Integrating Motivational Interviewing in Pain Neuroscience Education for People With Chronic Pain: A Practical Guide for Clinicians

The effect of mindfulness and motivational interviewing along with neuromuscular exercises on pain, function, and balance of women affected by knee osteoarthritis: a rater-blinded randomized controlled clinical trial

PURPOSE

This study aimed to evaluate the effect of motivational interviewing (MI) and mindfulness (MF) added to neuromuscular (NM) exercises on improving pain, function, balance, and quality of life in patients with knee osteoarthritis (KOA).

METHODS

This randomized clinical trial was conducted on sixty patients who were randomly assigned to the MI + NM, MF + NM, and NM groups. The groups received four training sessions for six weeks. Physical function with Western Ontario and McMaster Universities Arthritis Index timed up and go, going up and down eight stairs, pain with visual analogue scale, quality of life with SF36, and balance with Biodex were evaluated before and after interventions.

RESULTS

Within-group comparisons showed that NM + MI, NM + MF, and NM groups experienced significant improvement in all factors after six-week (p < 0.05). However, between groups, comparisons in the post-test revealed that the MI + NM group had a more significant effect on pain, function, and static balance than the MF + NM group. Nevertheless, the MF + NM group improved the quality of life better than the MI + NM and NM groups (p < 0.05).

CONCLUSION

Adding psychological interventions to physical exercises had a better effect on improving the symptoms of patients. Additionally, the MI showed more effectiveness in improving the symptoms of patients.

Novel motivational interviewing-based intervention improves engagement in physical activity and readiness to change among adolescents with chronic pain

INTRODUCTION

Engaging adolescents with chronic pain in physical activities is challenging. Motivational interviewing (MI) combined with activity promotion may encourage teens to make behavioural changes. This research aimed to assess the feasibility and acceptability of our MI-based physical activity promotion programme, the M3 training.

METHODS

In our exploratory study with 35 adolescent-parent dyads, we evaluated the feasibility by enrolment, drop-out and retention rates. Acceptability of the M3 training was examined by adherence rates and participation experiences through open-ended questions. We also assessed changes in pain self-efficacy and readiness to change after the M3 training intervention.

RESULTS

The M3 training was feasible with an adequate enrolment (77.8%) and retention (85.7%) rate. Both teens and parents found the M3 training acceptable and considered exercise and physical activity the most helpful elements of the programme (36% and 37%, respectively). While self-efficacy remained unchanged, we identified a significant increase in the readiness to change for adolescents and parents.

CONCLUSION

M3 training improved physical activity engagement while prioritising adolescents' autonomy. Furthermore, it appears to be a clinically relevant approach and could result in a positive shift in readiness to change within a shorter timeframe.

PATIENT OR PUBLIC CONTRIBUTION

The preliminary version of the M3 training was reviewed and commented upon by the public (adolescents and adults). Adolescents who participated in this study were designing their own movement programme, considering their lived experiences. Participants' feedback was used to create the online version of the M3 training (which will be published elsewhere).

Empowering patients with persistent pain: The potential of cognitive functional therapy in interdisciplinary care: A single-case experimental design

INTRODUCTION AND PURPOSE

Persistent musculoskeletal pain (PMP) is multifactorial and causes both societal and financial burdens. Integration of multifactorial management in patients with PMP remains challenging. A single-case experimental design was performed on three patients suffering from high impact PMP (lumbar spine, shoulder and knee) to i) assess the potential for Cognitive Functional Therapy (CFT) in interdisciplinary care, ii) describe in detail the clinical journey patients experienced during the intervention, and iii) evaluate the changes and associations in relation to the outcome measures of pain, disability, maladaptive movement behavior, subjective overall improvement, health related quality of life and work status. These were monitored over one year, at the end of each of the six intervention modules.

RESULTS

After introducing the intervention systematic changes were seen, with medium to large changes (Non-overlap of All Pairs 0.67-1) for all outcome measures. Associations between changes of the outcome measures were large (r ≥ 0.50) and changes occurred concurrently. Minimally clinically important difference thresholds were exceeded for all outcome measures and two patients achieved relevant improvements related to work reintegration.

DISCUSSION

The positive results of this study are comparable with recent CFT studies. However, the difference regarding the number of sessions and duration of the intervention is evident. The length of the intervention in this study seemed to enable continuous significant improvements up until 12 months post onset and follow-up.

CONCLUSION

CFT in interdisciplinary care was effective for all measures. The detailed descriptions of the clinical processes aim to improve clinical care.

