-text screening and data charting were completed by two independent reviewers.

INCLUSION CRITERIA

Original research, systematic reviews and clinical practice guidelines reporting assessment or classification of pain in athletes of any age with chronic or acute peripheral pain in English on human participants from database inception.

RESULTS

470 studies with 175 different pain assessment tools were mapped against the IOC Athlete Pain Framework. Papers included tools from neurophysiological (470/100%), biomechanical (425/90%), affective (103/22%), cognitive (59/13%) and socioenvironmental (182/39%) domains. Pain classification was included in 108 studies (23%). 4 studies (0.85%) defined pain. Athletes with physical disability were included in 13 (3%) studies and no studies included athletes with intellectual disabilities. Socioeconomic factors were addressed in 29 (6%) studies.

DISCUSSION

Neurophysiological and biomechanical domains are frequently addressed. Affective, socioenvironmental and cognitive tools are under-represented. Potential tools for use by researchers and clinicians are highlighted. Defining and classifying pain and determining predominant pain mechanisms is needed in both research and clinical practice. More work on underrepresented populations is needed.

CONCLUSION

This review informs researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and highlights future priorities.