Effects of Manual Therapy Plus Pain Neuroscience Education with Integrated Motivational Interviewing in Individuals with Chronic Non-Specific Low Back Pain: A Randomized Clinical Trial Study

Background and Objectives: Chronic non-specific low back pain (CNLBP) persists beyond 12 weeks. Manual therapy recommended for CNLBP demonstrates short-term efficacy. Pain Neuroscience Education (PNE) teaches patients to modify pain perception through explanations, metaphors, and examples, targeting brain re-education. Motivational Interviewing (MI) enhances motivation for behavioral change, steering patients away from ambivalence and uncertainty. These approaches collectively address the multifaceted nature of CNLBP for effective management. The aim of this study was to investigate a manual therapy intervention combined with PNE with MI on pain, pressure pain threshold (PPT), disability, kinesiophobia, catastrophizing, and low back functional ability in individuals experiencing CNLBP. Materials and Methods: Sixty adults with CNLBP were randomly divided into three equal groups (each n = 20). The first group received manual therapy and PNE with integrated MI (combined therapy group), the second group underwent only manual therapy (manual therapy group), and the third group followed a general exercise program at home (control group). Pain in the last 24 h was assessed using the Numeric Pain Rating Scale (NPRS), functional ability with the Roland-Morris Disability Questionnaire (RMDQ), PPT in the lumbar region through pressure algometry, kinesiophobia with the Tampa Scale for Kinesiophobia (TSK), catastrophizing with the Pain Catastrophizing Scale (PCS), and performance using the Back Performance Scale (BPS) at baseline, in the fourth week, and six months post-intervention. Results: Statistically significant differences between the intervention groups and the control group were found in both the fourth-week measurement and the six-month follow-up, as evident in the NPRS and RMDQ scores, as well as in the total values of tested PPTs (p < 0.05). Differences were also observed between the two intervention groups, with a statistically greater improvement in the combined therapy group at both time points (fourth week and six-month follow-up) (p < 0.05). Regarding the TSK and PCS scores in the fourth week, statistically significant differences were observed between the two intervention groups compared to the control group, as well as between the two intervention groups (p < 0.05). However, in the six-month follow-up, statistically significant differences were found only between the combined therapy group and the other two groups, with the combined therapy group showing significant improvements (p < 0.05). In relation to BPS, both intervention groups exhibited statistically significant differences compared to the control group in the fourth week, without any significant differences between the two intervention groups. However, in the six-month follow-up, significant differences were noted between the combined therapy group and the other two groups (p < 0.05), with combined therapy demonstrating greater improvement. Conclusions: The addition of PNE with integrated MI enhanced the positive effects of a manual therapy intervention in all outcome measures. The combination of manual therapy plus PNE with integrated MI appeared to provide greater improvements compared to the isolated application of manual therapy, and these improvements also lasted longer. These short- and long-term positive effects are likely attributed to the combination of PNE with integrated MI, which contributed to increasing the effectiveness of the treatment. Further studies are required to investigate the optimum dosage of manual therapy and PNE with integrated MI in individuals with CNLBP.

Clinical prediction model for interdisciplinary biopsychosocial rehabilitation in osteoarthritis patients

BACKGROUND

Osteoarthritis (OA) is a heterogenous condition, in which different subgroups are present. Individualized interdisciplinary multimodal pain treatments (IMPT) based on the biopsychosocial model have resulted in positive improvement of pain, health and disability in OA patients. Moreover, predictive factors for treatment success of IMPT in different musculoskeletal pain populations have been examined, but a clinical prediction model which informs whether an OA patient is expected to benefit or not from IMPT is currently lacking.

AIM

The aim was to develop and internally validate a clinical prediction model to inform patient-tailored care based on identified predictors for positive or negative outcomes of IMPT in patients with OA.

DESIGN

Longitudinal prospective cohort study.

SETTING

Center for Integral Rehabilitation at six locations in the Netherlands.

POPULATION

Chronic OA patients.

METHODS

Data in this study were collected during January 2019 until January 2022. Participants underwent a 10-week IMPT program based on the biopsychosocial model. Treatment success was defined by a minimal decrease from baseline of 9 points on the Pain Disability Index (PDI). Candidate predictors were selected by experts in IMPT and literature review. Backward logistic regression analysis was performed to develop the clinical predication model and bootstrap validation was performed for internal validation.

RESULTS

Overall, 599 OA patients were included, of which 324 experienced treatment success. Thirty-four variables were identified as possible predictors for good IMPT outcome. Age, gender, number of pain locations, PDI baseline score, maximal pain severity, use of pain medication and alcohol, work ability, brief illness perceptions questionnaire subscales timeline, consequences, identity and treatment control, pain catastrophizing scale and self-efficacy questionnaire score were found as predictors for treatment success. The internally validated model has an acceptable discriminative power of 0.71.

CONCLUSIONS

This study reports a specific clinical prediction model for good outcome of IMPT in patients with OA. The internally validated model has an acceptable discriminative power of 0.71.

CLINICAL REHABILITATION IMPACT

After external validation, this model could be used to develop a clinically useful decision tool.

Design of a Multicenter Randomized Controlled Trial comparing the effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for voluntary opioid tapering: The INSPIRE study protocol

BACKGROUND

This paper describes the design and protocol of a pragmatic, randomized trial to evaluate the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Integrated Services for Pain: Interventions to Reduce Pain Effectively (INSPIRE) is a multicenter, randomized trial conducted at three academic health centers in the southeastern United States. Participants are adults receiving long-term opioid therapy of at least 20 morphine milligram equivalents daily for chronic noncancer pain.

METHODS

Participants were randomized to either the shared decision-making intervention or the motivational interviewing session and cognitive behavioral therapy for chronic pain intervention. All participants also received guideline-concordant care supporting opioid pharmacotherapy. The primary outcome was change from baseline in average daily prescribed opioid dose at 12 months, using prescribing data from electronic health records. Secondary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference and Physical Function at 12 months.

CONCLUSION

This trial evaluates the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Results from this study can guide clinicians, researchers, and policymakers as they seek to reduce opioid prescribing and improve management of chronic pain.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov Identifier: NCT03454555 (https://clinicaltrials.gov/ct2/show/record/NCT03454555). Participant enrollment began on June 26, 2019.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

Effect of perceived injustice-targeted pain neuroscience education compared with biomedically focused education in breast cancer survivors: a study protocol for a multicentre randomised controlled trial (BCS-PI trial)

INTRODUCTION

Current treatments for pain in breast cancer survivors (BCSs) are mostly biomedically focused rather than biopsychosocially driven. However, 22% of BCSs with pain are experiencing perceived injustice, which is a known predictor for adverse pain outcomes and opioid prescription due to increased maladaptive pain behaviour. Educational interventions such as pain neuroscience education (PNE) are suggested to target perceived injustice. In addition, motivational interviewing can be an effective behavioural change technique. This trial aims to examine whether perceived injustice-targeted PNE with the integration of motivational interviewing is superior to biomedically focused pain education in reducing pain after 12 months in BCS with perceived injustice and pain. In addition, improvements in quality of life, perceived injustice and opioid use are evaluated, and a cost-effectiveness analysis will finally result in a recommendation concerning the use of perceived injustice-targeted PNE in BCSs with perceived injustice and pain.

METHODS AND ANALYSIS

This two-arm multicentre randomised controlled trial will recruit female BCS (n=156) with pain and perceived injustice. Participants will be randomly assigned to perceived injustice-targeted PNE or biomedically focused pain education in each centre. Both interventions include an online session, an information leaflet and three one-to-one sessions. The primary outcome (pain), secondary outcomes (quality of life, perceived injustice and outcomes for cost-effectiveness analysis) and explanatory outcomes (pain phenotyping, sleep, fatigue and cognitive-emotional factors) will be assessed at baseline and at 0, 6, 12 and 24 months postintervention using self-reported questionnaires online. Treatment effects over time will be evaluated using linear mixed model analyses. Additionally, a cost-utility analysis will be done from a healthcare payer and societal perspective.

ETHICS AND DISSEMINATION

The ethical agreement was obtained from the Main Ethics Committee (B.U.N.1432020000068) at the University Hospital Brussels and all other participating hospitals. Study results will be disseminated through presentations, conferences, social media, press and journals.

TRIAL REGISTRATION NUMBER

NCT04730154.

Weight management communications in idiopathic intracranial hypertension: challenges and recommendations from the patients' perspective

Background

Idiopathic intracranial hypertension (IIH) is a neurometabolic condition severely impacting the quality of life of people living with IIH (PwIIH). Most PwIIH are overweight or live with obesity, and weight loss is recommended by healthcare professionals (HCPs) as it is central to disease management. There is currently no research evaluating patient-clinician interactions when discussing weight management in IIH. The aim of this study was to evaluate the patient experience of communication with HCPs regarding weight management from the perspective of PwIIH.

Methods

A cross-sectional online survey was developed and distributed by the IIH UK charity via their mailing list and social media network. Eligible participants were adults with IIH who have been recommended to lose weight by their HCP. Descriptive statistics were used to summarise quantitative responses and content analysis was used to inductively draw out themes from open-ended free-text responses.

Results

There were 625 respondents. One-fifth of PwIIH (n=127/603, 21%) felt that HCPs were supportive and empathetic about weight management. Five themes were identified on how experiences regarding weight management for IIH can be improved, with PwIIH recommending for HCPs to: (1) detail the relationship between IIH and weight, (2) individualise care, (3) give advice, (4) provide support and (5) adapt communication.

Conclusion

The majority of PwIIH recalled a poor experience and negative emotions when engaged in discussions regarding weight management with their HCPs. Further research should explore the HCPs perspective and evaluate interventions aiming to improve the quality of patient-HCPs communication in IIH.

Hard Flaccid Syndrome: A Biopsychosocial Management Approach with Emphasis on Pain Management, Exercise Therapy and Education

Hard flaccid syndrome (HFS) is a rather rare, acquired clinical entity affecting young men's well-being, sexual and social life. HFS presents with a cluster of symptoms including penile-specific somatosensory disturbances, a semi-rigid penis at the flaccid state without any stimulation or desire, erectile dysfunction, perineal and/or penile pain, associated urinary symptoms, emotional distress as well as other psychosocial and stress-related manifestations. Although its pathophysiology is still not well understood, initial penile trauma causing minor nerve and vascular disturbances to the penis and associated pelvic floor musculature is suggested to trigger the syndrome. Despite the scarcity of research on HFS, the present report describes a case of a young male clinically diagnosed with HFS, who benefited from a biopsychosocial management strategy, focusing on pain management, therapeutic exercise approaches, such as pelvic floor exercise re-education, graded exposure to activity as well as education on lifestyle and stress-related modifications. This holistic management approach has been clinically reasoned in this case report, and the need for more evidence-based studies developing diagnosing criteria, elaborating pathophysiological mechanisms and testing the efficiency of different therapeutic options is highlighted.

Clinician perspectives on postamputation pain assessment and rehabilitation interventions

OBJECTIVE

The purpose of this study was to explore self-reported Veterans Affairs (VA) amputation clinician perspectives and clinical practices regarding the measurement and treatment for amputation-related pain.

STUDY DESIGN

Cross-sectional survey with 73 VA rehabilitation clinicians within the VA Health Care System.

RESULTS

The most frequent clinical backgrounds of respondents included physical therapists (36%), prosthetists (32%), and physical medicine and rehabilitation specialist (21%). Forty-one clinicians (56%) reported using pain outcome measures with a preference for average pain intensity numeric rating scale (generic) (97%), average phantom limb pain intensity numeric rating scale (80%), or Patient-Reported Outcomes Measurement Information System pain interference (12%) measures. Clinicians' most frequently recommended interventions were compression garments, desensitization, and physical therapy. Clinicians identified mindset, cognition, and motivation as factors that facilitate a patient's response to treatments. Conversely, clinicians identified poor adherence, lack of belief in interventions, and preference for traditional pain interventions (e.g., medications) as common barriers to improvement. We asked about the frequently used treatment of graded motor imagery. Although graded motor imagery was originally developed with 3 phases (limb laterality, explicit motor imagery, mirror therapy), clinicians reported primarily using explicit motor imagery and mirror therapy.

RESULTS

Most clinicians who use standardized pain measures prefer intensity ratings. Clinicians select pain interventions based on the patient's presentation. This work contributes to the understanding of factors influencing clinicians' treatment selection for nondrug interventions. Future work that includes qualitative components could further discern implementation barriers to amputation pain rehabilitation interventions for greater consistency in practice.

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.

Experience-based design: Empowering individuals while they wait for interprofessional chronic pain care

OBJECTIVES

Chronic pain is highly prevalent and a leading cause of disability. Long wait times for interprofessional care provide an opportunity to introduce web-based interventions that improve psychosocial function and patients' readiness and ability to manage their condition. Here we describe the process of partnering with people with lived experience (PWLE) to develop an online self-management program enhanced by motivational interviewing. We also report the multiphase usability testing of the program.

METHODS

PWLE were included in all aspects of this project from program inception to content creation, module development, usability testing, and knowledge dissemination. Phase 1 included the development of the interactive, web-based modules. This process involved weekly meetings and asynchronous content creation with a core team of interprofessional pain experts, researchers, and PWLE. Phase 2 included usability testing by our PWLE and clinical expert advisory. Phase 3 included survey-based usability testing with a sample of 10 PWLE.

RESULTS

We created a chronic pain & motivational empowerment program includes a series of eight interactive educational web-based modules. Topics included: setting expectations, chronic pain explained, biopsychosocial factors, empowered management, self-awareness & compassion & acceptance, values, goal setting, and communication. The program is accompanied by a reflection journal and can be enhanced by one-on-one coaching sessions using a motivational interviewing approach. Phase two usability testing resulted in numerous content changes and the addition of accessibility features. Phase 3 usability testing with PWLE found the program highly accessible and easy to use.

CONCLUSIONS

The engagement of our PWLE team member and advisors made the online program more relevant, sensitive and helpful to the needs of people with pain.

PRACTICAL VALUE

This PWLE-centric project sets the foundation for future work to examine the feasibility and effectiveness of the program for supporting individuals with chronic pain self-manage.

Autoimmune polyneuropathies

The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

Background

While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020.

Objective

This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program.

Methods

Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming.

Discussion/Results

Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement.

Conclusion

TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

Physiotherapists’ Perspectives on Type 2 Diabetes Management and as a Primary Condition for Referral to Physiotherapy Services: A Qualitative Descriptive Study

Purpose:

We explored the current and potential role of physiotherapists in the management of people with type 2 diabetes (T2D) and T2D as a primary condition for physiotherapy referral.

Method:

We conducted a qualitative descriptive study. Participants were physiotherapists practicing in community and outpatient settings across Canada. One-on-one telephone interviews were completed to explore provision of physiotherapy care for people with T2D, including current practices and readiness of physiotherapists to provide direct care. We employed thematic analysis for generation of themes from interviews.

Results:

We interviewed 21 participants from eight provinces and territories. Three themes were generated from the data: current approach to T2D management; challenges for physiotherapy integration; and merits of physiotherapy and needed evolution. Participants described that physiotherapists are not part of the healthcare team for T2D management. There is a gap in medical management of T2D that physiotherapy would fill, that is, education and prescription for exercise participation.

Conclusions:

Our findings support a gap in the management of T2D in Canadian healthcare, particularly in reference to physiotherapy. Further, our findings support the need for greater inclusion of physiotherapists for lifestyle counseling with an emphasis on physical activity and exercise for patients at risk of and with T2D to maximize health and improve/maintain function. Studies focusing on accessibility and funding of physiotherapy services are needed to validate these findings.

Effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent therapy in online and outdoor format in individuals with fibromyalgia: Study protocol of a randomized, controlled trial (On&Out study)

Introduction: The On&amp;Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their comparative effectiveness nor their long-term effects. For the first time, this study will also evaluate the cost-utility (6-month time-horizon) and the effects on immune-inflammatory biomarkers and Brain-Derived Neurotrophic Factor (BDNF) levels of both interventions. The objectives of this 6-month, randomized, controlled trial (RCT) are 1) to examine the effectiveness and cost-utility of adding FIBRO-On or FIBRO-Out to Treatment-As-Usual (TAU) for individuals with fibromyalgia (FM); 2) to identify pre–post differences in blood biomarker levels in the three study arms and 3) to analyze the role of process variables as mediators of 6-month follow-up clinical outcomes.

Methods and analysis: Participants will be 225 individuals with FM recruited at Vall d’Hebron University Hospital (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs. TAU + FIBRO-On vs. TAU + FIBRO-Out. A comprehensive assessment to collect functional impairment, pain, fatigue, depressive and anxiety symptoms, perceived stress, central sensitization, physical function, sleep quality, perceived cognitive dysfunction, kinesiophobia, pain catastrophizing, psychological inflexibility in pain and pain knowledge will be conducted pre-intervention, at 6 weeks, post-intervention (12 weeks), and at 6-month follow-up. Changes in immune-inflammatory biomarkers [i.e., IL-6, CXCL8, IL-17A, IL-4, IL-10, and high-sensitivity C-reactive protein (hs-CRP)] and Brain-Derived Neurotrophic Factor will be evaluated in 40 participants in each treatment arm (total n = 120) at pre- and post-treatment. Quality of life and direct and indirect costs will be evaluated at baseline and at 6-month follow-up. Linear mixed-effects regression models using restricted maximum likelihood, mediational models and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed.

Ethics and dissemination: This study has been approved by the Ethics Committee of the Vall d’Hebron Institute of Research. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities. Trial registration number NCT05377567 (clinicaltrials.gov).

Combining Cognitive Behavioral Therapy for Insomnia and Chronic Spinal Pain Within Physical Therapy: A Practical Guide for the Implementation of an Integrated Approach

Most people who have nonspecific chronic spinal pain (nCSP) report comorbid insomnia. However, in current treatment strategies for nCSP, insomnia is usually not addressed. Considering the bidirectional interaction between pain and sleep and its underlying psychophysiological mechanisms, insomnia may increase the risk of developing adverse physical and psychological health outcomes and should thus no longer be left untreated. As suggested by previous pilot studies, adding cognitive behavioral therapy for insomnia to the contemporary evidence-based biopsychosocial physical therapy approach may also improve pain outcomes in nCSP. This manuscript aims to provide practical guidelines on hybrid physical therapy, including the combination of the following components: (1) pain neuroscience education (eg, to reconceptualize pain) and cognition-targeted exercise therapy (eg, graded exposure to functional daily life movements), and (2) cognitive behavioral therapy for insomnia (sleep psychoeducation, behavioral and cognitive therapy, correction of sleep hygiene, and relaxation therapy) can be deployed for the management of patients who have chronic spinal pain. Impact. Due to the major impact sleep disturbances have on pain and disability, insomnia as a comorbidity should no longer be ignored when treating patients with chronic spinal pain.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

[Innovative interventions in pain physiotherapy : Advancing care for people with chronic pain]

BACKGROUND

Chronic pain, with a prevalence of at least 17%, is a costly health problem associated with a high burden of disease. Musculoskeletal chronic pain is particulary common, which in many cases is treated with physiotherapy.

AIM

The aim of this paper is to provide an overview of innovative, promising physiotherapy interventions in pain management, to present their effectiveness and to discuss their implementation in healthcare.

METHODS

A narrative review was conducted. The Cochrane, Medline (via PubMed) and PEDro databases were searched using the search terms chronic pain, physiotherapy, prevention, pain education, behavioural intervention, eHealth, and systematic review as well as chronic pain, guideline and relevant synonyms.

RESULTS

One guideline review, two guidelines and ten systematic reviews were included. Chronic pain prevention, digital health apps, lifestyle interventions and behavioural approaches were identified as promising and effective interventions for people with chronic pain, showing the potential to meaningfully complement pain physiotherapy and improve quality of care.

CONCLUSIONS

Despite the predominantly positive results from systematic reviews, implementation in everyday care is difficult due to conditions of care and the contemporary education system for physiotherapists in Germany. Health services research can play an important role in accelerating the transfer of innovations into practice.

Psychological Interventions for Pediatric Headache Disorders: A 2021 Update on Research Progress and Needs

PURPOSE OF REVIEW

This review summarizes key findings from recent investigations of psychological interventions for pediatric headache disorders and discusses important avenues for future research.

RECENT FINDINGS

Cognitive Behavioral Therapy (CBT) is effective in reducing headache days among youth with chronic headache. There is mixed evidence for the benefit of CBT on reducing disability associated with migraine, suggesting that there is room to optimize CBT by leveraging complementary or alternative psychological interventions, such as Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches. Tailoring CBT may be especially important for youth with more impairing or complex clinical presentations, such as those with continuous headache. Using eHealth and novel study designs to expand access to and dissemination of psychological interventions is promising. Although CBT is the gold standard psychological treatment for youth with migraine, we are only beginning to understand how and why it is effective. Other promising psychological treatments are available, and studies are beginning to examine how CBT can be optimized to fit the unique needs of each patient. Improving access and equitability of care for youth with migraine will require tailoring psychological treatments for patients with varying headache presentations and youth from a variety of cultural, racial, ethnic, and linguistic backgrounds.

Thoughts on Pain, Physical Activity, and Body in Patients With Recurrent Low Back Pain and Fear: An Interview Study

OBJECTIVE

The purpose of this study was to explore thoughts and ideas about the body and pain in patients with nonspecific low back pain (LBP) who have a high degree of fear of movement.

METHODS

Patients with nonspecific LBP and a high degree of fear of movement, as measured using the Tampa Scale of Kinesiophobia, were asked to participate in the study. Individual semistructured in-depth interviews were conducted with 11 participants. The material was analyzed using content analysis with an inductive approach.

RESULTS

From these patients' stories, an overarching theme-decreased confidence in the body becomes a barrier to living life to the fullest-emerged. This theme was further divided into 4 subthemes: (1) "What is wrong with my body?"-the constant search for an explanation; (2) searching for the right way to move; (3) loss of mobility means a lack of meaning in life; and (4) the message from health care professionals guides feelings, thoughts, and movement behavior.

CONCLUSION

This study indicates that the message of keeping physically active when experiencing LBP has succeeded, but patients with fear require support to feel secure and have enough confidence in their body to move and exercise. Clinicians need to better incorporate evidence-based practice for patients with fear and support them so that they can apply an understanding of pain to their bodies and their every day life.

IMPACT

These results offer guidance for health care professionals to enhance their practice by providing more updated information to their patients who have recurrent LBP and fear. With better support, patients may be able to regain confidence in their bodies and live their lives to the fullest.

LAY SUMMARY

If you have recurrent LBP and fear of moving your body, ask your health care professional to provide you with updated knowledge on pain and to help you regain confidence in your body so that you can live your life to the fullest.

Physiotherapists' knowledge, attitude and practice behavior to prevent chronification in patients with non-specific, non-traumatic, acute- and subacute neck pain: A qualitative study

BACKGROUND

The purpose of this study was to explore physiotherapists' knowledge, attitude, and practice behavior in assessing and managing patients with non-specific, non-traumatic, acute- and subacute neck pain, with a focus on prognostic factors for chronification.

METHOD

A qualitative study using in-depth semi-structured interviews was conducted with 13 physiotherapists working in primary care. A purposive sampling method served to seek the broadest perspectives. The knowledge-attitude and practice framework was used as an analytic lens throughout the process. Textual data were analyzed using qualitative content analysis with an inductive approach and constant comparison.

RESULTS

Seven main themes emerged from the data; physiotherapists self-estimated knowledge and attitude, role clarity, therapeutic relationship, internal- and external barriers to practice behavior, physiotherapists' practice behaviors, and self-reflection. These findings are presented in an adjusted knowledge-attitude and practice behavior framework.

CONCLUSION

A complex relationship was found between a physiotherapist's knowledge about, attitude, and practice behavior concerning the diagnostic process and interventions for non-specific, non-traumatic, acute, and subacute neck pain. Overall, physiotherapists used a biopsychosocial view of patients with non-specific neck pain. Physiotherapists' practice behaviors was influenced by individual attitudes towards their professional role and therapeutic relationship with the patient, and individual knowledge and skills, personal routines and habits, the feeling of powerlessness to modify patients' external factors, and patients' lack of willingness to a biopsychosocial approach influenced physiotherapists' clinical decisions. In addition, we found self-reflection to have an essential role in developing self-estimated knowledge and change in attitude towards their therapeutic role and therapist-patient relationship.

Effectiveness of a Multicomponent Treatment Based on Pain Neuroscience Education, Therapeutic Exercise, Cognitive Behavioral Therapy, and Mindfulness in Patients With Fibromyalgia (FIBROWALK Study): A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a 12-week multicomponent treatment based on pain neuroscience education, therapeutic exercise, cognitive behavioral therapy, and mindfulness-in addition to treatment as usual-compared with treatment as usual only in patients with fibromyalgia.

METHODS

This randomized controlled trial involved a total of 272 patients who were randomly assigned to either multicomponent treatment (n = 135) or treatment as usual (n = 137). The multicomponent treatment (2-hour weekly sessions) was delivered in groups of 20 participants. Treatment as usual was mainly based on pharmacological treatment according to the predominant symptoms. Data on functional impairment using the Revised Fibromyalgia Impact Questionnaire as the primary outcome were collected as were data for pain, fatigue, kinesiophobia, physical function, anxiety, and depressive symptoms (secondary outcomes) at baseline, 12 weeks, and, for the multicomponent group only, 6 and 9 months. An intention-to-treat approach was used to analyze between-group differences. Baseline differences between responders (>20% Revised Fibromyalgia Impact Questionnaire reduction) and nonresponders also were analyzed, and the number needed to treat was computed.

RESULTS

At posttreatment, significant between-group differences with a large effect size (Cohen d > 0.80) in favor of the multicomponent treatment were found in functional impairment, pain, kinesiophobia, and physical function, whereas differences with a moderate size effect (Cohen d > 0.50 and <0.80) were found in fatigue, anxiety, and depressive symptoms. Nonresponders scored higher on depressive symptoms than responders at baseline. The number needed to treat was 2 (95% CI = 1.7-2.3).

CONCLUSION

Compared with usual care, there was evidence of short-term (up to 3 months) positive effects of the multicomponent treatment for fibromyalgia. Some methodological shortcomings (eg, absence of follow-up in the control group and monitoring of treatment adherence, potential research allegiance) preclude robust conclusions regarding the proposed multicomponent program.

IMPACT

Despite some methodological shortcomings in the design of this study, the multicomponent therapy FIBROWALK can be considered a novel and effective treatment for patients with fibromyalgia. Physical therapists should detect patients with clinically relevant depression levels prior to treatment because depression can buffer treatment effects.

LAY SUMMARY

Fibromyalgia is prevalent and can be expensive to treat. This multicomponent treatment could significantly improve the core symptoms of fibromyalgia compared with usual treatment.

Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

Physiotherapy support for self-management of persisting musculoskeletal pain disorders

BACKGROUND

Musculoskeletal pain (MSKP) is an extremely common pain disorder in almost all populations. Self-management (SM) support is a programme to prepare people to self-manage their health condition effectively, while maintaining quality of life. SM is a cost-effective and context-specific strategy to address the global public health burden.

OBJECTIVES

Self-management needs a change in behaviour from seeking unnecessary medical care to safely self-managing symptoms. As changing individuals' behaviour is challenging, the objective of my literature review was to identify the characteristics, in both therapist and patient, to successfully engage in SM.

METHOD

A narrative literature review, that could inform evidence-based support programmes for SM of MSKP.

RESULTS

Studies on successful implementation of SM of MSKP do not report strong outcomes. However, in more recent years a few positive outcomes were reported, possibly as a result of research evidence for the application of psychosocial skills and contemporary pain neuroscience in the management of persistent MSKP.

CONCLUSION

Psychologically-informed physiotherapy, addressing psychosocial barriers to the maintenance of SM programmes, could facilitate more successful outcomes.

CLINICAL IMPLICATIONS

Before engaging in a SM support programme, obstacles to behaviour change must be identified and addressed in a SM support programme, to facilitate individuals towards taking safe responsibility for their healthcare. Therapists working with patients with persistent MSKP, should upskill themselves to be in line with the latest pain and psychosocial research literature. Moreover, communication skills training seems to be a priority for effective SM support programmes.

The effect of a pain educational video intervention upon child pain-related outcomes: A randomized controlled study

BACKGROUND

Pain neuroscience education (PNE) has received increasing research attention demonstrating beneficial effects on pain-related outcomes in adults. Conversely, studies on the effectiveness of PNE in children are scarce.

METHODS

This study investigated the effect of a pain educational video intervention on child pain-related outcomes (i.e. experienced pain intensity, pain-related fear and catastrophic worry about pain, pain threshold and pain knowledge) in healthy children undergoing an experimental pain task. Furthermore, the moderating role of children's demographic (i.e. sex and age) and psychological (i.e. baseline pain knowledge and anticipated pain intensity, pain-related fear and catastrophic worry) characteristics was examined. Participants were 89 children (M_age  = 11.85, SD = 1.78), randomly assigned to either a condition whereby they were instructed to watch a brief pain educational video (i.e. experimental group) or to a control condition whereby they did not watch any video.

RESULTS

Study findings revealed that accurate pain knowledge and pain threshold were higher amongst children in the experimental group compared to the control group. In contrast with expectations, no main effects of the video intervention were observed for experienced pain intensity, pain-related fear and catastrophic worry. Moderation analyses indicated that the video intervention contributed, in comparison with the control condition, to higher levels of pain knowledge amongst younger children only and to higher pain thresholds amongst boys only.

CONCLUSIONS

Further investigation is needed to optimize pain educational video interventions and to determine whether more beneficial outcomes can be found in clinical (i.e. non-experimental) situations and in children with persistent or recurring pain problems.

SIGNIFICANCE

Examining the impact of pain educational interventions within a non-clinical setting is deemed particularly important given that adaptive pain coping strategies likely play an important role in preventing the development and maintenance of future maladaptive pain-related behaviour. Further, study findings provide preliminary evidence of baseline and demographic (i.e. age and sex) characteristics explaining differences in the effect of a pain educational video intervention in pain knowledge and pain-related experiences during experimental pain.

Neuralgic amyotrophy

PURPOSE OF REVIEW

This review focuses on the current insights and developments in neuralgic amyotrophy (NA), an auto-immune multifocal peripheral nervous system disorder that leaves many patients permanently impaired if not recognized and treated properly.

RECENT FINDINGS

NA is not as rare as previously thought. The phenotype is broad, and recent nerve imaging developments suggest that NA is the most common cause of acute anterior or posterior interosseous nerve palsy. Phrenic nerve involvement occurs in 8% of all NA patients, often with debilitating consequences. Acute phase treatment of NA with steroids or i.v. immunoglobulin may benefit patients. Long-term consequences are the rule, and persisting symptoms are mainly caused by a combination of decreased endurance in the affected nerves and an altered posture and movement pattern, not by the axonal damage itself. Patients benefit from specific rehabilitation treatment. For nerves that do not recover, surgery may be an option.

SUMMARY

NA is not uncommon, and has a long-term impact on patients' well-being. Early immunomodulating treatment, and identifying phrenic neuropathy or complete nerve paralysis is important for optimal recovery. For persistent symptoms a specific treatment strategy aiming at regaining an energy balance and well-coordinated scapular movement are paramount.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.